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PREPROCEDURE DIAGNOSIS: , Abdominal pain, diarrhea, and fever.,POSTPROCEDURE DIAGNOSIS: , Pending pathology.,PROCEDURES PERFORMED: , Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.gastroenterology, colonoscopy with multiple biopsies, length of the colon, diarrhea and fever, terminal ileum cecum, multiple biopsies, ileum cecum, cecum hepatic, hepatic flexure, terminal ileum, sigmoid colon, colonoscopy, diarrhea, cecum, hepatic, flexure, inflammation, biopsies, terminal, ileum, sigmoid, scope,

INDICATIONS:, Atrial fibrillation, coronary disease.,STRESS TECHNIQUE:, The patient was infused with dobutamine to a maximum heart rate of 142. ECG exhibits atrial fibrillation.,IMAGE TECHNIQUE:, The patient was injected with 5.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT system.,IMAGE ANALYSIS:, It should be noted that the images are limited slightly by the patient's obesity with a weight of 263 pounds. There is normal LV myocardial perfusion. The LV systolic ejection fraction is normal at 65%. There is normal global and regional wall motion.,CONCLUSIONS:,1. Basic rhythm of atrial fibrillation with no change during dobutamine stress, maximum heart rate of 142.,2. Normal LV myocardial perfusion.,3. Normal LV systolic ejection fraction of 65%.,4. Normal global and regional wall motion.radiology, dobutamine stress test, atrial fibrillation, lv myocardial perfusion, lv systolic ejection fraction, coronary disease, dobutamine, ejection fraction, gated tomographic spect system, thallous chloride, wall motion, stress, fibrillation, atrial

LEFT LOWER EXTREMITY VENOUS DOPPLER ULTRASOUND,REASON FOR EXAM: , Status post delivery five weeks ago presenting with left calf pain.,INTERPRETATIONS: , There was normal flow, compression and augmentation within the right common femoral, superficial femoral and popliteal veins. Lymph nodes within the left inguinal region measure up to 1 cm in short-axis.,IMPRESSION: , Lymph nodes within the left inguinal region measure up to 1 cm in short-axis, otherwise no evidence for left lower extremity venous thrombosis.radiology, popliteal veins, superficial femoral, common femoral, inguinal region, lymph nodes, venous doppler, lower extremity, lymph, inguinal, axis, doppler, extremity, venous,

HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **. Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound. ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear. The baby was vertex presentation. The baby was dried, stimulated, and bulb suctioned. Apgar scores of ** at one minute and ** at five minutes.,PAST MEDICAL HISTORY,MATERNAL HISTORY:, The mother is a **-year-old, G**, P** female with blood type **. She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative. Mother was group B strep **. Mother's past medical history is **.,PRENATAL CARE: , Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits. She did not smoke, drink alcohol, or use illicit drugs during pregnancy.,SURGICAL HISTORY: , **,MEDICATIONS:, Medications taken during this pregnancy were **.,ALLERGIES: , **,FAMILY HISTORY: , **,SOCIAL HISTORY: , **,PHYSICAL EXAMINATION,VITAL SIGNS: Temperature **, heart rate **, respiratory rate **. Dextrose stick **. Ballard score by the RN is ** weeks. Birth weight is ** grams, which is the ** percentile for gestational age. Length is ** centimeters which is ** percentile for gestational age. Head circumference is ** centimeters which is ** percentile for gestational age.,GENERAL: **Alert, active, nondysmorphic-appearing infant in no acute distress.,HEENT: Anterior fontanelle open and flat. Positive bilateral red reflexes.,Ears have normal shape and position with no pits or tags. Nares patent. Palate intact. Mucous membranes moist.,NECK: Full range of motion.,CARDIOVASCULAR: Normal precordium, regular rate and rhythm. No murmurs. Normal femoral pulses.,RESPIRATORY; Clear to auscultation bilaterally. No retractions.,ABDOMEN: Soft, nondistended. Normal bowel sounds. No hepatosplenomegaly. Umbilical stump is clean, dry, and intact.,GENITOURINARY: Normal tanner I **. Anus patent.,MUSCULOSKELETAL: Negative Barlow and Ortolani. Clavicles intact. Spine straight. No sacral dimple or hair tuft. Leg lengths grossly symmetric. Five fingers on each hand and five toes on each foot.,SKIN: Warm and pink with brisk capillary refill. No jaundice.,NEUROLOGICAL: Normal tone. Normal root, suck, grasp, and Moro reflexes. Moves all extremities equally.,DIAGNOSTIC STUDIES,LABORATORY DATA:, **,ASSESSMENT: , Full term, appropriate for gestational age **.,PLAN:,1. Routine newborn care.,2. Anticipatory guidance.,3. Hepatitis B immunization prior to discharge.,nan

PREOPERATIVE DIAGNOSIS:, Phimosis.,POSTOPERATIVE DIAGNOSES:, Phimosis.,OPERATIONS:, Circumcision.,ANESTHESIA: , LMA.,EBL:, Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , This is a 3-year-old male, who was referred to us from Dr. X's office with phimosis. The patient had spraying of urine and ballooning of the foreskin with voiding. The urine seemed to have collected underneath the foreskin and then would slowly drip out. Options such as dorsal slit, circumcision, watchful waiting by gently pulling the foreskin back were discussed. Risk of anesthesia, bleeding, infection, pain, scarring, and expected complications were discussed. The patient's family understood all the complications and wanted to proceed with the procedure. Consent was obtained using interpreter.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the OR and anesthesia was applied. The patient was placed in supine position. The patient was prepped and draped in usual sterile fashion. All the penile adhesions were released prior to the prepping. The extra foreskin was marked off, 1 x 3 Gamco clamp was used. Hemostasis was obtained after removing the extra foreskin using the Gamco clamp.,Using 5-0 Monocryl, 4 quadrant stitches were placed and horizontal mattress suturing was done. There was excellent hemostasis. Dermabond was applied. The patient was brought to recovery at the end of the procedure in stable condition.surgery, ballooning of the foreskin, spraying of urine, gamco clamp, spraying, ballooning, circumcision, urine, phimosis, foreskin

PREOPERATIVE DIAGNOSIS:, Squamous cell carcinoma of right temporal bone/middle ear space.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of right temporal bone/middle ear space.,PROCEDURE: , Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: ,The patient was brought into the operating room, placed on the table in supine position. General endotracheal anesthesia was obtained in the usual fashion. The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen. The neck was prepped as well. After this was performed, I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl. A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle. After this was performed, I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible. The condyle was skeletonized so that it could be easily seen. The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared. The neck contents to the hyoid were dissected out. The hypoglossal nerve, vagus nerve, and spinal accessory nerve were dissected towards the jugular foramen. The neck contents were removed as a separate specimen. The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis. A large posterior facial vein was identified and likewise clipped for later use. I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus, dissecting or exposing the dura to the level of the jugular bulb. It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router, I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube. The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made. I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion. Once this was dissected out, Dr. X entered the procedure for completion of the resection with the craniotomy. For details, please see his operative note.,After Dr. X had completed the resection, I then harvested the rectus free flap. A skin paddle was drawn out next to the umbilicus about 4 x 4 cm. The skin paddle was incised with the Bovie and down to the anterior rectus sheath. Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle. The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin. The skin paddle was then sutured to the fascia and muscle with interrupted 3-0 Vicryl. The anterior rectus sheath was then reflected off the rectus muscle, which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction. The vascular pedicle could be seen entering the muscle in usual fashion. The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel. The wound was then packed with saline impregnated sponges. The rectus muscle with attached skin paddle was then transferred into the neck. The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9-0 Ethilon with standard microvascular technique. Ischemia time was less than 10 minutes. Likewise, the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9-0 Ethilon as well. There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case. The wound was irrigated with copious amounts of saline. The eustachian tube was obstructed with bone wax. The muscle was then laid into position with the skin paddle underneath the conchal bowl. I removed most the skin of the conchal bowl de-epithelializing and leaving the fat in place. The wound was closed in layers overlying the muscle, which was secured superiorly to the muscle overlying the temporal skull. The subcutaneous tissues were closed with interrupted 3-0 Vicryl. The skin was closed with skin staples. There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself. The skin paddle was closed with interrupted 4-0 Prolene to the edges of the conchal bowl.,The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with #1 Prolene with the more running suture, taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors. The subcutaneous tissues were closed with interrupted 2-0 Vicryl and skin was closed with skin staples. The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened. The patient was then transferred to the PACU in stable condition with spontaneous respirations, having tolerated the procedure well.neurosurgery, rectus abdominis myocutaneous, skull base defect, squamous cell carcinoma, skull base, squamous cell, rectus sheath, abdominis, muscle, rectus, sheath

PREOPERATIVE DIAGNOSES:, ,1. Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2. Neck pain with left radiculopathy, progressive (723.1/723.4).,3. Headaches, progressive (784.0).,POSTOPERATIVE DIAGNOSES:, ,1. Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2. Neck pain with left radiculopathy, progressive (723.1/723.4).,3. Headaches, progressive (784.0).,PROCEDURES:, ,1. Anterior cervical discectomy at C5-C6 for neural decompression (63075).,2. Anterior interbody fusion C5-C6 (22554) utilizing Bengal cage (22851).,3. Anterior cervical instrumentation at C5-C6 for stabilization by Uniplate construction at C5-C6 (22845); with intraoperative x-ray x2.,SERVICE: , Neurosurgery,ANESTHESIA:,surgery, spondylosis, neck pain, headaches, decompression, uniplate, anterior cervical discectomy, neural decompression, cervical stenosis, prevertebral space, antibiotic solution, cervical discectomy, interbody fusion, bengal cage, interbody, anterior, cervical, discectomy,

PREOPERATIVE DIAGNOSIS:, Right undescended testicle.,POSTOPERATIVE DIAGNOSIS:, Right undescended testicle.,OPERATIONS:,1. Right orchiopexy.,2. Right herniorrhaphy.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Sac.,BRIEF HISTORY: , This is a 10-year-old male who presented to us with his mom with consultation from Craig Connor at Cottonwood with right undescended testis. The patient and mother had seen the testicle in the right hemiscrotum in the past, but the testicle seemed to be sliding. The testis was identified right at the external inguinal ring. The testis was unable to be brought down into the scrotal sac. The patient could have had sliding testicle in the past and now the testis has become undescended as the child has grown. Options such as watchful waiting and wait for puberty to stimulate the descent of the testicle, HCG stimulation, orchiopexy were discussed. Risk of anesthesia, bleeding, infection, pain, hernia, etc. were discussed. The patient and parents understood and wanted to proceed with right orchiopexy and herniorrhaphy.,PROCEDURE IN DETAIL: , The patient was brought to the OR, anesthesia was applied. The patient was placed in supine position. The patient was prepped and draped in the inguinal and scrotal area. After the patient was prepped and draped, an inguinal incision was made on the right side about 1 cm away for the anterior superior iliac spine going towards the external ring over the inguinal canal. The incision came through the subcutaneous tissue and external oblique fascia was identified. The external oblique fascia was opened sharply and was taken all the way down towards the external ring. The ilioinguinal nerve was identified right underneath the external oblique fascia, which was preserved and attention was drawn throughout the entire case to ensure that it was not under any tension or pinched or got hooked in the suture. After dissecting proximally, the testis was identified in the distal end of the inguinal canal. The testis was pulled up. The cremasteric muscle was divided and dissection was carried all the way up to the internal inguinal ring. There was very small hernia, which was removed and was tied at the base. PDS suture was used to tie this hernia sac all the way up to the base. There was a Y right at the vas and cord indicating there was enough length into the scrotal sac. The testis was easily brought down into the scrotal sac. One centimeter superior scrotal incision was made and a Dartos pouch was created. The testicle was brought down into the pouch and was placed into the pouch. Careful attention was done to ensure that there was no torsion of the cord. The vas was medial all the way throughout and the cord was lateral all the way throughout. The epididymis was in the posterolateral location. The testicle was pexed using 4-0 Vicryl into the scrotal sac. Skin was closed using 5-0 Monocryl. The external oblique fascia was closed using 2-0 PDS. Attention was drawn to re-create the external inguinal ring. A small finger was easily placed in the external inguinal ring to ensure that there was no tightening of the cord. Marcaine 0.25% was applied, about 15 mL worth of this was applied for local anesthesia. After closing the external oblique fascia, the Scarpa was brought together using 4-0 Vicryl and the skin was closed using 5-0 Monocryl in subcuticular fashion. Dermabond and Steri-Strips were applied.,The patient was brought to recovery room in stable condition at the end of the procedure.,Please note that the testicle was viable. It was smaller than the other side, probably by 50%. There were no palpable testicular masses. Plan was for the patient to follow up with us in about 1 month. The patient was told not to do any heavy lifting for at least 3 months, okay to shower in 48 hours. No tub bath for 2 months. The patient and family understood all the instructions.surgery, undescended testicle, orchiopexy & herniorrhaphy, external oblique fascia, inguinal ring, scrotal sac, oblique fascia, testicle, herniorrhaphy, orchiopexy, inguinal

HISTORY:, A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis. The patient was status post coronary artery bypass surgery aortic valve repair at Shadyside Hospital. The patient subsequently developed CVA. She also developed thrombosis of the right arm, which ultimately required right hand amputation. She was stabilized and eventually transferred to HealthSouth for further management.,PHYSICAL EXAMINATION:,Vital Signs: Pulse of 90 and blood pressure 150/70.,Heart: Sounds were heard, grade 2/6 systolic murmur at the precordium.,Chest: Clinically clear.,Abdomen: Some suprapubic tenderness. Evidence of right lower arm amputation.,The patient was started on Prevacid 30 mg daily, levothyroxine 75 mcg a day, Toprol 25 mg twice a day, Zofran 4 mg q.6 h, Coumadin dose at 5 mg and was adjusted. She was given a pain control using Vicodin and Percocet, amiodarone 200 mg a day, Lexapro 20 mg a day, Plavix 75 mg a day, fenofibrate 145 mg, Lasix 20 mg IV twice a day, Lantus 50 units at bedtime and Humalog 10 units a.c. and sliding scale insulin coverage. Wound care to the right heel was supervised by Dr. X. The patient initially was fed through NG tube, which was eventually discontinued. Physical therapy was ordered. The patient continued to do well. She was progressively ambulated. Her meds were continuously adjusted. The patient's insulin was eventually changed from Lantus to Levemir 25 units twice a day. Dr. Y also followed the patient closely for left heel ulcer.,LABORATORY DATA: , The latest cultures from left heel are pending. Her electrolytes revealed sodium of 135 and potassium of 3.2. Her potassium was switched to K-Dur 40 mEq twice a day. Her blood chemistries are otherwise closely monitored. INRs were obtained and were therapeutic. Throughout her hospitalization, multiple cultures were also obtained. Urine cultures grew Klebsiella. She was treated with appropriate antibiotics. Her detailed blood work is as in the chart. Detailed radiological studies are as in the chart. The patient made a steady progress and eventually plans were made to transfer the patient to ABC furthermore aggressive rehabilitation.,FINAL DIAGNOSES:,1. Atherosclerotic heart disease, status post coronary artery bypass graft.,2. Valvular heart disease, status post aortic valve replacement.,3. Right arm arterial thrombosis, status post amputation right lower arm.,4. Hypothyroidism.,5. Uncontrolled diabetes mellitus, type 2.,6. Urinary tract infection.,7. Hypokalemia.,8. Heparin-induced thrombocytopenia.,9. Peripheral vascular occlusive disease.,10. Paroxysmal atrial fibrillation.,11. Hyperlipidemia.,12. Depression.,13. Carotid stenosis.consult - history and phy., arterial thrombosis, valvular heart disease, atherosclerotic heart disease, type ii diabetes, hypertension, carotid stenosis, heart disease, diabetes, carotid, stenosis, bypass, amputation, heart, atherosclerotic,

HISTORY: , The patient is a 19-year-old male who was involved in a fight approximately an hour prior to his ED presentation. He punched a guy few times on the face, might be the mouth and then punched a drinking glass, breaking it and lacerating his right hand. He has three lacerations on his right hand. His wound was cleaned out thoroughly with tap water, and one of the navy corpsman tried to use Superglue and gauze to repair it. However, it continues to bleed and he is here for evaluation.,PAST MEDICATION HISTORY:, Significant for asthma and acne.,CURRENT MEDICATIONS: , Accutane and takes no other medications.,TETANUS STATUS: , Up-to-date.,SOCIAL HISTORY: , He is a nonsmoker. He has been drinking alcohol today, but has no history of alcohol or drug abuse.,REVIEW OF SYSTEMS: , Otherwise well. No febrile illness. No motor or sensory complaints of any sort or paresthesias in the hand.,PHYSICAL EXAM: ,GENERAL: He is in no apparent distress. He is alert and oriented x3. Mental status is clear and appropriate. VITALS SIGNS: Temperature is 98.3, heart rate 100, respirations 18, blood pressure 161/98, oxygen saturation 99% on room air by pulse oximetry, which is normal. EXTREMITIES: Right hand, he has three lacerations all over the MCP joint of his right hand, irregular shaped over the fifth MCP and then over the fourth and third half wound, similarly the lacerations. All total approximately 4 cm in length. I see no foreign bodies, just capillary refills less than 2 seconds. Radial pulses intact. There is full range of motion with no gross deformities. No significant amount of edema associated with these in the dorsum of the hand.,STUDIES: , X-rays shows no open fracture or bony abnormality.,EMERGENCY DEPARTMENT COURSE: ,The patient was anesthetized with 1% Xylocaine. Wounds were thoroughly irrigated with tap water with at least 2 liters. They were repaired with simple sutures of 4-0 Ethilon, total of 17 sutures, 16 of which were simple, one is a horizontal mattress. The patient was given Augmentin 875 mg p.o. due to the possibility of human bite wound.,ASSESSMENT: , RIGHT HAND LACERATIONS, SIMPLE X3, REPAIRED AS DESCRIBED. NO SIGNS OF BONY ABNORMALITY OR FOREIGN BODY.,PLAN: ,The patient will be given Augmentin 875 mg 1 p.o. b.i.d. for 7 days. He will be given a prescription of Vicoprofen as he is unable to tolerate the Tylenol due to his Accutane. He will take 1 p.o. every 6 hours or as needed, #12. He will follow up for suture removal in 8 days. Should he develop any signs of infection, he will come immediately here for reevaluation. He is discharged in stable condition.,office notes, accutane, hand laceration, laceration, hand,

CHIEF COMPLAINT: , Chest pain and fever.,HISTORY OF PRESENT ILLNESS: , This 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin. The patient noted since she began to feel poorly earlier on the day of admission, had an episode of substernal chest discomfort that was associated with nausea, dizziness, and sweating. The patient does have a past medical history of diabetes and hypertension. In addition, the patient complained of some neck and head discomfort for which she underwent a lumbar puncture in the emergency room; this was normal, causes turned out to be normal as well. The patient denies nosebleed, visual changes, nausea, vomiting, diarrhea or changes in bowel habits. She has not had any musculoskeletal or neurological deficits. She denies any rashes or skin lesions.,PAST MEDICAL HISTORY: ,Hypertension, diabetes, hyperlipidemia, particularly elevated triglycerides with a slightly elevated LDL at 81 with an new standard LDL of 74, diabetics with a bad family history for cardiovascular disease such as this patient does have, and postmenopausal hot flashes.,PAST SURGICAL HISTORY: ,Cholecystectomy, appendectomy, oophorectomy.,FAMILY HISTORY: , Positive for coronary artery disease in her father and brother in their 40s.,SOCIAL HISTORY: , She is married and does not smoke or drink nor did she ever.,PHYSICAL EXAMINATION: , On admission, temperature 99.4 degrees F., blood pressure 137/60, pulse 90 and regular without ectopy, respiratory rate 20 without unusual respiratory effort. In general, she is well developed, well nourished, oriented, and alert and in no apparent distress. Head, ears, eyes, nose, and throat are unremarkable. Neck is supple. No neck vein distention is noted. No bruits are heard. Chest is clear to percussion and auscultation. Heart has a regular rhythm and rate without murmurs or rubs or gallops. Abdomen is soft, obese, and nontender. Musculoskeletal is intact without deformity. However, the patient did develop severe cramp behind her left knee during her treadmill testing. Neurologic: Cranial nerves are intact and she is nonfocal. Skin is warm and dry without rash or lesions noted.,LABORATORY FINDINGS: , Glucose 162, BUN 14, creatinine 1.0, sodium 137, potassium 3.6, chloride 103, bicarbonate 23, protein 4.2. Liver function panel is normal. CK was 82. MB fraction was 1.0. Troponin was less than 0.1 on three occasions. White count was 12,200 with a normal differential, hemoglobin was 12.1, platelet count 230,000. Urinalysis showed positive nitrites, positive leukocyte esterase, 5 to 10 white cells per high power field, and 1+ bacteria rods. Spinal fluid was clear with 11 red cells, glucose 75, protein 67, white count 0. EKG was normal.,DIAGNOSES ON ADMISSION:,1. Urinary tract infection.,2. Chest pain of unclear etiology, rule out myocardial infarction.,3. Neck and back pain of unclear etiology with a negative spinal tap.,4. Hypertension.,5. Diabetes type II, not treated with insulin.,6. Hyperlipidemia treated with TriCor but not statins.,7. Arthritis.,ADDITIONAL LABORATORY STUDIES:, B-natriuretic peptide was 26. Urine smear and culture negative on 24 and 48 hours. Chest x-ray was negative. Lipid panel - triglycerides 249, VLDL 49, HDL 33, LDL 81.,COURSE IN THE HOSPITAL: , The patient was placed on home medications. This will be listed at the end of the discharge summary. She was put on rule out acute myocardial infarction routine, and she did in fact rule out. She had a stress test completed on the day of discharge which was normal, and she was discharged with a diagnoses of chest pain, acute myocardial infarction ruled out, urinary tract infection, fever secondary to UTI, diabetes mellitus type 2 non-insulin treated, hyperlipidemia with elevated triglycerides and an LDL elevated to 81 with new normal being less than 70. She has a strong family history of early myocardial disease in the men in their 40s.,DISCHARGE MEDICATIONS:,1. Enteric-coated aspirin 81 mg one daily. This is new, as the patient was not taking aspirin at home.,2. TriCor 48 mg one daily.,3. Zantac 40 mg one daily.,4. Lisinopril 20 mg one daily.,5. Mobic 75 mg one daily for arthritis.,6. Metformin 500 mg one daily.,7. Macrodantin one two times a day for several more days.,8. Zocor 20 mg one daily, which is a new addition.,9. Effexor XR 37.5 mg one daily.,DIET: , ADA 1800-calorie diet.,ACTIVITY:, As tolerated. Continue water exercise five days a week.,DISPOSITION: , Recheck at Hospital with a regular physician there in 1 week. Consider Byetta as an adjunct to her diabetic treatment and efforts to weight control.nan

HISTORY OF PRESENT ILLNESS:, Patient is a 50-year-old white male complaining of continued lower back pain. Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago. He states he helped a friend unload a motorcycle from a vehicle two-and-a-half days ago, after which he "felt it" in his lower back. The following day (two days ago), he states he rode to Massachusetts and Maine to pick up clients. He feels that this aggravated his chronic back pain as well. He also claims to have a screw in his right hip from a previous surgery to repair a pelvic fracture. He is being prescribed Ultram, Celebrex, gabapentin, and amitriptyline by his PCP for his chronic back pain. He states that his PCP has informed him that he does not prescribe opiate medications for chronic back pain.,The patient did self-refer to another physician, who suggested that he follow up at a pain clinic for his chronic back pain to discuss other alternatives, particularly the medications that the patient feels that he needs. Patient states he did not do this because he was feeling well at that time.,The patient did present to our emergency room last night, at which time he saw Dr. X. He was given a prescription for 12 Vicodin as well as some to take home last night. The patient has not picked up his prescription as of yet and informed the triage nurse that he was concerned that he would not have enough to last through the weekend. Patient states he also has methadone and Darvocet at home from previous prescription and is wondering if he should restart these medicines. He is on several medications, the list of which is attached to the chart.,MEDICATIONS: , In addition to the aforementioned medications, he is on Cymbalta, pantoprazole, and a multivitamin.,ALLERGIES:, HE IS ALLERGIC TO RELAFEN (ITCHING).,SOCIAL HISTORY: , The patient is married and lives with his wife.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse is elevated at 105. Temp and other vitals signs are all within normal limits.,GENERAL: Patient is a middle-aged white male who is sitting on the stretcher in no acute distress.,BACK: Exam of the back shows some generalized tenderness on palpation of the musculature surrounding the lumbar spine, more so on the right than on the left. There is a well-healed upper lumbar incision from his previous L1-L2 fusion. There is no erythema, ecchymosis, or soft-tissue swelling. Mobility is generally very good without obvious signs of discomfort.,HEART: Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS: Clear without rales, rhonchi, or wheezes.,MUSCULOSKELETAL: With the patient supine, there is some discomfort in the lower back with bent-knee flexion of both hips as well as with straight leg abduction of the left leg. There is some mild discomfort on internal and external rotation of the hips as well. DTRs are 1+ at the knees and trace at the ankles.,I explained to the patient that he is suffering from a chronic condition and as his PCP has made it clear that he is unwilling to prescribe opiate medication, which the patient feels that he needs, and he is obligated to follow up at the pain clinic as suggested by the other physician even if he is having a "good day." I explained to him that if he did not investigate other alternatives to what his PCP is willing to prescribe, then on a "bad day," he will have nowhere else to turn. I explained to him that some emergency physicians do chose to use opiates for a short term as Dr. X did last night. It is unclear if the patient is looking for a different opiate medication, but I do not think it is wise to give him more, particularly as he has not even filled the prescription that was given to him last night. I did suggest that he not restart his methadone and Darvocet at this time as he is already on five different medications for his back (Celebrex, tramadol, amitriptyline, gabapentin, and the Vicodin that he was given last night). I did suggest that we could try a different anti-inflammatory if he felt that the Celebrex is not helping. The patient is agreeable to this.,ASSESSMENT,1. Lumbar muscle strain.,2. Chronic back pain.,PLAN: , At this point in time, I felt that it was safe for the patient to transition to heat to his back which he may use as often as possible. Rx for Voltaren 75 mg tabs, dispensed 20, sig. one p.o. q.12h. for pain instead of Celebrex. He may continue with his other medications as directed but not the methadone or Darvocet. I did urge him to reschedule his pain clinic appointment as he was urged to do originally. If unimproved this week, he should follow up with Dr. Y.orthopedic, back pain, lumbar muscle strain, chronic back pain, illness, lower, medications,

HISTORY AND CLINICAL DATA: ,The patient is an 88-year-old gentleman followed by Dr. X, his primary care physician, Dr. Y for the indication of CLL and Dr. Z for his cardiovascular issues. He presents to the Care Center earlier today with approximately a one-week history of increased progressive shortness of breath, orthopnea over the course of the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea presenting this morning.,He reports no clear-cut chest discomfort or difficulty with angina. He has had no dizziness, lightheadedness, no near or true syncope, nothing supportive of CVA, TIA, nor peripheral vascular claudication.,REVIEW OF SYSTEMS:, General review of system is significant for difficulty with intermittent constipation, which has been problematic recently. He reports no fever, shaking chills, nothing supportive of GI or GU blood loss, no productive or nonproductive cough.,PAST MEDICAL HISTORY:, Remarkable for hypertension, diabetes, prostate cancer, status post radium seed implant, COPD, single vessel coronary disease, esophageal reflux, CLL, osteopenia, significant hearing loss, anxiety, and degenerative joint disease.,SOCIAL HISTORY: , Remarkable for being married, retired, quit smoking in 1997, rare use of alcohol, lives locally with his wife.,MEDICATIONS AT HOME:, Include, Lortab 7.5 mg up to three times daily for chronic arthritic discomfort, Miacalcin nasal spray once daily, omeprazole 20 mg daily, Diovan 320 mg daily, Combivent two puffs t.i.d., folate, one adult aspirin daily, glyburide 5 mg daily, atenolol 50 mg daily, furosemide 40 mg daily, amlodipine 5 mg daily, hydralazine 50 mg p.o. t.i.d., in addition to Tekturna 150 mg daily, Zoloft 25 mg daily.,ALLERGIES: ,He has known history of allergy to clonidine, Medifast does fatigue.,DIAGNOSTIC AND LABORATORY DATA: , Chest x-ray upon presentation to the Ellis Emergency Room this evening demonstrate significant congestive heart failure with moderate-sized bilateral pleural effusions.,A 12-lead EKG, sinus rhythm at a rate of 68 per minute, right bundle-branch block type IVCV with moderate nonspecific ST changes. Low voltage in the limb leads.,WBC 29,000, hemoglobin 10.9, hematocrit 31, platelets 187,000. Low serum sodium at 132, potassium 4, BUN 28, creatinine 1.2, random glucose 179. Low total protein 5.7. Magnesium level 2.3, troponin 0.404 with the B-natriuretic peptide of 8200.,PHYSICAL EXAMINATION: ,He is an elderly gentleman, who appears to be in no acute distress, lying comfortably flat at 30 degrees, measured pressure of 150/80 with a pulse of 68 and regular. JVD difficult to assess. Normal carotids with obvious bruits. Conjunctivae pink. Oropharynx clear. Mild kyphosis. Diffusely depressed breath sounds halfway up both posterior lung fields. No active wheezing. Cardiac Exam: Regular, soft, 1-2/6 early systolic ejection murmur best heard at the base. Abdomen: Soft, nontender, protuberant, benign. Extremities: 2+ bilateral pitting edema to the level of the knees. Neuro Exam: Appears alert, oriented x3. Appropriate manner and affect, exceedingly hard of hearing.,OVERALL IMPRESSION:, An 88-year-old white male with the following major medical issues:,1. Presentation consists with subclinical congestive heart failure possibly systolic, no recent echocardiogram available for review.,2. Hypertension with suboptimal controlled currently.,3. Diabetes.,4. Prostate CA, status post radium seed implant.,5. COPD, on metered-dose inhaler.,6. CLL followed by Dr. Y.,7. Single-vessel coronary disease, no recent anginal quality chest pain, no changes in ECG suggestive of acute ischemia; however, initial troponin 0.4 - to be followed with serial enzyme determinations and telemetry.,8. Hearing loss, anxiety.,9. Significant degenerative joint disease.,PLAN:,1. Admit to A4 with telemetry, congestive heart failure pathway, intravenous diuretic therapy.,2. Strict I&O, Foley catheter has already been placed.,3. Daily BMP.,4. Two-dimensional echocardiogram to assess left ventricular systolic function. Serum iron determination to exclude the possibility of a subclinical ischemic cardiac event. Further recommendations will be forthcoming pending his clinical course and hospital.nan

