ImranzamanML/Clinical_Documents_on_Syndromes_Disease

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MEDICATIONS:

Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.

BASELINE EKG:

Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.

EXERCISE RESULTS:

1. The patient exercised for 3 minutes stopping due to fatigue. No chest pain.

2. Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate. Blood pressure rose from 150/88 to 210/100. There was a slight increase in her repolorization abnormalities in a non-specific pattern.

NUCLEAR PROTOCOL:

Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.

NUCLEAR RESULTS:

1. Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition. The resting images showed decreased uptake in the anterior wall. However the apex is spared of this defect. There is no significant change between rest and stress images. The sum score is 0.

2. The Gated SPECT shows moderate LVH with slightly low EF of 48%.

IMPRESSION:

1. No evidence of exercise induced ischemia at a high myocardial workload. This essentially excludes obstructive CAD as a cause of her elevated troponin.

2. Mild hypertensive cardiomyopathy with an EF of 48%.

3. Poor exercise capacity due to cardiovascular deconditioning.

4. Suboptimally controlled blood pressure on today's exam.
PROCEDURE:

Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.

ANESTHESIA:

Local sedation.

VITAL SIGNS:

See nurse's notes.

COMPLICATIONS:

None.

DETAILS OF PROCEDURE:

INT was placed. The patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion. The patient was given sedation and monitored. Lidocaine 1.5% for skin wheal was made 10 cm from the midline to the bilateral L2 distal vertebral body. A 20-gauge, 15 cm SMK needle was then directed using AP and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one-third and anterior border on the lateral view and on the AP view the tip of the needle was inside the lateral third of the border of the vertebral body. At this time a negative motor stimulation was obtained. Injection of 10 cc of 0.5% Marcaine plus 10 mg of Depo-Medrol was performed. Coagulation was then carried out for 90oC for 90 seconds. At the conclusion of this, the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated. This was repeated one more time with a 5 mm withdrawal and coagulation.

At that time, attention was directed to the L3 body where the needle was placed to the upper one-third/distal two-thirds junction and the sequence of injection, coagulation, and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated. There were no compilations from this. The patient was discharged to operating room recovery in stable condition.
EXAM:

Cervical, lumbosacral, thoracic spine flexion and extension.

HISTORY:

Back and neck pain.

CERVICAL SPINE

FINDINGS:

AP

lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable.
PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION

This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation. The original consultation and treatment planning will be separately performed. At the time of the implantation, special coordination will be required. Stepping ultrasound will be performed and utilized in the pre-planning process. Some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process. Re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound. Modifications will be made in real time to add or subtract needles and seeds as required. This may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.

The brachytherapy must be customized to fit the individual's tumor and prostate. Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.
EXAM:

Right foot series.

REASON FOR EXAM:

Injury.

FINDINGS:

Three images of the right foot were obtained. On the AP image only, there is a subtle lucency seen in the proximal right fourth metatarsal and a mild increased sclerosis in the proximal fifth metatarsal. Also on a single image, there is a lucency seen in the lateral aspect of the calcaneus that is seen on the oblique image only. Fractures in these bones cannot be completely excluded. There is soft tissue swelling seen overlying the calcaneus within this region.

IMPRESSION:

Cannot exclude nondisplaced fractures in the lateral aspect of the calcaneus or at the base of the fourth and fifth metatarsals. Recommend correlation with site of pain in addition to conservative management and followup imaging. A phone call will be placed to the emergency room regarding these findings.
EXAM:

Nuclear medicine lymphatic scan.

REASON FOR EXAM:

Left breast cancer.

TECHNIQUE:

1.0 mCi of Technetium-99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.

MEDICATIONS:

Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.

BASELINE EKG:

Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.

EXERCISE RESULTS:

1. The patient exercised for 3 minutes stopping due to fatigue. No chest pain.

2. Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate. Blood pressure rose from 150/88 to 210/100. There was a slight increase in her repolorization abnormalities in a non-specific pattern.

NUCLEAR PROTOCOL:

Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.

NUCLEAR RESULTS:

1. Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition. The resting images showed decreased uptake in the anterior wall. However the apex is spared of this defect. There is no significant change between rest and stress images. The sum score is 0.

2. The Gated SPECT shows moderate LVH with slightly low EF of 48%.

IMPRESSION:

1. No evidence of exercise induced ischemia at a high myocardial workload. This essentially excludes obstructive CAD as a cause of her elevated troponin.

2. Mild hypertensive cardiomyopathy with an EF of 48%.

3. Poor exercise capacity due to cardiovascular deconditioning.

4. Suboptimally controlled blood pressure on today's exam.

PROCEDURE:

Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.

ANESTHESIA:

Local sedation.

VITAL SIGNS:

See nurse's notes.

COMPLICATIONS:

None.

DETAILS OF PROCEDURE:

INT was placed. The patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion. The patient was given sedation and monitored. Lidocaine 1.5% for skin wheal was made 10 cm from the midline to the bilateral L2 distal vertebral body. A 20-gauge, 15 cm SMK needle was then directed using AP and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one-third and anterior border on the lateral view and on the AP view the tip of the needle was inside the lateral third of the border of the vertebral body. At this time a negative motor stimulation was obtained. Injection of 10 cc of 0.5% Marcaine plus 10 mg of Depo-Medrol was performed. Coagulation was then carried out for 90oC for 90 seconds. At the conclusion of this, the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated. This was repeated one more time with a 5 mm withdrawal and coagulation.

At that time, attention was directed to the L3 body where the needle was placed to the upper one-third/distal two-thirds junction and the sequence of injection, coagulation, and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated. There were no compilations from this. The patient was discharged to operating room recovery in stable condition.

EXAM:

Cervical, lumbosacral, thoracic spine flexion and extension.

HISTORY:

Back and neck pain.

CERVICAL SPINE

FINDINGS:

AP

lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable.

PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION

This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation. The original consultation and treatment planning will be separately performed. At the time of the implantation, special coordination will be required. Stepping ultrasound will be performed and utilized in the pre-planning process. Some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process. Re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound. Modifications will be made in real time to add or subtract needles and seeds as required. This may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.

The brachytherapy must be customized to fit the individual's tumor and prostate. Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.

EXAM:

Right foot series.

REASON FOR EXAM:

Injury.

FINDINGS:

Three images of the right foot were obtained. On the AP image only, there is a subtle lucency seen in the proximal right fourth metatarsal and a mild increased sclerosis in the proximal fifth metatarsal. Also on a single image, there is a lucency seen in the lateral aspect of the calcaneus that is seen on the oblique image only. Fractures in these bones cannot be completely excluded. There is soft tissue swelling seen overlying the calcaneus within this region.

IMPRESSION:

Cannot exclude nondisplaced fractures in the lateral aspect of the calcaneus or at the base of the fourth and fifth metatarsals. Recommend correlation with site of pain in addition to conservative management and followup imaging. A phone call will be placed to the emergency room regarding these findings.

EXAM:

Nuclear medicine lymphatic scan.

REASON FOR EXAM:

Left breast cancer.

TECHNIQUE:

1.0 mCi of Technetium-99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.