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SUBJECTIVE:, This is a 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet. The patient is in foster care, has a long history of the prematurity, born at 22 weeks. She has chronic lung disease, is on ventilator, but doing sprints, has been doing very well, is up to 4-1/2 hours sprints twice daily and may go up 15 minutes every three days or so; which she has been tolerating fairly well as long as they kind of get her distracted towards the end, otherwise, she does get sort of tachypneic. She is on 2-1/2 liters of oxygen and does require that. Her diet has been fluctuating. They have been trying to figure out what works best with her. She has been on some Pediasure for the increased calories but that really makes her distended in the abdomen and constipates her. They have been doing more pureed foods and that seems to loosen her up, so they have been doing more Isomil 24 cal and baby foods and not so much Pediasure. She was hospitalized a couple of weeks back for the distension she had in the abdomen. Dr. XYZ has been working with her G-tube, increasing her Mic-key button size, but also doing some silver nitrate applications, and he is going to evaluate her again next week, but they are happy with the way her G-tube site is looking. She also has been seen Dr. Eisenbaum, just got of new pair of glasses this week and sees him in another couple of weeks for reevaluation.,CURRENT MEDICATIONS:, Flagyl, vitamins, Zyrtec, albuterol, and some Colace.,ALLERGIES TO MEDICINES: , None.,FAMILY SOCIAL HISTORY:, As mentioned, she is in foster care. Foster mom is actually going to be out of town for a week the 19th through the 23rd, so she will probably be hospitalized in respite care because there are no other foster care situations that can handle the patient. Biological Mom and Grandma do visit on Thursdays for about an hour.,REVIEW OF SYSTEMS:, The patient has been eating fairly well, sleeping well, doing well with her sprints. A little difficulty with her stools hard versus soft as mentioned with the diet situation up in HPI.,PHYSICAL EXAMINATION:,Vital Signs: She is 28 pounds 8 ounces today, 33-1/2 inches tall. She is on 2-1/2 liters, but she is not the vent currently, she is doing her sprints, and her respiratory rate is around 40.,HEENT: Sclerae and conjunctivae are clear. TMs are clear. Nares are patent. Oropharynx is clear. Trach site is clear of any signs of infection.,Chest: Coarse. She has got little bit of wheezing going on, but she is moving air fairly well.,Abdomen: Positive bowel sounds and soft. The G-tube site looks fairly clean today and healthy. No signs of infection. Her tone is good. Capillary refill is less than three seconds.,ASSESSMENT:, A 2-year-old with chronic lung disease, doing the sprints, some bowel difficulties, also just weight gain issues because of the high-energy expenditure with the sprints that she is doing.,PLAN:, At this point is to continue with the Isomil and pureed baby foods, a little bit of Pediasure. They are going to see Dr. XYZ towards the end of this month and follow up with Dr. Eisenbaum. I would like to see her in approximately six weeks again, but we do need to keep a close check on her weight and call if there are problems beforehand. She is just doing wonderful progression on her development. Each time I see her, I am very impressed, that relayed to foster mom. Approximately 25 minutes spent with the patient, most of it counseling.general medicine, chronic lung disease, signs of infection, breathing status, foster mom, foster care, pediasure

DELIVERY NOTE: ,This is a 30-year-old G6, P5-0-0-5 with unknown LMP and no prenatal care, who came in complaining of contractions and active labor. The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks. The patient progressed to a normal spontaneous vaginal delivery over an intact perineum. Rupture of membranes occurred on 12/25/08 at 2008 hours via artificial rupture of membranes. No meconium was noted. Infant was delivered on 12/25/08 at 2154 hours. Two doses of ampicillin was given prior to rupture of membranes. GBS status unknown. Intrapartum events, no prenatal care. The patient had epidural for anesthesia. No observed abnormalities were noted on initial newborn exam. Apgar scores were 9 and 9 at one and five minutes respectively. There was a nuchal cord x1, nonreducible, which was cut with two clamps and scissors prior to delivery of body of child. Placenta was delivered spontaneously and was normal and intact. There was a three-vessel cord. Baby was bulb suctioned and then sent to newborn nursery. Mother and baby were in stable condition. EBL was approximately 500 mL, NSVD with postpartum hemorrhage. No active bleeding was noted upon deliverance of the placenta. Dr. X attended the delivery with second year resident, Dr. X. Upon deliverance of the placenta, the uterus was massaged and there was good tone. Pitocin was started following deliverance of the placenta. Baby delivered vertex from OA position. Mother following delivery had a temperature of 100.7, denied any specific complaints and was stable following delivery.obstetrics / gynecology, spontaneous vaginal delivery, rupture of membranes, gestational age, vaginal delivery, intact perineum, prenatal care, gestational, placentaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

HISTORY OF PRESENT ILLNESS:, This is the initial clinic visit for a 41-year-old worker who is seen for a foreign body to his left eye. He states that he was doing his normal job when he felt a foreign body sensation. He attempted to flush this at work, but has had persistent pain which has progressively worsened throughout the course of the day. He has no significant blurriness of vision or photophobia.nan

PREOPERATIVE DIAGNOSIS:, Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis, gangrenous.,PROCEDURE: , Appendectomy.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room under urgent conditions. After having obtained an informed consent, he was placed in the operating room and under anesthesia. Followed by a time-out process, his abdominal wall was prepped and draped in the usual fashion. Antibiotics had been given prior to incision. A McBurney incision was performed and it carried out through the peritoneal cavity. Immediately there was purulent material seen in the area. Samples were taken for culture and sensitivity of aerobic and anaerobic sets. The appendix was markedly swollen particularly in its distal three-fourth, where the distal appendix showed an abscess formation and devitalization of the wall. There was quite a bit of local peritonitis. The mesoappendix was clamped, divided and ligated, and then the appendix was ligated and divided, and the stump buried with a pursestring suture of Vicryl and then a Z stitch. The area was abundantly irrigated with normal saline and also the pelvis. The distal foot of small bowel had been explored and because it delivered itself __________ the incision and showed no pathology.,Then the peritoneal and internal fascia were approximated with a suture of 0 Vicryl and then the incision was closed in layers and after each layer the wound was irrigated with normal saline. The skin was closed with a combination of a subcuticular suture of fine Monocryl followed by the application of Dermabond. The patient tolerated the procedure well. Estimated blood loss was minimal, and the patient was sent to the recovery room for recovery in satisfactory condition.,surgery, mcburney incision, abdominal, small bowel, acute appendicitis, appendectomy, gangrenous, appendix,

CHIEF COMPLAINT:, Foul-smelling urine and stomach pain after meals.,HISTORY OF PRESENT ILLNESS:, Stomach pain with most meals x one and a half years and urinary symptoms for same amount of time. She was prescribed Reglan, Prilosec, Pepcid, and Carafate at ED for her GI symptoms and Bactrim for UTI. This visit was in July 2010.,REVIEW OF SYSTEMS:, HEENT: No headaches. No visual disturbances, no eye irritation. No nose drainage or allergic symptoms. No sore throat or masses. Respiratory: No shortness of breath. No cough or wheeze. No pain. Cardiac: No palpitations or pain. Gastrointestinal: Pain and cramping. Denies nausea, vomiting, or diarrhea. Has some regurgitation with gas after meals. Genitourinary: "Smelly" urine. Musculoskeletal: No swelling, pain, or numbness.,MEDICATION ALLERGIES:, No known drug allergies.,PHYSICAL EXAMINATION:,General: Unremarkable.,HEENT: PERRLA. Gaze conjugate.,Neck: No nodes. No thyromegaly. No masses.,Lungs: Clear.,Heart: Regular rate without murmur.,Abdomen: Soft, without organomegaly, without guarding or tenderness.,Back: Straight. No paraspinal spasm.,Extremities: Full range of motion. No edema.,Neurologic: Cranial nerves II-XII intact. Deep tendon reflexes 2+ bilaterally.,Skin: Unremarkable.,LABORATORY STUDIES:, Urinalysis was done, which showed blood due to her period and moderate leukocytes.,ASSESSMENT:,1. UTI.,2. GERD.,3. Dysphagia.,4. Contraception consult.,PLAN:,1. Cipro 500 mg b.i.d. x five days. Ordered BMP, CBC, and urinalysis with microscopy.,2. Omeprazole 20 mg daily and famotidine 20 mg b.i.d.,3. Prescriptions same as #2. Also referred her for a barium swallow series to rule out a stricture.,4. Ortho Tri-Cyclen Lo.,nan

REASON FOR CONSULTATION: , Questionable need for antibiotic therapy for possible lower extremity cellulitis.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Caucasian female with past medical history of morbid obesity and chronic lower extremity lymphedema. She follows up at the wound care center at Hospital. Her lower extremity edema is being managed there. She has had multiple episodes of cellulitis of the lower extremities for which she has received treatment with oral Bactrim and ciprofloxacin in the past according to her. As her lymphedema was not improving on therapy at that facility, she was referred for admission to Long-Term Acute Care Facility for lymphedema management. She at present has a stage II ulcer on the lower part of the medial aspect of left leg without any drainage and has slight erythema of bilateral lower calf and shin areas. Her measurements for lymphedema wraps have been taken and in my opinion, it is going to be started in a day or two.,I have been consulted to rule out the possibility of lower extremity cellulitis that may require antibiotic therapy.,PAST MEDICAL HISTORY:, Positive for morbid obesity, chronic lymphedema of the lower extremities, at least for the last three years, spastic colon, knee arthritis, recurrent cellulitis of the lower extremities. She has had a hysterectomy and a cholecystectomy in the remote past.,SOCIAL HISTORY: , The patient lives by herself and has three pet cats. She is an ex-smoker, quit smoking about five years ago. She occasionally drinks a glass of wine. She denies any other recreational drugs use. She recently retired from State of Pennsylvania as a psychiatric aide after 32 years of service.,FAMILY HISTORY: , Positive for mother passing away at the age of 38 from heart problems and alcoholism, dad passed away at the age of 75 from leukemia. One of her uncles was diagnosed with leukemia.,ALLERGIES: , ADHESIVE TAPE ALLERGIES.,REVIEW OF SYSTEMS:, At present, the patient is admitted with a nonresolving bilateral lower extremity lymphedema, which is a little bit more marked on the right lower extremity compared to the left. She denies any nausea, vomiting or diarrhea. She denies any pain, tenderness, increased warmth or drainage from the lower extremities. Denies chest pain, cough or phlegm production. All other systems reviewed were negative.,PHYSICAL EXAMINATION:,General: A 51-year-old morbidly obese Caucasian female who is not in any acute hemodynamic distress at present.,Vital signs: Her maximum recorded temperature since admission today is 96.8, pulse is 65 per minute, respiratory rate is 18 to 20 per minute, blood pressure is 150/54, I do not see a recorded weight at present.,HEENT: Pupils are equal, round, and reactive to light. Extraocular movements intact. Head is normocephalic and external ear exam is normal.,Neck: Supple. There is no palpable lymphadenopathy.,Cardiovascular system: Regular rate and rhythm of the heart without any appreciable murmur, rub or gallop. Heart sounds are little distant secondary to thick chest wall.,Lungs: Clear to auscultation and percussion bilaterally.,Abdomen: Morbidly obese, soft, nontender, nondistended, there is no percussible organomegaly, there is no evidence of lymphedema on the abdominal pannus. There is no evidence of cutaneous candidiasis in the inguinal folds. There is no palpable lymphadenopathy in the inguinal and femoral areas.,Extremities: Bilateral lower extremities with evidence of extensive lymphedema, there is slight pinkish discoloration of the lower part of calf and shin areas, most likely secondary to stasis dermatosis. There is no increased warmth or tenderness, there is no skin breakdown except a stage II chronic ulcer on the lower medial aspect of the right calf area. It has minimal serosanguineous drainage and there is no surrounding erythema. Therefore, in my opinion, there is no current evidence of cellulitis or wound infection. There is no cyanosis or clubbing. There is no peripheral stigmata of endocarditis.,Central nervous system: The patient is alert and oriented x3, cranial nerves II through XII are intact, and there is no focal deficit appreciated.,LABORATORY DATA: , White cell count is 7.4, hemoglobin 12.9, hematocrit 39, platelet count of 313,000, differential is normal with 51% neutrophils, 37% lymphocytes, 9% monocytes and 3% eosinophils. The basic electrolyte panel is within normal limits and the renal function is normal with BUN of 17 and creatinine of 0.5. Liver function tests are also within normal limits.,The nasal screen for MRSA is negative. Urine culture is negative so far from admission. Urinalysis was negative for pyuria, leucocyte esterase, and nitrites.,IMPRESSION AND PLAN:, A 51-year-old Caucasian female with multiple medical problems mentioned above including history of morbid obesity and chronic lower extremity lymphedema. Admitted for inpatient management of bilateral lower extremity lymphedema. I have been consulted to rule out possibility of active cellulitis and wound infection.,At present, I do not find evidence of active cellulitis that needs antibiotic therapy. In my opinion, lymphedema wraps could be initiated. We will continue to monitor her legs with lymphedema wraps changes 2 to 3 times a week. If she develops any cellulitis, then appropriate antibiotic therapy will be initiated. ,Her stage II ulcer on the right leg does not look infected. I would recommend continuation of wound care along with lymphedema wraps.,Other medical problems will continue to be followed and treated by Dr. X's group during this hospitalization. Dr. Y from Plastic Surgery and Lymphedema Management Clinic is following.,I appreciate the opportunity of participating in this patient's care. If you have any questions, please feel free to call me at any time. I will continue to follow the patient along with you 2-3 times per week during this hospitalization at the Long-Term Acute Care Facility.nan

NUCLEAR MEDICINE HEPATOBILIARY SCAN,REASON FOR EXAM: , Right upper quadrant pain.,COMPARISONS: ,CT of the abdomen dated 02/13/09 and ultrasound of the abdomen dated 02/13/09.,Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.,FINDINGS:, Imaging obtained up to 30 minutes after the injection of radiopharmaceutical shows a normal hepatobiliary transfer time. There is normal accumulation within the gallbladder.,After the injection of 2.1 mcg of intravenous cholecystic _______, the gallbladder ejection fraction at 30 minutes was calculated to be 32% (normal is greater than 35%). The patient experienced 2/10 pain at 5 minutes after the injection of the radiopharmaceutical and the patient also complained of nausea.,IMPRESSION:,1. Negative for acute cholecystitis or cystic duct obstruction.,2. Gallbladder ejection fraction just under the lower limits of normal at 32% that can be seen with very mild chronic cholecystitis.gastroenterology, radiopharmaceutical, gallbladder ejection fraction, nuclear medicine hepatobiliary, hepatobiliary scan, quadrant, nuclear, technetium, choletec, ejection, fraction, cholecystitis, scan, abdomen, injection, gallbladder, hepatobiliary, medicine

HISTORY:, The patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves. Symptoms worsened considerable about a month ago. This normally occurs after being on her feet for any length of time. She was started on amitriptyline and this has significantly improved her symptoms. She is almost asymptomatic at present. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness.,On brief examination, straight leg raising is normal. The patient is obese. There is mild decreased vibration and light touch in distal lower extremities. Strength is full and symmetric. Deep tendon reflexes at the knees are 2+ and symmetric and absent at the ankles.,NERVE CONDUCTION STUDIES: , Bilateral sural sensory responses are absent. Bilateral superficial sensory responses are present, but mildly reduced. The right radial sensory response is normal. The right common peroneal and tibial motor responses are normal. Bilateral H-reflexes are absent.,NEEDLE EMG:, Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle. It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle. Lumbar paraspinals were attempted, but were too painful to get a good assessment.,IMPRESSION: ,This electrical study is abnormal. It reveals the following:,1. A very mild, purely sensory length-dependent peripheral neuropathy.,2. Mild bilateral L5 nerve root irritation. There is no evidence of active radiculopathy.,Based on the patient's history and exam, her new symptoms are consistent with mild bilateral L5 radiculopathies. Symptoms have almost completely resolved over the last month since starting Elavil. I would recommend MRI of the lumbosacral spine if symptoms return. With respect to the mild neuropathy, this is probably related to her mild glucose intolerance/early diabetes. However, I would recommend a workup for other causes to include the following: Fasting blood sugar, HbA1c, ESR, RPR, TSH, B12, serum protein electrophoresis and Lyme titer.radiology, nerve conduction studies, needle emg, numbness, tibialis posterior muscle, sensory responses, muscle, tibialis, toes

PREOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,POSTOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,OPERATION PERFORMED:,1. Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.,2. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.,3. Right L4-S1 posterolateral fusion with local bone graft.,4. Left L4 through S1 segmental pedicle screw instrumentation.,5. Preparation harvesting of local bone graft.,ANESTHESIA: , General endotracheal.,PREPARATION:, Povidone-iodine.,INDICATION: , This is a gentleman with right-sided lumbosacral radiculopathy, MRI disclosed and lateral recess stenosis at the L4-5, L5-S1 foraminal narrowing in L4 and L5 roots. The patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain. The patient understood major risks and complications such as death and paralysis seemingly rare, main concern is a 10 to 15% of failure rate to respond to surgery for which further surgery may or may not be indicated, small risk of wound infection, spinal fluid leak. The patient is understanding and agreed to proceed and signed the consent.,PROCEDURE: , The patient was brought to the operating room, peripheral venous lines were placed. General anesthesia was induced. The patient was intubated. Foley catheter was in place. The patient laid prone onto the OSI table using 6-post, pressure points were carefully padded; the back was shaved, sterilely prepped and draped. A previous incision was infiltrated with local and incised with a scalpel. The posterior spine on the right side was exposed in routine fashion along with transverse processes in L4-L5 in the sacral ala. Laminotomies were then performed at L4-L5 and L5-S1 in a similar fashion using Midas Rex drill with AM8 bit, inferior portion of lamina below and superior portion of lamina above, and the medial facet was drilled down to the thin shelf of bone. The thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm Kerrison, bone was harvested throughout to be used for bone grafting. The L5 and S1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints. Transpedicular approaches were carried out for both L4 and L5 roots working lateral to medial and medial to lateral with foraminotomies, L4-L5 roots were extensively decompressed. Pars interarticularis were maintained. Using angled 2-mm Kerrisons hypertrophied ligamentum flavum, the superior facet of S1 and L5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise. Pedicle screws were placed L4-L5 and S1 on the right side. Initial hole began with Midas Rex drill, deepened with a gear shift and with 4.5 mm tap, palpating with pedicle probe. It showed no penetration outside the pedicle vertebral body. At L4-L5 5.5 x 45 mm screws were placed and at S1 5.5 x 40 mm screw was placed. Good bone purchase was obtained. Gelfoam was placed over the roots laterally, corticated transverse processes lateral facet joints were prepared, small infuse sponge was placed posterolaterally on the right side, then the local bone graft from L4 to S1. Traction was applied between the L4-L5, L5-S1 screws locking notes were tightened out, heads were rotated fractured off about 2-3 mm traction were applied at each side, further opening the foramen for the exiting roots. Prior to placement of BMP, the wound was irrigated with antibiotic irrigation. Medium Hemovac drain was placed in the depth of wound, brought out through a separate stab incision. Deep fascia was closed with #1 Vicryl, subcutaneous fascia with #1 Vicryl, and subcuticular with 2-0 Vicryl. Skin was stapled. The drain was sutured in place with 2-0 Vicryl and connected to closed drain system. The patient was laid supine on the bed, extubated, and taken to recovery room in satisfactory condition. The patient tolerated the procedure well without apparent complication. Final sponge and needle counts are correct. Estimated blood loss 600 mL.,The patient received 200 mL of cell saver blood back.neurosurgery, lumbosacral radiculopathy, lumbar spondylolysis, laminotomies, medial facetectomies, foraminotomies, decompression, nerve roots, fusion, bone graft, segmental, pedicle screw, transverse processes, bone, facetectomies, transpedicular, graft, pedicle

PROCEDURE PERFORMED: , Trigger point injections with Botox.,PREPROCEDURE DIAGNOSES:,1. Cervical spondylosis without myelopathy.,2. Myofascial pain syndrome.,3. Cervical dystonia.,4. Status post C5-6 anterior cervical fusion.,5. Multilevel degenerative disc disease.,6. Cervicogenic migraines.,7. Hypertension.,8. Hypothyroidism.,POSTPROCEDURE DIAGNOSES:,1. Cervical spondylosis without myelopathy.,2. Myofascial pain syndrome.,3. Cervical dystonia.,4. Status post C5-6 anterior cervical fusion.,5. Multilevel degenerative disc disease.,6. Cervicogenic migraines.,7. Hypertension.,8. Hypothyroidism.,COMPLICATIONS: , None.,The risks, benefits, complications, and alternatives to the procedure were discussed in detail and informed written consent was obtained.,INDICATIONS:, The patient is here today after establishing care at my new office. She is a long-term patient of mine at the Pain Management Clinic and has requested transference because of insurance reasons. Today, she is here for not only establishment of care, but continued management of her many neck-related complaints. Among these are spasms and ongoing pain for which she receives long-acting opioids. She states that she is in fact doing quite well since her cervical fusion. She is requesting that we decrease her medications from 480 mg to 240 mg to 360 mg of morphine per day in the form of Avinza. She also is quite pleased with her other medication regimen which has been greatly simplified over the past year.,Other treatment modalities that have been helpful have included cervical epidural steroid injections. The patient is requesting that we schedule this as well, as the relief provided by that lasted anywhere from four to six months. I agree that because of intermittent radicular symptoms that this may be helpful particularly in light of her recent surgery. She does complain of hand tingling and numbness, although she is not dropping objects or having difficulties with coordination. I believe that in addition, the steroid injections may help expedite her desire to decrease her reliance on medications which have been oversedating as well as racked with other side effects.,DETAILS OF PROCEDURE: , Alcohol prep and sterile technique were used. A total of 6 cc of preservative-free 1% lidocaine was used and injected into eight different sites using a 25-gauge, 1-1/2-inch needle at the trapezius muscles bilaterally as well as the levator scapulae, the splenius capitis, and the semispinalis musculature. The procedure was well tolerated.,TREATMENT PLAN:,1. The patient is tentatively scheduled for a cervical epidural steroid injection on March 14, 2005.,2. We will begin a weaning schedule for the patient's Avinza by decreasing in 60 mg intervals. The patient will have a target of 120 mg p.o. b.i.d., and then be reassessed. This is expected to occur after her cervical epidural steroid injection.nan

OPERATIONS,1. Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.,2. Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.,3. Posterior leaflet abscess resection.,ANESTHESIA: ,General endotracheal anesthesia,TIMES: ,Aortic cross-clamp time was ** minutes. Cardiopulmonary bypass time total was ** minutes.,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. Next, the patient's chest and legs were prepped and draped in standard surgical fashion. A #10-blade scalpel was used to make a midline median sternotomy incision. Dissection was carried down to the level of the sternum using Bovie electrocautery. The sternum was opened with a sternal saw, and full-dose heparinization was given. Next, the chest retractor was positioned. The pericardium was opened with Bovie electrocautery and pericardial stay sutures were positioned. We then prepared to place the patient on cardiopulmonary bypass. A 2-0 Ethibond double pursestring was placed in the ascending aorta. Through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine. Next, double cannulation with venous cannulas was instituted. A 3-0 Prolene pursestring was placed in the right atrial appendage. Through this was passed our SEC cannula. This was connected to the venous portion of the cardiopulmonary bypass machine in a Y-shaped circuit. Next, a 3-0 Prolene pursestring was placed in the lower border of the right atrium. Through this was passed our inferior vena cava cannula. This was likewise connected to the Y connection of our venous cannula portion. We then used a 4-0 U-stitch in the right atrium for our retrograde cardioplegia catheter, which was inserted. Cardiopulmonary bypass was instituted. Metzenbaum scissors were used to dissect out the SVC and IVC, which were subsequently encircled with umbilical tape. Sondergaard's groove was taken down. Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta. This was connected appropriately as was the retrograde cardioplegia catheter. Next, the aorta was cross-clamped, and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole. Next a #15-blade scalpel was used to open the left atrium. The left atrium was decompressed with pump sucker. Next, our self-retaining retractor was positioned so as to bring the mitral valve up into view. Of note was the fact that the mitral valve P2 segment of the posterior leaflet had an abscess associated with it. The borders of the P2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4-0 silk. After doing so, the P2 segment of the posterior leaflet was excised with a #11-blade scalpel. Given the laxity of the posterior leaflet, it was decided to reconstruct it with a 2-0 Ethibond pledgeted suture. This was done so as to reconstruct the posterior annular portion. Prior to doing so, care was taken to remove any debris and abscess-type material. The pledgeted stitch was lowered into place and tied. Next, the more anterior portion of the P2 segment was reconstructed by running a 4-0 Prolene stitch so as to reconstruct it. This was done without difficulty. The apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle. There was noted to be a small amount of central regurgitation. It was felt that this would be corrected with our annuloplasty portion of the procedure. Next, 2-0 non-pledgeted Ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion. Care was taken to go from trigone to trigone. Prior to placing these sutures, the annulus was sized and noted to be a *** size for the Cosgrove-Galloway suture band ring from Medtronic. After, as mentioned, we placed our interrupted sutures in the annulus, and they were passed through the CG suture band. The suture band was lowered into position and tied in place. We then tested our repair and noted that there was very mild regurgitation. We subsequently removed our self-retaining retractor. We closed our left atriotomy using 4-0 Prolene in a running fashion. This was done without difficulty. We de-aired the heart. We then gave another round of antegrade and retrograde cardioplegia in warm fashion. The aortic cross-clamp was removed, and the heart gradually resumed electromechanical activity. We then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5-0 Prolene. We placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin. The patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed. We then gave full-dose protamine; and after noting that there was no evidence of a protamine reaction, we removed our aortic cannula. This site was buttressed with a 4-0 Prolene on an SH needle. The patient tolerated the procedure well. We placed a mediastinal #32-French chest tube as well as a right chest Blake drain. The mediastinum was inspected for any signs of bleeding. There were none. We closed the sternum with #7 sternal wires in interrupted figure-of-eight fashion. The fascia was closed with a #1 Vicryl followed by a 2-0 Vicryl, followed by 3-0 Vicryl in a running subcuticular fashion. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the intensive care unit in good condition.cardiovascular / pulmonary, mitral valve repair, mitral valve, abscess resection, leaflet abscess, cosgrove galloway medtronic, bovie electrocautery, cannulation, bypass, annuloplasty, cardioplegia, mitral,

SUBJECTIVE:, This is a 38-year-old female who comes for dietary consultation for gestational diabetes. Patient reports that she is scared to eat because of its impact on her blood sugars. She is actually trying not to eat while she is working third shift at Wal-Mart. Historically however, she likes to eat out with a high frequency. She enjoys eating rice as part of her meals. She is complaining of feeling fatigued and tired all the time because she works from 10 p.m. to 7 a.m. at Wal-Mart and has young children at home. She sleeps two to four hours at a time throughout the day. She has been testing for ketones first thing in the morning when she gets home from work.,OBJECTIVE:, Today's weight: 155.5 pounds. Weight from 10/07/04 was 156.7 pounds. A diet history was obtained. Blood sugar records for the last three days reveal the following: fasting blood sugars 83, 84, 87, 77; two-hour postprandial breakfast 116, 107, 97; pre-lunch 85, 108, 77; two-hour postprandial lunch 86, 131, 100; pre-supper 78, 91, 100; two-hour postprandial supper 125, 121, 161; bedtime 104, 90 and 88. I instructed the patient on dietary guidelines for gestational diabetes. The Lily Guide for Meal Planning was provided and reviewed. Additional information on gestational diabetes was applied. A sample 2000-calorie meal plan was provided with a carbohydrate budget established.,ASSESSMENT:, Patient's basal energy expenditure adjusted for obesity is estimated at 1336 calories a day. Her total calorie requirements, including a physical activity factor as well as additional calories for pregnancy, totals to 2036 calories per day. Her diet history reveals that she has somewhat irregular eating patterns. In the last 24 hours when she was working at Wal-Mart, she ate at 5 a.m. but did not eat anything prior to that since starting work at 10 p.m. We discussed the need for small frequent eating. We identified carbohydrate as the food source that contributes to the blood glucose response. We identified carbohydrate sources in the food supply, recognizing that they are all good for her. The only carbohydrates she was asked to entirely avoid would be the concentrated forms of refined sugars. In regard to use of her traditional foods of rice, I pulled out a one-third cup measuring cup to identify a 15-gram equivalent of rice. We discussed the need for moderating the portion of carbohydrates consumed at one given time. Emphasis was placed at eating with a high frequency with a goal of eating every two to four hours over the course of the day when she is awake. Her weight loss was discouraged. Patient was encouraged to eat more generously but with attention to the amount of carbohydrates consumed at a time.,PLAN:, The meal plan provided has a carbohydrate content that represents 40 percent of a 2000-calorie meal plan. The meal plan was devised to distribute her carbohydrates more evenly throughout the day. The meal plan was meant to reflect an example for her eating, while the patient was encouraged to eat according to appetite and not to go without eating for long periods of time. The meal plan is as follows: breakfast 2 carbohydrate servings, snack 1 carbohydrate serving, lunch 2-3 carbohydrate servings, snack 1 carbohydrate serving, dinner 2-3 carbohydrate servings, bedtime snack 1-2 carbohydrate servings. Recommend patient include a solid protein with each of her meals as well as with her snack that occurs before going to sleep. Encouraged adequate rest. Also recommend adequate calories to sustain weight gain of one-half to one pound per week. If the meal plan reflected does not support slow gradual weight gain, then we will need to add more foods accordingly. This was a one-hour consultation. I provided my name and number should additional needs arise.soap / chart / progress notes, blood sugars, fatigued, total calorie, carbohydrate content, consultation for gestational diabetes, dietary consultation, weight gain, gestational diabetes, carbohydrate servings, meal planning, meals, weight, carbohydrate, dietary, servings, planning