PREOPERATIVE DIAGNOSIS:, Squamous cell carcinoma of right temporal bone/middle ear space.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of right temporal bone/middle ear space.,PROCEDURE: , Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: ,The patient was brought into the operating room, placed on the table in supine position. General endotracheal anesthesia was obtained in the usual fashion. The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen. The neck was prepped as well. After this was performed, I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl. A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle. After this was performed, I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible. The condyle was skeletonized so that it could be easily seen. The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared. The neck contents to the hyoid were dissected out. The hypoglossal nerve, vagus nerve, and spinal accessory nerve were dissected towards the jugular foramen. The neck contents were removed as a separate specimen. The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis. A large posterior facial vein was identified and likewise clipped for later use. I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus, dissecting or exposing the dura to the level of the jugular bulb. It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router, I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube. The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made. I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion. Once this was dissected out, Dr. X entered the procedure for completion of the resection with the craniotomy. For details, please see his operative note.,After Dr. X had completed the resection, I then harvested the rectus free flap. A skin paddle was drawn out next to the umbilicus about 4 x 4 cm. The skin paddle was incised with the Bovie and down to the anterior rectus sheath. Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle. The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin. The skin paddle was then sutured to the fascia and muscle with interrupted 3-0 Vicryl. The anterior rectus sheath was then reflected off the rectus muscle, which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction. The vascular pedicle could be seen entering the muscle in usual fashion. The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel. The wound was then packed with saline impregnated sponges. The rectus muscle with attached skin paddle was then transferred into the neck. The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9-0 Ethilon with standard microvascular technique. Ischemia time was less than 10 minutes. Likewise, the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9-0 Ethilon as well. There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case. The wound was irrigated with copious amounts of saline. The eustachian tube was obstructed with bone wax. The muscle was then laid into position with the skin paddle underneath the conchal bowl. I removed most the skin of the conchal bowl de-epithelializing and leaving the fat in place. The wound was closed in layers overlying the muscle, which was secured superiorly to the muscle overlying the temporal skull. The subcutaneous tissues were closed with interrupted 3-0 Vicryl. The skin was closed with skin staples. There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself. The skin paddle was closed with interrupted 4-0 Prolene to the edges of the conchal bowl.,The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with #1 Prolene with the more running suture, taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors. The subcutaneous tissues were closed with interrupted 2-0 Vicryl and skin was closed with skin staples. The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened. The patient was then transferred to the PACU in stable condition with spontaneous respirations, having tolerated the procedure well.neurology, rectus abdominis myocutaneous, skull base defect, squamous cell carcinoma, skull base, squamous cell, rectus sheath, abdominis, muscle, rectus, sheath

DIAGNOSIS:, Desires vasectomy.,NAME OF OPERATION: , Vasectomy.,ANESTHESIA:, General.,HISTORY: , Patient, 37, desires a vasectomy.,PROCEDURE: , Through a midline scrotal incision, the right vas was identified and separated from the surrounding tissues, clamped, transected, and tied off with a 4-0 chromic. No bleeding was identified.,Through the same incision the left side was identified, transected, tied off, and dropped back into the wound. Again no bleeding was noted.,The wound was closed with 4-0 Vicryl times two. He tolerated the procedure well. A sterile dressing was applied. He was awakened and transferred to the recovery room in stable condition.urology, scrotal incision, right vas, bleeding, anesthesia, vasectomy

S:, ABC is in today for a followup of her atrial fibrillation. They have misplaced the Cardizem. She is not on this and her heart rate is up just a little bit today. She does complain of feeling dizziness, some vertigo, some lightheadedness, and has attributed this to the Coumadin therapy. She is very adamant that she wants to stop the Coumadin. She is tired of blood draws. We have had a difficult time getting her regulated. No chest pains. No shortness of breath. She is moving around a little bit better. Her arm does not hurt her. Her back pain is improving as well.,O:, Vital signs as per chart. Respirations 15. Exam: Nontoxic. No acute distress. Alert and oriented. HEENT: TMs are clear bilaterally without erythema or bulging. Clear external canals. Clear tympanic. Conjunctivae are clear. Clear nasal mucosa. Clear oropharynx with moist mucous membranes. NECK is soft and supple. LUNGS are clear to auscultation. HEART is irregularly irregular, mildly tachycardic. ABDOMEN is soft and nontender. EXTREMITIES: No cyanosis, no clubbing, no edema.,EKG shows atrial fibrillation with a heart rate of 104.,A:,1.soap / chart / progress notes, soap, alert and oriented, no acute distress, no cyanosis, atrial fibrillation, blood draw, dizziness, general medicine, irregularly irregular, lightheadedness, no clubbing, no edema, shortness of breath, soft and nontender, vertigo, heart, fibrillation, coumadin, atrial,

OPERATION,1. Right upper lung lobectomy.,2. Mediastinal lymph node dissection.,ANESTHESIA,1. General endotracheal anesthesia with dual-lumen tube.,2. Thoracic epidural.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube. Next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion. We used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula. Dissection was carried down in a muscle-sparing fashion using Bovie electrocautery. The 5th rib was counted, and the 6th interspace was entered. The lung was deflated. We identified the major fissure. We then began by freeing up the inferior pulmonary ligament, which was done with Bovie electrocautery. Next, we used Bovie electrocautery to dissect the pleura off the lung. The pulmonary artery branches to the right upper lobe of the lung were identified. Of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable. As mentioned, a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung. Next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung. This was done with suture ligature in combination with clips. After taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung. This likewise was ligated with a 0 silk. It was stick-tied with a 2-0 silk. It was then divided. Next we dissected out the bronchial branch to the right upper lobe of the lung. A curved Glover was placed around the bronchus. Next a TA-30 stapler was fired across the bronchus. The bronchus was divided with a #10-blade scalpel. The specimen was handed off. We next performed a mediastinal lymph node dissection. Clips were applied to the base of the feeding vessels to the lymph nodes. We inspected for any signs of bleeding. There was minimal bleeding. We placed a #32-French anterior chest tube, and a #32-French posterior chest tube. The rib space was closed with #2 Vicryl in an interrupted figure-of-eight fashion. A flat Jackson-Pratt drain, #10 in size, was placed in the subcutaneous flap. The muscle layer was closed with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed by 4-0 Monocryl in a running subcuticular fashion. Sterile dressing was applied. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the PACU in good condition.surgery, mediastinal, thoracic, epidural, lymph node dissection, lymph node, artery branches, lobectomy, lung, anesthesia, bovie, electrocautery, lymph, pulmonary, branches

PROCEDURE: , Phacoemulsification with posterior chamber intraocular lens insertion.,INTRAOCULAR LENS: , Allergan Medical Optics model S140MB XXX diopter chamber lens.,PHACO TIME:, Not known.,ANESTHESIA: , Retrobulbar block with local minimal anesthesia care.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS:, None.,DESCRIPTION OF PROCEDURE: , While the patient was in the holding area, the operative eye was dilated with four sets of drops. The drops consisted of Cyclogyl 1%, Acular, and Neo-Synephrine 2.5 %. Additionally, a peripheral IV was established by the anesthesia team. Once the eye was dilated, the patient was wheeled to the operating suite.,Inside the operating suite, central monitoring lines were established. Through the peripheral IV, the patient received intravenous sedation consisting of Propofol and once somnolent from this, retrobulbar block was administered consisting of 2 cc's of 2% Xylocaine plain with 150 units of Wydase. The block was administered in a retrobulbar fashion using an Atkinson needle and a good block was obtained. Digital pressure was applied for approximately five minutes.,The patient was then prepped and draped in the usual sterile fashion for ophthalmological surgery. A Betadine prep was carried out of the face, lids, and eye. During the draping process, care was taken to isolate the lashes. A wire lid speculum was inserted to maintain patency of the lids. With benefit of the operating microscope, a diamond blade was used to place a groove temporally. A paracentesis wound was also placed temporally using the same blade. Viscoelastic was then instilled into the anterior chamber through the paracentesis site and a 2.8 mm. diamond keratome was used to enter the anterior chamber through the previously placed groove. The cystotome was then inserted into the eye and circular capsulorhexis was performed without difficulty. The capsular remnant was withdrawn from the eye using long angled McPherson forceps. Balanced salt solution with a blunt cannula was then inserted into the eye and hydrodissection was performed. The lens was noted to rotate freely within the capsular bag. The phaco instrument was then inserted into the eye using the Kelman tip. The lens nucleus was grooved and broken into two halves. One of the halves was in turn broken into quarters. Each of the quarters was removed from the eye using the memory 2 settings and phacoemulsification. Attention was then turned toward the remaining half of the nucleus and this, in turn, was removed as well, with the splitting maneuver. Once the nucleus had been removed from the eye, the irrigating and aspirating tip was inserted and the cortical material was stripped out in sections. Once the cortical material had been completely removed, a diamond dusted cannula was inserted into the eye and the posterior capsule was polished. Viscoelastic was again instilled into the capsular bag as well as the anterior chamber. The wound was enlarged slightly using the diamond keratome. The above described intraocular lens was folded outside the eye using a mustache fold and inserted using folding forceps. Once inside the eye, the lens was unfolded into the capsular bag in a single maneuver. It was noted to be centered nicely. The viscoelastic was then withdrawn from the eye using the irrigating and aspirating tip of the phaco machine.,Next, Miostat was instilled into the operative eye and the wound was checked for water tightness. It was found to be such. After removing the drapes and speculum, TobraDex drops were instilled into the operative eye and a gauze patch and Fox protective shield were placed over the eye.,The patient tolerated the procedure extremely well and was taken to the recovery area in good condition. The patient is scheduled to be seen in follow-up in the office tomorrow, but should any complications arise this evening, the patient is to contact me immediately.surgery, diopter, intraocular lens insertio, phacoemulsification, posterior chamber, diamond keratome, anterior chamber, capsular bag, intraocular lens, intraocular, allergan, eye, capsular, chamber, lens,

PROCEDURE PERFORMED: , Inguinal herniorrhaphy.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner.,A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated. The external oblique was then incised with a scalpel, and this incision was carried out to the external ring using Metzenbaum scissors. Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was placed around the cord structures at the level of the pubic tubercle. This Penrose drain was then used to retract the cord structures as needed. Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures. The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery. Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature. The sac was excised and went to Pathology. The ends of the suture were then cut and the stump retracted back into the abdomen.,The Penrose drain was removed. The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery. The incision in the external oblique was approximated using a 3-0 Vicryl in a running fashion, thus reforming the external ring. The skin incision was approximated with 4-0 Vicryl in a subcuticular fashion. The skin was prepped and draped with benzoin, and Steri-Strips were applied. A dressing consisting of a 2 x 2 and OpSite was then applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.urology, inguinal canal, cremasteric muscle, pubic tubercl, inguinal herniorrhaphy, blunt dissection, penrose drain, bovie electrocautery, cord structures, inguinal, electrocautery, cord

PAST MEDICAL HISTORY: , Significant for GERD, history of iron deficiency anemia, and asthma for which she takes an inhaler.,REVIEW OF SYSTEMS:, Positive for only for left knee arthritis. She has no exposure to tuberculosis or syphilis, she has no mouth or genital ulcers. She has no skin rashes. She has no connective tissue disorders.,PAST OCULAR HISTORY: , Significant for cataract and glaucoma surgery of the right eye.,PHYSICAL EXAMINATION: , On examination, visual acuity measures hand motions on the right and 20/25 in the left. There is an afferent pupillary defect on the right. On examination, there is a right hypertropia. There is dense anterior chamber inflammation on the right eye with a stagnant aqueous. There is either neovascularization on the iris or reactive iris vessels, it is difficult to discern. This seems to be complete iris synechia to the anterior lens capsule. There is a posterior chamber intraocular lens with an inflammatory debris on the anterior surface. The anterior chamber appears narrow. On the left, there is also dense inflammation at 4+ cell. There is 1+ nuclear sclerosis. Dilated fundus examination cannot be performed on the right secondary to intense inflammation. On the left, there is no evidence of active posterior uveitis. There is some inferior vitreous debris.,ASSESSMENT/PLAN:, Chronic bilateral recurrent nongranulomatous diffuse uveitis. Currently, there is very severe right eye inflammation and severe left eye. I discussed at length with the patient that this will likely take an oral steroid to quite her down. Since she has only one seeing eye, I am anxious to obtain a decreased inflammation as soon as possible. She has been on oral steroids in the past. We also discussed, considering the aggressive recurrent nature of this process, it is likely we will have to consider a steroid sparing agent to maintain longer term control of this recurrent process so that we do not use visual acuity in the left. I anticipate we will likely start methotrexate in the near future. In this acute phase, I have recommended oral steroids at a dose of 60 mg a day, hourly topical Pred Forte as well as atropine sulfate. We will watch her closely in clinic. I am sending a copy of this dictation to her primary care doctor, she said she has had a negative HLA-B27, rheumatoid factor, and ANA in the past. At this stage, to be thorough I would ask Dr. X to assist us in repeating her chest x-ray, PPD if not current, and an RPR. Additionally, in anticipation of need for methotrexate, it would be helpful to have a full liver function profile as well as hepatitis B and hepatitis C.consult - history and phy., iritis, nongranulomatous, uveitis, eye inflammation, photophobia, recurrent nongranulomatous anterior iritis, headache and photophobia, anterior chamber, anterior, chamber, inflammation,

SUBJECTIVE: ,The patient seen and examined feels better today. Still having diarrhea, decreased appetite. Good urine output 600 mL since 7 o'clock in the morning. Afebrile.,PHYSICAL EXAMINATION,GENERAL: Nonacute distress, awake, alert, and oriented x3.,VITAL SIGNS: Blood pressure 102/64, heart rate of 89, respiratory rate of 12, temperature 96.8, and O2 saturation 94% on room air.,HEENT: PERRLA, EOMI.,NECK: Supple.,CARDIOVASCULAR: Regular rate and rhythm.,RESPIRATORY: Clear to auscultation bilaterally.,ABDOMEN: Bowel sounds are positive, soft, and nontender. EXTREMITIES: No edema. Pulses present bilaterally.,LABORATORY DATA: ,CBC, WBC count today down 10.9 from 17.3 yesterday 26.9 on admission, hemoglobin 10.2, hematocrit 31.3, and platelet count 370,000. BMP, BUN of 28.3 from 32.2, creatinine 1.8 from 1.89 from 2.7. Calcium of 8.2. Sodium 139, potassium 3.9, chloride 108, and CO2 of 22. Liver function test is unremarkable.,Stool positive for Clostridium difficile. Blood culture was 131. O2 saturation result is pending.,ASSESSMENT AND PLAN:,1. Most likely secondary to Clostridium difficile colitis and urinary tract infection improving. The patient hemodynamically stable, leukocytosis improved and today he is afebrile.,2. Acute renal failure secondary to dehydration, BUN and creatinine improving.,3. Clostridium difficile colitis, Continue Flagyl, evaluation Dr. X in a.m.,4. Urinary tract infection, continue Levaquin for last during culture.,5. Leucocytosis, improving.,6. Minimal elevated cardiac enzyme on admission. Followup with Cardiology recommendations.,7. Possible pneumonia, continue vancomycin and Levaquin.,8. The patient may be transferred to telemetry.gastroenterology, decreased appetite, acute renal failure, urinary tract infection, leucocytosis, clostridium difficile colitis,

HISTORY OF PRESENT ILLNESS:, This is a 41-year-old registered nurse (R.N.). She was admitted following an overdose of citalopram and warfarin. The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage. She notes starting in January, her husband of five years seemed to be quite withdrawn. It turned out, he was having an affair with one of her best friends and he subsequently moved in with this woman. The patient is distressed, as over the five years of their marriage, she has gotten herself into considerable debt supporting him and trying to find a career that would work for him. They had moved to ABCD where he had recently been employed as a restaurant manager. She also moved her mother and son out there and is feeling understandably upset that he was being dishonest and deceitful with her. She has history of seasonal affective disorder, winter depressions, characterized by increased sleep, increased irritability, impatience, and fatigue. Some suggestion on her part that her father may have had some mild bipolar disorder and including the patient has a cyclical and recurrent mood disorder. In January, she went on citalopram. She reports since that time, she has lost 40 pounds of weight, has trouble sleeping at night, thinks perhaps her mood got worse on the citalopram, which is possible, though it is also possible that the progressive nature of getting divorce than financial problems has contributed to her worsening mood.,PAST AND DEVELOPMENTAL HISTORY: , She was born in XYZ. She describes the family as being somewhat dysfunctional. Father was a truckdriver. She is an only child. She reports that she had a history of anorexia and bulimia as a teenager. In her 20s, she served six years in Naval Reserve. She was previously married for four years. She described that as an abusive relationship. She had a history of being in counseling with ABC, but does not think this therapist, who is now by her estimate 80 years old, is still in practice.,PHYSICAL EXAMINATION: ,GENERAL: This is an alert and cooperative woman.,VITAL SIGNS: Temperature 98.1, pulse 60, respirations 18, blood pressure 95/54, oxygen saturation 95%, and weight is 132.,PSYCHIATRIC: She makes good eye contact. Speech is normal in rate, volume, grammar, and vocabulary. There is no thought disorder. She denies being suicidal. Her affect is appropriate for material being discussed. She has a sense of future, wants to get back to work, has plans to return to counseling. She appeared to have normal orientation, concentration, memory, and judgment.,Medical history is notable for factor V Leiden deficiency, history of pulmonary embolus, restless legs syndrome. She has been off her Mirapex. I did encourage her to go back on the Mirapex, which would likely lead to some improvement in mood by facilitating better sleep.,The patient at this time can contract for safety. She has made plans for outpatient counseling this Saturday and we will get a referral to a psychiatrist for which she is agreeable to following up with.,LABORATORY DATA: , INR, which is still 8.8. In 1998, she had a normal MRI. Electrolytes, BUN, creatinine, and CBC were all normal.,DIAGNOSES: ,1. Seasonal depressive disorder.,2. Restless legs syndrome.,3. Overdose of citalopram and warfarin.,RECOMMENDATIONS: , The patient reports she has been feeling better since discontinuing antidepressants. I, therefore, recommend she stay off antidepressants at present. If needed, she can take Prozac, which has been effective for her in the past and she plans to see a psychiatrist for consultation. She does give a fairly good history of seasonal depression and given that her mood has improved in the past with Prozac, this will be an appropriate agent to try as needed in the future, but given the situational nature of the depression, she primarily appears to need counseling.,Please feel free to contact me at digital pager if there is additional information I can provide.psychiatry / psychology, citalopram, depressive disorder, overdose, warfarin, restless legs syndrome, disorder, mood

PREOPERATIVE DIAGNOSES: ,1. Fractured and retained lumbar subarachnoid spinal catheter.,2. Pseudotumor cerebri (benign intracranial hypertension).,PROCEDURES: ,1. L1 laminotomy.,2. Microdissection.,3. Retrieval of foreign body (retained lumbar spinal catheter).,4. Attempted insertion of new external lumbar drain.,5. Fluoroscopy.,ANESTHESIA: , General.,HISTORY: ,The patient had a lumbar subarachnoid drain placed yesterday. All went well with the surgery. The catheter stopped draining and on pulling back the catheter, it fractured and CT scan showed that the remaining fragment is deep to the lamina. The patient continues to have right eye blindness and headaches, presumably from the pseudotumor cerebri.,DESCRIPTION OF PROCEDURE: ,After induction of general anesthesia, the patient was placed prone on the operating room table resting on chest rolls. Her face was resting in a pink foam headrest. Extreme care was taken positioning her because she weighs 92 kg. There was a lot of extra padding for her limbs and her limbs were positioned comfortably. The arms were not hyperextended. Great care was taken with positioning of the head and making sure there was no pressure on her eyes especially since she already has visual disturbance. A Foley catheter was in place. She received IV Cipro 400 mg because she is allergic to most antibiotics.,Fluoroscopy was used to locate the lower end of the fractured catheter and the skin was marked. It was also marked where we would try to insert the new catheter at the L4 or L3 interspinous space.,The patient was then prepped and draped in a sterile manner.,A 7-cm incision was made over the L1 lamina. The incision was carried down through the fascia all the way down to the spinous processes. A self-retaining McCullough retractor was placed. The laminae were quite deep. The microscope was brought in and using the Midas Rex drill with the AM-8 bit and removing some of the spinous process of L1-L2 with double-action rongeurs, the laminotomy was then done using the drill and great care was taken and using a 2-mm rongeur, the last layer of lamina was removed exposing the epidural fat and dura. The opening in the bone was 1.5 x 1.5 cm.,Occasionally, bipolar cautery was used for bleeding of epidural veins, but this cautery was kept to a minimum.,Under high magnification, the dura was opened with an 11 blade and microscissors. At first, there was a linear incision vertically to the left of midline, and I then needed to make a horizontal incision more towards the right. The upper aspect of the cauda equina was visualized and perhaps the lower end of the conus. Microdissection under high magnification did not expose the catheter. The fluoroscope was brought in 2 more times including getting a lateral view and the fluoroscope appeared to show that the catheter should be in this location.,I persisted with intensive microdissection and finally we could see the catheter deep to the nerves and I was able to pull it out with the microforceps.,The wound was irrigated with bacitracin irrigation.,At this point, I then attempted lumbar puncture by making a small incision with an 11 blade in the L4 interspinous space and then later in the L3 interspinous space and attempted to puncture the dural sac with the Tuohy needle. Dr. Y also tried. Despite using the fluoroscope and our best attempts, we were not able to convincingly puncture the lumbar subarachnoid space and so the attempted placement of the new lumbar catheter had to be abandoned. It will be done at a later date.,I felt it was unsafe to place a new catheter at this existing laminotomy site because it was very high up near the conus. The potential for complications involving her spinal cord was greater and we have already had a complication of the catheter now and I just did not think it was safe to put in this location.,Under high magnification, the dura was closed with #6-0 PDS interrupted sutures.,After the dura was closed, a piece of Gelfoam was placed over the dura. The paraspinous muscles were closed with 0 Vicryl interrupted sutures. The subcutaneous fascia was also closed with 0 Vicryl interrupted suture. The subcutaneous layer was closed with #2-0 Vicryl interrupted suture and the skin with #4-0 Vicryl Rapide. The 4-0 Vicryl Rapide sutures were also used at the lumbar puncture sites to close the skin.,The patient was then turned carefully on to her bed after sterile dressings were applied and then taken to the recovery room. The patient tolerated procedure well. No complications. Sponge and needle counts correct. Blood loss minimal, none replaced. This procedure took 5 hours. This case was also extremely difficult due to patient's size and the difficulty of locating the catheter deep to the cauda equina.surgery, laminotomy, microdissection, lumbar spinal catheter, external lumbar drain, fluoroscopy, lumbar subarachnoid, spinal catheter, intracranial hypertension, vicryl interrupted sutures, lumbar, catheter,

Because children need hearing to learn speech, hearing loss from fluid in the middle ear can result in speech delay. Children begin to speak some words by 18 months. Children with fluid in both ears can show significant delay in their use of language. In addition, young children learn to pronounce words by hearing them spoken. When there is a hearing loss, even a mild one, the spoken words of parents and siblings are distorted to the child with fluid in the ears. Identification of fluid in the middle ear is important, not only to prevent future speech problems, but to avoid permanent damage to the eardrum and the middle ear. Most children will have at least one ear infection before the age of four.,With treatment, the ear infections clear up promptly. Without the follow-up visit, fluid may still be present, even though the child has no complaints or symptoms. Therefore, it is essential that ear infections be rechecked after initial treatment. Usually, the presence of fluid results in a "mild conductive hearing loss." This could be as much as 30% hearing loss overall. After the specialist confirms that fluid is present behind both eardrums, further medical treatment is often advised. This may consist of additional antibiotics, decongestants, and in some cases, nasal sprays. If fluid has been present for over 12 weeks, surgical drainage of the fluid is often indicated. The decision to perform surgery should be based on the response to medical treatment, the degree of hearing loss and the appearance of the eardum itself under the surgical microscope. Surgery which drains fluid involves a small incision in the eardrum, so that the fluid can be gently removed and a tube can be inserted. The procedure, medically termed a myringotomy and tubes, or tympanostomy and tube, (BMT if Bilateral) or PET (Pressure Equalizing Tubes), is performed on children under general anesthesia.ent - otolaryngology, tube, bmt, pet, pressure equalizing tubes, serous otitis media, eustachian tube, ear infections, otitis media, middle ear, hearing loss, ear, children, fluid, drain, eustachian, otitis, media, eardrum, infections, middle, loss, hearingNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain with swelling at the site of the ileostomy.,TECHNIQUE:, Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN: ,The liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable. Punctate calcifications in the gallbladder lumen likely represent a gallstone.,CT PELVIS: ,Postsurgical changes of a left lower quadrant ileostomy are again seen. There is no evidence for an obstruction. A partial colectomy and diverting ileostomy is seen within the right lower quadrant. The previously seen 3.4 cm subcutaneous fluid collection has resolved. Within the left lower quadrant, a 3.4 cm x 2.5 cm loculated fluid collection has not significantly changed. This is adjacent to the anastomosis site and a pelvic abscess cannot be excluded. No obstruction is seen. The appendix is not clearly visualized. The urinary bladder is unremarkable.,IMPRESSION:,1. Resolution of the previously seen subcutaneous fluid collection.,2. Left pelvic 3.4 cm fluid collection has not significantly changed in size or appearance. These findings may be due to a pelvic abscess.,3. Right lower quadrant ileostomy has not significantly changed.,4. Cholelithiasis.nephrology, axial ct images, isovue-300, ct pelvis, ct abdomen, fluid collection, abdomen, obstruction, subcutaneous, abscess, pelvic, fluid, collection, pelvis, ileostomy, ct, isovue,

PREOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,INDICATIONS:, Mr. ABC is a 10-year-old boy who suffered a fall resulting in a right distal both-bone forearm fracture. Upon evaluation by Orthopedic Surgery team in the emergency department, it was determined that a closed reduction under conscious sedation and application of a splint was warranted. This was discussed with the parents who expressed verbal and written consent.,PROCEDURE:, Conscious sedation was achieved via propofol via the emergency department staff. Afterwards, traction with re-creation of the injury pattern was utilized to achieve reduction of the patient's fracture. This was confirmed with image intensifier. Subsequently, the patient was placed into a splint. The patient was aroused from conscious sedation and at this time it was noted that he had full sensation throughout radial, median, and ulnar nerve distributions and positive extensor pollicis longus, flexor pollicis longus, dorsal and palmar interossei.,DISPOSITION: ,Post-reduction x-rays revealed good alignment in the AP x-rays. The lateral x-rays also revealed adequate reduction. At this time, we will allow the patient to be discharged home and have him follow up with Dr. XYZ in one week.orthopedic, closed reduction, distal both bone forearm, emergency department, pollicis longus, bone forearm, forearm fracture, conscious sedation, emergency, department, pollicis, longus, splint, distal, bone, forearm, conscious, sedation, fracture, reduction,

