transcription,medical_specialty,sentiment
"OPERATIVE NOTE:  ,The patient was taken to the operating room and was placed in the supine position on the operating room table.  A general inhalation anesthetic was administered.  The patient was prepped and draped in the usual sterile fashion.  The urethral meatus was calibrated with a small mosquito hemostat and was gently dilated.  Next a midline ventral type incision was made opening the meatus.  This was done after clamping the tissue to control bleeding.  The meatus was opened for about 3 mm.  Next the meatus was calibrated and easily calibrated from 8 to 12 French with bougie sounds.  Next the mucosal edges were everted and reapproximated to the glans skin edges with approximately five interrupted 6-0 Vicryl sutures.  The meatus still calibrated between 10 and 12 French.  Antibiotic ointment was applied.  The procedure was terminated.  The patient was awakened and returned to the recovery room in stable condition.", Urology,39
"VITAL SIGNS:,  Reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.,CONSTITUTIONAL: , Normal appearance for chronological age, does not appear chronically ill.,HEENT: , The pupils are equal and reactive.  Funduscopic examination is normal.  Posterior pharynx is normal.  Tympanic membranes are clear.,NECK:  ,Trachea is midline.  Thyroid is normal.  The neck is supple.  Negative nodes.,RESPIRATORY:,  Lungs are clear to auscultation bilaterally.  The patient has a normal respiratory rate, no signs of consolidation and no egophony.  There are no retractions or secondary muscle use.  Good bilateral breath sounds are noted.,CARDIOVASCULAR: , No jugular venous distention or carotid bruits.  No increase in heart size to percussion.  There is no murmur.  Normal S1 and S2 sounds are noted without gallop.,ABDOMEN: , Soft to palpation in all four quadrants.  There is no organomegaly and no rebound tenderness.  Bowel sounds are normal.  Obturator and psoas signs are negative.,GENITOURINARY: , No bladder tenderness, negative flank pain.,MUSCULOSKELETAL:,  Extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation.,NEUROLOGIC: , Normal Glasgow Coma Scale.  Cranial nerves II through XII appear grossly intact.  Normal motor and cerebellar tests.  Reflexes are normal.,HEME/LYMPH:  ,No abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage.,PSYCHIATRIC: , Normal with no overt depression or suicidal ideations.", Office Notes,25
"HISTORY: , Neurologic consultation was requested to assess and assist with her seizure medication.  The patient is a 3-year 3 months old girl with refractory epilepsy.  She had been previously followed by XYZ, but has been under the care of the UCSF epilepsy program and recently by Dr. Y.  I reviewed her pertinent previous neurology evaluations at CHCC and also interviewed mom.,The patient had seizure breakthrough in August 2007, which requires inpatient admission, Thanksgiving and then after that time had seizures every other day, up-to-date early December.  She remained seizure-free until 12/25/2007 when she had a breakthrough seizure at home treated with Diastat.  She presented to our ER today with prolonged convulsive seizure despite receiving 20 mg of Diastat at home.  Mom documented 103 temperature at home.  In the ER, this was 101 to 102 degrees Fahrenheit.  I reviewed the ER notes.  At 0754 hours, she was having intermittent generalized tonic-clonic seizures despite receiving a total of 1.5 mg of lorazepam x5.  UCSF fellow was contacted.  She was given additional fosphenytoin and had a total dose of 15 mg/kg administered.  Vital weight was 27.  Seizures apparently had stopped.  The valproic acid level obtained at 0835 hours was 79.  According to mom, her last dose was at 6 p.m. and she did not receive her morning dose.  Other labs slightly showed leukocytosis with white blood cell count 21,000 and normal CMP.,Previous workup here showed an EEG on 2005, which showed a left posterior focus.  MRI on June 2007 and January 2005 were within normal limits.  Mom describes the following seizure types:,1.  Eye blinking with unresponsiveness.,2.  Staring off to one side.,3.  Focal motor activity in one arm and recently generalized tonic seizure.,She also said that she was supposed to see Dr. Y this Friday, but had postponed it to some subsequent time when results of genetic testing would be available.  She was being to physicians' care as Dr. Z had previously being following her last UCSF.,She had failed most of the first and second line anti-epileptic drugs.  These include Keppra, Lamictal, Trileptal, phenytoin and phenobarbital.  These are elicited to allergies, but she has not had any true allergic reactions to these.  Actually, it has resulted in an allergic reaction resulting in rash and hypotension.,She also had been treated with Clobazam.  Her best control is with her current regimen of valproic acid and Tranxene.  Other attempts to taper Topamax, but this resulted increased seizures.  She also has oligohidrosis during this summertime.,CURRENT MEDICATIONS: , Include Diastat 20 mg; Topamax 25 mg b.i.d., which is 3.3 per kilo per day; Tranxene 15 mg b.i.d.; Depakote 125 mg t.i.d., which is 25 per kilo per day.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight 15 kg.,GENERAL:  The patient was awake, she appeared sedated and postictal.,NECK:  Supple.,NEUROLOGICAL:  She had a few brief myoclonic jerks of her legs during drowsiness, but otherwise no overt seizure, no seizure activity nor involuntary movements were observed.,She was able to follow commands such as when I request that she gave mom a kiss.  She acknowledged her doll.  Left fundus is sharp.  She resisted the rest of the exam.  There was no obvious lateralized findings.,ASSESSMENT:,  Status epilepticus resolved.  Triggered by a febrile illness, possibly viral.  Refractory remote symptomatic partial epilepsy.,IMPRESSION: , I discussed the maximizing Depakote to mom and she concurred.  I recommend increasing her maintenance dose to one in the morning, one in the day, and two at bedtime.  For today, she did give an IV Depacon 250 mg and the above dosage can be continued IV until she is taking p.o.  Dr. X agreed with the changes and orders were written for this.  She can continue her current doses of Topamax and Tranxene.  This can be given by NG if needed.  Topamax can be potentially increased to 25 mg in the morning and 50 mg at night.  I will be available as needed during the rest of her hospitalization.  Mom will call contact Dr. Y an update him about the recent changes.", Neurology,22
"ANATOMICAL SUMMARY,1. Sharp force wound of neck, left side, with transection of left internal jugular vein.,2. Multiple stab wounds of chest, abdomen, and left thigh: Penetrating stab wounds of chest and abdomen with right hemothorax and hemoperitoneum.,3. Multiple incised wounds of scalp, face, neck, chest and left hand (defense wound).,4. Multiple abrasions upper extremities and hands (defense wounds).,NOTES AND PROCEDURES,1. The body is described in the Standard Anatomical Position. Reference is to this position only.,2. Where necessary, injuries are numbered for reference. This is arbitrary and does not correspond to any order in which they may have been incurred. All the injuries are antemortem, unless otherwise specified.,3. The term ""anatomic"" is used as a specification to indicate correspondence with the description as set forth in the textbooks of Gross Anatomy. It denotes freedom from significant, visible or morbid alteration.,EXTERNAL EXAMINATION:, The body is that of a well developed, well nourished Caucasian male stated to be 25 years old. The body weighs 171 pounds, measuring 69 inches from crown to sole. The hair on the scalp is brown and straight. The irides appear hazel with the pupils fixed and dilated.  The sclerae and conjunctive are unremarkable, with no evidence of petechial hemorrhages on either. Both upper and lower teeth are natural, and there are no injuries of the gums, cheeks, or lips.,There is a picture-type tattoo on the lateral aspect of the left upper arm. There are no deformities, old surgical scars or amputations.,Rigor mortis is fixed.,The body appears to the Examiner as stated above. Identification is by toe tag and  the autopsy is not material to identification. The body is not embalmed.,The head is normocephalic, and there is extensive evidence of external traumatic injury, to be described below. Otherwise, the eyes, nose and mouth are not remarkable. The neck shows sharp force injuries to be described below. The front of the chest and abdomen likewise show injuries to be described below. The genitalia are that of an adult male, with the penis circumcised, and no evidence of injury.,Examination of the posterior surface of the trunk reveals no antemortem traumatic injuries.,Refer to available photographs and diagrams and to the specific documentation of the autopsy protocol.,CLOTHING:,  The clothes were examined both before and after removal from the body.,The decedent was wearing a long-sleeved type of shirt/sweater; it was extensively bloodstained.,On the front, lower right side, there was a 1 1/2 inch long slit-like tear. Also on the lower right sleeve there was a 1 inch slit-like tear. On the back there was a 1/2 inch slit-like tear on the right lower side.,Decedent was wearing a pair of Levi jeans bloodstained.  On the outside of the left hip region there was a 1-1/2 inch long slit-like tear. The decedent also was wearing 2 canvas type boots and 2 sweat socks.,EVIDENCE OF THERAPEUTIC INTERVENTION:,  None.,EVIDENCE OF INJURY,SHARP FORCE INJURIES OF NECK,1.  Sharp force injury of neck, left side, transecting left internal jugular vein. This sharp force injury is complex, and appears to be a combination of a stabbing and cutting wound. It begins on the left side of the neck, at the level of the midlarynx, over the left sternocleidomastoid muscle; it is gaping, measuring 3 inches in length with smooth edges. It tapers superiorly to 1 inch in length cut skin. Dissection discloses that the wound path is through the skin, the subcutaneous tissue, and the sternocleidomastoid muscle with hemorrhage along the wound path and transection of the left internal jugular vein, with dark red-purple hemorrhage in the adjacent subcutaneous tissue and fascia. The direction of the pathway is upward and slightly front to back for a distance of approximately 4 inches where it exits, post-auricular, in a 2 inch in length gaping stab/incised wound which has undulating or wavy borders, but not serrated. Intersecting the wound at right angle superior inferior is a 2 inch in length interrupted superficial, linear incised wound involving only the skin. Also, intervening between the 2 gaping stab-incised wounds is a horizontally oriented 3-1/2 inch in length interrupted superficial, linear incised wound of the skin only.  In addition, there is a 1/2 inch long, linear-triangular in size wound of the inferior portion of the left earlobe.  The direction of the sharp force injury is upward (rostral), and slightly front to back with no significant angulation or deviation. The total length of the wound path is approximately 4 inches. However, there is a 3/4 inch in length, linear, cutting or incised wound of the top or superior aspect of the pinna of the left ear; a straight metallic probe placed through the major sharp force injury shows that the injury of the superior part of the ear can be aligned with the straight metallic rod, suggesting that the 3 injuries are related; in this instance the total length of the wound path is approximately 6 inches. Also, in the left postauricular region, transversely oriented, extending from the auricular attachment laterally to the scalp is a 1-1/8 inch in length linear superficial incised skin wound.,OPINION: , This sharp force injury of the neck is fatal, associated with transection of the left internal jugular vein.,2.  Sharp force wound of the right side of neck. This is a complex injury, appearing to be a combination stabbing and cutting wound. The initial wound is present on the right side of the neck, over the sternocleidomastoid muscle, 3 inches directly below the right external auditory canal. It is diagonally oriented, and after approximation of the edges measures 5/8 inch in length; there is a pointed or tapered end inferiorly and a split or forked end superiorly approximately 1/16 inch in maximal width. Subsequent autopsy shows that the wound path is through the skin and subcutaneous tissue, without penetration of injury of a major,artery or vein; the direction is front to back and upward for a total wound path length of 2 inches and the wound exits on the right side of the back of the neck, posterior to the right sternocleidomastoid muscle where a 2 inch long gaping incised/stab wound is evident on the skin; both ends are tapered; superiorly there is a 1 inch long superficial incised wounds extension on the skin to the back of the head; inferiorly there is a 2 inch long incised superficial skin extension, extending inferiorly towards the back of the neck. There is fresh hemorrhage and bruising along the wound path; the direction, as stated, is upward and slightly front to back.,OPINION: ,This is a nonfatal sharp force injury, with no injury or major artery or vein.,3.  At the level of the superior border of the larynx there is a transversely oriented, superficial incised wound of the neck, extending from 3 inches to the left of the anterior midline; it is 3 inches in length and involves the skin only; a small amount of cutaneous hemorrhage is evident.,OPINION:, This is a nonfatal superficial incised wound.,4.  ImmediateLY inferior and adjacent to incised wound #3 is a transversely oriented, superficial incised wound involving the skin and subcutaneous tissue; there is a small amount of dermal hemorrhage.,OPINION:, This is a nonfatal superficial incised wound.,SHARP FORCE INJURIES OF FACE,1.  There is a stab wound, involving the right earlobe; it is vertically oriented, and after approximation of the edges measures 1 inch in length with forked or split ends superiorly and inferiorly approximately 1/16 inch in total width both superior and inferior. Subsequent dissection discloses that the wound path is from right to left, in the horizontal plane for approximately 1-1/4 inches; there is fresh hemorrhage along the wound path; the wound path terminates in the left temporal bone and does not penetrate the cranial cavity.,OPINION:, This is a nonfatal stab wound.,2.  There is a group of 5 superficial incised or cutting wounds on the right side of the face, involving the right cheek and the right side of the jaw. They are varied in orientation both diagonal and horizontal; the smallest is 1/4 inch in length; the largest 5/8 inch in length. They are superficial, involving the skin only, associated with a small amount of cutaneous hemorrhage.,3.  On the back of the neck, right side, posterior to the ear and posterior border of the right sternocleidomastoid muscle there is vertically oriented superficial incised skin wound, measuring 3/4 inch in length.,4.  There are numerous superficial incised wounds or cuts, varied in orientation, involving the skin of the right cheek, intersection and mingled with the various superficial incised wounds described above. The longest is a 3 inch long diagonally oriented superficial incised wound extending from the right side of the forehead to the cheek; various other superficial wound vary from 1/2 to 1 inch.,5.  On the right side of the cheek, adjacent to the ramus of the mandible, right, there is a 1-1/2 x 3/4 inch superficial nonpatterned red-brown abrasion with irregular border, extending superiorly towards the angle of the jaw where there are poorly defined and circumscribed abrasions adjacent to the superficial cuts or abrasions described above. It should be noted that the 5th superficial incised wound of the right side of the mandible which measures 5/8 inch in length is tapered on the posterior aspect and forked on the anterior aspect where it has a width of 1/32 inch.,6.  On the left ear, there is a superficial incised wound measuring 1/4 inch, adjacent to the posterior border of the pinna. Just below this on the inferior pinna, extending to the earlobe, there is an interrupted superficial linear abrasion measuring 1 inch in length.", Autopsy,1
"INDICATIONS FOR PROCEDURE:, The patient has presented with atypical type right arm discomfort and neck discomfort. She had noninvasive vascular imaging demonstrating suspected right subclavian stenosis. Of note, there was bidirectional flow in the right vertebral artery, as well as 250 cm per second velocities in the right subclavian. Duplex ultrasound showed at least a 50% stenosis.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation with cardiac catheterization protocol. Local infiltration with 1% Xylocaine.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Less than 10 ml.,ESTIMATED CONTRAST:, Less than 250 ml.,PROCEDURE PERFORMED:, Right brachiocephalic angiography, right subclavian angiography, selective catheterization of the right subclavian, selective aortic arch angiogram, right iliofemoral angiogram, 6 French Angio-Seal placement.,DESCRIPTION OF PROCEDURE:, The patient was brought to the cardiac catheterization lab in the usual fasting state. She was laid supine on the cardiac catheterization table, and the right groin was prepped and draped in the usual sterile fashion. 1% Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was introduced into the right femoral artery via the modified Seldinger technique.,AORTIC ARCH ANGIOGRAM:, Next, a pigtail catheter was advanced to the aortic arch. Aortic arch angiogram was then performed with injection of 45 ml of contrast, rate of 20 ml per second, maximum pressure 750 PSI in the 4 degree LAO view.,SELECTIVE SUBCLAVIAN ANGIOGRAPHY:, Next, the right subclavian was selectively cannulated. It was injected in the standard AP, as well as the RAO view. Next pull back pressures were measured across the right subclavian stenosis. No significant gradient was measured.,ANGIOGRAPHIC DETAILS:, The right brachiocephalic artery was patent. The proximal portion of the right carotid was patent. The proximal portion of the right subclavian prior to the origin of the vertebral and the internal mammary showed 50% stenosis.,IMPRESSION:,1. Moderate grade stenosis in the right subclavian artery.,2. Patent proximal edge of the right carotid.", Cardiovascular / Pulmonary,3
"CLINICAL HISTORY: ,This 78-year-old black woman has a history of hypertension, but no other cardiac problems. She noted complaints of fatigue, lightheadedness, and severe dyspnea on exertion. She was evaluated by her PCP on January 31st and her ECG showed sinus bradycardia with a rate of 37 beats per minute. She has had intermittent severe sinus bradycardia alternating with a normal sinus rhythm, consistent with sinoatrial exit block, and she is on no medications known to cause bradycardia. An echocardiogram showed an ejection fraction of 70% without significant valvular heart disease.,PROCEDURE:, Implantation of a dual chamber permanent pacemaker.,APPROACH:, Left cephalic vein.,LEADS IMPLANTED: ,Medtronic model 12345 in the right atrium, serial number 12345. Medtronic 12345 in the right ventricle, serial number 12345.,DEVICE IMPLANTED: ,Medtronic EnRhythm model 12345, serial number 12345.,LEAD PERFORMANCE: ,Atrial threshold less than 1.3 volts at 0.5 milliseconds. P wave 3.3 millivolts. Impedance 572 ohms. Right ventricle threshold 0.9 volts at 0.5 milliseconds. R wave 10.3. Impedance 855.,ESTIMATED BLOOD LOSS:, 20 mL.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with Versed and fentanyl. The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. A 2-1/2-inch incision was made below the left clavicle and electrocautery was used for hemostasis. Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator. The deltopectoral groove was explored and a medium-sized cephalic vein was identified. The distal end of the vein was ligated and a venotomy was performed. Two guide wires were advanced to the superior vena cava and peel-away introducer sheaths were used to insert the two pacing leads. The venous pressures were elevated and there was a fair amount of back-bleeding from the vein, so a 3-0 Monocryl figure-of-eight stitch was placed around the tissue surrounding the vein for hemostasis. The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage. The leads were tested with a pacing systems analyzer and the results are noted above. The leads were then anchored in place with #0-silk around their suture sleeve and connected to the pulse generator. The pacemaker was noted to function appropriately. The pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket. The incision was closed with two layers of 3-0 Monocryl and a subcuticular closure of 4-0 Monocryl. The incision was dressed with Steri-Strips and a sterile bandage and the patient was returned to her room in good condition.,IMPRESSION: ,Successful implantation of a dual chamber permanent pacemaker via the left cephalic vein. The patient will be observed overnight and will go home in the morning.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,POSTOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,OPERATION:,  Cysto stent removal.,ANESTHESIA:,  Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,MEDICATIONS: , The patient was on vancomycin and Levaquin was given x1 dose.  The patient was on vancomycin for the last 5 days.,BRIEF HISTORY:  ,The patient is a 53-year-old female who presented with Enterococcus urosepsis.  CT scan showed a lower pole stone with a stent in place.  The stent was placed about 2 months ago, but when patient came in with a possibly UPJ stone with fevers of unknown etiology.  The patient had a stent placed at that time due to the fevers, thinking that this was an urospetic stone.  There was some pus that came out.  The patient was cultured; actually it was negative at that time.  The patient subsequently was found to have lower extremity DVT and then was started on Coumadin.  The patient cannot be taken off Coumadin for the next 6 months due to the significant swelling and high risk for PE.  The repeat films were taken which showed the stone had migrated into the pole.,The stent was intact.  The patient subsequently developed recurrent UTIs and Enterococcus in the urine with fevers.  The patient was admitted for IV antibiotics since the patient could not really tolerate penicillin due to allergy and due to patient being on Coumadin, Cipro, and Levaquin where treatment was little bit more complicated.  Due to drug interaction, the patient was admitted for IV antibiotic treatment.  The thinking was that either the stone or the stent is infected, since the stone is pretty small in size, the stent is very likely possibility that it could have been infected and now it needs to be removed.  Since the stone is not obstructing, there is no reason to replace the stent at this time.  We are unable to do the ureteroscopy or the shock-wave lithotripsy when the patient is fully anticoagulated.  So, the best option at this time is to probably wait and perform the ureteroscopic laser lithotripsy when the patient is allowed to off her Coumadin, which would be probably about 4 months down the road.,Plan is to get rid of the stent and improve patient's urinary symptoms and to get rid of the infection and we will worry about the stone at later point.,DETAILS OF THE OR: , Consent had been obtained from the patient.  Risks, benefits, and options were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed.  The patient understood all the risks and benefits of removing the stent and wanted to proceed.  The patient was brought to the OR.  The patient was placed in dorsal lithotomy position.  The patient was given some IV pain meds.  The patient had received vancomycin and Levaquin preop.  Cystoscopy was performed using graspers.  The stent was removed without difficulty.  Plan was for repeat cultures and continuation of the IV antibiotics.", Urology,39
"PREOPERATIVE DIAGNOSIS: , Penoscrotal abscess.,POSTOPERATIVE DIAGNOSIS:,  Penoscrotal abscess.,OPERATION: , Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.,BRIEF HISTORY: , The patient is a 75-year-old male presented with penoscrotal abscess.  Options such as watchful waiting, drainage, and antibiotics were discussed.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, completely the infection turning into necrotizing fascitis, Fournier's gangrene were discussed.  The patient already had significant phimotic changes and disfigurement of the penis.  For further debridement the patient was told that his penis is not going to be viable, he may need a total or partial penectomy now or in the future.  Risks of decreased penile sensation, pain, Foley, other unexpected issues were discussed.  The patient understood all the complications and wanted to proceed with the procedure.,DETAIL OF THE OPERATION:  ,The patient was brought to the OR.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in the usual fashion.  Pictures were taken prior to starting the procedure for documentation.  The patient had an open sore on the right side of the penis measuring about 1 cm in size with pouring pus out using blunt dissection.  The penile area was opened up distally to allow the pus to come out.  The dissection around the proximal scrotum was done to make sure there are no other pus pockets.  The corporal body was intact, but the distal part of the corpora was completely eroded and had a fungating mass, which was biopsied and sent for permanent pathology analysis.,Urethra was identified at the distal tip, which was dilated and using 23-French cystoscope cystoscopy was done, which showed some urethral narrowing in the distal part of the urethra.  The rest of the bladder appeared normal.  The prostatic urethra was slightly enlarged.  There are no stones or tumors inside the bladder.  There were moderate trabeculations inside the bladder.  Otherwise, the bladder and the urethra appeared normal.  There was a significantly fungating mass involving the distal part of the urethra almost possibility to have including the fungating wart or fungating squamous cell carcinoma.  Again biopsies were sent for pathology analysis.  Prior to urine irrigation anaerobic aerobic cultures were sent, irrigation with over 2 L of fluid was performed.  After irrigation, packing was done with Kerlix.  The patient was brought to recovery in a stable condition.  Please note that 18-French Foley was kept in place.  Electrocautery was used at the end of the procedure to obtain hemostasis as much as possible, but there was fungating mass with slight bleeding packing was done and tight scrotal Kling was applied.  The patient was brought to Recovery in a stable condition after applying 0.5% Marcaine about 20 mL were injected around for local anesthesia.", Surgery,38
"INDICATIONS:,  Ischemic cardiomyopathy, status post inferior wall myocardial infarction, status post left anterior descending PTCA and stenting.,PROCEDURE DONE:,  Adenosine Myoview stress test.,STRESS ECG RESULTS:,  The patient was stressed by intravenous adenosine, 140 mcg/kg/minute infused over four minutes.  The baseline resting electrocardiogram revealed an electronic pacemaker depolarizing the ventricles regularly at a rate of 70 beats per minute.  Underlying atrial fibrillation noted, very wide QRS complexes.  The heart rate remained unchanged at 70 beats per minute as the blood pressure decreased from 140/80 to 110/70 with adenosine infusion.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS: , Ruptured distal biceps tendon, right elbow.,POSTOPERATIVE DIAGNOSIS:,  Ruptured distal biceps tendon, right elbow.,PROCEDURE PERFORMED: , Repair of distal biceps tendon, right elbow.,PROCEDURE:  ,The patient was taken to OR, Room #2 and administered a general anesthetic.  The right upper extremity was then prepped and draped in the usual manner.  A sterile tourniquet was placed on the proximal aspect of the right upper extremity.  The extremity was then elevated and exsanguinated with an Esmarch bandage and tourniquet was inflated to 250 mmHg.  Tourniquet time was 74 minutes.  A curvilinear incision was made in the antecubital fossa of the right elbow down through the skin.  Hemostasis was achieved utilizing electrocautery.  Subcutaneous fat was separated and the skin flaps elevated.  The _________ was identified.  It was incised.  The finger was placed approximately up the anterior aspect of the arm and the distal aspect of the biceps tendon was found.  There was some serosanguineous fluid from the previous rupture.  This area was suctioned clean.  The biceps tendon ends were then placed over a sterile tongue blade and were then sharply cut approximately 5 mm to 7 mm from the tip to create a fresh surface.  At this point, the #2 fiber wire was then passed through the tendon.  Two fiber wires were utilized in a Krackow-type suture.  Once this was completed, dissection was taken digitally down into the antecubital fossa in the path where the biceps tendon had been previously.  The radial tuberosity was palpated.  Just ulnar to this, a curved hemostat was passed through the soft tissues and was used to tent the skin on the radial aspect of the elbow.  A skin incision was made over this area.  Approximately two inches down to the skin and subcutaneous tissues, the fascia was split and the extensor muscle was also split.,A stat was then attached through the tip of that stat and passed back up through the antecubital fossa.  The tails of the fiber wire suture were grasped and pulled down through the second incision.  At this point, they were placed to the side.  Attention was directed at exposure of the radial tuberosity with a forearm fully pronated.  The tuberosity came into view.  The margins were cleared with periosteal elevator and sharp dissection.  Utilizing the power bur, a trough approximately 1.5 cm wide x 7 mm to 8 mm high was placed in the radial tuberosity.  Three small drill holes were then placed along the margin for passage of the suture.  The area was then copiously irrigated with gentamicin solution.  A #4-0 pullout wire was utilized to pass the sutures through the drill holes, one on each outer hole and two in the center hole.  The elbow was flexed and the tendon was then pulled into the trough with the forearm supinated.  The suture was tied over the bone islands.  Both wounds were then copiously irrigated with gentamicin solution and suctioned dry.  Muscle fascia was closed with running #2-0 Vicryl suture on the lateral incision followed by closure of the skin with interrupted #2-0 Vicryl and small staples.  The anterior incision was approximated with interrupted #2-0 Vicryl for Subq. and then skin was approximated with small staples.  Both wounds were infiltrated with a total of 30 cc of 0.25% Marcaine solution for postop analgesia.  A bulky fluff dressing was applied to the elbow, followed by application of a long-arm plaster splint maintaining the forearm in the supinated position.  Tourniquet was inflated prior to application of the splint.  Circulatory status returned to the extremity immediately.  The patient was awakened.  He was rather boisterous during his awakening, but care was taken to protect the right upper extremity.  He was then transferred to the recovery room in apparent satisfactory condition.", Surgery,38
"HISTORY OF PRESENT ILLNESS: , The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat.  She had an EGD and colonoscopy with Dr. ABC a few days prior to this admission.  Colonoscopy did reveal diverticulosis and EGD showed retained bile and possible gastritis.  Biopsies were done.  The patient presented to our emergency room for worsening abdominal pain as well as swelling of the right lower leg.,PAST MEDICAL HISTORY: , Extensive and well documented in prior charts.,PHYSICAL EXAMINATION: , Abdomen was diffusely tender.  Lungs clear.  Blood pressure 129/69 on admission.  At the time of admission, she had just a trace of bilateral lower edema.,LABORATORY STUDIES: , White count 6.7, hemoglobin 13, hematocrit 39.3.  Potassium of 3.2 on 08/15/2007.,HOSPITAL COURSE: , Dr. ABC apparently could not advance the scope into the cecum and therefore warranted a barium enema.  This was done and did not really show what the cecum on the barium enema.  There was some retained stool in that area and the patient had a somewhat prolonged hospital course on the remaining barium from the colon.  She did have some enemas.  She had persistent nausea, headache, neck pain throughout this hospitalization.  Finally, she did improve enough to the point where she could be discharged home.,DISCHARGE DIAGNOSIS: , Nausea and abdominal pain of uncertain etiology.,SECONDARY DIAGNOSIS:  ,Migraine headache.,COMPLICATIONS:  ,None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN:  ,Follow up with me in the office in 5 to 7 days to resume all pre-admission medications.  Diet and activity as tolerated.", Discharge Summary,10
"Informed written consent has been obtained from the patient.  I explained the procedure to her prior to initiation of such.  The appropriate time-out procedure as per Medical Center protocol was performed prior to the procedure being begun while the patient was actively participating with appropriate identification of the patient, procedure, physician, documentation, position.  There were no safety concerns noted by staff nor myself.,REST ECHO:,  EF 60%.  No wall motion abnormalities.  EKG shows normal sinus rhythm with mild ST depressions.  The patient exercised for 7 minutes 30 seconds on a standard Bruce protocol, exceeding target heart rate; no angina nor significant ECG changes seen.  Peak stress echo imaging shows EF of 75%, no regional wall motion abnormalities.  There was resting hypertension noted, systolic of approximately 152 mmHg with appropriate response of blood pressure to exercise.  No dysrhythmias noted.,IMPRESSION:,1.  Negative exercise ECG/echocardiogram stress evaluation for inducible ischemia in excess of target heart rate.,2.  Resting hypertension with appropriate response of blood pressure to exercise.,These results have been discussed with the patient.  Other management as per the hospital-based internal medicine service.,To be clear, there were no complications of this procedure.", Cardiovascular / Pulmonary,3
"CC: ,Motor vehicle-bicycle collision.,HX:, A 5 y/o boy admitted 10/17/92. He was struck while riding his bicycle by a motor vehicle traveling at a high rate of speed. First responders found him unconscious with left pupil 6 mm and unreactive and the right pupil 3 mm and reactive. He had bilateral decorticate posturing and was bleeding profusely from his nose and mouth. He was intubated and ventilated in the field, and then transferred to UIHC.,PMH/FHX/SHX:, unremarkable.,MEDS:, none,EXAM:, BP 127/91 HR69 RR30,MS: unconscious and intubated,Glasgow coma scale=4,CN: Pupils 6/6 fixed. Corneal reflex: trace OD, absent OS. Gag present on manipulation of endotracheal tube.,MOTOR/SENSORY: bilateral decorticate posturing to noxious stimulation (chest).,Reflexes: bilaterally.,Laceration of mid forehead exposing calvarium.,COURSE:, Emergent Brain CT scan revealed: Displaced fracture of left calvarium. Left frontoparietal intraparenchymal hemorrhage. Right ventricular collection of blood. Right cerebral intraparenchymal hemorrhage. Significant mass effect with deviation of the midline structures to right. The left ventricle was compressed with obliteration of the suprasellar cistern. Air within the soft tissues in the left infra temporal region. C-spine XR, Abdominal/Chest CT were unremarkable.,Patient was taken to the OR emergently and underwent bifrontal craniotomy, evacuation of a small epidural and subdural hematomas, and duraplasty. He was given mannitol enroute to the OR and hyperventilated during and after the procedure. Postoperatively he continued to manifest decerebrate posturing . On 11/16/92 he underwent VP shunting with little subsequent change in his neurological status. On 11/23/92 he underwent tracheostomy. On 12/11/92 he underwent bifrontal acrylic prosthesis implantation for repair of the bifrontal craniectomy. By the time of discharge, 1/14/93, he tracked relatively well OD, but had a CN3 palsy OS. He had relatively severe extensor rigidity in all extremities (R>L). His tracheotomy was closed prior to discharge. A 11/16/92 Brain MRI demonstrated infarction in the upper brain stem (particularly in the Pons), left cerebellum, right basil ganglia and thalamus.,He was initially treated for seizure prophylaxis with DPH, but developed neutropenia, so it was discontinued. He developed seizures within several months of discharge and was placed on VPA (Depakene). This decreased seizure frequency but his liver enzymes became elevated and he changed over to Tegretol. 10/8/93 Brain MRI (one year after MVA) revealed interval appearance of hydrocephalus, abnormal increased T2 signal (in the medulla, right pons, both basal ganglia, right frontal and left occipital regions), a small mid-brain, and a right subdural fluid collection. These findings were consistent with diffuse axonal injury of the white matter and gray matter contusion, and signs of a previous right subdural hematoma.,He was last seen 10/30/96 in the pediatric neurology clinic--age 9 years. He was averaging 2-3 seizures per day---characterized by extension of BUE with tremor and audible cry or laughter---on Tegretol and Diazepam. In addition he experiences 24-48hour periods of ""startle response (myoclonic movement of the shoulders)"" with or without stimulation every 6 weeks. He had limited communication skills (sparse speech). On exam he had disconjugate gaze, dilated/fixed left pupil, spastic quadriplegia.", Neurology,22
"DIAGNOSIS ON ADMISSION: , Gastrointestinal bleed.,DIAGNOSES ON DISCHARGE,1. Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.,2. Atherosclerotic cardiovascular disease.,3. Hypothyroidism.,PROCEDURE:,  Colonoscopy.,FINDINGS:,  Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.,HOSPITAL COURSE:  ,The patient was admitted to the emergency room by Dr. X. He apparently had an NG tube placed in the emergency room with gastric aspirate revealing no blood.  Dr. Y Miller saw him in consultation and recommended a colonoscopy.  A bowel prep was done.  H&Hs were stable.  His most recent H&H was 38.6/13.2 that was this morning.  His H&H at admission was 41/14.3.  The patient had the bowel prep that revealed no significant bleeding.  His vital signs are stable.  He is continuing on his usual medications of Imdur, metoprolol, and Synthroid.  His Plavix is discontinued.  He is given IV Protonix.  I am hesitant to use Prilosec or Protonix because of his history of pancreatitis associated with Prilosec.,The patient's PT/INR was 1.03, PTT 25.8.  Chemistry panel was unremarkable.  The patient was given a regular diet after his colonoscopy today.  He tolerated it well and is being discharged home.  He will be followed closely as an outpatient.  He will continue his Pepcid 40 mg at night, Imdur, Synthroid, and metoprolol as prior to admission.  He will hold his Plavix for now.  They will call me for further dark stools and will avoid Pepto-Bismol.  They will follow up in the office on Thursday.", Gastroenterology,14
"PREOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Hiatal hernia.,POSTOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Hiatal hernia.,3.  Enterogastritis.,PROCEDURE PERFORMED:  ,Esophagogastroduodenoscopy, photography, and biopsy.,GROSS FINDINGS: , The patient has a history of epigastric abdominal pain, persistent in nature.  She has a history of severe gastroesophageal reflux disease, takes Pepcid frequently.  She has had a history of hiatal hernia.  She is being evaluated at this time for disease process.  She does not have much response from Protonix.,Upon endoscopy, the gastroesophageal junction is approximately 40 cm.  There appeared to be some inflammation at the gastroesophageal junction and a small 1 cm to 2 cm hiatal hernia.  There is no advancement of the gastric mucosa up into the lower one-third of the esophagus.  However there appeared to be inflammation as stated previously in the gastroesophageal junction.  There was some mild inflammation at the antrum of the stomach.  The fundus of the stomach was within normal limits.  The cardia showed some laxity to the lower esophageal sphincter.  The pylorus is concentric.  The duodenal bulb and sweep are within normal limits.  No ulcers or erosions.,OPERATIVE PROCEDURE: , The patient is taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position.  The patient was given IV sedation using Demerol and Versed.  Olympus videoscope was inserted into the hypopharynx and upon deglutition passed into the esophagus.  Using air insufflation, panendoscope was advanced down the esophagus into the stomach along the greater curvature of the stomach through the pylorus into the duodenal bulb and sweep and the above gross findings were noted.  Panendoscope was slowly withdrawn carefully examining the lumen of the bowel.  Photographs were taken with the pathology present.  Biopsy was obtained of the antrum of the stomach and also CLO test.  The biopsy is also obtained of the gastroesophageal junction at 12, 3, 6 and 9 o' clock positions to rule out occult Barrett's esophagitis.  Air was aspirated from the stomach and the panendoscope was removed.  The patient sent to recovery room in stable condition.", Surgery,38
"PROCEDURES: , Total knee replacement.,PROCEDURE DESCRIPTION:,  The patient was bought to the operating room and placed in the supine position.  After induction of anesthesia, a tourniquet was placed on the upper thigh.  Sterile prepping and draping proceeded.  The tourniquet was inflated to 300 mmHg.  A midline incision was made, centered over the patella.  Dissection was sharply carried down through the subcutaneous tissues.  A median parapatellar arthrotomy was performed.  The lateral patellar retinacular ligaments were released and the patella was retracted laterally.  Proximal medial tibia was denuded, with mild release of medial soft tissues.  The ACL and PCL were released.  The medial and lateral menisci and suprapatellar fat pad were removed.  These releases allowed for anterior subluxation of tibia.  An extramedullary tibial cutting jig was pinned to the proximal tibia in the appropriate alignment and flush cut was made along tibial plateau, perpendicular to the axis of the tibia.  Its alignment was checked with the rod and found to be adequate.  The tibia was then allowed to relocate under the femur.,An intramedullary hole was drilled into the femur and a femoral rod attached to the anterior cutting block was inserted, and the block was pinned in appropriate position, judging correct rotation using a variety of techniques.  An anterior rough cut was made.  The distal cutting jig was placed atop this cut surface and pinned to the distal femur, and the rod was removed.  The distal cut was performed.,A spacer block was placed, and adequate balance in extension was adjusted and confirmed, as was knee alignment.  Femoral sizing was performed with the sizer, and the appropriate size femoral 4-in-1 chamfer-cutting block was pinned in place and the cuts were made.  The notch-cutting block was pinned to the cut surface, slightly laterally, and the notch cut was then made.  The trial femoral component was impacted onto the distal femur and found to have an excellent fit.  A trial tibial plate and polyethylene were inserted, and stability was judged and found to be adequate in all planes.  Appropriate rotation of the tibial component was identified and marked.  The trials were removed and the tibia was brought forward again.  The tibial plate size was checked and the plate was pinned to plateau.  A keel guide was placed and the keel was then made.  The femoral intramedullary hole was plugged with bone from the tibia.  The trial tibial component and poly placed; and, after placement of the femoral component, range of motion and stability were checked and found to be adequate in various ranges of flexion and extension.,The patella was held in a slightly everted position with knee in extension.  Patellar width was checked with calipers.  A free-hand cut of the patellar articular surface was performed and checked to ensure symmetry with the calipers.  Sizing was then performed and 3 lug holes were drilled with the jig in place, taking care to medialize and superiorize the component as much as possible, given bony anatomy.  Any excess lateral patellar bone was recessed.  The trial patellar component was placed and found to have adequate tracking.  The trials were removed; and as the cement was mixed, all cut surfaces were thoroughly washed and dried.  The cement was applied to the components and the cut surfaces with digital pressurization, and then the components were impacted.  The excess cement was removed from the gutters and anterior and posterior parts of the knee.  The knee was brought into full extension with the trial polyethylene and further axially pressurized as cement hardened.  Once the cement had hardened, the tourniquet was deflated.  The knee was dislocated again, and any excess cement was removed with an osteotome.  Thorough irrigation and hemostasis were performed.  The real polyethylene component was placed and pinned.  Further vigorous power irrigation was performed, and adequate hemostasis was obtained and confirmed.  The arthrotomy was closed using 0 Ethibond and Vicryl sutures.  The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures.  The skin was sealed with staples.  Xeroform and a sterile dressing were applied followed by a cold-pack and Ace wrap.  The patient was transferred to the recovery room in stable condition, having tolerated the procedure well.", Surgery,38
