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A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina.

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

Chiropractic IME with answers to questions from Insurance Company.

Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung".

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

Total abdominal hysterectomy and bilateral salpingo-oophorectomy.

Excision of foreign body, right foot and surrounding tissue. This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot.

Mental status changes after a fall. She sustained a concussion with postconcussive symptoms and syndrome that has resolved.

A female with unknown gestational age who presents to the ED after a suicide attempt.

One-week history of decreased vision in the left eye. Past ocular history includes cataract extraction with lens implants in both eyes.

Direct inguinal hernia. Rutkow direct inguinal herniorrhaphy. A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.

Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.

Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.

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

Belly button piercing for insertion of belly button ring.

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

Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve.

The case with continued problems with her headaches.

Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.

Left thyroid mass. Left total thyroid lumpectomy. The client with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.

Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.

Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.

White male with onset of chest pain, with history of on and off chest discomfort over the past several days.

Mother states he has been wheezing and coughing.

Paracentesis. A large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room.

A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.

Foul-smelling urine and stomach ache after meals.

Chiropractic IME with old files review. Detailed Thoracic Spine Examination.

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

Dietary consultation for diabetes during pregnancy.

Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.

Patient with hypertension, dementia, and depression.

C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.

MRI Cervical Spine without contrast.

Lumbar muscle strain and chronic back pain. Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago.

Rotated cuff tear, right shoulder. Glenoid labrum tear. Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder.

Consultation for wrist pain.

Right ear ache with drainage - otitis media and otorrhea.

Plantar fascitis/heel spur syndrome. The client was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.

Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17. Removal of benign cyst and extraction of full bone impacted tooth #17.

Dietary consultation for gestational diabetes.

Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension. The patient is here for followup visit and chemotherapy.

Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck ache and left low back pain.

Pressure decubitus, right hip

Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.

Patient with a history of coronary artery disease, status post coronary artery bypass grafting presented to the emergency room following a syncopal episode.

Epidural steroid injection, epidurogram, fluroscopy - Low back pain, herniated disc, lumbosacral Facet, arthropathy.

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

Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.

Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection. Placement of a right femoral intraaortic balloon pump.

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

Plantar fascitis, left foot. Partial plantar fasciotomy.

Evacuation of epidural hematoma and insertion of epidural drain. Epidural hematoma, cervical spine. Status post cervical laminectomy, C3 through C7 postop day #10. Central cord syndrome and acute quadriplegia.

A sample note on Rheumatoid Arthritis

Chronic laryngitis, hoarseness. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.

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

Acute renal failure, suspected, likely due to multi-organ system failure syndrome.

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.

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

Right ureteropelvic junction obstruction. Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.

This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection.

A case with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma.

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

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

Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.

Specimen labeled "right ovarian cyst" is received fresh for frozen section.

Pain management sample progress note.

Routine colorectal cancer screening. He occasionally gets some loose stools.

Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.

Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.

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

The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.

Dietary consultation for carbohydrate counting for type I diabetes.

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.

Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.

Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat. Sharp excision of left distal foot plantar fascia.

Autopsy - Asphyxia due to ligature strangulation.

Chiropractic IME with answers to questions from Insurance Company.

Patient presents for a colostomy reversal as well as repair of an incisional hernia.

Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This case presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.

Autopsy - Asphyxia due to ligature strangulation.

Counting calorie points, exercising pretty regularly, seems to be doing well

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

A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.

A white female with a history of fevers.

Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.

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

Cosmetic rhinoplasty. Request for cosmetic change in the external appearance of the nose.

Nephrology office visit for followup of microscopic hematuria.

A sample note on Rheumatoid Arthritis

A lady with symptoms consistent with possible oligoarticular arthritis of her knees.

Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7

The patient has had abdominal discomfort associated with a 30-pound weight loss and then developed jaundice. He had epigastric discomfort 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.

Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction. The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission.

A female for a complete physical and follow up on asthma with allergic rhinitis.

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

Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.

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.

Cardiac Catheterization - An obese female with a family history of coronary disease and history of chest radiation for Hodgkin disease, presents with an acute myocardial infarction with elevated enzymes.

Consultation for wrist pain.