HISTORY:, A is a 55-year-old who I know well because I have been taking care of her husband. She comes for discussion of a screening colonoscopy. Her last colonoscopy was in 2002, and at that time she was told it was essentially normal. Nonetheless, she has a strong family history of colon cancer, and it has been almost four to five years so she wants to have a repeat colonoscopy. I told her that the interval was appropriate and that it made sense to do so. She denies any significant weight change that she cannot explain. She has had no hematochezia. She denies any melena. She says she has had no real change in her bowel habit but occasionally does have thin stools.,PAST MEDICAL HISTORY:, On today's visit we reviewed her entire health history. Surgically she has had a stomach operation for ulcer disease back in 1974, she says. She does not know exactly what was done. It was done at a hospital in California which she says no longer exists. This makes it difficult to find out exactly what she had done. She also had her gallbladder and appendix taken out in the 1970s at the same hospital. Medically she has no significant problems and no true medical illnesses. She does suffer from some mild gastroparesis, she says.,MEDICATIONS: , Reglan 10 mg once a day.,ALLERGIES: , She denies any allergies to medications but is sensitive to medications that cause her to have ulcers, she says.,SOCIAL HISTORY: , She still smokes one pack of cigarettes a day. She was counseled to quit. She occasionally uses alcohol. She has never used illicit drugs. She is married, is a housewife, and has four children.,FAMILY HISTORY: , Positive for diabetes and cancer.,REVIEW OF SYSTEMS: , Essentially as mentioned above.,PHYSICAL EXAMINATION:,GENERAL: A is a healthy appearing female in no apparent distress.,VITAL SIGNS: Her vital signs reveal a weight of 164 pounds, blood pressure 140/90, temperature of 97.6 degrees F.,HEENT: No cervical bruits, thyromegaly, or masses. She has no lymphadenopathy in the head and neck, supraclavicular, or axillary spaces bilaterally.,LUNGS: Clear to auscultation bilaterally with no wheezes, rubs, or rhonchi.,HEART: Regular rate and rhythm without murmur, rub, or gallop.,ABDOMEN: Soft, nontender, nondistended.,EXTREMITIES: No cyanosis, clubbing, or edema, with good pulses in the radial arteries bilaterally.,NEURO: No focal deficits, is intact to soft touch in all four.,ASSESSMENT AND RECOMMENDATIONS: , In light of her history and physical, clearly the patient would be well served with an upper and lower endoscopy. We do not know what the anatomy is, and if she did have an antrectomy, she needs to be checked for marginal ulcers. She also complains of significant reflux and has not had an upper endoscopy in over five to six years as well. I discussed the risks, benefits, and alternatives to upper and lower endoscopy, and these include over sedation, perforation, and dehydration, and she wants to proceed.,We will schedule her for an upper and lower endoscopy at her convenience.consult - history and phy., screening colonoscopy, colonoscopy, hematochezia, screening, endoscopy,

EXAM:, MRI head without contrast.,REASON FOR EXAM: , Severe headaches.,INTERPRETATION:, Imaging was performed in the axial and sagittal planes using numerous pulse sequences at 1 tesla. Correlation is made with the head CT of 4/18/05.,On the diffusion sequence, there is no significant bright signal to indicate acute infarction. There is a large degree of increased signal involving the periventricular white matter extending around to the subcortical regions in symmetrical fashion consistent with chronic microvascular ischemic disease. There is mild chronic ischemic change involving the pons bilaterally, slightly greater on the right, and when correlating with the recent scan, there is an old tiny lacunar infarct of the right brachium pontis measuring roughly 4 mm in size. There are prominent perivascular spaces of the lenticulostriate distribution compatible with the overall degree of moderate to moderately advanced atrophy. There is an old moderate-sized infarct of the mid and lateral aspects of the right cerebellar hemisphere as seen on the recent CT scan. This involves mostly the superior portion of the hemisphere in the superior cerebellar artery distribution. No abnormal mass effect is identified. There are no findings to suggest active hydrocephalus. No abnormal extra-axial collection is identified. There is normal flow void demonstrated in the major vascular systems.,The sagittal sequence demonstrates no Chiari malformation. The region of the pituitary/optic chiasm grossly appears normal. The mastoids and paranasal sinuses are clear.,IMPRESSION:,1. No definite acute findings identified involving the brain.,2. There is prominent chronic cerebral ischemic change as described with mild chronic pontine ischemic changes. There is an old moderate-sized infarct of the superior portion of the right cerebellar hemisphere.,3. Moderate to moderately advanced atrophy.neurology, severe headaches, chiari malformation, cerebral ischemic change, mri head without contrast, cerebellar hemisphere, superior portion, mri head, cerebellar, infarction, ischemic

CHIEF COMPLAINT:, Palpitations.,CHEST PAIN / UNSPECIFIED ANGINA PECTORIS HISTORY:, The patient relates the recent worsening of chronic chest discomfort. The quality of the pain is sharp and the problem started 2 years ago. Pain radiates to the back and condition is best described as severe. Patient denies syncope. Beyond baseline at present time. Past work up has included 24 hour Holter monitoring and echocardiography. Holter showed PVCs.,PALPITATIONS HISTORY:, Palpitations - frequent, 2 x per week. No caffeine, no ETOH. + stress. No change with Inderal.,VALVULAR DISEASE HISTORY:, Patient has documented mitral valve prolapse on echocardiography in 1992.,PAST MEDICAL HISTORY:, No significant past medical problems. Mitral Valve Prolapse.,FAMILY MEDICAL HISTORY:, CAD.,OB-GYN HISTORY:, The patients last child birth was 1997. Para 3. Gravida 3.,SOCIAL HISTORY:, Denies using caffeinated beverages, alcohol or the use of any tobacco products.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, Inderal 20 prn.,REVIEW OF SYSTEMS:, Generally healthy. The patient is a good historian.,ROS Head and Eyes: Denies vision changes, light sensitivity, blurred vision, or double vision.,ROS Ear, Nose and Throat: The patient denies any ear, nose or throat symptoms.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia.,ROS Genitourinary: Patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence.,ROS Gynecological: Denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc.,ROS Musculoskeletal: The patient denies any past or present problems related to the musculoskeletal system.,ROS Extremities: The patient denies any extremities complaints.,ROS Cardiovascular: As per HPI.,EXAMINATION:,Exam Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. No guarding, rigidity or rebound tenderness. The liver and spleen are not palpable. Bowel sounds are active and normal.,Exam Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted.,Range of motion is normal. There is no cyanosis, clubbing or edema.,General: Healthy appearing, well developed,. The patient is in no acute distress.,Exam Skin Negative to inspection or palpation. There are no obvious lesions or new rashes noted. Non-diaphoretic.,Exam Ears Canals are clear. Throat is not injected. Tonsils are not swollen or injected.,Exam Neck: There is no thyromegaly, carotid bruits, lymphadenopathy, or JVD. Neck is supple.,Exam Respiratory: Normal breath sounds are heard bilaterally. There is no wheezing. There is no use of accessory muscles.,Exam Cardiovascular: Regular heart rate and rhythm, Normal S1 and S2 without murmur, gallops or rubs.,IMPRESSION / DIAGNOSIS:, Mitral Valve Prolapse. Palpitations.,TESTS ORDERED:, Cardiac tests: Echocardiogram.,MEDICATION PRESCRIBED:, ,Cardizem 30-60 qid prn.nan

HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches. In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup. Neurology consult was called to evaluate the patient in view of the current symptomatology. The headaches were refractory to the treatment. The patient has been on Topamax and Maxalt in the past, but did not work and according to the patient she got more confused.,PAST MEDICAL HISTORY: , History of migraine.,PAST SURGICAL HISTORY: ,Significant for partial oophorectomy, appendectomy, and abdominoplasty.,SOCIAL HISTORY: ,No history of any smoking, alcohol, or drug abuse. The patient is a registered nurse by profession.,MEDICATIONS: , Currently taking no medication.,ALLERGIES: , No known allergies.,FAMILY HISTORY:, Nothing significant.,REVIEW OF SYSTEMS: , The patient was considered to ask systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy, immunology, endocrinology, toxicology, oncology, and was found to be positive for the symptoms mentioned in the history of the presenting illness.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure of 115/66, heart rate of 69, respiratory rate of 13, temperature normal, and pulse oximetry 98% on room air at the time of initial evaluation.,HEENT: Head, normocephalic, atraumatic. Neck supple. Throat clear. No discharge from the ears or nose. No discoloration of conjunctivae and sclerae. No bruits auscultated over temple, orbits, or the neck.,LUNGS: Clear to auscultation.,CARDIOVASCULAR: Normal heart sounds.,ABDOMEN: Benign.,EXTREMITIES: No edema, clubbing or cyanosis.,SKIN: No rash. No neurocutaneous disorder.,MENTAL STATUS: The patient is awake, alert and oriented to place and person. Speech is fluent. No language deficits. Mood normal. Affect is clear. Memory and insight is normal. No abnormality with thought processing and thought content. Cranial nerve examination intact II through XII. Motor examination: Normal bulk, tone and power. Deep tendon reflexes symmetrical. Downgoing toes. No sign of any myelopathy. Cortical sensation intact. Peripheral sensation grossly intact. Vibratory sense not tested. Gait not tested. Coordination is normal with no dysmetria.,IMPRESSION: , Intractable headaches, by description to be migraines. Complicated migraines by clinical criteria. Rule out sinusitis. Rule out vasculitis including temporal and arthritis, lupus, polyarthritis, moyamoya disease, Takayasu and Kawasaki disease.,PLAN AND RECOMMENDATIONS: , The patient to be given a trial of the prednisone with a plan to taper off in 6 days, as she already had received 50 mg today. Depakote as a part of migraine prophylaxis and Fioricet on p.r.n. basis.,The patient to get vasculitis workup, as it has not been ordered by the primary care physician initially. The patient already had MRI of the brain and the cervical spine. MRI of the brain reported negative and cervical spine as shown signs of disk protrusion at C5 and C6 level, which will not explain of the temporal headache. Plan and followup discussed with the patient in detail.nan

PREPROCEDURE DIAGNOSIS: , End-stage renal disease.,POSTPROCEDURE DIAGNOSIS: , End-stage renal disease.,PROCEDURES PERFORMED,1. Left arm fistulogram.,2. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.,3. Ultrasound-guided access of left upper arm brachiocephalic fistula.,ANESTHESIA:, Sedation with local.,COMPLICATIONS:, None.,CONDITION:, Fair.,DISPOSITION:, PACU.,ACCESS SITE:, Left upper arm brachiocephalic fistula.,SHEATH SIZE: , 5 French.,CONTRAST TYPE: , JC PEG tube 70.,CONTRAST VOLUME: , 48 mL.,FLUOROSCOPY TIME: , 16 minutes.,INDICATION FOR PROCEDURE: , This is a 38-year-old female with a left upper arm brachiocephalic fistula which has been transposed. The patient recently underwent a fistulogram with angioplasty at the proximal upper arm cephalic vein due to a stenosis detected on Duplex ultrasound. The patient subsequently was noted to have poor flow to the fistula, and the fistula was difficult to palpate. A repeat ultrasound was performed which demonstrated a high-grade stenosis involving the distal upper arm cephalic vein just distal to the brachial anastomosis. The patient presents today for a left arm fistulogram with angioplasty. The risks, benefits, and alternatives of the procedure were discussed with the patient and understands and in agreement to proceed.,PROCEDURE DETAILS: ,The patient was brought to the angio suite and laid supine on the table. After sedation was administered, the left arm was then prepped and draped in a standard surgical fashion. Continuous pulse oximetry and cardiac monitoring were performed throughout the procedure. The patient was given 1 g of IV Ancef prior to incision.,The left brachiocephalic fistula was visualized with bevel ultrasound. The cephalic vein in the proximal upper arm region appeared to be of adequate caliber. There was an area of stenosis at the proximal cephalic vein just distal to the brachial artery anastomosis. The cephalic vein in the proximal forearm region was easily compressible. The skin overlying the vessel was injected with 1% lidocaine solution. A small incision was made with the #11 blade. The cephalic vein then was cannulated with a 5 French micropuncture introducer sheath. The sheath was advanced over the wire. A fistulogram was performed which demonstrated a high-grade stenosis just distal to the brachial artery anastomosis. The introducer sheath was then exchanged for a 5 French sheath over a 0.025 guide wire. The sheath was aspirated and flushed with heparinized saline solution. A 0.025 glidewire was then obtained and advanced, placed over the sheath and across the area of stenosis into the brachial artery. A 5 French short Kumpe catheter was used to guide the wire into the distal brachial and radial artery. After crossing the area of stenosis, a 5 x 20 mm standard angioplasty balloon was obtained and prepped from the back table. This was placed over the glidewire into the area of stenosis and inflated to 14 mmHg pressure and then deflated. The balloon was then removed over the wire and repeat fistulogram was performed which demonstrated significant improvement. However, there is still a remainder of residual stenosis. The 5-mm balloon was placed over the wire again and a repeat angioplasty was performed. The balloon was then removed over the wire and a repeat angiogram was performed which demonstrated again an area of stenosis right at the anastomosis. The glidewire was removed and a 0.014 guide wire was then obtained and placed through the sheath and across the brachial anastomosis and into the radial artery. A 4 x 20 mm cutting balloon was obtained and prepped on the back table. The 5 French sheath was then exchanged for a 6 French sheath. The balloon was then placed over the 0.014 guide wire into the area of stenosis and then inflated to normal pressures at 8 mmHg. The balloon was then deflated and removed over the wire. A 5 mm x 20 mm balloon was obtained and prepped and placed over the wire into the area of stenosis and inflated to pressures of 14 mmHg. A repeat fistulogram was performed after the removal of the balloon which demonstrated excellent results with no significant residual stenosis. The patient actually had a nice palpable thrill at this point. The fistulogram of the distal cephalic vein at the subclavian anastomosis was performed which demonstrated a mild area of stenosis. The sheath was removed and blood pressure was held over the puncture site for approximately 10 minutes.,After hemostasis was achieved, the cephalic vein again was visualized with bevel ultrasound. The proximal cephalic vein was then cannulated after injecting the skin overlying the vessel with a 1% lidocaine solution. A 5 French micropuncture introducer sheath was then placed over the wire into the proximal cephalic vein. A repeat fistulogram was performed which demonstrated an area of stenosis within the distal cephalic vein just prior to the subclavian vein confluence. The 5 French introducer sheath was then exchanged for a 5 French sheath. The 5 mm x 20 mm balloon was placed over a 0.035 glidewire across the area of stenosis. The balloon was inflated to 14 mmHg. The balloon was then deflated and a repeat fistulogram was performed through the sheath which demonstrated good results. The sheath was then removed and blood pressure was held over the puncture site for approximately 10 minutes. After adequate hemostasis was achieved, the area was cleansed in 2x2 and Tegaderm was applied. The patient tolerated the procedure without any complications. I was present for the entire case. The sponge, instrument, and needle counts are correct at the end of the case. The patient was subsequently taken to PACU in stable condition.,ANGIOGRAPHIC FINDINGS:, The initial left arm brachiocephalic fistulogram demonstrated a stenosis at the brachial artery anastomosis and distally within the cephalic vein. After standard balloon angioplasty, there was a mild improvement but some residual area of stenosis remained at the anastomosis. Then postcutting balloon angioplasty, venogram demonstrated a significant improvement without any evidence of significant stenosis.,Fistulogram of the proximal cephalic vein demonstrated a stenosis just prior to the confluence with the left subclavian vein. Postangioplasty demonstrated excellent results with the standard balloon. There was no evidence of any contrast extravasation.,IMPRESSION,1. High-grade stenosis involving the cephalic vein at the brachial artery anastomosis and distally. Postcutting balloon and standard balloon angioplasty demonstrated excellent results without any evidence of contrast extravasation.,2. A moderate grade stenosis within the distal cephalic vein just prior to the confluence to the left subclavian vein. Poststandard balloon angioplasty demonstrated excellent results. No evidence of contrast extravasation.nan

PREOPERATIVE DIAGNOSIS:, Airway obstruction secondary to laryngeal subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: ,Airway obstruction secondary to laryngeal subglottic stenosis and tracheal stenosis.,OPERATION PERFORMED: , Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.,INDICATIONS FOR SURGERY: ,The patient is a 56-year-old white female with a history of relapsing polychondritis, which resulted in saddle nose deformity in glottic and subglottic stenosis for which she has undergone number of procedures in the past to the upper airway. She currently is trach dependent for her airway because of glottic and subglottic stenosis, but she is having no significant problems breathing and talking around her trach tube and came for further evaluation. Endoscopic reevaluation of her tube and nature of the proposed procedure done. Risk and complications of bleeding, infection, alteration of with speech or swallowing, failure to improve her airway, and loss of voice. Cardiorespiratory anesthetic results were discussed in length. The patient states she understood and wished to proceed.,DESCRIPTION OF OPERATION:, The patient was taken to the operating room and placed in the supine position. Under adequate general endotracheal anesthesia, the patient's #5 metal tracheostomy tube was removed and a #5 laser-safe endotracheal tube was inserted. The patient was then prepared for endoscopy. The Kantor laryngoscope was then inserted. Oral cavity, hypopharynx, larynx, and nasal cavity showed good dentition with good tongue, buccal cavity, and mucosa without lesions. Larynx was then ***** short epiglottis. Larynx was suspended with significant scarring beginning in the supraglottic area with loss of laryngeal contour beginning in the supraglottis with extensive scar tissue at the level of the false cord obliteration of ventricles and true cords. This appeared to be stable, and airway was patent at the supraglottic and glottic level with some narrowing at the subglottic level with mild-to-moderate subglottic stenosis, otherwise this appeared to be stable. However, distally, the level of the trach site examined with the microscope and 0 and 30-degree telescopes. The patient noted to have marked narrowing with dense scarring posterolaterally on the left securing good visualization of the trach tube. The laryngoscope was removed, and a 5 x 30 pediatric rigid bronchoscope was then passed. The LP contact tip laser was utilized to vaporize the scar tissue and release the scar banding following which the scope was passed and further dilation carried out. Mid and distal trachea were widely patent. Trachea and mainstem bronchi were patent without obvious disease. The patient did not appear to have any relapsing polychondritis with progressive scar tissue at the level of the trach site and the posterior trachea wall was significant. This was further dilated and following which was removed and a new #5 metal tracheostomy tube inserted. The patient tolerated the procedure well without complications and was taken to recovery room in satisfactory condition.cardiovascular / pulmonary, airway obstruction, oral cavity, bronchoscopy, buccal cavity, hypopharynx, laryngeal, larynx, microlaryngoscopy, nasal cavity, polychondritis, subglottic, tracheal stenosis, tracheostomy tube, scar tissue, subglottic stenosis, tracheal, airway, cavity, tube, scarring, stenosis,

PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE: , Right radical nephrectomy and assisted laparoscopic approach.,ANESTHESIA: ,General.,PROCEDURE IN DETAIL: ,The patient underwent general anesthesia with endotracheal intubation. An orogastric was placed and a Foley catheter placed. He was placed in a modified flank position with the hips rotated to 45 degrees. Pillow was used to prevent any pressure points. He was widely shaved, prepped, and draped. A marking pen was used to delineate a site for the Pneumo sleeve in the right lower quadrant and for the trocar sites in the midline just above the umbilicus and halfway between the xiphoid and the umbilicus. The incision was made through the premarked site through the skin and subcutaneous tissue. The aponeurosis of the external oblique was incised in the direction of its fibers. Muscle-splitting incision was made in the internal oblique and transversus abdominis. The peritoneum was opened and the Pneumo sleeve was placed in the usual fashion being sure that no bowel was trapped inside the ring. Then, abdominal insufflation was carried out through the Pneumo sleeve and the scope was passed through the Pneumo sleeve to visualize placement of the trocars in the other two positions. Once this had been completed, the scope was placed in the usual port and dissection begun by taking down the white line of Toldt, so that the colon could be retracted medially. This exposed the duodenum, which was gently swept off the inferior vena cava and dissection easily disclosed the takeoff of the right renal vein off the cava. Next, attention was directed inferiorly and the ureter was divided between clips and the inferior tongue of Gerota fascia was taken down, so that the psoas muscle was exposed. The attachments lateral to the kidney was taken down, so that the kidney could be flipped anteriorly and medially, and this helped in exposing the renal artery. The renal artery had been previously noticed on the CT scan to branch early and so each branch was separately ligated and divided using the stapler device. After the arteries had been divided, the renal vein was divided again using a stapling device. The remaining attachments superior to the kidney were divided with the Harmonic scalpel and also utilized the stapler, and the specimen was removed. Reexamination of the renal fossa at low pressures showed a minimal degree of oozing from the adrenal gland, which was controlled with Surgicel. Next, the port sites were closed with 0 Vicryl utilizing the passer and doing it over the hand to prevent injury to the bowel and the right lower quadrant incision for the hand port was closed in the usual fashion. The estimated blood loss was negligible. There were no complications. The patient tolerated the procedure well and left the operating room in satisfactory condition.surgery, renal mass, foley catheter, gerota fascia, muscle-splitting incision, pneumo sleeve, endotracheal, laparoscopic, nephrectomy, orogastric, renal fossa, right lower quadrant, trocar, umbilicus, vena cava, renal, pneumo, radical,

REASON FOR CONSULTATION: , Pulmonary embolism.,HISTORY:, The patient is a 78-year-old lady who was admitted to the hospital yesterday with a syncopal episode that happened for the first time in her life. The patient was walking in a store when she felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds. At that time, her daughter was with her. No tonic-clonic movements. No cyanosis. The patient woke up on her own. The patient currently feels fine, has mild shortness of breath upon exertion, but this is her usual for the last several years. She cannot get up one flight of stairs, but feels short of breath. She gets exerted and thinks to take a shower. She does not have any chest pain, no fever or syncopal episodes.,PAST MEDICAL HISTORY,1. Pulmonary embolism diagnosed one year ago. At that time, she has had an IVC filter placed due to massive GI bleed from diverticulosis and gastric ulcers. Paroxysmal atrial fibrillation and no anticoagulation due to history of GI bleed.,2. Coronary artery disease status post CABG at that time. She has had to stay in the ICU according to the daughter for 3 weeks due to again lower GI bleed.,3. Mitral regurgitation.,4. Gastroesophageal reflux disease.,5. Hypertension.,6. Hyperlipidemia.,7. History of aortic aneurysm.,8. History of renal artery stenosis.,9. Peripheral vascular disease.,10. Hypothyroidism.,PAST SURGICAL HISTORY,1. CABG.,2. Hysterectomy.,3. IVC filter.,4. Tonsillectomy.,5. Adenoidectomy.,6. Cosmetic surgery.,7. Renal stent.,8. Right femoral stent.,HOME MEDICATIONS,1. Aspirin.,2. Potassium.,3. Lasix.,4. Levothyroxine.,5. Lisinopril.,6. Pacerone.,7. Protonix.,8. Toprol.,9. Vitamin B.,10. Zetia.,11. Zyrtec.,ALLERGIES:, SULFA,SOCIAL HISTORY: , She used to be a smoker, not anymore. She drinks 2 to 3 glasses of wine per week. She is retired.,REVIEW OF SYSTEMS: , She has a history of snoring, choking for breath at night, and dry mouth in the morning.,PHYSICAL EXAMINATION,GENERAL APPEARANCE: In no acute distress.,VITAL SIGNS: Temperature 98.6, respirations 18, pulse 61, blood pressure 155/57, and oxygen saturation 93-98% on room air.,HEENT: No lymph nodes or masses.,NECK: No jugular venous distension.,LUNGS: Clear to auscultation bilaterally.nan

EXAM: , CT chest with contrast.,REASON FOR EXAM: , Pneumonia, chest pain, short of breath, and coughing up blood.,TECHNIQUE: , Postcontrast CT chest 100 mL of Isovue-300 contrast.,FINDINGS: , This study demonstrates a small region of coalescent infiltrates/consolidation in the anterior right upper lobe. There are linear fibrotic or atelectatic changes associated with this. Recommend followup to ensure resolution. There is left apical scarring. There is no pleural effusion or pneumothorax. There is lingular and right middle lobe mild atelectasis or fibrosis.,Examination of the mediastinal windows disclosed normal inferior thyroid. Cardiac and aortic contours are unremarkable aside from mild atherosclerosis. The heart is not enlarged. There is no pathologic adenopathy identified in the chest including the bilateral axillary and hilar regions.,Very limited assessment of the upper abdomen demonstrates no definite abnormalities.,There are mild degenerative changes in the thoracic spine.,IMPRESSION:,1.Anterior small right upper lobe infiltrate/consolidation. Recommend followup to ensure resolution given its consolidated appearance.,2.Bilateral atelectasis versus fibrosis.radiology, pneumonia, chest pain, short of breath, coughing up blood, upper lobe infiltrate, ct chest, ct, chest, isovue,

Pap smear in November 2006 showed atypical squamous cells of undetermined significance. She has a history of an abnormal Pap smear. At that time, she was diagnosed with CIN 3 as well as vulvar intraepithelial neoplasia. She underwent a cone biopsy that per her report was negative for any pathology. She had no vulvar treatment at that time. Since that time, she has had normal Pap smears. She denies abnormal vaginal bleeding, discharge, or pain. She uses Yaz for birth control. She reports one sexual partner since 1994 and she is a nonsmoker.,She states that she has a tendency to have yeast infections and bacterial vaginosis. She is also being evaluated for a possible interstitial cystitis because she gets frequent urinary tract infections. She had a normal mammogram done in August 2006 and a history of perirectal condyloma that have been treated by Dr. B. She also has a history of chlamydia when she was in college.,PAST MEDICAL HX: , Depression.,PAST SURGICAL HX: , None.,MEDICATIONS: , Lexapro 10 mg a day and Yaz.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,OB HX: , Normal spontaneous vaginal delivery at term in 2001 and 2004, Abc weighed 8 pounds 7 ounces and Xyz weighed 10 pounds 5 ounces.,FAMILY HX: ,Maternal grandfather who had a MI which she reports is secondary to tobacco and alcohol use. He currently has metastatic melanoma, mother with hypertension and depression, father with alcoholism.,SOCIAL HX:, She is a public relations consultant. She is a nonsmoker, drinks infrequent alcohol and does not use drugs. She enjoys horseback riding and teaches jumping.,PE: , VITALS: Height: 5 feet 6 inches. Weight: 139 lb. BMI: 22.4. Blood Pressure: 102/58. GENERAL: She is well-developed and well-nourished with normal habitus and no deformities. She is alert and oriented to time, place, and person and her mood and affect is normal. NECK: Without thyromegaly or lymphadenopathy. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm without murmurs. BREASTS: Deferred. ABDOMEN: Soft, nontender, and nondistended. There is no organomegaly or lymphadenopathy. PELVIC: Normal external female genitalia. Vulva, vagina, and urethra, within normal limits. Cervix is status post cone biopsy; however, the transformation zone grossly appears normal and cervical discharge is clear and normal in appearance. GC and chlamydia cultures as well as a repeat Pap smear were done.,Colposcopy is then performed without and with acetic acid. This shows an entirely normal transformation zone, so no biopsies are taken. An endocervical curettage is then performed with Cytobrush and curette and sent to pathology. Colposcopy of the vulva is then performed again with acetic acid. There is a thin strip of acetowhite epithelium located transversely on the clitoral hood that is less than a centimeter in diameter. There are absolutely no abnormal vessels within this area. The vulvar colposcopy is completely within normal limits.,A/P: , ASCUS Pap smear with history of a cone biopsy in 1993 and normal followup.,We will check the results of the Pap smear, in addition we have ordered DNA testing for high-risk HPV. We will check the results of the ECC. She will return in two weeks for test results. If these are normal, she will need two normal Pap smears six months apart, and I think followup colposcopy for the vulvar changes.consult - history and phy., lmp, ascus, pap smear, abnormal pap smear, atypical, bacterial vaginosis, chlamydia, cone biopsy, infection, interstitial cystitis, intraepithelial, mammogram, neoplasia, perirectal condyloma, squamous, vaginal bleeding, vulvar, yeast infection, pap smears, pap, ob/gyn, colposcopy, smear,

PREOPERATIVE DIAGNOSIS: ,Left breast mass with abnormal mammogram.,POSTOPERATIVE DIAGNOSIS:, Left breast mass with abnormal mammogram.,PROCEDURE PERFORMED:, Needle-localized excisional biopsy of the left breast.,ANESTHESIA:, Local with sedation.,COMPLICATIONS: , None.,SPECIMEN: , Breast mass.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,INTRAOPERATIVE FINDINGS: , The patient had a nonpalpable left breast mass, which was excised and sent to Radiology with confirmation that the mass is in the specimen.,BRIEF HISTORY:, The patient is a 62-year-old female who presented to Dr. X's office with an abnormal mammogram showing a suspicious area on the left breast with microcalcifications and a nonpalpable mass. So the patient was scheduled for a needle-localized left breast biopsy.,PROCEDURE:, After informed consent, the risks and benefits of the procedure were explained to the patient. The patient was brought to the operating suite. After IV sedation was given, the patient was prepped and draped in normal sterile fashion. Next, a curvilinear incision was made.,After anesthetizing the skin with 0.25% Marcaine and 1% lidocaine mixture, an incision was made with a #10 blade scalpel. The lesion with needle was then grasped with an Allis clamp. Using #10 blade scalpel, the specimen was colonized out and sent to Radiology for confirmation. Next, hemostasis was obtained using electrobovie cautery. The skin was then closed with #4-0 Monocryl suture in running subcuticular fashion. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and was sent to Recovery in stable condition.surgery, needle localized excisional biopsy, excisional biopsy, abnormal mammogram, breast mass, breast, radiology, biopsy, mammogram, needle

