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Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.

Is it BNP or BMP?

Autopsy of a white female who died of acute combined drug intoxication.

He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally.

A sample note on Rheumatoid Arthritis

The case has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.

The patient was admitted for symptoms that sounded like postictal state. CT showed edema and slight midline shift. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.

The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry. The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.

Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures

Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.

Patient was brought in the Emergency Room following an episode of syncope. The patient relates that he may have had a seizure activity prior to that. Prior to the episode, he denies having any symptoms of chest pain or shortness of breath.

Toenails are discolored, thickened, and painful - Onychomycosis

The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.

The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.

Common Excretory Urogram - IVP template

Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.

Hospice visit for 77-year-old gentleman with advanced colon cancer.

Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.

Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.

The case was referred for evaluation of cataracts bilaterally

Dietary consultation for diabetes during pregnancy.

Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.

Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal.

Open reduction and internal fixation of left lateral malleolus. Left lateral malleolus fracture.

Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury

Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions. Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.

Total thyroidectomy with removal of substernal extension on the left. Thyroid goiter with substernal extension on the left.

A 53-year-old female with left knee pain being evaluated for ACL tear.

Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula.

Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression.

Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.

A sample note on Rheumatoid Arthritis

Dietary consultation for gestational diabetes.

Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.

Letter on evaluation regarding extraction of mandibular left second molar tooth #18.

Occupational medicine consult with questions-answers and records review.

Onychomycosis present, #1 right and #1 left.

Nephrology Consultation - Patient with renal failure.

Work restrictions and disability evaluation

Elevated cholesterol and is on medication to lower it.

The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.

Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.

Sample normal ear, nose, mouth, and throat exam.

Laparoscopic cholecystectomy. Biliary colic and biliary dyskinesia. The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.

Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy and uterosacral ligament vault suspension. Cervical intraepithelial neoplasia grade-III postconization. Recurrent dysplasia. Uterine procidentia grade II-III. Mild vaginal vault prolapse.

Normal child physical exam template.

Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.

Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3. Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.

Exploratory laparotomy, lysis of adhesions and removal, reversal of Hartmann's colostomy, flexible sigmoidoscopy, and cystoscopy with left ureteral stent.

Still having diarrhea, decreased appetite.

Ligation (clip interruption) of patent ductus arteriosus. This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.

Follow up update on case with left carotid angioplasty and stent placement.

Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.

The patient has had abdominal ache associated with a 30-pound weight loss and then developed jaundice. He had epigastric ache and was admitted to the hospital. A thin-slice CT scan was performed, which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases.

Cause of death - Anoxic Encephalopathy

Ultrasound OB - followup for fetal growth.

Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome

A 23-year-old white female presents with complaint of allergies.

Cataract to right eye. Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.

Knee injection

Abscess of the left foot, etiology unclear at this time. Possibility of foreign body.

Dietary consultation for carbohydrate counting for type I diabetes.

EGD with PEG tube placement using Russell technique. Protein-calorie malnutrition, intractable nausea, vomiting, and dysphagia, and enterogastritis.

A 23-year-old white female presents with complaint of allergies.

Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.

The client was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.

Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.

Patient follows up for cataract extraction with lens implant 2 weeks ago. Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.

Cognitive linguistic impairment secondary to stroke. The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.

Status post brain tumor removal. The case is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.

Right axillary adenopathy, thrombocytopenia, and hepatosplenomegaly. Right axillary lymph node biopsy.

Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury

Patient presents for therapy of suspected rheumatoid arthritis.

Incision and drainage and removal of foreign body, right foot. The case has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.

Bunion, left foot. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.

Chiropractic Evaluation for neck and low back ache following a car accident.

Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.

Asked to see the patient in regards to a brain tumor. She was initially diagnosed with a glioblastoma multiforme. She presented with several lesions in her brain and a biopsy confirmed the diagnosis.

Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.

Chronic plantar fasciitis, right foot. Open plantar fasciotomy, right foot.

Is it BNP or BMP?

Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.

Incision and drainage of right buccal space abscess and teeth extraction.

Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis.

Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.

Elevated cholesterol and is on medication to lower it.

Patient complains of constipation. Has not had BM for two days.

Torn rotator cuff and subacromial spur with impingement syndrome, right shoulder. Diagnostic arthroscopy with subacromial decompression and open repair of rotator cuff using three Panalok suture anchors.

Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.

Emergency cesarean section.

CT Scan of brain without contrast.

Chiropractic IME with answers to questions from Insurance Company.

Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.

Diagnosis of benign rolandic epilepsy.

He got addicted to drugs. He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom.

Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.

Status post brain tumor with removal. The client did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.

The case underwent an overnight polysomnogram.

Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.

Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.