CC: ,RLE weakness.,HX: ,This 42y/o RHM was found 2/27/95 slumped over the steering wheel of the Fed Ex truck he was driving. He was cyanotic and pulseless according to witnesses. EMT evaluation revealed him to be in ventricular fibrillation and he was given epinephrine, lidocaine, bretylium and electrically defibrillated and intubated in the field. Upon arrival at a local ER his cardiac rhythm deteriorated and he required more than 9 counter shocks (defibrillation) at 360 joules per shock, epinephrine and lidocaine. This had no effect. He was then given intracardiac epinephrine and a subsequent electrical defibrillation placed him in atrial fibrillation. He was then taken emergently to cardiac catherization and was found to have normal coronary arteries. He was then admitted to an intensive care unit and required intraortic balloon pump pressure support via the right gorin. His blood pressure gradually improved and his balloon pump was discontinued on 5/5/95. Recovery was complicated by acute renal failure and liver failure. Initail CK=13,780, the CKMB fraction was normal at 0.8.,On 3/10/95, the patient experienced CP and underwent cardiac catherization. This time he was found to have a single occlusion in the distal LAD with association inferior hypokinesis. Subsequent CK=1381 and CKMB=5.4 (elevated). The patient was amnestic to the event and for 10 days following the event. He was transferred to UIHC for cardiac electrophysiology study.,MEDS: ,Nifedipine, ASA, Amiodarone, Capoten, Isordil, Tylenol, Darvocet prn, Reglan prn, Coumadin, KCL, SLNTG prn, CaCO3, Valium prn, Nubain prn.,PMH:, hypercholesterolemia.,FHX:, Father alive age 69 with h/o TIAs. Mother died age 62 and had CHF, A-Fib, CAD. Maternal Grandfather died of an MI and had h/o SVT. Maternal Grandmother had h/o SVT.,SHX: ,Married, 7 children, driver for Fed Ex. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP112/74 HR64 RR16 Afebrile.,MS: A&O to person, place and time. Euthymic with appropriate affect.,CN: unremarkable.,Motor: Hip flexion 3/5, Hip extension 5/5, Knee flexion5/5, Knee extension 2/5, Plantar flexion, extension, inversion and eversion 5/5. There was full strength thoughout BUE.,Sensory: decreased PP/Vib/LT/TEMP about anterior aspect of thigh and leg in a femoral nerve distribution.,Coord: poor and slowed HKS on right due to weakness.,Station: no drift or Romberg sign.,Gait: difficulty bearing weight on RLE.,Reflexes: 1+/1+ throughout BUE. 0/2 patellae. 2/2 archilles. Plantar responses were flexor, bilaterally.,COURSE:, MRI Pelvis, 3/28/95, revealed increased T1 weighted signal within the right iliopsoas suggestive of hematoma. An intra-osseous lipoma was incidentally notice in the right sacrum. Neuropsychologic assessment showed moderately compromised anterograde verbal memory, and temporal orientation and retrograde recall were below expectations. These findings were consistent with mesial temporal dysfunction secondary to anoxic injury and were mild in lieu of his history. He underwent implantation of a Medtronic internal cardiac difibrillator. His cardiac electrophysiology study found no inducible ventricular tachycardia or fibrillation. He suffered mild to moderate permanent RLE weakness, especially involving the quadriceps. His femoral nerve compression had been present to long to warrant decompression. EMG/NCV studies revealed severe axonal degeneration.consult - history and phy., cardiac electrophysiology study, iliopsoas hematoma, rle weakness, balloon pump, femoral nerve, cardiac catherization, hematoma, iliopsoas, catherization, epinephrine, fibrillation, cardiac,

HISTORY OF PRESENT ILLNESS: , The patient is a 71-year-old woman with history of coronary artery disease for which she has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1. She also has a significant history of chronic renal insufficiency and severe COPD. The patient and her husband live in ABC but they have family in XYZ. She came to our office today as she is in the area visiting her family. She complains of having shortness of breath for the past month that has been increasingly getting worse. She developed a frequent nonproductive cough about 2 weeks ago. She has also had episodes of paroxysmal nocturnal dyspnea, awaking in the middle of the night, panicking from dyspnea and shortness of breath. She has also gained about 15 pounds in the past few months and has significant peripheral edema. In the office, she is obviously dyspnea and speaking in 2 to 3 word sentences.,PAST MEDICAL HISTORY: , Coronary artery disease, anemia secondary to chronic renal insufficiency, stage IV chronic kidney disease, diabetic nephropathy, hypertension, hyperlipidemia, COPD, insulin-dependent diabetes, mild mitral valve regurgitation, severe tricuspid valve regurgitation, sick sinus syndrome, gastritis, and heparin-induced thrombocytopenia.,PAST SURGICAL HISTORY: , Status post pacemaker implantation, status post CABG x4 in 1999 and status post CABG x2 in 2003, status post PCA stenting x1 to the left anterior descending artery, cholecystectomy, back surgery, bladder surgery, and colonic polypectomies.,SOCIAL HISTORY: ,The patient is married. Lives with her husband. They are retired from ABC.,MEDICATIONS:,1. Plavix 75 mg p.o. daily.,2. Aspirin 81 mg p.o. daily.,3. Isosorbide mononitrate 60 mg p.o. daily.,4. Colace 100 mg p.o. b.i.d.,5. Atenolol 50 mg p.o. daily.,6. Lantus insulin 15 units subcutaneously every evening.,7. Protonix 40 mg p.o. daily.,8. Furosemide 40 mg p.o. daily.,9. Norvasc 5 mg p.o. daily.,ALLERGIES: , SHE IS ALLERGIC TO HEPARIN AGENTS, WHICH CAUSE HEPARIN-INDUCED THROMBOCYTOPENIA.,REVIEW OF SYSTEMS,CONSTITUTIONAL: Positive for generalized fatigue and malaise.,HEAD AND NECK: Negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions.,CARDIOVASCULAR: Positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain.,RESPIRATORY: Positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough. Negative for wheezing.,ABDOMEN: Negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis.,GENITOURINARY: Negative for dysuria, polyuria, hematuria, or incontinence.,MUSCULOSKELETAL: Negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy.,SKIN: Negative for rashes, petechiae, and hair or nail changes. Positive for easy bruising on forearms.,NEUROLOGIC: Negative for paralysis, paresthesias, dysphagia, or dysarthria.,PSYCHIATRIC: Negative for depression, anxiety, or mood swings.,All other systems reviewed are negative.,PHYSICAL EXAMINATION,VITAL SIGNS: Her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air. Her height is 63 inches. She is weighs 195 pounds and her BMI is 34.6.,CONSTITUTIONAL: A 71-year-old woman in significant distress from shortness of breath and dyspnea at rest.,HEENT: Eyes: Pupils are reactive. Sclera is nonicteric. Ears, nose, mouth, and throat.,NECK: Supple. No lymphadenopathy. No thyromegaly. Swallow is intact.,CARDIOVASCULAR: Positive JVD at 45 degrees. Heart tones are distant. S1 and S2. No murmurs.,EXTREMITIES: Have 3+ edema in the feet and ankles bilaterally that extends up to her knees. Femoral pulses are weakly palpable. Posterior tibial pulses are not palpable. Capillary refill is somewhat sluggish.,RESPIRATORY: Breath sounds are clear with some bilateral basilar diminishment. No rales and no wheezing. Speaking in 2 to 3 word sentences. Diaphragmatic excursions are limited. AP diameter is expanded.,ABDOMEN: Soft and nontender. Active bowel sounds x4 quadrants. No hepatosplenomegaly. No masses are appreciated.,GENITOURINARY: Deferred.,MUSCULOSKELETAL: Adequate range of motion along with extremities.,SKIN: Warm and dry. No lesions or ulcerations are noted.,NEUROLOGIC: Alert and oriented x3. Head is normocephalic and atraumatic. No focal, motor, or sensory deficits.,PSYCHIATRIC: Normal affect.,IMPRESSION,1. Coronary artery disease.nan

CLINICAL HISTORY: , This is a 64-year-old male patient, who had a previous stress test, which was abnormal and hence has been referred for a stress test with imaging for further classification of coronary artery disease and ischemia.,PERTINENT MEDICATIONS:, Include Tylenol, Robitussin, Colace, Fosamax, multivitamins, hydrochlorothiazide, Protonix and flaxseed oil.,With the patient at rest 10.5 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.,PROCEDURE AND INTERPRETATION: , The patient exercised for a total of 4 minutes and 41 seconds on the standard Bruce protocol. The peak workload was 7 METs. The resting heart rate was 61 beats per minute and the peak heart rate was 173 beats per minute, which was 85% of the age-predicted maximum heart rate response. The blood pressure response was normal with the resting blood pressure 126/86, and the peak blood pressure of 134/90. EKG at rest showed normal sinus rhythm with a right-bundle branch block. The peak stress EKG was abnormal with 2 mm of ST segment depression in V3 to V6, which remained abnormal till about 6 to 8 minutes into recovery. There were occasional PVCs, but no sustained arrhythmia. The patient had an episode of supraventricular tachycardia at peak stress. The ischemic threshold was at a heart rate of 118 beats per minute and at 4.6 METs. At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting images.,MYOCARDIAL PERFUSION IMAGING:,1. The overall quality of the scan was fair in view of increased abdominal uptake, increased bowel uptake seen.,2. There was a large area of moderate to reduced tracer concentration seen in the inferior wall and the inferior apex. This appeared to be partially reversible in the resting images.,3. The left ventricle appeared normal in size.,4. Gated SPECT images revealed normal wall motion and normal left ventricular systolic function with normal wall thickening. The calculated ejection fraction was 70% at rest.,CONCLUSIONS:,1. Average exercise tolerance.,2. Adequate cardiac stress.,3. Abnormal EKG response to stress, consistent with ischemia. No symptoms of chest pain at rest.,4. Myocardial perfusion imaging was abnormal with a large-sized, moderate intensity partially reversible inferior wall and inferior apical defect, consistent with inferior wall ischemia and inferior apical ischemia.,5. The patient had run of SVT at peak stress.,6. Gated SPECT images revealed normal wall motion and normal left ventricular systolic function.cardiovascular / pulmonary, stress test, arrhythmia, baseline heart rate, bruce, chest pain, mets, protocol, peak heart rate, spect, st segment response, svt, aerobic capacity, blood pressure, exercise, heart rate, ischemia, ventricular systolic function, myocardial perfusion imaging, cardiolite technetium, inferior apical, myocardial perfusion, perfusion imaging, stress, myocardial, imaging, perfusion

Laparoscopy. An incision was made in the umbilicus, allowing us to insert a micro-laparoscopic trocar. We then insufflated the abdomen with approximately 3 liters of carbon dioxide gas and inserted the micro-laparoscopic instrument.surgery, umbilicus, trocar, falope, laparoscopy, abdomen, suprapubic, laparoscopicNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

PREOPERATIVE DIAGNOSES:, Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,POSTOPERATIVE DIAGNOSES:, Cervical spondylotic myelopathy with cord compression and cervical spondylosis. In addition to this, he had a large herniated disk at C3-C4 in the midline.,PROCEDURE: , Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.,PROCEDURE IN DETAIL: , The patient placed in the supine position, the neck was prepped and draped in the usual fashion. Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4. Skin, subcutaneous tissue, and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially. The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4-C5. It appeared that the C5-C6 disk area had fused spontaneously. We then confirmed that position by taking intraoperative x-rays and then proceeded to do discectomy and fusion at C3-C4, C4-C5.,After placing distraction screws and self-retaining retractors with the teeth beneath the bellies of the longus colli muscles, we then meticulously removed the disk at C3-C4, C4-C5 using the combination of angled strip, pituitary rongeurs, and curettes after we had incised the anulus fibrosus with #15 blade.,Next step was to totally decompress the spinal cord using the operating microscope and high-speed cutting followed by the diamond drill with constant irrigation. We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments. This was then removed with 2-mm Kerrison rongeur. After we removed the posterior longitudinal ligament, we could see the dura pulsating nicely. We did foraminotomies at C3-C4 as well as C4-C5 as well. After having totally decompressed both the cord as well as the nerve roots of C3-C4, C4-C5, we proceeded to the next step, which was a fusion.,We sized two 8-mm cortical cancellous grafts and after distracting the bone at C3-C4, C4-C5, we gently tapped the grafts into place. The distraction was removed and the grafts were now within. We went to the next step for the procedure, which was the instrumentation and stabilization of the fused area.,We then placed a titanium ABC plate from C3-C5, secured it with 16-mm titanium screws. X-rays showed good position of the screws end plate.,The next step was to place Jackson-Pratt drain to the vertebral fascia. Meticulous hemostasis was obtained. The wound was closed in layers using 2-0 Vicryl for the subcutaneous tissue. Steri-Strips were used for skin closure. Blood loss less than about 200 mL. No complications of the surgery. Needle counts, sponge count, and cottonoid count was correct.orthopedic, titanium plates fixation, bone black bone procedure, anterior cervical discectomy, titanium plates, cervical discectomy, spondylotic myelopathy, cord compression, cervical spondylosis, foraminotomies, cervical, anterior

PREOPERATIVE DIAGNOSIS: , Pilonidal cyst with abscess formation.,POSTOPERATIVE DIAGNOSIS:, Pilonidal cyst with abscess formation.,OPERATION: , Excision of infected pilonidal cyst.,PROCEDURE: , After obtaining informed consent, the patient underwent a spinal anesthetic and was placed in the prone position in the operating room. A time-out process was followed. Antibiotics were given and then the patient was prepped and draped in the usual fashion. It appeared to me that the abscess had drained somewhat during the night, as it was much smaller than I was anticipating. An elliptical excision of all infected tissues down to the coccyx was performed. Hemostasis was achieved with a cautery. The wound was irrigated with normal saline and it was packed open with iodoform gauze and an absorptive dressing.,The patient was sent to recovery room in satisfactory condition. Estimated blood loss was minimal. The patient tolerated the procedure well.hematology - oncology, hemostasis, excision, pilonidal cyst, cyst, abscess, infected,

PAST MEDICAL HISTORY:, Significant for hypertension. The patient takes hydrochlorothiazide for this. She also suffers from high cholesterol and takes Crestor. She also has dry eyes and uses Restasis for this. She denies liver disease, kidney disease, cirrhosis, hepatitis, diabetes mellitus, thyroid disease, bleeding disorders, prior DVT, HIV and gout. She also denies cardiac disease and prior history of cancer.,PAST SURGICAL HISTORY: , Significant for tubal ligation in 1993. She had a hysterectomy done in 2000 and a gallbladder resection done in 2002.,MEDICATIONS: , Crestor 20 mg p.o. daily, hydrochlorothiazide 20 mg p.o. daily, Veramist spray 27.5 mcg daily, Restasis twice a day and ibuprofen two to three times a day.,ALLERGIES TO MEDICATIONS: , Bactrim which causes a rash. The patient denies latex allergy.,SOCIAL HISTORY: , The patient is a life long nonsmoker. She only drinks socially one to two drinks a month. She is employed as a manager at the New York department of taxation. She is married with four children.,FAMILY HISTORY: , Significant for type II diabetes on her mother's side as well as liver and heart failure. She has one sibling that suffers from high cholesterol and high triglycerides.,REVIEW OF SYSTEMS: , Positive for hot flashes. She also complains about snoring and occasional slight asthma. She does complain about peripheral ankle swelling and heartburn. She also gives a history of hemorrhoids and bladder infections in the past. She has weight bearing joint pain as well as low back degenerating discs. She denies obstructive sleep apnea, kidney stones, bloody bowel movements, ulcerative colitis, Crohn's disease, dark tarry stools and melena.,PHYSICAL EXAMINATION: ,On examination temperature is 97.7, pulse 84, blood pressure 126/80, respiratory rate was 20. Well nourished, well developed in no distress. Eye exam, pupils equal round and reactive to light. Extraocular motions intact. Neuro exam deep tendon reflexes 1+ in the lower extremities. No focal neuro deficits noted. Neck exam nonpalpable thyroid, midline trachea, no cervical lymphadenopathy, no carotid bruit. Lung exam clear breath sounds throughout without rhonchi or wheezes however diminished. Cardiac exam regular rate and rhythm without murmur or bruit. Abdominal exam positive bowel sounds, soft, nontender, obese, nondistended abdomen. No palpable tenderness. No right upper quadrant tenderness. No organomegaly appreciated. No obvious hernias noted. Lower extremity exam +1 edema noted. Positive dorsalis pedis pulses.,ASSESSMENT: , The patient is a 56-year-old female who presents to the bariatric surgery service with a body mass index of 41 with obesity related comorbidities. The patient is interested in gastric bypass surgery. The patient appears to be an excellent candidate and would benefit greatly in the management of her comorbidities.,PLAN: , In preparation for surgery will obtain the usual baseline laboratory values including baseline vitamin levels. Will proceed with our usual work up with an upper GI series as well as consultations with the dietician and the psychologist preoperatively. I have recommended six weeks of Medifast for the patient to obtain a 10% preoperative weight loss.consult - history and phy., weight watchers, roux en y, atkins, medifast, meridia, south beach, cabbage, diets, laparoscopic roux en y gastric bypass surgery, rice, weight loss, six weeks of medifast, weight loss modalities, body mass index, gastric bypass surgery, bariatric surgery, gastric bypass,

SUBJECTIVE:, This is a 62-year-old female who comes for dietary consultation for carbohydrate counting for type I diabetes. The patient reports that she was hospitalized over the weekend for DKA. She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood sugar was 477. She gave herself, in smaller increments, a total of 70 extra units of her Humalog. Ten of those units were injectable; the others were in the forms of pump. Her blood sugar was over 600 when she went to the hospital later that day. She is here at this consultation complaining of not feeling well still because she has a cold. She realizes that this is likely because her immune system was so minimized in the hospital.,OBJECTIVE:, Current insulin doses on her insulin pump are boluses set at 5 units at breakfast, 6 units at lunch and 11 units at supper. Her basal rates have not been changed since her last visit with Charla Yassine and totaled 30.5 units per 24 hours. A diet history was obtained. I instructed the patient on carbohydrate counting at 1 unit of insulin for every 10 g carbohydrate ratio was recommended. A correction dose of approximately 1 unit of insulin to bring the blood sugars down 30 mg/dl was also recommended. The Lilly guide for meal planning was provided and reviewed. Additional carbohydrate counting book was provided.,ASSESSMENT:, The patient was taught an insulin-to-carbohydrate ratio of 1 unit to 10 g of carbohydrates as recommended at the previous visit two years ago, which she does not recall. It is based on the 500 rule which suggests this ratio. We did identify carbohydrate sources in the food supply, recognizing 15-g equivalents. We also identified the need to dose her insulin at the time that she is eating her carbohydrate sources. She does seem to have a pattern of fixing blood sugars later in the day after they are elevated. We discussed the other option of trying to eat a consistent amount of carbohydrates at meals from day to day and taking a consistent amount of insulin at those meals. With this in mind, she was recommended to follow with three servings or 45 g of carbohydrate at breakfast, three servings or 45 g of carbohydrate at lunch and four servings or 60 g of carbohydrate at dinner. Joanne Araiza joined our consultation briefly to discuss whether her pump was working appropriately. The patient was given an 800 number for the pump to contact should there be any question about its failure to deliver insulin appropriately.,PLAN:, Recommend the patient use 1 unit of insulin for every 10-g carbohydrate load consumed. Recommend the patient either use this as a carbohydrate counting tool or work harder at keeping carbohydrate content consistent at meals from day to day. This was a one-hour consultation. Provided my name and number should additional needs arise.soap / chart / progress notes, insulin pump, carbohydrate load, immune system, dietary consultation, carbohydrate ratio, blood sugars, carbohydrate counting, carbohydrate, dietary, blood, counting, insulin

DIAGNOSES: , Traumatic brain injury, cervical musculoskeletal strain.,DISCHARGE SUMMARY: , The patient was seen for evaluation on 12/11/06 followed by 2 treatment sessions. Treatment consisted of neuromuscular reeducation including therapeutic exercise to improve range of motion, strength, and coordination; functional mobility training; self-care training; cognitive retraining; caregiver instruction; and home exercise program. Goals were not achieved, as the patient was admitted to inpatient rehabilitation center.,RECOMMENDATIONS: , Discharged from OT this date, as the patient has been admitted to Inpatient Rehabilitation Center.,Thank you for this referral.physical medicine - rehab, musculoskeletal strain, occupational therapy, traumatic, brain, cervical, musculoskeletal, rehabilitation,

SUBJECTIVE:, Overall, she has been doing well. Her blood sugars have usually been less than or equal to 135 by home glucose monitoring. Her fasting blood sugar today is 120 by our Accu-Chek. She is exercising three times per week. Review of systems is otherwise unremarkable. ,OBJECTIVE:, Her blood pressure is 110/60. Other vitals are stable. HEENT: Unremarkable. Neck: Unremarkable. Lungs: Clear. Heart: Regular. Abdomen: Unchanged. Extremities: Unchanged. Neurologic: Unchanged. ,ASSESSMENT:, ,1. NIDDM with improved control. ,2. Hypertension. ,3. Coronary artery disease status post coronary artery bypass graft. ,4. Degenerative arthritis. ,5. Hyperlipidemia. ,6. Hyperuricemia. ,7. Renal azotemia. ,8. Anemia. ,9. Fibroglandular breasts. ,PLAN:, We will get follow-up labs today. We will continue with current medications and treatment. We will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately Month DD, YYYY. The patient is advised to proceed with previous recommendations. She is to follow-up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow-up as directed.soap / chart / progress notes, general medicine, accu-chek, heent: unremarkable, hyperlipidemia, hypertension, lungs: clear, niddm, neck: unremarkable, progress note, soap, coronary artery bypass graft, follow-up labs, glucose monitoring, coronary artery

PREOPERATIVE DIAGNOSES:,1. Blepharochalasia.,2. Lower lid large primary and secondary bagging.,POSTOPERATIVE DIAGNOSES:,1. Blepharochalasia.,2. Lower lid large primary and secondary bagging.,PROCEDURE: , Quad blepharoplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,CONDITION: , The patient did well.,PROCEDURE: ,The patient had marks and measurements prior to surgery. Additional marks and measurements were made at the time of surgery; these were again checked. At this point, the area was injected with 0.5% lidocaine with 1:200,000 epinephrine. Appropriate time waited for the anesthetic and epinephrine effect.,Beginning on the left upper lid, the skin excision was completed. The muscle was opened, herniated, adipose tissue pad in the middle and medial aspect was brought forward, cross-clamped, excised, cauterized, and allowed to retract. The eyes were kept irrigated and protected throughout the procedure. Attention was turned to the opposite side. Procedure was carried out in the similar manner.,At the completion, the wounds were then closed with a running 6-0 Prolene, skin adhesives, and Steri-Strips. Attention was turned to the right lower lid. A lash line incision was made. A skin flap was elevated and the muscle was opened. Large herniated adipose tissue pads were present in each of the three compartments. They were individually elevated, cross-clamped, excised, cauterized, and allowed to retract.,At the completion, a gentle tension was placed on the facial skin and several millimeters of the skin excised. Attention was turned to he opposite side. The procedure was carried out as just described. The contralateral side was reexamined and irrigated. Hemostasis was good and it was closed with a running 6-0 Prolene. The opposite side was closed in a similar manner.,Skin adhesives and Steri-Strips were applied. The eyes were again irrigated and cool Swiss Eye compresses applied. At the completion of the case, the patient was extubated in the operating room, breathing on her own, doing well, and transferred in good condition from operating room to recovering room.cosmetic / plastic surgery, blepharochalasia, lower lid, swiss eye compresses, adipose tissue pad, bagging, blepharoplasty, lash line incision, quad blepharoplasty,

CHIEF COMPLAINT:, Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions). One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake. His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion. He sleeps well, but has been more tired and has been fussy over the past 2 days. The parents noticed no improvement with albuterol treatments given in the ER. His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours. Mom denies any diarrhea. His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne. The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count. This tap was reported as clear, then turning bloody in nature. The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture. This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status. Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness. Mom's nipples are currently cracked and bleeding. Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area. He is status post a circumcision. Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section. Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family). GBS status was negative. Mom smoked up to the last 5 months of the pregnancy. Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions. Mom and baby were both discharged out of the hospital last 48 hours. This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:, Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, Tylenol.,IMMUNIZATIONS:, None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:, At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother. Both brothers at home are sick with cold symptoms including diarrhea and vomiting. The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription. A nephew of the mom with an ear infection. Mom also states that she herself was sick with the flu soon after delivery. There has been recent travel exposure to dad's family over the Christmas holidays. At this time, there is also exposure to indoor cats and dogs. This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker. There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION: ,VITALS: Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air. Weight was 4.1 kg.,GENERAL: Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT: Normocephalic, atraumatic head. Anterior fontanelle was soft, open, and flat. Bilateral red reflexes were positive. Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR: Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature. Capillary refill was less than 3 seconds.,LUNGS: Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN: Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly. Umbilical site was with scant dried yellow discharge.,GU: Tanner stage 1 male, circumcised. There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS: Negative Barlow or Ortolani maneuvers.,SKIN: Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes. The hemoglobin was 14.4, hematocrit was 40. The platelet count was elevated at 698,000. A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89. A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1. Rule out sepsis.,2. Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever. The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria. We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER. Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV. The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use. Also, there is negative apnea in this patient.,PLAN: ,1. We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2. We will follow up with his blood, urine, and CSF cultures.nan

DELIVERY NOTE: , This is a 30-year-old G7, P5 female at 39-4/7th weeks who presents to Labor and Delivery for induction for history of large babies and living far away. She was admitted and started on Pitocin. Her cervix is 3 cm, 50% effaced and -2 station. Artificial rupture of membrane was performed for clear fluid. She did receive epidural anesthesia. She progressed to complete and pushing. She pushed to approximately one contraction and delivered a live-born female infant at 1524 hours. Apgars were 8 at 1 minute and 9 at 5 minutes. Placenta was delivered intact with three-vessel cord. The cervix was visualized. No lacerations were noted. Perineum remained intact. Estimated blood loss is 300 mL. Complications were none. Mother and baby remained in the birthing room in good condition.obstetrics / gynecology, perineum, placenta, rupture of membrane, artificial rupture, cervix, delivery, inductionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

PREOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,POSTOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,PROCEDURE PERFORMED: , Excision of soft tissue mass, right foot.,HISTORY: ,The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot. The patient has had previous injections to the site which have caused the mass to decrease in size, however, the mass continues to be present and is irritated and painful with shoes. The patient has requested surgical intervention at this time.,PROCEDURE: ,After an IV was instituted by the Department of Anesthesia, the patient was escorted from the preoperative holding area to the operating room. The patient was then placed on the operating room table in the supine position and a towel was placed around the patient's abdomen and secured her to the table. Using copious amounts of Webril, a pneumatic ankle tourniquet was applied to her right ankle. Using a Skin Skribe, the area of the soft tissue mass was outlined over the dorsum of her foot. After adequate amount of anesthesia was provided by the Department of Anesthesia, a local ankle block was given using 10 cc of 4.5 mL of 1% lidocaine plain, 4.5 mL of 0.5% Marcaine plain and 1.0 mL of Solu-Medrol and the foot was scrubbed and prepped in a normal sterile orthopedic manner. Following this, the ankle was elevated and Esmarch bandage applied to exsanguinate the foot and the ankle tourniquet was inflated to 250 mmHg. The foot was then brought back down to the table using bandage scissors. The stockinette was reflected and the right foot was exposed. Using a fresh #10 blade, a curvilinear incision was performed over the dorsum of the right foot. Then using a #15 blade, the incision was deepened with care taken to identify and avoid or cauterize any bleeders which were noted. Following this, the incision was deepened using a combination of sharp and blunt dissection and the muscle belly of the extensor digitorum brevis muscle was identified. Further dissection was then performed in the medial direction in the area of the soft tissue mass. The intermediate dorsal cutaneous nerve was identified and gently retracted laterally. Large amounts of adipose tissue were noted medial to the belly of the extensor digitorum brevis muscle. Using careful dissection, adipose tissue in this area was removed and saved for pathology. Following removal of adipose tissue in this area and identification of no more adipose tissue, attention was directed lateral to the belly of the extensor digitorum brevis muscle, which was also noted to have large amounts of adipose tissue in this area as well. Using careful dissection, from the lateral border of the foot as much adipose tissue as possible was removed from this area as well and saved for pathology. There was noted to be no other fluid-filled masses or lesions identifiable in this area then between the slits of the extensor digitorum brevis muscle, careful dissection was performed to examine the underside of the belly of the muscle as well as structures beneath and no abnormal structures were identified here as well. Following this, feeling adequately that no other mass remained in the area, the incision was flushed using copious amounts of sterile saline. The wound was then reinspected and all remaining tissues appeared healthy including the subcutaneous tissue. The tendon and muscle belly of the extensor digitorum brevis muscle, the nerves of the intermediate dorsal cutaneous nerve and also the medial dorsal cutaneous nerve which were identified medially, all appeared intact. No deficits were noted. No abnormal appearing tissue was present within the surgical site. Following this, the skin edges were reapproximated using #4-0 Vicryl deep closure of the subcutaneous layer was performed. Then, using #4-0 nylon and simple interrupted suture, the skin was reapproximated and closed with care taken to ensure eversion of the skin edges and good approximation of the borders. The patient was also given 7 cc of 1% lidocaine plain throughout the procedure to augment local anesthesia. Following this, the wound was dressed using Xeroform gauze and 4x4s and was dressed using two ABD pads, dorsal and plantar for compression and using Kling, Kerlix and Coban. The patient then had the ankle tourniquet deflated with a total tourniquet time of 55 minutes at 250 mmHg and immediate hyperemia was noted to digits one through five of the right foot. The patient tolerated the procedure and anesthesia well and was noted to have vascular status intact. The patient was then escorted to the Postanesthesia Care Unit where she was placed in a surgical shoe. The patient was then given postoperative instructions to include ice and elevation to her right foot. The patient was cleared for ambulation as tolerated, but was instructed that with increased ambulation will come increased swelling and pain. The patient will follow up with Dr. X in his office on Tuesday, 08/26/03 for further follow up. The patient was given prescription for Vicoprofen #25 taken one tablet q.4h. p.r.n., moderate to severe pain and also prescription for Keflex #20 500 mg tablets to be taken b.i.d. x10 days. The patient was given a number for the Emergency Room and instructed to return if any sign or symptom of infection should present and the patient was educated as to the nature of these. The patient had no further questions and recovered without any complications in the Postanesthesia Care Unit.podiatry, excision, digitorum brevis muscle, soft tissue mass, adipose tissue, soft tissue, mass, injections, foot, tissue, xeroform, dorsum, belly, extensor, digitorum, brevis, ankle, adipose, muscle,

PREOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,POSTOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,OPERATION PERFORMED: ,Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma.,ANESTHESIA: , General endotracheal.,PREPARATION: , Povidone.,INDICATION:, This is an 83-year-old male with herniation syndrome with large subdural hematoma 100%. This procedure is being done as an emergency procedure in an attempt to save his life and maximize the potential for recovery.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room intubated. The patient previously was given fresh frozen plasma plus recombinant activated factor VII. The patient had a roll placed on his right shoulder, head was maintained three point fixation with a Mayfield headholder. The right side of the head was shaved, thoroughly prepped and draped, a large ? scalp incision was marked, infiltrated with local and incised with a scalpel, Raney clips were applied to the scalp margins, hemostasis, temporalis muscle and fascia, pericranium opened and aligned with incision, flap was reflected anteriorly. Burr holes are placed low in the temporal bone at the keyhole posteriorly and then superiorly with a perforator, then using Midas Rex drill with a B1 foot plate a free flap was turned. The dura was opened in a cruciate fashion, acute subdural hematoma was evacuated. There was a small arterial bleeder in the anterior parietal region, which was controlled with bipolar electrocautery. Using suction and biopsy forceps, acute clot was resected from the frontotemporoparietal and occipital poles, subdural space was irrigated, no further bleeders were encountered. Dura was closed with 4-0 Nurolon. A subdural Camino ICP catheter was placed in the subdural space. Bone flaps secured in place with neuro clips with 5 mm screws, central pack up suture was placed, dural tack up sutures were placed using 4-0 Nurolon prior to placement of the bone flap. The wound was irrigated with saline, temporalis muscle and fascia closed with 2-0 Vicryl, subgaleal Hemovac was placed, galea was closed with 2-0 Vicryl, and scalp with staples. ICP monitor and the Hemovac were sutured in place with 2-0 Vicryl. The patient was taken out of the head holder, a sterile dressing placed. The head was wrapped. The patient was taken directly to ICU, still intubated in guarded condition. Brain was nicely soft and pulsatile. At the termination of the procedure, no significant contusion of the brain was identified. Final sponge and needle counts are correct. Estimated blood loss 400 cc.neurosurgery, subdural hematoma, craniotomy, herniation, subdural, temporalis, frontotemporoparietal, hematoma,

DIAGNOSIS:, Refractory anemia that is transfusion dependent.,CHIEF COMPLAINT: , I needed a blood transfusion.,HISTORY: , The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes. He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia. He has been placed on B12, oral iron, and Procrit. At this time, we are asked to evaluate him for further causes and treatment for his anemia. He denies any constitutional complaints except for fatigue, malaise, and some dyspnea. He has no adenopathy that he reports. No fevers, night sweats, bone pain, rash, arthralgias, or myalgias.,PAST MEDICAL HISTORY: ,Diabetes.,PAST SURGICAL HISTORY:, Hernia repair.,ALLERGIES: , He has no allergies.,MEDICATIONS: , Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol.,SOCIAL HISTORY: , He is a tobacco user. He does not drink. He lives alone, but has family and social support to look on him.,FAMILY HISTORY:, Negative for blood or cancer disorders according to the patient.,PHYSICAL EXAMINATION:,GENERAL: He is an elderly gentleman in no acute distress. He is sitting up in bed eating his breakfast. He is alert and oriented and answering questions appropriately.,VITAL SIGNS: Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4. He is 69 inches tall and weighs 174 pounds.,HEENT: Sclerae show mild arcus senilis in the right. Left is clear. Pupils are equally round and reactive to light. Extraocular movements are intact. Oropharynx is clear.,NECK: Supple. Trachea is midline. No jugular venous pressure distention is noted. No adenopathy in the cervical, supraclavicular, or axillary areas.,CHEST: Clear.,HEART: Regular rate and rhythm.,ABDOMEN: Soft and nontender. There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration.,EXTREMITIES: No clubbing, but there is some edema, but no cyanosis.,NEUROLOGIC: Noncontributory.,DERMATOLOGIC: Noncontributory.,CARDIOVASCULAR: Noncontributory.,IMPRESSION: , At this time is refractory anemia, which is transfusion dependent. He is on B12, iron, folic acid, and Procrit. There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative. His creatinine was 1. My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure. His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.,RECOMMENDATIONS: ,At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy. I have discussed the procedure in detail which the patient. I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him. He is willing to proceed with the studies I have described to him. We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.,As always, we greatly appreciate being able to participate in the care of your patient. We appreciate the consultation of the patient.nan

HISTORY:, Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.,Patient is currently living in ABC with his son as this was closer his to his job. At discharge, he will live with his spouse in a new job. The home is single level with no steps.,Prior to admission, his wife reports that he was independent with all activities. He was working full time for an oil company.,Past medical history includes hypertension and diabetes, mental status, and dysphagia.,Ability to follow instruction/rules: Not able to identify cognitive status as of yet.,COMMUNICATION SKILLS: , No initiation of conversation. He answered 1 yes/no question.,PHYSICAL STATUS:, Fall/safety. Aspiration precautions.,Endurance: Ball activities 4 to 5 minutes. Restorator 25 minutes. Standing and rolling type of 3 minutes.,LEISURE LIFESTYLE:,Level of participation/activities involved in: Reading and housework.,INFORMATION OBTAINED:, Interview, observation, and chart review.,TREATMENT PLAN: ,Treatment plan and goals were discussed with patient along with identification of results of FUNCTIONAL ASSESSMENT OF CHARACTERISTICS FOR THERAPEUTIC RECREATION identifying need for intervention in the following problem areas: Patient scored 10/11 in physical domain due to decreased endurance. He scored 11/11 in the cognitive and social domain.,Patient will attend 1 session per day focusing on: Endurance activities.,Patient will attend 1-2 group sessions per week focusing on leisure awareness and postdischarge resources.,GOALS:,PATIENT GOALS: , Not able to identify, but cooperative with all activities. He answered yes that he enjoyed the restorator.,SHORT TERM GOALS/ONE WEEK GOALS:,1. Patient to increase tolerance for ball activities to 7 minutes.,2. Patient provided to use the restorator as he enjoys and it is good for endurance.,LONG TERM GOALS:, Patient to increase standing tolerance, standing leisure activities to 7 to 10 minutes.,Patient has concurred with the above treatment planning goals.consult - history and phy., endurance, ball activities, therapeutic recreation, hemiparesis, tolerance, recreation, restorator, leisure, therapeutic,

DIAGNOSES ON ADMISSION,1. Cerebrovascular accident (CVA) with right arm weakness.,2. Bronchitis.,3. Atherosclerotic cardiovascular disease.,4. Hyperlipidemia.,5. Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1. Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2. Old coronary infarct, anterior aspect of the right external capsule.,3. Acute bronchitis with reactive airway disease.,4. Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5. Atherosclerotic cardiovascular disease.,6. Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room. Plavix was started in addition to baby aspirin. He was kept on oral Zithromax for his cough. He was given Xopenex treatment, because of his respiratory distress. Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid. Dr. X saw him in consultation and recommended CT angiogram. This showed no significant obstructive lesion other than what was known on the ultrasound. Head MRI was done and revealed the above findings. The patient was begun on PT and improved. By discharge, he had much improved strength in his right arm. He had no further progressions. His cough improved with oral Zithromax and nebulizer treatments. His platelets also improved as well. By discharge, his platelets was up to 107,000. His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential. Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate. Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1. PT/INR on admission was 1.03, PTT 34.7. At the time of discharge, the patient's cough was much improved. His right arm weakness has much improved. His lung examination has just occasional rhonchi. He was changed to a metered dose inhaler with albuterol. He is being discharged home. An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation. He will follow up in my office in 1 week. He is to start PT and OT as an outpatient. He is to avoid driving his car. He is to notify, if further symptoms. He has 2 more doses of Zithromax at home, he will complete. His prognosis is good.neurology, subacute infarct, atherosclerotic cardiovascular disease, cerebrovascular accident, coronary infarct, external capsule, cva, cerebrovascular, mri, bronchitis, cardiovascular, xopenex, atherosclerotic, accident

PREOPERATIVE DIAGNOSIS AND INDICATIONS:, Acute non-ST-elevation MI.,POSTOPERATIVE DIAGNOSIS AND SUMMARY:, The patient presented with an acute non-ST-elevation MI. Despite medical therapy, she continued to have intermittent angina. Angiography demonstrated the severe LAD as the culprit lesion. This was treated as noted above with angioplasty alone as the stent could not be safely advanced. She has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual LAD lesions as noted above. She will be continued on her medical therapy. At age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.,PROCEDURE PERFORMED: , Selective coronary angiography, coronary angioplasty.,PROCEDURE IN DETAIL:, After informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position. The area of the right femoral artery was prepped and draped in a sterile fashion. Using the percutaneous technique, a 6-French sheath was placed in the right femoral artery under fluoroscopic guidance. With the guidewire in place, a 5-French JL-4 catheter was used to selectively angiogram the left coronary system. The catheter was removed. The sheath flushed. The 5-French 3DRC catheter was then used to selectively angiogram the right coronary artery. The cath removed, the sheath flushed.,It was decided that intervention was needed in the severe lesions in the LAD, which appeared to be the culprit lesions for the non-ST elevation-MI. The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained, we rebolused and the ACT was slightly lower. We repeated the level and it was slightly higher. We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV. Additionally, the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started.,A 6-French CLS 3.5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal. An Apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated. Angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent. The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium. The balloon was inflated and removed, repeat angiography performed. We attempted to advance a Driver 2.5 x 24 mm bare metal stent, but I could not advance it beyond the proximal LAD, where there was significant calcification. The stent was removed. Attempts to advance the same 2.5 x 15 mm Apex balloon that was previously used were unsuccessful. It was removed, a new Apex 2.5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed. Repeat angiography demonstrated no evidence of dissection. One more attempt was made to advance the Driver 2.5 x 24 mm bare metal stent, but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal. I felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed. The guidewires and guide cath were removed. The sheath flushed and sutured into position. The patient moved to ICU in stable condition with no chest discomfort at all.,CONTRAST: , Isovue-370, 120 mL.,FLUORO TIME: , 9.4 minutes.,ESTIMATED BLOOD LOSS: , 30 mL.,HEMODYNAMICS:, Aorta 185/54.,Left ventriculography was not performed. I did not make an attempt to cross this severely stenotic aortic valve.,The left main is a large vessel, giving rise to LAD and circumflex vessels. The left main has no significant disease other than calcification in the walls.,The LAD is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal. The LAD has significant calcification proximally. There is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent. This resulted in a 30% residual, mostly eccentric calcified plaque. Following this, there was a 50% stenosis in the LAD just after the takeoff of the third diagonal. This was not ballooned. Beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal. These 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal. As noted above, this area was not stented because I could not safely advance the stent. Note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.,The circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches. The proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal. The remainder of the vessel was without significant disease.,The right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch. The right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch. The remainder of the right coronary and its branches were without significant disease.cardiovascular / pulmonary, non-st-elevation mi, selective coronary angiography, coronary angioplasty, calcified plaque, coronary angiography, st elevation, stenosis, lad, coronary, selective, angiography, angioplasty, balloon, vessel, stent,

PREOPERATIVE DIAGNOSES:,1. Hypermenorrhea.,2. Uterine fibroids.,3. Pelvic pain.,4. Left adnexal mass.,5. Pelvic adhesions.,POSTOPERATIVE DIAGNOSES:,1. Hypermenorrhea.,2. Uterine fibroids.,3. Pelvic pain.,4. Left adnexal mass.,5. Pelvic adhesions.,PROCEDURE PERFORMED:,1. Total abdominal hysterectomy (TAH).,2. Left salpingo-oophorectomy.,ANESTHESIA:, General endotracheal.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,INDICATIONS: , The patient is a 47-year-old Caucasian female with complaints of hypermenorrhea and pelvic pain, noted to have a left ovarian mass 7 cm at the time of laparoscopy in July of 2003. The patient with continued symptoms of pelvic pain and hypermenorrhea and desired definitive surgical treatment.,FINDINGS AT THE TIME OF SURGERY: , Uterus is anteverted and boggy with a very narrow introitus with a palpable left adnexal mass.,On laparotomy, the uterus was noted to be slightly enlarged with fibroid change as well as a hemorrhagic appearing left adnexal mass. The bowel, omentum, and appendix had a normal appearance.,PROCEDURE: , The patient was taken to the operative suite where anesthesia was found to be adequate. She was then prepared and draped in normal sterile fashion. A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia with the second scalpel. The fascia was then incised in the midline. The fascial incision was then extended laterally with Mayo scissors. The superior aspect of the fascial incision was grasped with Kochers with the underlying rectus muscle dissected off bluntly and sharply with Mayo scissors. Attention was then turned to the inferior aspect of this incision, which in a similar fashion was tented up with the underlying rectus muscle and dissected off bluntly and sharply with Mayo scissors. The rectus muscle was then separated in the midline. The peritoneum was identified, tented up with hemostats and entered sharply with Metzenbaum scissors. The peritoneal incision was then extended superiorly and inferiorly with good visualization of the bladder. The uterus and left adnexa were then palpated and brought out into the surgical field. The fundus of the uterus was grasped with a Lahey clamp. The GYN/Balfour retractor was placed. The bladder blade was placed. The bowel was packed away with moist laparotomy sponges and the extension through GYN/Balfour retractor was placed. At this time, the patient's anatomy was surveyed and there was found to be a left hemorrhagic appearing adnexal mass. Attention was first turned to the right round ligament, which was tented up with a Babcock and a small window was made beneath the round ligament with a hemostat. It was then suture ligated with #0 Vicryl suture, transected with the broad ligament being skeletonized on both sides. Next, the right ________ was isolated bluntly as the patient had a previous RSO. This was then suture ligated with #0 Vicryl suture, doubly clamped with Kocher clamps, transected, and suture ligated with #0 Vicryl suture with a Heaney stitch. Attention was then turned to the left round ligament, which was tented up with the Babcock. Small window was made beneath it and the broad ligament with hemostat was then suture ligated with #0 Vicryl suture, transected, and skeletonized with the aid of Metzenbaums. The left infundibulopelvic ligament was then bluntly isolated. It was then suture ligated with #0 Vicryl suture, doubly clamped with Kocher clamps, and transected and suture ligated with #0 Vicryl suture with a Heaney stitch. The bladder flap was then placed on tension with Allis clamps. It was then dissected off of the lower uterine segment with the aid of Metzenbaum scissors and Russians. It was then gently pushed off of lower uterine segment with the aid of a moist Ray-Tec. The uterine arteries were then skeletonized bilaterally.,They were then clamped with straight Kocher clamps, transected, and suture ligated with #0 Vicryl suture. The cardinal ligament and uterosacral complexes on both sides were then clamped with curved Kocher clamps. These were then transected and suture ligated with #0 Vicryl suture. The lower uterine segment was then grasped with Lahey clamps, at which time the cervix was already visible. It was then entered with the last transection. The cervix was grasped with a single-toothed tenaculum and the uterus, cervix, and left adnexa were amputated off the vagina with the aid of Jorgenson scissors. The angles of the vaginal cuff were then grasped with Kocher clamps. A Betadine-soaked Ray-Tec was then pushed into the vagina and the vaginal cuff was closed with #0 Vicryl suture in a running lock fashion with care taken to transect the ipsilateral cardinal ligament, at which time the suction tip was changed and copious suction irrigation was performed. Good hemostasis was appreciated. A figure-of-eight suture in the center of the vaginal cuff was placed with #0 Vicryl. This was tagged for later use. The uterosacrals on both sides were incorporated into the vaginal cuff with the aid of #0 Vicryl suture. The round ligaments were then pulled into the vaginal cuff using the figure-of-eight suture placed in the center of the vaginal cuff and these were tied in place. The pelvis was then again copiously suctioned irrigated and hemostasis was appreciated. The peritoneal surfaces were then reapproximated with the aid of #3-0 Vicryl suture in a running fashion. The GYN/Balfour retractor and bladder blade were then removed. The bowel was then packed. Again copious suction irrigation was performed with hemostasis appreciated. The peritoneum was then reapproximated with #2-0 Vicryl suture in a running fashion. The fascia was then reapproximated with #0 Vicryl suture in a running fashion. The Scarpa's fascia was then reapproximated with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a subcuticular fashion. Steri-Strips were placed. At the end of the procedure, the sponge that was pushed into the vagina previously was removed and hemostasis was appreciated vaginally. The patient tolerated the procedure well and was taken to Recovery in stable condition. Sponge, lap, and needle counts were correct x2. Specimens include uterus, cervix, left fallopian tube, and ovary.

PREOPERATIVE DIAGNOSIS: , Term pregnancy at 40 and 3/7th weeks.,PROCEDURE PERFORMED: , Spontaneous vaginal delivery.,HISTORY OF PRESENT ILLNESS: ,The patient is a 36-year-old African-American female who is a G-2, P-2-0-0-2 with an EDC of 08/30/2003. She is blood type AB -ve with antibody screen negative and is also rubella immune, VDRL nonreactive, hepatitis B surface antigen negative, and HIV nonreactive. She does have a history of sickle cell trait. She presented to Labor and Delivery Triage at 40 and 3/7th weeks gestation with complaint of contractions every ten minutes. She also stated that she has lost her mucous plug. She did have fetal movement, noted no leak of fluid, did have some spotting. On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions. She was evaluated by sterile vaginal exam and was noted to be 4 cm dilated, 70% effaced, and -3 station. This was a change from her last office exam, at which she was 1 cm to 2 cm dilated.,PROCEDURE DETAILS:, The patient was admitted to Labor and Delivery for expected management of labor and AROM was performed and the amniotic fluid was noted to be meconium stained. After her membranes were ruptured, contractions did increase to every two to three minutes as well as the intensity increased. She was given Nubain for discomfort with good result.,She had a spontaneous vaginal delivery of a live born female at 11:37 with meconium stained fluid as noted from ROA position. After controlled delivery of the head, tight nuchal cord was noted, which was quickly double clamped and cut and the shoulders and body were delivered without difficulty. The infant was taken to the awaiting pediatrician. Weight was 2870 gm, length was 51 cm. The Apgars were 6 at 1 minute and 9 at 5 minutes. There was initial neonatal depression, which was treated by positive pressure ventilation and the administration of Narcan.,Spontaneous delivery of an intact placenta with a three-vessel cord was noted at 11:45. On examination, there were no noted perineal abrasions or lacerations. On vaginal exam, there were no noted cervical or vaginal sidewall lacerations. Estimated blood loss was less than 250 cc. Mother and infant are in recovery doing well at this time.surgery, roa position, arom, labor and delivery, spontaneous vaginal delivery, term pregnancy, contracting, meconium, lacerations, pregnancy, contractions, vaginal,

SUBJECTIVE:, This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. The patient states that her husband has been diagnosed with high blood cholesterol as well. She wants some support with some dietary recommendations to assist both of them in healthier eating. The two of them live alone now, and she is used to cooking for large portions. She is having a hard time adjusting to preparing food for the two of them. She would like to do less food preparation, in fact. She is starting a new job this week.,OBJECTIVE:, Her reported height is 5 feet 4 inches. Today’s weight was 170 pounds. BMI is approximately 29. A diet history was obtained. I instructed the patient on a 1200 calorie meal plan emphasizing low-saturated fat sources with moderate amounts of sodium as well. Information on fast food eating was supplied, and additional information on low-fat eating was also supplied.,ASSESSMENT:, The patient’s basal energy expenditure is estimated at 1361 calories a day. Her total calorie requirement for weight maintenance is estimated at 1759 calories a day. Her diet history reflects that she is making some very healthy food choices on a regular basis. She does emphasize a lot of fruits and vegetables, trying to get a fruit or a vegetable or both at most meals. She also is emphasizing lower fat selections. Her physical activity level is moderate at this time. She is currently walking for 20 minutes four or five days out of the week but at a very moderate pace with a friend. We reviewed the efforts at weight reduction identifying 3500 calories in a pound of body fat and the need to gradually and slowly chip away at this number on a long-term basis for weight reduction. We discussed the need to reduce calories from what her current patterns are and to hopefully increase physical activity slightly as well. We discussed menu selection, as well as food preparation techniques. The patient appears to have been influenced by the current low-carb, high-protein craze and had really limited her food selections based on that. I was able to give her some more room for variety including some moderate portions of potatoes, pasta and even on occasion breading her meat as long as she prepares it in a low-fat fashion which was discussed.,PLAN:, Recommend the patient increase the intensity and the duration of her physical activity with a goal of 30 minutes five days a week working at a brisk walk. Recommend the patient reduce calories by 500 daily to support a weight loss of one pound a week. This translates into a 1200-calorie meal plan. I encouraged the patient to keep food records in order to better track calories consumed. I recommended low fat selections and especially those that are lower in saturated fats. Emphasis would be placed on moderating portions of meat and having more moderate snacks between meals as well. This was a one-hour consultation. I provided my name and number should additional needs arise.soap / chart / progress notes, hyperlipidemia, hypertension, gastroesophageal reflux disease, weight reduction, dietary recommendations, healthier eating, meal plan, dietary consultation, low fat, physical activity, weight, gastroesophageal, dietary, calories, food

PREOPERATIVE DIAGNOSES:,1. Acute pain.,2. Fever postoperatively.,POSTOPERATIVE DIAGNOSIS:,1. Acute pain.,2. Fever postoperatively.,3. Hemostatic uterine perforation.,4. No bowel or vascular trauma.,PROCEDURE PERFORMED:,1. Diagnostic laparoscopy.,2. Rigid sigmoidoscopy by Dr. X.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Scant.,SPECIMEN:, None.,INDICATIONS: ,This is a 17-year-old African-American female, gravida-1, para-1, and had a hysteroscopy and dilation curettage on 09/05/03. The patient presented later that evening after having increasing abdominal pain, fever and chills at home with a temperature up to 101.2. The patient denied any nausea, vomiting or diarrhea. She does complain of some frequent urination. Her vaginal bleeding is minimal.,FINDINGS: , On bimanual exam, the uterus is approximately 6-week size, anteverted, and freely mobile with no adnexal masses appreciated. On laparoscopic exam, there is a small hemostatic perforation noted on the left posterior aspect of the uterus. There is approximately 40 cc of serosanguineous fluid in the posterior cul-de-sac. The bilateral tubes and ovaries appeared normal. There is no evidence of endometriosis in the posterior cul-de-sac or along the bladder flap. There is no evidence of injury to the bowel or pelvic sidewall. The liver margin, gallbladder and remainder of the bowel including the appendix appeared normal.,PROCEDURE: , After consent was obtained, the patient was taken to the Operating Room where general anesthetic was administered. The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. A sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum. The uterine manipulator was then placed into the patient's cervix and the vulsellum tenaculum and sterile speculum were removed. Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made. Veress needle was placed through this incision and the gas turned on. When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate. A 11 mm trocar was then placed through this incision. The camera was placed with the above findings noted. A 5 mm step trocar was placed 2 cm superior to the pubic bone and along the midline. A blunt probe was placed through this trocar to help for visualization of the pelvic and abdominal organs. The serosanguineous fluid of the cul-de-sac was aspirated and the pelvis was copiously irrigated with sterile saline. At this point, Dr. X was consulted. He performed a rigid sigmoidoscopy, please see his dictation for further details. There does not appear to be any evidence of colonic injury. The saline in the pelvis was then suctioned out using Nezhat-Dorsey. All instruments were removed. The 5 mm trocar was removed under direct visualization with excellent hemostasis noted. The camera was removed and the abdomen was allowed to desufflate. The 11 mm trocar introducer was replaced and the trocar removed. The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion. Approximately 10 cc of 0.25% Marcaine was injected into the incision sites for postoperative pain relief. Steri-Strips were then placed across the incision. The uterine manipulator was then removed from the patient's cervix with excellent hemostasis noted. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct at the end of the procedure. The patient was taken to the recovery room in satisfactory condition.,She will be followed immediately postoperatively within the hospital and started on IV antibiotics.surgery, uterine perforation, vascular, bowel, diagnostic laparoscopy, vulsellum tenaculum, uterine manipulator, excellent hemostasis, rigid sigmoidoscopy, laparoscopy, sigmoidoscopy, postoperatively, trocar,

EXAM:, CT head.,REASON FOR EXAM:, Seizure disorder.,TECHNIQUE:, Noncontrast CT head.,FINDINGS: , There is no evidence of an acute intracranial hemorrhage or infarction. There is no midline shift, intracranial mass, or mass effect. There is no extra-axial fluid collection or hydrocephalus. Visualized portions of the paranasal sinuses and mastoid air cells appear clear aside from mild right frontal sinus mucosal thickening.,IMPRESSION:, No acute process in the brain.neurology, mass effect, extra-axial fluid, hydrocephalus, midline shift, intracranial mass, paranasal sinuses, mastoid air cells, frontal sinus, mucosal thickening, seizure disorder, ct head, seizure, sinuses, ct, head, noncontrast,

PREOPERATIVE DIAGNOSIS:, Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Left inguinal hernia, direct.,PROCEDURE: , Left inguinal herniorrhaphy, modified Bassini.,DESCRIPTION OF PROCEDURE: ,The patient was electively taken to the operating room. In same day surgery, Dr. X applied a magnet to the pacemaker defibrillator that the patient has to change it into a fixed mode and to protect the device from the action of the cautery. Informed consent was obtained, and the patient was transferred to the operating room where a time-out process was followed and the patient under general endotracheal anesthesia was prepped and draped in the usual fashion. Local anesthesia was used as a field block and then an incision was made in the left inguinal area and carried down to the external oblique aponeurosis, which was opened. The cord was isolated and protected. It was dissected out. The lipoma of the cord was removed and the sac was high ligated. The main hernia was a direct hernia due to weakness of the floor. A Bassini repair was performed. We used a number of interrupted sutures of 2-0 Tevdek __________ in the conjoint tendon and the ilioinguinal ligament.,The external oblique muscle was approximated same as the soft tissue with Vicryl and then the skin was closed with subcuticular suture of Monocryl. The dressing was applied and the patient tolerated the procedure well, estimated blood loss was minimal, was transferred to recovery room in satisfactory condition.surgery, inguinal herniorrhaphy, modified bassini, herniorrhaphy modified bassini, hernia direct, inguinal hernia, inguinal, bassini,

PREOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,POSTOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip.,ANESTHESIA: ,Spinal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Less than 100 cc.,HISTORY: ,The patient is an 86-year-old female who was seen and evaluated in ABCD General Hospital Emergency Department on 08/30/03 after sustaining a fall at her friend's house. The patient states that she was knocked over by her friend's dog. She sustained a subcapital left hip fracture. Prior to admission, she lived alone in Terrano, was ambulating with a walker. All risks, benefits, and potential complications of the procedure were then discussed with the patient and informed consent was obtained.,HARDWARE SPECIFICATIONS: , A 28 mm medium head was used, a small cemented femoral stem was used, and a 28 x 46 cup was used.,PROCEDURE: ,All risks, benefits, and potential complications of the procedure were discussed with the patient, informed consent was obtained. She was then transferred from the preoperative care unit to operating suite #1. Department of Anesthesia administered spinal anesthetic without complications.,After this, the patient was transferred to the operating table and positioned. All bony prominences were well padded. She was positioned on a beanbag in the right lateral decubitus position with the left hip facing upwards. The left lower extremity was then sterilely prepped and draped in the normal fashion. A skin maker was then used to mark all bony prominences. Skin incision was then carried out extending from the greater trochanter in a curvilinear fashion posteriorly across the buttocks. A #10 blade Bard-Parker scalpel was used to incise the skin through to the subcutaneous tissues. A second #10 blade was then used to incise through the subcutaneous tissue down to the fascia lata. This was then incised utilizing Metzenbaum scissors. This was taken down to the bursa, which was removed utilizing a rongeur. Utilizing a periosteal elevator as well as the sponge, the fat was then freed from the short external rotators of the left hip after these were placed and stretched. The sciatic nerve was then visualized and retracted utilizing a Richardson retractor. Bovie was used to remove the short external rotators from the greater trochanter, which revealed the joint capsule. The capsule was cleared and incised utilizing a T-shape incision. A fracture hematoma was noted upon entering the joint capsule as well as subcapital hip fracture. A cork screw was then used to remove the fractured femoral head, which was given to the scrub tech which was sized on the back table. All bony remnants were then removed from the acetabulum and surrounding soft tissue with a rongeur. Acetabulum was then inspected and found to be clear. Attention was then turned to the proximal femur where a cutting tunnel was used to mark the femur for the femoral neck cut. An oscillating saw was then used to make the femoral cut. Box osteotome was then used to remove the bone from proximal femur. A Charnley awl was then used to open the femoral canal, paying close attention to keep the awl in the lateral position. Next, attention was turned to broaching. Initially, a small broach was placed, first making efforts to lateralize the broach then the femoral canal. It was felt that the patient has less benefit from a cemented prosthesis and a small size was appropriate. Next, the trial components were inserted consisting of the above-mentioned component sizes. The hip was taken through range of motion and tested to adduction, internal and external rotations as well as with a shuck and a posterior directed force on a flexed tip. It was noted that these size were stable through the range of motion. Next, the trial components were removed and the femoral canal was copiously irrigated and suctioned dried utilizing Super sucker and __________ then inserted pressuring the femoral canal. The femoral component was then inserted and then held under pressure. Extruding cement was removed from the proximal femur. After the cement had fully hardened and dried, the head and cup were applied. The hip was subsequently reduced and taken again through range of motion, which was felt to be stable.,Next, the capsule was closed utilizing #1 Ethibond in figure-of-eight fashion. Next, the fascia lata was repaired utilizing a figure-of-eight Ethibond sutures. The most proximal region at the musculotendinous junction was repaired utilizing a running #1 Vicryl suture. The wound was then copiously irrigated again to suction dry. Next, the subcutaneous tissues were reapproximated using #2-0 Vicryl simple interrupted sutures. The skin was then reapproximated utilizing skin clips. Sterile dressing was applied consisting of Adaptic, 4x4s, ABDs as well as foam tape. The patient was then transferred from the operating table to the gurney. Leg lengths were checked, which were noted to be equal and abduction pillow was placed. The patient was then transferred to the Postoperative Care Unit in stable condition.surgery, austin-moore bipolar hemiarthroplasty, subcapital left hip fracture, hip fracture, austin moore bipolar hemiarthroplasty, subcutaneous tissues, hip, hemiarthroplasty, austin, cemented, femur, subcapital, fracture, femoral,