HISTORY OF PRESENT ILLNESS:, The patient is well known to me for a history of iron-deficiency anemia due to chronic blood loss from colitis. We corrected her hematocrit last year with intravenous (IV) iron. Ultimately, she had a total proctocolectomy done on 03/14/2007 to treat her colitis. Her course has been very complicated since then with needing multiple surgeries for removal of hematoma. This is partly because she was on anticoagulation for a right arm deep venous thrombosis (DVT) she had early this year, complicated by septic phlebitis.,Chart was reviewed, and I will not reiterate her complex history.,I am asked to see the patient again because of concerns for coagulopathy.,She had surgery again last month to evacuate a pelvic hematoma, and was found to have vancomycin resistant enterococcus, for which she is on multiple antibiotics and followed by infectious disease now.,She is on total parenteral nutrition (TPN) as well.,LABORATORY DATA:, Labs today showed a white blood count of 7.9, hemoglobin 11.0, hematocrit 32.8, and platelets 1,121,000. MCV is 89. Her platelets have been elevated for at least the past week, with counts initially at the 600,000 to 700,000 range and in the last couple of day rising above 1,000,000. Her hematocrit has been essentially stable for the past month or so. White blood count has improved.,PT has been markedly elevated and today is 44.9 with an INR of 5.0. This is despite stopping Coumadin on 05/31/2007, and with administration of vitamin K via the TPN, as well as additional doses IV. The PT is slightly improved over the last few days, being high at 65.0 with an INR of 7.3 yesterday.,PTT has not been checked since 05/18/2007 and was normal then at 28.,LFTs have been elevated. ALT is 100, AST 57, GGT 226, alkaline phosphatase 505, albumin low at 3.3, uric acid high at 4.9, bilirubin normal, LDH normal, and pre-albumin low at 16. Creatinine is at 1.5, with an estimated creatinine clearance low at 41.7. Other electrolytes are fairly normal.,B12 was assessed on 05/19/2007 and was normal at 941. Folic acid was normal. Iron saturation has not been checked since March, and was normal then. Ferritin has not been checked in a couple of months.,CURRENT MEDICATIONS: , Erythropoietin 45,000 units every week, started 05/16/2007. She is on heparin flushes, loperamide, niacin, pantoprazole, Diovan, Afrin nasal spray, caspofungin, daptomycin, Ertapenem, fentanyl or morphine p.r.n. pain, and Compazine or Zofran p.r.n. nausea.,PHYSICAL EXAMINATION: ,GENERAL: She is alert, and frustrated with her prolonged hospital stay. She notes that she had epistaxis a few days ago, requiring nasal packing and fortunately that had resolved now.,VITAL SIGNS: Today, temperature is 98.5, pulse 99, respirations 16, blood pressure 105/65, and pulse is 95. She is not requiring oxygen.,SKIN: No significant ecchymoses are noted.,ABDOMEN: Ileostomy is in place, with greenish black liquid output. Midline surgical scar has healed well, with a dressing in place in the middle, with no bleeding noted.,EXTREMITIES: She has no peripheral edema.,CARDIAC: Regular rate.,LYMPHATICS: No adenopathy is noted.,LUNGS: Clear bilaterally.,IMPRESSION AND PLAN:, Markedly elevated PT/INR despite stopping Coumadin and administering vitamin K. I will check mixing studies to see if she has deficiency, which could be due to poor production given her elevated LFTs, decreased albumin, and decreased pre-albumin.,It is possible that she has an inhibitor, which would have to be an acquired inhibitor, generally presenting with an elevated PTT and not PT. I will check a PTT and check mixing studies if that is prolonged. It is doubtful that she has a lupus anticoagulant since she has been presenting with bleeding symptoms rather than clotting. I agree with continuing off of anticoagulation for now.,She has markedly elevated platelet count. I suspect this is likely reactive to infection, and not from a new myeloproliferative disorder.,Anemia has been stable, and is multifactorial. Given her decreased creatinine clearance, I agree with erythropoietin support. She was iron deficient last year, and with her multiple surgeries and poor p.o. intake, may have become iron deficient again. She has had part of her small bowel removed, so there may be a component of poor absorption as well. If she is iron deficient, this may contribute also to her elevated platelet counts. I will check a ferritin. This may be difficult to interpret because of inflammation. If it is decreased, plan will be to add iron supplementation intravenously. If it is elevated, we could consider a bone marrow biopsy to evaluate her iron stores, and also assess her myelopoiesis given the markedly elevated platelet counts.,She needs continued treatment as you are for her infections.,I will discuss the case with Dr. X as well since there is a question as to whether she might need additional surgery. She is not a surgical candidate now with her elevated PT/INR.nan

CHIEF COMPLAINT: ,Severe tonsillitis, palatal cellulitis, and inability to swallow.,HISTORY OF PRESENT ILLNESS: , This patient started having sore throat approximately one week ago; however, yesterday it became much worse. He was unable to swallow. He complained to his parent. He was taken to Med Care and did not get any better, and therefore presented this morning to ER, where seen and evaluated by Dr. X and concerned as whether he had an abscess either pharyngeal, palatal, or peritonsillar. He was noted to have extreme tonsillitis with kissing tonsils, marked exudates especially right side and right palatal cellulitis. A CT scan at ER did not show abscess. He has not had airway compromise, but he has had difficulty swallowing. He may have had a low-grade fever, but nothing marked at home. His records from Hospital are reviewed as well as the pediatric notes by Dr. X. He did have some equivalent leukocytosis. He had a negative monospot and negative strep screen.,PAST MEDICAL HISTORY: ,The patient takes no medications, has had no illnesses or surgeries and he is generally in good health other than being significantly overweight. He is a sophomore at High School.,FAMILY HISTORY: ,Noncontributory to this illness.,SURGERIES: , None.,HABITS: , Nonsmoker, nondrinker. Denies illicit drug use.,REVIEW OF SYSTEMS:,ENT: The patient other than having dysphagia, the patient denies other associated ENT symptomatology.,GU: Denies dysuria.,Orthopedic: Denies joint pain, difficulty walking, etc.,Neuro: Denies headache, blurry vision, etc.,Eyes: Says vision is intact.,Lungs: Denies shortness of breath, cough, etc.,Skin: He states he has a rash, which occurred from penicillin that he was given IM yesterday at Covington Med Care. Mildly itchy. Mother has penicillin allergy.,Endocrine: The patient denies any weight loss, weight gain, skin changes, fatigue, etc, essentially no symptoms of hyper or hypothyroidism.,Physical Exam:,General: This is a morbidly obese white male adolescent, in no acute disease, alert and oriented x 4. Voice is normal. He is handling his secretions. There is no stridor.,Vital Signs: See vital signs in nurses notes.,Ears: TM and EACs are normal. External, normal.,Nose: Opening clear. External nose is normal.,Mouth: Has bilateral marked exudates, tonsillitis, right greater than left. Uvula is midline. Tonsils are touching. There is some redness of the right palatal area, but is not consistent with peritonsillar abscess. Tongue is normal. Dentition intact. No mucosal lesions other than as noted.,Neck: No thyromegaly, masses, or adenopathy except for some small minimally enlarged high jugular nodes.,Chest: Clear to auscultation.,Heart: No murmurs, rubs, or gallops.,Abdomen: Obese. Complete exam deferred.,Skin: Visualized skin dry and intact, except for rash on his inner thighs and upper legs, which is red maculopapular and consistent with possible allergic reaction.,Neuro: Cranial nerves II through XII are intact. Eyes, pupils are equal, round, and reactive to light and accommodation, full range.,IMPRESSION: , Marked exudative tonsillitis, non-strep, non-mono, probably mixed anaerobic infection. No significant prior history of tonsillitis. Possible rash to PENICILLIN.,RECOMMENDATIONS: , I concur with IV clindamycin and IV Solu-Medrol as per Dr. X. I anticipate this patient may need several days of IV antibiotics and then be able to switch over to oral. I do not insist that this patient will need surgical intervention since there is no evidence of abscess. This one episode of severe tonsillitis does not mean the patient needs tonsillectomy, but if he continues to have significant tonsil problems after this he should be referred for ENT evaluation as an outpatient. The patient's parents in the room had expressed good understanding, have a chance to ask questions. At this time, I will see the patient back on an as needed basis.nan

HISTORY OF PRESENT ILLNESS:, Briefly, this is a 17-year-old male, who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus. He is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved, to look for any stricture that may need to be dilated, or any other mucosal abnormality.,PROCEDURE PERFORMED: , EGD.,PREP: , Cetacaine spray, 100 mcg of fentanyl IV, and 5 mg of Versed IV.,FINDINGS:, The tip of the endoscope was introduced into the esophagus, and the entire length of the esophagus was dotted with numerous, white, punctate lesions, suggestive of eosinophilic esophagitis. There were come concentric rings present. There was no erosion or flame hemorrhage, but there was some friability in the distal esophagus. Biopsies throughout the entire length of the esophagus from 25-40 cm were obtained to look for eosinophilic esophagitis. There was no stricture or Barrett mucosa. The bony and the antrum of the stomach are normal without any acute peptic lesions. Retroflexion of the tip of the endoscope in the body of the stomach revealed a normal cardia. There were no acute lesions and no evidence of ulcer, tumor, or polyp. The pylorus was easily entered, and the first, second, and third portions of the duodenum are normal. Adverse reactions: None.,FINAL IMPRESSION: ,Esophageal changes suggestive of eosinophilic esophagitis. Biopsies throughout the length of the esophagus were obtained for microscopic analysis. There was no evidence of stricture, Barrett, or other abnormalities in the upper GI tract.surgery, length of the esophagus, food impacted, lower esophagus, upper endoscopy, entire length, eosinophilic esophagitis, egd, dysphagia, solids, impacted, endoscopy, mucosal, endoscope, biopsies, barrett, stomach, stricture, eosinophilic, esophagitis, esophagus,

PHYSICAL EXAMINATION,GENERAL: , The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative. No dysarthria is noted. No discomfort on presentation is noted. ,HEAD: , Atraumatic, normocephalic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Sclerae are white without injection or icterus. Fundi are without papilledema, hemorrhages or exudates with normal vessels. ,EARS: , The ear canals are patent without edema, exudate or drainage. Tympanic membranes are intact with a normal cone of light. No bulging or erythema to indicate infection is present. There is no hemotympanum. Hearing is grossly intact. ,NOSE:, Without deformity, bleeding or discharge. No septal hematoma is noted. ,ORAL CAVITY:, No swelling or abnormality to the lip or teeth. Oral mucosa is pink and moist. No swelling to the palate or pharynx. Uvula is midline. The pharynx is without exudate or erythema. No edema is seen of the tonsils. The airway is completely patent. The voice is normal. No stridor is heard. ,NECK: , No signs of meningismus. No Brudzinski or Kernig sign is present. No adenopathy is noted. No JVD is seen. No bruits are auscultated. Trachea is midline. ,CHEST: , Symmetrical with equal breath sounds. Equal excursion. No hyperresonance or dullness to percussion is noted. There is no tenderness on palpation of the chest. ,LUNGS: ,Clear to auscultation bilaterally. No rales, rhonchi or wheezes are appreciated. Good air movement is auscultated in all 4 lung fields. ,HEART:, Regular rate and rhythm. No murmur. No S3, S4 or rub is auscultated. Point of maximal impulse is strong and in normal position. Abdominal aorta is not palpable. The carotid upstroke is normal. ,ABDOMEN: ,Soft, nontender and nondistended. Normal bowel sounds are auscultated. No organomegaly is appreciated. No masses are palpated. No tympany is noted on percussion. No guarding, rigidity or rebound tenderness is seen on exam. Murphy and McBurney sign is negative. There is no Rovsing, obturator or psoas sign present. No hepatosplenomegaly and no hernias are noted. ,RECTAL:, Normal tone. No masses. Soft, brown stool in the vault. Guaiac negative. ,GENITOURINARY:, Penis is normal without lesion or urethral discharge. Scrotum is without edema. The testes are descended bilaterally. No masses are palpated. There is no tenderness. ,EXTREMITIES: , No clubbing, cyanosis or edema. Pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal. No deformity or signs of trauma. All joints are stable without laxity. There is good range of motion of all joints without tenderness or discomfort. Homan sign is negative. No atrophy or contractures are noted. ,SKIN: , No rashes. No jaundice. Pink and warm with good turgor. Good color. No erythema or nodules noted. No petechia, bulla or ecchymosis. ,NEUROLOGIC: , Cranial nerves II through XII are grossly intact. Muscle strength is graded 5/5 in the upper and lower extremities bilaterally. Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally. Babinski is downgoing bilaterally. Sensation is intact to light touch and vibration. Gait is normal. Romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal. There is no ataxia seen on gait testing. Tone is normal. No pronator drift is seen. ,PSYCHIATRIC: ,The patient is oriented x4. Mood and affect are appropriate. Memory is intact with good short- and long-term memory recall. No dysarthria is noted. Remote memory is intact. Judgment and insight appear normal.,nan

CHIEF COMPLAINT:, Urinary retention.,HISTORY OF PRESENT ILLNESS: , This is a 66-year-old gentleman status post deceased donor kidney transplant in 12/07, who has had recurrent urinary retention issues since that time. Most recently, he was hospitalized on 02/04/08 for acute renal insufficiency, which was probably secondary to dehydration. He was seen by urology again at this visit for urinary retention. He had been seen by urology during a previous hospitalization and he passed his voiding trial at the time of his stent removal on 01/22/08. Cystoscopy showed at that time obstructive BPH. He was started on Flomax at the time of discharge from the hospital. During the most recent readmission on 02/04/08, he went back into urinary retention and he had had a Foley placed at the outside hospital.,REVIEW OF SYSTEMS:, Positive for blurred vision, nasal congestion, and occasional constipation. Denies chest pain, shortness of breath or any rashes or lesions. All other systems were reviewed and found to be negative.,PAST MEDICAL HISTORY:,1. End-stage renal disease, now status post deceased donor kidney transplant in 12/07.,2. Hypertension.,3. History of nephrolithiasis.,4. Gout.,5. BPH.,6. DJD.,PAST SURGICAL HISTORY:,1. Deceased donor kidney transplant in 12/07.,2. Left forearm and left upper arm fistula placements.,FAMILY HISTORY: ,Significant for mother with an unknown type of cancer, possibly colon cancer or lung and prostate problems on his father side of the family. He does not know whether his father side of the family had any history of prostate cancer.,HOME MEDICATIONS:,1. Norvasc.,2. Toprol 50 mg.,3. Clonidine 0.2 mg.,4. Hydralazine.,5. Flomax.,6. Allopurinol.,7. Sodium bicarbonate.,8. Oxybutynin.,9. Coumadin.,10. Aspirin.,11. Insulin 70/30.,12. Omeprazole.,13. Rapamune.,14. CellCept.,15. Prednisone.,16. Ganciclovir.,17. Nystatin swish and swallow.,18. Dapsone.,19. Finasteride.,ALLERGIES:, No known drug allergies.,PHYSICAL EXAMINATION:,GENERAL: This is a well-developed, well-nourished male, in no acute distress. VITAL SIGNS: Temperature 98, blood pressure 129/72, pulse 96, and weight 175.4 pounds. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm with a 3/6 systolic murmur. ABDOMEN: Right lower quadrant incision site scar well healed. Nontender to palpation. Liver and spleen not enlarged. No hernias appreciated. PENIS: Normal male genitalia. No lesions appreciated on the penis. Previous DRE showed the prostate of approximately 40 grams and no nodules. Foley in place and draining clear urine.,The patient underwent fill and pull study, in which his bladder tolerated 120 ml of sterile water passively filling his bladder. He spontaneously voided without the Foley 110 mL.,ASSESSMENT AND PLAN: ,This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since the kidney transplant in 12/07. He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again. We discussed with Mr. Barker that he has a urologist closer to his home and he lives approximately 3 hours away; however, he desires to continue follow up with the urology clinic at MCG and has been set up for followup in 6 weeks. He was also given a prescription for 6 months of Flomax and Proscar. He did not have a PSA drawn today as he had a catheter in place, therefore his PSA could be falsely elevated. He will have PSA level drawn either just before his visit for followup.nan

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.urology, inguinal herniorrhaphy, modified bassini, herniorrhaphy modified bassini, hernia direct, inguinal hernia, inguinal, bassini,

PREOPERATIVE DIAGNOSIS: ,Thyroid goiter with substernal extension on the left.,POSTOPERATIVE DIAGNOSIS:, Thyroid goiter with substernal extension on the left.,PROCEDURE PERFORMED:, Total thyroidectomy with removal of substernal extension on the left.,THIRD ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 200 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:, The patient is a 54-year-old Caucasian male with a history of an enlarged thyroid gland who presented to the office initially with complaints of dysphagia and some difficulty in breathing while lying supine. The patient subsequently then had a CT scan which demonstrated a very large thyroid gland, especially on the left side with substernal extension down to the level of the aortic arch. The patient was then immediately set up for surgery. After risks, complications, consequences, and questions were addressed with the patient, a written consent was obtained.,PROCEDURE:, The patient was brought to the operative suite by Anesthesia and placed on the operative table in the supine position. The patient was then placed under general endotracheal intubation anesthesia and the patient then had a shoulder roll placed. After this, the patient then had the area marked initially. The preoperative setting was then localized with 1% lidocaine and epinephrine 1:100,000 approximately 10 cc total. After this, the patient was then prepped and draped in the usual sterile fashion. A #15 Bard-Parker was then utilized to make a skin incision horizontally, approximately 5 cm on either side from midline. After this, a blunt dissection was then utilized to dissect the subcutaneous fat from the platysmal muscle. There appeared to be a natural dehiscence of the platysma in the midline. A sub-platysmal dissection was then performed in the superior, inferior, and lateral directions with the help of a bear claw, Metzenbaum scissors and DeBakey forceps. Any bleeding was controlled with monopolar cauterization. After this, the two anterior large jugular veins were noted and resected laterally. The patient's trachea appeared to be slightly deviated to the right with identification finally of the midline raphe, off midline to the right. This was grasped on either side with a DeBakey forceps and dissected with monopolar cauterization and dissected with a Metzenbaum scissors. After this was dissected, the sternohyoid muscles were resected laterally and separated from the sternothyroid muscles. The sternothyroid muscles were then bluntly freed and dissected from the right thyroid gland. After this, attention was then drawn to the left gland, where the sternothyroid muscle was dissected bluntly on this side utilizing finger dissection and Kitners. The left thyroid gland was freed initially superiorly and worked inferiorly and laterally until the gland was pulled from the substernal region by blunt dissection and reflected and pulled anteriorly. After this, the superior and inferior parathyroid glands were noted. The dissection was carried very close to the thyroid gland to try to select these parathyroids posteriorly. After this, the superior pole was then identified and the superior laryngeal artery and vein were cross clamped and tied with __________ undyed Vicryl tie. The superior pole was finally freed and a small little feeding branched vessels from this area were cauterized with the bipolar cautery and cut with Metzenbaum scissors. After this, the thyroid gland was further freed down to the level of the Berry's ligament inferiorly and the dissection was carried once again more superiorly. The fine stats were then utilized to dissect along the superior aspect of the recurrent laryngeal nerve on the left side with freeing of the connective Berry's ligament tissue from the gland with the bipolar cauterization and the fine stat. Finally, attention was then drawn back to the patient's right side where the gland was rotated more anteriorly with fine dissection utilizing a fine stat to reflect the superior and inferior parathyroid glands laterally and posteriorly. The recurrent laryngeal nerve on this side was identified and further dissection was carried superiorly and anteriorly through this nerve to finally free the right side of the gland to Berry's ligament. The middle thyroid vein and inferior thyroid arteries were cross clamped and tied with #2-0 undyed Vicryl ties and also bipolared with the bipolar cauterization bilaterally. The Berry's ligament was then finally freed and the gland was then passed to scrub tech and passed off the field to Pathology. The neck was then thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization. After this, Surgicel was then placed in the bilateral neck regions and a #10 Jackson-Pratt drain was then placed within the left neck region with some extension over to the right neck region. This was brought out through the inferior skin incision and secured to the skin with a #2-0 nylon suture. The strap muscles were then reapproximated with a running #3-0 Vicryl suture followed by reapproximation of the platysma and subcutaneous tissue with a #4-0 undyed Vicryl. The skin was then reapproximated with a #5-0 Prolene subcuticular along with a #6-0 fast over the top. After this, Mastisol Steri-Strips and Bacitracin along with a sterile dressing and a __________ dressing were then placed. The patient intraoperatively did have approximately 50 cc of bloody drainage from this area within the JP drain. The patient was then turned back to Anesthesia, extubated in the operating room and transferred to Recovery in stable condition. The patient tolerated the procedure well and remained stable throughout.endocrinology, thyroid goiter, goiter, thyroid, total thyroidectomy, berry's ligament, dissection, gland, thyroidectomy, anesthesia, berry's, ligament, cauterization, extension, substernal,

EXAM: , OB Ultrasound.,HISTORY:, A 29-year-old female requests for size and date of pregnancy.,FINDINGS: , A single live intrauterine gestation in the cephalic presentation, fetal heart rate is measured 147 beats per minute. Placenta is located posteriorly, grade 0 without previa. Cervical length is 4.2 cm. There is normal amniotic fluid index of 12.2 cm. There is a 4-chamber heart. There is spontaneous body/limb motion. The stomach, bladder, kidneys, cerebral ventricles, heel, spine, extremities, and umbilical cord are unremarkable.,BIOMETRIC DATA:,BPD = 7.77 cm = 31 weeks, 1 day,HC = 28.26 cm = 31 weeks, 1 day,AC = 26.63 cm = 30 weeks, 5 days,FL = 6.06 cm = 31 weeks, 4 days,Composite sonographic age 30 weeks 6 days plus minus 17 days.,ESTIMATED DATE OF DELIVERY: , Month DD, YYYY.,Estimated fetal weight is 3 pounds 11 ounces plus or minus 10 ounces.,IMPRESSION: , Single live intrauterine gestation without complications as described.obstetrics / gynecology, ultrasound, ac, bpd, cervical length, estimated date of delivery, fl, hc, placenta, single live, amniotic fluid, bladder, cephalic, cephalic presentation, cerebral ventricles, extremities, fetal heart rate, fetal weight, gestation, heel, intrauterine, kidneys, pregnancy, previa, spine, stomach, umbilical cord, live intrauterine, intrauterine gestation

XYZ, M.D. ,Suite 123, ABC Avenue ,City, STATE 12345 ,RE: XXXX, XXXX ,MR#: 0000000,Dear Dr. XYZ: ,XXXX was seen in followup in the Pediatric Urology Clinic. I appreciate you speaking with me while he was in clinic. He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ,When I examined him, he seems to indicate that his pain is essentially in the lower abdomen in the suprapubic region; however, on actual physical examination, he seems to complain of pain through his entire right side. His parents have brought up the question of whether this could be gastrointestinal in origin and that is certainly an appropriate consideration. They also feel that since he has been on Detrol, his pain levels have been somewhat worse, and so, I have given them the option of stopping the Detrol initially. I think he should stay on MiraLax for management of his bowels. I would also suggest that he be referred to Pediatric Gastroenterology for evaluation. If they do not find any abnormalities from a gastrointestinal perspective, then the next step would be to endoscope his bladder and then make sure that he does not have any evidence of bladder anatomic abnormalities that is leading to this pain. ,Thank you for following XXXX along with us in Pediatric Urology Clinic. If you have any questions, please feel free to contact me. ,Sincerely yours,pediatrics - neonatal, differential function, diuretic renal scan, abdominal pain, renal scan, pediatric urology,

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.radiology, 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 DIAGNOSES:,1. Left diabetic foot abscess and infection.,2. Left calcaneus fracture with infection.,3. Right first ray amputation.,POSTOP DIAGNOSES:,1. Left diabetic foot abscess and infection.,2. Left calcaneus fracture with infection.,3. Right first ray amputation.,OPERATION AND PROCEDURE:,1. Left below-the-knee amputation.,2. Dressing change, right foot.,ANESTHESIA: , General.,BLOOD LOSS: , Less than 100 mL.,TOURNIQUET TIME:, 24 minutes on the left, 300 mmHg.,COMPLICATIONS:, None.,DRAINS: , A one-eighth-inch Hemovac.,INDICATIONS FOR SURGERY: , The patient is a 62 years of age with diabetes. He developed left heel abscess. He had previous debridements, developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads. After re-inspecting the wound last week, the plan was for possible debridement and he desired below-the-knee amputation. We are going to change the dressing on the right side also. The risks, benefits, and alternatives of surgery were discussed. The risks of bleeding, infection, damage to nerves and blood vessels, persistent wound healing problems, and the need for future surgery. He understood all the risks and desired operative treatment.,OPERATIVE PROCEDURE IN DETAIL: , After appropriate informed consent obtained, the patient was taken to the operating room and placed in the supine position. General anesthesia induced. Once adequate anesthesia had been achieved, cast padding placed on the left proximal thigh and tourniquet was applied. The right leg was redressed. I took the dressing down. There was a small bit of central drainage, but it was healing nicely. Adaptic and new sterile dressings were applied.,The left lower extremity was then prepped and draped in usual sterile fashion.,A transverse incision made about the mid shaft of the tibia. A long posterior flap was created. It was taken to the subcutaneous tissues with electrocautery. Please note that tourniquet had been inflated after exsanguination of the limb. Superficial peroneal nerve identified, clamped, and cut. Anterior compartment was divided. The anterior neurovascular bundle identified, clamped, and cut. The plane was taken between the deep and superficial compartments. The superficial compartment was reflected posteriorly. Tibial nerve identified, clamped, and cut. Tibial vessels identified, clamped, and cut.,Periosteum of the tibia elevated proximally along with the fibula. The tibia was then cut with Gigli saw. It was beveled anteriorly and smoothed down with a rasp. The fibula was cut about a cm and a half proximal to this using a large bone cutter. The remaining posterior compartment was divided. The peroneal bundle identified, clamped, and cut. The leg was then passed off of the field. Each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie. The nerves were each pulled at length, injected with 0.25% Marcaine with epinephrine, cut, and later retracted proximally. The tourniquet was released. Good bleeding from the tissues and hemostasis obtained with electrocautery. Copious irrigation performed using antibiotic-impregnated solution. A one-eighth-inch Hemovac drain placed in the depth of wound adhering on the medial side. A gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with #1 Vicryl in an interrupted fashion. The remaining fascia was closed with #1 Vicryl. Subcutaneous tissues were then closed with 2-0 PDS suture using 2-0 Monocryl suture in interrupted fashion. Skin closed with skin staples. Xeroform gauze, 4 x 4, and a padded soft dressing applied. He was placed in a well-padded anterior and posterior slab splint with the knee in extension. He was then awakened, extubated, and taken to recovery in stable condition. There were no immediate operative complications, and he tolerated the procedure well.orthopedic, infection, adaptic, gigli saw, hemovac, abscess, amputation, below-the-knee amputation, calcaneus fracture, debridement, diabetic foot, ray amputation, tourniquet, transverse incision, knee amputation, knee, dressing, clamped,

REASON FOR CONSULTATION: , Atrial fibrillation and shortness of breath.,HISTORY OF PRESENTING ILLNESS: , The patient is an 81-year-old gentleman. The patient had shortness of breath over the last few days, progressively worse. Yesterday he had one episode and got concerned and came to the Emergency Room, also orthopnea and paroxysmal dyspnea. Coronary artery disease workup many years ago. He also has shortness of breath, weakness, and tiredness.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Knee surgery, hip surgery, shoulder surgery, cholecystectomy, and appendectomy.,MEDICATIONS: , Thyroid supplementation, atenolol 25 mg daily, Lasix, potassium supplementation, lovastatin 40 mg daily, and Coumadin adjusted dose.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY:, Married, ex-smoker, and does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, atrial fibrillation chronic, on anticoagulation.,SURGICAL HISTORY: , As above.,PRESENTATION HISTORY: , Shortness of breath, weakness, fatigue, and tiredness. The patient also relates history of questionable TIA in 1994.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: Weakness, fatigue, tiredness.,HEENT: No history of cataracts, blurry vision or glaucoma.,CARDIOVASCULAR: Arrhythmia, congestive heart failure, no coronary artery disease.,RESPIRATORY: Shortness of breath. No pneumonia or valley fever.,GASTROINTESTINAL: Nausea, no vomiting, hematemesis, or melena.,UROLOGICAL: Some frequency, urgency, no hematuria.,MUSCULOSKELETAL: Arthritis, muscle weakness.,SKIN: Chronic skin changes.,CNS: History of TIA. No CVA, no seizure disorder.,ENDOCRINE: Nonsignificant.,HEMATOLOGICAL: Nonsignificant.,PSYCHOLOGICAL: No anxiety or depression.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 67, blood pressure 159/49, afebrile, and respiratory rate 18 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Neck veins flat. No significant carotid bruits.,LUNGS: Air entry bilaterally fair, decreased in basal areas. No rales or wheezes.,HEART: PMI displaced. S1 and S2 regular.,ABDOMEN: Soft and nontender. Bowel sounds present.,EXTREMITIES: Chronic skin changes. Pulses are palpable. No clubbing or cyanosis.,CNS: Grossly intact.,LABORATORY DATA: , H&H stable 30 and 39, INR of 1.86, BUN and creatinine within normal limits, potassium normal limits. First set of cardiac enzymes profile negative. BNP 4810.,Chest x-ray confirms unremarkable findings. EKG reveals atrial fibrillation, nonspecific ST-T changes.,IMPRESSION:nan