"PREOPERATIVE DIAGNOSES,1.  Pelvic mass.,2.  Suspected right ovarian cyst.,POSTOPERATIVE DIAGNOSES,1.  Pelvic mass.,2.  Suspected right ovarian cyst.,PROCEDURES,1.  Exploratory laparotomy.,2.  Extensive lysis of adhesions.,3.  Right salpingo-oophorectomy.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , 200 mL,SPECIMENS:  ,Right tube and ovary.,COMPLICATIONS: , None.,FINDINGS: , Extensive adhesive disease with the omentum and bowel walling of the entire pelvis, which required more than 45 minutes of operating time in order to establish visualization and to clear the bowel and other important structures from the ovarian cyst, tube, and ovary in order to remove them.  The large and small bowels were completely enveloping a large right ovarian cystic mass.  Normal anatomy was difficult to see due to adhesions.  Cyst was ruptured incidentally intraoperatively with approximately 150 mL to 200 mL of turbid fluid.  Cyst wall, tube, and ovary were stripped away from the bowel.  Posterior peritoneum was also removed in order to completely remove the cyst wall ovary and tube.  There was excellent postoperative hemostasis.,PROCEDURE:  ,The patient was taken to the operating room, where general anesthesia was achieved without difficulty.  She was then placed in a dorsal supine position and prepped and draped in the usual sterile fashion.  A vertical midline incision was made from the umbilicus and extended to the symphysis pubis along the line of the patient's prior incision.  Incision was carried down carefully until the peritoneal cavity was reached.  Care was taken upon entry of the peritoneum to avoid injury of underlying structures.  At this point, the extensive adhesive disease was noted, again requiring greater than 45 minutes of dissection in order to visualize the intended anatomy for surgery.  The omentum was carefully stripped away from the patient's right side developing a window.  This was extended down along the inferior portion of the incision removing the omentum from its adhesions to the anterior peritoneum and what appears to be the vesicouterine peritoneum.  A large mass of bowel was noted to be adherent to itself causing a quite tortuous course.  Adhesiolysis was performed in order to free up the bowel in order to pack it out of the pelvis.  Excellent hemostasis was noted.  The bowel was then packed over of the pelvis allowing visualization of a matted mass of large and small bowel surrounding a large ovarian cyst.  Careful adhesive lysis and dissection enabled the colon to be separated from the posterior wall of the cyst.  Small bowel and portion of the colon were adherent anteriorly on the cyst and during the dissection of these to remove them from their attachment, the cyst was ruptured.  Large amount of turbid fluid was noted and was evacuated.  The cyst wall was then carefully placed under tension and stripped away from the patient's small and large bowel.  Once the bowel was freed, the remnants of round ligament was identified, elevated, and the peritoneum was incised opening the retroperitoneal space.,The retroperitoneal space was opened following the line of the ovarian vessels, which were identified and elevated and a window made inferior to the ovarian vessels, but superior to the course of the ureter.  This pedicle was doubly clamped, transected, and tied with a free tie of #2-0 Vicryl.  A suture ligature of #0 Vicryl was used to obtain hemostasis.  Excellent hemostasis was noted at this pedicle.  The posterior peritoneum and portion of the remaining broad ligament were carefully dissected and shelled out to remove the tube and ovary, which was still densely adherent to the peritoneum.  Care was taken at the side of the remnant of the uterine vessels.  However, a laceration of the uterine vessels did occur, which was clamped with a right-angle clamp, and carefully sutured ligated with excellent hemostasis noted.  Remainder of the specimen was then shelled out including portions of the posterior and sidewall peritoneum and removed.,The opposite tube and ovary were identified, were also matted behind a large amount of large bowel and completely enveloped and wrapped in the fallopian tube.  Minimal dissection was performed in order to ascertain and ensure that the ovary appeared completely normal.  It was then left in situ.  Hemostasis was achieved in the pelvis with the use of electrocautery.  The abdomen and pelvis were copiously irrigated with warm saline solution.  The peritoneal edges were inspected and found to have good hemostasis after the side of the uterine artery pedicle, and the ovarian vessel pedicle.  The areas of the bowel had previously been dissected and due to adhesive disease, it was carefully inspected and excellent hemostasis was noted.,All instruments and packs removed from the patient's abdomen.  The abdomen was closed with a running mattress closure of #0 PDS, beginning at the superior aspect of the incision, and extending inferiorly.  Excellent closure of the incision was noted.  The subcutaneous tissues were then copiously irrigated.  Hemostasis was achieved with the use of cautery.  Subcutaneous tissues were reapproximated to close the edge space with a several interrupted sutures of #0 plain gut suture.  The skin was closed with staples.,Incision was sterilely clean and dressed.  The patient was awakened from general anesthesia and taken to the recovery room in stable condition.  All counts were noted correct times three.", Surgery,38
"REASON FOR REFERRAL:,  The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the ""early stages of a likely dementia"" and was thereafter terminated from her position as a psychiatric nurse.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.  Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning.  The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION:  ,Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  The patient reported that she had worked as a nurse supervisor for Hospital Center for four years.  She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work.  She continues to receive some compensation through FMLA hours.  She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services.  She said that these 90 days are up around the end of November.  She said the reason for her dismissal was performance complaints.  She said that they began ""as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off.  She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays.  She described it as a very chaotic and hectic work environment in which she was often putting in extra time.  She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time.  Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D.  He completed a Comprehensive Independent Medical Evaluation on 08/14/2009.  She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore.  Please note that we do not have copies of any of her work-related correspondence.  The patient never received a copy of the neuropsychological evaluation because she was told that it was ""too derogatory.""  A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation.  To summarize, the results indicated ""diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history.  This suggests that her intellectual functioning has declined.""  It concluded that ""results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy…  The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing.  The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other.  Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits.  His neurological examination on 09/23/2009 was unremarkable.  The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting.  A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions.  Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING:  ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her.  When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills.  She also denied any problems with attention and concentration or forgetfulness or memory problems.  She continues to independently perform all activities of daily living.  She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning.  She reported that if her children had noticed anything they definitely would have brought it to her attention.  She said that she does not currently have a lawyer and does not intend to return to her previous physician.  She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application.  Other current symptoms include excessive fatigue.  She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia.  She also reported having fallen approximately five times within the past year.  She said that this typically occurs when she is climbing up steps and is usually related to her right foot ""like dragging.""  Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis.  She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body.  Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal.  She denied any significant medical conditions during childhood.  As mentioned, she now has a history of fibromyalgia.  She also experiences some restriction in the range of motion with her right arm.  MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7.  MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon.  As mentioned, she was diagnosed with chronic fatigue syndrome in 1991.  She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control.  She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974.  Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007.  She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night.  She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:,  NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs.  She drinks two to four cups of coffee per day.,SOCIAL HISTORY:  ,The patient was born and raised in North Carolina.  She was the sixth of nine siblings.  Her father was a chef.  He completed third grade and died at 60 due to complications of diabetes.  Her mother is 93 years old.  Her last job was as a janitor.  She completed fourth grade.  She reported that she has no cognitive problems at this time.  Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression.  The patient completed a Bachelor of Science in Nursing through State University in 1979.  She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems.  She was married for two years.  Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse.  She has two children ages 43 and 30.  Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York.  In school, the patient reported obtaining primarily A's and B's.  She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling.  The patient worked for Hospital Center for four years.  Prior to that, she worked for an outpatient mental health center for 2-1/2 years.  She was reportedly either terminated or laid off and was unsure of the reason for that.  Prior to that, she worked for Walter P. Carter Center reportedly for 21 years.  She has also worked as an OB nurse in the past.  She reported that other than the two instances reported above, she had never been terminated or fired from a job.  In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue.  She was also taking Prozac during that time.  She then began taking Prozac again when she started working at secondary to stress with the work situation.  She reported a chronic history of mild sadness or depression, which was relatively stable.  When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things.  She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test", Consult - History and Phy.,5
"REASON FOR VISIT:,  This is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation.  Her chief complaint today is shortness of breath.,HISTORY OF PRESENT ILLNESS:,  I last saw her in 09/2008.  Since then, she has been admitted to ABCD Hospital from 11/05/2008 through 11/08/2008 for a near syncopal episode.  She was found to have a fast heart rate in the atrial fibrillation.  She was also found to be in heart failure and so they diuresed her.  They wanted to send her home on furosemide 40 mg daily, but unfortunately they never gave her a prescription for this and so she now is not on any furosemide and since being discharged she has regained fluid to no one's great surprise.  My plan advent is to control her heart rate.  This has been a bit difficult with her retaining fluid.  We will try again to diurese her as an outpatient and go forward from there with rate control and anticoagulation.  She may need to have a pacemaker placed and her AV node ablated if this does not work.,She notes the shortness of breath and wheezing at nights.  I think these are manifestations of heart failure.  She has peripheral edema.  She is short of breath when she tries to walk a city block.  I believe she takes her medications as directed, but I am never sure she actually is taking them correctly.  In any case, she did not bring her medications with her today.,Today, she had an ECG which shows atrial fibrillation with a ventricular response of 117 beats per minute.  There is a nonspecific IVCD.  This is unchanged from her last visit except that her heart rate is faster.  In addition, I reviewed her echocardiogram done at XYZ.  Her ejection fraction is 50% and she has paradoxical septal motion.  Her right ventricular systolic pressure is normal.  There are no significant valvular abnormalities.,MEDICATIONS:  ,1.  Fosamax - 70 mg weekly.,2.  Lisinopril - 20 mg daily.,3.  Metformin - 850 mg daily.,4.  Amlodipine - 5 mg daily.,5.  Metoprolol - 150 mg twice daily.,6.  Warfarin - 5 mg daily.,7.  Furosemide - none.,8.  Potassium - none.,9.  Magnesium oxide - 200 mg daily.,ALLERGIES: , Denied.,MAJOR FINDINGS:,  On my comprehensive cardiovascular examination, she again looks the same which is in heart failure.  Her blood pressure today was 130/60 and her pulse 116 blood pressure and regular.  She is 5 feet 11 inches and her weight is 167 pounds, which is up from 158 pounds from when I saw her last visit.  She is breathing 1two times per minute and it is unlabored.  Eyelids are normal.  She has vitiligo.  Pupils are round and reactive to light.  Conjunctivae are clear and sclerae are anicteric.  There is no oral thrush or central cyanosis.  She has marked keloid formation on both sides of her neck, the left being worse than the right.  The jugular venous pressure is elevated.  Carotids are brisk are without bruits.  Lungs are clear to auscultation and percussion.  The precordium is quiet.  The rhythm is irregularly irregular.  She has a variable first and second heart sounds.  No murmurs today.  Abdomen is soft without hepatosplenomegaly or masses, although she does have hepatojugular reflux.  She has no clubbing or cyanosis, but does have 1+ peripheral edema.  Distal pulses are good.  On neurological examination, her mentation is normal.  Her mood and affect are normal.  She is oriented to person, place, and time.,ASSESSMENTS: , She has chronic atrial fibrillation and heart failure now.,PROBLEMS DIAGNOSES:  ,1.  Chronic atrial fibrillation, anticoagulated and the plan is rate control.,2.  Heart failure and she needs more diuretic.,3.  High blood pressure controlled.,4.  Hyperlipidemia.,5.  Diabetes mellitus type 2.,6.  Nonspecific intraventricular conduction delay.,7.  History of alcohol abuse.,8.  Osteoporosis.,9.  Normal left ventricular function.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I have restarted her Lasix at 80 mg daily and I have asked her to return in about 10 days to the heart failure clinic.  There, I would like them to recheck her heart rate and if still elevated, and she is truly on 150 mg of metoprolol twice a day, one could switch her amlodipine from 5 mg daily to diltiazem 120 mg daily.  If this does not work, in terms of controlling her heart rate, then she will need to have a pacemaker and her AV node ablated.,Thank you for asking me to participate in her care.,MEDICATION CHANGES: , See the above.", Cardiovascular / Pulmonary,3
"NASAL EXAM: , The nose is grossly in the midline with no evidence of fractures or dislocations.  The nasal septum is roughly in the midline with pale boggy mucosa and moderately enlarged inferior turbinates.  There is no pus or polyps in the nose on anterior rhinoscopy.  The airway appears adequate.  No external valve prolapses are observed.,THROAT EXAM: , The oral cavity is clear.  The tongue is clear with no lesions noted and with good symmetrical movement.  The parotid and submaxillary ducts are producing clear mucus with no evidence of stones or infection.  Palate is clear.  The tonsils are not prominent.,No overt neoplasms in the mouth are noted.  Lips are clear.  The voice is adequate no deficits or hoarseness.  The saliva is clear.,EARS:  ,Canals are clear.  Eardrums are clear, moving on insufflation and swallowing.  No discharge is noted in the canals.  Hearing appears adequate in normal tonal conversations.,NECK EXAM: , Neck is supple with no palpable masses.  No lymphadenopathy.  The thyroid gland is not palpable.  The trachea is in the midline.  The parotid and submaxillary glands are not enlarged, are symmetrical and are not tender.  The neck movement is adequate.,GROSS NEUROLOGICAL EXAM: , Cranial nerves II-XII are intact.  Extraocular movements are full with no restrictions.  Patient is alert and responsive.,EYE EXAM: , Sclerae are clear.  Conjunctivae are clear.  Pupils respond symmetrically to light.  Extraocular movements are complete and full.", ENT - Otolaryngology,11
"HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall.  Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock.  When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped.  Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker.  An ECG this morning showing normal sinus rhythm with frequent APCs.  Her potassium at that time was 3.1.  She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior.  She denies any chest pain nor shortness of breath prior to or since the fall.  She states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,PAST CARDIAC HISTORY: , She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure.  On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement.  She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative.  She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant.  She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker.  She does have a history of significant hypertension in the past.  She has had dizzy spells and denies clearly any true syncope.  She has had bradycardia in the past from beta-blocker therapy.,MEDICATIONS ON ADMISSION:,1.  Multivitamin p.o. daily.,2.  Aspirin 325 mg once a day.,3.  Lisinopril 40 mg once a day.,4.  Felodipine 10 mg once a day.,5.  Klor-Con 20 mEq p.o. b.i.d.,6.  Omeprazole 20 mg p.o. daily presumably for GERD.,7.  MiraLax 17 g p.o. daily.,8.  Lasix 20 mg p.o. daily.,ALLERGIES: , PENICILLIN.  IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST.,FAMILY HISTORY:,  She states her brother died of an MI suddenly in his 50s.,SOCIAL HISTORY: , She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs.  She is retired from Morse Chain and delivering newspapers.  She is widowed.  She lives alone but has family members who live either on her property or adjacent to it.,REVIEW OF SYSTEMS: , She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers.  She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use.  She does note occasional peripheral edema.  She is not aware of prior history of MI.  She denies diabetes.  She does have a history of GERD.  She notes feeling depressed at times because of living alone.  She denies rheumatologic conditions including psoriasis or lupus.  Remainder of review of systems is negative times 15 except as described above.,PHYSICAL EXAM:  ,Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%.  On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive.  HEENT:  Shows cranium is  normocephalic and atraumatic.  She has moist mucosal membranes.  Neck veins were not distended.  There are no carotid bruits.  Lungs:  Clear to auscultation anteriorly without wheezes.  She is relatively immobile because of her left hip fracture.  Cardiac Exam:  S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound.  There is also a soft holosystolic murmur heard.  There is no rub or gallop.  PMI is nondisplaced.  Abdomen is soft and nondistended.  Bowel sounds present.  Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema.  Pulses appear grossly intact.  Affect is appropriate.  Visible skin warm and perfused.  She is not able to move because of left hip fracture easily in bed.,DIAGNOSTIC STUDIES/LAB DATA: , Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob.  No clear pulmonary vascular congestion.  Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06.  Troponin was 0.03 followed by 0.18.  INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,EKGs are reviewed.  Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes.  She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior.  Followup EKG done this morning shows normal sinus rhythm with frequent APCs.,IMPRESSION:  ,She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery.  Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected.  There has been no atrial fibrillation documented.  I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath.  She actually describes feeling good exercise capacity prior to this fall.  Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that.  Continued optimization of electrolytes.  The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil.  The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery.  I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge.  Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist.", Consult - History and Phy.,5
"TITLE OF OPERATION:,  Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.,INDICATION FOR SURGERY: ,  The patient is a patient well known to my service.  She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull.  I took her to the operating a few days ago for a large right-sided hemicraniectomy to save her life.  I spoke with the family, the mom, especially about the risks, benefits, and alternatives of this procedure, most especially given the fact that she had undergone a very severe traumatic brain injury with a very poor GCS of 3 in some brainstem reflexes.  I discussed with them that this was a life-saving procedure and the family agreed to proceed with surgery as a level 1.  We went to the operating room at that time and we did a very large right-sided hemicraniectomy.  The patient was put in the intensive care unit.  We had placed also at that time a left-sided intracranial pressure monitor both which we took out a few days ago.  Over the last few days, the patient began to slowly deteriorate little bit on her clinical examination, that is, she was at first localizing briskly with the right side and that began to be less brisk.  We obtained a CT scan at this point, and we noted that she had a fair amount of swelling in the left hemisphere with about 1.5 cm of midline shift.  At this point, once again I discussed with the family the possibility of trying to save her life and go ahead and doing a left-sided very large hemicraniectomy with this __________  this was once again a life-saving procedure and we proceeded with the consent of mom to go ahead and do a level 1 hemicraniectomy of the left side.,PROCEDURE IN DETAIL: , The patient was taken to the operating room.  She was already intubated and under general anesthesia.  The head was put in a 3-pin Mayfield headholder with one pin in the forehead and two pins in the back to be able to put the patient with the right-hand side down and the left-hand side up since on the right-hand side, she did not have a bone flap which complicated matters a little bit, so we had to use a 3-pin Mayfield headholder.  The patient tolerated this well.  We sterilely prepped everything and we actually had already done a midline incision prior to this for the prior surgery, so we incorporated this incision into the new incision, and to be able to open the skin on the left side, we did a T-shaped incision with T vertical portion coming from anterior to the ear from the zygoma up towards the vertex of the skull towards the midline of the skin.  We connected this.  Prior to this, we brought in all surgical instrumentation under sterile and standard conditions.  We opened the skin as in opening a book and then we also did a myocutaneous flap.  We brought in the muscle with it.  We had a very good exposure of the skull.  We identified all the important landmarks including the zygoma inferiorly, the superior sagittal suture as well as posteriorly and anteriorly.  We had very good landmarks, so we went ahead and did one bur hole and the middle puncta right above the zygoma and then brought in the craniotome and did a very large bone flap that measured about 7 x 9 cm roughly, a very large decompression of the left side.  At this point, we opened the dura and the dura as soon as it was opened, there was a small subdural hematoma under a fair amount of pressure and cleaned this very nicely irrigated completely the brain and had a few contusions over the operculum as well as posteriorly.  All this was irrigated thoroughly.  Once we made sure we had absolutely great hemostasis without any complications, we went ahead and irrigated once again and we had controlled the meddle meningeal as well as the superior temporal artery very nicely.  We had absolutely good hemostasis.  We put a piece of Gelfoam over the brain.  We had opened the dura in a cruciate fashion, and the brain clearly bulging out despite of the fact that it was in the dependent position.  I went ahead and  irrigated everything thoroughly putting a piece of DuraGen as well as a piece of Gelfoam with very good hemostasis and proceeded to close the skin with running nylon in place.  This running nylon we put in place in order not to put any absorbables, although I put a few 0 popoffs just to approximate the skin nicely.  Once we had done this, irrigated thoroughly once again the skin.  We cleaned up everything and then we took the patient off __________ anesthesia and took the patient back to the intensive care unit.  The EBL was about 200 cubic centimeters.  Her hematocrit went down to about 21 and I ordered the patient to receive one unit of blood intraoperatively which they began to work on as we began to continue to do the work and the sponges and the needle counts were correct.  No complications.  The patient went back to the intensive care unit.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  Left renal mass, 5 cm in diameter.,POSTOPERATIVE DIAGNOSIS:,  Left renal mass, 5 cm in diameter.,OPERATION PERFORMED: , Left partial nephrectomy.,ANESTHESIA: , General with epidural.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , About 350 mL.,REPLACEMENT: , Crystalloid and Cell Savers from the case.,INDICATIONS FOR SURGERY:  ,This is a 64-year-old man with a left renal mass that was confirmed to be renal cell carcinoma by needle biopsy.  Due to the peripheral nature of the tumor located in the mid to lower pole laterally, he has elected to undergo a partial nephrectomy.  Potential complications include but are not limited to,,1.  Infection.,2.  Bleeding.,3.  Postoperative pain.,4.  Herniation from the incision.,PROCEDURE IN DETAIL:,  Epidural anesthesia was administered in the holding area, after which the patient was transferred into the operating room.  General endotracheal anesthesia was administered, after which the patient was positioned in the flank standard position.  A left flank incision was made over the area of the twelfth rib.  The subcutaneous space was opened by using the Bovie.  The ribs were palpated clearly and the fascia overlying the intercostal space between the eleventh and twelfth rib was opened by using the Bovie.  The fascial layer covering of the intercostal space was opened completely until the retroperitoneum was entered.  Once the retroperitoneum had been entered, the incision was extended until the peritoneal envelope could be identified.  The peritoneum was swept medially.  The Finochietto retractor was then placed for exposure.  The kidney was readily identified and was mobilized from outside Gerota's fascia.  The ureter was dissected out easily and was separated with a vessel loop.  The superior aspect of the kidney was mobilized from the superior attachment.  The pedicle of the left kidney was completely dissected revealing the vein and the artery.  The artery was a single artery and was dissected easily by using a right-angle clamp.  A vessel loop was placed around the renal artery.  The tumor could be easily palpated in the lateral lower pole to mid pole of the left kidney.  The Gerota's fascia overlying that portion of the kidney was opened in the area circumferential to the tumor.  Once the renal capsule had been identified, the capsule was scored using a Bovie about 0.5 cm lateral to the border of the tumor.  Bulldog clamp was then placed on the renal artery.  The tumor was then bluntly dissected off of the kidney with a thin rim of a normal renal cortex.  This was performed by using the blunted end of the scalpel.  The tumor was removed easily.  The argon beam coagulation device was then utilized to coagulate the base of the resection.  The visible larger bleeding vessels were oversewn by using 4-0 Vicryl suture.  The edges of the kidney were then reapproximated by using 2-0 Vicryl suture with pledgets at the ends of the sutures to prevent the sutures from pulling through.  Two horizontal mattress sutures were placed and were tied down.  The Gerota's fascia was then also closed by using 2-0 Vicryl suture.  The area of the kidney at the base was covered with Surgicel prior to tying the sutures.  The bulldog clamp was removed and perfect hemostasis was evident.  There was no evidence of violation into the calyceal system.  A 19-French Blake drain was placed in the inferior aspect of the kidney exiting the left flank inferior to the incision.  The drain was anchored by using silk sutures.  The flank fascial layers were closed in three separate layers in the more medial aspect.  The lateral posterior aspect was closed in two separate layers using Vicryl sutures.  The skin was finally reapproximated by using metallic clips.  The patient tolerated the procedure well.", Nephrology,21
"Chief Complaint:, Chronic abdominal pain.,History of Present Illness:, 23-year-old Hispanic male who presented for evaluation of chronic abdominal pain. Patient described the pain as dull, achy, constant and located at the epigastric area with some radiation to the back. There are also occasional episodes of stabbing epigastric pain unrelated to meals lasting only minutes. Patient noted that the pain started approximately six months prior to this presentation. He self medicated ""with over the counter"" antacids and obtained some relief so he did not seek medical attention at that time.,Two months prior to current presentation, he had worsening of his pain as well as occasional nausea and vomiting. At this time the patient was found to be H. pylori positive by serology and was treated with triple therapy for two weeks and continued on omeprazole without relief of his pain.,The patient felt he had experienced a twenty-pound weight loss since his symptoms began but he also admitted to poor appetite. He stated that he had two to three loose bowel movements a day but denied melena or bright red blood per rectum. Patient denied NSAID use, ethanol abuse or hematemesis. Position did not affect the quality of the pain. Patient denied fever or flushing. He stated he was a very active and healthy individual prior to these recent problems.,Past Medical History:, No significant past medical history.,Past Surgical History:, No prior surgeries.,Allergies:, No known drug allergies.,Medications:, Omeprazole 40 mg once a day. Denies herbal medications.,Family History:, Mother, father and siblings were alive and well.,Social History:, He is employed as a United States Marine officer, artillery repair specialist. He was a social drinker in the past but quit altogether two years ago. He never used tobacco products or illicit/intravenous drugs.,Physical Examination:, The patient was a thin male in no apparent distress. His oral temperature was 98.2 Fahrenheit, blood pressure was 114/67 mmHg, pulse rate of 91 beats per minute and regular, respiratory rate was 14 and his pulse oximetry on room air was 98%. Patient was 52 kg in weight and 173 cm height.,SKIN: No skin rashes, lesions or jaundice. He had one tattoo on each upper arm.,HEENT: Head was normocephalic and atraumatic. Pupils were equal, round and reactive. Anicteric sclerae. Tympanic membranes had a normal appearance. Normal funduscopic examination. Oral mucosa was moist and pink. Oral/pharynx was clear.,NECK: No lymphadenopathy. No carotid bruits. Trachea midline. Thyroid non-palpable. No jugular venous distension.,CHEST: Lungs were clear bilaterally with good air movement.,HEART: Regular rate and rhythm. Normal S1 and S2 with no murmurs, gallops or rubs. PMI was non-displaced.,ABDOMEN: Abdomen was flat. Normal active bowel sounds. Liver span percussed sixteen centimeters, six centimeters below R costal margin with irregular border that was mildly tender to palpation. Slightly tender to palpation in epigastric area. There was no splenomegaly. No abdominal masses were appreciated. No CVA tenderness was noted.,RECTAL: No perirectal lesions were found. Normal sphincter tone and no rectal masses. Prostate size was normal without nodules. Guaiac positive.,GENITALIA: Testes descended bilaterally, no penile lesions or discharge.,EXTREMITIES: No clubbing, cyanosis, or edema. No peripheral lymphadenopathy was noted.,NEUROLOGIC: Alert and oriented times three. Cranial nerves II to XII appeared intact. No muscle weakness or sensory deficits. DTRs equal and normal.,Radiology/Studies: 2 view CXR: Mild elevation right diaphragm.,CT of abdomen and pelvis: Too numerous to count bilobar liver masses up to about 8 cm. Extensive mass in the pancreatic body and tail, peripancreatic region and invading the anterior aspect of the left kidney. Question of vague splenic masses. No definite abnormality of the moderately distended gallbladder, bile ducts, right kidney, poorly seen adrenals, bowel or bladder. Evaluation of the retroperitoneum limited by paucity of fat.,Patient underwent several diagnostic procedures and soon after he was transferred to Houston Veterans Administration Medical Center to be near family and to continue work-up and treatment. At the HVAMC these diagnostic procedures were reviewed.", Consult - History and Phy.,5
"ADMISSION DIAGNOSIS:  ,Adenocarcinoma of the prostate.,HISTORY:,  The patient is a 71-year-old male whose personal physician, Dr. X identified a change in the patient's PSA from 7/2008 (4.2) to 4/2009 (10.5).  The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base.  The patient also had Gleason 6 in the right lobe, midportion, as well as the left apical portion.  He underwent a bone scan which was normal and cystoscopy which was normal and renal ultrasound that was normal.,SURGICAL HISTORY: , Appendectomy.,MEDICAL HISTORY:,  Atrial fibrillation.,MEDICATIONS:,  Coumadin and lisinopril.,SOCIAL HISTORY:  ,Smokes none.  Alcohol none.,ALLERGIES:,  NONE.,REVIEW OF SYSTEMS: , The patient relates no recent weight gain, weight loss, night sweats, fevers or chills.  Eyes:  No change in vision or diplopia.  Ears:  No tinnitus or vertigo.  Mouth:  No dysphagia.  Pulmonary:  No chronic cough or shortness of breath.  Cardiac:  No angina or palpitations.  GI:  No nausea, vomiting, diarrhea or constipation.  Musculoskeletal:  No arthritides or myalgias.  Hematopoietic:  No easy bleeding or bruising.  Skin:  No chronic ulcers or persistent itch.,PHYSICAL EXAMINATION:,GENERAL:  The patient is well developed and well nourished.,HEENT:  Head is normocephalic.  Eyes, pupils are equal.  Conjunctivae are pink.  Sclerae are anicteric.,NECK:  There is no adenopathy.,PULMONARY:  Respirations are unlabored.,HEART:  Regular rhythm.,ABDOMEN:  Liver, spleen, kidney, and bladder are not palpable.  There are no discernible masses.  There are no peritoneal signs.,GENITALIA:  The penis has no plaques.  Meatus is on the glans.  Scrotal skin is healthy.  Testicles are fair consistency.  Epididymides are nontender.,RECTAL:  The prostate is +1 to 2/4.  There are no areas that are suspicious for tumor.  Consistency is even.  Sidewalls are sharp.  Seminal vesicles are not palpable.,MUSCULOSKELETAL:  The upper and lower extremities are symmetric bilaterally.,NEUROLOGIC:  There are no gross focal neurologic abnormalities.,IMPRESSION:,1.  Adenocarcinoma of the prostate.,2.  Atrial fibrillation.,PLAN: , The patient's wife and I have discussed his treatment options, which include primarily radiation and surgery.  He has _________ surviving prostate cancer by Dr. Y.  He is aware of incontinency, both total and partial.  We discussed erectile dysfunction.  We have discussed bleeding, infection, injury to the rectum, injury to vessels and nerves, deep vein thrombosis, pulmonary embolus, MI, stroke, and death.  He had no questions at the conclusion of the conversation and he does know that in his age group, though a nerve-sparing procedure will be performed, preserving any erectile function is highly unlikely.  He had no questions at the conclusion of our last conversation.", Consult - History and Phy.,5
"REASON FOR REFERRAL:  ,The patient was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.,BRIEF SUMMARY & IMPRESSIONS:,RELEVANT HISTORY:,Historical information was obtained from a review of available medical records and an interview with ,the patient.,The patient presented to Dr. X on August 05, 2008 as she had been recently hospitalized for prolonged episodes of syncope.  She was referred to Dr. X for diagnostic differentiation for possible seizures or other causes of syncope.  The patient reports an extensive neurological history.  Her mother used alcohol during her pregnancy with the patient.  In spite of exposure to alcohol in utero, the patient reported that she achieved ""honors in school"" and ""looked smart.""  She reported that she began to experience migraines at 11 years of age.  At 15 years of age, she reported that she was thought to have hydrocephalus.  She reported that she will frequently ""bang her head against the wall"" to relieve the pain.  The patient gave birth to her daughter at 17 years of age.  At 18 years of age, she received a spinal tap as a procedure to determine the cause of her severe headaches.  She reported, in 1995 to 1996 she experienced a severe head injury, as she was struck by a car as a pedestrian and ""thrown two and a half city blocks.""  The patient reported that she could recall before being hit, but could not recall the activities of that same day or the following day.  She reported that she had difficulty walking following this head injury, but received rehabilitation for approximately one month.  Her migraines became more severe following the head injury.  In 1998, she reportedly was experiencing episodes of syncope where she would experience a headache with photophobia, phonophobia, and flashing lights.  Following the syncope episode, she would experience some confusion.  These episodes reportedly were related to her donating plasma.,The patient also reported that her ex-husband stated that she frequently jerked and would shake in her sleep.  She reported that upon awakening, she would feel off balanced and somewhat confused.  These episodes diminished from 2002 to June 2008.  When making dinner, she suddenly dropped and hit the back of her head on refrigerator.  She reported that she was unconscious for five to six minutes.  A second episode occurred on July 20th when she lost consciousness for may be a full day.  She was admitted to Sinai Hospital and assessed by a neurologist.  Her EEG and head CT were considered to be completely normal.  She did not report any typical episodes during the time of her 36-hour EEG.  She reported that her last episode of syncope occurred prior to her being hospitalized.  She stated that she had an aura of her ears ringing, vision being darker and ""tunnel vision"" (vision goes smaller to a pinpoint), and she was ""spazzing out"" on the floor.  During these episodes, she reports that she cannot talk and has difficulty understanding.,The patient also reports that she has experienced some insomnia since she was 6 years old.  She reported that she was a heavy drinker until about 1998 or 1999 and that she would drink a gallon daily of Jack Daniel.  She stopped the use of alcohol and that time she experienced a suicide attempt.  In 2002, she was diagnosed with bipolar disorder and was started on medication.  At the time of the neuropsychological evaluation, she had stopped taking her medicine as she felt that she was now in remission and could manage her symptoms herself.  The patient's medical history is also significant for postpartum depression.,The patient reported that she has been experiencing difficulty with cognitive abilities of attention/concentration, spelling, tangential and slow thinking, poor sequencing memory for events, and variable verbal memory.  She reported that she sometimes has difficulty understanding what people say, specifically she has difficulty understanding jokes.  She finds that she often has difficulty with expressing her thoughts, as she is very tangential.  She experiences episodes of not recalling what she was speaking of or remembering what activities she was trying to perform.  She reported that she had a photographic memory for directions.  She said that she experienced a great deal of emotional lability, but in general her personality has become more subdued.  At the present time, her daughter has now moved on to college.  The patient is living with her biological mother.  Although she is going through divorce, she reported that it was not really stressful.  She reported that she spends her day driving other people around and trying to be helpful to them.,At the time of the neuropsychological evaluation, the patient's medication included Ativan, Imitrex, Levoxyl, vitamin B12, albuterol metered dose inhaler as needed, and Zofran as needed.  (It should be noted that The patient by the time of the feedback on September 19, 2008 had resumed taking her Trileptal for bipolar disorder.).  The patient's familial medical history is significant for alcohol abuse, diabetes, hypertension, and high cholesterol.,TESTS ADMINISTERED:,Clinical Interview,Cognistat,Mattis Dementia Rating Scale,Wechsler Adult Intelligence Scale - III (WAIS-III),Wechsler Abbreviated Scale of Intelligence (WASI),Selected Subtests from the Delis Kaplan Executive Function System (DKEFS),  Trail Making Test,  Verbal Fluency (Letter Fluency & Category Fluency),  Design Fluency,  Color-Word Interference Test,  Tower,Wisconsin Card Sorting Test (WCST),Stroop Test,Color Trails,Trails A & B,Test of Variables of Attention,Multilingual Aphasia Examination II,  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test-2 (BNT-2),Animal Naming Test,The Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI),The Beery-Buktenica Developmental Test of Motor Coordination,The Beery-Buktenica Developmental Test of Visual Perception,Judgment Line Orientation,Grooved Pegboard,Purdue Pegboard,Finger Tapping Test,Rey Complex Figure,Wechsler Memory Scale -III (WMS-III),California Verbal Learning Test", Consult - History and Phy.,5
"CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST,REASON FOR EXAM: , Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.,CT ABDOMEN: , There is no evidence for a retroperitoneal hematoma.,The liver, spleen, adrenal glands, and pancreas are unremarkable.  Within the superior pole of the left kidney, there is a 3.9 cm cystic lesion.  A 3.3 cm cystic lesion is also seen within the inferior pole of the left kidney.  No calcifications are noted.  The kidneys are small bilaterally.,CT PELVIS: , Evaluation of the bladder is limited due to the presence of a Foley catheter, the bladder is nondistended.  The large and small bowels are normal in course and caliber.  There is no obstruction.,Bibasilar pleural effusions are noted.,IMPRESSION:,1. No evidence for retroperitoneal bleed.,2. There are two left-sided cystic lesions within the kidney, correlation with a postcontrast study versus further characterization with an ultrasound is advised as the cystic lesions appear slightly larger as compared to the prior exam.,3. The kidneys are small in size bilaterally.,4. Bibasilar pleural effusions.", Gastroenterology,14
"EXAM:  ,Ultrasound neck/soft tissue, head.,HISTORY: , Right-sided facial swelling and draining wound.,TECHNIQUE AND FINDINGS:,  Ultrasound of the right mandibular region was performed.,No focal collection is identified.  This whole region appears to be phlegmonous.  It is hard to adequately delineate the exact margins of this region.,IMPRESSION:  ,Abnormal appearing right mandibular region has more phlegmonous changes.  No focal fluid collection.,Had a discussion with Dr. xx.  Consider CT for further evaluation.", Radiology,33
"EXAM: , MRI of lumbar spine without contrast.,HISTORY:,  A 24-year-old female with chronic back pain.,TECHNIQUE: , Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting.,FINDINGS: , The visualized cord is normal in signal intensity and morphology with conus terminating in proper position.  Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture/contusion, compression deformity, or marrow replacement process.  There are no paraspinal masses.,Disc heights, signal, and vertebral body heights are maintained throughout the lumbar spine.,L5-S1:  Central canal, neural foramina are patent.,L4-L5:  Central canal, neural foramina are patent.,L3-L4:  Central canal, neural foramen is patent.,L2-L3:  Central canal, neural foramina are patent.,L1-L2:  Central canal, neural foramina are patent.,The visualized abdominal aorta is normal in caliber.  Incidental note has been made of multiple left-sided ovarian, probable physiologic follicular cysts.,IMPRESSION: , No acute disease in the lumbar spine.", Neurology,22
"GENERAL APPEARANCE: , This is a well-developed and well-nourished, ??,VITAL SIGNS: , Blood pressure ??, heart rate ?? and regular, respiratory rate ??, temperature is ?? degrees Fahrenheit.  Height is ?? feet ?? inches.  Weight is ?? pounds.  This yields a body mass index of ??.,HEAD, EYES, EARS, NOSE AND THROAT:,  The pupils were equal, round and reactive to light.  Extraocular movements are intact.  Sclera are nonicteric.  Ears, nose, mouth and throat - Externally the ears and nose are normal.  The mucous membranes are moist and midline.,NECK:  ,The neck is supple without masses.  No thyromegaly, no carotid bruits, no adenopathy.,LUNGS:  ,There is a normal respiratory effort.  Bilateral breath sounds are clear.  No wheezes or rales or rhonchi.,CARDIAC: , Normal cardiac impulse location.  S1 and S2 are normal.  No rubs, murmurs or gallops.  A regular rate and rhythm.  There are no abdominal aortic bruits.  The carotid, brachial, radial, femoral, popliteal and dorsalis pedis pulses are 2+ and equal bilaterally.,EXTREMITIES: , The extremities are without clubbing, cyanosis, or edema.,CHEST: , The chest examination is unremarkable.,BREASTS:  ,The breasts show no masses or tenderness.  No axillary adenopathy.,ABDOMEN:,  The abdomen is flat, soft, nontender, no organomegaly, no masses, normal bowel sounds are present.,RECTAL: , Examination was deferred.,LYMPHATIC: , No neck, axillary or groin adenopathy was noted.,SKIN EXAMINATION:,  Unremarkable.,MUSCULOSKELETAL EXAMINATION: , Grossly normal.,NEUROLOGIC: , The cranial nerves two through twelve are grossly intact.  Patellar and biceps reflexes are normal.,PSYCHIATRIC: , The patient is awake, alert and oriented times three.  Judgment and insight are good.  Affect is appropriate.", General Medicine,15
"HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.  She has had a dry cough and a fever as high as 100, but this has not been since the first day.  She denies any vomiting or diarrhea.  She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe, but she does not think that this has helped.,FAMILY HISTORY: , The patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,REVIEW OF SYSTEMS:,  The patient does note some pressure in her sinuses.  She denies any skin rash.,SOCIAL HISTORY:,  Patient lives with her mother, who is here with her.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits.  Room air oximetry is 100%.,GENERAL:  Patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,HEENT:  Head is normocephalic, atraumatic.  Pharynx shows no erythema, tonsillar edema, or exudate.  Both TMs are easily visualized and are clear with good light reflex and no erythema.  Sinuses do show some mild tenderness to percussion.,NECK:  No meningismus or enlarged anterior/posterior cervical lymph nodes.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,SKIN:  No rash.,ASSESSMENT:,  Viral upper respiratory infection (URI) with sinus and eustachian congestion.,PLAN:,  I did educate the patient about her problem and urged her to switch to Advil Cold & Sinus for the next three to five days for better control of her sinus and eustachian discomfort.  I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses.  If she is unimproved in five days, follow up with her PCP for re-exam.", ENT - Otolaryngology,11
"PROCEDURE PERFORMED: , Modified radical mastectomy.,ANESTHESIA: , General endotracheal tube.,PROCEDURE:  ,After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.  Care was taken to ensure that the arm was placed in a relaxed manner away from the body to facilitate exposure and to avoid nerve injury.,An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site.  The skin incision was carried down to the subcutaneous fat but no further.  Using traction and counter-traction, the upper flap was dissected from the chest wall medially to the sternal border, superiorly to the clavicle, laterally to the anterior border of the latissimus dorsi muscle, and superolaterally to the insertion of the pectoralis major muscle.  The lower flap was dissected in a similar manner down to the insertion of the pectoralis fascia overlying the fifth rib medially and laterally out to the latissimus dorsi.  Bovie electrocautery was used for the majority of the dissection and hemostasis tying only the large vessels with 2-0 Vicryl.  The breast was dissected from the pectoralis muscle beginning medially and progressing laterally removing the pectoralis fascia entirely.  Once the lateral border of the pectoralis major muscle was identified, the pectoralis muscle was retracted medially and the interpectoral fat was removed with the specimen.,The axillary dissection was then begun by incising the fascia overlying axilla proper allowing visualization of the axillary vein.  The highest point of axillary dissection was then marked with a long stitch for identification by the surgical pathologist.  The axilla was then cleared of its contents by sharp dissection.  Small vessels entering the axillary vein were clipped and divided.  The axilla was cleared down to the chest wall, and dissection was continued laterally to the subscapular vein.  The long thoracic nerve was cleared identified lying against the chest and was carefully preserved.  The long thoracic nerve represented the posterior most aspect of the dissection.  As the axillary contents were dissected in the posterolateral axilla, the thoracodorsal nerve was identified and carefully preserved.  The dissection continued caudally until the entire specimen was freed and delivered from the operative field.  Copious water lavage was used to remove any debris, and hemostasis was obtained with Bovie electrocautery.,Two Jackson-Pratt drains were inserted through separate stab incisions below the initial incision and cut to fit.  The most posterior of the 2 was directed into the axilla and the other directed anteriorly across the pectoralis major.  These were secured to the skin using 2-0 silk, which was Roman-sandaled around the drain.,The skin incision was approximated with skin staples.  A dressing was applied.  The drains were placed on ""grenade"" suction.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  Desire for sterility.,POSTOPERATIVE DIAGNOSIS:,  Desire for sterility.,OPERATIVE PROCEDURES: , Vasectomy.,DESCRIPTION OF PROCEDURE: , The patient was brought to the suite, where after oral sedation, the scrotum was prepped and draped.  Then, 1% lidocaine was used for anesthesia.  The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas.  A segment about 3 cm in length was dissected out.  It was clipped proximally and distally, and then the ends were cauterized after excising the segment.  Minimal bleeding was encountered and the scrotal skin was closed with 3-0 chromic.  The identical procedure was performed on the contralateral side.  He tolerated it well.  He was discharged from the surgical center in good condition with Tylenol with Codeine for pain.  He will use other forms of birth control until he has confirmed azoospermia with two consecutive semen analyses in the month ahead.  Call if there are questions or problems prior to that time.", Urology,39
"PAST MEDICAL HX: , Significant for asthma, pneumonia, and depression.,PAST SURGICAL HX: , None.,MEDICATIONS:,  Prozac 20 mg q.d.  She desires to be on the NuvaRing.,ALLERGIES:,  Lactose intolerance.,SOCIAL HX: , She denies smoking or alcohol or drug use.,PE:,  VITALS: Stable.  Weight: 114 lb.  Height: 5 feet 2 inches.  GENERAL: Well-developed, well-nourished female in no apparent distress.  HEENT: Within normal limits. NECK: Supple without thyromegaly.  HEART: Regular rate and rhythm.  LUNGS: Clear to auscultation.  ABDOMEN: Soft and nontender.  There is no rebound or guarding.  No palpable masses and no peritoneal signs.  EXTREMITIES: Within normal limits.  SKIN: Warm and dry.  GU: External genitalia is without lesion.  Vaginal is clean without discharge.  Cervix appears normal; however, a colposcopy was performed using acetic acid, which showed a thick acetowhite ring around the cervical os and extending into the canal.  BIMANUAL: Reveals significant cervical motion tenderness and fundal tenderness.  She had no tenderness in her adnexa.  There are no palpable masses.,A:,  Although unlikely based on the patient's exam and pain, I have to consider subclinical pelvic inflammatory disease.  GC and chlamydia was sent and I treated her prophylactically with Rocephin 250 mg and azithromycin 1000 mg.  Repeat biopsies were not performed based on her colposcopy as well as her previous Pap and colposcopy by Dr. A.  A LEEP is a reasonable approach even in this 16-year-old.,P:,  We will schedule LEEP in the near future.  Even though she has already been exposed HPV Gardasil would still be beneficial in this patient to help prevent recurrence of low-grade lesions as well as high-grade lesions.  Now, we have her given her first shot.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,POSTOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,OPERATION,Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.,ANESTHESIA,General endotracheal anesthesia.,PROCEDURE,The patient was placed in the supine position.  Under effects of general endotracheal anesthesia, markings were made preoperatively for the mastopexy.  An eccentric circle was drawn around the nipple and a wedge drawn from the inferior border of the areola to the inframammary fold.  A stab incision was made bilaterally and tumescent infiltration of anesthesia, lactated ringers with 1 cc of epinephrine to 1000 cc of lactated ringers was infused with a tumescent blunt needle.  200 cc was infiltrated on each side.  This was followed by power-assisted liposuction and manual liposuction with removal of 350 cc of supernatant fat from both sides utilizing a radial tunneling technique with a 4-mm cannula.  This was followed by the epithelialization of skin between the inner circle corresponding to the diameter of the areola 4 cm diameter and the outer eccentric circle with a tangent at the 6 o'clock position.  This would result in an elevation of the nipple-areolar complex with transposition.  The epithelialization of the wedge inferiorly equalized the circumference distance between the inner circle and the outer circle.  Hemostasis was achieved with electrocautery.  After the epithelialization was performed on both sides, nipple-areolar complex was transposed to new nipple position and the wedge was closed with transposition of the nipple-areolar complex beneath the transposed nipple.  Closure was performed with interrupted 3-0 PDS suture on deep subcutaneous tissue and dermal skin closure with running subcuticular 4-0 Monocryl suture.  Dermabond was applied followed by Adaptic and Kerlix in the suturing spaces supportive mildly compressive dressing.  The patient tolerated the procedure well.  The patient was returned to recovery room in satisfactory condition.", Cosmetic / Plastic Surgery,6
"CC:, Found down.,HX:, 54y/o RHF went to bed at 10 PM at her boyfriend's home on 1/16/96. She was found lethargic by her son the next morning. Three other individuals in the house were lethargic and complained of HA that same morning. Her last memory was talking to her granddaughter at 5:00PM on 1/16/96. She next remembered riding in the ambulance from a Hospital. Initial Carboxyhemoglobin level was 24% (normal < 1.5%) and ABG 7.41/30/370 with O2Sat 75% on 100%FiO2.,MEDS:, unknown anxiolytic, estrogen.,PMH:, PUD, ?stroke and memory difficulty in the past 1-2 years.,FHX:, unknown.,SHX:, divorced. unknown history of tobacco/ETOH/illicit drug use.,EXAM: ,BP126/91, HR86, RR 30, 37.1C.,MS:, Oriented to name only. Speech without dysarthria. 2/3 recall at 5minutes.,CN:, unremarkable.,MOTOR: ,full strength throughout with normal muscle tone and bulk.,SENSORY: ,unremarkable.,COORD/STATION:, unremarkable.,GAIT:, not tested on admission.,GEN EXAM:, notable for erythema of the face and chest.,COURSE:, She underwent a total of four dives under Hyperbaric Oxygen ( 2 dives on 1/17 and 2 dives on 1/18). Neuropsychologic assessment on 1/18/96 revealed marked cognitive impairments with defects in anterograde memory, praxis, associative fluency, attention, and speed of information processing. She was discharged home on 1/19/96 and returned on 2/11/96 after neurologic deterioration. She progressively developed more illogical behavior, anhedonia, anorexia and changes in sleep pattern. She became completely dependent and could not undergo repeat neuropsychologic assessment in 2/96. She was later transferred to another care facility against medical advice. The etiology for these changes became complicated by a newly discovered history of possible ETOH abuse and usual ""anxiety"" disorder.,MRI brain, 2/14/96, revealed increased T2 signal within the periventricular white matter, bilaterally. EEG showed diffuse slowing without epileptiform activity.", General Medicine,15
"CHILD PHYSICAL EXAMINATION,VITAL SIGNS:  Birth weight is ** grams, length **, occipitofrontal circumference **.  Character of cry was lusty.,GENERAL APPEARANCE:  Well.,BREATHING:  Unlabored.,SKIN:  Clear.  No cyanosis, pallor, or icterus.  Subcutaneous tissue is ample.,HEAD:  Normal.  Fontanelles are soft and flat.  Sutures are opposed.,EYES:  Normal with red reflex x2.,EARS:  Patent.  Normal pinnae, canals, TMs.,NOSE:  Patent nares.,MOUTH:  No cleft.,THROAT:  Clear.,NECK:  No masses.,CHEST:  Normal clavicles.,LUNGS:  Clear bilaterally.,HEART:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, flat.  No hepatosplenomegaly.  The cord is three vessel.,GENITALIA:  Normal ** genitalia **with testes descended bilaterally.,ANUS:  Patent.,SPINE:  Straight and without deformity.,EXTREMITIES:  Equal movements.,MUSCLE TONE:  Good.,REFLEXES:  Moro, grasp, and suck are normal.,HIPS:  No click or clunk.", Office Notes,25
"PREOPERATIVE DIAGNOSIS:,  Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.,POSTOPERATIVE DIAGNOSIS:,  Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.,PROCEDURES PERFORMED:  ,1.  Repair flexor carpi radialis.,2.  Repair palmaris longus.,ANESTHETIC: , General.,TOURNIQUET TIME:  ,Less than 30 minutes.,CLINICAL NOTE:  ,The patient is a 21-year-old who sustained a clean laceration off a teapot last night.  She had lacerated her flexor carpi radialis completely and 90% of her palmaris longus.  Both were repaired proximal to the carpal tunnel.  The postoperative plans are for a dorsal splint and early range of motion passive and active assist.  The wrist will be at approximately 30 degrees of flexion.  The MPJ is at 30 degrees of flexion, the IP straight.  Splinting will be used until the 4-week postoperative point.,PROCEDURE: , Under satisfactory general anesthesia, the right upper extremity was prepped and draped in the usual fashion.  There were 2 transverse lacerations.  Through the first laceration, the flexor carpi radialis was completely severed.  The proximal end was found with a tendon retriever.  The distal end was just beneath the subcutaneous tissue.,A primary core stitch was used with a Kessler stitch.  This was with 4-0 FiberWire.  A second core stitch was placed, again using 4-0 FiberWire.  The repair was oversewn with locking, running, 6-0 Prolene stitch.  Through the second incision, the palmaris longus was seen to be approximately 90% severed.  It was an oblique laceration.  It was repaired with a 4-0 FiberWire core stitch and with a Kessler-type stitch.  A secure repair was obtained.  She was dorsiflexed to 75 degrees of wrist extension without rupture of the repair.  The fascia was released proximally and distally to give her more room for excursion of the repair.,The tourniquet was dropped, bleeders were cauterized.  Closure was routine with interrupted 5-0 nylon.  A bulky hand dressing as well as a dorsal splint with the wrist MPJ and IP as noted.  The splint was dorsal.  The patient was sent to the recovery room in good condition.", Orthopedic,27
"PROBLEM:  ,Rectal bleeding, positive celiac sprue panel.,HISTORY:  ,The patient is a 19-year-old Irish-Greek female who ever since elementary school has noted diarrhea, constipation, cramping, nausea, vomiting, bloating, belching, abdominal discomfort, change in bowel habits.  She noted that her symptoms were getting increasingly worse and so she went for evaluation and was finally tested for celiac sprue and found to have a positive tissue transglutaminase as well as antiendomysial antibody.  She has been on a gluten-free diet for approximately one week now and her symptoms are remarkably improved.  She actually has none of these symptoms since starting her gluten-free diet.  She has noted intermittent rectal bleeding with constipation, on the toilet tissue.  She feels remarkably better after starting a gluten-free diet.,ALLERGIES: , No known drug allergies.,OPERATIONS: , She is status post a tonsillectomy as well as ear tubes.,ILLNESSES: , Questionable kidney stone.,MEDICATIONS: , None.,HABITS: , No tobacco.  No ethanol.,SOCIAL HISTORY: , She lives by herself.  She currently works in a dental office.,FAMILY HISTORY: , Notable for a mother who is in good health, a father who has joint problems and questionable celiac disease as well.  She has two sisters and one brother.  One sister interestingly has inflammatory arthritis.,REVIEW OF SYSTEMS:  ,Notable for fever, fatigue, blurred vision, rash and itching; her GI symptoms that were discussed in the HPI are actually resolved in that she started the gluten-free diet.  She also notes headaches, anxiety, heat and cold intolerance, excessive thirst and urination.  Please see symptoms summary sheet dated April 18, 2005.,PHYSICAL EXAMINATION:  , GENERAL:  She is a well-developed pleasant 19 female.  She has a blood pressure of 120/80, a pulse of 70, she weighs 170 pounds.  She has anicteric sclerae.  Pink conjunctivae.  PERRLA.  ENT:  MMM.  NECK:  Supple.  LUNGS: Clear to auscultation.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,POSTOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,OPERATIVE PROCEDURE:  ,Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.,ANESTHESIA: , General endotracheal.,PREOPERATIVE INDICATIONS: , This is a 52-year-old patient of mine who I have repaired both shoulder rotator cuffs, the most recent one in the calendar year 2007.  While he was climbing a ladder recently in the immediate postop stage, he fell suffering the aforementioned heavily comminuted Frykman fracture.  This fracture had a fragment that extended in the distal radial ulnar joint, a die-punch fragment in the center of the radius.  The ulnar styloid and the radial styloid were off and there were severe dorsal comminutions.  He presented to my office the morning of April 3, 2007, having had a left reduction done elsewhere a day ago.  The reduction, although adequate, had allowed for the fragments to settle and I discussed with him the severity of the injury on a scale of 1-8, this was essentially an 8.  The best results have been either with external fixation or internal fixation, most recently volar plating of a locking variety has been popular, and I felt that this would be appropriate in his case.,Risks and benefits otherwise described were bleeding, infection, need to do operative revise or removal of hardware.  He is taking a job out of state in the next couple of months.  Hence I felt that even with close followup, this is a particularly difficult fracture as far as the morbidity of the injury proceeds.,OPERATIVE NOTE: , After adequate general endotracheal anesthesia was obtained, one gram of Ancef was given intravenously.  The left upper extremity was prepped and draped in supine position with the left hand in the arm table, magnification was used throughout.  The time out procedure was done to the satisfaction of all present that this was indeed the appropriate extremity on the appropriate patient.  A small C-arm was brought in to help guide the incision which was a volar curvilinear incision that included as part of this due to the fracture blisters eminent compartment syndrome and numbness in fingers.  A carpal tunnel release was done with the transverse carpal ligament being protected with a Freer elevator.  The usual amount of dissection of the pronator quadratus was necessary to view the distal radial fragment.  The pronator quadratus actually grasped several of the fragments itself which had to be dissected free from them, specifically the distal radial ulnar joint and die-punch fragment.  At this point, a locking Synthes distal radius plate from the modular handset was selected that had five articular screws as well as five locking shaft screws.  The ulnar styloid was not affixed in any portion of this repair.  The plate was viewed under the image intensification device, i.e., x-ray and the screws were placed in this order.  The most proximal shaft screw was placed to allow the remainder of the plate to form a buttress to then rearrange the fragments around the locking screws and a locking plate having been selected from the volar approach, a locking 12-mm screw through 16-mm screws were placed in the following order.  Most proximal on the radial shaft of the plate, then the radial styloid, i.e., the most distal and lateral screw, the next most proximal shaft screw followed by the distal radial ulnar joint screw.  Three screws were locking across the die-punch fragment.  The remaining two screws were placed into the radial shaft.  All of these were locking screws of 2 mm in diameter and as the construct was created, the relative motion of the intra-articular fragment in dorsal comminution all diminished greatly, although the exposure as well as the amount of reduction force used was substantial.  The tourniquet time was 1.5 hours.  At this point, the tourniquet was let down.  The entire construct was irrigated with copious amounts of bacitracin and normal saline.  Closure was affected with 0 Vicryl underneath the skin surface followed by 3-0 Prolene in interrupted sutures in the volar wound.  Several image intensification x-rays were taken at the conclusion of the case to check screw length.  Screw lengths were changed out during the case as needed based on the x-ray findings.  The wound was injected with Marcaine, lidocaine, Depo-Medrol, and Kantrex.  A very heavily padded fluffy cotton Jones-type dressing was applied with a volar splint.  Estimated blood loss was 10 mL.  There were no specimens.  Tourniquet time was 1.5 hours.", Surgery,38
"TITLE OF OPERATION:,  Bilateral endoscopic proximal shunt revision and a distal shunt revision.,INDICATIONS FOR OPERATION:,  Headaches, full subtemporal site.,PREOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,POSTOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,FINDINGS:,  Coaptation of ventricles against proximal end of ventricular catheter.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES: , A Codman Hakim programmable valve with Portnoy ventricular catheter, a 0/20 proGAV valve with a shunt assist of 20 cm dual right-angled connector, and a flushing reservoir.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the prone position with the head held on a soft foam padding.  The occipital area was shaven bilaterally and then the areas of the prior scalp incisions were infiltrated with 0.25% Marcaine with 1:200,000 epinephrine after routine prepping and draping.  Both U-shaped scalp incisions were opened exposing both the left and the right ventricular catheters as well as the old low pressure reservoir, which might have been leading to the coaptation of the ventricles.  The patient also had a right subtemporal depression, which was full preoperatively.  The entire old apparatus was dissected out.  We then cut both the ventricular catheters and secured them with sutures so that __________ could be inserted.  They were both inspected.  No definite debris were seen.  After removing the ventricular catheters, the old tracts were inspected and we could see where there was coaptation of the ventricles against the ventricular catheter.  On the right side, we elected to insert the Portnoy ventricular catheter and on the left a new Bactiseal catheter was inserted underneath the corpus callosum in a different location.  The old valve was dissected out and the proGAV valve with a 2-0 shunt assist was inserted and secured with a 2-0 Ethibond suture.  The proGAV valve was then connected to a Bactiseal distal tubing, which was looped in a cephalad way and then curved towards the left burr hole site and then the Portnoy catheter on the right was secured with a right-angled sleeve and then interposed between it and the left burr hole site with a flushing reservoir.  All connections secured with 2-0 Ethibond suture and a small piece of Bactiseal tubing between the flushing reservoir and the connector, which secured the left Bactiseal tubing to the two other Bactiseal tubings one being the distal Bactiseal tubing going towards the proGAV valve, which was set to an opening pressure of 8 and the other one being the Bactiseal tubing, which was going towards the flushing reservoir.,All the wounds were irrigated out with bacitracin and then closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well without complications.  CSF was not sent off.", Neurosurgery,23
"PREOPERATIVE DIAGNOSIS: , Right hemothorax.,POSTOPERATIVE DIAGNOSIS: , Right hemothorax.,PROCEDURE PERFORMED: , Insertion of a #32 French chest tube on the right hemithorax.,ANESTHESIA: , 1% Lidocaine and sedation.,INDICATIONS FOR PROCEDURE:,  This is a 54-year-old female with a newly diagnosed carcinoma of the cervix.  The patient is to have an Infuse-A-Port insertion today.  Postoperatively from that, she started having a blood tinged pink frothy sputum.  Chest x-ray was obtained and showed evidence of a hemothorax on the right hand side, opposite side of the Infuse-A-Port and a wider mediastinum.  The decision was made to place a chest tube in the right hemithorax to allow for the patient to be stable for transfer out of the operating room.,DESCRIPTION OF PROCEDURE: , The area was prepped and draped in the sterile fashion.  The area was anesthetized with 1% Lidocaine solution.  The patient was given sedation.  A #10 blade scalpel was used to make an incision approximately 1.5 cm long.  Then a curved scissor was used to dissect down to the level of the rib.  A blunt peon was then used to again enter into the right hemithorax.  Immediately a blood tinged effusion was released.  The chest tube was placed and directed in a posterior and superior direction.  The chest tube was hooked up to the Pleur-evac device which was ________ tip suction.  The chest tube was tied in with a #0 silk suture in a U-stitch fashion.  It was sutured in place with sterile dressing and silk tape.  The patient tolerated this procedure well.  We will obtain a chest x-ray in postop to ensure proper placement and continue to follow the patient very closely.", Cardiovascular / Pulmonary,3
"NERVE CONDUCTION TESTING AND EMG EVALUATION,1.  Right median sensory response 3.0, amplitude 2.5, distance 100.,2.  Right ulnar sensory response 2.1, amplitude 1, distance 90.,3.  Left median sensory response 3.0, amplitude 1.2, distance 100.,4.  Left median motor response distal 4.2, proximal 9, amplitude 2.2, distance 290, velocity 60.4 m/sec.,5.  Right median motor response distal 4.3, proximal 9.7, amplitude 2, and velocity 53.7 m/sec.,6.  Right ulnar motor response distal 2.5, proximal 7.5, amplitude 2, distance 300, velocity 60 m/sec.,NEEDLE EMG TESTING,1.  ,RIGHT BICEPS:,  Fibrillations 0, fasciculations occasional, positive waves 0.  Motor units, increased needle insertional activity and mild decreased number of motor units firing.,2.  ,RIGHT TRICEPS:,  Fibrillations 1+, fasciculations occasional to 1+, positive waves 1+.  Motor units, increased needle insertional activity and decreased number of motor units firing.,3.  ,EXTENSOR DIGITORUM:,  Fibrillations 0, fasciculations rare, positive waves 0, motor units probably normal.,4.  ,FIRST DORSAL INTEROSSEOUS: , Fibrillations 2+, fasciculations 1+, positive waves 2+.  Motor units, decreased number of motor units firing.,5.  ,RIGHT ABDUCTOR POLLICIS BREVIS:,  Fibrillations 1+, fasciculations 1+, positive waves 0.  Motor units, decreased number of motor units firing.,6. , FLEXOR CARPI ULNARIS:,  Fibrillations 1+, occasionally entrained, fasciculations rare, positive waves 1+.  Motor units, decreased number of motor units firing.,7.  ,LEFT FIRST DORSAL INTEROSSEOUS:,  Fibrillations 1+, fasciculations 1+, positive waves occasional.  Motor units, decreased number of motor units firing.,8.  ,LEFT EXTENSOR DIGITORUM:,  Fibrillations 1+, fasciculations 1+.  Motor units, decreased number of motor units firing.,9.  ,RIGHT VASTUS MEDIALIS:,  Fibrillations 1+ to 2+, fasciculations 1+, positive waves 1+.  Motor units, decreased number of motor units firing.,10.  ,ANTERIOR TIBIALIS: , Fibrillations 2+, occasionally entrained, fasciculations 1+, positive waves 1+.  Motor units, increased proportion of polyphasic units and decreased number of motor units firing.  There is again increased needle insertional activity.,11.  ,RIGHT GASTROCNEMIUS:,  Fibrillations 1+, fasciculations 1+, positive waves 1+.  Motor units, marked decreased number of motor units firing.,12.  ,LEFT GASTROCNEMIUS:,  Fibrillations 1+, fasciculations 1+, positive waves 2+.  Motor units, marked decreased number of motor units firing.,13.  ,LEFT VASTUS MEDIALIS: , Fibrillations occasional, fasciculations occasional, positive waves 1+.  Motor units, decreased number of motor units firing.,IMPRESSION: ", Physical Medicine - Rehab,30
"PROCEDURES:,1.  Release of ventral chordee.,2.  Circumcision.,3.  Repair of partial duplication of urethral meatus.,INDICATIONS: , The patient is an 11-month-old baby boy who presented for evaluation of a duplicated urethral meatus as well as ventral chordee and dorsal prepuce hooding.  He is here electively for surgical correction.,DESCRIPTION OF PROCEDURE: , The patient was brought back into operating room 35.  After successful induction of general endotracheal anesthetic, giving the patient, preoperative antibiotics and after completing a preoperative time out, the patient was prepped and draped in the usual sterile fashion.,A holding stitch was placed in the glans penis.  At this point, we probed both urethral meatus.  Using the Crede maneuver, we could see urine clearly coming out of the lower, the more ventral meatus.  At this point, we cannulated this with a 6-French hypospadias catheter.  We attempted to cannulate the dorsal opening, however, we were unsuccessful.  We then attempted to place lacrimal probes and were also unsuccessful indicating this was incomplete duplication.  At this point, we identified the band connecting both the urethral meatus and incised it with tenotomy scissors.  We sutured both meatus together such that there was one meatus at the normal position at the tip of the glans.,At this point, we made a circumcising incision around the penis and degloved the penis in its entirety relieving all chordee.  Once all the chordee had been adequately released, we turned our attention to the circumcision.  Excessive dorsal foreskin was removed from the skin and glans.  Mucosal cuts were reapproximated with interrupted 5-0 chromic suture.  Dermabond was placed over this and bacitracin was placed on this once dry.  This ended the procedure.  ,DRAINS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,URINE OUTPUT:  ,Unrecorded.,COMPLICATIONS: , None apparent.,DISPOSITION:  ,The patient will now go under the care of Dr. XYZ, Plastic Surgery, for excision of scalp hemangioma.", Surgery,38
"A 1 cm infraumbilical skin incision was made.  Through this a Veress needle was inserted into the abdominal cavity.  The abdomen was filled with approximately 2 liters of CO2 gas.  The Veress needle was withdrawn.  A trocar sleeve was placed through the incision into the abdominal cavity.  The trocar was withdrawn and replaced with the laparoscope.  A 1 cm suprapubic skin incision was made.  Through this a second trocar sleeve was placed into the abdominal cavity using direct observation with the laparoscope.  The trocar was withdrawn and replaced with a probe.,The patient was placed in Trendelenburg position, and the bowel was pushed out of the pelvis.  Upon visualization of the pelvis organs, the uterus, fallopian tubes and ovaries were all normal.  The probe was withdrawn and replaced with the bipolar cautery instrument.  The right fallopian tube was grasped approximately 1 cm distal to the cornual region of the uterus.  Electrical current was applied to the tube at this point and fulgurated.  The tube was then regrasped just distal to this and refulgurated.  It was then regrasped just distal to the lateral point and refulgurated again.  The same procedure was then carried out on the opposite tube.  The bipolar cautery instrument was withdrawn and replaced with the probe.  The fallopian tubes were again traced to their fimbriated ends to confirm the burn points on the tubes.  The upper abdomen was visualized, and the liver surface was normal.  The gas was allowed to escape from the abdomen, and the instruments were removed.  The skin incisions were repaired.  The instruments were removed from the vagina.,There were no complications to the procedure.  Blood loss was minimal.  The patient went to the postanesthesia recovery room in stable condition.", Surgery,38
"CHART NOTE:,  She is here to discuss possible open lung biopsy that she has actually scheduled for tomorrow.  Dr. XYZ had seen her because of her complaints of shortness of breath.  Then she had the pulmonary function test and CT scan and he felt that she probably had usual interstitial pneumonitis, but wanted her to have an open lung biopsy so he had her see Dr. XYZ Estep.  He had concurred with Dr. XYZ that an open lung biopsy was appropriate and she was actually scheduled for this but both Dr. XYZ and I were unavailable before the procedure was originally scheduled so he had it delayed so that she could talk with us prior to having the biopsy.  She was ready to go ahead with this and felt that it was important she find out why she is short of breath.  She is very concerned about the findings on her CAT scan and pulmonary function test.  She seemed alarmed to report that Dr. XYZ had found that her lung capacity was reduced to 60% of what should be normal.  However, I told her that two years ago Dr. XYZ did pulmonary function studies which showed the same change in function.  And that really her pulmonary function test, at least compared from two years ago, had not really changed over this period of time.  After discussing the serious nature of an open lung biopsy, the fact that her pulmonary function studies have not changed in two years, the fact that she likely has a number of other things that are contributing to her being out of breath, which is deconditioning and obesity, she seemed comfortable with the thought of simply monitoring this a little bit longer before undergoing something as risky as an open lung biopsy.  In fact when I called Dr. XYZ to talk to him about cancelling the procedure, he stated he would be very uncomfortable with doing an open lung biopsy on someone with pulmonary function studies which had not changed.  I also explained to patient that I did not think Dr. XYZ was aware that she had had pulmonary function studies two years previously and certainly did not know that there results of those.  And also I spoke with Dr. XYZ who agreed that although the two different tests may have some minor differences accounting for some of the similarity in results that may or may not be completely accurate, that generally a person with progressive interstitial lung disease without a fairly substantial change on pulmonary function tests even if they were done at different facilities.,I had a 30-minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it.  I also told her we could continue to monitor her breathing problems and continue to monitor her CAT scan, x-ray, and pulmonary function tests.  And if there was some sign that this was a progressive problem, she could still go ahead with the lung biopsy.  But she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her.  She understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful.,We are going to see her back in a month to see how her breathing is doing.  We will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time.  I told her I would try to talk to her sister sometime in the next day or two.", Cardiovascular / Pulmonary,3
"REASON FOR CONSULTATION: , Atrial fibrillation management.,HISTORY OF PRESENT ILLNESS: ,The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred by Dr. X for evaluation and management of atrial fibrillation.  The patient states that on Monday during routine Holt exam, it was detected by Dr. X that her heart was irregular on exam.  EKG obtained after that revealed atrial fibrillation, and subsequently the patient was started on Coumadin as well as having Toprol and referred for evaluation.  The patient states that for the last 3 years, she has had episodes of her heart racing.  It may last for minutes up to most 1 hour, and it will occasionally be related to eating a heavy meal or her caffeine or chocolate intake.  Denies dyspnea, diaphoresis, presyncope or syncope with the events, and she has had no episodes of chest pain.  They subsequently resolve on their own and do not limit her in anyway.  However, she states that for the last several years may be up to 7 years that she can recollect that she has been fatigued, and over the past couple of years, her symptoms have become more severe.  She said she can walk no more than 25 feet without becoming tired.  She states that she has to rest then her symptoms will go away, but she has been limited from that standpoint.  Denies peripheral edema, PND, orthopnea, abdominal pain, swelling, recent fever or chills.  She actually today has no complaints, and states that she has been compliant with her medications and has started taking her Coumadin as directed.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  Myocardial infarction in 2003.,3.  Left heart catheterization at University Hospital.,4.  Hypercholesterolemia.,5.  Arthritis.,6.  CVA in 2002 and in 2003 with right eye blindness.,PAST SURGICAL HISTORY:,1.  Left total knee replacement in 2002.,2.  Left lower quadrant abscess drainage in 12/07,FAMILY MEDICAL HISTORY: , Significant for lung and brain cancer.  There is no history that she is aware of cardiovascular disease in her family nor has any family member had sudden cardiac death.,SOCIAL HISTORY: , She is retired as a cook in a school cafeteria, where she worked for 34 years.  She retired 7 years ago because of low back pain.  She used to smoke 2-1/2 packs per day for 32 years, but quit in 1995.  Denies alcohol, and denies IV or illicit drug use.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,1.  Coumadin 5 mg a day.,2.  Toprol-XL 50 mg a day.,3.  Aspirin 81 mg a day.,4.  Hydrochlorothiazide 25 mg a day.,5.  Plendil 10 mg daily.,6.  Lipitor 40 mg daily.,REVIEW OF SYSTEMS:  ,As above stating that following her stroke, she has right eye blindness, but she does have some minimal vision in her periphery.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 138/66, pulse 96, and weight 229 pounds or 104 kg.  GENERAL:  A well-developed, well-nourished, middle-aged African American female in no acute distress.  NECK:  Supple.  No JVD.  No carotid bruits.  CARDIOVASCULAR:  Irregularly irregular rate and rhythm.  Normal S1 and S2.  No murmurs, gallops or rubs.  LUNGS:  Clear to auscultation bilaterally.  ABDOMEN:  Bowel sounds positive, soft, nontender, and nondistended.  No masses.  EXTREMITIES:  No clubbing, cyanosis or edema.  Pulses 2+ bilaterally.,LABORATORY DATA: , EKG today revealed atrial fibrillation with nonspecific lateral T-wave abnormalities and a rate of 94.,IMPRESSION:  ,The patient is a very pleasant 62-year-old African American female with atrial fibrillation of unknown duration with symptoms of paroxysmal episodes of palpitations, doing well today.,RECOMMENDATIONS:,1.  Her rate is suboptimally controlled, we will increase her Toprol-XL to 75 mg per day.,2.  We will obtain a transthoracic echocardiogram to evaluate her LV function as well as her valvular function.,3.  We will check a thyroid function panel.,4.  We will continue Coumadin as directed and to follow up with Dr. X for INR management.,5.  Given the patient's history of a stroke in her age and recurrent atrial fibrillation, the patient should be continued on Coumadin indefinitely.,6.  Depending upon the results of her transthoracic echocardiogram, the patient may benefit from repeat heart catheterization.  We will await results of transthoracic echocardiogram.,7.  We will arrange for the patient to wear a Holter monitor to monitor the rate controlled on a 24-hour period.  She will then return to the electrophysiology clinic in 1 month for followup visit with Dr. Y.,The patient was seen, discussed, and examined with Dr. Y in electrophysiology.", Cardiovascular / Pulmonary,3
"HISTORY:,  This 75-year-old man was transferred from the nursing home where he lived to the hospital late at night on 4/11 through the Emergency Department in complete urinary obstruction.  After catheterization, the patient underwent cystoscopy on 4/13.  On 4/14 the patient underwent a transurethral resection of the prostate and was discharged back to the nursing home later that day with voiding improved.  Final diagnosis was adenocarcinoma of the prostate.  Because of his mental status and general debility, the patient's family declined additional treatment.,LABORATORY:,  None,PROCEDURES:,Cystoscopy:  Blockage of the urethra by a markedly enlarged prostate.,Transurethral resection of prostate:  45 grams of tissue were sent to the Pathology Department for analysis.,PATHOLOGY: , Well differentiated adenocarcinoma, microacinar type, in 1 of 25 chips of prostatic tissue.", Urology,39
"PREOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,POSTOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,PROCEDURES PERFORMED:,1.  Right McBride bunionectomy.,2.  Right basilar wedge osteotomy with OrthoPro screw fixation.,ANESTHESIA: , Local with IV sedation.,HEMOSTASIS: , With pneumatic ankle cuff.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in a supine position.  The right foot was prepared and draped in usual sterile manner.  Anesthesia was achieved utilizing a 50:50 mixture of 2% lidocaine plain with 0.5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint.  Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg.  At this time, attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made.  The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure.  The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection.  Using a microsagittal saw, the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp.  At this time, attention was directed to the first inner space using sharp and blunt dissection.  Dissection was carried down to the underling level of the adductor hallucis tendon, which was isolated and freed from its phalangeal, sesamoidal, and metatarsal attachments.  The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0.5 cm to help prevent any re-fibrous attachment.  At this time, the lateral release was stressed and was found to be complete.  The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0.5-cm resection.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw.  The area was again copiously flushed and inspected for any abnormalities and/or prominences and none were noted.  At this time, attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length.  The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption.  At this time, there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint.  At this time, 0.5 cm was measured distal to that lateral measurement and using microsagittal saw, a wedge osteotomy was taken from the base with the apex of the osteotomy being medial, taking care to keep the medial cortex intact as a hinge.  The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3.0 x 22 mm.  The screw was placed following proper technique.  The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing.  A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy.  The packing of the cancellous bone was held in place with bone wax.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed.  At this time, a deep closure was achieved utilizing #2-0 Vicryl suture, subcuticular closure was achieved using #4-0 Vicryl suture, and skin repair was achieved at both surgical sites with #5-0 nylon suture in a running interlocking fashion.  The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site.  At this time, the surgical site was postoperatively injected with 0.5 Marcaine plain as well as dexamethasone 4 mg primarily.  The surgical sites were then dressed with sterile Xeroform, sterile 4x4s, cascading, and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion.  The tourniquet was dropped and color and temperature of all digits returned to normal.  The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition.,The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions, problems, or concerns at any time with the numbers provided.  The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot.,", Orthopedic,27
"CIRCUMCISION - OLDER PERSON,OPERATIVE NOTE:,  The patient was taken to the operating room and placed in the supine position on the operating table.  General endotracheal anesthesia was administered.  The patient was prepped and draped in the usual sterile fashion.  A 4-0 silk suture is used as a stay-stitch of the glans penis.  Next, incision line was marked circumferentially on the outer skin 3 mm below the corona.  The incision was then carried through the skin and subcutaneous tissues down to within a layer of * fascia.  Next, the foreskin was retracted.  Another circumferential incision was made 3 mm proximal to the corona.  The intervening foreskin was excised.  Meticulous hemostasis was obtained with electrocautery.  Next, the skin was reapproximated at the frenulum with a U stitch of 5-0 chromic followed by stitches at 12, 3, and 9 o'clock.  The stitches were placed equal distance among these to reapproximate all the skin edges.  Next, good cosmetic result was noted with no bleeding at the end of the procedure.  Vaseline gauze, Telfa, and Elastoplast dressing was applied.  The stay-stitch was removed and pressure held until bleeding stopped.  The patient tolerated the procedure well and was returned to the recovery room in stable condition.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Voluntary sterility.,POSTOPERATIVE DIAGNOSIS: , Voluntary sterility.,OPERATIVE PROCEDURE:,  Bilateral vasectomy.,ANESTHESIA:,  Local.,INDICATIONS FOR PROCEDURE:  ,A gentleman who is here today requesting voluntary sterility.  Options were discussed for voluntary sterility and he has elected to proceed with a bilateral vasectomy.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, and after appropriately identifying the patient, the patient was prepped and draped in the standard surgical fashion and placed in a supine position on the OR table.  Then, 0.25% Marcaine without epinephrine was used to anesthetize the scrotal skin.  A small incision was made in the right hemiscrotum.  The vas deferens was grasped with a vas clamp.  Next, the vas deferens was skeletonized.  It was clipped proximally and distally twice.  The cut edges were fulgurated.  Meticulous hemostasis was maintained.  Then, 4-0 chromic was used to close the scrotal skin on the right hemiscrotum.  Next, the attention was turned to the left hemiscrotum, and after the left hemiscrotum was anesthetized appropriately, a small incision was made in the left hemiscrotum.  The vas deferens was isolated.  It was skeletonized.  It was clipped proximally and distally twice.  The cut edges were fulgurated.  Meticulous hemostasis was maintained.  Then, 4-0 chromic was used to close the scrotal skin.  A jockstrap and sterile dressing were applied at the end of the case.  Sponge, needle, and instruments counts were correct.", Urology,39
"EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day.  Fever.  Right upper quadrant pain for one day.  ,COMPARISON: , None. ,TECHNIQUE:,  CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement.  ,CT ABDOMEN: , Lung bases are clear.  The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable.  The aorta is normal in caliber.  There is no retroperitoneal lymphadenopathy.  ,CT PELVIS: , The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change.  Per CT, the colon and small bowel are unremarkable.  The bladder is distended.  No free fluid/air.  Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1.  Unremarkable exam; specifically no evidence for acute appendicitis. ,2.  No acute nephro-/ureterolithiasis. ,3.  No secondary evidence for acute cholecystitis.,Results were communicated to the ER at the time of dictation.", Gastroenterology,14
"PREOPERATIVE DIAGNOSIS: , Aqueductal stenosis.,POSTOPERATIVE DIAGNOSIS:,  Aqueductal stenosis.,TITLE OF PROCEDURE:  ,Endoscopic third ventriculostomy.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES:,  Bactiseal ventricular catheter with an Aesculap burr hole port.,SKIN PREPARATION:  ,ChloraPrep.,COMPLICATIONS: , None.,SPECIMENS: , CSF for routine studies.,INDICATIONS FOR OPERATION:  ,Triventricular hydrocephalus most consistent with aqueductal stenosis.  The patient having a long history of some intermittent headaches, macrocephaly.,OPERATIVE PROCEDURE: , After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in supine position with the head neutral.  The right frontal area was shaven and then the head was prepped and draped in a standard routine manner.  The area of the proposed scalp incision was infiltrated with 0.25% Marcaine with 1:200,000 epinephrine.  A curvilinear scalp incision was made extending from just posterior to bregma curving up in the midline and then going off to the right anterior to the coronal suture.  Two Weitlaner were used to hold the scalp open.  A burr hole was made just anterior to the coronal suture and then the dura was opened in a cruciate manner and the pia was coagulated.  Neuropen was introduced directly through the parenchyma into the ventricular system, which was quite large and dilated.  CSF was collected for routine studies.  We saw the total absence of __________  consistent with the congenital form of aqueductal stenosis and a markedly thinned down floor of the third ventricle.  I could bend the ventricular catheter and look back and see the aqueduct, which was quite stenotic with a little bit of chorioplexus near its opening.  The NeuroPEN was then introduced through the midline of the floor of the third ventricle anterior to the mamillary bodies in front of the basilar artery and then was gently enlarged using NeuroPEN __________  various motions.  We went through the membrane of Liliequist.  We could see the basilar artery and the clivus, and there was no significant bleeding from the edges.  The Bactiseal catheter was then left to 7 cm of length because of her macrocephaly and secured to a burr hole port with a 2-0 Ethibond suture.  The wound was irrigated out with bacitracin and closed using 3-0 Vicryl for the deep layer and a Monocryl suture for the scalp followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well.", Neurosurgery,23
"PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,PROCEDURES PERFORMED:  ,Tailor bunionectomy, right foot, Weil-type with screw fixation.,ANESTHESIA: , Local with MAC, local consisting of 20 mL of 0.5% Marcaine plain.,HEMOSTASIS:,  Pneumatic ankle tourniquet at 200 mmHg.,INJECTABLES:,  A 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate.,MATERIAL: , A 2.4 x 14 mm, 2.4 x 16 mm, and 2.0 x 10 mm OsteoMed noncannulated screw.  A 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, and 5-0 nylon.,COMPLICATIONS: , None.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS:,  Minimal.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed on the operating table in the usual supine position.  At this time, a pneumatic ankle tourniquet was placed on the patient's right ankle for the purpose of maintaining hemostasis.  Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site.  The right foot was then scrubbed, prepped, and draped in the usual aseptic manner.  An Esmarch bandage was then used to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet inflated to 200 mmHg.  Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3.5 cm in length was made.  The incision was carried deep utilizing both sharp and blunt dissections.  All major neurovascular structures were avoided.  At this time, through the original skin incision, attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified.  This was then incised fully exposing the tendon and the abductor hallucis muscle.  This was then resected from his osseous attachments and a small tenotomy was performed.  At this time, a small lateral capsulotomy was also performed.  Lateral contractures were once again reevaluated and noted to be grossly reduced.,Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision.  The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw, the head of the first metatarsal and medial eminence was resected and passed from the operative field.  A 0.045 inch K-wire was then driven across the first metatarsal head in order to act as an access dye.  The patient was then placed in the frog-leg position, and two osteotomy cuts were made, one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position.  The dorsal arm was made longer than the plantar arm to accommodate for fixation.  At this time, the capital fragment was resected and shifted laterally into a more corrected position.  At this time, three portions of the 0.045-inch K-wire were placed across the osteotomy site in order to access temporary forms of fixation.  Two of the three of these K-wires were removed in sequence and following the standard AO technique two 3.4 x 15 mm and one 2.4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site.  Compression was noted to be excellent.  All guide wires and 0.045-inch K-wires were then removed.  Utilizing an oscillating bone saw, the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field.  The wound was then once again flushed with copious amounts of sterile normal saline.  At this time, utilizing both 2-0 and 3-0 Vicryl, the periosteal and capsular layers were then reapproximated.  At this time, the skin was then closed in layers utilizing 4-0 Vicryl and 4-0 nylon.  At this time, attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension.  Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided.,A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal.  Utilizing an oscillating bone saw, the lateral eminence was resected and passed from the operative field.  Utilizing the sagittal saw, a Weil-type osteotomy was made at the fifth metatarsal head.  The head was then shifted medially into a more corrected position.  A 0.045-inch K-wire was then used as a temporary fixation, and a 2.0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site.  This was noted to be in correct position and compression was noted to be excellent.  Utilizing a small bone rongeur, the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field.  The wound was once again flushed with copious amounts of sterile normal saline.  The periosteal and capsular layers were reapproximated utilizing 3-0 Vicryl, and the skin was then closed utilizing 4-0 Vicryl and 4-0 nylon.  At this time, 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site.  The right foot was then dressed with Xeroform gauze, fluffs, Kling, and Ace wrap, all applied in mild compressive fashion.  The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot.  The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot.  After a brief period of postoperative monitoring, the patient was discharged to home with proper written and verbal discharge instructions, which included to keep dressing clean, dry, and intact and to follow up with Dr. A.  The patient is to be nonweightbearing to the right foot.  The patient was given a prescription for pain medications on nonsteroidal anti-inflammatory drugs and was educated on these.  The patient tolerated the procedure and anesthesia well.  Dr. A was present throughout the entire case.", Radiology,33
"INDICATIONS:,  Atrial fibrillation, coronary disease.,STRESS TECHNIQUE:, The patient was infused with dobutamine to a maximum heart rate of 142.  ECG exhibits atrial fibrillation.,IMAGE TECHNIQUE:,  The patient was injected with 5.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT system.,IMAGE ANALYSIS:,  It should be noted that the images are limited slightly by the patient's obesity with a weight of 263 pounds.  There is normal LV myocardial perfusion.  The LV systolic ejection fraction is normal at 65%.  There is normal global and regional wall motion.,CONCLUSIONS:,1.  Basic rhythm of atrial fibrillation with no change during dobutamine stress, maximum heart rate of 142.,2.  Normal LV myocardial perfusion.,3.  Normal LV systolic ejection fraction of 65%.,4.  Normal global and regional wall motion.", Radiology,33
"HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **.  Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound.  ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear.  The baby was vertex presentation.  The baby was dried, stimulated, and bulb suctioned.  Apgar scores of ** at one minute and ** at five minutes.,PAST MEDICAL HISTORY,MATERNAL HISTORY:,  The mother is a **-year-old, G**, P** female with blood type **.  She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative.  Mother was group B strep **.  Mother's past medical history is **.,PRENATAL CARE: , Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits.  She did not smoke, drink alcohol, or use illicit drugs during pregnancy.,SURGICAL HISTORY: , **,MEDICATIONS:,  Medications taken during this pregnancy were **.,ALLERGIES: , **,FAMILY HISTORY: , **,SOCIAL HISTORY: , **,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature **, heart rate **, respiratory rate **.  Dextrose stick **.  Ballard score by the RN is ** weeks.  Birth weight is ** grams, which is the ** percentile for gestational age.  Length is ** centimeters which is ** percentile for gestational age.  Head circumference is ** centimeters which is ** percentile for gestational age.,GENERAL:  **Alert, active, nondysmorphic-appearing infant in no acute distress.,HEENT:  Anterior fontanelle open and flat.  Positive bilateral red reflexes.,Ears have normal shape and position with no pits or tags.  Nares patent.  Palate intact.  Mucous membranes moist.,NECK:  Full range of motion.,CARDIOVASCULAR:  Normal precordium, regular rate and rhythm.  No murmurs.  Normal femoral pulses.,RESPIRATORY;  Clear to auscultation bilaterally.  No retractions.,ABDOMEN:  Soft, nondistended.  Normal bowel sounds.  No hepatosplenomegaly.  Umbilical stump is clean, dry, and intact.,GENITOURINARY:  Normal tanner I **.  Anus patent.,MUSCULOSKELETAL:  Negative Barlow and Ortolani.  Clavicles intact.  Spine straight.  No sacral dimple or hair tuft.  Leg lengths grossly symmetric.  Five fingers on each hand and five toes on each foot.,SKIN:  Warm and pink with brisk capillary refill.  No jaundice.,NEUROLOGICAL:  Normal tone.  Normal root, suck, grasp, and Moro reflexes.  Moves all extremities equally.,DIAGNOSTIC STUDIES,LABORATORY DATA:,  **,ASSESSMENT: , Full term, appropriate for gestational age **.,PLAN:,1.  Routine newborn care.,2.  Anticipatory guidance.,3.  Hepatitis B immunization prior to discharge.,", General Medicine,15
"REASON FOR VISIT:,  Mr. A is an 86-year-old man who returns for his first followup after shunt surgery.,HISTORY OF PRESENT ILLNESS:  ,I have followed Mr. A since May 2008.  He presented with eight to ten years of progressive gait impairment, cognitive impairment, and decreased bladder control.  We established a diagnosis of adult hydrocephalus with the spinal catheter protocol in June of 2008 and ,Mr. A underwent shunt surgery performed by Dr. X on August 1st.  A Medtronic Strata programmable shunt in the ventriculoperitoneal configuration programmed at level 2.0 was placed.,Mr. A comes today with his daughter, Pam and together they give his history.,Mr. A has had no hospitalizations or other illnesses since I last saw him.  With respect to his walking, his daughter tells me that he is now able to walk to the dining room just fine, but could not before his surgery.  His balance has improved though he still has some walking impairment.  With respect to his bladder, initially there was some improvement, but he has leveled off and he wears a diaper.,With respect to his cognition, both Pam and the patient say that his thinking has improved.  The other daughter, Patty summarized it best according to two of them.  She said, ""I feel like I can have a normal conversation with him again.""  Mr. A has had no headaches and no pain at the shunt site or at the abdomen.,MEDICATIONS: , Plavix 75 mg p.o. q.d., metoprolol 25 mg p.o. q.d., Flomax 0.4 mg p.o. q.d., Zocor 20 mg p.o. q.d., Detrol LA 4 mg p.o. q.d., lisinopril 10 mg p.o. q.d., Imodium daily, Omega-3, fish oil, and Lasix.,MAJOR FINDINGS:,  Mr. A is a pleasant and cooperative man who is able to converse easily though his daughter adds some details.,Vital Signs:  Blood pressure 124/80, heart rate is 64, respiratory rate is 18, weight 174 pounds, and pain is 0/10.,The shunt site was clean, dry, and intact and confirmed at a setting of 2.0.,Mental Status:  Tested for recent and remote memory, attention span, concentration, and fund of knowledge.  He scored 26/30 on the MMSE when tested with spelling and 25/30 when tested with calculations.  Of note, he was able to get two of the three memory words with cuing and the third one with multiple choice.  This was a slight improvement over his initial score of 23/30 with calculations and 24/30 with spelling and at that time he was unable to remember any memory words with cuing and only one with multiple choice.,Gait:  Tested using the Tinetti assessment tool.  He was tested without an assistive device and received a gait score of 6-8/12 and a balance of score of 12/16 for a total score of 18-20/28.  This has slightly improved from his initial score of 15-17/28.,Cranial Nerves:  Pupils are equal.  Extraocular movements are intact.  Face symmetric.  No dysarthria.,Motor:  Normal for bulk and strength.,Coordination:  Slow for finger-to-nose.,IMAGING: , CT scan was reviewed from 10/15/2008.  It shows a frontal horn span at the level of foramen of Munro of 4.6 cm with a 3rd ventricular contour that is flat with the span of 10 mm.  By my reading, there is a tiny amount of blood in the right frontal region with just a tiny subdural collection.  This was not noticed by the radiologist who stated no extraaxial fluid collections.  There is also substantial small vessel ischemic change.,ASSESSMENT: , Mr. A has made some improvement since shunt surgery.,PROBLEMS/DIAGNOSES:,1.  Adult hydrocephalus (331.5).,2.  Gait impairment (781.2).,3.  Urinary incontinence and urgency (788.33).,4.  Cognitive impairment (290.0).,PLAN:,  I had a long discussion with Mr. A and his daughter.  We are all pleased that he has started to make some improvement with his hydrocephalus because I believe I see a tiny fluid collection in the right parietal region, I would like to leave the setting at 2.0 for another three months before we consider changing the shunt.  I do not believe that this tiny amount of fluid is symptotic and it was not documented by the radiologist when he read the CT scan.,Mr. A asked me about whether he will be able to drive again.  Unfortunately, I think it is unlikely that his speed of movement will improve to a level that he will be able to pass a driver's safety evaluation, however, occasionally patients surprise me by improving enough over 9 to 12 months that they are able to pass such a test.  I would certainly be happy to recommend such a test if I believe ,Mr. A is likely to pass it and he is always welcome to enroll in a driver's safety program without my recommendation, however, I think it is exceeding unlikely that he has the capability of passing this rigorous test at this time.  I also think it is quite likely he will not regain sufficient speed of motion to pass such a test.", Neurosurgery,23
"PREOPERATIVE DIAGNOSES:,  Bilateral inguinal hernias with bilateral hydroceles after right inguinal hernia repair, cerebral palsy, asthma, seizure disorder, developmental delay, and gastroesophageal reflux disease.,POSTOPERATIVE DIAGNOSES: , Left inguinal hernia, bilateral hydroceles, and right torsed appendix testis.,PROCEDURE: , Right inguinal exploration, left inguinal hernia repair, bilateral hydrocele repair, and excision of right appendix testis.,FLUIDS RECEIVED:  ,700 mL of crystalloid.,ESTIMATED BLOOD LOSS:  ,10 mL.,SPECIMENS:,  Tissue sent to pathology is calcified right appendix testis.,TUBES/DRAINS: , No tubes or drains were used.,COUNTS:  ,Sponge and needle counts were correct x2.,ANESTHESIA: , General inhalational anesthetic and 0.25% Marcaine ilioinguinal nerve block, 30 mL given per surgeon.,INDICATIONS FOR OPERATION:  ,The patient is a 14-1/2-year-old boy with multiple medical problems, primarily due to cerebral palsy, asthma, seizures, gastroesophageal reflux disease, and developmental delay.  He had a hernia repair done on the right in the past, but developed a new hernia on the right and a smaller on the left.  The plan is for repair.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then placed in the supine position.  IV antibiotics were given.  He was then sterilely prepped and draped.  A right inguinal incision was made in the previous incisional site with a 15-blade knife, extended down through the subcutaneous tissue and Scarpa fascia with electrocautery.  Electrocautery was used for hemostasis.,The external oblique fascia was then visualized and incised.  There was a moderate amount of scar tissue noted, but we were able to incise that and go down into the right inguinal canal.  Upon dissection there, we did not find any hernias; however, he did have a fairly sizable hydrocele.  We went down towards the external ring and found that this was indeed tight without any hernias.,We then closed up the external oblique fascia and made an incision after doing a shave on the right and left scrotum into the upper scrotal sac with a curvilinear incision with a 15-blade knife.  We then extended down to the subcutaneous tissue.  Electrocautery was used for hemostasis.  The hydrocele sac was visualized and then drained after incising into it with a curved Metzenbaum scissors.  The testis was then delivered and found to have a moderate amount of scar tissue with a calcified appendix testis, which was then excised and sent to pathology.  We then checked the upper aspect of the tunica vaginalis pouch and found that there was indeed no other connection, was up above, so we then wrapped the sac around the back of the testis, and closed it with a 4-0 chromic suture in a Lord maneuver.  We then closed the upper aspect of the subdartos pouch with a pursestring suture of 4-0 chromic and placed the testis into the scrotum in the proper orientation.  We then used an ilioinguinal nerve block and wound instillation on both incisional areas with 0.25% Marcaine without epinephrine; 15 mL was given.,We performed a similar procedure on the left, incising it at the scrotal area first, rather than below, and found this tunica vaginalis, and dissected it in a similar fashion and cauterized the appendix testis, which was not torsed.  This was a smaller hydrocele, but because of the __________ shunt, we went up above and found that there was a very small connection, which was then dissected off the cord structures gently, twisted upon itself, suture ligated with a 2-0 Vicryl suture.,The ilioinguinal nerve block and other wound instillations again with 15 mL total of 0.25% Marcaine were then done by the surgeon as well.  The external oblique fascia was closed on both sides with a running suture of 2-0 Vicryl.  4-0 chromic was then used to close the Scarpa fascia.  The skin was closed with a 4-0 Rapide subcuticular closure.  The scrotal incisions were closed with a subcutaneous and dartos closure using 4-0 chromic.  IV Toradol was given at the end of the procedure.  Dermabond tissue adhesive was placed on all 4 incisions.  The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room.", Urology,39
"PREOPERATIVE DIAGNOSIS:,  Blocked ventriculoperitoneal shunt.,POSTOPERATIVE DIAGNOSIS:,  Blocked ventriculoperitoneal shunt.,PROCEDURE: , Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end.,ANESTHESIA: , General.,HISTORY: , The patient is nonverbal.  He is almost 3 years old.  He presented with 2 months of irritability, vomiting, and increasing seizures.  CT scan was not conclusive, but shuntogram shows no flow through the shunt.,DESCRIPTION OF PROCEDURE: , After induction of general anesthesia, the patient was placed supine on the operating room table with his head turned to the left.  Scalp was clipped.  He was prepped on the head, neck, chest and abdomen with ChloraPrep.  Incisions were infiltrated with 0.5% Xylocaine with epinephrine 1:200,000.  He received oxacillin.,He was then reprepped and draped in a sterile manner.,The frontal incision was reopened and extended along the valve.  Subcutaneous sharp dissection with Bovie cautery was done to expose the shunt parts.  I separated the ventricular catheter from the valve, and this was a medium pressure small contour Medtronic valve.  There was some flow from the ventricular catheter, but not as much as I would expect.  I removed the right-angled clip with a curette and then pulled out the ventricular catheter, and there was gushing of CSF under high pressure.  So, I do believe that the catheter was obstructed, although inspection of the old catheter holes did not show any specific obstructions.  A new Codman BACTISEAL catheter was placed through the same hole.  I replaced it several times because I wanted to be sure it was in the cavity.  It entered easily and there was still just intermittent flow of CSF.  The catheter irrigated very well and seemed to be patent.,I tested the distal system with an irrigation filled feeding tube, and there was excellent flow through the distal valve and catheter.  So I did not think it was necessary to replace those at this time.  The new catheter was trimmed to a total length of 8 cm and attached to the proximal end of the valve.  The valve connection was secured to the pericranium with a #2-0 Ethibond suture.  The wound was irrigated with bacitracin irrigation.  The shunt pumped and refilled well.  The wound was then closed with #4-0 Vicryl interrupted galeal suture and Steri-Strips on the skin.  It was uncertain whether this will correct the problem or not, but we will continue to evaluate.  If his abdominal pressure is too high, then he may need a different valve.  This will be determined over time, but at this time, the shunt seemed to empty and refill easily.  The patient tolerated the procedure well.  No complications.  Sponge and needle counts were correct.  Blood loss was minimal.  None replaced.", Neurosurgery,23
"CHIEF COMPLAINT:  ,Blood in toilet.,HISTORY: , Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet.  They did not note any urine or stool in the toilet and the patient had no acute complaints.  The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events.  The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints.  There is no other history provided by the nursing staff from XYZ.  There apparently were no clots noted within there.  She does not have a history of being on anticoagulants.,PAST MEDICAL HISTORY: , Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.,PAST SURGICAL HISTORY:  ,Unknown.,SOCIAL HISTORY: , No tobacco or alcohol.,MEDICATIONS: , Listed in the medical records.,ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.,GENERAL:  This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress.,HEENT:  Visually normal.  Pupils are reactive.  TMs, canals, nasal mucosa, and oropharynx are intact.,NECK:  No lymphadenopathy or JVD.,HEART:  Regular rate and rhythm.  S1, S2.  No murmurs, gallops, or rubs.,LUNGS:  Clear to auscultation.  No wheeze, rales, or rhonchi.,ABDOMEN:  Benign, flat, soft, nontender, and nondistended.  Bowel sounds active.  No organomegaly or mass noted.,GU/RECTAL:  External rectum was normal.  No obvious blood internally.  There is no stool noted within the vault.  There is no gross amount of blood noted within the vault.  Guaiac was done and was trace positive.  Visual examination anteriorly during the rectal examination noted no blood within the vaginal region.,EXTREMITIES:  No significant abnormalities.,WORKUP: , CT abdomen and pelvis was negative.  CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%.  CMP also within normal limits.  PTT, PT, and INR were normal.  Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization.,ER COURSE:,  Uneventful.  I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient.  We have decided to send the patient back to XYZ with observation by the staff there.  She will have a CBC done daily for the next 3 days with results to Dr. X.  They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood.,ASSESSMENT: , Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Blood loss anemia.,PROCEDURE PERFORMED:,1.  Laparotomy.,2.  Myomectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS: , Less than a 100 cc.,URINE OUTPUT: , 110 cc, clear at the end of the procedure.,FLUIDS: , 500 cc during the procedure.,SPECIMENS: , Four uterine fibroids.,DRAINS:  ,Foley catheter to gravity.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses.  Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids, which is approximately 6+ cm and several small submucosal fibroids within the endometrium.  Both ovaries and tubes appeared within normal limits.,PROCEDURE: , The patient was taken to the operating room where she was prepped and draped in the normal sterile fashion in the dorsal supine position.  After the general anesthetic was found to be adequate, a Pfannenstiel skin incision was made with the first knife.  This was carried through the underlying layer of fascia with a second knife.  The fascia was incised in the midline with the second knife and the fascial incision was then extended laterally in both directions with the Mayo scissors.  The superior aspect of the fascial incision was then grasped with Ochsner clamps, tented up, and dissected off the underlying layer of rectus muscle bluntly.  It was then dissected in the middle with the Mayo scissors.  The inferior aspect of this incision was addressed in a similar manner.  The rectus muscles were separated in the midline bluntly.  The peritoneum was identified with hemostat clamps, tented up, and entered sharply with the Metzenbaum scissors.  The peritoneal incision was then extended superiorly and inferiorly with the Metzenbaum scissors and then extended bluntly.  Next, the uterus was grasped bluntly and removed from the abdomen.  The fundal fibroid was identified.  It was then injected with vasopressin, 20 units mixed in 30 cc of normal saline along the serosal surface and careful to aspirate to avoid any blood vessels.  15 cc was injected.  Next, the point tip was used with the cautery _______ cutting to cut the linear incision along the top of the _______ fibroid until fibroid fibers were seen.  The edges of the myometrium was grasped with Allis clamps, tented up, and a hemostat was used to bluntly dissect around the fibroid followed by blunt dissection with a finger.  The fibroid was easily and bluntly dissected out.  It was also grasped with Lahey clamp to prevent traction.  Once the blunt dissection of the large fibroid was complete, it was handed off to the scrub nurse.  The large fibroid traversed the whole myometrium down to the mucosal surface and the endometrial cavity was largely entered when this fibroid was removed.  At this point, several smaller fibroids were noticed along the endometrial surface of the uterus.  Three of these were removed just by bluntly grasping with the Lahey clamp and twisting, all three of these were approximately 1 cm to 2 cm in size.  These were also handed to the scrub tech.  Next, the uterine incision was then closed with first two interrupted layers of #0 chromic in an interrupted figure-of-eight fashion and then with a #0 Vicryl in a running baseball stitch.  The uterus was seen to be completely hemostatic after closure.  Next, a 3 x 4 inch piece of Interceed was placed over the incision and dampened with normal saline.  The uterus was then carefully returned to the abdomen and being careful not to disturb the Interceed.  Next, the greater omentum was replaced over the uterus.,The rectus muscles were then reapproximated with a single interrupted suture of #0 Vicryl in the midline.  Then the fascia was closed with #0 Vicryl in a running fashion.  Next, the Scarpa's fascia was closed with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a running subcuticular fashion.  The incision was then dressed with 0.5-inch Steri-Strips and bandaged appropriately.  After the patient was cleaned, she was taken to Recovery in stable condition and she will be followed for her immediate postoperative period during the hospital.", Obstetrics / Gynecology,24
"PROCEDURE PERFORMED:  ,DDDR permanent pacemaker.,INDICATION: , Tachybrady syndrome.,PROCEDURE:,  After all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to the Cardiac Catheterization Suite where the right subclavian region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein.  Once adequate anesthesia had been obtained, a thin-walled #18-gauze Argon needle was used to cannulate the left subclavian vein.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  The needle was then removed over the guidewire and the guidewire was secured to the field.  A second #18 gauze Argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen.  Likewise, the needle was removed over the guidewire and the guidewire was then secured to the field.  Next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area.  A #11-knife blade was used to make a deeper incision.  Hemostasis was made complete.  The edges of the incision were grasped and retracted.  Using Metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane.  Digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator.  Metzenbaum scissors were then used to dissect cephalad to expose the guide wires.  The guidewires were then pulled through the pacemaker pocket.  One guidewire was secured to the field.,A bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance.  The guidewire and dilator were then removed.  Next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.  The pacemaker lead was then placed in the appropriate position in the right ventricle.  Pacing and sensing thresholds were obtained.  The lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________.  Pacing and sensing threshold were then reconfirmed.  Next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen.  The guidewire and dilator were then removed.  Under fluoroscopic guidance, the atrial lead was passed into the right atrium.  The sheath was then turned away in standard fashion.  Using fluoroscopic guidance, the atrial lead was then placed in the appropriate position.  Pacing and sensing thresholds were obtained.  The lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________.  Sensing and pacing thresholds were then reconfirmed.  The leads were wiped free of blood and placed into the pacemaker generator.  The pacemaker generator leads were then placed into pocket with the leads posteriorly.  The deep tissues were closed utilizing #2-0 Chromic suture in an interrupted stitch fashion.  A #4-0 undyed Vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch.  Steri-Strips overlaid.  A sterile gauge dressing was placed over the site.  The patient tolerated the procedure well and was transferred to the Cardiac Catheterization Room in stable and satisfactory condition.,PACEMAKER DATA (GENERATOR DATA):,Manufacturer:  Medtronics.,Model:  Sigma.,Model #:  1234.,Serial #:  123456789.,LEAD INFORMATION:,Right Atrial Lead:,Manufacturer:  Medtronics.,Model #:  1234.,Serial #:  123456789.,VENTRICULAR LEAD:,Manufacturer:  Medtronics.,Model #:  1234.,Serial #:  123456789.,PACING AND SENSING THRESHOLDS:,Right Atrial Bipolar Lead:  Pulse width 0.50 milliseconds, impedance 518 ohms, P-wave sensing 2.2 millivolts, polarity is bipolar.,Ventricular Bipolar Lead:  Pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, R-wave sensing 9.7 millivolts, polarity is bipolar.,PARAMETER SETTINGS:,  Pacing mode DDDR:  Mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.,IMPRESSION:,  Successful implantation of DDDR permanent pacemaker.,PLAN:,1.  The patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.,2.  The patient will be placed on antibiotics for five days to avoid pacemaker infection.", Surgery,38
"TITLE OF OPERATION:  ,1.  Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.,2.  A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,INDICATION FOR SURGERY:  ,The patient is a 62-year-old white male who underwent cataract surgery in 09/06.  This was complicated by posterior capsule rupture.  An intraocular lens implant was not attempted.  He developed corneal edema and a preretinal hemorrhage.  He is aware of the risks, benefits, and alternatives of the surgery and now wishes to proceed with secondary scleral suture fixated posterior chamber intraocular lens implant in the left eye, vitrectomy, endolaser, and penetrating keratoplasty.,PREOP DIAGNOSIS:  ,1.  Preretinal hemorrhage.,2.  Diabetic retinopathy.,3.  Aphakia.,4.  Corneal edema.,POSTOP DIAGNOSIS:  ,1.  Preretinal hemorrhage.,2.  Diabetic retinopathy.,3.  Aphakia.,4.  Corneal edema.,ANESTHESIA: , General.,SPECIMEN:  ,1.  Donor corneal swab sent to Microbiology.,2.  Donor corneal scar rim sent to Eye Pathology.,3.  The patient's cornea sent to Eye Pathology.,PROS DEV IMPLANT:  ,ABC Laboratories 16.0 diopter posterior chamber intraocular lens, serial number 123456.,NARRATIVE: , Informed consent was obtained, and all questions were answered.  The patient was brought to the preoperative holding area, where the operative left eye was marked.  He was brought to the operating room and placed in the supine position.  EKG leads were placed.  General anesthesia was induced.  The left ocular surface and periorbital skin were disinfected and draped in the standard fashion for eye surgery after a shield and tape were placed over the unoperated right eye.  A lid speculum was placed.  The posterior segment infusion was placed by the vitreoretinal service.  Peritomy was performed at the 3 and 9 o'clock limbal positions.  A large Flieringa ring was then sutured to the conjunctival surface using 8-0 silk sutures tied in an interrupted fashion.  The cornea was then measured and was found to accommodate a 7.5-mm trephine.  The center of the cornea was marked.  The keratoprosthesis was identified.,A 7.5-mm trephine blade was then used to incise the anterior corneal surface.  This was done after a paracentesis was placed at the 1 o'clock position and viscoelastic was used to dissect peripheral anterior synechiae.  Once the synechiae were freed, the above-mentioned trephination of the anterior cornea was performed.  Corneoscleral scissors were then used to excise completely the central cornea.  The keratoprosthesis was placed in position and was sutured with six interrupted 8-0 silk sutures.  This was done without difficulty.  At this point, the case was turned over to the vitreoretinal team, which will dictate under a separate note.  At the conclusion of the vitreoretinal procedure, the patient was brought under the care of the cornea service.  The 9-0 Prolene sutures double armed were then placed on each lens haptic loop.  The keratoprosthesis was removed.  Prior to this removal, scleral flaps were made, partial thickness at the 3 o'clock and 9 o'clock positions underneath the peritomies.  Wet-field cautery also was performed to achieve hemostasis.  The leading hepatic sutures were then passed through the bed of the scleral flap.  These were drawn out of the eye and then used to draw the trailing hepatic into the posterior segment of the eye followed by the optic.  The trailing hepatic was then placed into the posterior segment of the eye as well.  The trailing haptic sutures were then placed through the opposite scleral flap bed and were withdrawn.  These were tied securely into position with the IOL nicely centered.  At this point, the donor cornea punched at 8.25 mm was then brought into the field.  This was secured with four cardinal sutures.  The corneal button was then sutured in place using a 16-bite 10-0 nylon running suture.  The knot was secured and buried after adequate tension was adjusted.  The corneal graft was watertight.  Attention was then turned back to the IOL sutures, which were locked into position.  The ends were trimmed.  The flaps were secured with single 10-0 nylon sutures to the apex, and the knots were buried.  At this point, the case was then turned back over to the vitreoretinal service for further completion of the retinal procedure.  The patient tolerated the corneal portions of the surgery well and was turned over to the retina service in good condition, having tolerated the procedure well.  No complications were noted.  The attending surgeon, Dr. X, performed the entire procedure.  No complications of the procedure were noted.  The intraocular lens was selected from preoperative calculations.  No qualified resident was available to assist.", Surgery,38
"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,27
"She was evaluated this a.m. and was without any significant clinical change.  Her white count has been improving and down to 12,000.  A chest x-ray obtained today showed some bilateral infiltrates, but no acute cardiopulmonary change.  There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia.,She has been on Zosyn for the infection.,Throughout her hospitalization, we have been trying to adjust her pain medications.  She states that the methadone did not work for her.  She was ""immune"" to oxycodone.  She had been on tramadol before and was placed back on that.  There was some question that this may have been causing some dizziness.  She also was on clonazepam and alprazolam for the underlying bipolar disorder.,Apparently, her husband was in this afternoon.  He had a box of her pain medications.  It is unclear whether she took a bunch of these or precisely what happened.  I was contacted that she was less responsive.  She periodically has some difficulty to arouse due to pain medications, which she has been requesting repeatedly, though at times does not appear to have objective signs of ongoing pain.  The nurse found her and was unable to arouse her at this point.  There was a concern that she had taken some medications from home.  She was given Narcan and appeared to come around some.  Breathing remained somewhat labored and she had some diffuse scattered rhonchi, which certainly changed from this a.m.  Additional Narcan was given as well as some medications to reverse a possible benzodiazepine toxicity.  With O2 via mask, oxygenation was stable at 90% to 95% after initial hypoxia was noted.  A chest x-ray was obtained at this time.  An ECG was obtained, which shows a sinus tachycardia, noted to have ischemic abnormalities.,In light of the acute decompensation, she was then transferred to the ICU.  We will continue the IV Zosyn.  Respiratory protocol with respiratory management.  Continue alprazolam p.r.n., but avoid if she appears sedated.  We will attempt to avoid additional pain medications, but we will continue with the Dilaudid for time being.  I suspect she will need something to control her bipolar disorder.,Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.  At this juncture, she does not appear to need an intubation.  Pending chest x-ray, she may require additional IV furosemide.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, left.,POSTOPERATIVE DIAGNOSES:,1.  Sixty-percent rotator cuff tear, joint side.,2.  Impingement syndrome.,ANESTHESIA: , General,NAME OF OPERATION:,1.  Arthroscopic subacromial decompression.,2.  Repair of rotator cuff through mini-arthrotomy.,FINDINGS AT OPERATION: , The patient's glenohumeral joint was completely clear, other than obvious tear of the rotator cuff.  The midportion of this appeared to be complete, but for the most part, this was about a 60% rupture of the tendon.  This was confirmed later when the bursal side was opened up.  Note, the patient also had abrasion of the coracoacromial ligament under the anterolateral edge of the acromion.  He did not have any acromioclavicular joint pain or acromioclavicular joint disease noted.,PROCEDURE:,  He was given an anesthetic, examined, prepped, and draped in a sterile fashion in a beach-chair position.  The shoulder was instilled with fluid from posteriorly, followed by the arthroscope.  The shoulder was instilled with fluid from posteriorly, followed by the arthroscope.  Arthroscopy was then carried out in standard fashion using a 30-degree Dionic scope.  With the scope in the posterior portal, the above findings were noted, and an anterior portal was established.  A curved shaver was placed for debridement of the tear.  I established this was about a 60-70% tear with a probable complete area of tear which was very small.  There were no problems at the biceps or the rest of the joint.  The subacromial space showed findings, as noted above, and a thorough subacromial decompression was carried out with a Bovie, rotary shaver, and bur.  I did not debride the acromioclavicular joint.  The lateral portal was then extended to a mini-arthrotomy, and subacromial space was entered by blunt dissection through the deltoid.  The area of weakness of the tendon was found, and was transversely cut, and findings were confirmed.  The diseased tissue was removed, and the greater tuberosity was abraded with a rongeur.  Tendon-to-tendon repair was then carried out with buried sutures of 2-0 Ethibond, giving a very nice repair.  The shoulder was carried through a range of motion.  I could see no evidence of impingement.  Copious irrigation was carried out.  The deltoid deep fascia was anatomically closed, as was the superficial fascia.  The subcutaneous tissue and skin were closed in layers.  A sterile dressing was applied.  The patient appeared to tolerate the procedure well.", Surgery,38
"EXAM: , Screening full-field digital mammogram.,HISTORY:,  Screening examination of a 58-year-old female who currently denies complaints.  Patient has had diagnosis of right breast cancer in 1984 with subsequent radiation therapy.  The patient's sister was also diagnosed with breast cancer at the age of 59.,TECHNIQUE: , Standard digital mammographic imaging was performed.  The examination was performed with iCAD Second Look Version 7.2.,COMPARISON: , Most recently obtained __________.,FINDINGS: , The right breast is again smaller than the left.  There is a scar marker with underlying skin thickening and retraction along the upper margin of the right breast.  The breasts are again composed of a mixture of adipose tissue and a moderate amount of heterogeneously-dense fibroglandular tissue.  There is again some coarsening of the right breast parenchyma with architectural distortion which is unchanged and most consistent with postsurgical and postradiation changes.  A few benign-appearing microcalcifications are present.,No dominant malignant-appearing mass lesion, developing area of architectural distortion or suspicious-appearing cluster of microcalcifications are identified.  The skin is stable.  No enlarged axillary lymph node is seen.,IMPRESSION:,1.  No significant interval changes are seen.  No mammographic evidence of malignancy is identified.,2.  Annual screening mammography is recommended or sooner if clinical symptoms warrant.,BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.", Obstetrics / Gynecology,24
"CHIEF COMPLAINT: , Dental pain.,HISTORY OF PRESENT ILLNESS: , This is a 45-year-old Caucasian female who states that starting last night she has had very significant pain in her left lower jaw.  The patient states that she can feel an area with her tongue and one of her teeth that appears to be fractured.  The patient states that the pain in her left lower teeth kept her up last night.  The patient did go to Clinic but arrived there later than 7 a.m., so she was not able to be seen there will call line for dental care.  The patient states that the pain continues to be very severe at 9/10.  She states that this is like a throbbing heart beat in her left jaw.  The patient denies fevers or chills.  She denies purulent drainage from her gum line.  The patient does believe that there may be an area of pus accumulating in her gum line however.  The patient denies nausea or vomiting.  She denies recent dental trauma to her knowledge.,PAST MEDICAL HISTORY:,1.  Coronary artery disease.,2.  Hypertension.,3.  Hypothyroidism.,PAST SURGICAL HISTORY:  ,Coronary artery stent insertion.,SOCIAL HABITS: , The patient denies alcohol or illicit drug usage.  Currently she does have a history of tobacco abuse.,MEDICATIONS:,1.  Plavix.,2.  Metoprolol.,3.  Synthroid.,4.  Potassium chloride.,ALLERGIES:,1.  Penicillin.,2.  Sulfa.,PHYSICAL EXAMINATION:,GENERAL:  This is a Caucasian female who appears of stated age of 45 years.  She is well-nourished, well-developed, in no acute distress.  The patient is pleasant but does appear to be uncomfortable.,VITAL SIGNS:  Afebrile, blood pressure 145/91, pulse of 78, respiratory rate of 18, and pulse oximetry of 98% on room air.,HEENT:  Head is normocephalic.  Pupils are equal, round and reactive to light and accommodation.  Sclerae are anicteric and noninjected.  Nares are patent and free of mucoid discharge.  Mucous membranes are moist and free of exudate or lesion.  Bilateral tympanic membranes are visualized and free of infection or trauma.  Dentition shows significant decay throughout the dentition.  The patient has had extraction of teeth 17, 18, and 19.  The patient's tooth #20 does have a small fracture in the posterior section of the tooth and there does appear to be a very minor area of fluctuance and induration located at the alveolar margin at this site.  There is no pus draining from the socket of the tooth.  No other acute abnormality to the other dentition is visualized.,DIAGNOSTIC STUDIES: , None.,PROCEDURE NOTE:  ,The patient does receive an injection of 1.5 mL of 0.5% bupivacaine for inferior alveolar nerve block on the left mandibular teeth.  The patient undergoes this all procedure without complication and does report some mild decrease of her pain with this and patient was also given two Vicodin here in the Emergency Department and a dose of Keflex for treatment of her dental infection.,ASSESSMENT:  ,Dental pain with likely dental abscess.  ,PLAN: , The patient was given a prescription for Vicodin.  She is also given prescription for Keflex, as she is penicillin allergic.  She has tolerated a dose of Keflex here in the Emergency Department well without hypersensitivity.  The patient is strongly encouraged to follow up with Dental Clinic on Monday, and she states that she will do so.  The patient verbalizes understanding of treatment plan and was discharged in satisfactory condition from the ER.,", Emergency Room Reports,12
