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Removal of the hardware and revision of right AC separation. Loose hardware with superior translation of the clavicle implants. Arthrex bioabsorbable tenodesis screws.

Left and right coronary system cineangiography. Left ventriculogram. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.

Letter to the client to let him know about his abnormal cholesterol test results.

MRI report Cervical Spine (Chiropractic Specific)

Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.

Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.

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

This is a middle-aged female with two month history of low back ache and leg pain.

Laparoscopic cholecystectomy.

Autopsy - Homicide - Blunt force cranial trauma

Encephalopathy related to normal-pressure hydrocephalus.

The case was referred for evaluation of cataracts bilaterally

Exam under anesthesia with uterine suction curettage. A 10-1/2 week pregnancy, spontaneous, incomplete abortion.

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.

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

Pediatric Gastroenterology - Rectal Bleeding Consult.

Followup of moderate-to-severe sleep apnea. The case returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.

Patient has prostate cancer with metastatic disease to his bladder. The patient has had problems with hematuria in the past. The patient was encouraged to drink extra water and was given discharge instructions on hematuria.

Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.

Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.

Lumbar epidural steroid injection, L5-S1. Low back pain.

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

Excision of ganglion of the left wrist. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.

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

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

Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI. The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.

The client 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.

Fever, otitis media, and possible sepsis.

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

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

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

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

Overactive bladder with microscopic hematuria.

Phacoemulsification of cataract and posterior chamber lens implant, right eye.

A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.

The client is being referred for evaluation of diabetic retinopathy.

Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor. Left hallux bone invasion of the distal phalanx.

Excision of left breast mass. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin.

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

Left third digit numbness and wrist pain.

Consultation for left foot pain.

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

Sample/template for a normal male multisystem exam.

Management of end-stage renal disease (ESRD), the case on chronic hemodialysis, being admitted for chest pain.

The patient is a 53-year-old woman with history of hypertension, diabetes, and depression. Serotonin syndrome secondary to high doses of Prozac and atypical chest pain with myocardial infarction ruled out.

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

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

Consultation for left foot pain.

Sample post dilation client instructions.

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

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

Evaluation for chronic pain program

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

Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.

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

MRI Brain & T-spine - Demyelinating disease.

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.

Consult for laparoscopic gastric bypass.

A sample note on Rheumatoid Arthritis

Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.

Left masticator space infection secondary to necrotic tooth #17. Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.

Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,

A 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.

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

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 discomfort and left low back pain.

Endoscopic proximal shunt revision.

Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.

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

Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.

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

Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.

School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom. Asperger disorder. Obsessive compulsive disorder.

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

Nerve root decompression at L45 on the left side. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. Interpretation of radiograph.

Occupational medicine consult with questions-answers and records review.

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

Phacoemulsification of cataract and posterior chamber lens implant, right eye.

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

Repair of left inguinal hernia indirect. The case states that she noticed there this bulge and pain for approximately six days prior to arrival. Upon examination in the office, the case was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.

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 client 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.

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

Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.

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

Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.

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

Excision of left breast mass. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin.

Creation of AV fistula, left wrist in the anatomic snuffbox.

Consultation for wrist pain.

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

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

Female with intermittent rectal bleeding, not associated with any weight loss. The case is chronically constipated.

Pain management for post-laminectomy low back syndrome and radiculopathy.

Patient with NIDDM, hypertension, CAD status post CABG, hyperlipidemia, etc.

CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.

A sample note on Rheumatoid Arthritis

Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.

Backache, stomachache, and dysuria for the last two days - Urinary dysuria, left flank pain, pharyngitis.

MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.

Occupational medicine consult with questions-answers and records review.