HISTORY OF PRESENT ILLNESS: ,This 59-year-old white male is seen for comprehensive annual health maintenance examination on 02/19/08, although this patient is in excellent overall health. Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change, dyslipidemia well controlled with niacin, history of hemorrhoids with occasional external bleeding, although no problems in the last 6 months, and also history of concha bullosa of the left nostril, followed by ENT associated with slight septal deviation. There are no other medical problems. He has no symptoms at this time and remains in excellent health.,PAST MEDICAL HISTORY: , Otherwise noncontributory. There is no operation, serious illness or injury other than as noted above.,ALLERGIES: , There are no known allergies.,FAMILY HISTORY: , Father died of an MI at age 67 with COPD and was a heavy smoker. His mother is 88, living and well, status post lung cancer resection. Two brothers, living and well. One sister died at age 20 months of pneumonia.,SOCIAL HISTORY:, The patient is married. Wife is living and well. He jogs or does Cross Country track 5 times a week, and weight training twice weekly. No smoking or significant alcohol intake. He is a physician in allergy/immunology.,REVIEW OF SYSTEMS:, Otherwise noncontributory. He has no gastrointestinal, cardiopulmonary, genitourinary or musculoskeletal symptomatology. No symptoms other than as described above.,PHYSICAL EXAMINATION:,GENERAL: He appears alert, oriented, and in no acute distress with excellent cognitive function. VITAL SIGNS: His height is 6 feet 2 inches, weight is 181.2, blood pressure is 126/80 in the right arm, 122/78 in the left arm, pulse rate is 68 and regular, and respirations are 16. SKIN: Warm and dry. There is no pallor, cyanosis or icterus. HEENT: Tympanic membranes benign. The pharynx is benign. Nasal mucosa is intact. Pupils are round, regular, and equal, reacting equally to light and accommodation. EOM intact. Fundi reveal flat discs with clear margins. Normal vasculature. No hemorrhages, exudates or microaneurysms. No thyroid enlargement. There is no lymphadenopathy. LUNGS: Clear to percussion and auscultation. Normal sinus rhythm. No premature beat, murmur, S3 or S4. Heart sounds are of good quality and intensity. The carotids, femorals, dorsalis pedis, and posterior tibial pulsations are brisk, equal, and active bilaterally. ABDOMEN: Benign without guarding, rigidity, tenderness, mass or organomegaly. NEUROLOGIC: Grossly intact. EXTREMITIES: Normal. GU: Genitalia normal. There are no inguinal hernias. There are mild hemorrhoids in the anal canal. The prostate is small, if any normal to mildly enlarged with discrete margins, symmetrical without significant palpable abnormality. There is no rectal mass. The stool is Hemoccult negative.,IMPRESSION:,1. Comprehensive annual health maintenance examination.,2. Dyslipidemia.,3. Tinnitus, left ear.,4. Hemorrhoids.,PLAN:, At this time, continue niacin 1000 mg in the morning, 500 mg at noon, and 1000 mg in the evening; aspirin 81 mg daily; multivitamins; vitamin E 400 units daily; and vitamin C 500 mg daily. Consider adding lycopene, selenium, and flaxseed to his regimen. All appropriate labs will be obtained today. Followup fasting lipid profile and ALT in 6 months.general medicine, tinnitus, dyslipidemia, annual health maintenance, health, hemorrhoids, benign

ADMISSION DIAGNOSES:,1. Pneumonia, likely secondary to aspiration.,2. Chronic obstructive pulmonary disease (COPD) exacerbation.,3. Systemic inflammatory response syndrome.,4. Hyperglycemia.,DISCHARGE DIAGNOSES:,1. Aspiration pneumonia.,2. Aspiration disorder in setting of severe chronic obstructive pulmonary disease.,3. Chronic obstructive pulmonary disease (COPD) exacerbation.,4. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.,5. Hypercapnia on admission secondary to chronic obstructive pulmonary disease.,6. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures or sputum culture.,7. Atrial fibrillation with episodic rapid ventricular rate, now rate control.,8. Hyperglycemia secondary to poorly controlled type ii diabetes mellitus, insulin requiring.,9. Benign essential hypertension, poorly controlled on admission, now well controlled on discharge.,10. Aspiration disorder exacerbated by chronic obstructive pulmonary disease and acute respiratory failure.,11. Hyperlipidemia.,12. Acute renal failure on chronic renal failure on admission, now resolved.,HISTORY OF PRESENT ILLNESS:, Briefly, this is 73-year-old white male with history of multiple hospital admissions for COPD exacerbation and pneumonia who presented to the emergency room on 04/23/08, complaining of severe shortness of breath. The patient received 3 nebulizers at home without much improvement. He was subsequently treated successfully with supplemental oxygen provided by normal nasal cannula initially and subsequently changed to BiPAP.,HOSPITAL COURSE: ,The patient was admitted to the hospitalist service, treated with frequent small volume nebulizers, treated with IV Solu-Medrol and BiPAP support for COPD exacerbation. The patient also noted with poorly controlled atrial fibrillation with a rate in the low 100s to mid 100s. The patient subsequently received diltiazem, also received p.o. digoxin. The patient subsequently responded well as well received IV antibiotics including Levaquin and Zosyn. The patient made slow, but steady improvement over the course of his hospitalization. The patient subsequently was able to be weaned off BiPAP during the day, but continued BiPAP at night and will continue with BiPAP if needed. The patient may require a sleep study after discharge, but by the third day prior to discharge he was no longer utilizing BiPAP, was simply using supplemental O2 at night and was able to maintain appropriate and satisfactory O2 saturations on one-liter per minute supplemental O2 per nasal cannula. The patient was able to participate with physical therapy, able to ambulate from his bed to the bathroom, and was able to tolerate a dysphagia 2 diet. Note that speech therapy did provide a consultation during this hospitalization and his modified barium swallow was thought to be unremarkable and really related only to the patient's severe shortness of breath during meal time. The patient's chest x-ray on admission revealed some mild vascular congestion and bilateral pleural effusions that appeared to be unchanged. There was also more pronounced patchy alveolar opacity, which appeared to be, "mass like" in the right suprahilar region. This subsequently resolved and the patient's infiltrate slowly improved over the course of his hospitalization. On the day prior to discharge, the patient had a chest x-ray 2 views, which allowing for differences in technique revealed little change in the bibasilar infiltrates and atelectatic changes at the bases bilaterally. This was compared with an examination performed 3 days prior. The patient also had minimal bilateral effusions. The patient will continue with clindamycin for the next 2 weeks after discharge. Home health has been ordered and the case has been discussed in detail with Shaun Eagan, physician assistant at Eureka Community Health Center. The patient was discharged as well on a dysphagia 2 diet, thin liquids are okay. The patient discharged on the following medications.,DISCHARGE MEDICATIONS:,1. Home oxygen 1 to 2 liters to maintain O2 saturations at 89 to 91% at all times.,2. Ativan 1 mg p.o. t.i.d.,3. Metformin 1000 mg p.o. b.i.d.,4. Glucotrol 5 mg p.o. daily.,5. Spiriva 1 puff b.i.d.,6. Lantus 25 units subcu q.a.m.,7. Cardizem CD 180 mg p.o. q.a.m.,8. Advair 250/50 mcg, 1 puff b.i.d. The patient is instructed to rinse with mouthwash after each use.,9. Iron 325 mg p.o. b.i.d.,10. Aspirin 325 mg p.o. daily.,11. Lipitor 10 mg p.o. bedtime.,12. Digoxin 0.25 mg p.o. daily.,13. Lisinopril 20 mg p.o. q.a.m.,14. DuoNeb every 4 hours for the next several weeks, then q.6 h. thereafter, dispensed 180 DuoNeb ampule's with one refill.,15. Prednisone 40 mg p.o. q.a.m. x3 days followed by 30 mg p.o. q.a.m. x3 days, then followed by 20 mg p.o. q.a.m. x5 days, then 10 mg p.o. q.a.m. x14 days, then discontinue, #30 days supply given. No refills.,16. Clindamycin 300 mg p.o. q.i.d. x2 weeks, dispensed #64 with one refill.,The patient's aspiration pneumonia was discussed in detail. He is agreeable to obtaining a chest x-ray PA and lateral after 2 weeks of treatment. Note that this patient did not have community-acquired pneumonia. His discharge diagnosis is aspiration pneumonia. The patient will continue with a dysphagia 2 diet with thin liquids after discharge. The patient discharged with home health. A dietary and speech therapy evaluation has been ordered. Speech therapy to treat for chronic dysphagia and aspiration in the setting of severe chronic obstructive pulmonary disease.,Total discharge time was greater than 30 minutes.nan

REASON FOR CT SCAN: , The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan performed on January 16, 2008. I changed the shunt setting from 1.5 to 2.0 on February 12, 2008 and his family obtained this repeat CT scan to determine whether his subdural effusions were improving.,CT scan from 03/11/2008 demonstrates frontal horn span at the level of foramen of Munro of 2.6 cm. The 3rd ventricular contour which is flat with a 3rd ventricular span of 10 mm. There is a single shunt, which enters on the right occipital side and ends in the left lateral ventricle. He has symmetric bilateral subdurals that are less than 1 cm in breadth each, which is a reduction from the report from January 16, 2008, which states that he had a subdural hygroma, maximum size 1.3 cm on the right and 1.1 cm on the left.,ASSESSMENT: , The patient's subdural effusions are still noticeable, but they are improving at the setting of 2.0.,PLAN: , I would like to see the patient with a new head CT in about three months, at which time we can decide whether 2.0 is the appropriate setting for him to remain at or whether we can consider changing the shunt setting.radiology, ct scan, subdural, adult hydrocephalus, bilateral effusions, shunt setting, subdural effusions, hydrocephalus, ventricular, scan, ct,

EXAM: , Ultrasound abdomen, complete.,HISTORY: , 38-year-old male admitted from the emergency room 04/18/2009, decreased mental status and right upper lobe pneumonia. The patient has diffuse abdominal pain. There is a history of AIDS.,TECHNIQUE:, An ultrasound examination of the abdomen was performed.,FINDINGS:, The liver has normal echogenicity. The liver is normal sized. The gallbladder has a normal appearance without gallstones or sludge. There is no gallbladder wall thickening or pericholecystic fluid. The common bile duct has a normal caliber at 4.6 mm. The pancreas is mostly obscured by gas. A small portion of the head of pancreas is visualized which has a normal appearance. The aorta has a normal caliber. The aorta is smooth walled. No abnormalities are seen of the inferior vena cava. The right kidney measures 10.8 cm in length and the left kidney 10.5 cm. No masses, cysts, calculi, or hydronephrosis is seen. There is normal renal cortical echogenicity. The spleen is somewhat prominent with a maximum diameter of 11.2 cm. There is no ascites. The urinary bladder is distended with urine and shows normal wall thickness without masses. The prostate is normal sized with normal echogenicity.,IMPRESSION: ,1. Spleen size at the upper limits of normal.,2. Except for small portions of pancreatic head, the pancreas could not be visualized because of bowel gas. The visualized portion of the head had a normal appearance.,3. The gallbladder has a normal appearance without gallstones. There are no renal calculi.radiology, echogenicity, gallbladder, ultrasound abdomen complete, ultrasound abdomen, abdomen, liver, gallstones, kidney, calculi, renal, spleen, pancreas, ultrasound

PREOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,POSTOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,OPERATION: , Excision of ganglion.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,OPERATION: , After a successful anesthetic, the patient was positioned on the operating table. A tourniquet applied to the upper arm. The extremity was prepped in a usual manner for a surgical procedure and draped off. The superficial vessels were exsanguinated with an elastic wrap and the tourniquet was then inflated to the usual arm pressure. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist. By blunt and sharp dissection, it was dissected out from underneath the extensor tendons and the stalk appeared to arise from the distal radiocapitellar joint and the dorsal capsule was excised along with the ganglion and the specimen was removed and submitted. The small superficial vessels were electrocoagulated and instilled after closing the skin with 4-0 Prolene, into the area was approximately 6 to 7 mL of 0.25 Marcaine with epinephrine. A Jackson-Pratt drain was inserted and then after the tourniquet was released, it was kept deflated until at least 5 to 10 minutes had passed and then it was activated and then removed in the recovery room. The dressings applied to the hand were that of Xeroform, 4x4s, ABD, Kerlix, and elastic wrap over a volar fiberglass splint. The tourniquet was released. Circulation returned to the fingers. The patient then was allowed to awaken and left the operating room in good condition.orthopedic, curved incision, superficial vessels, tourniquet, excision, dorsal, wrist, ganglion

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

REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in consultation for a new diagnosis of colon cancer.,HISTORY OF PRESENT ILLNESS:, The patient presented to medical attention after she noticed mild abdominal cramping in February 2007. At that time, she was pregnant and was unsure if her symptoms might have been due to the pregnancy. Unfortunately, she had miscarriage at about seven weeks. She again had abdominal cramping, severe, in late March 2007. She underwent colonoscopy on 04/30/2007 by Dr. Y. Of note, she is with a family history of early colon cancers and had her first colonoscopy at age 35 and no polyps were seen at that time.,On colonoscopy, she was found to have a near-obstructing lesion at the splenic flexure. She was not able to have the scope passed past this lesion. Pathology showed a colon cancer, although I do not have a copy of that report at this time.,She had surgical resection done yesterday. The surgery was laparoscopic assisted with anastomosis. At the time of surgery, lymph nodes were palpable.,Pathology showed colon adenocarcinoma, low grade, measuring 3.8 x 1.7 cm, circumferential and invading in to the subserosal mucosa greater than 5 mm, 13 lymph nodes were negative for metastasis. There was no angiolymphatic invasion noted. Radial margin was 0.1 mm. Other margins were 5 and 6 mm. Testing for microsatellite instability is still pending.,Staging has already been done with a CT scan of the chest, abdomen, and pelvis. This showed a mass at the splenic flexure, mildly enlarged lymph nodes there, and no evidence of metastasis to liver, lungs, or other organs. The degenerative changes were noted at L5-S1. The ovaries were normal. An intrauterine device (IUD) was present in the uterus.,REVIEW OF SYSTEMS:, She has otherwise been feeling well. She has not had fevers, night sweats, or noticed lymphadenopathy. She has not had cough, shortness of breath, back pain, bone pain, blood in her stool, melena, or change in stool caliber. She was eating well up until the time of her surgery. She is up-to-date on mammography, which will be due again in June. She has no history of pulmonary, cardiac, renal, hepatic, thyroid, or central nervous system (CNS) disease.,ALLERGIES: , PENICILLIN, WHICH CAUSED HIVES WHEN SHE WAS A CHILD.,MEDICATIONS PRIOR TO ADMISSION:, None.,PAST MEDICAL HISTORY: , No significant medical problem. She has had three miscarriages, all of them at about seven weeks. She has no prior surgeries.,SOCIAL HISTORY: ,She smoked cigarettes socially while in her 20s. A pack of cigarettes would last for more than a week. She does not smoke now. She has two glasses of wine per day, both red and white wine. She is married and has no children. An IUD was recently placed. She works as an esthetician.,FAMILY HISTORY: ,Father died of stage IV colon cancer at age 45. This occurred when the patient was young and she is not sure of the rest of the paternal family history. She does believe that aunts and uncles on that side may have died early. Her brother died of pancreas cancer at age 44. Another brother is aged 52 and he had polyps on colonoscopy a couple of years ago. Otherwise, he has no medical problem. Mother is aged 82 and healthy. She was recently diagnosed with hemochromatosis.,PHYSICAL EXAMINATION: , ,GENERAL: She is in no acute distress.,VITAL SIGNS: The patient is afebrile with a pulse of 78, respirations 16, blood pressure 124/70, and pulse oximetry is 93% on 3 L of oxygen by nasal cannula.,SKIN: Warm and dry. She has no jaundice.,LYMPHATICS: No cervical or supraclavicular lymph nodes are palpable.,LUNGS: There is no respiratory distress.,CARDIAC: Regular rate.,ABDOMEN: Soft and mildly tender. Dressings are clean and dry.,EXTREMITIES: No peripheral edema is noted. Sequential compression devices (SCDs) are in place.,LABORATORY DATA:, White blood count of 11.7, hemoglobin 12.8, hematocrit 37.8, platelets 408, differential shows left shift, MCV is 99.6. Sodium is 136, potassium 4.1, bicarb 25, chloride 104, BUN 5, creatinine 0.7, and glucose is 133. Calcium is 8.8 and magnesium is 1.8.,IMPRESSION AND PLAN: , Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1. She does not have high-risk factors such as high grade or angiolymphatic invasion, and adequate number of lymph nodes were sampled. Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.,A lengthy discussion was held with the patient regarding her diagnosis and prognosis. Firstly, she has a good prognosis for being cured without adjuvant therapy. I would consider her borderline for chemotherapy given her young age. Referring to the database that had been online, she has a 13% chance of relapse in the next five years, and with aggressive chemotherapy (X-linked agammaglobulinemia (XLA) platinum-based), this would be reduced to an 8% risk of relapse with a 5% benefit. Chemotherapy with 5-FU based regimen would have a smaller benefit of around 2.5%.,Plan was made to allow her to recuperate and then meet with her and her husband to discuss the pros and cons of adjuvant chemotherapy including what regimen she could consider including the side effects. We did not review all that information today.,She has a family history of early colon cancer. Her mother will be visiting in the weekend and plan is to obtain the rest of the paternal family history if we can. Tumor is being tested for microsatellite instability and we will discuss this when those results are available. She has one sibling and he is up-to-date on colonoscopy. She does report multiple tubes of blood were drawn prior to her admission. I will check with Dr. Y's office whether she has had a CEA and liver-associated enzymes assessed. If not, those can be drawn tomorrow.nan

PREOPERATIVE DIAGNOSIS:, Mass lesion, right upper extremity.,POSTOPERATIVE DIAGNOSIS: , Intramuscular lipoma, right arm, approximately 4 cm.,PROCEDURE PERFORMED: ,Excision of intramuscular lipoma with flap closure by Dr. Y.,INDICATIONS FOR PROCEDURE: ,This is a 77-year-old African-American female who presents as an outpatient to the General Surgical Service with a mass in the anterior aspect of the mid-biceps region of the right upper extremity. The mass has been increasing in size and symptoms according to the patient. The risks and benefits of the surgical excision were discussed. The patient gave informed consent for surgical removal.,GROSS FINDINGS: , At the time of surgery, the patient was found to have intramuscular lipoma within the head of the biceps. It was removed in its entirety and submitted to Pathology for appropriate analysis.,PROCEDURE: , The patient was taken to the operating room. She was given intravenous sedation and the arm area was sterilely prepped and draped in the usual fashion. Xylocaine was utilized as local anesthetic and a longitudinal incision was made in the axis of the extremity. The skin and subcutaneous tissue were incised as well as the muscular fascia. The fibers of the biceps were divided bluntly and retracted. The lipoma was grasped with an Allis clamp and blunt and sharp dissection was utilized to remove the mass without inuring the underlying neurovascular structures. The mass was submitted to Pathology. Good hemostasis was seen. The wound was irrigated and closed in layers. The deep muscular fascia was reapproximated with #2-0 Vicryl suture.,The subcutaneous tissues were reapproximated with #3-0 Vicryl suture and the deep dermis was reapproximated with #3-0 Vicryl suture. Re-approximated wound flaps without tension and the skin was closed with #4-0 undyed Vicryl in running subcuticular fashion. The patient was given wound care instructions and will follow up again in my office in one week. Overall prognosis is good.surgery, excision, mass lesion, intramuscular, muscular fascia, vicryl suture, intramuscular lipoma, suture, mass, lipoma

PROCEDURE PERFORMED: , Ultrasound-guided placement of multilumen central venous line, left femoral vein.,INDICATIONS:, Need for venous access in a patient on a ventilator and on multiple IV drugs.,CONSENT: , Consent obtained from patient's sister.,PREOPERATIVE MEDICATIONS: , Local anesthesia with 1% plain lidocaine.,PROCEDURE IN DETAIL: , The ultrasound was used to localize the left femoral vein and to confirm it's patency and course. The left inguinal area was then prepped and draped in a sterile manner. The overlying soft tissues were anesthetized with 1% plain lidocaine. Under direct ultrasound visualization, the femoral vein was cannulated without difficulty, and a guidewire advanced. This was followed by a stab incision and the vein dilator in order to form a tract for the catheter itself. Finally, the multilumen catheter itself was inserted over the guidewire. Once the catheter was fully inserted, the guidewire was completely withdrawn. Placement was confirmed by the withdrawal of dark venous blood from all ports; all ports were then flushed, the catheter sewn into place, and the dressing applied. He tolerated the procedure very well, without complications.surgery, plain lidocaine, femoral vein, ultrasound, venous, femoral, guidewire, placement, vein, catheter, access,

He has no voiding complaints and no history of sexually transmitted diseases.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , Back surgery with a fusion of L5-S1.,MEDICATIONS: , He does take occasional Percocet for his back discomfort.,ALLERGIES:, HE HAS NO ALLERGIES.,SOCIAL HISTORY:, He is a smoker. He takes rare alcohol. His employment is that he does dynamite work and actually putting in the dynamite in large holes for destroying ground to that pipeline can be laid. He travels to anywhere for his work. He is married with one son.,FAMILY HISTORY: , Negative for prostate cancer, kidney cancer, bladder cancer, enlarged prostate or kidney disease.,REVIEW OF SYSTEMS:, Negative for tremors, headaches, dizzy spells, numbness, tingling, feeling hot or cold, tired or sluggishness, abdominal pain, nausea or vomiting, indigestion, heartburn, fevers, chills, weight loss, wheezing, frequent cough, shortness of breath, chest pain, varicose veins, high blood pressure, skin rash, joint pain, ear infections, sore throat, sinus problems, hay fever, blood clotting problems, depressive affect or eye problems.,PHYSICAL EXAMINATION,GENERAL: The patient is afebrile. His vital signs are stable. He is 177 pounds, 5 feet, 8 inches. Blood pressure 144/66. He is healthy appearing. He is alert and oriented x 3.,HEART: Regular rate and rhythm.,LUNGS: Clear to auscultation.,ABDOMEN: Soft and nontender. His penis is circumcised. He has a pedunculated cauliflower-like lesion on the dorsum of the penis at approximately 12 o'clock. It is very obvious and apparent. He also has a mildly raised brown lesion that the patient states has been there ever since he can remember and has not changed in size or caliber. His testicles are descended bilaterally. There are no masses.,ASSESSMENT AND PLAN: , This is likely molluscum contagiosum (genital warts) caused by HPV. I did state to the patient that this is likely a viral infection that could have had a long incubation period. It is not clear where this came from but it is most likely sexually transmitted. He is instructed that he should use protected sex from this point on in order to try and limit the transmission. Regarding the actual lesion itself, I did mention that we could apply a cream of Condylox, which could take up to a month to work. I also offered him C02 laser therapy for the genital warts, which is an outpatient procedure. The patient is very interested in something quick and effective such as a CO2 laser procedure. I did state that the recurrence rate is significant and somewhere as high as 20% despite enucleating these lesions. The patient understood this and still wished to proceed. There is minimal risk otherwise except for those inherent in laser injury and accidental injury. The patient understood and wished to proceed.consult - history and phy., sexually transmitted, molluscum contagiosum, genital warts, hpv,

PREOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,POSTOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,PROCEDURE:,1. C5-C6 arthrodesis, anterior interbody technique.,2. C5-C6 anterior cervical discectomy.,3. C5-C6 anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws.,4. Implantation of machine bone implant.,5. Microsurgical technique.,ANESTHESIA: ,General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,BACKGROUND INFORMATION AND SURGICAL INDICATIONS: ,The patient is a 45-year-old right-handed gentleman who presented with neck and right arm radicular pain. The pain has become more and more severe. It runs to the thumb and index finger of the right hand and it is accompanied by numbness. If he tilts his neck backwards, the pain shoots down the arm. If he is working with the computer, it is very difficult to use his mouse. He tried conservative measures and failed to respond, so he sought out surgery. Surgery was discussed with him in detail. A C5-C6 anterior cervical discectomy and fusion was recommended. He understood and wished to proceed with surgery. Thus, he was brought in same day for surgery on 07/03/2007.,DESCRIPTION OF PROCEDURE: , He was given Ancef 1 g intravenously for infection prophylaxis and then transported to the OR. There general endotracheal anesthesia was induced. He was positioned on the OR table with an IV bag between the scapulae. The neck was slightly extended and taped into position. A metal arch was placed across the neck and intraoperative x-ray was obtain to verify a good position for skin incision and the neck was prepped with Betadine and draped in the usual sterile fashion.,A linear incision was created in the neck beginning just to the right of the midline extending out across the anterior border of the sternocleidomastoid muscle. The incision was extended through skin, subcutaneous fat, and platysma. Hemostasis was assured with Bovie cautery. The anterior aspect of the sternocleidomastoid muscle was identified and dissection was carried medial to this down to the carotid sheath. The trachea and the esophagus were swept out of the way and dissection proceeded medial to the carotid sheath down between the two bellies of the longus colli muscle on to the anterior aspect of the spine. A Bovie cautery was used to mobilize the longus colli muscle around initially what turned out to be C6-C7 disk based on x-rays and then around the C5-C6 disk space. An intraoperative x-ray confirmed C5-C6 disk space had been localized and then the self-retained distraction system was inserted to maintain exposure. A 15-blade knife was used to incise the C5-C6 disk and remove disk material. and distraction pins were inserted into C5-C6 and distraction placed across the disk space. The operating microscope was then brought into the field and used throughout the case except for the closure. Various pituitaries, #15 blade knife, and curette were used to evacuate the disk as best as possible. Then, the Midas Rex drill was taken under the microscope and used to drill where the cartilaginous endplate driven back all the way into the posterior aspect of the vertebral body. A nerve hook was swept underneath the posterior longitudinal ligament and a fragment of disk was produced and was pulled up through the ligament. A Kerrison rongeur was used to open up the ligament in this opening and then to march out in the both neural foramina. A small amount of disk material was found at the right neural foramen. After a good decompression of both neural foramina was obtained and the thecal sac was exposed throughout the width of the exposure, the wound was thoroughly irrigated. A spacing mechanism was intact into the disk space and it was determined that a #7 spacer was appropriate. So, a #7 machine bone implant was taken and tapped into disk space and slightly counter sunk. The wound was thoroughly irrigated and inspected for hemostasis. A Mystique plate 23 mm in length was then inserted and anchored to the anterior aspect of C5-C6 to hold the bone into position and the wound was once again irrigated. The patient was valsalved. There was no further bleeding seen and intraoperative x-ray confirmed a good position near the bone, plate, and screws and the wound was enclosed in layers. The 3-0 Vicryl was used to approximate platysma and 3-0 Vicryl was used in inverted interrupted fashion to perform a subcuticular closure of the skin. The wound was cleaned.,Mastisol was placed on the skin, and Steri-strips were used to approximate skin margins. Sterile dressing was placed on the patient's neck. He was extubated in the OR and transported to the recovery room in stable condition. There were no complications.orthopedic, herniation, radiculopathy, interbody, mystique, bone implant, anterior cervical discectomy, neural foramina, mystique plate, disc herniation, arm radiculopathy, cervical discectomy, disk space, disk, cervical, anterior, wound, discectomy,

PREOPERATIVE DIAGNOSIS,Bilateral macromastia.,POSTOPERATIVE DIAGNOSIS,Bilateral macromastia.,OPERATION,Bilateral reduction mammoplasty.,ANESTHESIA,General.,FINDINGS,The patient had large ptotic breasts bilaterally and had had chronic difficulty with pain in the back and shoulder. Right breast was slightly larger than the left this was repaired with a basic wise pattern reduction mammoplasty with anterior pedicle.,PROCEDURE,With the patient under satisfactory general endotracheal anesthesia, the entire chest was prepped and draped in usual sterile fashion. A previously placed mark to identify the neo-nipple site was re-identified and carefully measured for asymmetry and appeared to be satisfactory. A keyhole wire ring was then used to outline the basic wise pattern with 6-cm lamps inferiorly. This was then carefully checked for symmetry and appeared to be satisfactory. All marks were then completed and lightly incised on both breasts. The right breast was approached first. The neo-nipple site was de-epithelialized superiorly and then the inferior pedicle was de-epithelialized using cutting cautery. After this had been completed, cutting cautery was used to carry down an incision along the inferior aspect of the periosteum starting immediately. This was taken down to the prepectoral fashion dissected for short distance superiorly, and then blunt dissection was used to mobilize under the superior portion of the breast tissues to the lateral edge of the pectoral muscle. There was very little bleeding with this procedure. After this had been completed, attention was directed to the lateral side, and the inferior incision was made and taken down to the serratus. Cautery dissection was then used to carry this up superiorly over the lateral edge of the pectoral muscle to communicate with the previous pocket. After this had been completed, cutting cautery was used to cut around the inferior pedicle completely freeing the superior breast from the inferior breast. Hemostasis was obtained with electrocautery. After this had been completed, cutting cautery was used to cut along the superior edge of the redundant tissue and this was tapered under the superior flaps. On the right side, there was a small palpable lobule, which had shown up on mammogram, but nothing except some fat density was identified. This site had been previously marked carefully, and there were no unusual findings and the superior tissue was then sent out separately for pathology. After this had been completed, final hemostasis obtained, and the wound was irrigated and a tagging suture placed to approximate the tissues. The breast cleared and the nipple appeared good.,Attention was then directed to the left breast, which was completed in the similar manner. After this had been completed, the patient was placed in a near upright position, and symmetry appeared good, but it was a bit poor on the lateral aspect of the right side, which was little larger and some suction lipectomy was carried out in this area. After completion of this, 1860 grams had been removed from the right and 1505 grams was removed from the left. Through separate stab wounds on the lateral aspect, 10-mm flat Blake drains were brought out and sutures were then placed **** and irrigated. The wounds were then closed with interrupted 4-0 Monocryl on the deep dermis and running intradermal 4-0 Monocryl on the skin, packing sutures and staples were removed as they were approached. The nipple was sutured with running intradermal 4-0 Monocryl. Vascularity appeared good throughout. After this had been completed, all wounds were cleaned and Steri-Stripped. The patient tolerated the procedure well. All counts were correct. Estimated blood loss was less than 150 mL, and she was sent to recovery room in good condition.surgery, macromastia, estimated blood loss, monocryl, steri-stripped, dermis, inferior breast, mammoplasty, neo-nipple, prepped and draped, ptotic breasts, recovery room in good condition, reduction mammoplasty, superior breast, upright position, bilateral macromastia, incision, superiorly, breasts

PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSIS: , Gastroesophageal reflux disease.,POSTOPERATIVE DIAGNOSIS:, Barrett esophagus.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum to the transverse duodenum. The preparation was excellent and all surfaces were well seen. The hypopharynx appeared normal. The esophagus had a normal contour and normal mucosa throughout its distance, but at the distal end, there was a moderate-sized hiatal hernia noted. The GE junction was seen at 40 cm and the hiatus was noted at 44 cm from the incisors. Above the GE junction, there were three fingers of columnar epithelium extending cephalad, to a distance of about 2 cm. This appears to be consistent with Barrett esophagus. Multiple biopsies were taken from numerous areas in this region. There was no active ulceration or inflammation and no stricture. The hiatal hernia sac had normal mucosa except for one small erosion at the hiatus. The gastric body had normal mucosa throughout. Numerous small fundic gland polyps were noted, measuring 3 to 5 mm in size with an entirely benign appearance. Biopsies were taken from the antrum to rule out Helicobacter pylori. A retroflex view of the cardia and fundus confirmed the small hiatal hernia and demonstrated no additional lesions. The scope was passed through the pylorus, which was patent and normal. The mucosa throughout the duodenum in the first, second, and third portions was entirely normal. The scope was withdrawn and the patient was sent to the recovery room. He tolerated the procedure well.,FINAL DIAGNOSES:,1. A short-segment Barrett esophagus.,2. Hiatal hernia.,3. Incidental fundic gland polyps in the gastric body.,4. Otherwise, normal upper endoscopy to the transverse duodenum.,RECOMMENDATIONS:,1. Follow up biopsy report.,2. Continue PPI therapy.,3. Follow up with Dr. X as needed.,4. Surveillance endoscopy for Barrett in 3 years (if pathology confirms this diagnosis).surgery, olympus, gastroscope, barrett, gastroesophageal reflux disease, transverse duodenum, barrett esophagus, hiatal hernia, gastroscopy, endoscopy, hiatal, duodenum, esophagus, hernia,

HPI - WORKERS COMP:, The current problem began on or about 2/10/2000. The symptoms were sudden in onset. According to the patient, the current problem is a result of a work injury involving lifting approximately 40 pounds. Pain location (lower body): left hip. The patient describes the pain as dull, aching and stabbing. The severity of the pain ranges from mild to severe. The pain is severe occasionally. It is present constantly. The pain is made worse by sitting, riding in a car, twisting and lifting. The pain is made better by rest. The patient's symptoms appear to be soft tissue (spine), myofascial (spine) and musculoskeletal (spine) in origin. Sleep alteration because of pain: positive and wakes up after getting to sleep nightly. Systemic signs/symptoms relevant or potentially relevant to the spine: none. Patient reports the following symptoms: depressed mood, loss of interest or pleasure in all or most activities, insomnia, inability to concentrate, fatigue and loss of energy.,WORK STATUS:,nan

PREOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.,POSTOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion; finding of volar radial wrist mass of bulging inflammatory tenosynovitis from the volar radial wrist joint rather than a true ganglion cyst; synovitis was debrided and removed.,PROCEDURE: , Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist.,ANESTHESIA:, Axillary block plus IV sedation.,ESTIMATED BLOOD LOSS:, Zero.,SPECIMENS,1. Inflammatory synovitis from the volar radial wrist area.,2. Inflammatory synovitis from the dorsal wrist area.,DRAINS:, None.,PROCEDURE DETAIL: , Patient brought to the operating room. After induction of IV sedation a right upper extremity axillary block anesthetic was performed by anesthesia staff. Routine prep and drape was employed. Patient received 1 gm of IV Ancef preoperatively. Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet. Tourniquet inflated to 250 mmHg pressure. Hand positioned palm up in a lead hand-holder. A longitudinal zigzag incision over the volar radial wrist mass was made. Skin was sharply incised. Careful blunt dissection was used in the subcutaneous tissue. Antebrachial fascia was bluntly dissected and incised to reveal the radial artery. Radial artery was mobilized preserving its dorsal and palmar branches. Small transverse concomitant vein branches were divided to facilitate mobilization of the radial artery. Wrist mass was exposed by blunt dissection. This appeared to be an inflammatory arthritic mass from the volar radial wrist capsule. This was debrided down to the wrist capsule with visualization of the joint through a small capsular window. After complete volar synovectomy the capsular window was closed with 4-0 Mersilene figure-of-eight suture. Subcutaneous tissue was closed with 4-0 PDS and the skin was closed with a running subcuticular 4-0 Prolene. Forearm was pronated and C-arm image intensifier was used to confirm localization of the radial styloid for marking of the skin incision. An oblique incision overlying the radial styloid centered on the second extensor compartment was made. Skin was sharply incised. Blunt dissection was used in the subcutaneous tissue. Care was taken to identify and protect the superficial radial nerve. Blunt dissection was carried out in the extensor retinaculum. This was incised longitudinally over the second extensor compartment. EPL tendon was identified, mobilized and released to facilitate retraction and prevent injury. The interval between the ECRL and the ECRB was developed down to bone. Dorsal capsulotomy was made and local synovitis was identified. This was debrided and sent as second pathologic specimen. Articular surface of the scaphoid was identified and seen to be completely devoid of articular cartilage with hard, eburnated subchondral bone consistent with a SLAC pattern arthritis. Radial styloid had extensive spurring and was exposed subperiosteally and osteotomized in a dorsal oblique fashion preserving the volar cortex as the attachment point of the deep volar carpal ligament layer. Dorsally the styloidectomy was beveled smooth and contoured with a rongeur. Final x-rays documenting the styloidectomy were obtained. Local synovitis beneath the joint capsule was debrided. Remnants of the scapholunate interosseous which was completely deteriorated were debrided. The joint capsule was closed anatomically with 4-0 PDS and extensor retinaculum was closed with 4-0 PDS. Subcutaneous tissues closed with 4-0 Vicryl. Skin was closed with running subcuticular 4-0 Prolene. Steri-Strips were applied to wound edge closure; 10 cc of 0.5% plain Marcaine was infiltrated into the areas of the surgical incisions and radial styloidectomy for postoperative analgesia. A bulky gently compressive wrist and forearm bandage incorporating an EBI cooling pad were applied. Tourniquet was deflated. Good vascular color and capillary refill were seen to return to the tips of all digits. Patient discharged to the ambulatory recovery area and from there discharged home.,DISCHARGE PRESCRIPTIONS:,1. Keflex 500 mg tablets, #20, one PO q.6h. x 5 days.,2. Vicodin, 40 tablets, one to two PO q.4h. p.r.n.,3. Percocet, #20 tablets, one to two PO q.3-4h. p.r.n. severe pain.surgery, osteophytic, spurring, ganglion, synovitis, volar radial wrist mass, excision, inflammatory synovitis, radial styloidectomy, inflammatory, styloidectomy, volar, wrist, radial, mass

SUBJECTIVE:, Mom brings the patient in today for possible ear infection. He is complaining of left ear pain today. He was treated on 04/14/2004, with amoxicillin for left otitis and Mom said he did seem to get better but just started complaining of the left ear pain today. He has not had any fever but the congestion has continued to be very thick and purulent. It has never really resolved. He has a loose, productive-sounding cough but not consistently and not keeping him up at night. No wheezing or shortness of breath.,PAST MEDICAL HISTORY:, He has had some wheezing in the past but nothing recently.,FAMILY HISTORY: , All siblings are on antibiotics for ear infections and URIs.,OBJECTIVE:,General: The patient is a 5-year-old male. Alert and cooperative. No acute distress.,Neck: Supple without adenopathy.,HEENT: Ear canals clear. TMs, bilaterally, have distorted light reflexes but no erythema. Gray in color. Oropharynx pink and moist with a lot of postnasal discharge. Nares are swollen and red. Thick, purulent drainage. Eyes are a little puffy.,Chest: Respirations regular, nonlabored.,Lungs: Clear to auscultation throughout.,Heart: Regular rhythm without murmur.,Skin: Warm, dry, pink. Moist mucus membranes. No rash.,ASSESSMENT:, Ongoing purulent rhinitis. Probable sinusitis and serous otitis.,PLAN:, Change to Omnicef two teaspoons daily for 10 days. Frequent saline in the nose. Also, there was some redness around the nares with a little bit of yellow crusting. It appeared to be the start of impetigo, so hold off on the Rhinocort for a few days and then restart. Use a little Neosporin for now.consult - history and phy., ear infection, productive-sounding cough, purulent rhinitis, serous otitis, sinusitis, wheezing, ear, amoxicillin,

CONSTITUTIONAL:, Normal; negative for fever, weight change, fatigue, or aching.,HEENT:, Eyes normal; Negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects. Ears normal; Negative for hearing or balance problems. Nose normal; Negative for runny nose, sinus problems, or nosebleeds. Mouth normal; Negative for dental problems, dentures, or bleeding gums. Throat normal; Negative for hoarseness, difficulty swallowing, or sore throat.,CARDIOVASCULAR:, Normal; Negative for angina, previous MI, irregular heartbeat, heart murmurs, bad heart valves, palpitations, swelling of feet, high blood pressure, orthopnea, paroxysmal nocturnal dyspnea, or history of stress test, arteriogram, or pacemaker implantation.,PULMONARY: , Normal; Negative for cough, sputum, shortness of breath, wheezing, asthma, or emphysema.,GASTROINTESTINAL: , Normal; Negative for pain, vomiting, heartburn, peptic ulcer disease, change in stool, rectal pain, hernia, hepatitis, gallbladder disease, hemorrhoids, or bleeding.,GENITOURINARY:, Normal female OR male; Negative for incontinence, UTI, dysuria, hematuria, vaginal discharge, abnormal bleeding, breast lumps, nipple discharge, skin or nipple changes, sexually transmitted diseases, incontinence, yeast infections, or itching.,SKIN: , Normal; Negative for rashes, keratoses, skin cancers, or acne.,MUSCULOSKELETAL: , Normal; Negative for back pain, joint pain, joint swelling, arthritis, joint deformity, problems with ambulation, stiffness, osteoporosis, or injuries.,NEUROLOGIC: , Normal; Negative for blackouts, headaches, seizures, stroke, or dizziness.,PSYCHIATRIC: , Normal; Negative for anxiety, depression, or phobias.,ENDOCRINE:, Normal; Negative for diabetes, thyroid, or problems with cholesterol or hormones.,HEMATOLOGIC/LYMPHATIC: , Normal; Negative for anemia, swollen glands, or blood disorders.,IMMUNOLOGIC: , Negative; Negative for steroids, chemotherapy, or cancer.,VASCULAR:, Normal; Negative for varicose veins, blood clots, atherosclerosis, or leg ulcers.consult - history and phy., cough, sputum, shortness of breath, fever, weight, fatigue, aching, nose, throat, swelling, disease, incontinence, bleeding, heartbeat, blood, joint,

REASON FOR CONSULTATION:, Cardiac evaluation.,HISTORY: , This is a 42-year old Caucasian male with no previous history of hypertension, diabetes mellitus, rheumatic fever, rheumatic heart disease, or gout. Patient used to take medicine for hyperlipidemia and then that was stopped. He used to live in Canada and he moved to Houston four months ago. He started complaining of right-sided upper chest pain, starts at the right neck and goes down to the right side. It lasts around 10-15 minutes at times. It is 5/10 in quality. It is not associated with shortness of breath, nausea, vomiting, or sweating. It is not also associated with food. He denies exertional chest pain, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema. No palpitations, syncope or presyncope. He said he has been having little cough at night and he went to see an allergy doctor who prescribed several medications for him and told him that he has asthma. No fever, chills, cough, hemoptysis, hematemesis or hematochezia. His EKG shows normal sinus rhythm, normal EKG.,PAST MEDICAL HISTORY:, Unremarkable, except for hyperlipidemia.,SOCIAL HISTORY: , He said he quit smoking 20 years ago and does not drink alcohol.,FAMILY HISTORY: , Positive for high blood pressure and heart disease. His father died in his 50s with an acute myocardial infarction.,MEDICATION:, Ranitidine 300 mg daily, Flonase 50 mcg nasal spray as needed, Allegra 100 mg daily, Advair 500/50 bid.,ALLERGIES:, No known allergies.,REVIEW OF SYSTEMS:, As mentioned above,EXAMINATION:, This is a 42-year old male awake, alert, and oriented x3 in no acute distress.,Wt: 238nan

PREOPERATIVE DIAGNOSIS:, Right lateral epicondylitis.,POSTOPERATIVE DIAGNOSIS:, Right lateral epicondylitis.,OPERATION PERFORMED:, OssaTron extracorporeal shockwave therapy to right lateral epicondyle.,ANESTHESIA:, Bier block.,DESCRIPTION OF PROCEDURE: , With the patient under adequate Bier block anesthesia, the patient was positioned for extracorporeal shockwave therapy. The OssaTron equipment was brought into the field and the nose piece for treatment was placed against the lateral epicondyle targeting the area previously determined with the patient's input of maximum pain. Then using standard extracorporeal shockwave protocol, the OssaTron treatment was applied to the lateral epicondyle of the elbow. After completion of the treatment, the tourniquet was deflated, and the patient was returned to the holding area in satisfactory condition having tolerated the procedure well.surgery, epicondylitis, ossatron extracorporeal shockwave therapy, bier block, epicondyle, ossatron, extracorporeal, shockwave,

PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSES: , Dysphagia, possible stricture.,POSTOPERATIVE DIAGNOSIS: , Gastroparesis.,MEDICATION: , MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum. The hypopharynx was normal. The esophagus had a normal upper esophageal sphincter, normal contour throughout, and a normal gastroesophageal junction viewed at 39 cm from the incisors. There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair. There was no sign of reflux esophagitis. On entering the gastric lumen, a large bezoar of undigested food was seen occupying much of the gastric fundus and body. It had 2 to 3 mm diameter. This was broken up using a scope into smaller pieces. There was no retained gastric liquid. The antrum appeared normal and the pylorus was patent. The scope passed easily into the duodenum, which was normal through the second portion. On withdrawal of the scope, additional views of the cardia were obtained, and there was no evidence of any tumor or narrowing. The scope was withdrawn. The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Normal postoperative hernia repair.,2. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.,3. Otherwise normal upper endoscopy to the descending duodenum.,RECOMMENDATIONS:,1. Continue proton pump inhibitors.,2. Use Reglan 10 mg three to four times a day.gastroenterology

GROSS DESCRIPTION: , Specimen labeled "sesamoid bone left foot" is received in formalin and consists of three irregular fragments of grey-brown, hard, bony tissue admixed with multiple fragments of brown-tan, rubbery, fibrocollagenous, soft tissue altogether measuring 3.1 x 1.5 x 0.9 cm. The specimen is entirely submitted, after decalcification.,DIAGNOSIS:, Acute Osteomyelitis, with foci of marrow fibrosis.,Focal acute and chronic inflammation of fascia and soft tissue. Arteriosclerosis, severely occlusive.orthopedic, marrow fibrosis, osteomyelitis, arteriosclerosis, inflammation of fascia, specimen, fragmentsNOTE,: 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.

INDICATIONS:, Dysphagia.,PREMEDICATION:, Topical Cetacaine spray and Versed IV.,PROCEDURE:,: The scope was passed into the esophagus under direct vision. The esophageal mucosa was all unremarkable. There was no evidence of any narrowing present anywhere throughout the esophagus and no evidence of esophagitis. The scope was passed on down into the stomach. The gastric mucosa was all examined including a retroflexed view of the fundus and there were no abnormalities seen. The scope was then passed into the duodenum and the duodenal bulb and second and third portions of the duodenum were unremarkable. The scope was again slowly withdrawn through the esophagus and no evidence of narrowing was present. The scope was then withdrawn.,IMPRESSION:, Normal upper GI endoscopy without any evidence of anatomical narrowing.surgery, dysphagia, cetacaine spray, esophagus, esophageal mucosa, duodenum, scope was passed, upper gi, gi endoscopy, gi, endoscopy, scope

PROCEDURE PERFORMED: , Esophagogastroduodenoscopy performed in the emergency department.,INDICATION: , Melena, acute upper GI bleed, anemia, and history of cirrhosis and varices.,FINAL IMPRESSION,1. Scope passage massive liquid in stomach with some fresh blood near the fundus, unable to identify source due to gastric contents.,2. Endoscopy following erythromycin demonstrated grade I esophageal varices. No stigmata of active bleeding. Small amount of fresh blood within the hiatal hernia. No definite source of bleeding seen.,PLAN,1. Repeat EGD tomorrow morning following aggressive resuscitation and transfusion.,2. Proton-pump inhibitor drip.,3. Octreotide drip.,4. ICU bed.,PROCEDURE DETAILS: ,Prior to the procedure, physical exam was stable. During the procedure, vital signs remained within normal limits. Prior to sedation, informed consent was obtained. Risks, benefits, and alternatives including, but not limited to risk of bleeding, infection, perforation, adverse reaction to medication, failure to identify pathology, pancreatitis, and death explained to the patient and his wife, who accepted all risks. The patient was prepped in the left lateral position. IV sedation was given to a total of fentanyl 100 mcg and midazolam 4 mg for the initial EGD. An additional 50 mcg of fentanyl and 2 mg of midazolam were given following erythromycin. Scope tip of the Olympus gastroscope was passed into the esophagus. Proximal, middle, and distal thirds of the esophagus were well visualized. There was fresh blood in the esophagus, which was washed thoroughly, but no source was seen. No evidence of varices was seen. The stomach was entered. The stomach was filled with very large clot and fresh blood and liquid, which could not be suctioned due to the clot burden. There was a small amount of bright red blood near the fundus, but a source could not be identified due to the clot burden. Because of this, the gastroscope was withdrawn. The patient was given 250 mg of erythromycin in the Emergency Department and 30 minutes later, the scope was repassed. On the second look, the esophagus was cleared. The liquid gastric contents were cleared. There was still a moderate amount of clot burden in the stomach, but no active bleeding was seen. There was a small grade I esophageal varices, but no stigmata of bleed. There was also a small amount of fresh blood within the hiatal hernia, but no source of bleeding was identified. The patient was hemodynamically stable; therefore, a decision was made for a second look in the morning. The scope was withdrawn and air was suctioned. The patient tolerated the procedure well and was sent to recovery without immediate complications.surgery, gi bleed, anemia, cirrhosis, stomach, fundus, hiatal hernia, esophagogastroduodenoscopy, erythromycin, varices, esophagus,

CHIEF COMPLAINT:, Dog bite to his right lower leg.,HISTORY OF PRESENT ILLNESS:, This 50-year-old white male earlier this afternoon was attempting to adjust a cable that a dog was tied to. Dog was a German shepherd, it belonged to his brother, and the dog spontaneously attacked him. He sustained a bite to his right lower leg. Apparently, according to the patient, the dog is well known and is up-to-date on his shots and they wanted to confirm that. The dog has given no prior history of any reason to believe he is not a healthy dog. The patient himself developed a puncture wound with a flap injury. The patient has a flap wound also below the puncture wound, a V-shaped flap, which is pointing towards the foot. It appears to be viable. The wound is open about may be roughly a centimeter in the inside of the flap. He was seen by his medical primary care physician and was given a tetanus shot and the wound was cleaned and wrapped, and then he was referred to us for further assessment.,PAST MEDICAL HISTORY: ,Significant for history of pulmonary fibrosis and atrial fibrillation. He is status post bilateral lung transplant back in 2004 because of the pulmonary fibrosis.,ALLERGIES: ,There are no known allergies.,MEDICATIONS:, Include multiple medications that are significant for his lung transplant including Prograf, CellCept, prednisone, omeprazole, Bactrim which he is on chronically, folic acid, vitamin D, Mag-Ox, Toprol-XL, calcium 500 mg, vitamin B1, Centrum Silver, verapamil, and digoxin.,FAMILY HISTORY: , Consistent with a sister of his has ovarian cancer and his father had liver cancer. Heart disease in the patient's mother and father, and father also has diabetes.,SOCIAL HISTORY:, He is a non-cigarette smoker. He has occasional glass of wine. He is married. He has one biological child and three stepchildren. He works for ABCD.,REVIEW OF SYSTEMS:, He denies any chest pain. He does admit to exertional shortness of breath. He denies any GI or GU problems. He denies any bleeding disorders.,PHYSICAL EXAMINATION,GENERAL: Presents as a well-developed, well-nourished 50-year-old white male who appears to be in mild distress.,HEENT: Unremarkable.,NECK: Supple. There is no mass, adenopathy or bruit.,CHEST: Normal excursion.,LUNGS: Clear to auscultation and percussion.,COR: Regular. There is no S3 or S4 gallop. There is no obvious murmur.,ABDOMEN: Soft. It is nontender. Bowel sounds are present. There is no tenderness.,SKIN: He does have like a Chevron incisional scar across his lower chest and upper abdomen. It appears to be well healed and unremarkable.,GENITALIA: Deferred.,RECTAL: Deferred.,EXTREMITIES: He has about 1+ pitting edema to both legs and they have been present since the surgery. In the right leg, he has an about midway between the right knee and right ankle on the anterior pretibial area, he has a puncture wound that measures about may be centimeter around that appears to be relatively clean, and just below that about may be 3 cm below, he has a flap traumatic injury that measures about may be 4 cm to the point of the flap. The wound is spread apart about may be a centimeter all along that area and it is relatively clean. There was some bleeding when I removed the dressing and we were able to pretty much control that with pressure and some silver nitrate. There were exposed subcutaneous tissues, but there was no exposed tendons that we could see, etc. The flap appeared to be viable.,NEUROLOGIC: Without focal deficits. The patient is alert and oriented.,IMPRESSION:, A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago. He is on multiple medications and he is on chronic Bactrim. We are going to also add some fluoroquinolone right now to protect the skin and probably going to obtain an Infectious Disease consult. We will see him back in the office early next week to reassess his wound. He is to keep the wound clean with the moist dressing right now. He may shower several times a day.nan

PREOPERATIVE DIAGNOSES:,1. Plantar flex third metatarsal, right foot.,2. Talus bunion, right foot.,POSTOPERATIVE DIAGNOSES:,1. Plantar flex third metatarsal, right foot.,2. Talus bunion, right foot.,PROCEDURE PERFORMED:,1. Third metatarsal osteotomy, right foot.,2. Talus bunionectomy, right foot.,3. Application of short-leg cast, right foot.,ANESTHESIA: , TIVA/local.,HISTORY: ,This 31-year-old female presents to ABCD Preoperative Holding Area after keeping herself n.p.o., since mid night for surgery on her painful right third plantar flex metatarsal. In addition, she complains of a painful right talus bunion to the right foot. She has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief. At this time she desires to attempt a surgical correction. The risks versus benefits of the procedure have been explained to the patient by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: ,After IV was established by the Department Of Anesthesia, the patient was taken to the operating room via cart. She was placed on the operating table in supine position and a safety strap was placed across her waist for retraction. Next, copious amounts of Webril were applied around the right ankle and a pneumatic ankle tourniquet was applied.,Next, after adequate IV sedation was administered by the Department Of Anesthesia, a total of 10 cc mixture of 4.5 cc of 1% lidocaine/4.5 cc of 0.5% Marcaine/1 cc of Kenalog was injected into the right foot in an infiltrative type block. 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. Next, the foot was lowered in the operative field and attention was directed to the dorsal third metatarsal area. There was a plantar hyperkeratotic lesion and a plantar flex palpable third metatarsal head. A previous cicatrix was noted with slight hypertrophic scarring. Using a #10 blade, a lazy S-type incision was created over the dorsal aspect of the third metatarsal, approximately 3.5 cm in length. Two semi-elliptical converging incisions were made over the hypertrophic scar and it was removed and passed off as a specimen. Next, the #15 blade was used to deepen the incision down to the subcutaneous tissue. Any small traversing veins were ligated with electrocautery. Next, a combination of blunt and sharp dissection were used to undermine the long extensor tendon, which was tacked down with a moderate amount of fibrosis and fibrotic scar tissue. Next, the extensor tendon was retracted laterally and the deep fascia over the metatarsals was identified. A linear incision down to bone was made with a #15 blade to the capsuloperiosteal tissues. Next, the capsuloperiosteal tissues were elevated using a sharp dissection with a #15 blade, off of the third metatarsal. McGlamry elevator was carefully inserted around the head of the metatarsal and freed and all the plantar adhesions were freed. A moderate amount of plantar adhesions were encountered. The third toe was plantar flex and the third metatarsal was delivered into the wound. Next, a V-shaped osteotomy with an apex distally was created using a sagittal saw. The metatarsal head was allowed to float. The wound was flushed with copious amounts of sterile saline. #3-0 Vicryl was used to close the capsuloperiosteal tissues, which kept the metatarsal head contained. Next, #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted suture technique. Next, #4-0 nylon was used to close the skin in a simple interrupted technique.,Attention was directed to the right fifth metatarsal. There was a large palpable hypertrophic prominence, which is the area of maximal pain, which the patient complained of preoperatively. A #10 blade was used to make a 3 cm incision through the skin. Next, a #15 blade was used to deepen the incision through the subcutaneous tissue. Next, the medial and lateral aspects were undermined. The abductor tendon was identified and retracted. A capsuloperiosteal incision was made with a #15 blade in a linear fashion down to the bone. The capsuloperiosteal tissues were elevated off the bone with a Freer elevator and a #15 blade.,Next, the sagittal saw was used to resect the large hypertrophic dorsal exostosis. A reciprocating rasp was used to smooth all bony prominences. The wound was flushed with copious amount of sterile saline. #3-0 Vicryl was used to close the capsuloperiosteal tissues. #4-0 Vicryl was used to close subcutaneous layer with a simple interrupted suture. Next, #4-0 nylon was used to close the skin in a simple interrupted technique. Next, attention was directed to the plantar aspect of the third metatarsal where a bursal sac was felt to be palpated under the plantar flex third metatarsal head. A #15 blade was used to make a small linear incision under the third metatarsal head. The incision was deepened through the dermal layer and curved hemostats and Metzenbaum scissors were used to undermine the skin from the underlying bursa. The wound was flushed and two simple interrupted sutures with #4-0 nylon were applied.,Standard postoperative dressing was applied consisting of Xeroform, 4x4s, Kerlix, Kling, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,A sterile stockinet was placed on the toes just below the knee. Copious amounts of Webril were placed on all bony prominences. 3 inch and 4 inch fiberglass cast tape was used to create a below the knee well-padded, well-moulded cast. One was able to insert two fingers to the distal and proximal aspects of the _cast. The capillary refill time to the digits was less than three seconds after cast application. The patient tolerated the above anesthesia and procedures without complications. She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot. She was given standard postoperative instructions to rest, ice and elevate her right foot. She was counseled on smoking cessation. She was given Vicoprofen #30 1 p.o. q.4-6h p.r.n., pain. She was given Keflex #30 1 p.o. t.i.d. She is to follow up with Dr. X on Monday. She is to be full weightbearing with a cast boot. She was given emergency contact numbers to call us if problem arises.surgery, plantar flex, talus bunion, talus bunionectomy, metatarsal osteotomy, osteotomy, short-leg cast, hypertrophic scarring, subcutaneous tissue, sharp dissection, linear incision, foot talus, pneumatic ankle, capsuloperiosteal tissues, plantar, foot, metatarsal, capsuloperiosteal, bunionectomy

CC: ,Bilateral lower extremity numbness.,HX: ,21 y/o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11/5/96. The symptoms became maximal over a 12-24 hour period and have not changed since. The symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally. He noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space. He denied bowel/bladder problems, or weakness or numbness elsewhere. Hot showers may improve his symptoms. He has suffered no recent flu-like illness. Past medical and family histories are unremarkable. He was on no medications.,EXAM:, Unremarkable except for mild distal vibratory sensation loss in the toes (R>L).,LAB:, CBC, Gen Screen, TSH, FT4, SPE, ANA were all WNL.,MRI L-SPINE:, Normal.,COURSE:, Normal exam and diminished symptoms at following visit 4/23/93.neurology, bilateral lower extremity numbness, mri l spine, bilateral lower extremity, lower extremity numbness, bilateral, spine, mri, extremities, numbness

ADMITTING DIAGNOSES:, Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity.,HISTORY OF PRESENTING ILLNESS: , The baby is an ex-32 weeks small for gestational age infant with birth weight 1102. Baby was born at ABCD Hospital at 1333 on 07/14/2006. Mother is a 20-year-old gravida 1, para 0 female who received prenatal care. Prenatal course was complicated by low amniotic fluid index and hypertension. She was evaluated for evolving preeclampsia and had a C-section secondary to the nonreassuring fetal status. Baby delivered operatively, Apgar scores were 8 and 9 initially taken to level 2 satellite nursery and arrangements were to transfer to Children's Hospital. Infant was transferred to Children's Hospital for higher level of care, stayed at Children's Hospital for approximately 2 weeks, and was transferred back to ABCD where he stayed until he was discharged on 08/16/2006.,HOSPITAL COURSE: , At the time of transfer to ABCD, these were the following issues.,FEEDING AND NUTRITION: , Baby was on TPN and p.o. feeds had been started and were advanced 1 ml q.6h. Baby was tolerating p.o. feeds of expressed breast milk and baby began to experience some abdominal distention. The p.o. feeds were held and IV D10 water was given. Baby was started on Mylicon drops and glycerin suppositories. Abdominal ultrasound showed gaseous distention without signs of obstruction. OG tube was passed. Baby improved after couple of days when p.o. feedings were restarted. Baby was also given Reglan. At the time of discharge, baby was tolerating p.o. feeds well of BM fortified with 22-cal NeoSure. Feeding amounts at the time of discharge was between 35 to 50 mL per feed and weight was 1797 grams.,RESPIRATIONS: , At the time of admission, baby was not having any apnea spells, no bradycardia or desaturations, was saturating well on room air and continued to do well on room air until the time of discharge.,HYPOGLYCEMIA: , Baby began to experience hypoglycemic episodes on 07/24/2006. Blood glucose level was as low as 46. D10 was given initially as bolus. Baby continued to experience hypoglycemic episodes. Diazoxide was started 5 mg/kg per os every 8 hours and fingersticks were done to monitor blood glucose level. The baby improved with diazoxide, hypoglycemic issues resolved and then began again. Diazoxide was discontinued, but the hypoglycemic issues restarted. The Diazoxide was restarted again. Blood glucose level stabilized and then diazoxide was weaned off until daily dose of 6 mg/kg and then the diazoxide was discontinued. At the time of discharge, blood glucose levels were not being stable for 24 hours.,CARDIOVASCULAR: , Infant was hemodynamically stable on admission from Madera. Infant has a closed PDA. Infant had two cardiac echograms done. The lab showing normal antegrade flow across the right coronary artery as well as the left main and left anterior descending coronary artery, then the circumflex coronary artery.,CNS:, Infant had a head ultrasound done to rule out intracranial abnormalities and intracranial hemorrhage. The ultrasound was negative for intracranial hemorrhage.,INFECTIOUS DISEASE:, The patient had been on antibiotics during the stay at Madera. At the time of admission to the ABCD, the patient was not on any antibiotics and his clinically condition has remained stable.,HEMATOLOGY: , The patient is status post phototherapy at Madera and was started on iron.,OPHTHALMOLOGY: , Exam on 07/17/2006 showed immature retina. The patient is to get followup exam after discharge.,DISCHARGE DIAGNOSIS: , Stable ex-32-weeks preemie.,DISCHARGE INSTRUCTIONS: , The patient has been educated on CPR measures. Followup appointment has been made at Kid's Care. Calcium challenge has been done. The patient's parents are comfortable with feeding. The patient has been discharged on NeoSure and expressed breast milk.,discharge summary, delivered, preeclampsia, immaturity, intrauterine, prenatal, coronary artery, blood glucose, discharge, baby, coronary, intracranial, hypoglycemia, hypoglycemic, infant,