"EXAM:,  CT cervical spine (C-spine) for trauma.,FINDINGS:,  CT examination of the cervical spine was performed without contrast.  Coronal and sagittal reformats were obtained for better anatomical localization.  Cervical vertebral body height, alignment and interspacing are maintained.  There is no evidence of fractures or destructive osseous lesions.  There are no significant degenerative endplate or facet changes.  No significant osseous central canal or foraminal narrowing is present.,IMPRESSION: , Negative cervical spine.", Orthopedic,27
"DESCRIPTION OF OPERATION:,  The patient was brought to the operating room and appropriately identified.  Local anesthesia was obtained with a 50/50 mixture of 2% lidocaine and 0.75% bupivacaine given as a peribulbar block.  The patient was prepped and draped in the usual sterile fashion.  A lid speculum was used to provide exposure to the right eye.,A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants.  Calipers were set at 3.5 mm and a mark was made 3.5 mm posterior to the limbus in the inferotemporal quadrant.,A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark.  The MVR blade was used to make a sclerotomy between the pre-placed sutures.  An 8-0 nylon suture was then pre-placed for later sclerotomy closure.  The infusion cannula was inspected and found to be in good working order.  The infusion cannula was placed in the vitreous cavity and secured with the pre-placed sutures.  The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.,Additional sclerotomies were made 3.5 mm posterior to the limbus in the supranasal and supratemporal quadrants.  The light pipe and vitrectomy handpieces were then placed in the vitreous cavity and a vitrectomy was performed.  There was moderately severe vitreous hemorrhage, which was removed.  Once a view of the posterior pole could be obtained, there were some diabetic membranes emanating along the arcades.  These were dissected with curved scissors and judicious use of the vitrectomy cutter.  There was some bleeding from the inferotemporal frond.  This was managed by raising the intraocular pressure and using intraocular cautery.  The surgical view became cloudy and the corneal epithelium was removed with a beaver blade.  This improved the view.  There is an area suspicious for retinal break near where the severe traction was inferotemporally.  The Endo laser was used to treat in a panretinal scatter fashion to areas that had not received previous treatment.  The indirect ophthalmoscope was used to examine the retinal peripheral for 360 degrees and no tears, holes or dialyses were seen.  There was some residual hemorrhagic vitreous skirt seen.  The soft-tip cannula was then used to perform an air-fluid exchange.  Additional laser was placed around the suspicious area inferotemporally.  The sclerotomies were then closed with 8-0 nylon suture in an X-fashion, the infusion cannula was removed and it sclerotomy closed with the pre-existing 8-0 nylon suture.,The conjunctiva was closed with 6-0 plain gut.  A subconjunctival injection of Ancef and Decadron were given and a drop of atropine was instilled over the eye.  The lid speculum was removed.  Maxitrol ointment was instilled over the eye and the eye was patched.  The patient was brought to the recovery room in stable condition.", Ophthalmology,26
"PROCEDURE PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,ANESTHESIA: , 1% lidocaine and IV sedation, including fentanyl 25 mcg.,INDICATION: , The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest.  It was accompanied by diaphoresis and shortness of breath.  The patient was felt to be a candidate for mitral valve repair versus mitral valve replacement and underwent a stress test as part of his evaluation for chest pain.  He underwent adenosine Cardiolite, which revealed 2 mm ST segment depression in leads II, III aVF, and V3, V4, and V5.  Stress images revealed left ventricular dilatations suggestive of multivessel disease.  He is undergoing evaluation today as a part of preoperative evaluation and because of the positive stress test.,PROCEDURE: , After risks, benefits, alternatives of the above mentioned procedure were explained to the patient in detail, informed consent was obtained both verbally and writing.  The patient was taken to the Cardiac Catheterization Laboratory where the procedure was performed.  The right inguinal area was sterilely cleansed with a Betadine solution and the patient was draped in the usual manner.  1% lidocaine solution was used to anesthetize the right inguinal area.  Once adequate anesthesia had been obtained, a thin-walled Argon needle was used to cannulate the right femoral artery.,The guidewire was then advanced through the lumen of the needle without resistance and a small nick was made in the skin.  The needle was removed and a pressure was held.  A #6 French arterial sheath was advanced over the guidewire without resistance.  The dilator and guidewire were removed and the sheath was flushed.  A Judkins left #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with the use of the guidewire.  The guidewire was removed and the catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was carefully engaged and limited evaluation was performed after noticing that the patient had a significant left main coronary artery stenosis.  The catheter was withdrawn from the ostium of the left main coronary artery and the guidewire was inserted through the tip of the catheter.  The catheter was removed over guidewire and a Judkins right #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with use of a guidewire.  The guidewire was removed and the catheter was connected to the manifold and flushed.  The ostium of the right coronary artery was carefully engaged and using hand injections of nonionic contrast material, the right coronary artery was evaluated in both diagonal views.  This catheter was removed.  The sheath was flushed the final time.  The patient was taken to the postcatheterization holding area in stable condition.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,  This vessel is seen to be heavily calcified throughout its course.  Begins as a moderate caliber vessel.  There is a 60% stenosis in the distal portion with extension of the lesion to the ostium and proximal portions of the left anterior descending and left circumflex coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  This vessel is heavily calcified in its proximal portion.  It is of moderate caliber and seen post anteriorly in the intraventricular groove and wraps around the apex.  There is a 90% stenosis in the proximal portion and 90% ostial stenosis in the first and second anterolateral branches.  There is sequential 80% and 90% stenosis in the mid-portion of the vessel.  Otherwise, the LAD is seen to be diffusely diseased.,LEFT CIRCUMFLEX CORONARY ARTERY:  ,This vessel is also calcified in its proximal portion.  There is a greater than 90% ostial stenosis, which appears to be an extension of the lesion in the left main coronary artery.  There is a greater than 70% stenosis in the proximal portion of the first large obtuse marginal branch, otherwise, the circumflex system is seen to be diffusely diseased.,RIGHT CORONARY ARTERY: , This is a large caliber vessel and is the dominant system.  There is diffuse luminal irregularities throughout the vessel and a 80% to 90% stenosis at the bifurcation above the posterior descending artery and posterolateral branch.,IMPRESSION:,1.  Three-vessel coronary artery disease as described above.,2.  Moderate mitral regurgitation per TEE.,3.  Status post venous vein stripping of the left lower extremity and varicosities in both lower extremities.,4.  Long-standing history of phlebitis.,PLAN: , Consultation will be obtained with Cardiovascular and Thoracic Surgery for CABG and mitral valve repair versus replacement.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSIS: , Superior labrum anterior and posterior lesion (peel-back), right shoulder.,PROCEDURE PERFORMED:,1.  Arthroscopy with arthroscopic SLAP lesion.,2.  Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.  This was done under a interscalene block anesthetic and subsequent general anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS:  ,This is a 54-year-old white female suffering an increasing right shoulder pain for a few months prior to surgical intervention.  She had an injury to her right shoulder when she fell off a bike.  She was diagnosed preoperatively with a rotated cuff tear.,Intra-articularly besides we noted a large SLAP lesion, superior and posterior to the attachment of the glenoid labrum from approximately 12:30 back to 10:30.  This acted as a peel-back type of mechanism and was displaced into the joint beyond the superior rim of the glenoid.  This was an obvious avulsion into subchondral bone with bone exposed.  The anterior aspect had degenerative changes, but did not have evidence of avulsion.  The subscapular was noted to be intact.  On the joint side of the supraspinatus, there was noted to be a laminated type of tearing to the rotated cuff to the anterior and mid-aspect of the supraspinatus attachment.,This was confirmed subacromially.  The patient had a type-I plus acromion in outlet view and thus it was elected to not perform a subacromial decompression, but soft tissue release of the CA ligament in a releasing resection type fashion.,OPERATIVE PROCEDURE: , The patient was placed supine upon the operative table after she was given interscalene and then general anesthesia by the Anesthesia Department.  She was safely placed in a modified beachchair position.  She was prepped and draped in the usual sterile manner.  The portals were created from outside the ends, posterior to the scope and anteriorly for an intraoperative portal and then laterally.  She had at least two other portals appropriate for both repair mechanisms described above.,Attention was then turned to the SLAP lesion.  The edges were debrided both on the bony side as well as soft tissue side.  We used the anterior portal to lift up the mechanism and created a superolateral portal through the rotator cuff and into the edge of the labrum.  Further debridement was carried out here.  A drill hole was made just on the articular surface superiorly for a knotless anchor.  A pull-through suture of #2 fiber wire was utilized with the ________.  This was pulled through.  It was tied to the leader suture of the knotless anchor.  This was pulled through and one limb of the anchor loop was grabbed and the anchor impacted with a mallet.  There was excellent fixation of the superior labrum.  It was noted to be solid and intact.  The anchor was placed safely in the bone.  There was no room for further knotless or other anchors.  After probing was carried out, hard copy Polaroid was obtained.,Attention was then turned to the articular side for the rotator cuff.  It was debrided.  Subchondral debridement was carried out to the tuberosity also.  Care was taken to go to the subchondral region but not beyond.  The bone was satisfactory.,Scope was then placed in the subacromial region.  Gross bursectomy was carried out with in the lateral portal.  This was done throughout as well as in the gutters anterolaterally and posteriorly.  Debridement was carried out further to the rotator cuff.  Two types of fixation were carried out, one with a superolateral portal a drill hole was made and anchor of the _knotless suture placed after PDS leader suture placed with a Caspari punch.  There was an excellent reduction of the tear posteriorly and then anteriorly.  Tendon to tendon repair was accomplished by placing a fiber wire across the tendon and tying sutured down through the anterolateral portal.  This was done with a sliding stitch and then two half stitches.  There was excellent reduction of the tear.,Attention was then turned to the CA ligament.  It was released along with periosteum and the undersurface of the anterior acromion.  The CA ligament was not only released but resected.  There was noted to be no evidence of significant spurring with only a mostly type-I acromion.  Thus, it was not elected to perform subacromial decompression for bone with soft tissue only.  A pain buster catheter was placed separately.  It was cut to length.  An interrupted #4-0 nylon was utilized for portal closure.  A 0.5% Marcaine was instilled subacromially.  Adaptic, 4x4s, ABDs, and Elastoplast tape placed for dressing.  The patient's arm was placed in a arm sling.  She was transferred to PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  End-stage renal disease with need for a long-term hemodialysis access.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with need for a long-term hemodialysis access.,PROCEDURE: , Right basilic vein transposition.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,FINDINGS:,  Excellent flow through fistula following the procedure.,STATEMENT OF MEDICAL NECESSITY:  ,The patient is a 68-year-old black female who recently underwent a brachiobasilic AV fistula, but without transposition.  She has good flow, excellent physical exam, and now is ready for superficialization of the basilic vein.  After discussing the risks and benefits of the procedure with the patient preoperatively, the patient voiced understanding and signed informed consent.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room, placed supine on the operating table.  After adequate general endotracheal anesthesia was obtained, the right arm was circumferentially prepped and draped in a standard sterile fashion.  A longitudinal incision was made from just above the antecubital crease along the medial aspect of the arm overlying the palpable thrill using a 15 blade knife.  The sharp dissection was then used to identify dissection created of the basilic vein from its surrounding tissues.  This was continued and the incision was elongated up the arm as the vein was exposed in a serial fashion.  Branch points were then taken down using multitude of techniques based upon the luminal diameter of the branch before transection.  The basilic vein was ultimately freed in its entirety from just above the antecubital crease to the axilla at the level of the axillary vein.  There was noted to be excellent flow through the vein.  A pocket was then created just lateral to the incision in the subcutaneous tissue.  The vein was then placed into this pocket securing with multiple interrupted 3-0 Vicryl sutures.  The bed of dissection of the basilic vein was then treated with fibrin sealant.  The subcutaneous tissue was then reapproximated with 3-0 Vicryl sutures in interrupted fashion.  The skin was closed using 4-0 Monocryl suture for a subcuticular stitch.  Dermabond was applied to the incision.  Again, there was noted to be good palpable thrill throughout the superficialized vein.  The patient was then awakened, and taken to the recovery room in stable condition.", Nephrology,21
"CHIEF COMPLAINT: , Septal irritation.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old African-American female status post repair of septal deviation but unfortunately, ultimately ended with a large septal perforation.  The patient has been using saline nasal wash 2-3 times daily, however, she states that she still has discomfort in her nose with a ""stretching"" like pressure.  She says her nose is frequently dry and she occasionally has nosebleeds due to the dry nature of her nose.  She has no other complaints at this time.,PHYSICAL EXAM:,GENERAL:  This is a pleasant African-American female resting in the examination room chair in no apparent distress.,ENT:  External auditory canals are clear.  Tympanic membrane shows no perforation, is intact.,NOSE:  The patient has a slightly deviated right septum.  Septum has a large perforation in the anterior 2/3rd of the septum.  This appears to be well healed.  There is no sign of crusting in the nose.,ORAL CAVITY:  No lesions or sores.  Tonsils show no exudate or erythema.,NECK:  No cervical lymphadenopathy.,VITAL SIGNS:  Temperature 98 degrees Fahrenheit, pulse 77, respirations 18, blood pressure 130/73.,ASSESSMENT AND PLAN:  ,The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation.  At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis.  At this time, I counseled the patient on the risks and benefits of surgery.  She will consider surgery but at this time, would like to continue using the saline nasal wash as well as occasional Bactroban to the nose if there is occasional irritation or crusting, which she will apply with the edge of a Q-tip.  We will see her back in 3 weeks and if the patient does not feel relieved from the Bactroban as well as saline nasal spray wash, we will consider setting the patient for surgery at that time.", SOAP / Chart / Progress Notes,35
"PREOPERATIVE DIAGNOSES,1.  Metastatic carcinoma of the bladder.,2.  Bowel obstruction.,POSTOPERATIVE DIAGNOSES,1.  Metastatic carcinoma of the bladder.,2.  Bowel obstruction.,PROCEDURE: , Port insertion through the right subclavian vein percutaneously under radiological guidance.,PROCEDURE DETAIL:  ,The patient was electively taken to the operating room after obtaining an informed consent.  A time-out process was followed.  Antibiotics were given.  Then, the patient's right deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated.  The right subclavian vein was percutaneously cannulated without any difficulty.  Then using the Seldinger technique, the catheter part of the port, which was a single-lumen port, was passed through the introducer under x-ray guidance and placed in the junction of the superior vena cava and the right atrium.,A pocket had been fashioned and a single-lumen drum of the port was connected to the catheter, which had been trimmed and affixed to the pectoralis fascia with couple of sutures of Vicryl.  Then, the fascia was closed using subcuticular suture of Monocryl.  The drum was aspirated and irrigated with heparinized saline and then was put in the pocket and the skin was closed.  A dressing was applied including the needle and the port with the catheter so that the floor could use the catheter right away.,The patient tolerated the procedure well and was sent to recovery room in satisfactory condition.  A chest x-ray was performed that showed that there were no complications of procedure and that the catheter was in right place.", Surgery,38
"EXAM:,  Lexiscan Nuclear Myocardial Perfusion Scan.,INDICATION:,  Chest pain.,TYPE OF TEST:  ,Lexiscan, unable to walk on a treadmill.,INTERPRETATION: , Resting heart rate of 96, blood pressure of 141/76.  EKG, normal sinus rhythm, nonspecific ST-T changes, left bundle branch block.  Post Lexiscan 0.4 mg injected intravenously by standard protocol.  Peak heart rate was 105, blood pressure of 135/72.  EKG remains the same.  No symptoms are noted.,SUMMARY:,1.  Nondiagnostic Lexiscan.,2.  Nuclear interpretation as below.,NUCLEAR MYOCARDIAL PERFUSION SCAN WITH STANDARD PROTOCOL:,  Resting and stress images were obtained with 10.4, 32.5 mCi of tetrofosmin injected intravenously by standard protocol.  Myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake.  There is no evidence of reversible or fixed defect.  Gated SPECT revealed mild global hypokinesis, more pronounced in the septal wall possibly secondary to prior surgery.  Ejection fraction calculated at 41%.  End-diastolic volume of 115, end-systolic volume of 68.,IMPRESSION:,1.  Normal nuclear myocardial perfusion scan.,2.  Ejection fraction 41% by gated SPECT.", Cardiovascular / Pulmonary,3
"HISTORY: , The patient is a 71-year-old female, who was referred for an outpatient modified barium swallow study to objectively evaluate her swallowing function and safety.  The patient complained of globus sensation high in her throat particularly with solid foods and with pills.  She denied history of coughing and chocking with meals.  The patient's complete medical history is unknown to me at this time.  The patient was cooperative and compliant throughout this evaluation.,STUDY:,  Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. X. The patient was seated upright at a 90-degree angle in a video imaging chair.  To evaluate her swallowing function and safety, she was administered graduated amounts of food and liquid mixed with barium in the form of thin liquids (teaspoon x3. cup sip x4); thickened liquid (cup sip x3); puree consistency (teaspoon x3); and solid consistency (1/4 cracker x1).  The patient was given 2 additional cup sips of thin liquid following the puree and solid food presentation.,ORAL STAGE:  ,The patient had no difficulty with bolus control and transport.  No spillage out lips.  The patient appears to have pocketing __________ particularly with puree and solid food between her right faucial pillars.  The patient did state that she had her tonsil taken out as a child and appears to be a diverticulum located in this state.  Further evaluation by an ENT is highly recommended based on the residual and pooling that occurred during this evaluation.  We were not able to clear out the residual with alternating cup sips and thin liquid.,PHARYNGEAL STAGE:  ,No aspiration or penetration occurred during this evaluation.  The patient's hyolaryngeal elevation and anterior movements are within the functional limits.  Epiglottic inversion is within functional limits.  She had no residual or pooling in the pharynx after the swallow.,CERVICAL ESOPHAGEAL STAGE:  ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION:  ,The patient had no aspiration or penetration occurred during this evaluation.  She does appear to have a diverticulum in the area between her right faucial pillars.  Additional evaluation is needed by an ENT physician.,PLAN:  ,Based on this evaluation, the following is recommended:,1.  The patient's diet should consist regular consistency food with thin liquids.  She needs to take small bites and small sips to help decrease her risk of aspiration and penetration as well as reflux.,2.  The patient should be referred to an otolaryngologist for further evaluation of her oral cavity particularly the area between her faucial pillars.,The above recommendations and results of the evaluation were discussed with the patient as well as her daughter and both responded appropriately.,Thank you for the opportunity to be required the patient's medical care.  She is not in need of skilled speech therapy and is discharged from my services.", Gastroenterology,14
"PREOPERATIVE DIAGNOSES: , Carious teeth #2 and #19 and left mandibular dental abscess.,POSTOPERATIVE DIAGNOSES:,  Carious teeth #2 and #19 and left mandibular dental abscess.,PROCEDURES:,  Extraction of teeth #2 and #19 and incision and drainage of intraoral and extraoral of left mandibular dental abscess.,ANESTHESIA: , General, oral endotracheal.,COMPLICATIONS: , None.,DRAINS: , Penrose 0.25 inch intraoral and vestibule and extraoral.,CONDITION:,  Stable to PACU.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room, placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure.  In addition, the extraoral area on the left neck was prepped with Betadine and draped accordingly.  Gauze throat pack was placed and local anesthetic was administered in the left lower quadrant, total of 3.4 mL of lidocaine 2% with 1:100,000 epinephrine and Marcaine 1.7 mL of 0.5% with 1:200,000 epinephrine.  An incision was made with #15 blade in the left submandibular area through the skin and blunt dissection was accomplished with curved mosquito hemostat to the inferior border of the mandible.  No purulent drainage was obtained.  The 0.25 inch Penrose drain was then placed in the extraoral incision and it was secured with 3-0 silk suture.  Moving to the intraoral area, periosteal elevator was used to elevate the periosteum from the buccal aspect of tooth #19.  The area did not drain any purulent material.  The carious tooth #19 was then extracted by elevator and forceps extraction.  After the tooth was removed, the 0.25 inch Penrose drain was placed in a subperiosteal fashion adjacent to the extraction site and secured with 3-0 silk suture.  The tube was then repositioned to the left side allowing access to the upper right quadrant where tooth #2 was then extracted by routine elevator and forceps extraction.  After the extraction, the throat pack was removed.  An orogastric tube was then placed by Dr. X, and stomach contents were suctioned.  The pharynx was then suctioned with the Yankauer suction.  The patient was awakened, extubated, and taken to the PACU in stable condition.", Surgery,38
"PROCEDURE: , Laparoscopy with ablation of endometriosis.,DIAGNOSIS: , Endometriosis.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , None.,FINDINGS: , Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac.  Normal tubes and ovaries, normal gallbladder, smooth liver edge.,PROCEDURE:  ,The patient was taken to the operating room and placed under general anesthesia.  She was put in the dorsal lithotomy position, and the perineum and abdomen were prepped and draped in a sterile manner.  Subumbilical area was injected with Marcaine, and a Veress needle was placed subumbilically through which approximately 2 L of CO2 were inflated.  Scalpel was used to make a subumbilical incision through which a 5-mm trocar was placed.  Laparoscope was inserted through the cannula and the pelvis was visualized.  Under direct visualization, two 5-mm trocars were placed in the right and left suprapubic midline.  Incision sites were transilluminated and injected with Marcaine prior to cutting.  Hulka manipulator was placed on the cervix.  Pelvis was inspected and blood tinged fluid was aspirated from the cul-de-sac.  The beginnings of an Allen-Masters window in the left side of the cul-de-sac were visualized along with bronze lesions of endometriosis.  Some more lesions were noted above the left uterosacral ligament.  Flame lesions were noted above the right uterosacral ligament.  Tubes and ovaries were normal bilaterally with the presence of a few small paratubal cysts on the left tube.  There was a somewhat leathery appearance to the ovaries.  The lesions of endometriosis were ablated with the argon beam coagulator, as was a region of the Allen-Masters window.  Pelvis was irrigated and all operative sites were hemostatic.  No other abnormalities were visualized and all instruments were moved under direct visualization.  Approximately 200 mL of fluid remained in the abdominal cavity.  All counts were correct and the skin incisions were closed with 2-0 Vicryl after all CO2 was allowed to escape.  The patient was taken to the recovery in stable condition.", Obstetrics / Gynecology,24
"PREOPERATIVE DIAGNOSIS: , Severe low back pain.,POSTOPERATIVE DIAGNOSIS: , Severe low back pain.,OPERATIONS PERFORMED: , Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 mL.,DRAINS:,  None.,COMPLICATIONS: , None.,PATHOLOGICAL FINDINGS:,  Dr. X made the approach and once we were at the L5-S1 disk space, we removed the disk and we placed a 13-mm PEEK vertebral spacer filled with a core of bone taken from the L5 vertebral body.  This was filled with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug.  At L4-L5, we used a 13-mm PEEK vertebral spacer with structural autograft and BMP, and then we placed a two-level 87-mm Integra sacral plate with 28 x 6-mm screws, two each at L4 and L5 and 36 x 6-mm screws at S1.,OPERATION IN DETAIL:,  The patient was placed under general endotracheal anesthesia.  The abdomen was prepped and draped in the usual fashion.  Dr. X made the approach, and once the L5-S1 disk space was identified, we incised this with a knife and then removed a large core of bone taking rotating cutters.  I was able to remove additional disk space and score the vertebral bodies.  The rest of the disk removal was done with the curette, scraping the endplates.  I tried various sized spacers, and at this point, we exposed the L5 body and took a dowel from the body and filled the hole with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug.  Half of this was used to fill the spacer at L5-S1, BMP was placed in the spacer as well and then it was tapped into place.  We then moved the vessels over the opposite way approaching the L4-L5 disk space laterally, and the disk was removed in a similar fashion and we also used a 13-mm PEEK vertebral spacer, but this is the variety that we could put in from one side.  This was filled with bone and BMP as well.  Once this was done, we were able to place an 87-mm Integra sacral plate down over the three vertebral bodies and place these screws.  Following this, bleeding points were controlled and Dr. X proceeded with the closure of the abdomen.,SUMMARY: , This is a 51-year-old man who reports 15-year history of low back pain and intermittent bilateral leg pain and achiness.  He has tried multiple conservative treatments including physical therapy, epidural steroid injections, etc.  MRI scan shows a very degenerated disk at L5-S1, less so at L3-L4 and L4-L5.  A discogram was positive with the lower 3 levels, but he has pain, which starts below the iliac crest and I feel that the L3-L4 disk is probably that symptomatic.  An anterior lumbar interbody fusion was suggested.  Procedure, risks, and complications were explained.", Neurosurgery,23
"REASON FOR RETURN VISIT: , Followup of left hand discomfort and systemic lupus erythematosus.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female with a history of systemic lupus erythematosus, who was last seen in rheumatology clinic approximately 4 months ago for bilateral hand discomfort, left greater than right.  The patient was seen on 10/30/07.  She had the same complaint.  She was given a trial of Elavil at bedtime because the thought was to see that represented ulnar or radial neuropathy.  She was also given a prescription for Zostrix cream but was unable to get it filled because of insurance coverage.  The patient reports some worsening of the symptoms especially involving at the dorsum of the left hand, and she points to the area that actually involves the dorsal aspect of the second, third, and fourth digits.  The patient recently has developed what sounds like an upper respiratory problem with a nonproductive cough for 3 days, although she reports that she has had subjective fevers for the past 3 or 4 days, but has not actually taken the temperature.  She has not had any night sweats or chills.  She has had no recent problems with chest pain, chest discomfort, shortness of breath or problems with GU or GI complaints.  She is returning today for routine followup evaluation.,CURRENT MEDICATIONS:,1.  Plaquenil 200 mg twice a day.,2.  Fosamax 170 mg once a week.,3.  Calcium and vitamin D complex twice daily.,4.  Folic acid 1 mg per day.,5.  Trilisate 1000 mg a day.,6.  K-Dur 20 mEq twice a day.,7.  Hydrochlorothiazide 15 mg once a day.,8.  Lopressor 50 mg one-half tablet twice a day.,9.  Trazodone 100 mg at bedtime.,10.  Prempro 0.625 mg per day.,11.  Aspirin 325 mg once a day.,12.  Lipitor 10 mg per day.,13.  Pepcid 20 mg twice a day.,14.  Reglan 10 mg before meals and at bedtime.,15.  Celexa 20 mg per day.,REVIEW OF SYSTEMS: , Noncontributory except for what was noted in the HPI and the remainder or complete review of systems is unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 155/84, pulse 87, weight 223 pounds, and temperature 99.2.  GENERAL:  She is a well-developed, well-nourished female appearing her staged age.  She is alert, oriented, and cooperative.  HEENT:  Normocephalic and atraumatic.  There is no facial rash.  No oral lesions.  LUNGS:  Clear to auscultation.  CARDIOVASCULAR:  Regular rate and rhythm without murmurs, rubs or gallops.  EXTREMITIES:  No cyanosis or clubbing.  Sensory examination of the upper extremity decreased to light touch on the distal tips of the left second and third digits compared to the fifth digit.  Positive Tinel sign.  Full range of motion of the wrist with no evidence of motor atrophy or muscle loss.,LABORATORY DATA:  ,WBC 5100, hemoglobin 11.1, hematocrit 32.8, and platelets 200,000.  Westergren sedimentation rate of 47.  Urinalysis is negative for protein and blood.  Lupus serology is pending.,ASSESSMENT:,1.  Systemic lupus erythematosus that is chronically stable at this point.,2.  Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.,3.  Upper respiratory infection with cough, cold, and congestion.,RECOMMENDATIONS:,1.  The patient will have a trial of a resting wrist splint at night for the next 4 to 6 weeks.  If there is no improvement, the patient will return for corticosteroid injection of her carpal tunnel.,2.  Azithromycin 5-day dose pack.,3.  Robitussin Cough and Cold Flu to be taken twice a day.,4.  Atarax 25 mg at bedtime for sleep.,5.  The patient will return to the rheumatology clinic for a routine followup evaluation in 4 months.", SOAP / Chart / Progress Notes,35
"PREOPERATIVE DIAGNOSIS:,  History of perforated sigmoid diverticuli with Hartmann's procedure.,POSTOPERATIVE DIAGNOSES:  ,1.  History of perforated sigmoid diverticuli with Hartmann's procedure.,2.  Massive adhesions.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Lysis of adhesions and removal.,3.  Reversal of Hartmann's colostomy.,4.  Flexible sigmoidoscopy.,5.  Cystoscopy with left ureteral stent.,ANESTHESIA: , General.,HISTORY: , This is a 55-year-old gentleman who had a previous perforated diverticula.  Recommendation for reversal of the colostomy was made after more than six months from the previous surgery for a sigmoid colon resection and Hartmann's colostomy.,PROCEDURE:  ,The patient was taken to the operating room placed into lithotomy position after being prepped and draped in the usual sterile fashion.  A cystoscope was introduced into the patient's urethra and to the bladder.  Immediately, no evidence of cystitis was seen and the scope was introduced superiorly, measuring the bladder and immediately a #5 French ____ was introduced within the left urethra.  The cystoscope was removed, a Foley was placed, and wide connection was placed attaching the left ureteral stent and Foley.  At this point, immediately the patient was re-prepped and draped and immediately after the ostomy was closed with a #2-0 Vicryl suture, immediately at this point, the abdominal wall was opened with a #10 blade Bard-Parker down with electrocautery for complete hemostasis through the midline.,The incision scar was cephalad due to the severe adhesions in the midline.  Once the abdomen was entered in the epigastric area, then massive lysis of adhesions was performed to separate the small bowel from the anterior abdominal wall.  Once the small bowel was completely free from the anterior abdominal wall, at this point, the ostomy was taken down with an elliptical incision with cautery and then meticulous dissection with Metzenbaum scissors and electrocautery down to the anterior abdominal wall, where a meticulous dissection was carried with Metzenbaum scissors to separate the entire ostomy from the abdominal wall.  Immediately at this point, the bowel was dropped within the abdominal cavity, and more lysis of adhesions was performed cleaning the left gutter area to mobilize the colon further down to have no tension in the anastomosis.  At this point, the rectal stump, where two previous sutures with Prolene were seen, were brought with hemostats.  The rectal stump was free in a 360 degree fashion and immediately at this point, a decision to perform the anastomosis was made.  First, a self-retaining retractor was introduced in the abdominal cavity and a bladder blade was introduced as well.  Blue towel was placed above the small bowel retracting the bowel to cephalad and at this point, immediately the rectal stump was well visualized, no evidence of bleeding was seen, and the towels were placed along the edges of the abdominal wound.  Immediately, the pursestring device was fired approximately 1 inch from the skin and on the descending colon, this was fired.  The remainder of the excess tissue was closed with Metzenbaum scissors and immediately after dilating #25 and #29 mushroom tip from the T8 Ethicon was placed within the colon and then #9-0 suture was tied.  Immediately from the anus, the dilator #25 and #29 was introduced dilating the rectum.  The #29 EEA was introduced all the way anteriorly to the staple line and this spike from the EEA was used to perforate the rectum and then the mushroom from the descending colon was attached to it.  The EEA was then fired.  Once it was fired and was removed, the pelvis was filled with fluid.  Immediately both doughnuts were ____ from the anastomosis.  A Doyen was placed in both the anastomosis.  Colonoscope was introduced.  No bubble or air was seen coming from the anastomosis.  There was no evidence of bleeding.  Pictures of the anastomosis were taken.  The scope then was removed from the patient's rectum.  Copious amount of irrigation was used within the peritoneal cavity.  Immediately at this point, all complete sponge and instrument count was performed.  First, the ostomy site was closed with interrupted figure-of-eight #0 Vicryl suture.  The peritoneum was closed with running #2-0 Vicryl suture.  Then, the midline incision was closed with a loop PDS in cephalad to caudad and caudad to cephalad tight in the middle.  Subq tissue was copiously irrigated and the staples on the skin.,The iodoform packing was placed within the old ostomy site and then the staples on the skin as well.  The patient did tolerate the procedure well and will be followed during the hospitalization.  The left ureteral stent was removed at the end of the procedure.  _____ were performed.  Lysis of adhesions were performed.  Reversal of colostomy and EEA anastomosis #29 Ethicon.", Surgery,38
"HISTORY: , The patient is an 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia, incomplete compliance with obstructive sleep apnea therapy with CPAP, chocolate/caffeine ingestion and significant mental stress.  Despite repletion of her electrolytes and maintenance with Diltiazem IV she has maintained atrial fibrillation.  I have discussed in detail with the patient regarding risks, benefits, and alternatives of the procedure.  After an in depth discussion of the procedure (please see my initial consultation for further details) I asked the patient this morning if she would like me to repeat that as that discussion had happened yesterday.  The patient declined.  I invited questions for her which she stated she had none and wanted to go forward with the cardioversion which seemed appropriate.,PROCEDURE NOTE: , The appropriate time-out procedure was performed as per Medical Center protocol including proper identification of the patient, physician, procedure, documentation, and there were no safety issues identified by myself nor the staff.  The patient participated actively in this.  She received a total of 4 mg of Versed then and 50 micrograms of fentanyl with utilizing titrated conscious sedation with good effect.  She was placed in the supine position and hands free patches had previously been placed in the AP position and she received one synchronized cardioversion attempt after Diltiazem drip had been turned off with successful resumption of normal sinus rhythm.  This was confirmed on 12 lead EKG.,IMPRESSION/PLAN: , Successful resumption of normal sinus rhythm from recurrent atrial fibrillation.  The patient's electrolytes are now normal and that will need close watching to avoid hypokalemia in the future, as well as she has been previously counseled for strict adherence to sleep apnea therapy with CPAP and perhaps repeat sleep evaluation would be appropriate to titrate her settings, as well as avoidance of caffeine ingestion including chocolate and minimization of mental stress.  She will be discharged on her usual robust AV nodal antiarrhythmic therapy with sotalol 80 mg p.o. b.i.d., metoprolol 50 mg p.o. b.i.d., Diltiazem CD 240 mg p.o. daily and digoxin 0.125 mg p.o. daily and to be clear she does have a permanent pacemaker implanted.  She will follow-up with her regular cardiologist, Dr. X, for whom I am covering this weekend.,This was all discussed in detail with the patient, as well as her granddaughter with the patient's verbal consent at the bedside.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar.,POSTOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar,PROCEDURE: , Hardware removal, right ulnar.,ANESTHESIA:,  The patient received 2.5 mL of 0.25% Marcaine and local anesthetic.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HISTORY AND PHYSICAL:  ,The patient is a 5-year, 5-month-old male who sustained a both-bone forearm fracture in September 2007.  The fracture healed uneventfully, but then the patient subsequently suffered a refracture one month ago.  The patient had shortening in arms, noted in both bones.  The parents opted for surgical stabilization with nailing.  This was performed one month ago on return visit.  His ulnar nail was quite prominent underneath the skin.  It was decided to remove the ulnar nail early and place the patient in another cast for 3 weeks.,Risks and benefits of the surgery were discussed with the mother.  Risk of surgery incudes risks of anesthesia, infection, bleeding, changes in sensation in most of the extremity, need for longer casting.  All questions were answered and mother agreed to above plan.,PROCEDURE IN DETAIL:  ,The patient was seen in the operative room, placed supine on operating room table.  General anesthesia was then administered.  The patient was given Ancef preoperatively.  The left elbow was prepped and draped in a standard surgical fashion.  A small incision was made over the palm with K-wire.  This was removed without incident.  The wound was irrigated.  The bursitis was curetted.  Wounds closed using #4-0 Monocryl.  The wound was clean and dry, dressed with Xeroform 4 x 4s and Webril.  Please note the area infiltrated with 0.25% Marcaine.  The patient was then placed in a long-arm cast.  The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN:  ,The patient will maintain the cast for 3 more weeks.  Intraoperative nail was given to the mother.  The patient to take Tylenol with Codeine as needed.  All questions were answered.,", Orthopedic,27
"IMPRESSION:,  Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right.  Clinical correlation is suggested.", Sleep Medicine,36
"PREOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,POSTOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,PROCEDURE:, Full-mouth extraction of tooth #3,5,6, 7, 8, 9, 10, 11, 12, 13, 14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 31, and alveoloplasty in all four quadrants.,ANESTHESIA:,  Nasotracheal general anesthesia.,IV FLUIDS:, A 700 mL of crystalloid.,EBL:, Minimum.,URINE:, Not recorded.,COMPLICATIONS:, None.,CONDITION:, Good.,DISPOSITION:,  The patient was extubated in OR, transferred to PACU for recovery and will be transferred for 23-hour observation and discharged on subsequent day.,BRIEF HISTORY OF THE PATIENT:, Indicated the patient for surgery.  The patient is a 41-year-old white female with multiple grossly decaying nonrestorable teeth.  After discussing treatment options, she decided she will like to have extraction of remaining teeth with subsequent placement of upper and lower complete dentures.,PAST MEDICAL HISTORY:, Positive for a narcotic abuse, presently on methadone treatment, hepatitis C, and headaches.,PAST SURGICAL HISTORY:, C-section x2.,MEDICATIONS,Right now include:,1.  Methadone.,2.  Beta-blocker.,3.  Xanax.,4.  Norco.,5.  Clindamycin.,ALLERGIES:, THE PATIENT IS ALLERGIC TO PENICILLIN.,PROCEDURE IN DETAIL:, The patient was greeted in preoperative holding area, subsequently transferred to OR #17 where the patient was intubated with anesthesia staff present.  The patient was prepped and draped in sterile fashion.  Local anesthesia consisting of 1% lidocaine and 1:100,000 epinephrine, total 15 mL were injected into the maxillomandible.  Throat pack was placed in the mouth after a thorough suction.,A full-thickness mucoperiosteal flap was reflected from the upper right to the upper left, tooth number 3,5,6,7,8,9,10,11,12,13, and 14 and were elevated and delivered.  Extraction sites were thoroughly curettaged and irrigated.  Bony undercuts were removed then smoothed with rongeurs and bone saw.  After thorough irrigation, the postsurgical site closed in a running fashion with 3-0 chromic sutures.  Subsequently, a full-thickness mucoperiosteal flap was reflected in the mandible, tooth numbers 31, 28, 27, 26, 25, 24, 23, 22, 21, 20, and 19 were elevated and delivered with simple forceps extractions.  Bony undercuts were removed with rongeurs and smoothed with bone saw.,Extraction sites were thoroughly irrigated and curettaged.  Wound was closed in continuous fashion 3-0 chromic.  After adequate hematosis was achieved, 0.5% Marcaine and 1:200,000 epinephrine was injected in the maxillomandible thus to heal to aid in hematosis and pain control.  Total of 8 mL were used.  Throat pack was subsequently removed.  Orogastric tube was passed to suction out the stomach.,The patient was subsequently extubated in OR and transferred to PACU for recovery.  The patient would be placed in 23-hour observation.", Dentistry,7
"XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your referral of patient ABC.  The patient was referred for evaluation of cataracts bilaterally.,On examination, the patient was seeing 20/40 in her right eye and 20/50 in the left eye.  Extraocular muscles were intact, visual fields were full to confrontation OU, and applanations are 12 mmHg bilaterally.  There is no relative afferent pupillary defect.  On slit lamp examination, lids and lashes were within normal limits.  The conj is quiet.  The cornea shows 1+ guttata bilaterally.  The AC is deep and quiet and irises are within normal limits bilaterally.  There is a dense 3 to 4+ nuclear sclerotic cataract in each eye.  On dilated fundus examination, cup-to-disc ratio is 0.1 OU.  The vitreous, macula, vessels, and periphery all appear within normal limits.,Impression:  It appears that Ms. ABC' visual decline is caused by bilateral cataracts.  She would benefit from having removed.  The patient also showed some mild guttata OU indicating possible early Fuchs dystrophy.  The patient should do well with cataract surgery and I have recommended this and she agreed to proceed with the first eye here shortly.  I will keep you up to date of her progress and any new findings as we perform her surgery in each eye.,Again, thank you for your kind referral of this kind lady and I will be in touch with you.,Sincerely,,", Ophthalmology,26
"PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,DETAILS OF PROCEDURE: ,The child was placed in a Circumstraint board and restrained in the usual fashion.  The area of the penis and scrotum were prepared with povidone iodine solution.  The area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure.  A dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine.  A dorsal slit was made, and the prepuce was dissected away from the glans penis.  A Gomco clamp was properly placed for 5 minutes.  During this time, the foreskin was sharply excised using a #10 blade.  With removal of the clamp, there was a good cosmetic outcome and no bleeding.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.", Urology,39
"PREOPERATIVE DIAGNOSIS:  ,Symptomatic disk herniation, C7-T1.,FINAL DIAGNOSIS:  ,Symptomatic disk herniation, C7-T1.,PROCEDURES PERFORMED,1.  Anterior cervical discectomy with decompression of spinal cord C7-T1.,2.  Anterior cervical fusion, C7-T1.,3.  Anterior cervical instrumentation, anterior C7-T1.,4.  Insertion of intervertebral device, C7-T1.,5.  Use of operating microscope.,ANESTHESIOLOGY: , General endotracheal.,ESTIMATED BLOOD LOSS:  ,A 30 mL.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room where he was orally intubated by The Anesthesiology Service.  He was placed in the supine position on an OR table.  His arms were carefully taped down.  He was sterilely prepped and draped in the usual fashion.,A 4-cm incision was made obliquely over the left side of his neck.  Subcutaneous tissue was dissected down to the level of the platysma.  The platysma was incised using electrocautery.  Blunt dissection was done to create a plane between the strap muscles and the sternoclavicular mastoid muscle.  This allowed us to get right down on to the anterior cervical spine.  Blunt dissection was done to sweep off the longus colli.  We isolated the C7-T1 interspace.  An x-ray was taken to verify; we were indeed at the C7-T1 interspace.,Shadow-Line retractor was placed as well as Caspar pins.  This provided very, very good access to the C7-T1 disk.,At this point, the operating microscope was brought into the decompression.,A thorough and aggressive C7-T1 discectomy was done using a succession of curettes, pituitary rongeur, 4-mm cutting bur and a #2 Kerrison rongeur.  At the end of the discectomy, the cartilaginous endplates were carefully removed using 4-mm cutting burr.  The posterior longitudinal ligament was carefully resected using #2 Kerrison rongeur.  Left-sided C8 foraminotomy was accomplished using nerve hook and a 2-mm Kerrison rongeur.  At the end of the decompression, there was no further compression on the left C8 nerve root.,A Synthes cortical cancellous ____________ bone was placed in the interspace.  Sofamor Danek Atlantis plate was then placed over the interspace and four screws were placed, two in the body of C7 and two in the body of T1.  An x-ray was taken.  It showed good placement of the plate and screws.,A deep drain was placed.  The platysma layer was closed in running fashion using #1 Vicryl.  Subcutaneous tissue was closed in an interrupted fashion using 2-0 Vicryl.  Skin was closed in a running fashion using 4-0 Monocryl.  Steri-Strips and dressings were applied.  All counts were correct.  There were no complications.", Surgery,38
"HISTORY:  ,We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic.  He was sent here with a chief complaint of joint pain in several joints for few months.  This is a 7-year-old white male who has no history of systemic disease, who until 2 months ago, was doing well and 2 months ago, he started to complain of pain in his fingers, elbows, and neck.  At this moment, this is better and is almost gone, but for several months, he was having pain to the point that he would cry at some point.  He is not a complainer according to his mom and he is a very active kid.  There is no history of previous illness to this or had gastrointestinal problems.  He has problems with allergies, especially seasonal allergies and he takes Claritin for it.  Other than that, he has not had any other problem.  Denies any swelling except for that doctor mentioned swelling on his elbow.  There is no history of rash, no stomach pain, no diarrhea, no fevers, no weight loss, no ulcers in his mouth except for canker sores.  No lymphadenopathy, no eye problems, and no urinary problems.,MEDICATIONS: , His medications consist only of Motrin only as needed and Claritin currently for seasonal allergies and rhinitis.,ALLERGIES: , He has no allergies to any drugs.,BIRTH HISTORY:  ,Pregnancy and delivery with no complications.  He has no history of hospitalizations or surgeries.,FAMILY HISTORY: , Positive for arthritis in his grandmother.  No history of pediatric arthritis.  There is history of psoriasis in his dad.,SOCIAL HISTORY: , He lives with mom, dad, brother, sister, and everybody is healthy.  They live in Easton.  They have 4 dogs, 3 cats, 3 mules and no deer.  At school, he is in second grade and he is doing PE without any limitation.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Temperature is 98.7, pulse is 96, respiratory rate is 24, height is 118.1 cm, weight is 22.1 kg, and blood pressure is 61/44.,GENERAL:  He is alert, active, in no distress, very cooperative.,HEENT:  He has no facial rash.  No lymphadenopathy.  Oral mucosa is clear.  No tonsillitis.  His ear canals are clear and pupils are reactive to light and accommodation.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm and no murmur.,ABDOMEN:  Soft, nontender with no visceromegaly.,MUSCULOSKELETAL:  Shows no limitation in any of his joints or active swelling today.  He has no tenderness either in any of his joints.  Muscle strength is 5/5 in proximal muscles.,LABORATORY DATA:,  Includes an arthritis panel.  It has normal uric acid, sedimentation rate of 2, rheumatoid factor of 6, and antinuclear antibody that is negative and C-reactive protein that is 7.1.  His mother stated that this was done while he was having symptoms.,ASSESSMENT AND PLAN: , This patient may have had reactive arthritis.  He is seen frequently and the patient has family history of psoriatic arthritis or psoriasis.  I do not see any problems at this moment on his laboratories or on his physical examination.  This may have been related to recent episode of viral infection or infection of some sort.  Mother was oriented about the finding and my recommendation is to observe him and if there is any recurrence of the symptoms or persistence of swelling or limitation in any of his joints, I will be glad to see him back.,If you have any question on further assessment and plan, please do no hesitate to contact us.", Orthopedic,27
"OPERATIVE NOTE:,  The patient was taken to the operating room and placed in the supine position on the operating room table.  The patient was prepped and draped in usual sterile fashion.  An incision was made in the groin crease overlying the internal ring.  This incision was about 1.5 cm in length.  The incision was carried down through the Scarpa's layer to the level of the external oblique.  This was opened along the direction of its fibers and carried down along the external spermatic fascia.  The cremasteric fascia was then incised and the internal spermatic fascia was grasped and pulled free.  A hernia sac was identified and the testicle was located.  Next the internal spermatic fascia was incised and the hernia sac was dissected free inside the internal ring.  This was performed by incising the transversalis fascia circumferentially.  The hernia sac was ligated with a 3-0 silk suture high and divided and was noted to retract into the abdominal cavity.  Care was taken not to injure the testicular vessels.  Next the abnormal attachments of the testicle were dissected free distally with care not to injure any long loop vas and these were divided beneath the testicle for a fair distance.  The lateral attachments tethering the cord vessels were freed from the sidewalls in the retroperitoneum high.  This gave excellent length and very adequate length to bring the testicle down into the anterior superior hemiscrotum.  The testicle was viable.  This was wrapped in a moist sponge.,Next a hemostat was passed down through the inguinal canal down into the scrotum.  A small 1 cm incision was made in the anterior superior scrotal wall.  Dissection was carried down through the dartos layer.  A subdartos pouch was formed with blunt dissection.  The hemostat was then pushed against the tissues and this tissue was divided.  The hemostat was then passed through the incision.  A Crile hemostat was passed back up into the inguinal canal.  The distal attachments of the sac were grasped and pulled down without twisting these structures through the incision.  The neck was then closed with a 4-0 Vicryl suture that was not too tight, but tight enough to prevent retraction of the testicle.  The testicle was then tucked down in its proper orientation into the subdartos pouch and the subcuticular tissue was closed with a running 4-0 chromic and the skin was closed with a running 6-0 subcuticular chromic suture.  Benzoin and a Steri-Strip were placed.  Next the transversus abdominis arch was reapproximated to the iliopubic tract over the top of the cord vessels to tighten up the ring slightly.  This was done with 2 to 3 interrupted 3-0 silk sutures.  The external oblique was then closed with interrupted 3-0 silk suture.  The Scarpa's layer was closed with a running 4-0 chromic and the skin was then closed with a running 4-0 Vicryl intracuticular stitch.  Benzoin and Steri-Strip were applied.  The testicle was in good position in the dependent portion of the hemiscrotum and the patient had a caudal block, was awakened, and was returned to the recovery room in stable condition.", Urology,39
"PREOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE PERFORMED: , Laparoscopic bilateral tubal occlusion with Hulka clips.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:  ,None.,FINDINGS: , On bimanual exam, the uterus was found to be anteverted at approximately six weeks in size.  There were no adnexal masses appreciated.  The vulva and perineum appeared normal.  Laparoscopic findings revealed normal appearing uterus, fallopian tubes bilaterally as well as ovaries bilaterally.  There was a functional cyst on the left ovary.  There was filmy adhesion in the left pelvic sidewall.  There were two clear lesions consistent with endometriosis, one was on the right fallopian tube and the other one was in the cul-de-sac.  The uterosacrals and ovarian fossa as well as vesicouterine peritoneum were free of any endometriosis.  The liver was visualized and appeared normal.  The spleen was also visualized.,INDICATIONS: , This patient is a 34-year-old gravida 4, para-4-0-0-4 Caucasian female who desires permanent sterilization.  She recently had a spontaneous vaginal delivery in June and her family planning is complete.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed under general anesthesia.  She was then prepped and draped and placed in the dorsal lithotomy position.  A bimanual exam was performed and the above findings were noted.  Prior to beginning the procedure, her bladder was drained with a red Robinson catheter.  A weighted speculum was placed in the patient's posterior vagina and the 12 o' clock position of the cervix was grasped with a single-toothed tenaculum.  The cervix was dilated so that the uterine elevator could be placed.  Gloves were exchanged and attention was then turned to the anterior abdominal wall where the skin at the umbilicus was everted and using the towel clips, a 1 cm infraumbilical skin incision was made.  The Veress needle was then inserted and using sterile saline ______ the pelvic cavity.  The abdomen was then insufflated with appropriate volume and flow of CO2.  The #11 bladed trocar was then placed and intraabdominal placement was confirmed with the laparoscope.  A second skin incision was made approximately 2 cm above the pubic symphysis and under direct visualization, a 7 mm bladed trocar was placed without difficulty.  Using the Hulka clip applicator, the left fallopian tube was identified, followed out to its fimbriated end and the Hulka clip was then placed snugly against the uterus across the entire diameter of the fallopian tube.  A second Hulka clip was then placed across the entire diameter just proximal to this.  There was good hemostasis at the fallopian tube.  The right fallopian tube was then identified and followed out to its fimbriated end and the Hulka clip was placed. snugly against the uterus across the entire portion of the fallopian tube in a 90 degree angle.  A second Hulka clip was placed just distal to this again across the entire diameter.  Good hemostasis was obtained.  At this point, the abdomen was desufflated and after it was desufflated, the suprapubic port site was visualized and found to be hemostatic.  The laparoscope and remaining trocars were then removed with good visualization of the peritoneum and fascia and the laparoscope was removed.  The umbilical incision was then closed with two interrupted #4-0 undyed Vicryl.  The suprapubic incision was then closed with Steri-Strips.  The uterine elevator was removed and the single-toothed tenaculum site was found to be hemostatic.  The patient tolerated that procedure well.  The sponge, lap, and needle counts were correct x2.  She will follow up postoperatively for followup care.", Obstetrics / Gynecology,24
"REASON FOR CONSULTATION: , Left flank pain, ureteral stone.,BRIEF HISTORY: , The patient is a 76-year-old female who was referred to us from Dr. X for left flank pain.  The patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient's history.  The patient has had pain in the abdomen and across the back for the last four to five days.  The patient has some nausea and vomiting.  The patient wants something done for the stone.  The patient denies any hematuria, dysuria, burning or pain.  The patient denies any fevers.,PAST MEDICAL HISTORY: , Negative.,PAST SURGICAL HISTORY:  ,Years ago she had surgery that she does not recall.,MEDICATIONS: , None.,ALLERGIES: , None.,REVIEW OF SYSTEMS: , Denies any seizure disorder, chest pain, denies any shortness of breath, denies any dysuria, burning or pain, denies any nausea or vomiting at this time.  The patient does have a history of nausea and vomiting, but is doing better.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Vitals are stable.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft, left-sided flank pain and left lower abdominal pain.,The rest of the exam is benign.,LABORATORY DATA: , White count of 7.8, hemoglobin 13.8, and platelets 234,000.  The patient's creatinine is 0.92.,ASSESSMENT:,1.  Left flank pain.,2.  Left ureteral stone.,3.  Nausea and vomiting.,PLAN: , Plan for laser lithotripsy tomorrow.  Options such as watchful waiting, laser lithotripsy, and shockwave lithotripsy were discussed.  The patient has a pretty enlarged stone.  Failure of the procedure if the stone is significantly impacted into the ureteral wall was discussed.  The patient understood that the success of the surgery may be or may not be 100%, that she may require shockwave lithotripsy if we are unable to get the entire stone out in one sitting.  The patient understood all the risk, benefits of the procedure and wanted to proceed.  Need for stent was also discussed with the patient.  The patient will be scheduled for surgery tomorrow.  Plan for continuation of the antibiotics, obtain urinalysis and culture, and plan for KUB to evaluate for the exact location of the stone prior to surgery tomorrow.", General Medicine,15
"GENERAL:  ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX.  Height XXX, weight XXX.,HEAD: , Normocephalic.  Negative lesions, negative masses.,EYES: , PERLA, EOMI.  Sclerae clear.  Negative icterus, negative conjunctivitis.,ENT:,  Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates.  Negative ear obstructions, negative exudates.  Negative inflammation in external auditory canals.  Negative throat inflammation or masses.,SKIN: , Negative rashes, negative masses, negative ulcers.  No tattoos.,NECK:,  Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,HEART:,  Regular rate and rhythm.  Negative rubs, negative gallops, negative murmurs.,LUNGS:,  Clear to auscultation.  Negative rales, negative rhonchi, negative wheezing.,ABDOMEN: , Soft, nontender, adequate bowel sounds.  Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,EXTREMITIES: , Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing.  Pulses adequate bilaterally.,MUSCULOSKELETAL:,  Negative muscle atrophy, negative masses.  Strength adequate bilaterally.  Negative movement restriction, negative joint crepitus, negative deformity.,NEUROLOGIC: , Cranial nerves I through XII intact.  Negative gait disturbance.  Balance and coordination intact.  Negative Romberg, negative Babinski.  DTRs equal bilaterally.,GENITOURINARY:  ,Deferred.,", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS:, Senile cataract OX,POSTOPERATIVE DIAGNOSIS: ,Senile cataract OX,PROCEDURE: ,Phacoemulsification with posterior chamber intraocular lens OX, model SN60AT (for Acrysof natural lens), XXX diopters.,INDICATIONS: ,This is a XX-year-old (wo)man with decreased vision OX.,PROCEDURE:, The risks and benefits of cataract surgery were discussed at length with the patient, including bleeding, infection, retinal detachment, re-operation, diplopia, ptosis, loss of vision, and loss of the eye. Informed consent was obtained. On the day of surgery, (s)he received several sets of drops in the XXX eye including 2.5% phenylephrine, 1% Mydriacyl, 1% Cyclogyl, Ocuflox and Acular. (S)he was taken to the operating room and sedated via IV sedation. 2% lidocaine jelly was placed in the XXX eye (or, retrobulbar anesthesia was performed using a 50/50 mixture of 2% lidocaine and 0.75% marcaine). The XXX eye was prepped using a 10% Betadine solution. (S)he was covered in sterile drapes leaving only the XXX eye exposed. A Lieberman lid speculum was placed to provide exposure. The Thornton fixation ring and a Superblade were used to create a paracentesis at approximately 2 (or 11 depending upon side and handedness, and assuming superior incision) o'clock. Then 1% lidocaine was injected through the paracentesis. After the nonpreserved lidocaine was injected, Viscoat was injected through the paracentesis to fill the anterior chamber. The Thornton fixation ring and a 2.75 mm keratome blade were used to create a two-step full-thickness clear corneal incision superiorly. The cystitome and Utrata forceps were used to create a continuous capsulorrhexis in the anterior lens capsule. BSS on a hydrodissection cannula was used to perform gentle hydrodissection. Phacoemulsification was then performed to remove the nucleus. I & A was performed to remove the remaining cortical material. Provisc was injected to fill the capsular bag and anterior chamber. A XXX diopter SN60AT (for Acrysof natural lens) intraocular lens was injected into the capsular bag. The Kuglen hook was used to rotate it into proper position in the capsular bag. I & A was performed to remove the remaining Viscoelastic material from the eye. BSS on the 30-gauge cannula was used to hydrate the wound. The wounds were checked and found to be watertight. The lid speculum and drapes were carefully removed. Several drops of Ocuflox were placed in the XXX eye. The eye was covered with an eye shield. The patient was taken to the recovery area in a good condition. There were no complications.", Ophthalmology,26
"She is stable at this time and does not require any intervention at today's visit.  I have asked her to return in six months' for a followup dilated examination, but would be happy to see her sooner should you or she notice any changes in her vision.", SOAP / Chart / Progress Notes,35
"REASON FOR VISIT:  ,This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. She is accompanied by her daughter.,HISTORY OF PRESENT ILLNESS:,  The patient' daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak.  She has not been having any headaches.  She has had a significant decrease in appetite.  She is known to have lung cancer, but Ms. Wilson does not know what kind.  According to her followup notes, it is presumed non-small cell lung cancer of the left upper lobe of the lung.  The last note I have to evaluate is from October 2008.  CT scan from 12/01/2009 shows atrophy and small vessel ischemic change, otherwise a normal head CT, no mass lesion.  I also reviewed the MRI from September 2009, which does not suggest normal pressure hydrocephalus and shows no mass lesion.,Blood tests from 11/18/2009 demonstrate platelet count at 132 and INR of 1.0.,MAJOR FINDINGS: , The patient is a pleasant and cooperative woman who answers the questions the best she can and has difficulty moving her left arm and hand.  She also has pain in her left arm and hand at a level of 8-9/10.,VITAL SIGNS: , Blood pressure 126/88, heart rate 70, respiratory rate 16, and weight 95 pounds.,I screened the patient with questions to determine whether it is likely she has abnormal CSF pressure and she does not have any of the signs that would suggest this, so we performed the procedure in the upright position.,PROCEDURE:,  Lumbar puncture, diagnostic (CPT 62270).,PREOPERATIVE DIAGNOSIS: , Possible CSF malignancy.,POSTOPERATIVE DIAGNOSIS:  ,To be determined after CSF evaluation.,PROCEDURE PERFORMED: , Lumbar puncture.,ANESTHESIA: , Local with 2% lidocaine at the L4-L5 level.,SPECIMEN REMOVED:  ,15 cc of clear CSF.,ESTIMATED BLOOD LOSS: , None.,DESCRIPTION OF THE PROCEDURE:  ,I explained the procedure, its rationale, risks, benefits, and alternatives to the patient and her daughter.  The patient' daughter remained present throughout the procedure.  The patient provided written consent and her daughter signed as witness to the consent.,I located the iliac crest and spinous processes before the procedure and determined the level I planned for the puncture.  During the procedure, I spoke constantly with the patient to explain what was happening and to warn when there might be pain or discomfort.  The skin was prepped with chlorhexidine solution with the patient seated on the chair leaning forward with her face resting on the exam table.  Using local anesthetic and aseptic technique, I inserted a 20-gauge spinal needle at the L4-L5 interspace and 15 cc of CSF was collected without difficulty.,The patient tolerated the procedure well.,ASSESSMENT:  ,White blood cells 1, red blood cells 54, glucose 59, protein 51, Gram stain negative, bacterial culture negative after three days, and remaining tests pending.", Neurology,22
"CHIEF COMPLAINT:,1.  Infection.,2.  Pelvic pain.,3.  Mood swings.,4.  Painful sex.,HISTORY OF PRESENT ILLNESS:,  The patient is a 29-year-old female who is here today with the above-noted complaints.  She states that she has been having a lot of swelling and infection in her inner thigh area with the folliculitis she has had in the past.  She is requesting antibiotics.  She has been squeezing them and some of them are very bruised and irritated.  She also states that she is having significant pelvic pain and would like to go back and see Dr. XYZ again.  She also states that she took herself off of lithium, but she has been having significant mood swings, anger outbursts and not dealing with the situation well at all.  She also has had some psychiatric evaluation, but she states that she did not feel like herself on the medication, so she took herself off.  She states she does not wish to be on any medication at the current time.  She otherwise states that sex is so painful that she is unable to have sex with her husband, even though she ""wants to."",PAST MEDICAL HISTORY:,  Significant for cleft palate.,ALLERGIES:,  She is allergic to Lortab.,CURRENT MEDICATIONS:,  None.,REVIEW OF SYSTEMS:,  Please see history of present illness.,Psychiatric:  She has had some suicidal thoughts, but no plans.  She denies being suicidal at the current time.,Cardiopulmonary:  She has not had any chest pain or shortness of breath.,GI:  Denies any nausea or vomiting.,Neurological:  No numbness, weakness or tingling.,PHYSICAL EXAMINATION:,General:  The patient is a well-developed, well-nourished, 29-year-old female who is in no acute distress.,Vital signs:  Weight:  160 pounds.  Blood pressure:  100/60.  Pulse:  62.,Psychiatric:  I did spend over 25 minutes face-to-face with the patient talking about the situation she was in and the medication and her discontinuing use of that.,Extremities:  Her inner thighs are covered with multiple areas of folliculitis and mild abscesses.  They are bruised from her squeezing them.  We talked about that in detail.,ASSESSMENT:,1.  Folliculitis.,2.  Pelvic pain.,3.  Mood swings.,4.  Dyspareunia.,PLAN:,1.  I would like her to go to the lab and get a CBC, chem-12, TSH and UA.,2.  We will put her on cephalexin 500 mg three times a day.,3.  We will send her back to see Dr. XYZ regarding the pelvic pain per her request.,4.  We will get her an appointment with a psychiatrist for evaluation and treatment.,5.  She is to call if she has any further problems or concerns.  Otherwise I will see her back for her routine care or sooner if there are any further issues.", General Medicine,15
"PREOPERATIVE DIAGNOSIS: ,  Hematemesis in a patient with longstanding diabetes. ,POSTOPERATIVE DIAGNOSIS:  ,Mallory-Weiss tear, submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis.,PROCEDURE:  , The procedure, indications explained and he understood and agreed.  He was sedated with Versed 3, Demerol 25 and topical Hurricane spray to the oropharynx.  A bite block was placed.  The Pentax video gastroscope was advanced through the oropharynx into the esophagus under direct vision.  Esophagus revealed distal ulcerations.  Additionally, the patient had a Mallory-Weiss tear.  This was subjected to bicap cautery with good ablation.  The stomach was entered, which revealed areas of submucosal hemorrhage consistent with trauma from vomiting.  There were no ulcerations or erosions in the stomach.  The duodenum was entered, which was unremarkable.  The instrument was then removed.  The patient tolerated the procedure well with no complications.,IMPRESSION: , Mallory-Weiss tear, successful BICAP cautery. ,We will keep the patient on proton pump inhibitors.  The patient will remain on antiemetics and be started on a clear liquid diet.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  Carcinoma of the left breast.,POSTOPERATIVE DIAGNOSIS:,  Carcinoma of the left breast.,PROCEDURE PERFORMED: , True cut needle biopsy of the breast.,GROSS FINDINGS:  ,This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.  At this time, a true cut needle biopsy was performed.,PROCEDURE: , The patient was taken to operating room, is laid in the supine position, sterilely prepped and draped in the usual fashion.  The area over the left breast was infiltrated with 1:1 mixture of 0.25% Marcaine and 1% Xylocaine.  Using a #18 gauge automatic true cut needle core biopsy, five biopsies were taken of the left breast in core fashion.  Hemostasis was controlled with pressure.  The patient tolerated the procedure well, pending the results of biopsy.", Surgery,38
"CHIEF COMPLAINT: , MGUS.,HISTORY OF PRESENT ILLNESS:,  This is an extremely pleasant 86-year-old gentleman, who I follow for his MGUS.  I initially saw him for thrombocytopenia when his ANC was 1300.  A bone marrow biopsy was obtained.  Interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.0 and his white blood cell count was 6.5 with a platelet count of 484,000.  His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia.  All his tests came back as consistent with an MGUS.,Overall, he is doing well.  Since I last saw him, he tells me that he has had onset of atrial fibrillation.  He has now started going to the gym two times per week, and has lost over 10 pounds.  He has a good energy level and his ECOG performance status is 0.  He denies any fever, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Multivitamin q.d., aspirin one tablet q.d., Lupron q. three months, Flomax  0.4 mg q.d., and Warfarin 2.5 mg q.d.,ALLERGIES:  ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post left inguinal hernia repair.,2.  Prostate cancer diagnosed in December 2004, which was a Gleason 3+4.  He is now receiving Lupron.,SOCIAL HISTORY: , He has a very remote history of tobacco use.  He has one to two alcoholic drinks per day.  He is married.,FAMILY HISTORY: , His brother had prostate cancer.,PHYSICAL EXAM:,VIT:", Hematology - Oncology,16
"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.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS:,  Squamous cell carcinoma of right temporal bone/middle ear space.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of right temporal bone/middle ear space.,PROCEDURE: , Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the operating room, placed on the table in supine position.  General endotracheal anesthesia was obtained in the usual fashion.  The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen.  The neck was prepped as well.  After this was performed, I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl.  A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle.  After this was performed, I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible.  The condyle was skeletonized so that it could be easily seen.  The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared.  The neck contents to the hyoid were dissected out.  The hypoglossal nerve, vagus nerve, and spinal accessory nerve were dissected towards the jugular foramen.  The neck contents were removed as a separate specimen.  The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis.  A large posterior facial vein was identified and likewise clipped for later use.  I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus, dissecting or exposing the dura to the level of the jugular bulb.  It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router, I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube.  The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made.  I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion.  Once this was dissected out, Dr. X entered the procedure for completion of the resection with the craniotomy.  For details, please see his operative note.,After Dr. X had completed the resection, I then harvested the rectus free flap.  A skin paddle was drawn out next to the umbilicus about 4 x 4 cm.  The skin paddle was incised with the Bovie and down to the anterior rectus sheath.  Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle.  The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin.  The skin paddle was then sutured to the fascia and muscle with interrupted 3-0 Vicryl.  The anterior rectus sheath was then reflected off the rectus muscle, which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction.  The vascular pedicle could be seen entering the muscle in usual fashion.  The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel.  The wound was then packed with saline impregnated sponges.  The rectus muscle with attached skin paddle was then transferred into the neck.  The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9-0 Ethilon with standard microvascular technique.  Ischemia time was less than 10 minutes.  Likewise, the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9-0 Ethilon as well.  There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case.  The wound was irrigated with copious amounts of saline.  The eustachian tube was obstructed with bone wax.  The muscle was then laid into position with the skin paddle underneath the conchal bowl.  I removed most the skin of the conchal bowl de-epithelializing and leaving the fat in place.  The wound was closed in layers overlying the muscle, which was secured superiorly to the muscle overlying the temporal skull.  The subcutaneous tissues were closed with interrupted 3-0 Vicryl.  The skin was closed with skin staples.  There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself.  The skin paddle was closed with interrupted 4-0 Prolene to the edges of the conchal bowl.,The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with #1 Prolene with the more running suture, taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors.  The subcutaneous tissues were closed with interrupted 2-0 Vicryl and skin was closed with skin staples.  The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened.  The patient was then transferred to the PACU in stable condition with spontaneous respirations, having tolerated the procedure well.", Neurology,22
"PROCEDURE:,  Laparoscopic cholecystectomy.,DISCHARGE DIAGNOSES:,1.  Acute cholecystitis.,2.  Status post laparoscopic cholecystectomy.,3.  End-stage renal disease on hemodialysis.,4.  Hyperlipidemia.,5.  Hypertension.,6.  Congestive heart failure.,7.  Skin lymphoma 5 years ago.,8.  Hypothyroidism.,HOSPITAL COURSE: , This is a 78-year-old female with past medical condition includes hypertension, end-stage renal disease, hyperlipidemia, hypothyroidism, and skin lymphoma who had a left AV fistula done about 3 days ago by Dr. X and the patient went later on home, but started having epigastric pain and right upper quadrant pain and mid abdominal pain, some nauseated feeling, and then she could not handle the pain, so came to the emergency room, brought by the family.  The patient's initial assessment, the patient's vital signs were stable, showed temperature 97.9, pulse was 106, and blood pressure was 156/85.  EKG was not available and ultrasound of the abdomen showed there is a renal cyst about 2 cm.  There is sludge in the gallbladder wall versus a stone in the gallbladder wall.  Thickening of the gallbladder wall with positive Murphy sign.  She has a history of cholecystitis.  Urine shows positive glucose, but negative for nitrite and creatinine was 7.1, sodium 131, potassium was 5.2, and lipase and amylase were normal.  So, the patient admitted to the Med/Surg floor initially and the patient was started on IV fluid as well as low-dose IV antibiotic and 2-D echocardiogram and EKG also was ordered.  The patient also had history of CHF in the past and recently had some workup done.  The patient does not remember initially.  Surgical consult also requested and blood culture and urine culture also ordered.  The same day, the patient was seen by Dr. Y and the patient should need cholecystectomy, but the patient also needs dialysis and also needs to be cleared by the cardiologist, so the patient later on seen by Dr. Z and cleared the patient for the surgery with moderate risk and the patient underwent laparoscopic cholecystectomy.  The patient also seen by nephrologist and underwent dialysis.  The patient's white count went down 6.1, afebrile.  On postop day #1, the patient started eating and also walking.  The patient also had chronic bronchitis.  The patient was later on feeling fine, discussed with surgery.  The patient was then able to discharge to home and follow with the surgeon in about 3-5 days.  Discharged home with Synthroid 0.5 mg 1 tablet p.o. daily, Plavix 75 mg p.o. daily, folic acid 1 mg p.o. daily, Diovan 80 mg p.o. daily, Renagel 2 tablets 800 mg p.o. twice a day, Lasix 40 mg p.o.  2 tablets twice a day, lovastatin 20 mg p.o. daily, Coreg 3.125 mg p.o. twice a day, nebulizer therapy every 3 hours as needed, also Phenergan 25 mg p.o. q.8 hours for nausea and vomiting, Pepcid 20 mg p.o. daily, Vicodin 1 tablet p.o. q.6 hours p.r.n. as needed, and Levaquin 250 mg p.o. every other day for the next 5 days.  The patient also had Premarin that she was taking, advised to discontinue because of increased risk of heart disease and stroke explained to the patient.  Discharged home.", Discharge Summary,10
"PREOPERATIVE DIAGNOSES:,  Increased intracranial pressure and cerebral edema due to severe brain injury.,POSTOPERATIVE DIAGNOSES: , Increased intracranial pressure and cerebral edema due to severe brain injury.,PROCEDURE:,  Burr hole and insertion of external ventricular drain catheter.,ANESTHESIA: , Just bedside sedation.,PROCEDURE: , Scalp was clipped.  He was prepped with ChloraPrep and Betadine.  Incisions are infiltrated with 1% Xylocaine with epinephrine 1:200000.  He did receive antibiotics post procedure.  He was draped in a sterile manner.,Incision made just to the right of the right mid pupillary line 10 cm behind the nasion.  A self-retaining retractor was placed.  Burr hole was drilled with the cranial twist drill.  The dura was punctured with a twist drill.  A brain needle was used to localize the ventricle that took 3 passes to localize the ventricle.  The pressure was initially high.  The CSF was clear and colorless.  The CSF drainage rapidly tapered off because of the brain swelling.  With two tries, the ventricular catheter was then able to be placed into the ventricle and then brought out through a separate stab wound, the depth of catheter is 7 cm from the outer table of the skull.  There was intermittent drainage of CSF after that.  The catheter was secured to the scalp with #2-0 silk suture and the incision was closed with Ethilon suture.  The patient tolerated the procedure well.  No complications.  Sponge and needle counts were correct.  Blood loss is minimal.  None replaced.", Surgery,38
"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2.  Protein S low.,3.  Oligohydramnios.,POSTOPERATIVE:,1.  Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2.  Protein S low.,3.  Oligohydramnios.,4.  Delivery of a viable female, weight 5 pound, 14 ounces.  Apgars of 9 and 9 at 1 and 5 minutes respectively and cord pH is 7.314.,OPERATION PERFORMED:,  Low transverse C-section.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS: , Foley.,ANESTHESIA: , Spinal with Duramorph.,HISTORY OF PRESENT ILLNESS:  ,This is a 21-year-old white female gravida 1, para 0, who had presented to the hospital at 37-3/7 weeks for induction.  The patient had oligohydramnios and also when placed on the monitor had nonreassuring fetal heart rate with late deceleration.  Due to the IUGR as well a decision for a C-section was made.,PROCEDURE: , The patient was taken to the operating room and placed in a seated position with standard spinal form of anesthesia administered by the Anesthesia Department.  The patient was then repositioned, prepped and draped in a slight left lateral tilt.  Once this was completed first knife was used to make a low transverse skin incision approximately two fingerbreadths above the pubic symphysis.  This was extended down to the level of the fascia.  The fascia was nicked in the center and extended in transverse fashion.  Edges of the fascia were grasped with Kocher and both blunt and sharp dissection both caudally and cephalic was completed consistent with the Pfannenstiel technique.  The abdominal rectus muscle was divided in the center, extended in vertical fashion and the peritoneum was entered at a high point and extended in vertical fashion.  Bladder blade was put in place and a bladder flap was created with the use of Metzenbaum and pickups and then bluntly dissected via cautery and reincorporated in the bladder blade.  Second knife was used to make a low transverse uterine incision with care being taken to avoid the presenting part of fetus.  Presenting part was vertex, the head was delivered, followed by the remaining portion of the body.  The mouth and nose were suctioned through bulb syringe and the cord was doubly clamped and cut and then the newborn handed off to waiting nursing personnel.  Cord pH blood and cord blood was obtained.  The placenta was delivered manually and the uterus was externalized and the lining was cleaned off any remaining placental fragments and blood and the incisional edges were reapproximated with 0-chromic and a continuous locking stitch with a second layer used to imbricate the first.  The bladder flap was re-peritonized with Gelfoam underneath and abdomen was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position.  The gutters were wiped clean of any remaining blood and fluid and the edges of the perineum grasped with hemostats and continuous locking stitches of 2-0 Vicryl was used to reapproximate the abdominal rectus muscle as well as the perineum.  This area was then irrigated.  Cautery was used for adequate hemostasis, corners of the fascia grasped with hemostats and continuous locking stitch of 1-Vicryl was started at both corners and overlapped in the center.  Subcutaneous tissue was irrigated with saline and reapproximated with 3-0 Vicryl.  Skin edges reapproximated with sterile staples.  Sterile dressing was applied.  The uterus was evacuated of any remaining clots vaginally.  The patient was taken to recovery room in stable condition.  Instrument count, needle count, and sponge counts were all correct.", Surgery,38
"We discovered new T-wave abnormalities on her EKG.  There was of course a four-vessel bypass surgery in 2001.  We did a coronary angiogram.  This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have nitroglycerin available for that if needed.,Her blood pressure has been elevated and so instead of metoprolol, we have started her on Coreg 6.25 mg b.i.d.  This should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case.  She also is on an ACE inhibitor.,So her discharge meds are as follows:,1.  Coreg 6.25 mg b.i.d.,2.  Simvastatin 40 mg nightly.,3.  Lisinopril 5 mg b.i.d.,4.  Protonix 40 mg a.m.,5.  Aspirin 160 mg a day.,6.  Lasix 20 mg b.i.d.,7.  Spiriva puff daily.,8.  Albuterol p.r.n. q.i.d.,9.  Advair 500/50 puff b.i.d.,10.  Xopenex q.i.d. and p.r.n.,I will see her in a month to six weeks.  She is to follow up with Dr. X before that.", SOAP / Chart / Progress Notes,35
"PREOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,POSTOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,OPERATIONS PERFORMED,1.  Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at C5-C6.,2.  Bilateral C6 nerve root decompression.,3.  Anterior cervical discectomy at C4-C5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4.  Bilateral C5 nerve root decompression.,5.  Anterior cervical discectomy at C3-C4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6.  Bilateral C4 nerve root decompression.,7.  Harvesting of autologous bone from the vertebral bodies.,8.  Grafting of allograft bone for creation of arthrodesis.,9.  Creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C5-C6.,10.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C4-C5.,11.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C3-C4.,12.  Placement of anterior spinal instrumentation from C3 to C6 using a Synthes Small Stature Plate, using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at C5-C6.  There was a herniated disk with cord compression and radiculopathy at C4-C5.  C3-C4 was the source of neck pain as documented by facet injections.,A detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels.  Because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6.,I explained the nature of this procedure in great detail including all risks and alternatives.  He clearly understands and has no further questions and requests that I proceed.,PROCEDURE:  ,The patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,The left side of the neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made in the neck crease.  Dissection was carried down through the platysma musculature and the anterior spine was exposed.  The medial borders of the longus colli muscle were dissected free from their attachments to the spine.  Caspar self-retaining pins were placed into the bodies of C3, C4, C5, and C6 and x-ray localization was obtained.  A needle was placed in what was revealed to be the disk space at C4-C5 and an x-ray confirmed proper localization.,Self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,First I removed the large amount of anterior overhanging osteophytes at C5-C6 and distracted the space.  The high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,An incision was then made at C4-C5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,The retractors were then adjusted and again discectomy was performed at C3-C4 back to the posterior lips of the vertebral bodies.  The operating microscope was then utilized.,Working under magnification, I started at C3-C4 and began to work my way down to the posterior longitudinal ligament.  The ligament was incised and the underlying dura was exposed.  I worked out laterally towards the takeoff of the C4 nerve root and widely decompressed the nerve root edge of the foramen.  There were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, I left them intact.  However, I could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right.  The microscope was angled to the left side where similar decompression was achieved.,The retractors were readjusted and attention was turned to C4-C5.  I worked down through bony osteophytes and identified the posterior longitudinal ligament.  The ligament was incised; and as I worked to the right of the midline, I encountered herniated disk material which was removed in a number of large pieces.  The C5 root was exposed and then widely decompressed until I was flush with the pedicle and into the foramen.  The root had a somewhat high takeoff but I worked to expose the axilla and widely decompressed it.  Again the microscope was angled to the left side where similar decompression was achieved.  Central decompression was achieved here where there was a moderate amount of spinal cord compression.  This was removed by undercutting with 1 and 2-mm Cloward punches.,Attention was then turned to the C5-C6 space.  Here there were large osteophytes projecting posteriorly against the cord.  I slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm Cloward punches to widely decompress the spinal cord.  This necessitated undercutting the bodies of both C5 and C6 extensively, but I was then able to achieve a good decompression of the cord.  I exposed the C6 root and widely decompressed it until I was flush with the pedicle and into the foramen on the right.  The microscope was angled to the left side where a similar decompression was achieved.,Attention was then turned to creation of the arthrodesis.  A high-speed Cornerstone bur was used to decorticate the bodies of C5-C6, C4-C5 and C3-C4 to create a posterior shelf to prevent backwards graft migration.  Bone dust during the drilling was harvested for later use.,Attention was turned to creation of the arthrodesis.  Using the various Synthes sizers, I selected a 7-mm lordotic graft at C5-C6 and an 8-mm lordotic graft at C4-C5 and a 9-mm lordotic graft at C3-C4.  Each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge.  I decided to use BMP in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks.  The BMP sponge and the ____________ bone were then packed in the center of the allograft.,Under distraction, the graft was placed at C3-C4, C4-C5, and C5-C6 as described.  An x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,Attention was turned to the placement of anterior spinal instrumentation.  Various sizes of Synthes plates were selected until I decided that a 54-mm plate was appropriate.  The plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush.  The holes were drilled and the screws were placed.  Eight screws were placed with two screws at C3, two screws at C4, two screws at C5, and two screws at C6.  All eight screws had good purchase.  The locking screws were tightly applied.  An x-ray was obtained which showed good placement of the graft, plate, and screws.,Attention was turned to closure.  The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained.  A medium Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct.  There were no intraoperative complications.,Specimens were sent to Pathology consisting of disk material and bone and soft tissue.", Surgery,38