PREOPERATIVE DIAGNOSIS: ,Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Ahmed valve model S2 implant with pericardial reinforcement XXX eye,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage, hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox and Ocular. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion. A speculum was placed on the eyelids and microscope was brought into position. A #7-0 Vicryl suture was passed through the superotemporal limbus and traction suture was placed at the superotemporal limbus and the eye was rotated infranasally so as to expose the superotemporal conjunctiva. At this point, smooth forceps and Westcott scissors were used to create a 100-degree superotemporal conjunctival peritomy, approximately 2 mm posterior to the superotemporal limbus. This was then dissected anteriorly to the limbus edge and then posteriorly. Steven scissors were then dissected in a superotemporal quadrant between the superior and lateral rectus muscles to provide good exposure. At this point, we primed the Ahmed valve with a #27 gauge cannula using BSS and it was noted to be patent. We then placed Ahmed valve in the superotemporal subconjunctival recess underneath the subtenon space and this was pushed posteriorly. We then measured with calipers so that it was positioned 9 mm posterior to the limbus. The Ahmed valve was then tacked down with #8-0 nylon suture through both fenestrations. We then applied light cautery to the superotemporal episcleral bed. We placed a paracentesis at the temporal position and inflated the anterior chamber with a small amount of Healon. We then used a #23 gauge needle and entered the superotemporal sclera, approximately 1 mm posterior to the limbus into the anterior chamber away from iris and away from cornea. We then trimmed the tube, beveled up in a 30 degree fashion with Vannas scissors, and introduced the tube through the #23 gauge tract into the anterior chamber so that approximately 2-3 mm of tube was extending into the anterior chamber. We burped some of the Healon out of the anterior chamber and filled it with BSS and we felt that the tube was in good position away from the lens, away from the cornea, and away from the iris. We then tacked down the tubes to the sclera with #8-0 Vicryl suture in a figure-of- eight fashion. The pericardium was soaked in gentamicin. We then folded the pericardium 1x1 cm piece onto itself and then placed it over the tube and this was tacked down in all four quadrants to the sclera with #8-0 nylon suture. At this point, we then re-approximated the conjunctiva to its original position and we closed it with an #8-0 Vicryl suture on a TG needle in a running fashion with interrupted locking bites. We then removed the traction suture. At the end of the case, the pupil was round, the chamber was deep, the tube appeared to be well positioned. The remaining portion of the Healon was burped out of the anterior chamber with BSS and the pressure was felt to be adequate. The speculum was removed. Ocuflox and Maxitrol ointment were placed over the eye. Then, an eye patch and shield were placed over the eye. The patient was awakened and taken to the recovery room in stable condition.ophthalmology, tube shunt, ahmed valve, healon, maxitrol ointment, ocuflox, open angle, anterior chamber, bleeding, conjunctival peritomy, cornea, corneal edema, corneal hemorrhage, diplopia, elevated pressure, glaucoma, hypotony, infection, loss of the eye, loss of vision, ophthalmic fashion, ptosis, reoperation, retinal detachment, sclera, superotemporal, worsening of glaucoma, ahmed valve model, superotemporal limbus, eye, ahmed, implant, bss, valve, limbus,

HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. He states that he was in his usual state of health when he awoke one morning in January 2009. He had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. He was able to drive. However, the next day he woke up and he had double vision again. Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe. He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation. He was seen by a primary care physician who sent him for an ophthalmologic evaluation. He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm. The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia. Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together. He still does not drive. He also is not working due to the double vision. There is no temporal fluctuation to the double vision. More recently, over the past month, he has developed right supraorbital pain. It actually feels like there is pain under his right lid. He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system. Dr. X saw the patient on February 2, 2009, when he was in the emergency department. He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side. MRV was negative and MRI of the brain with and without contrast was also negative. He also had an MRI of the orbit with and without contrast that was normal. His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis. He had left gaze diplopia. The pupils were equal, round, and reactive to light. His neurological examination was otherwise entirely normal. According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil. There was also right medial rectus as well as possibly other extraocular abnormalities. I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history. He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:, He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife. He was an IT software developer, but he has been out of work for several months. He smokes less than a pack of cigarettes daily. He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s. His father had colon cancer. He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: BP 124/76nan

PREOPERATIVE DIAGNOSIS: , Bladder tumor.,POSTOPERATIVE DIAGNOSIS: , Bladder tumor.,PROCEDURE PERFORMED: , Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Bladder tumor and specimen from base of bladder tumor.,DRAINS: , A 22-French 3-way Foley catheter, 30 mL balloon.,ESTIMATED BLOOD LOSS:, Minimal.,INDICATIONS FOR PROCEDURE: , This is a 74-year-old male who presented with microscopic and an episode of gross hematuria. He underwent an IVP, which demonstrated enlarged prostate and normal upper tracts. Cystoscopy in the office demonstrated a 2.5- to 3-cm left lateral wall bladder tumor. He is brought to the operating room for transurethral resection of that bladder tumor.,DESCRIPTION OF OPERATION: , After preoperative counseling of the patient and his wife, the patient was taken to the operating room and administered a spinal anesthetic. He was placed in lithotomy position and prepped and draped in the usual fashion. Using the visual obturator, the resectoscope was then inserted per urethra into the bladder. The bladder was inspected confirming previous cystoscopic findings of a 2.5- to 3-cm left lateral wall bladder tumor away from the ureteral orifice. Using the resectoscope loop, the tumor was then resected down to its base in a stepwise fashion. Following completion of resection down to the base, the bladder was _______ free of tumor specimen. The resectoscope was then reinserted and the base of the bladder tumor was then resected to get the base of the bladder tumor specimen, this was sent as a separate pathological specimen. Hemostasis was assured with electrocautery. The base of the tumor was then fulgurated again and into the periphery out in the normal mucosa surrounding the base of the bladder tumor. Following completion of the fulguration, there was good hemostasis. The remainder of the bladder was without evidence of significant abnormality. Both ureteral orifices were visualized and noted to drain freely of clear urine. The bladder was filled and the resectoscope was removed. A 22-French 3-way Foley catheter was inserted per urethra into the bladder. The balloon was inflated to 30 mL. The catheter with sterile continuous irrigation and was noted to drain clear irrigant. The patient was then removed from lithotomy position. He was in stable condition.urology, turbt, bladder tumor, cystoscopic, resectoscope, hemostasis, foley catheter, tumor, bladder, lithotomy, transurethral, resection, hematuria,

HISTORY OF PRESENT ILLNESS: , This is a 48-year-old black male with stage IV chronic kidney disease, likely secondary to HIV nephropathy who presents to clinic for followup having missed prior clinic appointments. He was last seen in this clinic on 05/29/2007 by Dr. X. This is the first time that I have met the patient. The patient's history of renal insufficiency dates back to 06/2006 when he was hospitalized for an HIV-associated complication. He is unclear of the exact reason for his hospitalization at that time, but he was diagnosed with renal insufficiency and was followed in our Renal Clinic for approximately one year. He had a baseline creatinine during that time of between 3.2 to 3.3. When he was initially diagnosed with renal insufficiency, he had been noncompliant with his HAART regimen. Since that time, he has been very compliant with treatment for his HIV and is seeing Dr. Y in our Infectious Disease Clinic. He is currently on three-drug antiretroviral therapy. His last CD4 count in 03/2008 was 350. He has had no HIV complications since he was last seen in our clinic. The patient is also followed by Dr. Z at the outpatient VA Clinic, here in ABCD, although he has not seen her in approximately one year. The patient has an AV fistula that was placed in late 2006. The latest blood work that I have is from 06/11/2008 and shows a serum creatinine of 3.8, which represents a GFR of 22 and a potassium of 5.9. These laboratories were drawn by his infectious disease doctor and the results prompted their recommendation for him to return to our clinic for further evaluation. The only complaint that the patient has at this time is some difficulty sleeping. He was given Ambien by his primary care doctor, but this has not helped significantly with his difficulty sleeping. He says that he has trouble getting to sleep. The Ambien will allow him to sleep for about two hours, and then he is awake again. He is tired during the day, but is not taking any daytime naps. He has no history of excessive snoring or apneic periods. He has no history of falling asleep at work or while driving. He has never had a formal sleep study. He does continue to work in sales at a local butcher shop.,REVIEW OF SYSTEMS: ,He denies any change in his appetite. He has actually gained some weight in recent months. He denies any nausea, vomiting, or abdominal discomfort. He denies any pruritus. He denies any lower extremity edema. All other systems are reviewed and negative.,PAST MEDICAL HISTORY:,1. Stage IV chronic kidney disease with most recent GFR of 22.,2. HIV diagnosed in 09/2006 with the most recent CD4 count of 350 in 03/2008.,3. Hyperlipidemia.,4. Hypertension.,5. Secondary hyperparathyroidism.,6. Status post right upper extremity AV fistula in the fall of 2006.,7. History of a right brachial plexus palsy.,8. Recent lower back pain, status post lumbar steroid injection.,ALLERGIES:, HE SAYS THAT VITAMIN D HAS CAUSED HEADACHES.,MEDICATIONS:,1. Kaletra daily.,2. Epivir one daily.,3. Ziagen two daily.,4. Lasix 20 mg b.i.d.,5. Valsartan 20 mg b.i.d.,6. Ambien 10 mg q.h.s.,SOCIAL HISTORY: , He lives here in ABCD. He is employed at the sales counter of a local butcher shop. He continues to smoke one pack of cigarettes daily, as he has for the past 28 years. He denies any alcohol or illicit substances.,FAMILY HISTORY:, His mother is deceased. He said that she had some type of paralysis before she died. His father is deceased at age 64 of a head and neck cancer. He has a 56-year-old brother with type-two diabetes and blindness secondary to diabetic retinopathy. He has a 41-year-old brother who has hypertension. He has a sister who has thyroid disease.,PHYSICAL EXAMINATION:,VITAL SIGNS: Weight is 191 pounds. His temperature is 97.1. Pulse is 94. Blood pressure by automatic cuff 173/97, by manual cuff 180/90.,HEENT: His oropharynx is clear without thrush or ulceration.,NECK: Supple without lymphadenopathy or thyromegaly.,HEART: Regular with normal S1 and S2. There are no murmurs, rubs, or gallops. He has no JVD.,LUNGS: Clear to auscultation bilaterally without wheezes, rhonchi, or crackles.,ABDOMEN: Soft, nontender, nondistended, without abdominal bruit or organomegaly.,MUSCULOSKELETAL: He has difficulty with abduction of his right shoulder.,ACCESS: He has a right forearm AV fistula with an audible bruit and a palpable thrill. There is no sign of stenosis. The vascular access looks like it is ready to use.,EXTREMITIES: No peripheral edema.,SKIN: No bruises, petechiae, or rash.,LABS: ,Sodium was 140, potassium 5.9, chloride 114, bicarbonate 18. BUN is 49, creatinine 4.3. GFR is 19. Albumin 3.2. Protein 7. AST 17, ALT 16, alkaline phosphatase 106. Total bilirubin 0.4. Calcium 9.1., phosphorus 4.7, PTH of 448. The corrected calcium was 9.7. WBC is 8.9, hemoglobin 13.4, platelet 226. Total cholesterol 234, triglycerides 140, LDL 159, HDL 47. His ferritin is 258, iron is 55, and percent sat is 24.,IMPRESSION: ,This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.,RECOMMENDATIONS:,1. Renal. His serum creatinine is progressively worsening. His creatinine was 3.2 the last time we saw him in 05/2007 and today is 4.3. This represents a GFR of 19. This is stage IV chronic kidney disease. He does have vascular access and this appears to be ready to use. He is having some difficulty sleeping and it is possible that this represents some early signs of uremia. Otherwise, he has no signs or symptoms of uremia at this time. I am going to touch base with the dialysis educator and try to get The patient in to the dialysis teaching classes. He has already received some literature for the dialysis teaching, but has not yet enrolled in the classes. I have encouraged him to continue to exercise his right forearm. I am also going to contact the transplant coordinator and see if he can be evaluated for possible transplant. Given his progression of his chronic kidney disease, I will anticipate that he will need to start dialysis soon.,2. Hypertension. I have added labetolol 100 mg b.i.d. to his antihypertensive regimen. He shows no signs at this point of volume overload, although if he does demonstrate this in the future, his Lasix could be increased. Goal blood pressure would be less than 130/80.,3. Hyperkalemia. I am going to instruct him in a low-potassium diet and decrease his valsartan to 20 mg daily. I will have him return in one week to recheck his potassium. If his potassium continues to remain elevated, he may require initiation of dialysis for this.,4. Bone metabolism. His PTH is elevated and I am going to add PhosLo 800 mg t.i.d. with meals. His corrected calcium is 9.7, and I would like to avoid calcium-containing phosphate bonders in this situation.,5. Acid base. His bicarbonate is 18 and I will initiate the sodium bicarbonate 650 mg three tablets t.i.d.,6. Anemia. His hemoglobin is at goal for this stage of chronic kidney disease. His iron stores are adequate.nan

ADMISSION PSYCHIATRIC EVALUATION,IDENTIFYING INFORMATION/REFERRAL DATA: ,This is a 16-year-old Caucasian adolescent female who is going into ninth grade and lives with her mother, the mother's boyfriend, and a 12, 11, and 10-year-old sister. She also has a stepsister that is 8 years old. The patient was brought in by her mother after being picked up by Anchorage Police Department (APD). She was brought to our institution for an assessment. ,REASON FOR ADMISSION/CHIEF COMPLAINT: ,The patient ran away in the middle of the night on Sunday, 07/19/04, and she has been on the run since then. Her friends report to the parents that she is suicidal and that she had a knife. A friend took a knife away from her to keep her from cutting herself. ,HISTORY OF PRESENT ILLNESS: ,This is a 16-year-old Caucasian adolescent girl who was brought in by APD and her parents. This is her first admission. APD picked her up from a runaway and brought her at her mother's request after some friends told the mother that she was suicidal. The mother found journals in her room talking about suicide, and that she has been raped. There were no details and the client denies that she was raped. She is sexually active with one boyfriend, also 16 years old, that she met while going to school in Ketchican in the last school year. She has been with the mother only the last two months and the same Ketchican boyfriend, Michael, followed her to Anchorage. She reports symptoms of depression, no energy, initial and middle insomnia, eating more. She is very irritable and has verbal altercations wither sister who is 14. She admits to being sad and also having poor concentration. She had marked drop in school functioning in the last year, and will need to repeat the ninth grade. The mother is very concerned with the patent's safety and feels she is not able to control her. She lived with her stepfather when she was 8 to 9 years old, but she was too problematic and not successful living there in Ketchican. She went to live with her dad up to age 16. Now she is living with her mother and her mother's boyfriend for the last two months. In December, her grandmother passed away and she was with her grandmother and her mother during all this process, which is when she started feeling depressed.,LEGAL HISTORY: ,No legal history.,TREATMENT/PSYCHIATRIC HISTORY: ,The patient was evaluated once at XYZ when she was 14 due to depression, also when she was 3 years old when a new sibling came into the family. ,FAMILY PSYCHIATRIC HISTORY: ,The patient has three siblings with ADHD (Attention Deficit Hyperactivity Disorder) and two of her siblings are in an RTC (Residential Treatment Center) Program, one with the diagnosis of Bipolar Disorder, and the other with ADHD and bipolar condition.,PERTINENT MEDICAL HISTORY: ,She was born with some eczema. At age 4 she was involved in an accident where she cut one of her legs and needed sutures. There is no history of seizure or head injury. She reports loss of consciousness. This will be investigated; there are no details about it. She admits to being sexually active, protecting herself using condoms. Her last menstruation period was 07/20/04. ,ALLERGIES: ,No allergies.,DEVELOPMENT AGE FACTORS: , The mother reports she was born with some jaundice and eczema. Early milestones walk and talk. The patient appears to function at the expected age level. ,PERTINENT PSYCHOSOCIAL DATA: ,Complete pertinent psychosocial will be obtained by our clinician. The patient admits witnessing seeing some domestic violence when she was small, around five years old. There is an allegation of a rape that the mother found in her journal, but this is going to be investigated. ,SCHOOL HISTORY:nan

EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 26 year old with a history of instability. Examination was preformed on 12/20/2005.,FINDINGS:,There is supraspinatus tendinosis without a full-thickness tear, gap or fiber retraction and there is no muscular atrophy (series #105 images #4-6).,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is medial subluxation of the tendon under the transverse humeral ligament, and there is tendinosis of the intracapsular portion of the tendon with partial tearing, but there is no complete tear or discontinuity. Biceps anchor is intact (series #105 images #4-7; series #102 images #10-22).,There is a very large Hill-Sachs fracture, involving almost the entire posterior half of the humeral head (series #102 images #13-19). This is associated with a large inferior bony Bankart lesion that measures approximately 15 x 18mm in AP and craniocaudal dimension with impaction and fragmentation (series #104 images #10-14; series #102 images #18-28). There is medial and inferior displacement of the fragment. There are multiple interarticular bodies, some of which may be osteochondromatous and some may be osseous measuring up to 8mm in diameter. (These are too numerous to count.) There is marked stretching, attenuation and areas of thickening of the inferior and middle glenohumeral ligaments, compatible with a chronic tear with scarring but there is no discontinuity or demonstrated HAGL lesion (series #105 images #5-10).,Normal superior glenohumeral ligament.,There is no SLAP tear.,Normal acromioclavicular joint without narrowing of the subacromial space.,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There is fluid in the glenohumeral joint and biceps tendon sheath.,IMPRESSION:,There is a very large Hill-Sachs fracture involving most of the posterior half of the humeral head with an associated large and inferior and medial displaced osseous Bankart lesion.,There are multiple intraarticular bodies, and there is a partial tear of the inferior and middle glenohumeral ligaments.,There is medial subluxation of the long biceps tendon under the transverse humeral ligament with partial tearing of the intracapsular portion.,radiology, inferior and middle glenohumeral, biceps tendon, partial tearing, glenohumeral ligaments, mri, shoulder, ligament, ligaments, biceps, humeral, glenohumeral, tear, tendons

EXAM: , CT scan of the abdomen and pelvis without and with intravenous contrast.,CLINICAL INDICATION: , Left lower quadrant abdominal pain.,COMPARISON: , None.,FINDINGS: , CT scan of the abdomen and pelvis was performed without and with intravenous contrast. Total of 100 mL of Isovue was administered intravenously. Oral contrast was also administered.,The lung bases are clear. The liver is enlarged and decreased in attenuation. There are no focal liver masses.,There is no intra or extrahepatic ductal dilatation.,The gallbladder is slightly distended.,The adrenal glands, pancreas, spleen, and left kidney are normal.,A 12-mm simple cyst is present in the inferior pole of the right kidney. There is no hydronephrosis or hydroureter.,The appendix is normal.,There are multiple diverticula in the rectosigmoid. There is evidence of focal wall thickening in the sigmoid colon (image #69) with adjacent fat stranding in association with a diverticulum. These findings are consistent with diverticulitis. No pneumoperitoneum is identified. There is no ascites or focal fluid collection.,The aorta is normal in contour and caliber.,There is no adenopathy.,Degenerative changes are present in the lumbar spine.,IMPRESSION: , Findings consistent with diverticulitis. Please see report above.radiology, extrahepatic ductal dilatation, gallbladder, glands, pancreas, spleen, kidney, adrenal, abdomen and pelvis, ct scan, intravenous, abdomen,

SUBJECTIVE: , The patient states that she feels better. She is on IV amiodarone, the dosage pattern is appropriate for ventricular tachycardia. Researching the available records, I find only an EMS verbal statement that tachycardia of wide complex was seen. There is no strip for me to review all available EKG tracings show a narrow complex atrial fibrillation pattern that is now converted to sinus rhythm.,The patient states that for a week, she has been home postoperative from aortic valve replacement on 12/01/08 at ABC Medical Center. The aortic stenosis was secondary to a congenital bicuspid valve, by her description. She states that her shortness of breath with exertion has been stable, but has yet to improve from its preoperative condition. She has not had any decline in her postoperative period of her tolerance to exertion.,The patient had noted intermittent bursts of fast heart rate at home that had been increasing over the last several days. Last night, she had a prolonged episode for which she contacted EMS. Her medications at home had been uninterrupted and without change from those listed, being Toprol-XL 100 mg q.a.m., Dyazide 25/37.5 mg, Nexium 40 mg, all taken once a day. She has been maintaining her Crestor and Zetia at 20 and 10 mg respectively. She states that she has been taking her aspirin at 325 mg q.a.m. She remains on Zyrtec 10 mg q.a.m. Her only allergy is listed to latex.,OBJECTIVE:,VITAL SIGNS: Temperature 36.1, heart rate 60, respirations 14, room air saturation 98%, and blood pressure 108/60. The patient shows a normal sinus rhythm on the telemetry monitor with an occasional PAC.,GENERAL: She is alert and in no apparent distress.,HEENT: Eyes: EOMI. PERRLA. Sclerae nonicteric. No lesions of lids, lashes, brows, or conjunctivae noted. Funduscopic examination unremarkable. Ears: Normal set, shape, TMs, canals and hearing. Nose and Sinuses: Negative. Mouth, Tongue, Teeth, and Throat: Negative except for dental work.,NECK: Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST: Lungs are clear bilaterally to auscultation. The incision is well healed and without evidence of significant cellulitis.,HEART: Shows a regular rate and rhythm without murmur, gallop, heave, click, thrill or rub. There is an occasional extra beat noted, which corresponds to a premature atrial contraction on the monitor.,ABDOMEN: Soft and benign without hepatosplenomegaly, rebound, rigidity or guarding.,EXTREMITIES: Show no evidence of DVT, acute arthritis, cellulitis or pedal edema.,NEUROLOGIC: Nonfocal without lateralizing findings for cranial or peripheral nervous systems, strength, sensation, and cerebellar function. Gait and station were not tested.,MENTAL STATUS: Shows the patient to be alert, coherent with full capacity for decision making.,BACK: Negative to inspection or percussion.,LABORATORY DATA: , Shows from 12/15/08 2100, hemoglobin 11.6, white count 12.9, and platelets 126,000. INR 1.0. Electrolytes are normal with exception potassium 3.3. GFR is decreased at 50 with creatinine of 1.1. Glucose was 119. Magnesium was 2.3. Phosphorus 3.8. Calcium was slightly low at 7.8. The patient has had ionized calcium checked at Munson that was normal at 4.5 prior to her discharge. Troponin is negative x2 from 2100 and repeat at 07:32. This morning, her BNP was 163 at admission. Her admission chest x-ray was unremarkable and did not show evidence of cardiomegaly to suggest pericardial effusion. Her current EKG tracing from 05:42 shows a sinus bradycardia with Wolff-Parkinson White Pattern, a rate of 58 beats per minute, and a corrected QT interval of 557 milliseconds. Her PR interval was 0.12.,We received a call from Munson Medical Center that a bed had been arranged for the patient. I contacted Dr. Varner and we reviewed the patient's managed to this point. All combined impression is that the patient was likely to not have had actual ventricular tachycardia. This is based on her EP study from October showing her to be non-inducible. In addition, she had a cardiac catheterization that showed no evidence of coronary artery disease. What is most likely that the patient has postoperative atrial fibrillation. Her WPW may have degenerated into a ventricular tachycardia, but this is unlikely. At this point, we will convert the patient from IV amiodarone to oral amiodarone and obtain an echocardiogram to verify that she does not have evidence of pericardial effusion in the postoperative period. I will recheck her potassium, magnesium, calcium, and phosphorus at this point and make adjustments if indicated. Dr. Varner will be making arrangements for an outpatient Holter monitor and further followup post-discharge.,IMPRESSION:,1. Atrial fibrillation with rapid ventricular response.,2. Wolff-Parkinson White Syndrome.,3. Recent aortic valve replacement with bioprosthetic Medtronic valve.,4. Hyperlipidemia.general medicine, ventricular tachycardia, wolff-parkinson white syndrome., ventricular response, medtronic valve, wolff parkinson white syndrome, aortic valve replacement, atrial fibrillation, atrial, aortic, tachycardia, fibrillation, ventricular, valve, medtronic,

REASON FOR CONSULTATION:, Breast reconstruction post mastectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old lady, who had gone many years without a mammogram when she discovered a lump in her right breast early in February of this year. She brought this to the attention of her primary care doctor and she soon underwent ultrasound and mammogram followed by needle biopsy, which revealed that there was breast cancer. This apparently was positive in two separate locations within the suspicious area. She also underwent MRI, which suggested that there was significant size to the area involved. Her contralateral left breast appeared to be uninvolved. She has had consultation with Dr. ABC and they are currently in place to perform a right mastectomy.,PAST MEDICAL HISTORY: , Positive for hypertension, which is controlled on medications. She is a nonsmoker and engages in alcohol only moderately.,PAST SURGICAL HISTORY: , Surgical history includes uterine fibroids, some kind of cyst excision on her foot, and cataract surgery.,ALLERGIES: , None known.,MEDICATIONS: , Lipitor, ramipril, Lasix, and potassium.,PHYSICAL EXAMINATION: , On examination, the patient is a healthy looking 51-year-old lady, who is moderately overweight. Breast exam reveals significant breast hypertrophy bilaterally with a double D breast size and significant shoulder grooving from her bra straps. There are no any significant scars on the right breast as she has only undergone needle biopsy at this point. Exam also reveals abdomen where there is moderate excessive fat, but what I consider a good morphology for a potential TRAM flap.,IMPRESSION:, A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction. We discussed the breast reconstruction options in some detail including immediate versus delayed reconstruction and autologous tissue versus implant reconstruction. I think for a lady of this physical size and breast morphology that the likelihood of getting a good result with a tissue expander reconstruction is rather slim. A further complicating factor is the fact that she may well be undergoing radiation after her mastectomy. I would think this would make a simple tissue expander reconstruction virtually beyond the balance of consideration. I have occasionally gotten away with tissue expanders with reasonable results in irradiated patients when they are thinner and smaller breasted, but in a heavier lady with large breasts, I think it virtually deemed to failure. We therefore, mostly confine our discussion to the relative merits of TRAM flap breast reconstruction and latissimus dorsi reconstruction with implant. In either case, the contralateral breast reduction would be part of the overall plan., ,The patient understands that the TRAM flap although not much more lengthy of a procedure is a little comfortable recovery. Since we are sacrificing a rectus abdominus muscle that can be more discomfort and difficulties in healing both due to it being a respiratory muscle and to its importance in sitting up and getting out of bed. In any case, she does prefer this option in order to avoid the need for an implant. We discussed pros and cons of the surgery, including the risks such as infection, bleeding, scarring, hernia, or bulging of the donor site, seroma of the abdomen, and fat necrosis or even the skin slough in the abdomen. We also discussed some of the potential flap complications including partial or complete necrosis of the TRAM flap itself.,PLAN: , The patient is definitely interested in undergoing TRAM flap reconstruction. At the moment, we are planning to do it as an immediate reconstruction at the time of the mastectomy. For this reason, I have made arrangements to do initial vascular delay procedure within the next couple of days. We may cancel this if the chance of postoperative irradiation is high. If this is the case, I think we can do a better job on the reconstruction if we defer it. The patient understands this and will proceed according to the recommendations from Dr. ABC and from the oncologist.consult - history and phy., breast reconstruction, mastectomy, lump, breast, mammogram, needle biopsy, breast cancer, hypertrophy, tram flap, latissimus dorsi,

Collar Tubes techniqueent - otolaryngology, ototopical drops, tympanic, membrane, ear canals, cerumen, collar tubes, incision, myringotomy, collar, tubes, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