REASON FOR VISIT:, Syncope.,HISTORY:, The patient is a 75-year-old lady who had a syncopal episode last night. She went to her room with a bowl of cereal and then blacked out for a few seconds and then when she woke up, the cereal was on the floor. She did not have any residual deficit. She had a headache at that time. She denies chest pains or palpitations.,PAST MEDICAL HISTORY: , Arthritis, first episode of high blood pressure today. She had a normal stress test two years ago.,MEDICATIONS: , Her medication is one dose of hydrochlorothiazide today because her blood pressure was so high at 150/70.,SOCIAL HISTORY: , She does not smoke and she does not drink. She lives with her daughter.,PHYSICAL EXAMINATION:,GENERAL: Lady in no distress.,VITAL SIGNS: Blood pressure 172/91, came down to 139/75, heart rate 91, and respirations 20. Afebrile.,HEENT: Head is normal.,NECK: Supple.,LUNGS: Clear to auscultation and percussion.,HEART: No S3, no S4, and no murmurs.,ABDOMEN: Soft.,EXTREMITIES: Lower extremities, no edema.,DIAGNOSTIC DATA: , Her EKG shows sinus rhythm with nondiagnostic Q-waves in the inferior leads.,ASSESSMENT: ,Syncope.,PLAN: ,She had a CT scan of the brain that was negative today. The blood pressure is high. We will start Maxzide. We will do an outpatient Holter and carotid Doppler study. She has had an echocardiogram along with the stress test before and it was normal. We will do an outpatient followup.consult - history and phy., residual deficit, headache, ct scan, syncopal episode, stress test, blood pressure, syncope,

VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE:, Alert and in no apparent distress, calm, cooperative, and communicative.,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 bilaterally clear to auscultation and percussion.,HEART: , S1 and S2. Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop. PMI nondisplaced. Chest wall unremarkable to inspection and palpation. No axillary or supraclavicular adenopathy detected.,BREASTS:, In the seated and supine position unremarkable.,ABDOMEN: , No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding. No widening of the aortic impulse and no intraabdominal bruit auscultated.,EXTERNAL GENITALIA: , Normal for age.,RECTAL: , Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis. Nails of the hands and feet, and creases of the palms and soles are unremarkable. Good active and passive range of motion of all major joints.,BACK:, Normal to inspection and percussion. Negative for spinous process tenderness or CVA tenderness. Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC:, Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function. Affect is normal. Speech is clear and fluent. Thought process is lucid and rational. Gait and station are unremarkable.,SKIN: , Unremarkable for any premalignant or malignant condition with normal changes for age.general medicine, heent, general appearance, hepatosplenomegaly, mass, tenderness, rebound, rigidity, pulse, bruit, adenopathy, chest, percussion, inspection, palpation, signs, tongue,

SUBJECTIVE:, Mom brings the patient in today for possible ear infection. He is complaining of left ear pain today. He was treated on 04/14/2004, with amoxicillin for left otitis and Mom said he did seem to get better but just started complaining of the left ear pain today. He has not had any fever but the congestion has continued to be very thick and purulent. It has never really resolved. He has a loose, productive-sounding cough but not consistently and not keeping him up at night. No wheezing or shortness of breath.,PAST MEDICAL HISTORY:, He has had some wheezing in the past but nothing recently.,FAMILY HISTORY: , All siblings are on antibiotics for ear infections and URIs.,OBJECTIVE:,General: The patient is a 5-year-old male. Alert and cooperative. No acute distress.,Neck: Supple without adenopathy.,HEENT: Ear canals clear. TMs, bilaterally, have distorted light reflexes but no erythema. Gray in color. Oropharynx pink and moist with a lot of postnasal discharge. Nares are swollen and red. Thick, purulent drainage. Eyes are a little puffy.,Chest: Respirations regular, nonlabored.,Lungs: Clear to auscultation throughout.,Heart: Regular rhythm without murmur.,Skin: Warm, dry, pink. Moist mucus membranes. No rash.,ASSESSMENT:, Ongoing purulent rhinitis. Probable sinusitis and serous otitis.,PLAN:, Change to Omnicef two teaspoons daily for 10 days. Frequent saline in the nose. Also, there was some redness around the nares with a little bit of yellow crusting. It appeared to be the start of impetigo, so hold off on the Rhinocort for a few days and then restart. Use a little Neosporin for now.general medicine, ear infection, productive-sounding cough, purulent rhinitis, serous otitis, sinusitis, wheezing, ear, amoxicillin,

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.discharge summary, musculoskeletal strain, occupational therapy, traumatic, brain, cervical, musculoskeletal, rehabilitation,

HISTORY OF PRESENT ILLNESS: ,This 59-year-old white male is seen for comprehensive annual health maintenance examination on 02/19/08, although this patient is in excellent overall health. Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change, dyslipidemia well controlled with niacin, history of hemorrhoids with occasional external bleeding, although no problems in the last 6 months, and also history of concha bullosa of the left nostril, followed by ENT associated with slight septal deviation. There are no other medical problems. He has no symptoms at this time and remains in excellent health.,PAST MEDICAL HISTORY: , Otherwise noncontributory. There is no operation, serious illness or injury other than as noted above.,ALLERGIES: , There are no known allergies.,FAMILY HISTORY: , Father died of an MI at age 67 with COPD and was a heavy smoker. His mother is 88, living and well, status post lung cancer resection. Two brothers, living and well. One sister died at age 20 months of pneumonia.,SOCIAL HISTORY:, The patient is married. Wife is living and well. He jogs or does Cross Country track 5 times a week, and weight training twice weekly. No smoking or significant alcohol intake. He is a physician in allergy/immunology.,REVIEW OF SYSTEMS:, Otherwise noncontributory. He has no gastrointestinal, cardiopulmonary, genitourinary or musculoskeletal symptomatology. No symptoms other than as described above.,PHYSICAL EXAMINATION:,GENERAL: He appears alert, oriented, and in no acute distress with excellent cognitive function. VITAL SIGNS: His height is 6 feet 2 inches, weight is 181.2, blood pressure is 126/80 in the right arm, 122/78 in the left arm, pulse rate is 68 and regular, and respirations are 16. SKIN: Warm and dry. There is no pallor, cyanosis or icterus. HEENT: Tympanic membranes benign. The pharynx is benign. Nasal mucosa is intact. Pupils are round, regular, and equal, reacting equally to light and accommodation. EOM intact. Fundi reveal flat discs with clear margins. Normal vasculature. No hemorrhages, exudates or microaneurysms. No thyroid enlargement. There is no lymphadenopathy. LUNGS: Clear to percussion and auscultation. Normal sinus rhythm. No premature beat, murmur, S3 or S4. Heart sounds are of good quality and intensity. The carotids, femorals, dorsalis pedis, and posterior tibial pulsations are brisk, equal, and active bilaterally. ABDOMEN: Benign without guarding, rigidity, tenderness, mass or organomegaly. NEUROLOGIC: Grossly intact. EXTREMITIES: Normal. GU: Genitalia normal. There are no inguinal hernias. There are mild hemorrhoids in the anal canal. The prostate is small, if any normal to mildly enlarged with discrete margins, symmetrical without significant palpable abnormality. There is no rectal mass. The stool is Hemoccult negative.,IMPRESSION:,1. Comprehensive annual health maintenance examination.,2. Dyslipidemia.,3. Tinnitus, left ear.,4. Hemorrhoids.,PLAN:, At this time, continue niacin 1000 mg in the morning, 500 mg at noon, and 1000 mg in the evening; aspirin 81 mg daily; multivitamins; vitamin E 400 units daily; and vitamin C 500 mg daily. Consider adding lycopene, selenium, and flaxseed to his regimen. All appropriate labs will be obtained today. Followup fasting lipid profile and ALT in 6 months.consult - history and phy., tinnitus, dyslipidemia, annual health maintenance, health, hemorrhoids, benign

CHIEF COMPLAINT: , Jaw pain.,HISTORY OF PRESENT ILLNESS: ,This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear. Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, but has not seen a dentist since this new toothache began. The patient denies any facial swelling. No headache. No swelling to the throat. No sore throat. No difficulty swallowing liquids or solids. No neck pain. No lymph node swelling. The patient denies any fever or chills. Denies any other problems or complaints.,REVIEW OF SYSTEMS:, CONSTITUTIONAL: No fever or chills. No fatigue or weakness. HEENT: No headache. No neck pain. No eye pain or vision change. No rhinorrhea. No sinus congestion, pressure, or pain. No sore throat. No throat swelling. The patient does have the toothache on the left lower side that radiates towards his left ear as previously described. The patient does not have ear pain or hearing change. No pressure in the ear. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath. GASTROINTESTINAL: No nausea or vomiting. No abdominal pain. MUSCULOSKELETAL: No back pain. SKIN: No rashes or lesions. NEUROLOGIC: No vision or hearing change. No speech change. HEMATOLOGIC/LYMPHATIC: No lymph node swelling.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY:, None.,CURRENT MEDICATIONS: , None.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient smokes marijuana. The patient does not smoke cigarettes.,PHYSICAL EXAMINATION: , VITAL SIGNS: Temperature 98.2 oral, blood pressure is 168/84, pulse is 87, respirations 16, and oxygen saturation is 100% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished, well developed. The patient appears to be healthy. The patient is calm, comfortable in no acute distress, looks well. The patient is pleasant and cooperative. HEENT: Head is atraumatic, normocephalic, and nontender. Eyes are normal with clear cornea and conjunctivae bilaterally. Nose, normal without rhinorrhea or audible congestion. There is no tenderness over the sinuses. Ears are normal without any sign of infection. No erythema or swelling of the canals. Tympanic membranes are intact and normal without any erythema, bulging, air fluid levels, or bubbles behind it. MOUTH: The patient has a dental fracture at tooth #18. The patient states that the fracture is a couple of months old. The patient does not have any obvious dental caries. The gums are normal without any erythema, swelling, or evidence of infection. There is no fluctuance or suggestion of abscess. There is slight tenderness of the tooth #18. The oropharynx is normal without any sign of infection. There is no erythema, exudate, lesion, or swelling. Mucous membranes are moist. Floor of the mouth is normal without any tenderness or swelling. No suggestion of abscess. There is no pre or post auricular lymphadenopathy either. NECK: Supple. Nontender. Full range of motion. No meningismus. No cervical lymphadenopathy. No JVD. No carotid artery or vertebral artery bruits. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub, or gallop. RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. GASTROINTESTINAL: Abdomen is normal and nontender. MUSCULOSKELETAL: No abnormalities are noted to the back, arms, or legs. The patient has normal use of the extremities. SKIN: No rashes or lesions. NEUROLOGIC: Cranial nerves II through XII are intact. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. No evidence of clinical intoxification. HEMATOLOGIC/LYMPHATIC: No lymphadenitis is palpated.,DIAGNOSES:,1. ACUTE LEFT JAW PAIN.,2. #18 DENTAL FRACTURE, WHICH IS AN ELLIS TYPE II FRACTURE.,3. ELEVATED BLOOD PRESSURE.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:, Home.,PLAN: , We will have the patient follow up with his dentist Dr. X in three to five days for reevaluation. The patient was encouraged to take Motrin 400 mg q.6h. as needed for pain. The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain. He was given precautions for drowsiness and driving with the use of this medication. The patient was also given a prescription for pen V. The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition, develop any other problems or symptoms of concern.emergency room reports, jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema,

CHRONIC SNORING,Chronic snoring in children can be associated with obstructive sleep apnea or upper airway resistant syndrome. Both conditions may lead to sleep fragmentation and/or intermittent oxygen desaturation, both of which have significant health implications including poor sleep quality and stress on the cardiovascular system. Symptoms like daytime somnolence, fatigue, hyperactivity, behavior difficulty (i.e., ADHD) and decreased school performance have been reported with these conditions. In addition, the most severe cases may be associated with right ventricular hypertrophy, pulmonary and/or systemic hypertension and even cor pulmonale.,In this patient, the risks for a sleep-disordered breathing include obesity and the tonsillar hypertrophy. It is therefore indicated and medically necessary to perform a polysomnogram for further evaluation. A two week sleep diary will be given to the parents to fill out daily before the polysomnogram is performed.sleep medicine, snoring, chronic snoring, behavior difficulty, fatigue, hyperactivity, obstructive sleep apnea, oxygen, oxygen desaturation, polysomnogram, poor sleep quality, right ventricular hypertrophy, school performance, sleep fragmentation, somnolence, systemic hypertension, upper airway, upper airway resistant syndrome, snoring chronic, hypertrophy, sleepNOTE,: 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.

REASON FOR VISIT:, Six-month follow-up visit for CAD.,He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.,He has been having a lot of pain in his back and pain in his left knee. He is also having trouble getting his nerves under control. He is having stomach pains and occasional nausea. His teeth are bad and need to be pulled.,He has been having some chest pains, but overall he does not sound too concerning. He does note some more shortness of breath than usual. He has had no palpitations or lightheadedness. No problems with edema.,MEDICATIONS:, Lipitor 40 mg q.d., metoprolol 25 mg b.i.d., Plavix 75 mg q.d-discontinued, enalapril 10 mg b.i.d., aspirin 325 mg-reduced to 81 mg, Lorcet 10/650-given a 60 pill prescription, and Xanax 0.5 mg b.i.d-given a 60 pill prescription.,REVIEW OF SYSTEMS: , Otherwise unremarkable.,PEX:, BP: 140/78. HR: 65. WT: 260 pounds (which is up one pound). There is no JVD. No carotid bruit. Cardiac: Regular rate and rhythm and distant heart sounds with a 1/6 murmur at the upper sternal border. Lungs: Clear. Abdomen: Mildly tender throughout the epigastrium.,Extremities: No edema.,EKG:, Sinus rhythm, left axis deviation, otherwise unremarkable.,Echocardiogram (for dyspnea and CAD): Normal systolic and diastolic function. Moderate LVH. Possible gallstones seen.,IMPRESSION:,1. CAD-Status post anterior wall MI 07/07 and was found to a have multivessel CAD. He has a stent in his LAD and his obtuse marginal. Fairly stable.,2. Dyspnea-Seems to be due to his weight and the disability from his knee. His echocardiogram shows no systolic or diastolic function.,3. Knee pain-We well refer to Scotland Orthopedics and we will refill his prescription for Lorcet 60 pills with no refills.,4. Dyslipidemia-Excellent numbers today with cholesterol of 115, HDL 45, triglycerides 187, and LDL 33, samples of Lipitor given.,5. Panic attacks and anxiety-Xanax 0.5 mg b.i.d., 60 pills with no refills given.,6. Abdominal pain-Asked to restart his omeprazole and I am also going to reduce his aspirin to 81 mg q.d.,7. Prevention-I do not think he needs to be on the Plavix any more as he has been relatively stable for two years.,PLAN:,1. Discontinue Plavix.,2. Aspirin reduced to 81 mg a day.,3. Lorcet and Xanax prescriptions given.,4. Refer over to Scotland Orthopedics.,5. Peridex mouthwash given for his poor dentition and told he was cardiovascularly stable and have his teeth extracted.

CHIEF COMPLAINT:, Newly diagnosed mantle cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old woman who presented with abdominal pain in September 2006. On chest x-ray, she had a possible infiltrate and it was thought she might have pneumonia and she was treated with antibiotics and prednisone. Symptoms improved temporarily, but did not completely resolve. By the end of September, her pain had worsened and she was seen in the emergency room at ABC. Chest x-ray was compatible with pleurisy and she was treated with Percocet. Few days later, she was seen and given a prescription for Ultram because Percocet was causing nausea. Eventually, she was seen by Dr. X and noted to have splenomegaly. Repeat ultrasound was done and showed the spleen enlarged at 19 cm. In retrospect, this was not changed in comparison to an ultrasound that was done in September. She underwent positron emission tomography (PET) scanning, which showed diffuse hypermetabolic lymph nodes measuring 1 to 2 cm in diameter, as well as a hypermetabolic spleen that was enlarged.,The patient underwent lymph node biopsy on the right neck on 10/27/2006. Pathology is consistent with mantle cell lymphoma.,On 10/31/2006, she had a bone marrow biopsy. This does show involvement of bone marrow with lymphoma.,She was noted to have circulating lymphoma cells on peripheral smear as well.,Although CBC was normal, MCV was low and the ferritin was assessed and was low at 8, consistent with iron deficiency.,ALLERGIES:, NONE.,MEDICATIONS: ,1. Estradiol/Prometrium. ,2. Ultram p.r.n. ,3. Baby aspirin. ,4. Lunesta for sleep. ,5. She has been started on iron supplements.,PAST MEDICAL HISTORY: ,1. Tubal ligation in 1986.,2. Possible cyst removed from the left neck in 1991.,3. Tonsillectomy.,4. Migraines, which are rare.,SOCIAL HISTORY: , She does not smoke cigarettes and drinks alcohol only occasionally. She is married and has two children, ages 24 and 20. She works as a project administrator.,FAMILY HISTORY: ,Father is deceased. He had emphysema and colon cancer at age 68. Mother has arrhythmia and hypertension. Her sister has hypertension and her brother is healthy.,PHYSICAL EXAMINATION: ,GENERAL: She is in no acute distress.,VITAL SIGNS: Her weight is 168 pounds, and she is afebrile with a normal blood pressure and pulse.,HEENT: The oropharynx is benign.,SKIN: The skin is warm and dry and shows no jaundice.,NECK: There is shotty adenopathy in the neck.,CARDIAC: Regular rate without murmur.,LUNGS: Clear to auscultation bilaterally.,ABDOMEN: Soft and nontender and shows the spleen palpable about 10 cm below the right costal margin.,EXTREMITIES: No peripheral edema is noted.,LABORATORY DATA: , CBC and chemistry panel are pending. CBC was normal last week. PT/INR was normal as well.,IMPRESSION:, Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy. She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone. Toxicities have already been discussed with her including myelosuppression, mucositis, diarrhea, nausea, alopecia, the low risk for cardiac toxicity, bladder toxicity, neuropathy, constipation, etc. Written materials were provided to her last week.,PLAN: , Plan will be to add Rituxan a little later in her course because she has circulating lymphoma cells. She will be started on allopurinol today as well as hydration further to avoid the possibility of tumor lysis syndrome.,Plan will be to have her evaluated for bone marrow transplant in first remission. I will have Dr. Y see her while she is in the hospital.,The patient is anxious, and will be given Ativan as needed. We will discontinue aspirin for now, but continue estradiol/Prometrium.,Iron deficiency will be treated with oral iron supplements and we will follow her counts. She may well have gastrointestinal (GI) involvement, which is not uncommon with mantle cell lymphoma. After she undergoes remission, we will consider colonoscopy for biopsies prior to proceeding to transplant.nan

ADMITTING DIAGNOSIS:, Abscess with cellulitis, left foot.,DISCHARGE DIAGNOSIS:, Status post I&D, left foot.,PROCEDURES:, Incision and drainage, first metatarsal head, left foot with culture and sensitivity.,HISTORY OF PRESENT ILLNESS:, The patient presented to Dr. X's office on 06/14/07 complaining of a painful left foot. The patient had been treated conservatively in office for approximately 5 days, but symptoms progressed with the need of incision and drainage being decided.,MEDICATIONS:, Ancef IV.,ALLERGIES:, ACCUTANE.,SOCIAL HISTORY:, Denies smoking or drinking.,PHYSICAL EXAMINATION: , Palpable pedal pulses noted bilaterally. Capillary refill time less than 3 seconds, digits 1 through 5 bilateral. Skin supple and intact with positive hair growth. Epicritic sensation intact bilateral. Muscle strength +5/5, dorsiflexors, plantar flexors, invertors, evertors. Left foot with erythema, edema, positive tenderness noted, left forefoot area.,LABORATORY: , White blood cell count never was abnormal. The remaining within normal limits. X-ray is negative for osteomyelitis. On 06/14/07, the patient was taken to the OR for incision and drainage of left foot abscess. The patient tolerated the procedure well and was admitted and placed on vancomycin 1 g q.12h after surgery and later changed Ancef 2 g IV every 8 hours. Postop wound care consists of Aquacel Ag and dry dressing to the surgical site everyday and the patient remains nonweightbearing on the left foot. The patient progressively improved with IV antibiotics and local wound care and was discharged from the hospital on 06/19/07 in excellent condition.,DISCHARGE MEDICATIONS: , Lorcet 10/650 mg, dispense 24 tablets, one tablet to be taken by mouth q.6h as needed for pain. The patient was continued on Ancef 2 g IV via PICC line and home health administration of IV antibiotics.,DISCHARGE INSTRUCTIONS: , Included keeping the foot elevated with long periods of rest. The patient is to wear surgical shoe at all times for ambulation and to avoid excessive ambulation. The patient to keep dressing dry and intact, left foot. The patient to contact Dr. X for all followup care, if any problems arise. The patient was given written and oral instruction about wound care before discharge. Prior to discharge, the patient was noted to be afebrile. All vitals were stable. The patient's questions were answered and the patient was discharged in apparent satisfactory condition. Followup care was given via Dr. X' office.discharge summary, accutane, metatarsal head left foot, abscess with cellulitis, culture and sensitivity, incision and drainage, metatarsal head, foot, cellulitis, ancef, abscess, incision, drainage,

EXAM: , Three views of the right ankle.,INDICATIONS: ,Pain.,FINDINGS: , Three views of the right ankle are obtained. There is no evidence of fractures or dislocations. No significant degenerative changes or destructive osseous lesions of the ankle are noted. There is a small plantar calcaneal spur. There is no significant surrounding soft tissue swelling.,IMPRESSION: ,Negative right ankle.orthopedic, three views, calcaneal, plantar, spur, osseous, ankle

PREOPERATIVE DIAGNOSIS:, Refractory urgency and frequency.,POSTOPERATIVE DIAGNOSIS: , Refractory urgency and frequency.,OPERATION: , Stage I and II neuromodulator.,ANESTHESIA: , Local MAC.,ESTIMATED BLOOD LOSS:, Minimal.,FLUIDS: , Crystalloid. The patient was given Ancef preop antibiotic. Ancef irrigation was used throughout the procedure.,BRIEF HISTORY: , The patient is a 63-year-old female who presented to us with urgency and frequency on physical exam. There was no evidence of cystocele or rectocele. On urodyanamcis, the patient has significant overactivity of the bladder. The patient was tried on over three to four different anticholinergic agents such as Detrol, Ditropan, Sanctura, and VESIcare for at least one month each. The patient had pretty much failure from each of the procedure. The patient had less than 20% improvement with anticholinergics. Options such as continuously trying anticholinergics, continuation of the Kegel exercises, and trial of InterStim were discussed. The patient was interested in the trial. The patient had percutaneous InterStim trial in the office with over 70% to 80% improvement in her urgency, frequency, and urge incontinence. The patient was significantly satisfied with the results and wanted to proceed with stage I and II neuromodulator. Risks of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed. Risk of failure of the procedure in the future was discussed.,Risk of lead migration that the treatment may or may not work in the long-term basis and data on the long term were not clear were discussed with the patient. The patient understood and wanted to proceed with stage I and II neuromodulator. Consent was obtained.,DETAILS OF THE OPERATION: , The patient was brought to the OR. The patient was placed in prone position. A pillow was placed underneath her pelvis area to slightly lift the pelvis up. The patient was awake, was given some MAC anesthesia through the IV, but the patient was talking and understanding and was able to verbalize issues. The patient's back was prepped and draped in the usual sterile fashion. Lidocaine 1% was applied on the right side near the S3 foramen. Under fluoroscopy, the needle placement was confirmed. The patient felt stimulation in the vaginal area, which was tapping in nature. The patient also had a pressure feeling in the vaginal area. The patient had no back sensation or superficial sensation. There was no sensation down the leg. The patient did have __________, which turned in slide bellows response indicating the proper positioning of the needle. A wire was placed. The tract was dilated and lead was placed. The patient felt tapping in the vaginal area, which is an indication that the lead is in its proper position. Most of the leads had very low amplitude and stimulation. Lead was tunneled under the skin and was brought out through an incision on the left upper buttocks. Please note that the lidocaine was injected prior to the tunneling. A pouch was created about 1 cm beneath the subcutaneous tissue over the muscle where the actual unit was connected to the lead. Screws were turned and they were dropped. Attention was made to ensure that the lead was all the way in into the InterStim. Irrigation was performed after placing the main unit in the pouch. Impedance was checked. Irrigation was again performed with antibiotic irrigation solution. The needle site was closed using 4-0 Monocryl. The pouch was closed using 4-0 Vicryl and the subcutaneous tissue with 4-0 Monocryl. Dermabond was applied.,The patient was brought to recovery in a stable condition.urology, refractory urgency, urgency, frequency, neuromodulator, subcutaneous tissue, interstim,

OCULAR FINDINGS: , Anterior chamber space: Cornea, iris, lens, and pupils all unremarkable on gross examination in each eye.,Ocular adnexal spaces appear very good in each eye.,Cyclomydril x2 was used to dilate the pupil in each eye.,Medial spaces are clear and the periphery is still hazy in each eye.,Ocular disc space, normal size and shape with a pink color with clear margin in each eye.,Macular spaces are normal in appearance for the age in each eye.,Posterior pole. No dilated blood vessels seen in each eye.,Periphery: The peripheral retina is still hazy and retinopathy of prematurity cannot be ruled out at this time in each eye.,IMPRESSION: ,Premature retina and vitreous, each eye.,PLAN: ,Recheck in two weeks.,office notes, eye ocular, premature retina, pupils, periphery, premature, vitreous, retina, eye,

PREOPERATIVE DIAGNOSES,1. Dyspnea on exertion with abnormal stress echocardiography.,2. Frequent PVCs.,3. Metabolic syndrome.,POSTOPERATIVE DIAGNOSES,1. A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.,2. Frequent PVCs.,3. Metabolic syndrome.,PROCEDURES,1. Left heart catheterization with left ventriculography.,2. Selective coronary angiography.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory in fasting state. Both groins were prepped and draped in the usual sterile fashion. Xylocaine 1% was used as local anesthetic. Versed and fentanyl were used for conscious sedation. Next, a #6-French sheath was placed in the right femoral artery using modified Seldinger technique. Next, selective angiography of the left coronary artery was performed in multiple views using #6-French JL4 catheter. Next, selective angiography of the right coronary artery was performed in multiple views using #6-French 3DRC catheter. Next, a #6-French angle pigtail catheter was advanced into the left ventricle. The left ventricular pressure was then recorded. Left ventriculography was the performed using 36 mL of contrast injected over 3 seconds. The left heart pull back was then performed. The catheter was then removed.,Angiography of the right femoral artery was performed. Hemostasis was obtained by Angio-Seal closure device. The patient left the Cardiac Catheterization Laboratory in stable condition.,HEMODYNAMICS,1. LV pressure was 163/0 with end-diastolic pressure of 17. There was no significant gradient across the aortic valve.,2. Left ventriculography showed old inferior wall hypokinesis. Global left ventricular systolic function is normal. Estimated ejection fraction was 58%. There is no significant mitral regurgitation.,3. Significant coronary artery disease.,4. The left main is approximately 7 or 8 mm proximally. It trifurcates into left anterior descending artery, ramus intermedius artery, and left circumflex artery. The distal portion of the left main has an ulcerated excentric plaque, up to about 50% in severity.,5. The left anterior descending artery is around 4 mm proximally. It extends slightly beyond the apex into the inferior wall. It gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators. At the ostium of the left anterior descending artery, there was an eccentric plaque up to 70% to 80%, best seen in the shallow LAO with caudal angulation.,There was no other flow-limiting disease noted in the rest of the left anterior descending artery or its major branches.,The ramus intermedius artery is around 3 mm proximally, but shortly after its origin, it bifurcates into two medium size branches. There was no significant disease noted in the ramus intermedius artery however.,The left circumflex artery is around 2.5 mm proximally. It gave off a recurrent atrial branch and a small AV groove branch prior to terminating into a bifurcating medium size obtuse marginal branch. The mid to distal circumflex has a moderate disease, which is relatively diffuse up to about 40% to 50%.,The right coronary artery is around 4 mm in diameter. It gives off conus branch, two medium size acute marginal branches, relatively large posterior descending artery and a posterior lateral branch. In the mid portion of the right coronary artery at the origin of the first acute marginal branch, there is a relatively discrete stenosis of about 80% to 90%. Proximally, there is an area of eccentric plaque, but seem to be non-flow limiting, at best around 20% to 30%. Additionally, there is what appears to be like a shell-like lesion in the proximal segment of the right coronary artery as well. The posterior descending artery has an eccentric plaque of about 40% to 50% in its mid segment.,PLAN: ,Plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery. Continue risk factor modification, aspirin, and beta blocker.cardiovascular / pulmonary, heart catheterization, ventriculography, coronary angiography, dyspnea, metabolic syndrome, two-vessel coronary artery disease, echocardiography, selective coronary angiography, anterior descending artery, branches, coronary, angiography, artery, catheterization,