"SUBJECTIVE:,  Mom brings patient in today because of sore throat starting last night.  Eyes have been very puffy.  He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday.  He has had low-grade fever and just felt very run down, appearing very tired.  He is still eating and drinking well, and his voice has been hoarse but no coughing.  No shortness of breath, vomiting, diarrhea or abdominal pain.,PAST MEDICAL HISTORY:,  Unremarkable.  There is no history of allergies.  He does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year.,FAMILY HISTORY: , Noncontributory.  No one else at home is sick.,OBJECTIVE:,General:  A 13-year-old male appearing tired but in no acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, gray in color.  Good light reflex.  Oropharynx pink and moist.  No erythema or exudate.  Some drainage is seen in the posterior pharynx.  Nares:  Swollen, red.  No drainage seen.  No sinus tenderness.  Eyes are clear.,Chest:  Respirations are regular and nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry and pink, moist mucous membranes.  No rash.,LABORATORY:,  Strep test is negative.  Strep culture is negative.,RADIOLOGY:,  Water's View of the sinuses is negative for any sinusitis or acute infection.,ASSESSMENT:,  Upper respiratory infection.,PLAN:,  At this point just treat symptomatically.  I gave him some samples of Levall for the congestion and as an expectorant.  Push fluids and rest.  May use ibuprofen or Tylenol for discomfort.", SOAP / Chart / Progress Notes,35
"PREOPERATIVE DIAGNOSIS:,  Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,POSTOPERATIVE DIAGNOSIS: , Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,PROCEDURES PERFORMED:,1.  Left hip cemented hemiarthroplasty.,2.  Biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,IMPLANTS USED:,1.  DePuy Ultima calcar stem, size 3 x 45.,2.  Bipolar head 28 x 43.,3.  Head with +0 neck length.,4.  Distal centralizer and cement restrictor.,5.  SmartSet antibiotic cement x2.,ANESTHESIA: , General.,NEEDLE AND SPONGE COUNT: , Correct.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS: , 300 mL.,SPECIMEN: , Resected femoral head and tissue from the fracture site as well as the marrow from the canal.,FINDINGS:  ,On exposure, the fracture was noted to be basicervical pattern with no presence of calcar about the lesser trochanter.  The lesser trochanter was intact.  The fracture site was noted to show abnormal pathological tissue with grayish discoloration.  The quality of the bone was also pathologically abnormal with soft trabecular bone.  The abnormal pathological tissues were sent along with the femoral head to pathology for assessment.  Articular cartilage of the acetabulum was intact and well preserved.,INDICATION: , The patient is a 53-year-old female with a history of malignant melanoma, who apparently had severe pain in her left lower extremity and was noted to have a basicervical femoral neck fracture.  She denied any history of fall or trauma.  The presentation was consistent with pathological fracture pending tissue assessment.  Indication, risks, and benefits were discussed.  Treatment options were reviewed.  No guarantees have been made or implied.,PROCEDURE:  ,The patient was brought to the operating room and once an adequate general anesthesia was achieved, she was positioned on a pegboard with the left side up.  The left lower extremity was prepped and draped in a standard sterile fashion.  Time-out procedure was called.  Antibiotics were infused.,A standard posterolateral approach was made.  Subcutaneous dissection was performed and the dissection was carried down to expose the fascia of the gluteus maximus.  This was then incised along the line of the incision.  Hemostasis was achieved.  Charnley retractor was positioned.  The trochanter was intact.  The gluteus medius was well protected with retractor.  The piriformis and minimus junction was identified.  The minimus was also reflected along with the medius.  Using Bovie and knife, the piriformis and external rotators were detached from its trochanteric insertion.  Similarly, L-shaped capsulotomy was performed.  A #5 Ethibond was utilized to tag the piriformis and the capsule for late repair.  Fracture site was exposed.  The femoral neck fracture was noted to be very low-lying basicervical type.  Femoral head was retrieved without any difficulty with the help of a corkscrew.  The head size was measured to be 43 mm.  Bony fragments were removed.  The acetabular socket was thoroughly irrigated.  A 43-mm bipolar trial head was inserted and this was noted to give a satisfactory fit with good stability.  The specimens submitted to pathology included the resected femoral head and the tissue at the fracture site, which was abnormal with grayish discoloration.  This was sent to the pathology.  The fracture was noted to be basicervical and preoperatively, decision was made to consider cemented calcar stem.  An L-shaped osteotomy was performed in order to accept the calcar prosthesis.  The basicervical fracture was noted to be just at the level of superior border of the lesser trochanter.  There was no calcar superior to the lesser trochanter.  The L-shaped osteotomy was performed to refine the bony edges and accept the calcar prosthesis.  Hemostasis was achieved.  Now, the medullary canal was entered with a canal finder.  The fracture site was well exposed.  Satisfactory lateralization was performed.  Attention was for the reaming process.  Using a size 1 reamer, the medullary canal was entered and reamed up to size 3, which gave us a satisfactory fit into the canal.  At this point, a trial prosthesis size 3 with 45 mm calcar body was inserted.  Appropriate anteversion was positioned.  The anteversion was marked with a Bovie to identify subsequent anteversion during implantation.  The bony edges were trimmed.  The calcar implant with 45 mm neck length was fit in the host femur very well.  There was no evidence of any subsidence.  At this point, trial reduction was performed using a bipolar trial head with 0 neck length.  The relationship between the central femoral head and the greater trochanter was satisfactory.  The hip was well reduced without any difficulty.  The stability and range of motion in extension and external rotation as well as flexion-adduction, internal rotation was satisfactory.  The shuck was less than 1 mm.  Leg length was satisfactory in reference to the contralateral leg.  Stability was satisfactory at 90 degrees of flexion and hip at 75-80 degrees of internal rotation.  Similarly, keeping the leg completely adducted, I was able to internally rotate the hip to 45 degrees.  After verifying the stability and range of motion in all direction, trial components were removed.  The canal was thoroughly irrigated and dry sponge was inserted and canal was dried completely.  At this point, 2 batches of SmartSet cement with antibiotics were mixed.  The definitive Ultima calcar stem size 3 with 45 mm calcar body was selected.  Centralizer was positioned.  The cement restrictor was inserted.  Retrograde cementing technique was applied once the canal was dried.  Using cement gun, retrograde cementing was performed.  The stem was then inserted into cemented canal with appropriate anteversion, which was maintained until the cement was set hard and cured.  The excess cement was removed with the help of a curette and Freer elevator.  All the cement debris was removed.,Attention was now placed for the insertion of the trial femoral head.  Once again, 0 neck length trial bipolar head was inserted over the trunnion.  It was reduced and range of motion and stability was satisfactory.  I also attempted with a -3 trial head, but the 0 gave us a satisfactory stability, range of motion, as well as the length and the shuck was also minimal.  The hip was raised to 90 degrees of flexion and 95 degrees of internal rotation.  There was no evidence of any impingement on extension and external rotation as well as flexion-adduction, internal rotation.  I also tested the hip at 90 degrees of flexion with 10 degrees adduction and internal rotation and further progressive flexion of the hip beyond 90 degrees, which was noted to be very stable.  At this point, a definitive component using +0 neck length and bipolar 43 head were placed over the trunnion and the hip was reduced.  Range of motion and stability was as above.  Now, the attention was placed for the repair of the capsule and the external rotators and the piriformis.  This was repaired to the trochanteric insertion using #5 Ethibond and suture plaster.  Satisfactory reinforcement was achieved with the #5 Ethibond.  The wound was thoroughly irrigated.  Hemostasis was achieved.  The fascia was closed with #1 Vicryl followed by subcutaneous closure using 2-0 Vicryl.  The wound was thoroughly washed and a local injection with mixture of morphine and Toradol was infiltrated including the capsule and the pericapsular structures.  Skin was approximated with staples.  Sterile dressings were placed.  Abduction pillow was positioned and the patient was then extubated and transferred to the recovery room in a stable condition.  There were no intraoperative complications noted.", Surgery,38
"EXAM: , CT stone protocol.,REASON FOR EXAM:,  History of stones, rule out stones.,TECHNIQUE: , Noncontrast CT abdomen and pelvis per renal stone protocol.,FINDINGS: , Correlation is made with a prior examination dated 01/20/09.,Again identified are small intrarenal stones bilaterally.  These are unchanged.  There is no hydronephrosis or significant ureteral dilatation.  There is no stone along the expected course of the ureters or within the bladder.  There is a calcification in the low left pelvis not in line with ureter, this finding is stable and is compatible with a phlebolith.  There is no asymmetric renal enlargement or perinephric stranding.,The appendix is normal.  There is no evidence of a pericolonic inflammatory process or small bowel obstruction.,Scans through the pelvis disclose no free fluid or adenopathy.,Lung bases aside from very mild dependent atelectasis appear clear.,Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas are grossly unremarkable.  The gallbladder is present.  There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. Bilateral intrarenal stones, no obstruction.,2. Normal appendix.", Nephrology,21
"EYES: , The conjunctivae are clear.  The lids are normal appearing without evidence of chalazion or hordeolum.  The pupils are round and reactive.  The irides are without any obvious lesions noted.  Funduscopic examination shows sharp disk margins.  There are no exudates or hemorrhages noted.  The vessels are normal appearing.,EARS, NOSE, MOUTH AND THROAT:,  The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.,NECK:,  The neck is nontender and supple.  The trachea is midline.  The thyroid is without any evidence of thyromegaly.  No obvious adenopathy is noted to the neck.,RESPIRATORY: , The patient has normal respiratory effort.  There is normal lung excursion.  Percussion of the chest is without any obvious dullness.  There is no tactile fremitus or egophony noted.  There is no tenderness to the chest wall or ribs.  There are no obvious abnormalities.  The lungs are clear to auscultation.  There are no wheezes, rales or rhonchi heard.  There are no obvious rubs noted.,CARDIOVASCULAR: , There is a normal PMI on palpation.  I do not hear any obvious abnormal sounds.  There are no obvious murmurs.  There are no rubs or gallops noted.  The carotid arteries are without bruit.  No obvious thrill is palpated. There is no evidence of enlarged abdominal aorta to palpation.  There is no abdominal mass to suggest enlargement of the aorta.  Good strong femoral pulses are palpated.  The pedal pulses are intact.  There is no obvious edema noted to the extremities.  There is no evidence of any varicosities or phlebitis noted.,GASTROINTESTINAL: , The abdomen is soft.  Bowel sounds are present in all quadrants.  There are no obvious masses.  There is no organomegaly, and no liver or spleen is palpable.  No obvious hernia is noted.  The perineum and anus are normal in appearance.  There is good sphincter tone and no obvious hemorrhoids are noted.  There are no masses.  On digital examination, there is no evidence of any tenderness to the rectal vault; no lesions are noted.  Stool is brown and guaiac negative.,GENITOURINARY (FEMALE): , The external genitalia is normal appearing with no obvious lesions, no evidence of any unusual rash.  The vagina is normal in appearance with normal-appearing mucosa.  The urethra is without any obvious lesions or discharge.  The cervix is normal in color with no obvious cervical discharge.  There are no obvious cervical lesions noted.  The uterus is nontender and small, and there is no evidence of any adnexal masses or tenderness.  The bladder is nontender to palpation.  It is not enlarged.,GENITOURINARY (MALE): , Normal scrotal contents are noted.  The testes are descended and nontender.  There are no masses and no swelling to the epididymis noted.  The penis is without any lesions.  There is no urethral discharge.  Digital examination of the prostate reveals a nontender, non-nodular prostate.,BREASTS:,  The breasts are normal in appearance.  There is no puckering noted.  There is no evidence of any nipple discharge.  There are no obvious masses palpable.  There is no axillary adenopathy.  The skin is normal appearing over the breasts.,LYMPHATICS: , There is no evidence of any adenopathy to the anterior cervical chain.  There is no evidence of submandibular nodes noted.  There are no supraclavicular nodes palpable.  The axillae are without any abnormal nodes.  No inguinal adenopathy is palpable.  No obvious epitrochlear nodes are noted.,MUSCULOSKELETAL/EXTREMITIES: , The patient has normal gait and station.  The patient has normal muscle strength and tone to all extremities.  There is no obvious evidence of any muscle atrophy.  The joints are all stable.  There is no evidence of any subluxation or laxity to any of the joints.  There is no evidence of any dislocation.  There is good range of motion of all extremities without any pain or tenderness to the joints or extremities.  There is no evidence of any contractures or crepitus.  There is no evidence of any joint effusions.  No obvious evidence of erythema overlying any of the joints is noted.  There is good range of motion at all joints.  There are normal-appearing digits.  There are no obvious lesions to any of the nails or nail beds.,SKIN:,  There is no obvious evidence of any rash.  There are no petechiae, pallor or cyanosis noted.  There are no unusual nodules or masses palpable.,NEUROLOGIC: , The cranial nerves II XII are tested and are intact.  Deep tendon reflexes are symmetrical bilaterally.  The toes are downgoing with normal Babinskis.  Sensation to light touch is intact and symmetrical.  Cerebellar testing reveals normal finger nose, heel shin.  Normal gait.  No ataxia.,PSYCHIATRIC:  ,The patient is oriented to person, place and time.  The patient is also oriented to situation.  Mood and affect are appropriate for the present situation.  The patient can remember 3 objects after 3 minutes without any difficulties.  Remote memory appears to be intact.  The patient seems to have normal judgment and insight into the situation.", General Medicine,15
"CC:, Left hemiplegia.,HX: , A 58 y/o RHF awoke at 1:00AM on 10/23/92 with left hemiplegia and dysarthria which cleared within 15 minutes. She was seen at a local ER and neurological exam and CT Brain were reportedly unremarkable. She was admitted locally. She then had two more similar spells at 3AM and 11AM with resolution of the symptoms within an hour. She was placed on IV Heparin following the 3rd episode and was transferred to UIHC. She had not been taking ASA.,PMH:, 1)HTN. 2) Psoriasis.,SHX:, denied ETOH/Tobacco/illicit drug use.,FHX:, Unknown.,MEDS:, Heparin only.,EXAM:, BP160/90 HR145 (supine). BP105/35 HR128 (light headed, standing) RR12 T37.7C,MS: Dysarthria only. Lucid thought process.,CN: left lower facial weakness only.,Motor: mild left hemiparesis with normal muscle bulk. Mildly increased left sided muscle tone.,Sensory: unremarkable.,Coordination: impaired secondary to weakness on left. Otherwise unremarkable.,Station: left pronator drift. Romberg testing not done.,Gait: not tested.,Reflexes: symmetric; 2+ throughout.,Gen Exam: CV: Tachycardic without murmur.,COURSE:, The patients signs and symptoms worsening during and after standing to check orthostatic blood pressures. She was immediately placed in a reverse Trendelenburg position and given IV fluids. Repeat neurologic exam at 5PM on the day of presentation revealed a return to the initial presentation of signs and symptoms. PT/PTT/GS/CBC/ABG were unremarkable. EKG revealed sinus tachycardia with rate dependent junctional changes. CXR unremarkable. MRI Brain was obtained and showed an evolving right thalamic/lentiform nucleus infarction best illustrated by increased signal on the Proton density weighted images. Over the ensuing days of admission she had significant fluctuations of her BP (200mmHG to 140mmHG systolic). Her symptoms worsened with falls in BP. Her BP was initially controlled with esmolol or labetalol. Renal Ultrasound, abdominal/pelvic CT, renal function scan, serum and urine osmolality, urine catecholamines/metanephrine studies were unremarkable. Carotid doppler study revealed 0-15%BICA stenosis and antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram was unremarkable. Cerebral angiogram was performed to r/o vasculitis. This revealed narrowing of the M1 segment of the right MCA. This was thought secondary to atherosclerosis and not vasculitis. She was discharged on ASA, Procardia XL, and Labetalol.", Radiology,33
"The patient's abdomen was prepped and draped in the usual sterile fashion.  A subumbilical skin incision was made.  The Veress needle was inserted, and the patient's abdominal cavity was insufflated with moderate pressure all times.  A subumbilical trocar was inserted.  The camera was inserted in the panoramic view.  The abdomen demonstrated some inflammation around the gallbladder.  A 10-mm midepigastric trocar was inserted.  A. 2 mm and 5 mm trocars were inserted.  The most lateral trocar grasping forceps was inserted and grasped the fundus of the gallbladder and placed in tension at liver edge.,Using the dissector, the cystic duct was identified and double Hemoclips were invited well away from the cystic-common duct junction.  The cystic artery was identified and double Hemoclips applied.  The gallbladder was taken down from the liver bed using Endoshears and electrocautery.  Hemostasis was obtained.  The gallbladder was removed from the midepigastric trocar site without difficulty.  The trocars were removed and the skin incisions were reapproximated using 4-0 Monocryl.  Steri-Strips and sterile dressing were placed.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.", Surgery,38
"EXAM: , Bilateral diagnostic mammogram and right breast ultrasound.,History of palpable abnormality at 10 o'clock in the right breast.  Family history of a sister with breast cancer at age 43.,TECHNIQUE: , CC and MLO views of both breasts were obtained.  Spot compression views of the palpable area were also obtained.  Right breast ultrasound was performed.  Comparison is made with mm/dd/yy.,FINDINGS: , The breast parenchymal pattern is stable with heterogeneous scattered areas of fibroglandular tissue.  No new mass or architectural distortion is evident.  Asymmetric density in the upper outer posterior left breast and a nodule in the upper outer right breast are unchanged.  There is no suspicious cluster of microcalcifications.,Directed ultrasonography of the upper outer quadrant of the right breast revealed no cystic or hypoechoic solid mass.,IMPRESSION:,1.  Stable mammographic appearance from mm/dd/yy.,2.  No sonographic evidence of a mass at 10 o'clock in the right breast to correspond to the palpable abnormality.  The need for further assessment of a palpable abnormality should be determined clinically.,BIRADS Classification 2 - Benign", Obstetrics / Gynecology,24
"PROCEDURE NOTE: , Pacemaker ICD interrogation.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old gentleman who was admitted to the hospital.  He has had ICD pacemaker implantation.  This is a St. Jude Medical model current DRRS, 12345 pacemaker.,DIAGNOSIS: , Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,FINDINGS: , The patient is a DDD mode base rate of 60, max tracking rate of 110 beats per minute, atrial lead is set at 2.5 volts with a pulse width of 0.5 msec, ventricular lead set at 2.5 volts with a pulse width of 0.5 msec.  Interrogation of the pacemaker shows that atrial capture is at 0.75 volts at 0.5 msec, ventricular capture 0.5 volts at 0.5 msec, sensing in the atrium is 5.34 to 5.8 millivolts, R sensing is 12-12.0 millivolts, atrial lead impendence 590 ohms, ventricular lead impendence 750 ohms.  The defibrillator portion is set at VT1 at 139 beats per minute with SVT discrimination on therapy is monitor only.  VT2 detection criteria is 169 beats per minute with SVT discrimination on therapy of ATP times 3 followed by 25 joules, followed by 36 joules, followed by 36 joules times 2.  VF detection criteria set at 187 beats per minute with therapy of 25 joules, followed by 36 joules times 5.  The patient is in normal sinus rhythm.,IMPRESSION:  ,Normally functioning pacemaker ICD post implant day number 1.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS: , Morbid obesity. ,POSTOPERATIVE DIAGNOSIS: , Morbid obesity. ,PROCEDURE:,  Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. ,ANESTHESIA: , General with endotracheal intubation. ,INDICATIONS FOR PROCEDURE: , This is a 50-year-old male who has been overweight for many years and has tried multiple different weight loss diets and programs.  The patient has now begun to have comorbidities related to the obesity.  The patient has attended our bariatric seminar and met with our dietician and psychologist.  The patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form.,PROCEDURE IN DETAIL: , The risks and benefits were explained to the patient.  Consent was obtained.  The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation.  A Foley catheter was placed for bladder decompression.  All pressure points were carefully padded, and sequential compression devices were placed on the legs.  The abdomen was prepped and draped in standard, sterile, surgical fashion.  Marcaine was injected into the umbilicus.", Surgery,38
"DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1.  Glucosamine complex.,2.  Toprol XL.,3.  Alprazolam,4.  Hydrochlorothiazide.,5.  Dyazide.,6.  Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck.  She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area.  As such, I feel that we could safely re-treat the lower neck.  Her weight has increased to 189.5 from 185.2.  She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK:  On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area.  No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY:  Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected.  No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN:  Normal bowel sounds, no hepatomegaly.  No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress.  Thank you for having allowed me to participate in her care.", Obstetrics / Gynecology,24
"REASON FOR EXAM:,  CVA.,INDICATIONS: , CVA.,This is technically acceptable.  There is some limitation related to body habitus.,DIMENSIONS:  ,The interventricular septum 1.2, posterior wall 10.9, left ventricular end-diastolic 5.5, and end-systolic 4.5, the left atrium 3.9.,FINDINGS: , The left atrium was mildly dilated.  No masses or thrombi were seen.  The left ventricle showed borderline left ventricular hypertrophy with normal wall motion and wall thickening, EF of 60%.  The right atrium and right ventricle are normal in size.,Mitral valve showed mitral annular calcification in the posterior aspect of the valve.  The valve itself was structurally normal.  No vegetations seen.  No significant MR. Mitral inflow pattern was consistent with diastolic dysfunction grade 1.  The aortic valve showed minimal thickening with good exposure and coaptation.  Peak velocity is normal.  No AI.,Pulmonic and tricuspid valves were both structurally normal.,Interatrial septum was appeared to be intact in the views obtained.  A bubble study was not performed.,No pericardial effusion was seen.  Aortic arch was not assessed.,CONCLUSIONS:,1.  Borderline left ventricular hypertrophy with normal ejection fraction at 60%.,2.  Mitral annular calcification with structurally normal mitral valve.,3.  No intracavitary thrombi is seen.,4.  Interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,TITLE OF THE PROCEDURE: , Right carpal tunnel release.,COMPLICATIONS:,  There were no complications during the procedure.,SPECIMEN:  ,The specimen was sent to pathology.,INSTRUMENTS: , All counts were correct at the end of the case and no complications were encountered.,INDICATIONS:  ,This is a 69-year-old female who have been complaining of right hand pain, which was steadily getting worse over a prolonged period of time.  The patient had tried nonoperative therapy, which did not assist the patient.  The patient had previous diagnosis of carpal tunnel and EMG showed compression of the right median nerve.  As a result of these findings, the patient was sent to my office presenting with this history and was carefully evaluated.  On initial evaluation, the patient had the symptomology of carpal tunnel syndrome.  The patient at the time had the risks, benefits, and alternatives thoroughly explained to her.  All questions were answered.  No guarantees were given.  The patient had agreed to the surgical procedure and the postoperative rehabilitation as needed.,DETAILS OF THE PROCEDURE:  ,The patient was brought to the operating room, placed supine on the operating room table, prepped and draped in the sterile fashion and was given sedation.  The patient was then given sedation.  Once this was complete, the area overlying the carpal ligament was carefully injected with 1% lidocaine with epinephrine.  The patient had this area carefully and thoroughly injected with approximately 10 mL of lidocaine with epinephrine and once this was complete, a 15-blade knife was then used to incise the skin opposite the radial aspect of the fourth ray.  Careful dissection under direct visualization was performed through the subcutaneous fat as well as through the palmar fascia.  A Weitlaner retractor was then used to retract the skin and careful dissection through the palmar fascia would then revealed the transverse carpal ligament.  This was then carefully incised using a 15-blade knife and once entry was again into the carpal canal, a Freer elevator was then inserted and under direct visualization, the carpal ligament was then released.  The transverse carpal ligament was carefully released first in the distal direction until palmar fat could be visualized and by palpation no further ligament could be felt.  The area was well hemostased with the 1% lidocaine with epinephrine and both proximal and distal dissection along the nerve was performed.  Visualization of the transverse carpal ligament was maintained with Weitlaner retractor as well as centric.  Both the centric and the Ragnell were used to retract both proximal and distal corners of the incision and the entirety of the area was under direct visualization at all times.  Palmar fascia was released both proximally and distally as well as the transverse carpal ligament.  Direct palpation of the carpal canal demonstrated a full and complete release.  Observation of the median nerve revealed an area of hyperemia in the distal two-thirds of the nerve, which demonstrated the likely area of compression.  Once this was complete, hemostasis was established using bipolar cautery and some small surface bleeders and irrigation of the area was performed and then the closure was achieved with 4-0 chromic suture in a horizontal mattress and interrupted stitch.  Xeroform was then applied to the incision.  A bulky dressing was then applied consisting of Kerlix and Ace wrap, and the patient was taken to the recovery room in stable condition without any complications.", Surgery,38
"PREOPERATIVE DIAGNOSES:,1.  Eyebrow ptosis.,2.  Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid.,3.  Cervical facial aging with submental lipodystrophy.,OPERATION:,1.  Hairline biplanar temporal browlift.,2.  Quadrilateral blepharoplasty with lateral canthopexy with arcus marginalis release and fat transposition over inferior orbital rim to lower eyelid.,3.  Cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.,ASSISTANT:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE: , The patient was placed in a supine position and prepped with general endotracheal anesthesia.  Local infiltration anesthesia with 1% Xylocaine and 1:100,000 epinephrine was infiltrated in upper and lower eyelids.,Markings were made and fusiform ellipse of skin was resected from the upper eyelid.  The lower limb of the fusiform ellipse was at the superior palpebral fold.  A 9 mm of upper eyelid skin was resected at the widest portion of the lips, which extended from medial canthal area to the lateral orbital rim.  This was performed bilaterally and symmetrically and the skin was removed.  Incision was made through the pretarsal orbicularis with small amount of fat being removed from the medial and middle fat pocket.  An incision was made over the superior orbital rim.  Subperiosteal dissection was performed over the forehead.  The dissection proceeded medially.  The corrugator and procerus muscles were carefully dissected from the supratrochlear nerves on both right and left side and cauterized.,Hemostasis was achieved with electrocautery in this fashion.  A 4-cm incision was made, and the forehead at the hairline, subcutaneous dissection was performed and extended over the frontalis muscle for approximately 4 cm.  A subperiosteal dissection was performed after the fibers of the frontalis muscle were separated and subperiosteal dissection from the forehead lead the subperiosteal dissection from the upper eyelid.  The incision was made in the lower lid just beneath the lashline.  Subcutaneous dissection was performed over the pretarsal and preseptal muscle.  Dissection was then proceeded down to the inferior orbital rim.  The arcus marginalis was released and the lower eyelid fat was teased over the inferior orbital rim and sutured to the suborbicularis oculi fat and periosteum, which was separated from the inferior orbital rim.  The orbital fat was sutured to the suborbicularis oculi fat with multiple preplaced sutures of 5-0 Vicryl on a P2 needle.  The upper eyelid incision was closed with a running subcuticular 6-0 Prolene suture bilaterally.  The forehead was then elevated, and the nonhairbearing forehead skin was resected 1.5 cm wide raising the tail of the eyebrow.  The head of the eyebrow was felt to be elevated by the antagonistic frontalis muscle now that the accessory muscles specifically the corrugator and procerus and depressor supercilii were released and divided.,A lateral canthopexy was performed with 5-0 Prolene suture on a C1 double-arm tapered needle being passed from the lateral commissure of the eyelid to the small stab incision being passed to the medial superior orbital rim and sutured to tighten the lower lid.  The distal lateral resection of excessive lower eyelid skin was reduced at risk of eyelid malposition.  The lower lid incision was closed after the redundancy of skin measuring approximately 3 mm was resected on both sides.  Closure was performed with interrupted 6-0 silk suture for the lower lid.  The eyebrow hairline brow lift was closed with interrupted 4-0 PDS suture, deep subcutaneous tissue, and dermis, and the skin closed with a running 5-0 Prolene suture.,Attention then was directed to the cervical facial rhytidectomy and purse-string SMAS elevation with submental lipectomy.  Incisions were made in preauricular area, postauricular area, mastoid and occipital area.  Subcutaneous dissection was performed to the nasolabial fold and cheek and extending across the neck in the midline.  Submental lipectomy was performed through the incision in the submental crease.  Fat was directly removed from the fascia.,Hemostasis was achieved with electrocautery.  A SMAS elevation was performed with a purse-string suture of 2-0 PDS suture from temporalis fascia in front of the ear extending beneath the mandible and then brought back up to be sutured to the temporalis fascia.  This was performed bilaterally and symmetrically.  Hemostasis was achieved with electrocautery.  The cheek flap was brought back posteriorly and the cervical flap posteriorly and superiorly with redundant skin on the right massaged and closed.  The skin of the cheek and neck were resected which was redundant after the ***** posteriorly and superiorly in the neck and transversely in the cheek.,Closure was performed with interrupted 3-0 and 4-0 PDS suture of deep subcutaneous tissue and dermis of the skin was closed with a running 5-0 Prolene suture.  Drains were placed prior to final closure.  A 7-mm flat Jackson-Pratt was then secured with 3-0 silk suture.  Dressing consisting of fluffs and Kerlix and a 4-inch Ace were applied to support mildly compressive dressing.  Scleral eye protectors were removed.  Maxitrol eye ointment was placed followed by Swiss therapy eye pads.  The patient tolerated the procedure well, and she returned to recovery room in satisfactory condition with Foley catheter and Pneumatic compression stockings, TED hose, two Jackson-Pratt drains, and an IV.", Surgery,38
"PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,PROCEDURE:  ,After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A 2 cm infraumbilical midline incision was made.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp.  A 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident.  Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening.  Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg.,The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar.  A total of 3 other trocars were placed.  The first was a 10/11 mm trocar in the upper midline position.  The second was a 5 mm trocar placed in the anterior iliac spine.  The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars.  All of the trocars were placed without difficulty.,The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left.  The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder.  A laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of Calot were meticulously dissected free.,A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct proximally and distally.  The duct was divided between the clips.  The clips were carefully placed to avoid occluding the juncture with the common bile duct.  The cystic artery was found medially and slightly posterior to the cystic duct.  It was carefully dissected free from its surrounding tissues.  A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally.  The artery was divided between the clips.  The 2 midline port sites were injected with 5% Marcaine.,After the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula.  The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula.  As the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen.  The neck of the gallbladder was removed from the abdomen.  Following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,Both midline fascial defects were then approximated using 0 Vicryl suture.  All skin incisions were approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  Dressings were applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.", Gastroenterology,14
"HISTORY:, This is a digital EEG performed on a 75-year-old male with seizures.,BACKGROUND ACTIVITY:, The background activity consists of a 8 Hz to 9 Hz rhythm arising in the posterior head region. This rhythm is also accompanied by some beta activity which occurs infrequently. There are also muscle contractions occurring at 4 Hz to 5 Hz which suggests possible Parkinson's. Part of the EEG is obscured by the muscle contraction artifact. There are also left temporal sharps occurring infrequently during the tracing. At one point of time, there was some slowing occurring in the right frontal head region.,ACTIVATION PROCEDURES:, Photic stimulation was performed and did not show any significant abnormality.,SLEEP PATTERNS:, No sleep architecture was observed during this tracing.,IMPRESSION:, This awake/alert/drowsy EEG is abnormal due to the presence of slowing in the right frontal head region, due to the presence of sharps arising in the left temporal head region, and due to the tremors. The slowing can be consistent with underlying structural abnormalities, so a stroke, subdural hematoma, etc., should be ruled out. The tremor probably represents a Parkinson's tremor and the sharps arising in the left temporal head region can potentially give way to seizures or may also represent underlying structural abnormalities, so clinical correlation is recommended.", Sleep Medicine,36
"REVIEW OF SYSTEMS,GENERAL:  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY:  Negative rash, negative jaundice.,HEMATOPOIETIC:  Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC:  Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS:  Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  Negative postnasal drip, negative sore throat.,CARDIOVASCULAR:  Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL:  Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY:  Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.  **No history of OB/GYN problems.,MUSCULOSKELETAL:  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC:  See psychiatric evaluation.,ENDOCRINE:  No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.", Office Notes,25
"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.", Consult - History and Phy.,5
"Doctor's Address,Dear Doctor:,This letter serves as a reintroduction of my patient, A, who will be seeing you on Thursday, 06/12/2008.  As you know, he is an unfortunate gentleman who has reflex sympathetic dystrophy of both lower extremities.  His current symptoms are more severe on the right and he has had a persisting wound that has failed to heal on his right leg.  He has been through Wound Clinic to try to help heal this, but was intolerant of compression dressings and was unable to get satisfactory healing of this.  He has been seen by Dr. X for his pain management and was considered for the possibility of amputation being a therapeutic option to help reduce his pain.  He was seen by Dr. Y at Orthopedic Associates for review of this.  However, in my discussion with Dr. Z and his evaluation of Mr. A, it was felt that this may be an imprudent path to take given the lack of likelihood of reduction of his pain from his RST, his questionable healing of his wound given noninvasive studies that did reveal tenuous oxygenation of the right lower leg, and concerns of worsening of his RST symptoms on his left leg if he would have an amputation.  Based on the results of his transcutaneous oxygen levels and his dramatic improvement with oxygen therapy at this test, Dr. Z felt that a course of hyperbaric oxygen may be of utility to help in improving his wounds.  As you may or may not know we have certainly pursued aggressive significant measures to try to improve Mr. A's pain.  He has been to Cleveland Clinic for implantable stimulator, which was unsuccessful at dramatically improving his pain.  He currently is taking methadone up to eight tablets four times a day, morphine up to 100 mg three times a day, and Dilaudid two tablets by mouth every two hours to help reduce his pain.  He also is currently taking Neurontin 1600 mg three times a day, Effexor XR 250 mg once a day, Cytomel 25 mcg once a day, Seroquel 100 mg p.o. q. day, levothyroxine 300 mcg p.o. q. day, Prinivil 20 mg p.o. q. day, and Mevacor 40 mg p.o. q day.,I appreciate your assistance in determining if hyperbaric oxygen is a reasonable treatment course for this unfortunate situation.  Dr. Z and I have both tried to stress the fact that amputation may be an abrupt and irreversible treatment course that may not reach any significant conclusion.  He has been evaluated by Dr. X for rehab concerns to determine.  He agrees that a less aggressive form of therapy may be most appropriate.,I thank you kindly for your prompt evaluation of this kind gentleman in an unfortunate situation.  If you have any questions regarding his care please feel free to call me at my office.  Otherwise, I look forward to hearing back from you shortly after your evaluation.  Please feel free to call me if it is possible or if you have any questions about anything.", Letters,20
"PREOPERATIVE DIAGNOSIS:,  Left adnexal mass.,POSTOPERATIVE DIAGNOSIS:,  Left ovarian lesion.,PROCEDURE PERFORMED:  ,Laparoscopy with left salpingo-oophorectomy.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:,  None.,FINDINGS:,  The labia and perineum were within normal limits.  The hymen was found to be intact.  Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled.  There were a few calcifications on the surface of the mass.  The right ovary and fallopian tube appeared normal.  There was no evidence of endometriosis.  The uterus appeared normal in size.  There were no pelvic adhesions noted.,INDICATIONS: , The patient is a 55-year-old gravida 0, para 0 Caucasian female who presents with a left adnexal mass on ultrasound which is 5.3 cm.  She does complain of minimal discomfort.  Bimanual exam was not able to be performed secondary to the vaginal stenosis and completely intact hymen.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the Operative Suite, prepped and draped, and placed in the dorsal lithotomy position.  A 1 cm skin incision was made in the infraumbilical vault.  While tenting up the abdominal wall, the Veress needle was inserted without difficulty and the abdomen was insufflated.  This was done using appropriate flow and volume of CO2.  The #11 step trocar was then placed without difficulty.  The above findings were confirmed.  A #12 mm port was then placed approximately 2 cm above the pubic symphysis under direct visualization.  Two additional ports were placed, one on the left lateral aspect of the abdominal wall and one on the right lateral aspect of the abdominal wall.  Both #12 step ports were done under direct visualization.  Using a grasper, the mass was tented up at the inferior pelvic ligament and the LigaSure was placed across this and several bites were taken with good visualization while ligating.  The left ovary was then placed in an Endocatch bag and removed through the suprapubic incision.  The skin was extended around this incision and the fascia was extended using the Mayo scissors.  The specimen was removed intact in the Endocatch bag through this site.  Prior to desufflation of the abdomen, the site where the left adnexa was removed was visualized to be hemostatic.  All the port sites were hemostatic as well.  The fascia of the suprapubic incision was then repaired using a running #0 Vicryl stitch on a UR6 needle.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  The remaining incisions were also closed with #4-0 undyed Vicryl in a running fashion after all instruments were removed and the abdomen was completely desufflated.  Steri-Strips were placed on each of the incisions.  The patient tolerated the procedure well.  Sponge, lap, and needle count were x2.  She will go home on Vicodin for pain and followup postoperatively in the office where we will review path report with her.", Surgery,38