PREOPERATIVE DIAGNOSIS:, Cervical spondylosis.,POSTOPERATIVE DIAGNOSIS:, Cervical spondylosis.,OPERATION PERFORMED:, Cervical Medial Branch Blocks under fluoroscopic control.,ANESTHESIA:, Local and IV.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE:, After proper consent was obtained, the patient was taken to the fluoroscopy suite and place on a fluoroscopy table in a prone position with a chest roll in place. The neck was placed in a flexed position. The patient was monitored with blood pressure cuff, EKG, and pulse oximetry and given oxygen via nasal cannula. The patient was lightly sedated. The skin was prepped and draped in a sterile classical fashion.,Under fluoroscopy control, the waists of the articular pillars were identified and marked. Local anesthesia infiltrated subcutaneously and deep extending down toward these previously marked points. Once the anesthesia was established, a 10-cm, 22-gauge needle was placed in contact with the waists of the articular pillars at the affected levels that were previously mentioned. This was done under direct fluoroscopic control with PA views initially for orientation utilizing a gun barrel technique and then a lateral view to determine the depth of the needle. The needle tip was positioned such that the tip was at the posterior aspect of the articular pillar's waist and was then incrementally advanced until the tip was at the center of the pedicle, where the medial branch lies. For C3 to C6, the medial branch is along the ventral aspect of a line that connects the greatest antero-posterior diameter of the articular pillar but remains dorsal to the foramen as seen on lateral imaging. For a C7 medial branch block, the needle tip is positioned more superiorly such that it overlies the superior articular process. For a C8 medial branch block, the needle is placed at the junction of the superior articulating facet and the base of the transverse process of T1.,Once the needles were in place, each level was then injected with 1cc of a 10 cc solution of Marcaine 0.5% mixed with 50mg on methyl prednisolone acetate. The patient tolerated the procedure well without any difficulties or complications.pain management, fluoroscopic control, fluoroscopy, cervical medial branch blocks, medial branch blocks, cervical spondylosis, articular pillars, cervical, anesthesia, spondylosis, fluoroscopic, blocks, needle, medial, branch,

OPERATION PERFORMED:, Full mouth dental rehabilitation in the operating room under general anesthesia.,PREOPERATIVE DIAGNOSES: ,1. Severe dental caries.,2. Hemophilia.,POSTOPERATIVE DIAGNOSES: ,1. Severe dental caries.,2. Hemophilia.,3. Nonrestorable teeth.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: ,1 hour and 22 minutes.,BRIEF HISTORY: ,The patient was first seen by me on 08/23/2007, who is 4-year-old with hemophilia, who received infusion on Tuesdays and Thursdays and he has a MediPort. Mom reported history of high fever after surgery and he has one seizure previously. He has history of trauma to his front teeth and physician put him on antibiotics. He was only cooperative for having me do a visual examination on his anterior teeth. Visual examination revealed severe dental caries and dental abscess from tooth #E and his maxillary anterior teeth needed to be extracted. Due to his young age and hemophilia, I felt that he would be best served to be taken to the hospital operating room.,OTHER PREPARATION: ,The child was brought to the Hospital Day Surgery accompanied by his mother. There, I met with her and discussed the needs of the child, types of restoration to be performed, and the risks, and benefits of the treatment as well as the options and alternatives of the treatment. After all her questions and concerns were addressed, she gave her informed consent to proceed with treatment. The patient's history and physical examination was reviewed. He was given factor for appropriately for his hemophilia prior to being taken back to the operating room. Once he was cleared by Anesthesia, the child was taken back to the operating room.,OPERATIVE PROCEDURE: ,The patient was placed on the surgical table in the usual supine position with all extremities protected. Anesthesia was induced by mask. The patient was then intubated with an oral tube and the tube was stabilized. The head was wrapped and IV was started. The head and neck were draped with sterile towels and the body was covered with a lead apron and sterile sheath. A moist continuous throat pack was placed beyond tonsillar pillars. Plastic lip and cheek retractors were then placed. Preoperative clinical photographs were taken. Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiograph. After the radiographs were taken, the lead shield was removed.,Prophylaxis was then performed using a prophy cup and fluoridated prophy paste. The patient's teeth were rinsed well. The patient's oral cavity was suctioned clean. Clinical and radiographic examination followed and areas of decay were noted. During the restorative phase, these areas of decay were incidentally removed. Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it. Final caries removal was confirmed upon reaching hard, firm and sound dentin.,Teeth restored with composite ___________ bonded with a one-step bonding agent. Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement. Non-restorable primary teeth would be extracted. The caries were extensive and invaded the pulp tissues, pulp therapy was initiated using ViscoStat and then IRM pulpotomies. Teeth treated in such a manner would then be crowned with stainless steel crowns.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris. The original treatment plan was verified with the actual treatment provided. Postoperative clinical photographs were then taken. The continuous gauze throat pack was removed with continuous suction with visualization. Topical fluoride was then placed on the teeth. At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, was taken to the recovery room, breathing spontaneously with stable vital signs.,FINDINGS: , This young patient presented with mild generalized marginal gingivitis, secondary to light generalized plaque accumulation and fair oral hygiene. All primary teeth were present. Dental carries were present on the following teeth: Tooth B, OL caries, tooth C, M, L, S caries, tooth B, caries on all surfaces, tooth E caries on all surfaces, tooth F caries on all surfaces, tooth T caries on all surfaces, tooth H, lingual and facial caries, tooth I, caries on all surfaces, tooth L caries on all surfaces, and tooth S, all caries. The remainder of his teeth and soft tissues were within normal limits. The following restoration and procedures were performed. Tooth B, OL amalgam, tooth C, M, L, S composite, tooth D, E, F, and G were extracted, tooth H, and L and separate F composite. Tooth I is stainless steel crown, tooth L pulpotomy and stainless steel crown and tooth S no amalgam. Sutures were also placed at extraction site D, E, S, and G.,CONCLUSION: ,The mother was informed of the completion of the procedure. She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care. She is to contact to myself with an event of immediate postoperative complications and after full recovery, he was discharged from recovery room in the care of his mother. She was also given prescription for Tylenol with Codeine Elixir for postoperative pain control.,

CHIEF COMPLAINT:,nan

CLINICAL HISTORY:, A 48-year-old smoker found to have a right upper lobe mass on chest x-ray and is being evaluated for chest pain. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan. The lower lobe mass was approximately 1 cm in diameter and the upper lobe mass was 4 cm to 5 cm in diameter. The patient was referred for surgical treatment.,SPECIMEN:,A. Lung, wedge biopsy right lower lobe,B. Lung, resection right upper lobe,C. Lymph node, biopsy level 2 and 4,D. Lymph node, biopsy level 7 subcarinal,FINAL DIAGNOSIS:,A. Wedge biopsy of right lower lobe showing: Adenocarcinoma, Grade 2, Measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin.,B. Right upper lobe lung resection showing: Adenocarcinoma, grade 2, measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin. Two (2) hilar lymph nodes with no metastatic tumor.,C. Lymph node biopsy at level 2 and 4 showing seven (7) lymph nodes with anthracosis and no metastatic tumor.,D. Lymph node biopsy, level 7 subcarinal showing (5) lymph nodes with anthracosis and no metastatic tumor.,COMMENT: ,The morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe. This suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor, there is isolated nests of tumor cells within the air spaces. Furthermore, immunoperoxidase stain for Ck-7, CK-20 and TTF are performed on both the right lower and right upper lobe nodule. The immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe.,lab medicine - pathology, pet scan, wedge biopsy, morphology, lung wedge biopsy, lymph node biopsy, lymph node, lower lobe, tumor, biopsy, lobe, lung, mass, lymph, node

NAME OF PROCEDURE: , Celiac plexus block.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS:, None.,PROCEDURE: , INT was placed. The patient was in the prone position back prepped and draped in sterile fashion. Then 1.5% of Lidocaine for skin wheal was made approximately 10 cm lateral to the L1-L2 vertebral junction. A 20 gauge, 15 cm needle was then placed in a cephalad medial 45o direction; the tip of the needle was just inside the L1 vertebral body. On lateral view, this was noted to be approximately 1.5-2.5 cm anterior to the vertebral body. At this time, 3 cc of Omnipaque dye was injected to the opposite side where the same sequence was performed. Following this, a mixture of 18 cc of 0.5% Marcaine was injected on each side Neosporin and band-aids was applied over the puncture sites. The patient was taken to the outpatient recovery where blood pressure was monitored and fluids given as needed. The patient was discharged to operating room recovery in stable condition.pain management, omnipaque, vertebral body, puncture sites, celiac plexus block, celiac, plexus, block, vertebral

CHIEF COMPLAINT:,orthopedic, hip pain, radiculopathy, degenerative changes, avascular necrosis, hip resurfacing, arthrodesis, hip replacement, avn,

PREOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,POSTOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,PROCEDURE PERFORMED: , Excision of soft tissue mass on the right flank.,ANESTHESIA: , Sedation with local.,INDICATIONS FOR PROCEDURE:, This 54-year-old male was evaluated in the office with a large right flank mass. He would like to have this removed.,DESCRIPTION OF PROCEDURE:, Consent was obtained after all risks and benefits were described. The patient was brought back into the operating room. The aforementioned anesthesia was given. Once the patient was properly anesthetized, the area was prepped and draped in the sterile fashion. With the area properly prepped and draped, a needle was used to localize the area directly above the mass on the patient's right flank. Then a #10 blade scalpel was used to make the incision approximately 4 cm to 5 cm in length just above the mass. The incision was extended down using electrocautery. The excision then had a Allis clamp placed on it and was retracted using sharp dissection and electrocautery was used to dissect the mass off the muscle. The mass was sent off to Pathology for investigation. Hemostasis maintained with electrocautery and then the subcutaneous fascia was closed using a #3-0 Vicryl suture in interrupted fashion and the skin was reapproximated using a #4-0 undyed Vicryl suture in a running subcuticular fashion. The patient's wound was cleaned. Steri-Strips were placed and sterile dressings were placed on top of this. The patient tolerated the procedure well and will reevaluate in the office in one week's time.surgery, electrocautery, soft tissue mass, subcutaneous, excision

TYPE OF PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS:, Abdominal pain.,POSTOPERATIVE DIAGNOSIS:, Normal endoscopy.,PREMEDICATION: , Fentanyl 125 mcg IV, Versed 8 mg IV.,INDICATIONS: ,This healthy 28-year-old woman has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods. She has had similar episodes couple of years ago and was told, at one point, that she had gallstones, but after her pregnancy, a repeat ultrasound was done, and apparently was normal, and nothing was done at that time. She was evaluated in the emergency department recently, when she developed this recurrent pain, and laboratory studies were unrevealing. Ultrasound was normal and a HIDA scan was done, which showed a low normal ejection fraction of 40%, and moderate reproduction of her pain. Endoscopy was requested to make sure there is not upper GI source of her pain before considering cholecystectomy.,PROCEDURE: , The patient was premedicated and the Olympus GIF 160 video endoscope advanced to the distal duodenum. Gastric biopsies were taken to rule out Helicobacter and the procedure was completed without complication.,IMPRESSION: ,Normal endoscopy.,PLAN: , Refer to a general surgeon for consideration of cholecystectomy.gastroenterology, hida scan, endoscopy, gallstones, olympus, esophagogastroduodenoscopy with biopsy, biliary colic, colic type, greasy foods, normal endoscopy, esophagogastroduodenoscopy, biliary, colic, greasy, foods, cholecystectomy, biopsy,

ADMITTING DIAGNOSIS:, Aftercare of multiple trauma from an motor vehicle accident.,DISCHARGE DIAGNOSES:,1. Aftercare following surgery for injury and trauma.,2. Decubitus ulcer, lower back.,3. Alcohol induced persisting dementia.,4. Anemia.,5. Hypokalemia.,6. Aftercare healing traumatic fracture of the lower arm.,7. Alcohol abuse, not otherwise specified.,8. Aftercare healing traumatic lower leg fracture.,9. Open wound of the scalp.,10. Cervical disk displacement with myelopathy.,11. Episodic mood disorder.,12. Anxiety disorder.,13. Nervousness.,14. Psychosis.,15. Generalized pain.,16. Insomnia.,17. Pain in joint pelvic region/thigh.,18. Motor vehicle traffic accident, not otherwise specified.,PRINCIPAL PROCEDURES:, None.,HISTORY OF PRESENT ILLNESS: , As per Dr. X without any changes or corrections.,HOSPITAL COURSE: ,This is a 50-year-old male, who is initially transferred from Medical Center after treatment for multiple fractures after a motor vehicle accident. He had a left tibial plateau fracture, right forearm fracture with ORIF, head laceration, and initially some symptoms of head injury. When he was initially transferred to HealthSouth, he was status post ORIF for his right forearm. He had a brace placed in the left leg for his left tibial plateau fracture. He was confused initially and initially started on rehab. He was diagnosed with some acute psychosis and thought problems likely related to his alcohol abuse history. He did well from orthopedic standpoint. He did have a small sacral decubitus ulcer, which was well controlled with the wound care team and healed quite nicely. He did have some anemia initially and he had dropped down in to the low 9, but he was 9.2 with his lowest on 06/11/2008, which had responded well to iron treatment and by the time of discharge, he was lower at 11.0. He made slow progress from therapy. His confusion gradually cleared. He did have some problems with insomnia and was placed on Seroquel to help with both of his moods and other issues and he did quite well with this. He did require some Ativan for agitation. He was on chronic pain medications as an outpatient. His medications were adjusted here and he did well with this as well. The patient was followed throughout his entire stay with case management and discussions were made with them and the psychologist concerning the placement upon discharge to an acute alcohol rehab facility; however, the patient refused throughout this entire stay. We did have orthopedic followup. He was taken out of his right leg brace the week of 06/16/2008. He did well with therapy. Overall, he was doing much and much better. He had progressed with the therapy to the point where that he was comfortable to go home and receive outpatient therapy and follow up with his primary care physician. On 06/20/2008, with all parties in agreement, the patient was discharged to home in stable condition.,At the time of discharge, the patient's ambulatory status was much better. He was using a wheeled walker. He was able to bear weight on his left leg. His pain level had been well controlled and his moods had improved dramatically. He was no longer having any signs of agitation or confusion and he seemed to be at a stable baseline. His anemia had resolved almost completely and he was doing quite well. ,MEDICATIONS: , On discharge included:,1. Calcium with vitamin D 1 tablet twice a day.,2. Ferrous sulfate 325 mg t.i.d.,3. Multivitamin 1 daily.,4. He was on nicotine patch 21 mg per 24 hour.,5. He was on Seroquel 25 mg at bedtime.,6. He was on Xenaderm for his sacral pressure ulcer.,7. He was on Vicodin p.r.n. for pain.,8. Ativan 1 mg b.i.d. for anxiety and otherwise he is doing quite well.,The patient was told to follow up with his orthopedist Dr. Y and also with his primary care physician upon discharge.nan

PREOPERATIVE DIAGNOSES: ,1. Left back skin nevus 2 cm.,2. Right mid back skin nevus 1 cm.,3. Right shoulder skin nevus 2.5 cm.,4. Actinic keratosis left lateral nasal skin 2.5 cm.,POSTOPERATIVE DIAGNOSES: ,1. Left back skin nevus 2 cm.,2. Right mid back skin nevus 1 cm.,3. Right shoulder skin nevus 2.5 cm.,4. Actinic keratosis, left lateral nasal skin, 2.5 cm.,PATHOLOGY: ,Pending.,TITLE OF PROCEDURES: ,1. Excisional biopsy of left back skin nevus 2 cm, two layer plastic closure.,2. Excisional biopsy of mid back skin nevus 1 cm, one-layer plastic closure.,3. Excisional biopsy of right shoulder skin nevus 2.5 cm, one-layer plastic closure.,4. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 8 mL.,BLOOD LOSS: , Minimal.,COMPLICATIONS:, None.,PROCEDURE:, Consent was obtained. The areas were prepped and draped and localized in the usual manner. First attention was drawn to the left back. An elliptical incision was made with a 15-blade scalpel. The skin ellipse was then grasped with a Bishop forceps and curved Iris scissors were used to dissect the skin ellipse. After dissection, the skin was undermined. Radiofrequency cautery was used for hemostasis, and using a 5-0 undyed Vicryl skin was closed in the subcuticular plane and then skin was closed at the level of the skin with 4-0 nylon interrupted suture.,Next, attention was drawn to the mid back. The skin was incised with a vertical elliptical incision with a 15-blade scalpel and then the mass was grasped with a Bishop forceps and excised with curved Iris scissors. Afterwards, the skin was approximated using 4-0 nylon interrupted sutures. Next, attention was drawn to the shoulder lesion. It was previously marked and a 15-blade scalpel was used to make an elliptical incision into the skin.,Next, the skin was grasped with a small Bishop forceps and curved Iris scissors were used to dissect the skin ellipse and removed the skin. The skin was undermined with the curved Iris scissors and then radio frequency treatment was used for hemostasis.,Next, subcuticular plain was closed with 5-0 undyed Vicryl interrupted suture. Skin was closed with 4-0 nylon suture, interrupted. Lastly, trichloroacetic acid chemical peel treatment to the left lateral nasal skin was performed. Please refer to separate operative report for details. The patient tolerated this procedure very well and we will follow up next week for postoperative re-evaluation or sooner if there are any problems.dermatology, mid back skin nevus, actinic keratosis, trichloroacetic acid treatment, bishop forceps, skin nevus, plastic closure, curved iris, iris scissors, nasal skin, nevus, biopsy, nasal, forceps,

REASON FOR CONSULT: , Medical management, status post left total knee arthroplasty.,PAST MEDICAL HISTORY:,1. Polyarthritis.,2. Acromegaly.,3. Hypothyroidism.,4. Borderline hypertension.,5. Obesity.,PAST SURGICAL HISTORY: , Hernia repair, resection of tumor, right thumb arthrodesis, carpal tunnel decompression, bilateral hip replacement, right total knee replacement about 2 months ago, open reduction of left elbow fracture.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS: No fever or recent general malaise.,ENT: Not remarkable.,RESPIRATORY: No cough or shortness of breath.,CARDIOVASCULAR: The patient denies any heart problems. No orthopnea. No palpitations. No syncopal episodes.,GASTROINTESTINAL: No nausea. No vomiting. No history of GI bleed.,GENITOURINARY: No dysuria, no hematuria.,ENDOCRINE: The patient is status post pituitary tumor resection and is on supplemental hormone.,MEDICATIONS: Depo-Testosterone 200 mg IM q.3 weekly, prednisone 1 tablet p.o. daily, octreotide IM on a monthly basis, morphine extended release 50 mg p.o. b.i.d., Synthroid 100 mcg p.o. daily, desmopressin 1 tablet p.o. every bedtime, aspirin/oxycodone on a p.r.n. basis, aspirin on p.r.n. basis.,ALLERGIES: , IBUPROFEN AND TYLENOL.,SOCIAL HISTORY: , The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION,GENERAL: Obese, 57-year-old gentleman, not in acute distress.,VITAL SIGNS: Blood pressure of 105/55, pulse is 90. He is afebrile. O2 saturation is 95% on room air.,HEAD AND NECK: Face symmetrical. Cranial nerves are intact. No distended neck veins. No palpable neck masses.,CHEST: Clear to auscultation. No wheezing. No crepitations.,CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated.,ABDOMEN: Benign.,EXTREMITIES: The left knee is in closed dressing. The lower extremities are still numb from spinal anesthesia.,ASSESSMENT AND PLAN:,1. Polyarthritis, status post left total knee replacement. The patient tolerated the procedure well.,2. Acromegaly, status post pituitary resection. Continue supplemental hormones.,3. Borderline hypertension, blood pressure is under control with monitoring.,4. Deep venous thrombosis prophylaxis as per surgeon.,5. Anemia due to repeated blood loss with monitor hemoglobin and hematocrit.nan

ADMISSION DIAGNOSIS:, End-stage renal disease (ESRD).,DISCHARGE DIAGNOSIS: , End-stage renal disease (ESRD).,PROCEDURE:, Cadaveric renal transplant.,HISTORY OF PRESENT ILLNESS: , This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis since 1993 and is also status post cadaveric kidney transplant in 1996 with chronic rejection.,PAST MEDICAL HISTORY: ,1. Diabetes mellitus diagnosed 12 years ago.,2. Hypertension.,3. Coronary artery disease with a myocardial infarct in September of 2006.,4. End-stage renal disease.,PAST SURGICAL HISTORY: , Coronary artery bypass graft x5 in 1995 and cadaveric renal transplant in 1996.,SOCIAL HISTORY: ,The patient denies tobacco or ethanol use.,FAMILY HISTORY:, Hypertension.,PHYSICAL EXAMINATION: ,GENERAL: The patient was alert and oriented x3 in no acute distress, healthy-appearing male.,VITAL SIGNS: Temperature 96.6, blood pressure 166/106, heart rate 83, respiratory rate 18, and saturations 96% on room air.,CARDIOVASCULAR: Regular rate and rhythm.,PULMONARY: Clear to auscultation bilaterally.,ABDOMEN: Soft, nontender, and nondistended with positive bowel sounds.,EXTREMITIES: No clubbing, cyanosis, or edema.,PERTINENT LABORATORY DATA: , White blood cell count 6.4, hematocrit 34.6, and platelet count 182. Sodium 137, potassium 5.4, BUN 41, creatinine 7.9, and glucose 295. Total protein 6.5, albumin 3.4, AST 51, ALT 51, alk phos 175, and total bilirubin 0.5.,COURSE IN HOSPITAL: , The patient was admitted postoperatively to the surgical intensive care unit. Initially, the patient had a decrease in hematocrit from 30 to 25. The patient's hematocrit stabilized at 25. During the patient's stay, the patient's creatinine progressively decreased from 8.1 to a creatinine at the time of discharge of 2.3. The patient was making excellent urine throughout his stay. The patient's Jackson-Pratt drain was removed on postoperative day #1 and he was moved to the floor. The patient was advanced in diet appropriately. The patient was started on Prograf by postoperative day #2. Initial Prograf levels came back high at 18. The patient's Prograf doses were changed accordingly and today, the patient is deemed stable to be discharged home. During the patient's stay, the patient received four total doses of Thymoglobulin. Today, he will complete his final dose of Thymoglobulin prior to being discharged. In addition, today, the patient has an elevated blood pressure of 198/96. The patient is being given an extra dose of metoprolol for this blood pressure. In addition, the patient has an elevated glucose of 393 and for this reason he has been given an extra dose of insulin. These labs will be rechecked later today and once his blood pressure has decreased to systolic blood pressure less than 116 and his glucose has come down to a more normal level, he will be discharged to home.,DISCHARGE INSTRUCTIONS: , The patient is discharged with instructions to seek medical attention in the event if he develops fevers, chills, nausea, vomiting, decreased urine output, or other concerns. He is discharged on a low-potassium diet with activity as tolerated. He is instructed that he may shower; however, he is to undergo no underwater soaking activities for approximately two weeks. The patient will be followed up in the Transplant Clinic at ABCD tomorrow, at which time, his labs will be rechecked. The patient's Prograf levels at the time of discharge are pending; however, given that his Prograf dose was decreased, he will be followed tomorrow at the Renal Transplant Clinic.nan

She started her periods at age 13. She is complaining of a three-month history of lower abdominal pain for which she has been to the emergency room twice. She describes the pain as bilateral, intermittent, and non-radiating. It decreases slightly when she eats and increases with activity. She states the pain when it comes can last for half-a-day. It is not associated with movement, but occasionally the pain was so bad that it was associated with vomiting. She has tried LactAid, which initially helped, but then the pain returned. She has tried changing her diet and Pepcid AC. She was seen at XYZ where blood work was done. At that time, she had a normal white count and a normal H&H. She was given muscle relaxants, which did not work.,Approximately two weeks ago, she was seen in the emergency room at XYZ where a pelvic ultrasound was done. This showed a 1.9 x 1.4-cm cyst on the right with no free fluid. The left ovary and uterus appeared normal. Two days later, the pain resolved and she has not had a recurrence. She denies constipation and diarrhea. She has had some hot flashes, but has not taken her temperature.,In addition, she states that her periods have been very irregular coming between four and six weeks. They are associated with cramping which she is not happy about.,She has never had a pelvic exam. She states she is not sexually active and declined having her mother leave the room, so she was not questioned regarding this without her mother present. She is very interested in not having pain with her periods and if this was a cyst that caused her pain, she is interested in starting birth control pills to prevent this from happening again.,PAST MEDICAL HX: ,Pneumonia in 2002, depression diagnosed in 2005, and seizures as an infant.,PAST SURGICAL HX: ,Plastic surgery on her ear after a dog bite in 1997.,MEDICATIONS: ,Zoloft 50 mg a day and LactAid.,ALLERGIES: ,NO KNOWN DRUG ALLERGIES.,SOCIAL HX: , She enjoys cooking and scrapbooking. She does have a boyfriend; again she states she is not sexually active. She also states that she exercises regularly, does not smoke cigarettes, use drugs, or drink alcohol.,FAMILY HX: , Significant for her maternal grandfather with adult-onset diabetes, a maternal grandmother with hypertension, mother with depression, and a father who died of colon cancer at 32 years of age. She also has a paternal great grandfather who was diagnosed with colon cancer.,PE: , VITALS: Height: 5 feet 5 inches. Weight: 190 lb. Blood Pressure: 120/88. GENERAL: She is well-developed, well-nourished with normal habitus and no deformities. NECK: Without thyromegaly or lymphadenopathy. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm without murmurs. ABDOMEN: Soft, nontender, and nondistended. There is no organomegaly or lymphadenopathy. PELVIC: Deferred.,A/P: , Abdominal pain, unclear etiology. I expressed my doubt that her pain was secondary to this 1.9-cm ovarian cyst given the fact that there was no free fluid surrounding this. However, given that she has irregular periods and they are painful for her, I think it is reasonable to start her on a low-dose birth control pill. She has no personal or familial contraindications to start this. She was given a prescription for Lo/Ovral, dispensed 30 with refill x 4. She will come back in six weeks for blood pressure check as well as in six months to followup on her pain and her bleeding patterns.,If she should have the recurrence of her pain, I have advised her to call.obstetrics / gynecology, irregular periods, lactaid, abdominal pain, birth control pills, cyst, ovarian cyst, ovaries, ovary, pelvic exam, sexually active, uterus, lymphadenopathy, pelvic, irregular, periods

PREOPERATIVE DIAGNOSIS: , Blighted ovum, severe cramping.,POSTOPERATIVE DIAGNOSIS:, Blighted ovum, severe cramping.,OPERATION PERFORMED: , Vacuum D&C.,DRAINS: , None.,ANESTHESIA: , General.,HISTORY: , This 21-year-old white female gravida 1, para 0 who was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office. Due to the severe cramping, a decision to undergo vacuum D&C was made. At the time of the procedure, moderate amount of tissue was obtained.,PROCEDURE: ,The patient was taken to the operating room and placed in a supine position, at which time a general form of anesthesia was administered by the anesthesia department. The patient was then repositioned in a modified dorsal lithotomy position and then prepped and draped in the usual fashion. A weighted vaginal speculum was placed in the posterior vaginal vault. Anterior lip of the cervix was grasped with single tooth tenaculum, and the cervix was dilated to approximately 8 mm straight. Plastic curette was placed into the uterine cavity and suction was applied at 60 mmHg to remove the tissue. This was followed by gentle curetting of the lining as well as followed by suction curetting and then another gentle curetting and a final suction. Methargen 0.2 mg was given IM and Pitocin 40 units and a 1000 was also started at the time of the procedure. Once the procedure was completed, the single tooth tenaculum was removed from the vaginal vault with some _____ remaining blood and the weighted speculum was also removed. The patient was repositioned to supine position and taken to recovery room in stable condition.surgery, pitocin, single tooth tenaculum, vaginal vault, vacuum d&c, blighted ovum, speculum, tenaculum, curetting, blighted, cramping,