CC: ,Fall with subsequent nausea and vomiting.,HX: ,This 52 y/o RHM initailly presented in 10/94 with a two year hisotry of gradual progressive difficulty with speech. He "knew what he wanted to say, but could not say it.",His speech was slurred and he found it difficult to control his tongue. Examination at that time was notable for phonemic paraphasic errors, fair repetition of short phrases with decreased fluency, and slurred nasal speech. He could read, but could not write. He exhibited facial-limb apraxia, decreased gag reflex and positive grasp reflex. He was thougth to have possible Pick's disease vs. Cortical Basal Ganglia Degeneration.,On 11/18/94, he fell and was seen in Neurology clinic on 11/23/94. EEG showed borderline background slowing and no other abnormalities. An MRI on 11/8/94, revealed mild atrophy of the left temporal lobe. Neuropsychological evaluations were obtained on 10/25/94 and 11/8/94. These were consistent with progressive aphasia and apraxia with relative sparing of nonverbal reasoning.,He reported consuming 8 beers on the evening of 1/1/95. On 1/2/95, at 9:30AM, he fell forward while stading in his kitchen and struck his forehead on the counter top, and then struck his occiput on the floor. He subsequently developed nausea and vomiting, tinnitus, vertigo, headache and mild shortness of breath. He was taken to the ETC at UIHC. Skull films were negative and he was treated with IV Compazine and IV fluid hydration and sent home. His nausea and vomiting persisted and he became generally weak. He returned to the ETC at UIHC on 1/5/95. HCT scan revealed a right frontal SDH containing signs of both chronic and acute bleeding.,MEDS:, None.,PMH:, 1)fell in 1990 from 15 feet up and landed on his feet sustaining crush injury to both feet and ankles. He reportedly had brief loss of consciousness with no reported head injury.,2)Progressive aphasia. In 10/93, he was able to draw blue prints and write checks for his family business, 3) Left frontoparietal headache for 1.5 years prior to 10/94. Headaches continue to occur once a week, 4)right ankle fusion 4/94, right ankle fusion pending at present.,FHX:, No neurologic disease in family.,SHX:, Divorced and lives with girlfriend. One child by current girlfriend. He has 3 children with former wife. Smoked more than 15 years ago. Drinks 1-2 beers/day. Former Iron worker.,EXAM: ,BP128/83, HR68, RR18, 36.5C. Supine: BP142/71, HR64; Sitting: BP127/73, HR91 and lightheaded.,MS: Appeared moderately distressed and persistently held his forehead. A&O to person, place and time. Dysarthric and dysphagic. Non-fluent speech and able to say single syllable words such as "up" or "down". He comprehended speech, but could not repeat or write.,CN: Pupils 4/3.5 decreasing to 2/2 on exposure to light. EOM were full and smooth. Optic disks were flat and without sign of hemorrhage. Moderate facial apraxia, but had intact facial sensation.,Motor: 5/5 strength with normal muscle bulk and tone.,Sensory: no abnormalities noted.,Coord: Decreased RAM in the RUE. He had difficulty mmicking movements and postures with his RUE,Gait: ND.,Station: No truncal ataxia, but he had a slight RUE upward drift.,Reflexes 2/2 BUE, 2+/2+ patellae, 2/2 archilles, and plantar responses were flexor, bilaterally.,Rectal exam was unremarkable. The rest of the General Physical exam was unremarkable.,HEENT: atraumatic normocephalic skull. No carotid bruitts.,COURSE:, PT, PTT, CBC, GS, UA and Skull XR were negative. HCT brain, revealed a left frontal SDH with acute and cronic componenets.,He was markedly orthostatic during the first few days of his hospital stay. He was given a 3 day trial of Florinef, which showed mild to moderate improvement of his symptoms of lightheadedness. This improved still further with a trial of Sigvaris pressure stockings. A second HCT was obtained on 12/10/94 and revealed decreased intensity and sized of the left frontal SDH. He was discharged home.,His ideomotor apraxia worsened by 1/96. He developed seizures and was treated with CBZ. He progressively worsened and his overall condition was marked by aphasia, dysphagia, apraxia, and rigidity. He was last seen in 10/96 and the working diagnosis was CBGD vs. Pick's Disease.nan

HISTORY OF PRESENT ILLNESS:, Ms. Connor is a 50-year-old female who returns to clinic for a wound check. The patient underwent an APR secondary to refractory ulcerative colitis. Subsequently, she developed a wound infection, which has since healed. On our most recent visit to our clinic, she has her perineal stitches removed and presents today for followup of her perineal wound. She describes no drainage or erythema from her bottom. She is having good ostomy output. She does not describe any fevers, chills, nausea, or vomiting. The patient does describe some intermittent pain beneath the upper portion of the incision as well as in the right lower quadrant below her ostomy. She has been taking Percocet for this pain and it does work. She has since run out has been trying extra strength Tylenol, which will occasionally help this intermittent pain. She is requesting additional pain medications for this occasional abdominal pain, which she still experiences.,PHYSICAL EXAMINATION: , Temperature 95.8, pulse 68, blood pressure 132/73, and weight 159 pounds. This is a pleasant female in no acute distress. The patient's abdomen is soft, nontender, nondistended with a well-healed midline scar. There is an ileostomy in the right hemiabdomen, which is pink, patent, productive, and protuberant. There are no signs of masses or hernias over the patient's abdomen.,ASSESSMENT AND PLAN: , This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis. Overall, her quality of life has significantly improved since she had her APR. She is functioning well with her ileostomy. She did have concerns or questions about her diet and we discussed the BRAT diet, which consisted of foods that would slow down the digestive tract such as bananas, rice, toast, cheese, and peanut butter. I discussed the need to monitor her ileostomy output and preferential amount of daily output is 2 liters or less. I have counseled her on refraining from soft drinks and fruit drinks. I have also discussed with her that this diet is moreover a trial and error and that she may try certain foods that did not agree with her ileostomy, however others may and that this is something she will just have to perform trials with over the next several months until she finds what foods that she can and cannot eat with her ileostomy. She also had questions about her occasional abdominal pain. I told her that this was probably continue to improve as months went by and I gave her a refill of her Percocet for the continued occasional pain. I told her that this would the last time I would refill the Percocet and if she has continued pain after she finishes this bottle then she would need to start ibuprofen or Tylenol if she had continued pain. The patient then brought up some right hand and arm numbness, which has been there postsurgically and was thought to be from positioning during surgery. This is all primarily gone away except for a little bit of numbness at the tip of the third digit as well as some occasional forearm muscle cramping. I told her that I felt that this would continue to improve as it has done over the past two months since her surgery. I told her to continue doing hand exercises as she has been doing and this seems to be working for her. Overall, I think she has healed from her surgery and is doing very well. Again, her quality of life is significantly improved. She is happy with her performance. We will see her back in six months just for a general routine checkup and see how she is doing at that time.gastroenterology, perineal wound, wound infection, wound, wound check, ulcerative colitis, apr, ileostomyNOTE

SUBJECTIVE:, This 47-year-old white female presents with concern about possible spider bite to the left side of her neck. She is not aware of any specific injury. She noticed a little tenderness and redness on her left posterior shoulder about two days ago. It seems to be getting a little bit larger in size, and she saw some red streaks extending up her neck. She has had no fever. The area is very minimally tender, but not particularly so.,CURRENT MEDICATIONS:, Generic Maxzide, Climara patch, multivitamin, Tums, Claritin, and vitamin C.,ALLERGIES:, No known medicine allergies.,OBJECTIVE:,Vital Signs: Weight is 150 pounds. Blood pressure 122/82.,Extremities: Examination of the left posterior shoulder near the neckline is an area of faint erythema which is 6 cm in diameter. In the center is a tiny mark which could certainly be an insect or spider bite. There is no eschar there, but just a tiny marking. There are a couple of erythematous streaks extending towards the neck.,ASSESSMENT:, Possible insect bite with lymphangitis.,PLAN:,1. Duricef 1 g daily for seven days.,2. Cold packs to the area.,3. Discussed symptoms that were suggestive of the worsening, in which case she would need to call me.,4. Incidentally, she has noticed a little bit of dryness and redness on her eyelids, particularly the upper ones’ and the lower lateral areas. I suspect she has a mild contact dermatitis and suggested hydrocortisone 1% cream to be applied sparingly at bedtime only.general medicine, spider bite, injury, tenderness, redness, insect bite, lymphangitis, streaks, spider, neck, bite,

PREOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,POSTOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,PROCEDURE: , Revision and in situ pinning of the right hip.,ANESTHESIA: , Surgery performed under general anesthesia.,COMPLICATIONS: ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,LOCAL: ,10 mL of 0.50% Marcaine local anesthetic.,HISTORY AND PHYSICAL: , The patient is a 13-year-old girl who presented in November with an acute on chronic right slipped capital femoral epiphysis. She underwent in situ pinning. The patient on followup; however, noted to have intraarticular protrusion of her screw. This was not noted intraoperatively on previous fluoroscopic views. Given this finding, I explained to the father and especially the mother that this can cause further joint damage and that the screw would need to be exchanged for a shorter one. Risks and benefits of surgery were discussed. Risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, failure to remove the screw, possible continued joint stiffness or damage. All questions were answered and parents agreed to above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table. General anesthesia was then administered. The patient received Ancef preoperatively. A small bump was placed underneath her right buttock. The right upper thigh was then prepped and draped in standard surgical fashion. The upper aspect of the incision was reincised. The dissection was carried down to the crew, which was easily found. A guidewire was placed inside the screw with subsequent removal of the previous screw. The previous screw measured 65 mm. A 60 mm screw was then placed under direct visualization with fluoroscopy. The hip was taken through full range of motion to check on the length of the screw, which demonstrated no intraarticular protrusion. The guidewire was removed. The wound was then irrigated and closed using 2-0 Vicryl in the fascial layer as well as the subcutaneous fat. The skin was closed with 4-0 Monocryl. The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, 4 x 4s, and tape. The area was infiltrated with total 10 mL of 0.5% Marcaine local anesthetic.,POSTOPERATIVE PLAN: , The patient will be discharged on the day of surgery. She should continue toe touch weightbearing on her leg. The wound may be wet in approximately 5 days. The patient should follow up in clinic in about 10 days. The patient is given Vicodin for pain. Intraoperative findings were relayed to the mother.orthopedic, guidewire, capital femoral epiphysis, intraarticular protrusion, femoral epiphysis, pinning, screw,

CHIEF COMPLAINT:, "I can’t walk as far as I used to.",HISTORY OF PRESENT ILLNESS:, The patient is a 66-year-old African American gentleman with a past medical history of atrial fibrillation and arthritis who presented c/o progressively worsening shortness of breath. The patient stated that he had been in his usual state of health six years ago at which time he had been able to walk more than five blocks without difficulty. Approximately five years prior to admission, he began to note a decreased tolerance to exercise. This progressed with a gradual worsening in his functional capacity such that he is presently unable to walk for more than 25 feet. Over the two years prior to admission, he has been having a gradually worsening non-productive cough associated with shortness of breath. His shortness of breath is worse when he lies flat, and he periodically wakes at night gasping for air. He sleeps with three pillows. He has also noted swelling of his legs and states that he has had two episodes of syncope at home for which he has not sought medical attention. Approximately one month prior to admission he was seen in an outside clinic where he states that he was started on medications for heart failure. He stated that he had had a brother who died of heart failure at age 72.,He did report that he had had an episode of hemoptysis approximately 2 years prior to admission for which he did not seek medical attention. He denied any history of chest pain and did not report any history of myocardial infarction. He denied fever, chills, and night sweats. He denied diarrhea, dysuria, hematuria, urgency and frequency. He denied any history of rash. He had been diagnosed with osteoarthritis of the knees and had undergone arthroscopy years prior to admission.,PAST MEDICAL HISTORY :, Atrial fibrillation on anticoagulation, osteoarthritis of the knees bilaterally, h/o retinal tear.,PAST SURGICAL HISTORY :, Hernia repair, bilateral arthroscopic evaluation, h/o surgical correction of retinal tear.,FAMILY HISTORY:, The Father of the patient died at age 69 with a CVA. The Mother of the patient died at age 79 when her "heart stopped". There were 12 siblings. Four siblings have died, two due to diabetes, one cause unknown, and one brother died at age 72 with heart failure. The patient has four children with no known medical problems.,SOCIAL HISTORY:, The patient retired one year PTA due to his disability. He was formerly employed as an electronic technician for the US postal service. The patient lives with his wife and daughter in an apartment. He denied any smoking history. He used to drink alcohol rarely but stopped entirely with the onset of his symptoms. He denied any h/o drug abuse. He denied any recent travel history.,MEDICATIONS:,1. Spironolactone 25 mg po qd.,2. Digoxin 0.125 mg po qod.,3. Coumadin 3 mg Monday and Tuesday and 4.5 mg Saturday and Sunday.,4. Metolazone 10 mg po qd.,5. Captopril 25 mg po tid.,6. Torsemide 40 mg po qam and 20 mg po qpm.,7. Carvedilol 3.125 mg po bid.,ALLERGIES:, No known drug allergies.,REVIEW OF SYSTEMS:, No headaches. No visual, hearing, or swallowing difficulties. No changes in bowel or urinary habits.,PHYSICAL EXAM:,Temperature: 98.4 degrees Fahrenheit.,Blood pressure: 134/84.,Heart rate: 98 beats per minute.,Respiratory rate: 18 breaths per minute.,Pulse oximetry: 92% on 2L O 2 via nasal canula.,GEN: Elderly gentleman lying in bed in mild respiratory distress, thin, tired appearing, wife and daughter present at bedside, articulate.,HEENT: The right eye was opacified. The left pupil was reactive to light. There was mild bitemporal wasting. The tongue was moist. There was no lymphadenopathy. The sclerae were anicteric. The oropharynx was clear. The conjunctivae were pink.,NECK: The neck was supple with 15 cm of jugular venous distension.,HEART: Irregularly irregular. No murmurs, gallops, rubs. No displaced PMI.,LUNGS: Breath sounds were absent over two thirds of the right lower lung field. There were trace crackles at the left base.,ABDOMEN: Soft, nontender, nondistended, bowel sounds were present. There was no hepatosplenomegaly. No rebound or guarding.,EXT: Bilateral pitting edema to the thighs with diminished peripheral pulses bilaterally.,NEURO: The patient was alert and oriented x three. Cranial nerves were intact. The DTRs were 2+ bilaterally and symmetrically. Motor strength and sensation were within normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes were present.,SKIN: Warm, no rashes, no lesions; no tattoos.,MUSCULOSKELETAL: No synovitis. There were no joint deformities. Full range of motion b/l throughout.,STUDIES:,CXR: Large right sided pleural effusion. A small pleural effusion with atelectatic changes are seen on the left. The heart size is borderline.,ECHO: LV size is normal. There is severe concentric LV hypertrophy. Global hypokinesis. LV function is severely depressed. Estimate EF is 20-24%. There is RV hypertrophy. RV size is mildly enlarged. RV function is severely depressed. RV wall motion is severely hypokinetic. LA size is moderately enlarged. RA size is mildly enlarged. Trace aortic regurgitation. Moderate tricuspid regurgitation. Estimated PA systolic pressure is 46-51 mmHg, assuming a mean RAP of 15-20mmHg. Small anterior and posterior pericardial effusion.,HOSPITAL COURSE:, The patient was admitted to the hospital for workup and management. A diagnostic procedure was performed.nan

The patient states that she has been doing fairly well at home. She balances her own checkbook. She does not do her own taxes, but she has never done so in the past. She states that she has no problems with cooking meals, getting her own meals, and she is still currently driving. She denies burning any dishes because she forgot them on the stove or forgetting what she is doing in the middle of a task or getting lost while she is driving around or getting lost in her own home. She states that she is very good remembering the names of her family members and does not forget important birthdays such as the date of birth of her grandchildren. She is unfortunately living alone, and although she seems to miss her grandchildren and is estranged from her son, she denies any symptoms of frank depression. There is unfortunately no one available to us to corroborate how well she is doing at home. She lives alone and takes care of herself and does not communicate very much with her brother and sister. She also does not communicate very much with her son who lives in Santa Cruz or her grandchildren. She denied any sort of personality change, paranoid ideas or hallucinations. She does appear to have headaches that can be severe about four times a month and have primarily photophobia and some nausea and occasionally emesis associated with it. When these headaches are very severe, she goes to the emergency room to get a single shot. She is unclear if this is some sort of a migraine medication or just a primary pain medication. She takes Fiorinal for these headaches and she states that this helps greatly. She denies visual or migraine symptoms.,REVIEW OF SYSTEMS: , Negative for any sort of focal neurologic deficits such as weakness, numbness, visual changes, dysarthria, diplopia or dysphagia. She also denies any sort of movement disorders, tremors, rigidities or clonus. Her personal opinion is that some of her memory problems may be due to simply to her age and/or nervousness. She is unclear as if her memory is any worse than anyone else in her age group.,PAST MEDICAL HISTORY: , Significant for mesothelioma, which was diagnosed seemingly more than 20 to 25 years ago. The patient was not sure of exactly when it was diagnosed. This has been treated surgically by debulking operations for which she states that she has undergone about 10 operations. The mesothelioma is in her abdomen. She does not know of any history of having lung mesothelioma. She states that she has never gotten chemotherapy or radiation for her mesothelioma. Furthermore, she states that her last surgical debulking was more than 10 years ago and her disease has been fairly stable. She does have a history of three car accidents that she says were all rear-enders where she was hit while essentially in a stopped position. These have all occurred over the past five years. She also has a diagnosis of dementing illness, possibly Alzheimer disease from her previous neurology consultation. This diagnosis was given in March 2006.,MEDICATIONS:, Fiorinal, p.r.n. aspirin, unclear if baby or full sized, Premarin unclear of the dose.,ALLERGIES:, NONE.,SOCIAL HISTORY:, Significant for her being without a companion at this point. She was born in Munich, Germany. She immigrated to of America in 1957 after her family had to move to Eastern Germany, which was under Russian occupation at that time. She is divorced. She used to work as a secretary and later worked as a clerical worker at IBM. She stopped working more than 20 years ago due to complications from her mesothelioma. She denies any significant tobacco, alcohol or illicit drugs. She is bilingual speaking, German and English. She has known English from before her teens. She has the equivalent of a high school education in Germany. She has one brother and one sister, both of whom are healthy and she does not spend much time communicating with them. She has one son who lives in Santa Cruz. He has grandchildren. She is trying to contact with her grandchildren.,FAMILY HISTORY: , Significant for lung, liver, and prostate cancer. Her mother died in her 80s of "old age," but it appears that she may have had a mild dementing illness at that time. Whatever that dementing illness was, appears to have started mostly in her 80s per the patient. No one else appears to have Alzheimer disease including her brother and sister.,PHYSICAL EXAMINATION: , Her blood pressure is 152/92, pulse 80, and weight 80.7 kg. She is alert and well nourished in no apparent distress. She occasionally fumbles with questions of orientation, missing the day and the date. She also did not know the name of the hospital, she thought it was O'Connor and she thought she was in Orange County and also did not know the floor of the hospital that we are in. She lost three points for recall. Even with prompting, she could not remember the objects that she was given to remember. Her Mini Mental Score was 22/30. There were no naming problems or problems with repetition. There were also no signs of dysarthria. Her pupils were bilaterally reactive to light and accommodation. Her extraocular movements were intact. Her visual fields were full to confrontation. Her sensations of her face, arm, and leg were normal. There were no signs of neglect with double simultaneous stimulation. Tongue was midline. Her palate was symmetric. Her face was symmetric as well. Strength was approximately 5/5. She did have some right knee pain and she had a mildly antalgic gait due to her right knee pain. Her reflexes were symmetric and +2 except for her toes, which were +1 to trace. Her plantar reflexes were mute. Her sensation was normal for pain, temperature, and vibration. There were no signs of ataxia on finger-to-nose and there was no dysdiadochokinesia. Gait was narrow and she could toe walk briefly and heel walk without difficulty.,SUMMARY:, Ms. A is a pleasant 72-year-old right-handed woman with a history of mesothelioma that appears stable at this time and likely mild dementia, most likely Alzheimer type. We tactfully discussed the patient's diagnosis with her, and she felt reassured. We told her that this most likely was in the earlier stages of disease and she would benefit from trying Aricept. She stated that she did not have the prescription anymore from her outpatient neurology consult for the Aricept, so we wrote her another prescription for Aricept. The patient herself seemed very concerned about the stigma of the disease, but our lengthy discussion, expressed genuine understanding as to why her outpatient physician had reported her to DMV. It was explicitly told to not drive by her outpatient neurologist and we concur with this assessment. She will follow up with us in the next six months and will call us if she has any problems with the Aricept. She was written for Aricept to start at 5 mg for three weeks, and if she has no side effects which typically are GI side effects, then she can go up to 10 mg a day. We also reviewed with Ms. A the findings for outpatient MRI, which showed some mild atrophy per report and also that her metabolic workup, which included an RPR, TSH, and B12 were all within normal limits.,neurology, neurology consultation, dementing illness, alzheimer disease, dementia, alzheimer, mesothelioma,

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,PROCEDURE: , Anterior cervical discectomy with fusion C5-C6.,PROCEDURE IN DETAIL: , The patient was placed in supine position. The neck was prepped and draped in the usual fashion. An incision was made from midline to the anterior border of the sternocleidomastoid in the right side. Skin and subcutaneous tissue were divided sharply. Trachea and esophagus were retracted medially. Carotid sheath was retracted laterally. Longus colli muscles were dissected away from the vertebral bodies of C5-C6. We confirmed our position by taking intraoperative x-rays. We then used the operating microscope and cleaned out the disk completely. We then sized the interspace and then tapped in a #7 mm cortical cancellous graft. We then used the DePuy Dynamic plate with 14-mm screws. Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision. The wound was closed in layers using 2-0 Vicryl for muscle and fascia. The blood loss was less than 10-20 mL. No complication. Needle count, sponge count, and cottonoid count was correct.orthopedic, carotid sheath, jackson-pratt drain, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, herniated nucleus, nucleus pulposus, spinal stenosis, discectomy, fusion, herniated, nucleus, pulposus, spinal, stenosis, anterior

GENERAL: , Alert, well developed, in no acute distress.,MENTAL STATUS: , Judgment and insight appropriate for age. Oriented to time, place and person. No recent loss of memory. Affect appropriate for age.,EYES: ,Pupils are equal and reactive to light. No hemorrhages or exudates. Extraocular muscles intact.,EAR, NOSE AND THROAT: , Oropharynx clean, mucous membranes moist. Ears and nose without masses, lesions or deformities. Tympanic membranes clear bilaterally. Trachea midline. No lymph node swelling or tenderness.,RESPIRATORY: ,Clear to auscultation and percussion. No wheezing, rales or rhonchi.,CARDIOVASCULAR: , Heart sounds normal. No thrills. Regular rate and rhythm, no murmurs, rubs or gallops.,GASTROINTESTINAL: , Abdomen soft, nondistended. No pulsatile mass, no flank tenderness or suprapubic tenderness. No hepatosplenomegaly.,NEUROLOGIC: , Cranial nerves II-XII grossly intact. No focal neurological deficits. Deep tendon reflexes +2 bilaterally. Babinski negative. Moves all extremities spontaneously. Sensation intact bilaterally.,SKIN: , No rashes or lesions. No petechia. No purpura. Good turgor. No edema.,MUSCULOSKELETAL: , No cyanosis or clubbing. No gross deformities. Capable of free range of motion without pain or crepitation. No laxity, instability or dislocation.,BONE: , No misalignment, asymmetry, defect, tenderness or effusion. Capable of from of joint above and below bone.,MUSCLE: ,No crepitation, defect, tenderness, masses or swellings. No loss of muscle tone or strength.,LYMPHATIC:, Palpation of neck reveals no swelling or tenderness of neck nodes. Palpation of groin reveals no swelling or tenderness of groin nodes.office notes, mental status, ear, nose and throat, abdomen soft, nondistended, cranial nerves ii-xii grossly intact, physical exam,

PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of the scalp.,POSTOPERATIVE DIAGNOSIS:, Same.,OPERATION PERFORMED: , Radical resection of tumor of the scalp (CPT 11643). Excision of tumor from the skull with debridement of the superficial cortex with diamond bur. Advancement flap closure, with total undermined area 18 centimeters by 16 centimeters (CPT 14300).,ANESTHESIA:, General endotracheal anesthesia.,INDICATIONS: ,This is an 81-year-old male who has a large exophytic 7cm lesion of the anterior midline scalp which is biopsy-positive for skin malignancy, specifically, squamous call carcinoma. This appears to be affixed to the underlying scalp.,PLAN: , Radical resection with frozen sections to clear margins thereafter, with planned reconstruction.,CONSENT:, I have discussed with the patient the possible risks of bleeding, infection, renal problems, scar formation, injury to muscle, nerves, and possible need for additional surgery with possible recurrence of the patient's carcinoma, with review of detailed informed consent with the patient, who understood, and wished to proceed.,FINDINGS: , The patient had a 7cm large exophytic lesion which appeared to be invasive into the superficial table of the skull. The final periosteal margin which centrally appeared was positive for carcinoma. The final margins peripherally were all negative.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was taken to the operating room and there was placed supine on the operating room table.,General endotracheal anesthesia was administered after endotracheal tube intubation was performed by the Anesthesia Service personnel. The patient was thereafter prepped and draped in the usual sterile manner using Betadine Scrub and Betadine paint. Thereafter, the local anesthesia was injected into the area around the tumor. A **** type excision was planned down to the periosteum. A supraperiosteal radical resection was performed.,It was obvious that there was tumor at the deep margin, involving the periosteum. The edges were marked along the four quadrants, at the 12 o'clock, 3 o'clock, 6 o'clock, and the 9 o'clock positions, and these were sent for frozen section evaluation. Frozen section revealed positive margins at one end of the resection. Therefore, an additional circumferential resection was performed and the final margins were all negative.,Following completion, the deep periosteal margin was resected. The circumferential periosteal margins were noted to be negative; however, centrally, there was a small area which showed tumor eroding into the superficial cortex of the skull. Therefore, the Midas Rex drill was utilized to resect approximately 1-2 mm of the superficial cortex of the bone at the area where the positive margin was located. Healthy bone was obtained; however, it did not enter the diploic or marrow-containing bone in the area. Therefore, no bong margin was taken. However, at the end of the procedure, it did not appear that the residual bone had any residual changes consistent with carcinoma.,Following completion of the bony resection, the area was irrigated with copious amounts of saline. Thereafter, advancement flaps were created, both on the left and the right side of the scalp, with the total undermined area being approximately 18cm by 16cm. The galea was incised in multiple areas, to provide for additional mobilization of the tissue. The tissue was closed under tension with 3-0 Vicryl suture deep in the galea and surgical staples superficially.,The patient was awakened from anesthetic, was extubated and was taken to the recovery room in stable condition.,DISPOSITION:, The patient was discharged to home with antibiotics and analgesics, to follow-up in approximately one week.,NOTE: , The final margins of both periosteal, as well as skin were negative circumferentially, around the tumor. The only positive margin was deep, which was a periosteal margin and bone underlying it was partially resected, as was indicated above.surgery, squamous cell carcinoma of the scalp, squamous cell carcinoma, radical resection, margin, midas rex drill, radical resection of tumor, resection of tumor, endotracheal anesthesia, superficial cortex, margins, periosteum, skull, cortex, periosteal, scalp, resection, tumor,

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.surgery, marcaine, steri-strips, mattress sutures, umbilical hernia, repair, umbilical, hernia,

CHIEF COMPLAINT:, "Trouble breathing.",HISTORY OF PRESENT ILLNESS:, A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. Approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. Approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. On the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. On arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. She denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. She denied any history of IVDA, tattoos, or high risk sexual behavior. She did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an IVC filter had been placed in Germany . She had been living in the United States for years, and had had no recent travel. She denied any occupational exposures. Before the onset of her shortness of breath she had been very active and had exercised regularly.,PAST MEDICAL HISTORY:, Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis. Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed. Psoriasis. She denied any history of miscarriage.,PAST SURGICAL HISTORY:, IVC filter placement 1999.nan

DELIVERY NOTE: , The patient is a very pleasant 22-year-old primigravida with prenatal care with both Dr. X and myself and her pregnancy has been uncomplicated except for the fact that she does live a significant distance away from the hospital. The patient was admitted to labor and delivery on Tuesday, December 22, 2008 at 5:30 in the morning at 40 weeks and 1 day gestation for elective induction of labor since she lives a significant distance away from the hospital. Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring. At a later time, Pitocin was started. The next day at about 9 o'clock in the morning, I checked her cervix and performed artifical rupture of membranes, which did reveal Meconium-stained amniotic fluid and so an intrauterine pressure catheter was placed and then MDL infusion started. The patient did have labor epidural, which worked well. It should be noted that the patient's recent vaginal culture for group B strep did come back negative for group B strep. The patient went on to have a normal spontaneous vaginal delivery of a live-term male newborn with Apgar scores of 7 and 9 at 1 and 5 minutes respectively and a newborn weight of 7 pounds and 1.5 ounces at birth. The intensive care nursery staff was present because of the presence of Meconium-stained amniotic fluid. DeLee suctioning was performed at the perineum. A second-degree midline episiotomy was repaired in layers in the usual fashion using 3-0 Vicryl. The placenta was simply delivered and examined and found to be complete and bimanual vaginal exam was performed and revealed that the uterus was firm.,ESTIMATED BLOOD LOSS: , Approximately 300 mL.obstetrics / gynecology, amniotic fluid, contractions, pitocin, meconium, cervix, labor, vaginal, delivery, intravaginallyNOTE,: 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.,