PREOPERATIVE DIAGNOSES:,1. Hoarseness.,2. Bilateral true vocal cord lesions.,3. Leukoplakia.,POSTOPERATIVE DIAGNOSES:,1. Hoarseness.,2. Bilateral true vocal cord lesions.,3. Leukoplakia.,PROCEDURE PERFORMED: ,Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: The patient is a 33-year-old Caucasian male with a history of chronic hoarseness and bilateral true vocal cord lesions, and leukoplakia discovered on a fiberoptic nasal laryngoscopy in the office. Discussed risks, complications, and consequences of a surgical biopsy of the left true vocal cord and consent was obtained.,PROCEDURE: , The patient was brought to operative suite by anesthesia, placed on the operating table in supine position. After this, the patient was placed under general endotracheal intubation anesthesia and the operative table was turned 90 degrees by the Department of Anesthesia. A shoulder roll was then placed followed by the patient being placed in reverse Trendelenburg.,After this, a mouthguard was placed in the upper teeth and a Dedo laryngoscope was placed in the patient's oral cavity and advanced through the oral cavity in the oropharynx down into the hypopharynx. The patient's larynx was then brought into view with the true vocal cords hidden underneath what appeared to be redundant false vocal cords. The left true vocal cord was then first addressed and appeared to have an extensive area of leukoplakia extending from the posterior one-third up to the anterior third. The false vocal cord also appeared to be very full on the left side along with fullness in the subglottic region. The patient's anterior commissure appeared to be clear. The false cord on the right side also appeared to be very redundant and overshadowing the true vocal cord. Once the true vocal cord was retracted laterally, there was revealed a second area of leukoplakia involving the right true vocal cord in the anterior one-third aspect. The patient's subglottic region was very edematous and with redundant mucosal tissue. The areas of leukoplakia appeared to be cobblestoned in appearance, irregularly bordered, and very hard to the touch. The left true vocal cord was then first addressed, was stripped from posteriorly to anteriorly utilizing a #45 laryngeal forceps. After this, the patient had pressure placed upon this area with tropical adrenaline and a rectal swab to maintain hemostasis. The specimen was passed off the field and was sent to Pathology for evaluation. Hemostasis was maintained on the left side. Prior to taking this biopsy, the Louie arm was attached to the laryngoscope and then suspended on the Mayo stand. The Zeiss operating microscope was then brought into view to directly visualize the vocal cords. The biopsies were taken under direct visualization utilizing the Zeiss operating microscope. After the specimen was taken and the laryngoscope was desuspended from the Mayo stand and Louie arm was removed, the scope was then pulled more cephalad and the piriform sinuses, valecula, and base of the tongue were all directly visualized, which appeared normal except for the left base of tongue appeared to be full. This area was biopsied multiple times with a straight laryngeal forceps and passed off the field and sent to Pathology as specimen. The scope was then pulled back into the superior aspect of hypopharynx into the oropharynx and the oral cavity demonstrated no signs of any gross lesions. A bimanual examination was then performed, which again demonstrated a fullness on the left base of tongue region with no signs of any other gross lesions. There were no signs of any palpable cervical lymphadenopathy. The tooth guard was removed and the patient was then turned back to anesthesia. The patient did receive intraoperatively 10 mg of Decadron. The patient tolerated the procedure well and was extubated in the operating room.,The patient was transferred to recovery room in stable condition and tolerated the procedure well. The patient will be sent home with prescriptions for Medrol DOSEPAK, Tylenol with Codeine, Elixir, and amoxicillin 250 mg per 5 cc.ent - otolaryngology, direct laryngoscopy, zeiss operating microscope, vocal cord lesions, vocal cord, cord, vocal, microscopic, laryngoscopy, hoarseness, biopsy, leukoplakia

CHIEF COMPLAINT: , Left knee pain and stiffness.,HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old with severe bilateral knee DJD, left greater than right, with significant pain and limitations because of both. He is able to walk approximately a 1/2-mile a day but is limited because of his knees. Stairs are negotiated 1 at a time. His problems with bilateral knee DJD have been well documented. He had arthroscopy in the 1991/199two time frame for both of these. He has been on long-standing conservative course for these including nonsteroidals, narcotics, injections. At this point because of his progressive and persistent limitations he has opted for total joint surgery on the left side. He does have other arthritic complaints including multiple back surgeries for spinal stenosis including decompression and epidural steroids. Significant pain is handled by narcotic medication. His attending physician is Dr. X.,PAST MEDICAL HISTORY: , Hypertension.,PRIOR SURGERIES:,1. Inguinal hernia on the left.,2. Baker's cyst.,3. Colon cancer removal.,4. Bilateral knee scopes.,5. Right groin hernia.,6. Low back surgery for spinal stenosis.,7. Status post colon cancer second surgery.,MEDICATIONS:,1. Ambien 12.5 mg nightly.,2. Methadone 10 mg b.i.d.,3. Lisinopril 10 mg daily.,IV MEDICATIONS FOR PAIN: ,Demerol appears to work the best.,ALLERGIES: , Levaquin and Cipro cause rashes; ibuprofen causes his throat to swell, Fortaz causes an unknown reaction.,REVIEW OF SYSTEMS: ,He does have paresthesias down into his thighs secondary to spinal stenosis.,SOCIAL HISTORY: , Married. He is retired, being a Pepsi-Cola driver secondary to his back and knees.,HABITS: , No tobacco or alcohol. Chewed until 2003.,RECREATIONAL PURSUITS: ,Golfs, gardens, woodworks.,FAMILY HISTORY:,1. Cancer.,2. Coronary artery disease.,PHYSICAL EXAMINATION:,GENERAL APPEARANCE: A pleasant, cooperative 57-year-old white male.,VITAL SIGNS: Height 5' 9", weight 167. Blood pressure 148/86. Pulse 78 per minute and regular.,HEENT: Unremarkable. Extraocular movements are full. Cranial nerves II-XII intact.,NECK: Supple.,CHEST: Clear.,CARDIOVASCULAR: Regular rhythm. Normal S1 and 2.,ABDOMEN: No organomegaly. No tenderness. Normal bowel sounds.,NEUROLOGIC: Intact.,MUSCULOSKELETAL: Left knee reveals a range of -10 degrees extension, 126 flexion. His extensor mechanism is intact. There is mild varus. He has good stability at 30 degrees of flexion. Lachman's and posterior drawer are negative. He has good muscle turgor. Dorsalis pedis pulse 2+.,DIAGNOSTICS: ,X-rays revealed severe bilateral knee DJD with joint space narrowing medially as well as the patellofemoral joint with large osteophytes, left greater than right.,IMPRESSION:,1. Bilateral knee degenerative joint disease.,2. Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.nan

HISTORY: , Advanced maternal age and hypertension.,FINDINGS:, There is a single live intrauterine pregnancy with a vertex lie, posterior placenta, and adequate amniotic fluid. The amniotic fluid index is 23.2 cm. Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of delivery of 03/28/08. Based on fetal measurements obtained today, estimated fetal weight is 3249 plus or minus 396 g, 7 pounds 3 ounces plus or minus 14 ounces, which places the fetus in the 66th percentile for the estimated gestational age. Fetal heart motion at a rate of 156 beats per minute is documented. The cord Doppler ratio is normal at 2.2. The biophysical profile score, assessing fetal breathing movement, gross body movement, fetal tone, and qualitative amniotic fluid volume is 8/8.,IMPRESSION:,1. Single live intrauterine pregnancy in vertex presentation with an estimated gestational age of 36 weeks 4 days and established due date of 03/28/08.,2. Biophysical profile (BPP) score 8/8.obstetrics / gynecology, ultrasound, bpp, maternal age, intrauterine pregnancy, biophysical profile, amniotic fluid, gestational age, amniotic, gestational, fetal,

PREOPERATIVE DIAGNOSES:,1. Eyebrow ptosis.,2. Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid.,3. Cervical facial aging with submental lipodystrophy.,OPERATION:,1. Hairline biplanar temporal browlift.,2. Quadrilateral blepharoplasty with lateral canthopexy with arcus marginalis release and fat transposition over inferior orbital rim to lower eyelid.,3. Cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.,ASSISTANT: ,None.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE: , The patient was placed in a supine position and prepped with general endotracheal anesthesia. Local infiltration anesthesia with 1% Xylocaine and 1:100,000 epinephrine was infiltrated in upper and lower eyelids.,Markings were made and fusiform ellipse of skin was resected from the upper eyelid. The lower limb of the fusiform ellipse was at the superior palpebral fold. A 9 mm of upper eyelid skin was resected at the widest portion of the lips, which extended from medial canthal area to the lateral orbital rim. This was performed bilaterally and symmetrically and the skin was removed. Incision was made through the pretarsal orbicularis with small amount of fat being removed from the medial and middle fat pocket. An incision was made over the superior orbital rim. Subperiosteal dissection was performed over the forehead. The dissection proceeded medially. The corrugator and procerus muscles were carefully dissected from the supratrochlear nerves on both right and left side and cauterized.,Hemostasis was achieved with electrocautery in this fashion. A 4-cm incision was made, and the forehead at the hairline, subcutaneous dissection was performed and extended over the frontalis muscle for approximately 4 cm. A subperiosteal dissection was performed after the fibers of the frontalis muscle were separated and subperiosteal dissection from the forehead lead the subperiosteal dissection from the upper eyelid. The incision was made in the lower lid just beneath the lashline. Subcutaneous dissection was performed over the pretarsal and preseptal muscle. Dissection was then proceeded down to the inferior orbital rim. The arcus marginalis was released and the lower eyelid fat was teased over the inferior orbital rim and sutured to the suborbicularis oculi fat and periosteum, which was separated from the inferior orbital rim. The orbital fat was sutured to the suborbicularis oculi fat with multiple preplaced sutures of 5-0 Vicryl on a P2 needle. The upper eyelid incision was closed with a running subcuticular 6-0 Prolene suture bilaterally. The forehead was then elevated, and the nonhairbearing forehead skin was resected 1.5 cm wide raising the tail of the eyebrow. The head of the eyebrow was felt to be elevated by the antagonistic frontalis muscle now that the accessory muscles specifically the corrugator and procerus and depressor supercilii were released and divided.,A lateral canthopexy was performed with 5-0 Prolene suture on a C1 double-arm tapered needle being passed from the lateral commissure of the eyelid to the small stab incision being passed to the medial superior orbital rim and sutured to tighten the lower lid. The distal lateral resection of excessive lower eyelid skin was reduced at risk of eyelid malposition. The lower lid incision was closed after the redundancy of skin measuring approximately 3 mm was resected on both sides. Closure was performed with interrupted 6-0 silk suture for the lower lid. The eyebrow hairline brow lift was closed with interrupted 4-0 PDS suture, deep subcutaneous tissue, and dermis, and the skin closed with a running 5-0 Prolene suture.,Attention then was directed to the cervical facial rhytidectomy and purse-string SMAS elevation with submental lipectomy. Incisions were made in preauricular area, postauricular area, mastoid and occipital area. Subcutaneous dissection was performed to the nasolabial fold and cheek and extending across the neck in the midline. Submental lipectomy was performed through the incision in the submental crease. Fat was directly removed from the fascia.,Hemostasis was achieved with electrocautery. A SMAS elevation was performed with a purse-string suture of 2-0 PDS suture from temporalis fascia in front of the ear extending beneath the mandible and then brought back up to be sutured to the temporalis fascia. This was performed bilaterally and symmetrically. Hemostasis was achieved with electrocautery. The cheek flap was brought back posteriorly and the cervical flap posteriorly and superiorly with redundant skin on the right massaged and closed. The skin of the cheek and neck were resected which was redundant after the ***** posteriorly and superiorly in the neck and transversely in the cheek.,Closure was performed with interrupted 3-0 and 4-0 PDS suture of deep subcutaneous tissue and dermis of the skin was closed with a running 5-0 Prolene suture. Drains were placed prior to final closure. A 7-mm flat Jackson-Pratt was then secured with 3-0 silk suture. Dressing consisting of fluffs and Kerlix and a 4-inch Ace were applied to support mildly compressive dressing. Scleral eye protectors were removed. Maxitrol eye ointment was placed followed by Swiss therapy eye pads. The patient tolerated the procedure well, and she returned to recovery room in satisfactory condition with Foley catheter and Pneumatic compression stockings, TED hose, two Jackson-Pratt drains, and an IV.surgery, eyebrow ptosis, dermatochalasia, hairline, jackson-pratt, swiss therapy, arcus marginalis, blepharoplasty, browlift, canthopexy, fat transposition, inferior orbital rim, lipectomy, lipodystrophy, lower eyelid, purse-string, rhytidectomy, string smas elevation, suborbicularis oculi, frontalis muscle, pds suture, smas elevation, submental lipectomy, upper eyelid, subperiosteal dissection, lower lid, prolene suture, lower eyelids, orbital rim, lower, eyelids, sutured, subcutaneous, eyebrow, orbital,

PREOPERATIVE/POSTOPERATIVE DIAGNOSES:,1. Severe tracheobronchitis.,2. Mild venous engorgement with question varicosities associated pulmonary hypertension.,3. Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.,PROCEDURE PERFORMED: , Flexible fiberoptic bronchoscopy with:,a. Right lower lobe bronchoalveolar lavage.,b. Right upper lobe endobronchial biopsy.,SAMPLES: , Bronchoalveolar lavage for cytology and for microbiology of the right lower lobe endobronchial biopsy of the right upper lobe.,INDICATIONS: , The patient with persistent hemoptysis of unclear etiology.,PROCEDURE: , After obtaining informed consent, the patient was brought to Bronchoscopy Suite. The patient had previously been on Coumadin and then heparin. Heparin was discontinued approximately one-and-a-half hours prior to the procedure. The patient underwent topical anesthesia with 10 cc of 4% Xylocaine spray to the left nares and nasopharynx. Blood pressure, EKG, and oximetry monitoring were applied and monitored continuously throughout the procedure. Oxygen at two liters via nasal cannula was delivered with saturations in the 90% to 100% throughout the procedure. The patient was premedicated with 50 mg of Demerol and 2 mg of Versed. After conscious sedation was achieved, the bronchoscope was advanced through the left nares into the nasopharynx and oropharynx. There was minimal redundant oral soft tissue in the oropharynx. There was mild erythema. Clear secretions were suctioned.,Additional topical anesthesia was applied to the larynx and then throughout the tracheobronchial tree for the procedure, a total of 16 cc of 2% Xylocaine was applied. Vocal cord motion was normal. The bronchoscope was then advanced through the larynx into the trachea. There was evidence of moderate inflammation with prominent vascular markings and edema. No frank blood was visualized. The area was suction clear of copious amounts of clear white secretions. Additional topical anesthesia was applied and the bronchoscope was advanced into the left main stem. The bronchoscope was then sequentially advanced into each segment and sub-segment of the left upper lobe and left lower lobe. There was significant amount of inflammation, induration, and vascular tortuosity in these regions. No frank blood was identified. No masses or lesions were identified. There was senile bronchiectasis with slight narrowing and collapse during the exhalation. The air was suctioned clear. The bronchoscope was withdrawn and advanced into the right main stem. Bronchoscope was introduced into the right upper lobe and each sub-segment was visualized. Again significant amounts of tracheobronchitis was noted with vascular infiltration. In the sub-carina of the anterior segment of the right upper lobe, there was evidence of a submucosal hematoma without frank mass underneath this. The bronchoscope was removed and advanced into the right middle and right lower lobe. There was marked injection and inflammation in these regions. In addition, there was marked vascular engorgement with near frank varicosities identified throughout the region. Again, white clear secretions were identified. No masses or other processes were noted. The area was suctioned clear. A bronchoalveolar lavage was subsequently performed in the anterior segment of the right lower lobe. The bronchoscope was then withdrawn and readvanced into the right upper lobe. Endobronchial biopsies of the carina of the sub-segment and anterior segment of the right upper lobe were obtained. Minimal hemorrhage occurred after the biopsy, which stopped after 1 cc of 1:1000 epinephrine. The area remained clear. No further hemorrhage was identified. The bronchoscope was subsequently withdrawn. The patient tolerated the procedure well and was stable throughout the procedure. No further hemoptysis was identified. The patient was sent to Recovery in good condition.surgery, bronchoalveolar lavage, endobronchial biopsy, cytology, microbiology, tracheobronchitis, venous engorgement, varicosities, pulmonary hypertension, flexible fiberoptic bronchoscopy, fiberoptic bronchoscopy, lobe, bronchoalveolar, lavage, endobronchial, hemorrhage, oropharynx, vascular, bronchoscopy, biopsy, submucosal, bronchoscope

The patient's abdomen was prepped and draped in the usual sterile fashion. A subumbilical skin incision was made. The Veress needle was inserted, and the patient's abdominal cavity was insufflated with moderate pressure all times. A subumbilical trocar was inserted. The camera was inserted in the panoramic view. The abdomen demonstrated some inflammation around the gallbladder. A 10-mm midepigastric trocar was inserted. A. 2 mm and 5 mm trocars were inserted. The most lateral trocar grasping forceps was inserted and grasped the fundus of the gallbladder and placed in tension at liver edge.,Using the dissector, the cystic duct was identified and double Hemoclips were invited well away from the cystic-common duct junction. The cystic artery was identified and double Hemoclips applied. The gallbladder was taken down from the liver bed using Endoshears and electrocautery. Hemostasis was obtained. The gallbladder was removed from the midepigastric trocar site without difficulty. The trocars were removed and the skin incisions were reapproximated using 4-0 Monocryl. Steri-Strips and sterile dressing were placed. The patient tolerated the procedure well and was taken to the recovery room in stable condition.surgery, gallbladder, laparoscopic cholecystectomy, midepigastric trocar, double hemoclips, laparoscopic, cholecystectomy, midepigastric, trocars, hemoclips, trocarNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

PREOPERATIVE DIAGNOSES:,1. Radiation cystitis.,2. Refractory voiding dysfunction.,3. Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,POSTOPERATIVE DIAGNOSES:,1. Radiation cystitis.,2. Refractory voiding dysfunction.,3. Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,TITLE OF OPERATION: , Salvage cystectomy (very difficult due to postradical prostatectomy and postradiation therapy to the pelvis), Indiana pouch continent cutaneous diversion, and omental pedicle flap to the pelvis.,ANESTHESIA: , General endotracheal with epidural.,INDICATIONS: ,This patient is a 65-year-old white male who in 1998 had a radical prostatectomy. He was initially dry without pads and then underwent salvage radiation therapy for rising PSA. After that he began with episodes of incontinence as well as urinary retention requiring catheterization. One year ago, he was unable to catheterize and was taken to the operative room and had cystoscopy. He had retained staple removed and a diverticulum identified. There were also bladder stones that were lasered and removed, and he had been incontinent ever since that time. He wears 8 to 10 pads per day, and this has affected his quality of life significantly. I took him to the operating room on January 16, 2008, and found diffuse radiation changes with a small capacity bladder and wide-open bladder neck. We both felt that his lower urinary tract was not rehabilitatable and that a continent cutaneous diversion would solve the number of problems facing him. I felt like if we could remove the bladder safely, then this would also provide a benefit.,FINDINGS: , At exploration, there were no gross lesions of the smaller or large bowel. The bladder was predictably sucked into the pelvic sidewall both inferiorly and laterally. The opened bladder, which we were able to remove completely, had a wide-open capacious diverticulum in its very distal segment. Because of the previous radiation therapy and a dissection down to the pelvis, I elected to place an omental pedicle flap to provide additional blood supply for healing as well in the pelvis and also under the pubic bone which was exposed inferiorly due to previous surgery and treatment.,PROCEDURE IN DETAIL: ,The patient was brought to the operative suite and after adequate general endotracheal and epidural anesthesia obtained, placed in the supine position, flexed over the anterosuperior iliac spine, and his abdomen and genitalia were sterilely prepped and draped in the usual fashion. A nasogastric tube was placed as well as radial arterial line. He was given intravenous antibiotics for prophylaxis. A generous midline skin incision was made from the midepigastrium down to the symphysis pubis, deep into the rectus fascia, the rectus muscle separated in the midline, and exploration carried out with the findings described. Moist wound towels and a Bookwalter retractor were placed for exposure. We began by retracting the bowels by mobilizing the cecum and ascending colon and hepatic flexure and elevating the terminal ileum up to the second and third portion of the duodenum. The ureter was identified as a crisis over the iliac vessels and dissected deep into pelvis and subsequently divided between clips. An identical procedure was performed in the left side with similar findings and the bowels were packed cephalad.,We began then dissecting the bladder away from the pelvic side walls staying medial to both epigastric arteries. This was quite challenging because of the previous radiation therapy and radical prostatectomy. We essentially carved the bladder off of the pelvic sidewall inferiorly as best we could and then we were able to have enough freedom to identify the lateral pedicles, and these were taken between double clips approximately and clipped distally. We then approached things posteriorly and carefully dissected between the __________ and posterior bladder. There was some remnant seminal vesicle on the right as well as both remnant ejaculatory duct and we used this to dissect the longus safe plane anterior to the rectum. We then entered the bladder anteriorly as distal as we could and remove the bladder and what we thought was a bladder neck and this appeared to end in a diverticulum. We then peeled it off the remaining rectum and passed the specimen off the operative field. Bladder was irrigated with warm sterile water and a meticulous inspection was made for hemostasis.,We then completely mobilized the omentum off of the proximal transverse colon. This allowed a generous flap to be able to be laid into the pelvis without tension.,We then turned our attention to forming the Indiana pouch. I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon. The colon was divided proximal to the middle colic using a GIA-80 stapler. I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum. The mesentery was then sealed with a LigaSure device and divided, and the bowel was divided with a GIA-60 stapler. We then performed a side-to-side ileo-transverse colostomy using a GIA-80 stapler, closing the open end with a TA 60. The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,We then removed the staple line along the terminal ileum, passed a 12-French Robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the GIA-60 stapler. The ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by Rowland, et al, and following this, passage of an 18-French Robinson catheter was associated with the characteristic "pop," indicating that we had adequately plicated the ileocecal valve.,As the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy. We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 Vicryl sutures. The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb-75. Between the staple lines, Vicryl sutures were placed and the defects closed with 3-0 Vicryl suture ligatures.,We then turned our attention to forming the ileocolonic anastomosis. The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 Vicryl sutures, and this was stented with a Cook 8.4-French ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture. The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis. We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture. A 24-French Malecot catheter was placed through the cecum and secured with a chromic suture. The staple lines were then buried with a running 3-0 Vicryl two-layer suture and the open end of the pouch closed with a TA 60 Polysorb suture. The pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,We then made a final inspection for hemostasis. The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures. We then matured our stoma through the umbilicus. We removed the plug of skin through the umbilicus and delivered the ileal segment through this. A portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures. We left an 18-French Robinson through the stomag and secured this to the skin with silk sutures. The Malecot and stents were also secured in a similar fashion.,We matured the stoma to the umbilicus with interrupted chromic stitches. The stitch was brought out to the right upper quadrant and the Malecot to the left lower quadrant. A Large JP drain was placed in the pelvis dependent to the omentum pedicle flap as well as the Indiana pouch.,The rectus fascia was closed with a buried #2 Prolene running stitch, tying a new figure-of-eight proximally and distally and meeting in the middle and tying it underneath the fascia. Subcutaneous tissue was irrigated with saline and skin was closed with surgical clips. The estimated blood loss was 450 mL, and the patient received no packed red blood cells. The final sponge and needle count were reported to be correct. The patient was awakened and extubated, and taken on stretcher to the recovery room in satisfactory condition.urology, radiation cystitis, voiding dysfunction, retropubic prostatectomy, salvage radiation therapy, salvage cystectomy, indiana pouch continent cutaneous diversion, omental pedicle flap, ligasure, gia, stapler, gia stapler, vicryl sutures, radiation therapy, silk sutures, bladder, therapy, sutures, endotracheal,

PREOPERATIVE DIAGNOSIS:, Prostate cancer.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer.,OPERATIONS: , Brachytherapy, iodine-125 seed implantation, and cystoscopy.,ANESTHESIA:, LMA.,ESTIMATED BLOOD LOSS: , Minimal.,Total number of seeds placed, 63. Needles, 24.,BRIEF HISTORY OF THE PATIENT: , This is a 57-year-old male who was seen by us for elevated PSA. The patient had a prostate biopsy with T2b disease, Gleason 6. Options such as watchful waiting, robotic prostatectomy, seed implantation with and without radiation were discussed. Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, incontinence, rectal dysfunction, voiding issues, burning pain, unexpected complications such as fistula, rectal injury, urgency, frequency, bladder issues, need for chronic Foley for six months, etc., were discussed. The patient understood all the risks, benefits, and options, and wanted to proceed with the procedure. The patient was told that there could be other unexpected complications. The patient has history of urethral stricture. The patient was told about the risk of worsening of the stricture with radiation. Consent was obtained.,DETAILS OF THE OPERATION: , The patient was brought to the OR. Anesthesia was applied. The patient was placed in the dorsal lithotomy position. The patient had SCDs on. The patient was given preop antibiotics. The patient had done bowel prep the day before. Transrectal ultrasound was performed. The prostate was measured at about 32 gm. The images were transmitted to the computer system for radiation oncologist to determine the dosing etc. Based on the computer analysis, the grid was placed. Careful attention was drawn to keep the grid away from the patient. There was a centimeter distance between the skin and the grid. Under ultrasound guidance, the needles were placed, first in the periphery of the prostate, a total of 63 seeds were placed throughout the prostate. A total of 24 needles was used. Careful attention was drawn to stay away from the urethra. Under longitudinal ultrasound guidance, all the seeds were placed. There were no seeds visualized in the bladder under ultrasound. There was only one needle where the seeds kind of dragged as the needle was coming out on the left side and were dropped out of position. Other than that, all the seeds were very well distributed throughout the prostate under fluoroscopy. Please note that the Foley catheter was in place throughout the procedure. Prior to the seed placement, the Foley was attempted to be placed, but we had to do it using a Glidewire to get the Foley in and we used a Councill-tip catheter. The patient has had history of bulbar urethral stricture. Pictures were taken of the strictures in the pre-seed placement cysto time frame. We needed to do the cystoscopy and Glidewire to be able to get the Foley catheter in. At the end of the procedure, again cystoscopy was done, the entire bladder was visualized. The stricture was wide open. The prostate was slightly enlarged. The bladder appeared normal. There was no sheath inside the urethra or in the bladder. The cysto was done using 30-degree and 70-degree lens. At the end of the procedure, a Glidewire was placed, and 18 Councill-tip catheter was placed. The plan was for Foley to be left in place overnight since the patient has history of urethral strictures. The patient is to follow up tomorrow to have the Foley removed. The patient could also be shown to have it removed at home.,The patient was brought to Recovery in stable condition at the end of the procedure. The patient tolerated the procedure well.surgery, iodine-125 seed implantation, seed implantation, prostate cancer, cystoscopy, brachytherapy, councill tip catheter, brachytherapy iodine, ultrasound, catheter, urethral, prostate,

CHIEF COMPLAINT:, Followup on diabetes mellitus, status post cerebrovascular accident.,SUBJECTIVE:, This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see a neurologist. We have tried different medications and it just does not seem to help. He checks his blood sugars at home two to three times a day. He kind of adjusts his own insulin himself. Re-evaluation of symptoms is essentially negative. He has a past history of heavy tobacco and alcohol usage.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt; 118 lbs, B/P; 108/72, T; 96.5, P; 80 and regular. ,General: A 70-year-old male who does not appear to be in acute distress but does look older than his stated age. He has some missing dentition.,Skin: Dry and flaky. ,CV: Heart tones are okay, adequate carotid pulsations. He has 2+ pedal pulse on the left and 1+ on the right.,Lungs: Diminished but clear.,Abdomen: Scaphoid.,Rectal: His prostate check was normal per Dr. Gill.,Neuro: Sensation with monofilament testing is better on the left than it is on the right.,IMPRESSION:,1. Diabetes mellitus.,2. Neuropathy.,3. Status post cerebrovascular accident.,PLAN:, Refill his medications x 3 months. We will check an A1c and BMP. I have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood. We will check a PSA. Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in three months and p.r.n.soap / chart / progress notes, diabetes mellitus, neuropathy, genernal medicine, post cerebrovascular accident, progerss note, post cerebrovascular, cerebrovascular accident, accident, cerebrovascular, neurologist, insulin,

PREOPERATIVE DIAGNOSIS: , Umbilical hernia.,POSTOPERATIVE DIAGNOSIS: , Umbilical hernia.,PROCEDURE PERFORMED: , Repair of umbilical hernia.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,PROCEDURE IN DETAIL: ,The patient was prepped and draped in the sterile fashion. An infraumbilical incision was formed and taken down to the fascia. The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia, and then the wounds were infiltrated with 0.25% Marcaine. The skin was reattached to the fascia with 2-0 Vicryls. The skin was approximated with 2-0 Vicryl subcutaneous and then 4-0 Monocryl subcuticular stitches, dressed with Steri-Strips and 4 x 4's. Patient was extubated and taken to the recovery area in stable condition.gastroenterology, marcaine, steri-strips, mattress sutures, umbilical hernia, repair, umbilical, hernia,

PREOPERATIVE DIAGNOSES:,1. Ischemic cardiomyopathy.,2. Status post redo coronary artery bypass.,3. Status post insertion of intraaortic balloon.,POSTOPERATIVE DIAGNOSES:,1. Ischemic cardiomyopathy.,2. Status post redo coronary artery bypass.,3. Status post insertion of intraaortic balloon.,4. Postoperative coagulopathy.,OPERATIVE PROCEDURE:,1. Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass.,2. Open sternotomy covered with Ioban.,3. Insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.,ANESTHESIA: , General endotracheal.,OPERATIVE PROCEDURE: , With the patient in the supine position, he was prepped from shin to knees and draped in a sterile field. A right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass. A sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm, freeing up the right atrium and the ascending aorta and anterior right ventricle. The patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava. A percutaneous catheter for arterial return was placed using Seldinger technique through exposed right femoral artery and then two 3-mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava. After satisfactory heparinization has been obtained, the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium. After the heart was brought to the operating room and triggered, the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place. A cardiectomy was then performed by starting in the right atrium. The wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the Swan-Ganz catheter was brought out into the operative field. Cardiectomy was then performed, first resecting the anterior portion of the right atrium and then transecting the aorta, the pulmonary artery, the septum between the right and left atriums, and then the heart was removed. The right and left atrium, aorta, and pulmonary artery were prepared for the transplant. First, we did a side-to-side anastomosis, continued to the left atrium and this was performed using 3-0 Prolene suture and a right atrial anastomosis side-to-side was performed using 3-0 Prolene suture. The pulmonary artery was then anastomosed using 5-0 Prolene and the aorta was anastomosed with 4-0 Prolene. The arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood. Air was evacuated and the sutures were tied down. The clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass. The patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass. Blood factors and factor VII were given to try and correct the coagulopathy. Because of excessive transfusions that were required, a Mahurkar catheter was inserted through the left common femoral vein, first placing a needle into the vein and then guidewire removed, and the needle dilators were then placed and then the Mahurkar catheter was then placed with 2-0 nylon suture. Hemofiltration was started in the operating room at this time. After he had satisfactory hemostasis, we decided to do the chest open and cover it with Ioban, which we did, and one chest tube was inserted into the mediastinum through a separate stab wound. The patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively. This was left in place and the pulse generation, the pacemaker was in a right infraclavicular position, which was left in place because of the coagulopathy. The patient received 11 units of packed red blood cells, 7 platelets, 23 fresh-frozen plasma, 20 cryoprecipitates, and factor VII. Urine output for the procedure was 520 mL. The preservation time of the heart is in the anesthesia sheet. The estimated blood loss was at least 6 L. The patient was taken to the intensive care unit in guarded condition.surgery, cardiomyopathy, ioban, ischemic, ischemic cardiomyopathy, mahurkar catheter, orthostatic, seldinger, swan-ganz, allograft, aorta, balloon, cardiac, cardiopulmonary bypass, catheter, coagulopathy, coronary artery bypass, femoral vein, hemofiltration, intraaortic, intraaortic balloon, sternotomy, transplantation, ventricle, inferior vena cava, cardiac allograft, common femoral, vena cava, pulmonary artery, atrium, insertion, cardiopulmonary, artery

PREOPERATIVE DIAGNOSIS: , Right tympanic membrane perforation.,POSTOPERATIVE DIAGNOSIS: , Right tympanic membrane perforation along with chronic otitis media.,PROCEDURE: , Right ear examination under anesthesia.,INDICATIONS: , The patient is a 15-year-old child with history of a right tympanic membrane perforation following tube placement as well as right conductive hearing loss. Exam in the office revealed a posterior superior right marginal tympanic perforation. Risks and benefits of surgery including risk of bleeding, general anesthesia, hearing loss as well as recurrent perforation were discussed with the mother. The mother wished to proceed with surgery.,FINDINGS:, The patient was brought to the room, placed in supine position, given general endotracheal anesthesia. The postauricular crease was then injected with 1% Xylocaine with 1:200,000 epinephrine along with external meatus. An area of the scalp was shaved above the ear and then also 1% Xylocaine with 1:200,000 epinephrine injected, a total of 4 mL local anesthetic was used. The ear was then prepped and draped in the usual sterile fashion. The microscope was then brought into view and examining the marginal perforation, the patient was noted to have large granuloma under the tympanic membrane at the anterior border of the drum. The granulation tissue was debrided as much as possible. Decision was made to cancel the tympanoplasty after debriding the middle ear space as much as possible. The middle ear space was filled with Floxin drops. The patient woke up anesthesia, extubated, and brought to recovery room in stable condition. There were no intraoperative complications. Needle and sponge was correct. Estimated blood loss minimal.ent - otolaryngology, chronic otitis media, middle ear space, tympanic membrane perforation, otitis media, hearing loss, middle ear, ear space, ear examination, membrane perforation, tympanic membrane, anesthesia, membrane, tympanic, ear, perforation,

PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS: ,Tailor's bunion, right foot.,PROCEDURE PERFORMED: , Removal of bone, right fifth metatarsal head.,ANESTHESIA: ,TIVA/local.,HISTORY: , This 60-year-old male presents to ABCD Preoperative Holding Area after keeping himself n.p.o., since mid night for surgery on his painful right Tailor's bunion. The patient has a history of chronic ulceration to the right foot which has been treated on an outpatient basis with conservative methods Dr. X. At this time, he desires surgical correction as the ulcer has been refractory to conservative treatment. Incidentally, the ulcer is noninfective and practically healed at this date. The consent is available on the chart for review and Dr. X has discussed the risks versus benefits of this procedure to the patient in detail.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room, placed on the operating table in supine position and a safety strap was placed across his waist for his protection. A pneumatic ankle tourniquet was applied about the right foot over copious amount of Webril for the patient's protection. After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 1:1 mixture of 1% lidocaine and 0.5% Marcaine plain were administered into the right fifth metatarsal using a Mayo type block technique. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered in the operating field and a sterile stockinet was reflected. The Betadine was cleansed with saline-soaked gauze and dried. Anesthesia was tested with a one tooth pickup and found to be adequate. A #10 blade was used to make 3.5 cm linear incision over the fifth metatarsophalangeal joint. A #15 blade was used to deepen the incision to the subcutaneous layer. Care was taken to retract the extensor digitorum longus tendon medially and the abductor digiti minimi tendon laterally. Using a combination of sharp and blunt dissection, the medial and lateral edges of the wound were undermined down to the level of the capsule and deep fascia. A linear capsular incision was made with a #15 blade down to the bone. The capsular periosteal tissues were elevated off the bone with a #15 blade. Metatarsal head was delivered into the wound. There was hypertrophic exostosis noted laterally as well as a large bursa in the subcuteneous tissue layer. The ulcer on the skin was approximately 2 x 2 mm, it was partial skin thickness and did not probe. A sagittal saw was used to resect the hypertrophic lateral eminence. The hypertrophic bone was split in half and one half was sent to Pathology and the other half was sent to Microbiology for culture and sensitivity. Next, a reciprocating rasp was used to smoothen all bony surfaces. The bone stock had an excellent healthy appearance and did not appear to be infected. Copious amount of sterile gentamicin impregnated saline were used to flush the wound. The capsuloperiosteal tissues were reapproximated with #3-0 Vicryl in simple interrupted technique. The subcutaneous layer was closed with #4-0 Vicryl in simple interrupted technique. Next, the skin was closed with #4-0 nylon in a horizontal mattress suture technique. A standard postoperative dressing was applied consisting of Betadine-soaked Owen silk, 4x4s, Kerlix, and Kling. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted at the digits. The patient tolerated the above anesthesia and procedure without complications. He was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot. He was given a postop shoe and will be full weightbearing. He has prescription already at home for hydrocodone and does not need to refill. He is to follow up with Dr. X and was given emergency contact numbers. He was discharged in stable condition.podiatry, pneumatic ankle, metatarsal head, tailor's bunion, head, pneumatic, ulceration, metatarsal, bone

CHIEF COMPLAINT:, GI bleed.,HISTORY OF PRESENT ILLNESS:, The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue. CBC revealed microcytic anemia with hemoglobin of 8.9. Stool dark brown, strongly OB positive. The patient denied any shortness of breath. No chest pain. No GI complaints. The patient was admitted to ABCD for further evaluation.,PAST MEDICAL HISTORY: ,Significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism.,PHYSICAL EXAMINATION:,GENERAL: The patient is in no acute distress.,VITAL SIGNS: Stable.,HEENT: Benign.,NECK: Supple. No adenopathy.,LUNGS: Clear with good air movement.,HEART: Irregularly regular. No gallops.,ABDOMEN: Positive bowel sounds, soft, and nontender. No masses or organomegaly.,EXTREMITIES: 1+ lower extremity edema bilaterally.,HOSPITAL COURSE: , The patient underwent upper endoscopy performed by Dr. A, which revealed erosive gastritis. Colonoscopy did reveal diverticulosis as well as polyp, which was resected. The patient tolerated the procedure well. She was transfused, and prior to discharge hemoglobin was stable at 10.7. The patient was without further GI complaints. Coumadin was held during hospital stay and recommendations were given by GI to hold Coumadin for an additional three days after discharge then resume. The patient was discharged with outpatient PMD, GI, and Cardiology followup.,DISCHARGE DIAGNOSES:,1. Upper gastrointestinal bleed.,2. Anemia.,3. Atrial fibrillation.,4. Non-insulin-dependent diabetes mellitus.,5. Hypertension.,6. Hypothyroidism.,7. Asthma.,CONDITION UPON DISCHARGE: , Stable.,MEDICATIONS: , Feosol 325 mg daily, multivitamins one daily, Protonix 40 mg b.i.d., KCl 20 mEq daily, Lasix 40 mg b.i.d., atenolol 50 mg daily, Synthroid 80 mcg daily, Actos 30 mg daily, Mevacor 40 mg daily, and lisinopril 20 mg daily.,ALLERGIES:, None.,DIET: , 1800-calorie ADA.,ACTIVITY: , As tolerated.,FOLLOWUP: , The patient to hold Coumadin through weekend. Followup CBC and INR were ordered. Outpatient followup as arranged.nan

Patient was informed by Dr. ABC that he does not need sleep study as per patient.,PHYSICAL EXAMINATION:,General: Pleasant, brighter.,Vital signs: 117/78, 12, 56.,Abdomen: Soft, nontender. Bowel sounds normal.,ASSESSMENT AND PLAN:,1. Constipation. Milk of Magnesia 30 mL daily p.r.n., Dulcolax suppository twice a week p.r.n.,2. CAD/angina. See cardiologist this afternoon.,Call me if constipation not resolved by a.m., consider a Fleet enema then as discussed.,office notes, constipation, bm, milk of magnesia, suppository, dulcolax, fleet enema,

PROBLEMS AND ISSUES:,1. Headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment.,2. Some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercise daily.,HISTORY OF PRESENT ILLNESS: , The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. I obtained and documented a full history and physical examination. I reviewed the new patient questionnaire, which she completed prior to her arrival today. I also reviewed the results of tests, which she had brought with her.,Briefly, she is a 60-year-old woman initially from Ukraine, who had headaches since age 25. She recalls that in 1996 when her husband died her headaches became more frequent. They were pulsating. She was given papaverine, which was successful in reducing the severity of her symptoms. After six months of taking papaverine, she no longer had any headaches. In 2004, her headaches returned. She also noted that she had "zig-zag lines" in her vision. Sometimes she would not see things in her peripheral visions. She had photophobia and dizziness, which was mostly lightheadedness. On one occasion she almost had a syncope. Again she has started taking Russian medications, which did help her. The dizziness and headaches have become more frequent and now occur on average once to twice per week. They last two hours since she takes papaverine, which stops the symptoms within 30 minutes.,PAST MEDICAL HISTORY: ,Her past medical history is significant for injury to her left shoulder, gastroesophageal reflux disorder, diabetes, anxiety, and osteoporosis.,MEDICATIONS:, Her medications include hydrochlorothiazide, lisinopril, glipizide, metformin, vitamin D, Centrum multivitamin tablets, Actos, lorazepam as needed, Vytorin, and Celexa.,ALLERGIES: , She has no known drug allergies.,FAMILY HISTORY: ,There is family history of migraine and diabetes in her siblings.,SOCIAL HISTORY: , She drinks alcohol occasionally.,REVIEW OF SYSTEMS: , Her review of systems was significant for headaches, pain in her left shoulder, sleeping problems and gastroesophageal reflex symptoms. Remainder of her full 14-point review of system was unremarkable.,PHYSICAL EXAMINATION:, On examination, the patient was pleasant. She was able to speak English fairly well. Her blood pressure was 130/84. Heart rate was 80. Respiratory rate was 16. Her weight was 188 pounds. Her pain score was 0/10. Her general exam was completely unremarkable. Her neurological examination showed subtle weakness in her left arm due to discomfort and pain. She had reduced vibration sensation in her left ankle and to some degree in her right foot. There was no ataxia. She was able to walk normally. Reflexes were 2+ throughout.,She had had a CT scan with constant, which per Dr. X's was unremarkable. She reports that she had a brain MRI two years ago which was also unremarkable.,IMPRESSION AND PLAN:, The patient is a delightful 60-year-old chemist from Ukraine who has had episodes of headaches with nausea, photophobia, and dizziness since her 20s. She has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms. Her diagnosis is consistent with vestibular migraine. I do not see evidence of multiple sclerosis, Ménière's disease, or benign paroxysmal positional vertigo.,I talked to her in detail about the importance of following a migraine diet. I gave her instructions including a list of foods times, which worsen migraine. I reviewed this information for more than half the clinic visit. I would like to start her on amitriptyline at a dose of 10 mg at time. She will take Motrin at a dose of 800 mg as needed for her severe headaches.,She will make a diary of her migraine symptoms so that we can find any triggering food items, which worsen her symptoms. I encouraged her to walk daily in order to improve her fitness, which helps to reduce migraine symptoms.psychiatry / psychology, nausea, dizziness, migraine, peripheral neuropathy, diabetic neuropathy, neuropathy, positional vertigo, photophobia and dizziness, neurology consultation, tunnel vision, vestibular migraine, migraine symptoms, headaches, photophobia, ataxia,

PREOPERATIVE DIAGNOSES:, OM, chronic, serous, simple or unspecified. Adenoid hyperplasia. Hypertrophy of tonsils.,POSTOPERATIVE DIAGNOSIS: , Same as preoperative diagnosis.,OPERATION: , Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.,ANESTHESIA:, General.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS: , None.,CONSENT:, The procedure, benefits, and risks were discussed in detail preoperatively. The parentsagreed to proceed after all questions were answered.,TECHNIQUE: , The patient was brought to the operating room and placed in the supine position. After general mask anesthesia was adequately obtained, the right external auditory canal was cleaned out under the microscope. Serous fluid was aspirated from the middle ear space. An Armstrong grommet tube was placed down through the incision and rotated into place. The opposite ear was then cleaned out under the microscope. Serous fluid was aspirated from the middle ear space. An Armstrong grommet tube was placed down through the incision and rotated into place. Cortisporin suspension was placed in both ear canals.,Then the patient was intubated. A Crowe-Davis mouth gag was placed into the mouth and extended and hung on the Mayo stand. The red rubber catheter was placed down through the nose and brought out through the mouth to retract the palate. The adenoid fossa was visualized with the mirror. The adenoids were removed using the microdebrider. Two adenoid packs were placed. The packs were removed one by one. Using mirror and suction bovie, adequate hemostasis was achieved.,The tonsils were quite large and cryptic. The tenaculum was placed on the superior pole of the right tonsil. Cheesy material came out from the crypts. The tonsils were retracted medially. The bovie electrocautery was used to make an incision in the right anterior tonsillar pillar, and the plane was developed between the tonsil and the musculature. The tonsil was completely dissected out of this plane, preserving both the anterior and posterior tonsillar pillars. All bleeders were cauterized as they were encountered. The tenaculum was then placed on the superior pole of the left tonsil. Cheesy material came out from the crypts. The tonsils were retracted medially. The bovie electrocautery was used to make an incision in the left anterior tonsillar pillar, and the plane was developed between the tonsil and the musculature. The tonsil was completely dissected out of this plane, preserving both the anterior and posterior tonsillar pillars. All bleeders were cauterized as they were encountered. Both tonsil beds were then re-cauterized, paying particular attention to the inferior and superior poles.,The stomach was evacuated with the nasogastric tube. The patient was then awakened in the operating room, extubated and taken to the recovery room in satisfactory condition.ent - otolaryngology, adenoid hyperplasia, om, adenoidectomy, tonsillectomy, auditory canal, serous fluid, crowe-davis mouth gag, tonsils, adenoidectomy and tonsillectomy, armstrong grommet tubes, bovie electrocautery, tonsillar pillar, bilateral myringotomies, armstrong, tubes, grommet, tonsillar, bilateral, myringotomies, tenaculum

GENERAL: Negative for any nausea, vomiting, fevers, chills, or weight loss.,NEUROLOGIC: Negative for any blurry vision, blind spots, double vision, facial asymmetry, dysphagia, dysarthria, hemiparesis, hemisensory deficits, vertigo, ataxia.,HEENT: Negative for any head trauma, neck trauma, neck stiffness, photophobia, phonophobia, sinusitis, rhinitis.,CARDIAC: Negative for any chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema.,PULMONARY: Negative for any shortness of breath, wheezing, COPD, or TB exposure.,GASTROINTESTINAL: Negative for any abdominal pain, nausea, vomiting, bright red blood per rectum, melena.,GENITOURINARY: Negative for any dysuria, hematuria, incontinence.,INTEGUMENTARY: Negative for any rashes, cuts, insect bites.,RHEUMATOLOGIC: Negative for any joint pains, photosensitive rashes, history of vasculitis or kidney problems.,HEMATOLOGIC: Negative for any abnormal bruising, frequent infections or bleeding.general medicine, review of systems, trauma, neck, dyspnea, rashes, nausea, vomiting,

PRE AND POSTOPERATIVE DIAGNOSIS:, Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR. After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted. At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position. The patient's posterior cervical area was then prepped and draped in the usual sterile fashion. At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine. A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated. After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken. This showed the spinous process to be at the C4 level. Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified. After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken. This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time. At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina. The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe. This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur. However, progress was limited because of thickness of the bone. Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area. After the bone had been thinned out, further bone was removed using the Kerrison rongeur. At this point the nerve root was visually inspected and observed to be decompressed. However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade. Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery. After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin. Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches. The subcutaneous layer was then reapproximated using 000 Dexon. The skin was reapproximated using a running 000 nylon. Sterile dressings were applied. The patient was then extubated in the OR and transferred to the Recovery room in stable condition.,ESTIMATED BLOOD LOSS:, minimal.neurosurgery, foraminotomy with medial facetectomy, facetectomy for microscopic decompression, decompression of nerve root, hemilaminotomy and foraminotomy, decompression of nerve, microscopic decompression, medial facetectomy, kerrison rongeur, nerve root, spinous processes, facetectomy, kerrison, hemilaminotomy, foraminotomy,

PREOPERATIVE DIAGNOSIS:, Metastatic glossal carcinoma, needing chemotherapy and a port.,POSTOPERATIVE DIAGNOSIS: , Metastatic glossal carcinoma, needing chemotherapy and a port.,PROCEDURES,1. Open exploration of the left subclavian/axillary vein.,2. Insertion of a double lumen port through the left femoral vein, radiological guidance.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was electively taken to the operating room, where he underwent a general anesthetic through his tracheostomy. The left deltopectoral and cervical areas were prepped and draped in the usual fashion. Local anesthetic was infiltrated in the area. There was some evidence that surgical procedure had happened in the area nearby and also there was collateral venous circulation under the skin, which made us suspicious that may be __________, but at any rate I tried to cannulate it subcutaneously and I was unsuccessful. Therefore, I proceeded to make an incision and was able to isolate the vein, which would look very sclerotic. I tried to cannulate it, but I could not advance the wire.,At that moment, I decided that there was no way we are going to put a port though that area. I packed the incision and we prepped and redraped the patient including both groins. Local anesthetic was infiltrated and then the left femoral vein was percutaneously cannulated without any difficulty. The introducer was placed and then a wire and then the catheter of the double lumen port, which had been trimmed to position it near the heart. It was done with radiological guidance. Again, I was able to position the catheter in the junction of inferior vena cava and right atrium. The catheter was looked upwards and the double lumen port was inserted subcutaneously towards the iliac area. The port had been aspirated satisfactorily and irrigated with heparin solution. The drain incision was closed in layers including subcuticular suture with Monocryl. Then, we went up to the left shoulder and closed that incision in layers. Dressings were applied.,The patient tolerated the procedure well and was sent back to recovery room in satisfactory condition.cardiovascular / pulmonary, axillary, vein, subclavian, double lumen port, femoral vein, radiological guidance, glossal carcinoma, port, inserstion, femoral, radiological, metastatic, carcinoma, chemotherapy, anesthetic, catheter,

IDENTIFYING DATA: , The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital. He says he had a "panic attack leading to the car wreck" and denies that any of his behavior was suicidal in nature responding, "I was just trying to scare my mother.",CHIEF COMPLAINT: , The patient does say, "I screwed up my whole life and wrecked my car." The patient claims he is med compliant, although his mother, and stepfather saying he is off his meds. He had a two-day stay at XYZ Hospital for medical clearance after his car accident, and no injuries were found other than a sore back, which was negative by x-ray and CT scan.,PRESENT ILLNESS: ,The patient is on a 72-your involuntary hold for danger to self and grave disability. He has a history of bipolar disorder with mania and depression with anxiety and panic attacks. Today, he went to involuntary court hearing and was released by the court. He is now being discharged from second floor ABCD Psychiatric Hospital.,PAST PSYCHIATRIC HISTORY:, Listed extensively in his admission note and will not be repeated.,MEDICAL HISTORY: , Includes migraine headaches and a history of concussion. He describes "allergy" to Haldol medication.,OUTPATIENT CARE: , The patient sees a private psychiatrist, Dr. X. Followup with Dr. X is arranged in four days' time and the patient is discharged with four days of medication. This information is known to Dr. X.,DISCHARGE MEDICATIONS:,The patient is discharged with:,1. Klonopin 1 mg t.i.d. p.r.n.,2. Extended-release lithium 450 mg b.i.d.,3. Depakote 1000 mg b.i.d.,4. Seroquel 1000 mg per day.,SOCIAL HISTORY: ,The patient lives with his girlfriend on an on-and-off basis and is unclear if they will be immediately moving back in together.,SUBSTANCE ABUSE: , The patient was actively tox screen positive for benzodiazepines, cocaine, and marijuana. The patient had an inpatient stay in 2008 at ABC Lodge for drug abuse treatment.,MENTAL STATUS EXAM:, Notable for lack of primary psychotic symptoms, some agitation, and psychomotor hyperactivity, uncooperative behavior regarding his need for ongoing acute psychiatric treatment and stabilization. There is an underlying hostile oppositional message in his communications.,FORMULATION: , The patient is a 21-year-old male with a history of bipolar disorder, anxiety, polysubstance abuse, and in addition ADHD. His recent behavior is may be at least in part associated with active polysubstance abuse and also appears to be a result of noncompliance with meds.,DIAGNOSES:,AXIS I:,1. Bipolar disorder.,2. Major depression with anxiety and panic attacks.,3. Polysubstance abuse, benzodiazepines, and others street meds.,4. ADHD.,AXIS II: , Deferred at present, but consider personality disorder traits.,AXIS III:, History of migraine headaches and past history of concussion.,AXIS IV: , Stressors are moderate.,AXIS V: , GAF is 40.,PLAN: , The patient is released from the hospital secondary to court evaluation, which did not extend his involuntary stay. He has an appointment in four days with his outpatient psychiatrist, Dr. X. He has four days' worth of medications and agrees to no self-harm or harm of others. Additionally, he agrees to let staff know or authorities know if he becomes acutely unsafe. His mother and stepfather have been informed of the patient's discharge and the followup plan.nan

PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 30 and 4/7th weeks.,2. Previous cesarean section x2.,3. Multiparity.,4. Request for permanent sterilization.,POSTOPERATIVE DIAGNOSIS:,1. Intrauterine pregnancy at 30 and 4/7th weeks.,2. Previous cesarean section x2.,3. Multiparity.,4. Request for permanent sterilization.,5. Breach presentation in the delivery of a liveborn female neonate.,PROCEDURES PERFORMED:,1. Repeat low transverse cesarean section.,2. Bilateral tubal ligation (BTL).,TUBES: , None.,DRAINS: , Foley to gravity.,ESTIMATED BLOOD LOSS: , 600 cc.,FLUIDS:, 200 cc of crystalloids.,URINE OUTPUT:, 300 cc of clear urine at the end of the procedure.,FINDINGS:, Operative findings demonstrated a wire mesh through the anterior abdominal wall and the anterior fascia. There were bowel adhesions noted through the anterior abdominal wall. The uterus was noted to be within normal limits. The tubes and ovaries bilaterally were noted to be within normal limits. The baby was delivered from the right sacral anterior position without any difficulty. Apgars 8 and 9. Weight was 7.5 lb.,INDICATIONS FOR THIS PROCEDURE: ,The patient is a 23-year-old G3 P 2-0-0-2 with reported 30 and 4/7th weeks' for a scheduled cesarean section secondary to repeat x2. She had her first C-section because of congenial hip problems. In her second C-section, baby was breached, therefore, she is scheduled for a third C-section. The patient also requests sterilization. Therefore, she requested a tubal ligation.,PROCEDURE: , After informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where a spinal with Astramorph anesthesia was obtained without any difficulty. She was placed in the dorsal supine position with a leftward tilt and prepped and draped in the usual sterile fashion. A Pfannenstiel skin incision was made removing the old scar with a first knife and then carried down to the underlying layer of fascia with a second knife. The fascia was excised in the midline extended laterally with the Mayo scissors. The superior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply with the Metzenbaum scissors. There was noted dense adhesions at this point as well as a wire mesh was noted. The anterior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply as well as bluntly. The rectus muscle superiorly was opened with a hemostat. The peritoneum was identified and entered bluntly digitally. The peritoneal incision was then extended superiorly up to the level of the mesh. Then, inferiorly using the knife, the adhesions were taken down and the bladder was identified and the peritoneum incision extended inferiorly to the level of the bladder. The bladder blade was inserted and vesicouterine peritoneum was identified and tented up with Allis clamps and bladder flap was created sharply with the Metzenbaum scissors digitally. The bladder blade was then reinserted to protect the bladder and the uterine incision was made with a first knife and then extended laterally with the Bandage scissors. The amniotic fluid was noted to be clear. At this point, upon examining the intrauterine contents, the baby was noted to be breached. The right foot was identified and then the baby was delivered from the double footling breach position without any difficulty. The cord was clamped and the baby was then handed off to awaiting pediatricians. The placenta cord gases were obtained and the placenta was then manually extracted from the uterus. The uterus was exteriorized and cleared of all clots and debris. Then, the uterine incision was then closed with #0 Vicryl in a double closure stitch fashion, first layer in locking stitch fashion and the second layer an imbricating layer. Attention at this time was turned to the tubes bilaterally.,Both tubes were isolated and followed all the way to the fimbriated end and tented up with the Babcock clamp. The hemostat was probed through the mesosalpinx in the avascular area and then a section of tube was clamped off with two hemostats and then transected with the Metzenbaum scissors. The ends was then burned with the cautery and then using a #2-0 Vicryl suture tied down. Both tube sections were noted to be hemostatic and the tubes were then sent to pathology for review. The uterus was then replaced back into the abdomen. The gutters were cleared of all clots and debris. The uterine incision was then once again inspected and noted to be hemostatic. The bladder flap was then replaced back into the uterus with #3-0 interrupted sutures. The peritoneum was then closed with #3-0 Vicryl in a running fashion. Then, the area at the fascia where the mesh had been cut and approximately 0.5 cm portion was repaired with #3-0 Vicryl in a simple stitch fashion. The fascia was then closed with #0 Vicryl in a running fashion. The subcutaneous layer and Scarpa's fascia were repaired with a #3-0 Vicryl. Then, the skin edges were reapproximated using sterile clips. The dressing was placed. The uterus was then cleared of all clots and debris manually. Then, the patient tolerated the procedure well. Sponge, lap, and needle, counts were correct x2. The patient was taken to recovery in sable condition. She will be followed up throughout her hospital stay.nan

EXAM:,MRI/LOW EX NOT JNT RT W/O CONTRAST,CLINICAL:,Pain and swelling in the right foot, peroneal tendon tear.,FINDINGS:, Contours of marrow signal patterns of the regional bones are within normal range treating there is increased T2 signal within the soft tissues at the lateral margin of the cuboid bone. A small effusion is noted within the peroneal tendon sheath. There is a 3mm slight separation of the distal tip of the peroneus longus tendon from the lateral margin of the cuboid bone, consistent with an avulsion. There is no sign of cuboid fracture. The fifth metatarsal base appears intact. The calcaneus is also normal in appearance.,IMPRESSION: ,Findings consistent with an avulsion of the peroneus longus tendon from the insertion on the lateral aspect of cuboid bone.,radiology, peroneus longus tendon, peroneal tendon, lateral margin, peroneus longus, longus tendon, cuboid bone, foot, peroneal, peroneus, longus, avulsion, tendon, bones, cuboid,

PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES: , Rectal bleeding and perirectal abscess.,POSTOPERATIVE DIAGNOSIS: , Perianal abscess.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum. The preparation was excellent and all surfaces were well seen. The mucosa throughout the colon and in the terminal ileum was normal, with no evidence of colitis. Special attention was paid to the rectum, including retroflexed views of the distal rectum and the anorectal junction. There was no evidence of either inflammation or a fistulous opening. The scope was withdrawn. A careful exam of the anal canal and perianal area demonstrated a jagged 8-mm opening at the anorectal junction posteriorly (12 o'clock position). Some purulent material could be expressed through the opening. There was no suggestion of significant perianal reservoir of inflamed tissue or undrained material. Specifically, the posterior wall of the distal rectum and anal canal were soft and unremarkable. In addition, scars were noted in the perianal area. The first was a small dimpled scar, 1 cm from the anal verge in the 11 o'clock position. The second was a dimpled scar about 5 cm from the anal verge on the left buttock's cheek. There were no other abnormalities noted. The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Normal colonoscopy to the terminal ileum.,2. Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.,RECOMMENDATIONS:,1. Continue antibiotics.,2. Followup with Dr. X.,3. If drainage persists, consider surgical drainage.gastroenterology, olympus, colonoscope, rectal bleeding, perianal abscess, terminal ileum, anal verge, anorectal, fistulous, ileum, verge, rectum, anal, perianal, colonoscopy, abscess