FINDINGS:,There is a well demarcated mass lesion of the deep lobe of the left parotid gland measuring approximately 2.4 X 3.9 X 3.0cm (AP X transverse X craniocaudal) in size. The lesion is well demarcated. There is a solid peripheral rim with a mean attenuation coefficient of 56.3. There is a central cystic appearing area with a mean attenuation coefficient of 28.1 HU, suggesting an area of central necrosis. There is the suggestion of mild peripheral rim enhancement. This large lesion within the deep lobe of the parotid gland abuts and effaces the facial nerve. Primary consideration is of a benign mixed tumor (pleomorphic adenoma), however, other solid mass lesions cannot be excluded, for which histologic evaluation would be necessary for definitive diagnosis. The right parotid gland is normal.,There is mild enlargement of the left jugulodigastric node, measuring 1.1cm in size, with normal morphology (image #33/68). There is mild enlargement of the right jugulodigastric node, measuring 1.2cm in size, with normal morphology (image #38/68).,There are demonstrated bilateral deep lateral cervical nodes at the midlevel, measuring 0.6cm on the right side and 0.9cm on the left side (image #29/68). There is a second midlevel deep lateral cervical node demonstrated on the left side (image #20/68), measuring 0.7cm in size. There are small bilateral low level nodes involving the deep lateral cervical nodal chain (image #15/68) measuring 0.5cm in size.,There is no demonstrated nodal enlargement of the spinal accessory or pretracheal nodal chains.,The right parotid gland is normal and there is no right parotid gland mass lesion.,Normal bilateral submandibular glands.,Normal parapharyngeal, retropharyngeal and perivertebral spaces.,Normal carotid spaces.,IMPRESSION:,Large, well demarcated mass lesion of the deep lobe of the left parotid gland, with probable involvement of the left facial nerve. See above for size, morphology and pattern enhancement. Primary consideration is of a benign mixed tumor (pleomorphic adenoma), however, other solid mass lesions cannot be excluded, for which histologic evaluation is necessary for specificity.,Multiple visualized nodes of the bilateral deep lateral cervical nodal chain, within normal size and morphology, most compatible with mild hyperplasia.radiology, cervical nodal, mass lesion, deep lobe, deep lateral, lateral cervical, parotid gland, cervical, lesion, gland, parotid, deep

PREOPERATIVE DIAGNOSES: ,Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,POSTOPERATIVE DIAGNOSES: , Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,OPERATIVE PROCEDURE: , Bilateral myringotomies with insertion of Santa Barbara T-tube.,ANESTHESIA: , General mask.,FINDINGS:, The patient is an 8-year-old white female with chronic eustachian tube dysfunction and TM atelectasis, was taken to the operating room for tubes. At the time of surgery, she has had an extruding right Santa Barbara T-tube and severe left TM atelectasis with retraction. There was a scant amount of fluid in both middle ear clefts.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position, and general mask anesthesia was established. The right ear was draped in normal sterile fashion. Cerumen was removed from the external canal. The extruding Santa Barbara T-tube was identified and atraumatically removed. A fresh Santa Barbara T-tube was atraumatically inserted and Ciloxan drops applied.,The attention was then directed to the left side where severe TM atelectasis was identified. With a mask anesthetic, the eardrum elevated. A radial incision was made in the inferior aspect of the tympanic membrane and middle ear fluid aspirated. A Santa Barbara T-tube was then inserted without difficulty and 5 drops Ciloxan solution applied. Anesthesia was then reversed and the patient taken to recovery room in satisfactory condition.surgery, tympanic membrane, cerumen, ciloxan, santa barbara t-tube, tm atelectasis, atelectasis, eardrum, eustachian tube, eustachian tube dysfunction, middle ear, middle ear fluid, myringotomies, atelectasis and chronic eustachian, santa barbara t tube, myringotomies with insertion, chronic eustachian tube, barbara t tube, santa barbara, insertion, tube, tympanic

PREOPERATIVE DIAGNOSIS: , Chronic hypertrophic adenotonsillitis.,POSTOPERATIVE DIAGNOSIS: , Chronic hypertrophic adenotonsillitis.,OPERATIVE PROCEDURE:, Adenotonsillectomy, primary, patient under age 12.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE IN DETAIL: , This patient was brought from the holding area and did receive preoperative antibiotics of Cleocin as well as IV Decadron. She was placed supine on the operating room table. General endotracheal anesthesia was induced without difficulty. In the holding area, her allergies were reviewed. It is unclear whether she is actually allergic to penicillin. Codeine caused her to be excitable, but she did not actually have an allergic reaction to codeine. She might be allergic to BACTRIM and SULFA. After positioning a small shoulder roll and draping sterilely, McIvor mouthgag, #3 blade was inserted and suspended from the Mayo stand. There was no bifid uvula or submucous cleft. She had 3+ cryptic tonsils with significant debris in the tonsillar crypts. Injection at each peritonsillar area with 0.25% with Marcaine with 1:200,000 Epinephrine, approximately 1.5 mL total volume. The left superior tonsillar pole was then grasped with curved Allis forceps. _______ incision and dissection in the tonsillar capsule and hemostasis and removal of the tonsil was obtained with Coblation Evac Xtra Wand on 7/3. Mouthgag was released, reopened, no bleeding was seen. The right tonsil was then removed in the same fashion. The mouthgag released, reopened, and no bleeding was seen. Small red rubber catheter in the nasal passage was used to retract the soft palate. She had mild-to-moderate adenoidal tissue residual. It was removed with Coblation Evac Xtra gently curved Wand on 9/5. Red rubber catheter was then removed. Mouthgag was again released, reopened, no bleeding was seen. Orogastric suction carried out with only scant clear stomach contents. Mouthgag was then removed. Teeth and lips were inspected and were in their preoperative condition. The patient then awakened, extubated, and taken to recovery room in good condition.,TOTAL BLOOD LOSS FROM TONSILLECTOMY: , Less than 2 mL.,TOTAL BLOOD LOSS FROM ADENOIDECTOMY: , Less than 2 mL.,COMPLICATIONS: , No intraoperative events or complications occurred.,PLAN:, Family will be counseled postoperatively. Postoperatively, the patient will be on Zithromax oral suspension 500 mg daily for 5 to 7 days, Lortab Elixir for pain. _______ and promethazine if needed for nausea and vomiting.ent - otolaryngology, hypertrophic adenotonsillitis, adenotonsillitis, endotracheal anesthesia, coblation evac xtra wand, lortab elixir, red rubber catheter, total blood loss, adenotonsillectomy, forceps, mouthgag,

CHIEF COMPLAINT:, Vomiting and nausea.,HPI: , The patient is a 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe. She states she has it at least once a day. It can be any time, but can also be postprandial. She states she will vomit up some dark brown-to-green fluid. There has been no hematemesis. She states because of the nausea and vomiting, she has not been able to take much in the way of PO intake over the past week. She states her appetite is poor. The patient has lost 40 pounds of weight over the past 16 months. She states for the past few days, she has been getting severe heartburn. She used Tums over-the-counter and that did not help. She denies having any dysphagia or odynophagia. She is not having any abdominal pain. She has no diarrhea, rectal bleeding, or melena. She has had in the past, which was remote. She did have some small amounts of rectal bleeding on the toilet tissue only if she passed a harder stool. She has a history of chronic constipation for most of her life but she definitely has a bowel movement every 3 to 4 days and this is unchanged. The patient states she has never had any endoscopy or barium studies of the GI tract.,The patient is anemic and her hemoglobin is 5.7 and she is thrombocytopenic with the platelet count of 34. She states she has had these abnormalities since she has been diagnosed with breast cancer. She states that she has metastatic breast cancer and that is in her rib cage and spine and she is getting hormonal chemotherapy for this and she is currently under the care of an oncologist. The patient also has acute renal failure at this point. The patient said she had a PET scan done about a week ago.,PAST MEDICAL HISTORY:, Metastatic breast cancer to her rib cage and spine, hypothyroidism, anemia, thrombocytopenia, hypertension, Bells palsy, depression, uterine fibroids, hysterectomy, cholecystectomy, breast lumpectomy, and thyroidectomy.,ALLERGIES: , No known drug allergies.,MEDICINES:, She is on Zofran, Protonix, fentanyl patch, Synthroid, Ativan, and Ambien.,SOCIAL HISTORY: ,The patient is divorced and is a homemaker. No smoking or alcohol.,FAMILY HISTORY:, Negative for any colon cancer or polyps. Her father died of mesothelioma, mother died of Hodgkin lymphoma.,SYSTEMS REVIEW: , No fevers, chills or sweats. She has no chest pain, palpitations, coughing or wheezing. She does get shortness of breath, no hematuria, dysuria, arthralgias, myalgias, rashes, jaundice, bleeding or clotting disorders. The rest of the system review is negative as per the HPI.,PHYSICAL EXAM: , Temperature 98.4, blood pressure 95/63, heart rate 84, respiratory rate of 18, and weight is 108 kg. GENERAL APPEARANCE: The patient was comfortable in bed. Skin exam is negative for any rashes or jaundice. LYMPHATICS: There is no palpable lymphadenopathy of the cervical or the supraclavicular area. HEENT: She has some mild ptosis of the right eye. There is no icterus. The patient's conjunctivae and sclerae are normal. Pupils are equal, round, and reactive to light and accommodation. No lesions of the oral mucosa or mucosa of the pharynx. NECK: Supple. Carotids are 2+. No thyromegaly, masses or adenopathy. HEART: Has regular rhythm. Normal S1 and S2. She has a 2/6 systolic ejection murmur. No rubs or gallops. Lungs are clear to percussion and auscultation. Abdomen is obese, it may be mildly distended. There is no increased tympany. The patient does have hepatosplenomegaly. There is no obvious evidence of ascites. The abdomen is nontender, bowel sounds are present. The extremities show some swelling and edema of the ankle regions bilaterally. Legs are in SCDs. No cyanosis or clubbing. For the rectal exam, it shows brown stool that is very trace heme positive at most. For the neuro exam, she is awake, alert, and oriented x3. Memory intact. No focal deficits. Insight and judgment are intact.,X-RAY AND LABORATORY DATA: ,She came in, white count 9.2, hemoglobin 7.2, hematocrit 22.2, MCV of 87, platelet count is 47,000. Calcium is 8.1, sodium 134, potassium 5.3, chloride 102, bicarbonate 17, BUN of 69, creatinine of 5.2, albumin 2.2, ALT 28, bilirubin is 2.2, alkaline phosphatase is 359, AST is 96, and lipase is 30. Today, her hemoglobin is 5.7, TSH is 1.1, platelet count is 34,000, alkaline phosphatase is 303, and bilirubin of 1.7.,IMPRESSION,1. The patient has one week of nausea and vomiting with decreased p.o. intake as well as dehydration. This could be on the basis of her renal failure. She may have a viral gastritis. The patient does have a lot of gastroesophageal reflux disease symptoms recently. She could have peptic mucosal inflammation or peptic ulcer disease.,2. The patient does have hepatosplenomegaly. There is a possibility she could have liver metastasis from the breast cancer.,3. She has anemia as well as thrombocytopenia. The patient states this is chronic.,4. A 40-pound weight loss.,5. Metastatic breast cancer.,6. Increased liver function tests. Given her bone metastasis, the elevated alkaline phosphatase may be from this as opposed to underlying liver disease.,7. Chronic constipation.,8. Acute renal failure.,PLAN: ,The patient will be on a clear liquid diet. She will continue on the Zofran. She will be on IV Protonix. The patient is going to be transfused packed red blood cells and her hemoglobin and hematocrit will be monitored. I obtained the result of the abdominal x-rays she had done through the ER. The patient has a consult pending with the oncologist to see what her PET scan show. There is a renal consult pending. I am going to have her get a total abdominal ultrasound to see if there is any evidence of liver metastasis and also to assess her kidneys. Her laboratory studies will be followed. Based upon the patient's medical condition and including her laboratory studies including a platelet count, we talked about EGD versus upper GI workup per upper GI symptoms. I discussed informed consent for EGD. I discussed the indications, risks, benefits, and alternatives. The risks reviewed included, but were not limited to an allergic reaction or side effect to medicines, cardiopulmonary complications, bleeding, infection, perforation, and needing to get admitted for antibiotics or blood transfusion or surgery. The patient voices her understanding of the above. She wants to think about what she wants to do. Overall, this is a very ill patient with multiorgan involvement.nan

PREOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,POSTOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,ANESTHESIA: , Conscious Sedation.,INFORMED CONSENT: , After adequate explanation of the medical surgical and procedural options, this patient has decided to proceed with the recommended spinal Manipulation under Anesthesia (MUA). The patient has been informed that more than one procedure may be necessary to achieve the satisfactory results.,INDICATION:, This patient has failed extended conservative care of condition/dysfunction by means of aggressive physical medical and pharmacological intervention.,COMMENTS: , This patient understands the essence of the diagnosis and the reasons for the MUA- The associated risks of the procedure, including anesthesia complications, fracture, vascular accidents, disc herniation and post-procedure discomfort, were thoroughly discussed with the patient. Alternatives to the procedure, including the course of the condition without MUA, were discussed. The patient understands the chances of success from undergoing MUA and that no guarantees are made or implied regarding outcome. The patient has given both verbal and written informed consent for the listed procedure.,PROCEDURE IN DETAIL: , The patient was draped in the appropriate gowning and accompanied to the operative area. Following their sacral block injection, they were asked to lie supine on the operative table and they were placed on the appropriate monitors for this procedure. When the patient and I were ready, the anesthesiologist administered the appropriate medications to assist the patient into the twilight sedation using medication which allows the stretching, mobilization, and adjustments necessary for the completion of the outcome I desired.,THORACIC SPINE: , With the patient in the supine position on the operative table, the upper extremities were flexed at the elbow and crossed over the patient's chest to achieve maximum traction to the patient's thoracic spine. The first assistant held the patient's arms in the proper position and assisted in rolling the patient for the adjusting procedure. With the help of the first assist, the patient was rolled to their right side, selection was made for the contact point and the patient was rolled back over the doctor's hand. The elastic barrier of resistance was found, and a low velocity thrust was achieved using a specific closed reduction anterior to posterior/superior manipulative procedure. The procedure was completed at the level of TI-TI2. Cavitation was achieved.,LUMBAR SPINE/SACRO-ILIAC JOINTS:, With the patient supine on the procedure table, the primary physician addressed the patient's lower extremities which were elevated alternatively in a straight leg raising manner to approximately 90 degrees from the horizontal. Linear force was used to increase the hip flexion gradually during this maneuver. Simultaneously, the first assist physician applied a myofascial release technique to the calf and posterior thigh musculature. Each lower extremity was independently bent at the knee and tractioned cephalad in a neutral sagittal plane, lateral oblique cephalad traction, and medial oblique cephalad traction maneuver. The primary physician then approximated the opposite single knee from his position from neutral to medial slightly beyond the elastic barrier of resistance. (a piriformis myofascial release was accomplished at this time). This was repeated with the opposite lower extremity. Following this, a Patrick-Fabere maneuver was performed up to and slightly beyond the elastic barrier of resistance.,With the assisting physician stabling the pelvis and femoral head (as necessary), the primary physician extended the right lower extremity in the sagittal plane, and while applying controlled traction gradually stretched the para-articular holding elements of the right hip by means gradually describing an approximately 30-35 degree horizontal arc. The lower extremity was then tractioned, and straight caudal and internal rotation was accomplished. Using traction, the lower extremity was gradually stretched into a horizontal arch to approximately 30 degrees. This procedure was then repeated using external rotation to stretch the para-articular holding elements of the hips bilaterally. These procedures were then repeated on the opposite lower extremity.,By approximating the patient's knees to the abdomen in a knee-chest fashion (ankles crossed), the lumbo-pelvic musculature was stretched in the sagittal plane, by both the primary and first assist, contacting the base of the sacrum and raising the lower torso cephalad, resulting in passive flexion of the entire lumbar spine and its holding elements beyond the elastic barrier of resistancesurgery, fibromyositis, myalgia, segmental dysfunction, sacro-iliitis, spinal manipulation under anesthesia, lumbar segmental dysfunction, informed consent, iliac joints, spinal manipulation, sacro iliitis, lower extremity, spinal, mua, cephalad, dysfunction, segmental, lumbar,

REASON FOR CONSULTATION: , Pulmonary embolism.,HISTORY:, The patient is a 78-year-old lady who was admitted to the hospital yesterday with a syncopal episode that happened for the first time in her life. The patient was walking in a store when she felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds. At that time, her daughter was with her. No tonic-clonic movements. No cyanosis. The patient woke up on her own. The patient currently feels fine, has mild shortness of breath upon exertion, but this is her usual for the last several years. She cannot get up one flight of stairs, but feels short of breath. She gets exerted and thinks to take a shower. She does not have any chest pain, no fever or syncopal episodes.,PAST MEDICAL HISTORY,1. Pulmonary embolism diagnosed one year ago. At that time, she has had an IVC filter placed due to massive GI bleed from diverticulosis and gastric ulcers. Paroxysmal atrial fibrillation and no anticoagulation due to history of GI bleed.,2. Coronary artery disease status post CABG at that time. She has had to stay in the ICU according to the daughter for 3 weeks due to again lower GI bleed.,3. Mitral regurgitation.,4. Gastroesophageal reflux disease.,5. Hypertension.,6. Hyperlipidemia.,7. History of aortic aneurysm.,8. History of renal artery stenosis.,9. Peripheral vascular disease.,10. Hypothyroidism.,PAST SURGICAL HISTORY,1. CABG.,2. Hysterectomy.,3. IVC filter.,4. Tonsillectomy.,5. Adenoidectomy.,6. Cosmetic surgery.,7. Renal stent.,8. Right femoral stent.,HOME MEDICATIONS,1. Aspirin.,2. Potassium.,3. Lasix.,4. Levothyroxine.,5. Lisinopril.,6. Pacerone.,7. Protonix.,8. Toprol.,9. Vitamin B.,10. Zetia.,11. Zyrtec.,ALLERGIES:, SULFA,SOCIAL HISTORY: , She used to be a smoker, not anymore. She drinks 2 to 3 glasses of wine per week. She is retired.,REVIEW OF SYSTEMS: , She has a history of snoring, choking for breath at night, and dry mouth in the morning.,PHYSICAL EXAMINATION,GENERAL APPEARANCE: In no acute distress.,VITAL SIGNS: Temperature 98.6, respirations 18, pulse 61, blood pressure 155/57, and oxygen saturation 93-98% on room air.,HEENT: No lymph nodes or masses.,NECK: No jugular venous distension.,LUNGS: Clear to auscultation bilaterally.nan

PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:, Basal Cell CA.,LOCATION: ,Medial right inferior helix.,PREOP SIZE:, 1.4 x 1 cm,POSTOP SIZE: , 2.7 x 2 cm,INDICATION: , Poorly defined borders.,COMPLICATIONS: , None.,HEMOSTASIS: , Electrodessication.,PLANNED RECONSTRUCTION: , Wedge resection advancement flap.,DESCRIPTION OF PROCEDURE: , Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.,The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision. With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique. A map was prepared to correspond to the area of skin from which it was excised. The tissue was prepared for the cryostat and sectioned. Each section was coded, cut and stained for microscopic examination. The entire base and margins of the excised piece of tissue were examined by the surgeon. Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.,No tumor was identified after the final stage of microscopically controlled surgery. The patient tolerated the procedure well without any complication. After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.dermatology, medial right inferior helix, wedge resection advancement flap, tumor-laden tissue, mohs fresh tissue technique, mohs technique, mohs micrographic surgery, basal cell ca, micrographic surgery, basal cell, micrographic, helix, basal, cell, ca, mohs, tissue, stage,

REFERRING DIAGNOSIS: , Motor neuron disease.,PERTINENT HISTORY AND EXAMINATION:, Briefly, the patient is an 83-year-old woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.,SUMMARY: ,The right median sensory response showed a borderline normal amplitude for age with mild slowing of conduction velocity. The right ulnar sensory amplitude was reduced with slowing of the conduction velocity. The right radial sensory amplitude was reduced with slowing of the conduction velocity. The right sural and left sural sensory responses were absent. The right median motor response showed a prolonged distal latency across the wrist, with proximal slowing. The distal amplitude was very reduced, and there was a reduction with proximal stimulation. The right ulnar motor amplitude was borderline normal, with slowing of the conduction velocity across the elbow. The right common peroneal motor response showed a decreased amplitude when recorded from the EDB, with mild slowing of the proximal conduction velocity across the knee. The right tibial motor response showed a reduced amplitude with prolongation of the distal latency. The left common peroneal response recorded from the EDB showed a decreased amplitude with mild distal slowing. The left tibial motor response showed a decreased amplitude with a borderline normal distal latency. The minimum F-wave latencies were normal with the exception of a mild prolongation of the ulnar F-wave latency, and the tibial F-wave latency as indicated above. With repetitive nerve stimulation, there was no significant decrement noted in either the right nasalis or the right trapezius muscles. Concentric needle EMG studies were performed in the right lower extremity, right upper extremity, thoracic paraspinals, and in the tongue. There was evidence of increased insertional activity in the right tibialis anterior muscle, with evidence of fasciculations noted in several lower and upper extremity muscles and in the tongue. In addition, there was evidence of increased amplitude, long duration and polyphasic motor units with a decreased recruitment noted in most muscles tested as indicated in the table above.,INTERPRETATION: , Abnormal electrodiagnostic study. There is electrodiagnostic evidence of a disorder of the anterior motor neurons affecting at least four segments. There is also evidence of a more generalized neuropathy that seems to be present in both the upper and lower extremities. There is also evidence of a right median mononeuropathy at the wrist and a right ulnar neuropathy at the elbow. Even despite the patient's age, the decrease in sensory responses is concerning, and makes it difficult to be certain about the diagnosis of motor neuron disease. However, the overall changes on the needle EMG would be consistent with a diagnosis of motor neuron disease. The patient will return for further evaluation.radiology, electrodiagnostic study, electrodiagnostic, edb, latency, nerve conduction study, emg, motor neuron disease, distal latency, motor response, motor, amplitude, conduction

SUBJECTIVE:, This is a followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome. The patient reports that she has worked hard for a number of weeks following the meal plan prescribed, but felt like she was gaining weight and not losing weight on it. She is not sure that she was following it accurately. She is trying to walk 1-1/2 to 2 miles every other day, but is increasing her time in the garden and doing other yard work as well. Once she started experiencing some weight gain, she went back to her old South Beach Diet and felt like she was able to take some of that weight off. However she realizes that the South Beach Diet is not a healthy diet for her and so is coming back for better instruction on safe weight loss and low-fat eating.,OBJECTIVE:, Weight is 275 pounds. Food records were reviewed.,ASSESSMENT:, The patient experienced a weight gain of 2 pounds since our last consultation which was two months ago. I did carefully review her food records and evaluated calories consumed. While she was carefully tracking the volume of protein and carbohydrates, she was getting some excess calories from the fatty proteins selected. Thus we rearranged her meal plan a little bit and talked about how to track her fat calories as well. She was more open to reducing the amount of protein from the previous meal plan and increasing slightly the amount of carbohydrates. While this still is not as much carbohydrate as I would normally recommend, I am certainly willing to work with her on how she feels her body best handles weight reduction. We also discussed a snack that could be eliminated in the morning because she really is not hungry at that time.,PLAN:, A new 1500 calorie meal plan was developed based on 35% of the calories coming from protein, 40% of the calories from carbohydrate, and 25% of the calories from fat. This translates in to 10 servings at 15 grams a piece of carbohydrates throughout the day dividing them in to groups of two servings per meal and per snack. This also translates in to 2 ounces of protein at breakfast, 6 ounces at lunch, 2 ounces in the afternoon snack, 6 ounces at supper, and 2 ounces in the evening snack. We have eliminated the morning snack. The patient will now track the grams of fat in her meats as well as added fats. Her goal for total fats over the course of the day is no more than 42 grams of fat per day. This was a half hour consultation. We will plan to see the patient back in one month for support.soap / chart / progress notes, hyperlipidemia, hypertension, metabolic syndrome, meal, food records, south beach diet, dietary consultation, meal plan, carbohydrates, snack, dietary, calories, weight

SUBJECTIVE: , This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma. She says her asthma has been worse over the last three months. She has been using her inhaler daily. Her allergies seem to be a little bit worse as well. Her husband has been hauling corn and this seems to aggravate things. She has not been taking Allegra daily but when she does take it, it seems to help somewhat. She has not been taking her Flonase which has helped her in the past. She also notes that in the past she was on Advair but she got some vaginal irritation with that.,She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle. She has been more impatient around that time. Says otherwise her mood is normal during the rest of the month. It usually is worse the week before her cycle and improves the day her menstrual cycle starts. Menses have been regular but somewhat shorter than in the past. Occasionally she will get some spotting after her cycles. She denies any hot flashes or night sweats with this. In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously. Her urine has not been rechecked. She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available.,REVIEW OF SYSTEMS: , As above. No fevers, no headaches, no shortness of breath currently. No chest pain or tightness. No abdominal pain, no heartburn, no constipation, diarrhea or dysuria. Occasional stress incontinence. No muscle or joint pain. No concerns about her skin. No polyphagia, polydipsia or polyuria.,PAST MEDICAL HISTORY: , Significant for asthma, allergic rhinitis and cervical dysplasia.,SOCIAL HISTORY: , She is married. She is a nonsmoker.,MEDICATIONS: , Proventil and Allegra.,ALLERGIES: , Sulfa.,OBJECTIVE:,Vital signs: Her weight is 151 pounds. Blood pressure is 110/60. Pulse is 72. Temperature is 97.1 degrees. Respirations are 20.,General: This is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress. Affect is appropriate and is pleasant.,HEENT: Normocephalic, atraumatic. Tympanic membranes are clear. Conjunctivae are clear. Pupils are equal, round and reactive to light. Nares without turbinate edema. Oropharynx is nonerythematous.,Neck: Supple without lymphadenopathy, thyromegaly, carotid bruit or JVD.,Chest: Clear to auscultation bilaterally.,Cardiovascular: Regular rate and rhythm without murmur.,Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds. No masses or organomegaly to palpation.,Extremities: Without cyanosis or edema.,Skin: Without abnormalities.,Breasts: Normal symmetrical breasts without dimpling or retraction. No nipple discharge. No masses or lesions to palpation. No axillary masses or lymphadenopathy.,Genitourinary: Normal external genitalia. The walls of the vaginal vault are visualized with normal pink rugae with no lesions noted. Cervix is visualized without lesion. She has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault. No cervical motion tenderness. No adnexal tenderness or fullness.,ASSESSMENT/PLAN:,1. Asthma. Seems to be worse than in the past. She is just using her Proventil inhaler but is using it daily. We will add Flovent 44 mcg two puffs p.o. b.i.d. May need to increase the dose. She did get some vaginal irritation with Advair in the past but she is willing to retry that if it is necessary. May also need to consider Singulair. She is to call me if she is not improving. If her shortness of breath worsens she is to call me or go into the emergency department. We will plan on following up for reevaluation in one month.,2. Allergic rhinitis. We will plan on restarting Allegra and Flonase daily for the time being.,3. Premenstrual dysphoric disorder. She may have some perimenopausal symptoms. We will start her on fluoxetine 20 mg one tablet p.o. q.d.,4. Hematuria. Likely this is secondary to urinary tract infection but we will repeat a UA to document clearing. She does have some frequent dysuria but is not having it currently.,5. Cervical dysplasia. Pap smear is taken. We will notify the patient of results. If normal we will go back to yearly Pap smear. She is scheduled for screening mammogram and instructed on monthly self-breast exam techniques. Recommend she get 1200 mg of calcium and 400 U of vitamin D a day.nan

CHIEF COMPLAINT: , I need refills.,HISTORY OF PRESENT ILLNESS:, The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking. She is a new patient today. She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain. She states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office. She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try.,OBJECTIVE: ,Well developed and well nourished. She does not appear to be in any acute distress. Cardiovascular: Regular rhythm. No murmurs, gallops, or rubs. Capillary refill less than 3 seconds. Peripheral pulses are 2+ bilaterally. Respiratory: Her lungs are clear to auscultation bilaterally with good effort. No tenderness to palpation over chest wall. Musculoskeletal: She has full range of motion of all four extremities. No tenderness to palpation over long bones. Skin: Warm and dry. No rashes or lesions. Neuro: Alert and oriented x3. Cranial nerves II-XII are grossly intact. No focal deficits.,PLAN: , I did refill her medications. I have requested that she have her primary doctor forward her records to me. I have discussed Chantix and its use and success rate. She was given a prescription, as well as a coupon. She is to watch for any worsening signs or symptoms. She verbalized understanding of discharge instructions and prescriptions. I would like to see her back to proceed with her preventive health measures.consult - history and phy., quit smoking, chantix, mesothelioma, smoking, xanax, refills

EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS: ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration. Pre-contrast images through the abdomen were also obtained.,COMPARISON: ,There were no comparison studies.,FINDINGS: ,The lung bases are clear.,The liver demonstrates mild intrahepatic biliary ductal dilatation. These findings may be secondary to the patient's post cholecystectomy state. The pancreas, spleen, adrenal glands, and kidneys are unremarkable.,There is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology. There are numerous nonspecific retroperitoneal and mesenteric lymph nodes. These may be reactive; however, an early neoplastic process would be difficult to totally exclude.,There is a right inguinal hernia containing a loop of small bowel. This may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant. The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis.,There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine.,The urinary bladder is unremarkable. The uterus is not visualized.,IMPRESSION:,1. Right inguinal hernia containing small bowel. Partial obstruction is suspected.,2. Nonspecific retroperitoneal and mesenteric lymph nodes.,3. Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology.,4. Diverticulosis without evidence of diverticulitis.,5. Status post cholecystectomy with mild intrahepatic biliary ductal dilatation.,6. Osteopenia and degenerative changes of the spine and pelvis.gastroenterology, pre-contrast images, contrast, biliary ductal dilatation, pancreas, spleen, adrenal glands, kidneys, mesenteric lymph nodes, fluid collection, inguinal hernia, ct abdomen, hernia, diverticulosis, diverticulitis, osteopenia, degenerative, spine, bowel, pelvis, ct, abdomen,