"DOBUTAMINE STRESS ECHOCARDIOGRAM,REASON FOR EXAM: , Chest discomfort, evaluation for coronary artery disease.,PROCEDURE IN DETAIL: , The patient was brought to the cardiac center.  Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute.  The patient maximized at 30 mcg/kg per minute.  Images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145.  Maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.,Wall motion assessed at all levels as well as at recovery.,The patient got nauseated, had some mild shortness of breath.  No angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.,The resting heart rate was 78 with the resting blood pressure 186/98.  Heart rate reduced by the vasodilator effects of dobutamine to 130/80.  Maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.,The EKG at rest showed sinus rhythm with no ST-T wave depression suggestive of ischemia or injury.  Incomplete right bundle-branch block was seen.  The maximal stress test EKG showed sinus tachycardia.  There was subtle upsloping ST depression in III and aVF, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no ST elevation seen.,No ventricular tachycardia or ventricular ectopy seen during the test.  The heart rate recovered in a normal fashion after using metoprolol 5 mg.,The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.,The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose.  All walls mentioned were augmented in a normal fashion.  At maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation.  EF improved to about 70%.,The wall motion score was unchanged.,IMPRESSION:,1.  Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.,2.  Negative EKG criteria for ischemia.,3.  Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view.  This is considered the negative dobutamine stress echocardiogram test, medical management.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS:  ,Left hemothorax, rule out empyema.,POSTOPERATIVE DIAGNOSIS: , Left hemothorax rule out empyema.,PROCEDURE: , Insertion of a 12-French pigtail catheter in the left pleural space.,PROCEDURE DETAIL:  ,After obtaining informed consent, the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion.  Xylocaine 1% was injected and then a 12-French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space.  It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR.  Samples were sent for culture and sensitivity, aerobic and anaerobic.,The patient and I decided to admit him for a period of observation at least overnight.,He tolerated the procedure well and the postprocedure chest x-ray showed no complications.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1.  Lumbar discogram L2-3.,2.  Lumbar discogram L3-4.,3.  Lumbar discogram L4-5.,4.  Lumbar discogram L5-S1.,ANESTHESIA:  ,IV sedation.,PROCEDURE IN DETAIL:  ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table.  The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained.  We then proceeded to prepare the low back with a Betadine solution and draped sterile.  Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space.  A metallic marker was then placed laterally and a needle entrance point was determined.  A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections.  A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus.  We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.", Radiology,33
"TITLE OF OPERATION: , Right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage.,INDICATION FOR SURGERY: , The patient is very well known to our service.  In brief, the patient is status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor.  He was taken to the operating room for the orbitozygomatic approach.  Intraoperatively, everything went well without any complications.  The brain at the end of the procedure was absolutely intact, but the patient developed a seizure in the Intensive Care Unit and then was taken to the CT scan, developed a second seizure.  He was given Ativan for this, and then began to identify a large component measuring about 3 x 3 cm of the right frontal lobe, what appeared to be a hemorrhagic conversion of potential venous infarct.  I had a long discussion immediately with Dr. X and Dr. Y.  We decided to take the patient immediately as a level 1 for evacuation of this hematoma with a small amount of a midline shift with an intraventricular component.  It worried me and I think that we needed to go ahead and take him to the operating room immediately.  The patient was taken as a level 1 immediately and emergently and into the operating room for this procedure.  The original plan was to do first a right-sided orbitozygomatic procedure and then stage it a few weeks later with an endonasal endoscopic procedure for resection of this pituitary tumor component.  He was taken to the operating room for evacuation of a right frontal intraparenchymal hematoma.,PREOP DIAGNOSIS:,  Pituitary tumor with a large intracranial component, status post resection and now development of an intracranial hemorrhage.,POSTOP DIAGNOSIS:,  Intracranial hemorrhage in the right frontal lobe with extension into the intraventricular space after resection of a pituitary tumor via orbitozygomatic approach.,ANESTHESIA: , General.,PROCEDURE IN DETAIL: , The patient was taken to the operating room.  In the supine position, his head was put in a horseshoe without any complications.  The patient tolerated this very well, and the prior incision was immediately opened.  The surgery had taken place a few hours prior to this, the original orbitozygomatic approach.  At this point, this was a life-saving procedure.  We went ahead, opened the old incision after everything was sterilely prepped, and all the surgical instrumentation was brought into place.  We went ahead and opened the incision and took out the pterional bone flap without any complications.  We immediately opened the dura expeditiously, and the brain was moderately under some pressure, but not really bulging out.  So I went ahead and identified an area over the right frontal lobe that was a little bit consistent with a hemorrhagic infarct and nonviable tissue.  So we went ahead and did a corticectomy right there and identified the actual clot immediately and went ahead, and over the next few hours, very meticulously began to evacuate these clots without any complication whatsoever.  We went all the way down to the ventricle and identified this clot in the ventricle and went ahead and removed this clot without any complications, and we had a very nice resection.  The brain was very relaxed.  We had a very good resection of the actual blood clot, and the brain was very relaxed.  We irrigated thoroughly.  We identified the ventricles.  We went ahead and did a very careful hemostasis with Avitene with thrombin and Gelfoam with thrombin over the next times in doing the procedure.  All this was done very well, and then we lined the cavity with Surgicel, and the Surgicel was only put at the edge and draping down as to not to leave any fragments potentially to communicate with the actual ventricle, and then after this, everything was good.  We went ahead and closed back the actual dura back.  We had done a pericranial flap.  This was also put back in place and the dura was closed with 4-0 Surgilons.  We reconstructed everything.  The frontal sinus was reconstructed thoroughly without any complications.  We went ahead and put once again a watertight closure and went ahead and put another piece of DuraGen with Hemaseel in place, and went ahead and put the bone flap back and reconstructed very nicely once again with self-tapping, self-drilling screws, low-profile plates.  Once everything was confirmed to be in place, we went ahead and closed the muscle flap and also the actual fat pad was put back into place and closed together with 0 pop-offs, and the skin with staples without any complications.  In summary, the procedure was going back to the operating room for evacuation of a right-sided intracranial hemorrhage, most likely a conversion of an intraparenchymal hematoma with extension into the ventricle without any complications.  So everything was stable.  Estimated blood loss was about 100 cubic centimeters.  The sponges and needle counts were correct.  No specimens were sent to pathology.,DISPOSITION: , The patient after this procedure was brought to the Neuro Intensive Care Unit for close observation.", Surgery,38
"Pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete, and then as she began to push, there were additional decelerations of the baby's heart rate, which were suspicions of cord around the neck.  These were variable decelerations occurring late in the contraction phase.  The baby was in a +2 at a 3 station in an occiput anterior position, and so a low-forceps delivery was performed with Tucker forceps using gentle traction, and the baby was delivered with a single maternal pushing effort with retraction by the forceps.  The baby was a little bit depressed at birth because of the cord around the neck, and the cord had to be cut before the baby was delivered because of the tension, but she responded quickly to stimulus and was given an Apgar of 8 at 1 minute and 9 at 5 minutes.  The female infant seemed to weigh about 7.5 pounds, but has not been officially weighed yet.  Cord gases were sent and the placenta was sent to Pathology.  The cervix, the placenta, and the rectum all seemed to be intact.  The second-degree episiotomy was repaired with 2-O and 3-0 Vicryl.  Blood loss was about 400 mL.,Because of the hole in the dura, plan is to keep the patient horizontal through the day and a Foley catheter is left in place.  She is continuing to be attended to by the anesthesiologist who will manage the epidural catheter.  The baby's father was present for the delivery, as was one of the patient's sisters.  All are relieved and pleased with the good outcome.", Obstetrics / Gynecology,24
"S - ,An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,O - ,On examination, the lateral aspect of her left great toenail is deeply ingrown.  Her toenails are thick and opaque.  Vibratory sensation appears to be intact.  Dorsal pedal pulses are 1/4.  There is no hair growth seen on her toes, feet or lower legs.  Her feet are warm to the touch.  All of her toenails are hypertrophic, opaque, elongated and discolored.,A - ,1.  Onychocryptosis.,", SOAP / Chart / Progress Notes,35
"PREOPERATIVE DIAGNOSIS:,  Ovarian cyst, persistent.,POSTOPERATIVE DIAGNOSIS: , Ovarian cyst.,ANESTHESIA:,  General,NAME OF OPERATION:,  Diagnostic laparoscopy and drainage of cyst.,PROCEDURE:,  The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced.  An infraumbilical incision was made, and Veress needle placed without difficulty.  Gas was entered into the abdomen at two liters.  The laparoscope was entered, and the abdomen was visualized.  The second puncture site was made, and the second trocar placed without difficulty.  The cyst was noted on the left, a 3-cm, ovarian cyst.  This was needled, and a hole cut in it with the scissors.  Hemostasis was intact.  Instruments were removed.  The patient was awakened and taken to the recovery room in good condition.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,POSTOPERATIVE DIAGNOSIS: , Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,SURGICAL PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA: , General endotracheal technique.,SURGICAL FINDINGS:  ,A 4+/4+ cryptic and hypertrophic tonsils with 2+/3+ hypertrophic adenoid pads.,INDICATIONS: , We were requested to evaluate the patient for complaints of enlarged tonsils, which cause difficulty swallowing, recurrent pharyngitis, and sleep-induced respiratory disturbance.  She was evaluated and scheduled for an elective procedure.,DESCRIPTION OF SURGERY:  ,The patient was brought to the operative suite and placed supine on the operating room table.  General anesthetic was administered.  Once appropriate anesthetic findings were achieved, the patient was intubated and prepped and draped in the usual sterile manner for a tonsillectomy.  He was placed in semi-Rose ___ position and a Crowe Davis-type mouth gag was introduced into the oropharynx.  Under an operating headlight, the oropharynx was clearly visualized.  The right tonsil was grasped with the fossa triangularis and using electrocautery enucleation technique, was removed from its fossa.  This followed placing the patient in a suspension position using a McIvor-type mouth gag and a red rubber Robinson catheter via the right naris.  Once the right tonsil was removed, the left tonsil was removed in a similar manner, once again using a needle point Bovie dissection at 20 watts.  With the tonsils removed, it was possible to visualize the adenoid pads.  The oropharynx was irrigated and the adenoid pad evaluated with an indirect mirror technique.  The adenoid pad was greater than 2+/4 and hypertrophic.  It was removed with successive passes of electrocautery suction.  The tonsillar fossa was then once again hemostased with suction cautery, injected with 0.5% ropivacaine with 1:100,000 adrenal solution and then closed with 2-0 Monocryl on an SH needle.  The redundant soft tissue of the uvula was removed posteriorly and cauterized with electrocautery to prevent swelling of the uvula in the postoperative period.  The patient's oropharynx and nasopharynx were irrigated with copious amounts of normal saline contained with small amount of iodine, and she was recovered from her general endotracheal anesthetic.  She was extubated and left the operating room in good condition to the postoperative recovery room area.,Estimated blood loss was minimal.  There were no complications.  Specimens produced were right and left tonsils.  The adenoid pad was ablated with electrocautery.", ENT - Otolaryngology,11
"HYPERFRACTIONATION,This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy.  The radiotherapy will be given in a hyperfractionated fraction (decreased dose per fraction but 2 fractions delivered daily separated by a period of at least 6 hours).  The rationale for this treatment is based on radiobiologic principles that make this type of therapy more effective in rapidly growing, previously irradiated or poorly oxygenated tumors.  The dose per fraction and the total dose are calculated by me, and this is individualized for each patient according to radiobiologic principles.,During the hyperfractionated radiotherapy, the chance of severe acute side effects is increased, so the patient will be followed more intensively for the development of any side effects and treatment instituted accordingly.", Radiology,33
"S -, An 84-year-old diabetic female, 5'7-1/2"" tall, 148 pounds, history of hypertension and diabetes.  She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot.  She also has a left great toenail that is giving her problems as well.,O - ,Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1.1 cm in diameter.  There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1.1 cm in diameter.  These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening.  The first and fifth metatarsal heads are plantarflexed.  Vibratory sensation appears to be absent.  Dorsal pedal pulses are nonpalpable.  Varicose veins are visible to the skin on the patient's feet that are very thin, almost transparent.  The medial aspect of the left great toenail has dried blood under the nail.  The nail itself is very opaque, loose from the nailbed almost rotten, opaque, discolored, hypertrophic.  All of the patient's toenails are elongated and discolored and opaque as well.  There is dried blood under the medial aspect of the left great toenail.,A - ,1.  Painful feet.,", Podiatry,31
, Surgery,38
"PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1.  Bilateral facet Arthrogram at L34, L45, L5S1.,2.  Bilateral facet injections at L34, L45, L5S1.,3.  Interpretation of radiograph.,ANESTHESIA:  ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS:  ,None.,INDICATION: , Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,SUMMARY OF PROCEDURE: , The patient was admitted to the OR, consent was obtained and signed.  The patient was taken to the Operating room and was placed in the prone position.  Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring.  Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, EKG, respiration and heart rate and at intervals of three minutes for blood pressure.  After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels.,The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view.  A skin wheal was placed with 1% Lidocaine at the L34 facet region on the left.  Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side.  This was performed using the oblique view under fluoroscopy to the enable the view of the ""Scotty Dog,"" After obtaining the ""Scotty Dog"" view the joints were easily seen.  Negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow.  After negative aspiration was verified, 1/8th of a cc of Omnipaque 240 dye was then injected.  Negative aspiration was again performed and 1/2 cc of solution (Solution consisting of 9 cc of 0.5% Marcaine with 1 cc of Triamcinolone) was then injected into the joint.  The needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint.  The 22-gauge needle was then removed.  Pressure was place over the puncture site for approximately one minute.  This exact same procedure was then repeated along the left-sided facets at L45, and L5S1.  This exact same procedure was then repeated on the right side.  At each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,The patient was noted to have tolerated the procedure well without any complications.,Interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, L34, L45, and L5S1.  Visualizing the ""Scotty Dog"" technique under fluoroscopy facilitated this.  Dye spread into each joint space is visualized.  No venous or arterial run-off is noted.  No epidural run-off is noted.  The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis.", Pain Management,28
"TITLE OF OPERATION: , Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.,PREOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,POSTOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,ANESTHESIA:,  Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,ESTIMATED BLOOD LOSS:,  Less than 10 mL.,HEMOSTASIS:,  Right ankle tourniquet set at 250 mmHg for 35 minutes.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, and two partially threaded cannulated screws from 3.0 OsteoMed System for internal fixation.,INJECTABLES:  ,Ancef 1 g IV 30 minutes preoperatively.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical site.  The right ankle was then covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set at 250 mmHg.  The right ankle tourniquet was then inflated.  The right foot was prepped, scrubbed, and draped in normal sterile technique.  Attention was then directed on the dorsal aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed just parallel and medial to the course of the extensor hallucis longus to the right great toe.  The incision was deepened through the subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, all the capsular and periosteal attachments were mobilized from the base of the proximal phalanx of the right great toe and head of the first right metatarsal.  Once the base of the proximal phalanx of the right great toe and the first right metatarsal head were adequately exposed, multiple osteophytes were encountered.  Gouty tophi were encountered both intraarticularly and periarticularly for the first right metatarsophalangeal joint, which were consistent with a medical history that is positive for gout for this patient.,Using sharp and dull dissection, all the ligamentous and soft tissue attachments were mobilized and the right first metatarsophalangeal joint was freed from all adhesions.  Using the sagittal saw, all the osteophytes were removed from the dorsal, medial, and lateral aspect of the first right metatarsal head as well as the dorsal, medial, and lateral aspect of the base of the proximal phalanx of the right great toe.  Although some improvement of the range of motion was encountered after the removal of the osteophytes, some tightness and restriction was still present.  The decision was thus made to perform a Youngswick-type osteotomy on the head of the first right metatarsal.  The osteotomy consistent of two dorsal cuts and a plantar cut in a V-pattern with the apex of the osteotomy distal and the base of the osteotomy proximal.  The two dorsal cuts were longer than the plantar cut in order to accommodate for the future internal fixation.  The wedge of bone that was formed between the two dorsal cuts was resected and passed off to Pathology for further examination.  The head of the first right metatarsal was then impacted on the shaft of the first right metatarsal and provisionally stabilized with two wires from the OsteoMed System.  The wires were inserted from a dorsal distal to plantar proximal direction through the dorsal osteotomy.  The wires were also used as guidewires for the insertion of two 16-mm proximally threaded cannulated screws from the OsteoMed System.  The 2 screws were inserted using AO technique.  Upon insertion of the screws, the two wires were removed.  Fixation of the osteotomy on the table was found to be excellent.  The area was copiously flushed with saline and range of motion was reevaluated and was found to be much improved from the preoperative levels without any significant restriction.  The cartilaginous surfaces on the base of the first right metatarsal and the base of the proximal phalanx were also fenestrated in order to induce some cartilaginous formation.  The capsule and periosteal tissues were then reapproximated with 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues.  Steri-Strips were used to approximate and reinforce the skin edges.  At this time, the right ankle tourniquet was deflated.  Immediate hyperemia was noted in the entire right lower extremity upon deflation of the cuff.  The patient's surgical site was then covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's right foot was placed in a surgical shoe and the patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and neurovascular status at appropriate levels.  The patient was given instructions and education on how to continue caring for her right foot surgery at home.  The patient was also given pain medication instructions on how to control her postoperative pain.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.", Surgery,38
"HISTORY:,  The patient is 14 months old, comes in with a chief complaint of difficulty breathing.  Difficulty breathing began last night.  He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home.  They were home for about an hour when he began to get worse and they drove here to Children's Hospital.  He has a history of reactive airway disease.  He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing.  He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time.  He has been on albuterol off and on over that period.  He has had fever overnight.  No vomiting, no diarrhea.  Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department.  Normal urine output.  No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above.  No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:,  Up-to-date.,BIRTH HISTORY:,  The child was full term, no complications, home with mom.  No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home.  No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL:  The child is awake, alert, in moderate respiratory distress.,HEENT:  Pupils equal, round, reactive to light.  Extraocular movements are intact.  The TMs are clear.  The nares show some dry secretions.  Audible congestion and wheezing is noted.  Mucous membranes are dry.  Throat is clear.  No oral lesions noted.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Show inspiratory and expiratory wheezes in all fields.  Audible wheezes are noted.  There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART:  Shows tachycardia.  Regular rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding.  No rebound.  No hepatosplenomegaly.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed.  I felt the child was dehydrated on examination.  We gave 20 mL/kg bolus of normal saline over one hour.  The child was given Solu-Medrol 2 mg/kg IV.  He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally.  Normal heart size.  No evidence of pneumothorax.  No evidence of focal pneumonia.  After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time.  The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour.  The child's pulse ox on breathing treatments with 100% oxygen was 100%.  Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea.  The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time.  After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout.  After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia.  The child has a normal level of alertness; however, has not had any vomiting here.  I spoke with Dr. X, on call for hospitalist service.  She has come down and evaluated the patient.  We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family.  The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES:  ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT:  ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION:  ,Status asthmaticus, hypoxia.,PLAN:  ,Admitted to Pediatrics.", Pediatrics - Neonatal,29
"ADMISSION DIAGNOSES:,1.  Seizure.,2.  Hypoglycemia.,3.  Anemia.,4.  Hypotension.,5.  Dyspnea.,6.  Edema.,DISCHARGE DIAGNOSES:,1.  Colon cancer, status post right hemicolectomy.,2.  Anemia.,3.  Hospital-acquired pneumonia.,4.  Hypertension.,5.  Congestive heart failure.,6.  Seizure disorder.,PROCEDURES PERFORMED:,1.  Colonoscopy.,2.  Right hemicolectomy.,HOSPITAL COURSE: , The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD, bipolar disorder, and anemia.  She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia.  Regarding the seizure disorder, Neurology was consulted.  Noncontrast CT of the head was negative.  Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d.  Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour.  Her insulin pump had a basal rate of roughly three at night during the feedings.  While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times.  She seemed to tolerate the insulin pump rate well throughout her hospital course.  There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course.,At discharge, her endocrinologist was contacted.  It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m., from 0.8 units per hour from 6 a.m. until 8 a.m., and then at 0.2 units per hour from 8 a.m. until 6 p.m.  The insulin was to be NovoLog.  Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools.  A colonoscopy was performed, which found a mass at the right hepatic flexure.  General Surgery was then consulted and a right hemicolectomy was performed on the patient.  The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour.  Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer.  CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis.  Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia.  She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well.  Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness.  The patient was seen by the Infectious Disease specialist.  The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site.  At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours.  The Bactrim was used to cover the MRSA at the J-tube site.  It was found that MRSA was sensitive to Bactrim.  Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable.  She also received Lipitor for her high cholesterol.  Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night.  The dosage increases can begin on an outpatient basis.,DISCHARGE INSTRUCTIONS/MEDICATIONS: , The patient was discharged to home.  She was told to shy away from strenuous activity.  Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night.  The discharge medications were as follows:,1.  Coreg 12.5 mg p.o. b.i.d.,2.  Lipitor 10 mg p.o. at bedtime.,3.  Nitro-Dur patch 0.3 mg per hour one patch daily.,4.  Phenergan syrup 6.25 mg p.o. q.4h. p.r.n.,5.  Synthroid 0.175 mg p.o. daily.,6.  Zyrtec 10 mg p.o. daily.,7.  Lamictal 100 mg p.o. daily.,8.  Lamictal 150 mg p.o. at bedtime.,9.  Ferrous sulfate drops 325 mg, PEG tube b.i.d.,10.  Nexium 40 mg p.o. at breakfast.,11.  Neurontin 400 mg p.o. t.i.d.,12.  Lasix 40 mg p.o. b.i.d.,13.  Fentanyl 50 mcg patch transdermal q.72h.,14.  Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d.,15.  Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days.,16.  Levaquin 750 mg one tablet p.o. x3 days.,The medications listed above, one listed as p.o. are to be administered via the J-tube.,FOLLOWUP:  ,The patient was instructed to see Dr. X in approximately five to seven days.  She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X.  She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer.  She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes.  We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment.  She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.,CONDITION ON DISCHARGE: , Stable.", General Medicine,15
"PREOPERATIVE DIAGNOSIS:,  Dural tear, postoperative laminectomy, L4-L5.,POSTOPERATIVE DIAGNOSES,1.  Dural tear, postoperative laminectomy, L4-L5.,2.  Laterolisthesis, L4-L5.,3.  Spinal instability, L4-L5.,OPERATIONS PERFORMED,1.  Complete laminectomy, L4.,2.  Complete laminectomy plus facetectomy, L3-L4 level.,3.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.,4.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.,5.  Posterior spinal fusion, L4 to S1.,6.  Insertion of morselized autograft, L4 to S1.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,DRAINS:  ,Hemovac x1.,DISPOSITION: , Vital signs stable, taken to the recovery room in a satisfactory condition, extubated.,INDICATIONS FOR OPERATION: , The patient is a 48-year-old gentleman who has had a prior decompression several weeks ago.  He presented several days later with headaches as well as a draining wound.  He was subsequently taken back for a dural repair.  For the last 10 to 11 days, he has been okay except for the last two days he has had increasing headaches, has nausea, vomiting, as well as positional migraines.  He has fullness in the back of his wound.  The patient's risks and benefits have been conferred him due to the fact that he does have persistent spinal leak.  The patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively.,PROCEDURE IN DETAIL:,  After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #7.  The patient was placed in the usual supine position and intubated under general anesthesia without any difficulties.  The patient was given intraoperative antibiotics.  The patient was rolled onto the OSI table in usual prone position and prepped and draped in usual sterile fashion.,Initially, a midline incision was made from the cephalad to caudad level.  Full-thickness skin flaps were developed.  It was seen immediately that there was large amount of copious fluid emanating from the wound, clear-like fluid, which was the cerebrospinal fluid.  Cultures were taken, aerobic, anaerobic, AFB, fungal.  Once this was done, the paraspinal muscles were affected from the posterior elements.  It was seen that there were no facet complexes on the right side at L4-L5 and L5-S1.  It was seen that the spine was listhesed at L5 and that the dural sac was pinched at the L4-5 level from the listhesis.  Once this was done; however, the fluid emanating from the dura could not be seen appropriately.  Complete laminectomy at L4 was performed as well extending the L5 laminectomy more to the left.  Complete laminectomy at L3 was done.  Once this was done within the subarticular recess on the right side at the L4 pedicle level, a rent in the dura was seen.  Once this was appropriately cleaned, the dural edges were approximated using a running 6-0 Prolene suture.  A Valsalva confirmed no significant lead after the repair was made.  There was a significant laterolisthesis at L4-L5 and due to the fact that there were no facet complexes at L5-S1 and L4-L5 on the right side as well as there was a significant concavity on the right L4-L5 disk space which was demonstrated from intraoperative x-rays and compared to preoperative x-rays, it was decided from an instrumentation.  The lateral pedicle screws were placed at L4, L5, and S1 using the standard technique of Magerl.  After this the standard starting point was made.  Trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall.  Once this was done, this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall.  The screws were subsequently placed.  Tricortical purchase was obtained at S1 ________ appropriate size screws.  Precontoured titanium rod was then appropriately planned and placed between the screws at L4, L5, and S1.  This was done on the right side first.  The screw was torqued at S1 appropriately and subsequently at L5.  Minimal compression was then placed between L5 and L4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at L4.  Neutral compression distraction was obtained on the left side.  Screws were torqued at L4, L5, and S1 appropriately.  Good placement was seen both in AP and lateral planes using fluoroscopy.  Laterolisthesis corrected appropriately at L4 and L5.,Posterior spinal fusion was completed by decorticating the posterior elements at L4-L5 and the sacral ala with a curette.  Once good bleeding subchondral bone was appreciated, the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix.  This was placed in the posterior lateral gutters.  DuraGen was then placed over the dural repair, and after this, fibrin glue was placed appropriately.  Deep retractors then removed from the confines of the wound.  Fascia was closed using interrupted Prolene running suture #1.  Once this was done, suprafascial drain was placed appropriately.  Subcutaneous tissues were opposed using a 2-0 Prolene suture.  The dermal edges were approximated using staples.  Wound was dressed sterilely using bacitracin ointment, Xeroform, 4 x 4's, and tape.  The drain was connected appropriately.  The patient was rolled on stretcher in usual supine position, extubated uneventfully, and taken back to the recovery room in a satisfactory stable condition.  No complications arose.", Orthopedic,27
"SUBJECTIVE:,  This is a 1-month-old who comes in for a healthy checkup.  Mom says things are gone very well.  He is kind of acting like he has got a little bit of sore throat but no fevers.  He is still eating well.  He is up to 4 ounces every feeding.  He has not been spitting up.  Voiding and stooling well.,PAST MEDICAL HISTORY:,  Reviewed, very healthy.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,DIETARY: , His formula fed on Enfamil Lipil.  Voiding and stooling well.  Growth chart reviewed with Mom.,DEVELOPMENTAL:,  He is starting to track with his eyes.  He is smiling a little bit, moving hands and feet symmetrically.,PHYSICAL EXAMINATION:,  In general well-developed, well-nourished male in no acute distress.,DERMATOLOGIC:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Anterior fontanel soft and flat.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes present bilaterally.  Does appear to have conjugate gaze.  Ears:  Tympanic membranes are pink to gray, translucent, neutral position, normal light reflex and mobility.  Nares are patent, pink mucosa, moist.  Oropharynx clear with pink mucosa, normal moisture.,NECK:  Supple without masses.,CHEST:  Clear to auscultation and percussion with easy respirations and no accessory muscle use.,CARDIOVASCULAR:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,ABDOMEN:  Soft, nontender, nondistended without hepatosplenomegaly.,GU EXAM:  Normal Tanner I male.  Testes descended bilaterally.  No hernias noted.,EXTREMITIES:  Pink and warm.  Moving all extremities well.  No subluxation of the hips and leg creases appear symmetric.,NEUROLOGIC:  Alert, otherwise nonfocal.  2+ deep tendon reflexes at the knees.  Fixes and follows appropriately to both voice and face.,ASSESSMENT:,  Well child check.,PLAN:,1.  Diet, growth and safety discussed.,2.  Immunizations discussed and updated with hepatitis B.,3.  Return to clinic at two months of age.  Call if problems.", Consult - History and Phy.,5
"CHIEF COMPLAINT:, Headaches.,HEADACHE HISTORY:, The patient describes the gradual onset of a headache problem. The headache first began 2 months ago. The headaches are located behind both eyes. The pain is characterized as a sensation of pressure. The intensity is moderately severe, making normal activities difficult. Associated symptoms include sinus congestion and photophobia. The headache may be brought on by stress, lack of sleep and alcohol. The patient denies vomiting and jaw pain.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, ,No significant past surgical history.,FAMILY MEDICAL HISTORY:, ,There is a history of migraine in the family. The condition affects the patient’s brother and maternal grandfather.,ALLERGIES:, Codeine.,CURRENT MEDICATIONS:, See chart.,PERSONAL/SOCIAL HISTORY:, Marital status: Married. The patient smokes 1 pack of cigarettes per day.  Denies use of alcohol.,NEUROLOGIC DRUG HISTORY:, The patient has had no help with the headaches from over-the-counter analgesics.,REVIEW OF SYSTEMS:,ROS General: Generally healthy. Weight is stable.,ROS Head and Eyes: Patient has complaints of headaches. Vision can best be described as normal.,ROS Ears Nose and Throat: The patient notes some sinus congestion.,ROS Cardiovascular: The patient has no history of any cardiovascular problems and denies any present problems.,ROS Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,ROS Musculoskeletal: No muscle cramps, no joint back or limb pain. The patient denies any past or present problem related to the musculoskeletal system.,EXAM:,Exam General Appearance: The patient was alert and cooperative, and did not appear acutely or chronically ill.,Sex and Race: Male, Caucasian.,Exam Mental Status: Serial 7’s were performed normally. The patient was oriented with regard to time, place and situation.,Three out of three objects were readily recalled after several minutes. The patient correctly identified the president and past president. The patient could repeat 7 digits forward and 4 digits reversed without difficulty. The patient’s affect and emotional response was normal and appropriate. The patient related the clinical history in a coherent, organized fashion.,Exam Cranial Nerves: Sense of smell was intact.,Exam Neck: Neck range of motion was normal in all directions. There was no evidence of cervical muscle spasm.  No radicular symptoms were elicited by neck motions. Shoulder range of motion was normal bilaterally. There were no areas of tenderness. Tests of neurovascular compression were negative. There were no carotid bruits.,Exam Back: Back range of motion was normal in all directions.,Exam Sensory: Position and vibratory sense was normal.,Exam Reflexes: Active and symmetrical. There were no pathological reflexes.,Exam Coordination: The patient’s gait had no abnormal components. Tandem gait was performed normally.,Exam Musculoskeletal: Peripheral pulses palpably normal. There is no edema or significant varicosities.  No lesions identified.,IMPRESSION DIAGNOSIS: ,Migraine without aura (346.91),COMMENTS:, The patient has evolved into a chronic progressive course. Medications Prescribed: Therapeutic trial of Inderal 40mg - 1/2 tab b.i.d. x 1 week, then 1 tab. b.i.d. x 1 week then 1 tab t.i.d.,OTHER TREATMENT:, The patient was given a thorough explanation of the role of stress in migraine, and given a number of suggestions about implementing appropriate changes in lifestyle.,RATIONALE FOR TREATMENT PLAN:, The treatment plan chosen is the most effective and should result in the most beneficial outcome for the patient. There are no reasonable alternatives.,FOLLOW UP INSTRUCTIONS:", Neurology,22
"HISTORY OF PRESENT ILLNESS: , The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer.  She returns for a routine surveillance visit.,She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the left kidney.  She underwent barium swallow, which demonstrates a small sliding hiatal hernia with minimal reflux.  She has a minimal delayed emptying secondary tertiary contractions.  PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates.  Review of systems, the patient continues to have periodic odynophagia and mid thoracic dysphagia.  This most likely is secondary to tertiary contractions with some delayed emptying.  She has also had increased size of the left calf without tenderness, which has not resolved over the past several months.  She has had a previous DVT in 1975 and 1985.  She denies weight loss, anorexia, fevers, chills, headaches, new aches or pains, cough, hemoptysis, shortness of breath at rest, or dyspnea on exertion.,MEDICATIONS: , Aspirin 81 mg p.o. q.d., Spiriva 10 mcg q.d., and albuterol p.r.n.,PHYSICAL EXAMINATION: , BP:  117/78.  RR:  18.  P:  93.,WT:  186 lbs.  RAS:  100%.,HEENT:  Mucous membranes are moist.  No cervical or supraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIAC:  Regular rate and rhythm without murmurs.,EXTREMITIES:  No cyanosis, clubbing or edema.,NEURO:  Alert and oriented x3.  Cranial nerves II through XII intact.,ASSESSMENT: , The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.,PLAN:  ,She is to return to clinic in six months with a chest CT.  She was given a prescription for an ultrasound of the left lower extremity to rule out DVT.  She will be called with the results.  She was given a prescription for nifedipine 10 mg p.o. t.i.d. p.r.n. esophageal spasm.", SOAP / Chart / Progress Notes,35
"PROCEDURE PERFORMED:,  PICC line insertion.,DESCRIPTION OF PROCEDURE:,  The patient was identified by myself on presentation to the angiography suite.  His right arm was prepped and draped in sterile fashion from the antecubital fossa up.  Under ultrasound guidance, a #21-gauge needle was placed into his right cephalic vein.  A guidewire was then threaded through the vein and advanced without difficulty.  An introducer was then placed over the guidewire.  We attempted to manipulate the guidewire to the superior vena cava; however, we could not pass the point of the subclavian vein and we tried several maneuvers and then opted to do a venogram.  What we did was we injected approximately 4 mL of Visipaque 320 contrast material through the introducer and did a mapping venogram and it turned out that the cephalic vein was joining into the subclavian vein.  It was very tortuous area.  We made several more attempts using the mapping system to pass the glide over that area, but we were unable to do that.  Decision was made at that point then to just do a midline catheter.  The catheter was cut to 20 cm, then we inserted back to the introducer.  The introducer was removed.  The catheter was secured by two #3-0 silk sutures.  Appropriate imaging was then taken.  Sterile dressing was applied.  The patient tolerated the procedure nicely and was discharged from Angiography in satisfactory condition back to the general floor.  We may make another attempt in the near future using a different approach.,", Cardiovascular / Pulmonary,3
"PROCEDURE:  ,Trigger thumb release.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual sterile fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A transverse incision was made over the MPJ crease of the thumb.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The flexor sheath was opened under direct vision with a scalpel, and then a scissor was used to release the A1 pulley under direct vision on the radial side, from its proximal extent to its distal extent at the junction of the proximal and middle thirds of the proximal phalanx.  Meticulous hemostasis was maintained with bipolar electrocautery.,The flexor pollicis longus tendon was identified and atraumatically pulled to ensure that no triggering remained.  The patient then actively moved the thumb and no triggering was noted.,After irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,The wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.", Orthopedic,27
"She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and diabetic neuropathy.  She was referred to Dr. XYZ and will be seeing him on August 8, 2006.,She was also never referred to the endocrine clinic to deal with her poor diabetes control.  Her last hemoglobin A1c was 10.,PAST MEDICAL HISTORY:,  Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy.,MEDICATIONS: , Glyburide, Avandia, metformin, lisinopril, Lipitor, aspirin, metoprolol and Zonegran.,PHYSICAL EXAMINATION:,  Blood pressure was 140/70, heart rate was 76, respiratory rate was 18, and weight was 226 pounds.  On general exam she has an area of tenderness on palpation in the left parietal region of her scalp.  Neurological exam is detailed on our H&P form.  Her neurological exam is within normal limits.,IMPRESSION AND PLAN:,  For her headaches we are going to titrate Zonegran up to 200 mg q.h.s. to try to maximize the Zonegran therapy.  If this is not effective, when she comes back on August 7, 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica.  We also discussed with Ms. Hawkins the possibility of nerve block injection; however, at this point she is not interested.,She will be seeing Dr. XYZ for her neuropathies.,We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult.", General Medicine,15
"PREOPERATIVE DIAGNOSIS: , Lipodystrophy of the abdomen and thighs.,POSTOPERATIVE DIAGNOSIS:,  Lipodystrophy of the abdomen and thighs.,OPERATION: , Suction-assisted lipectomy.,ANESTHESIA:,  General.,FINDINGS AND PROCEDURE:,  With the patient under satisfactory general endotracheal anesthesia, the entire abdomen, flanks, perineum, and thighs to the knees were prepped and draped circumferentially in sterile fashion.  After this had been completed, a #15 blade was used to make small stab wounds in the lateral hips, the pubic area, and upper edge of the umbilicus.  Through these small incisions, a cannula was used to infiltrate lactated Ringers with 1000 cc was infiltrated initially into the abdomen.  A 3 and 4-mm cannulas were then used to carry out the liposuction of the abdomen removing a total of 1100 cc of aspirate, which was mostly fat, little fluid, and blood.  Attention was then directed to the thighs both inner and outer.  A total of 1000 cc was infiltrated in both lateral thighs only about 50 cc in the medial thighs.  After this had been completed, 3 and 4-mm cannulas were used to suction 650 cc from each side, approximately 50 cc in the inner thigh and 600 on each lateral thigh.  The patient tolerated the procedure very well.  All of this aspirate was mostly fat with little fluid and very little blood.  Wounds were cleaned and steri-stripped and dressing of ABD pads and ***** was then applied.  The patient tolerated the procedure very well and was sent to the recovery room in good condition.", Bariatrics,2
"HISTORY: , The patient is a 34-year-old right-handed female who states her symptoms first started after a motor vehicle accident in September 2005.  She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision, which lasted about a week and then resolved.  Since that time she has had right low neck pain and left low back pain.  She has been extensively worked up and treated for this.  MRI of the C & T spine and LS spine has been normal.  She has improved significantly, but still complains of pain.  In June of this year she had different symptoms, which she feels are unrelated.  She had some chest pain and feeling of tightness in the left arm and leg and face.  By the next morning she had numbness around her lips on the left side and encompassing the whole left arm and leg.  Symptoms lasted for about two days and then resolved.  However, since that time she has had intermittent numbness in the left hand and leg.  The face numbness has completely resolved.  Symptoms are mild.  She denies any previous similar episodes.  She denies associated dizziness, vision changes incoordination, weakness, change in gait, or change in bowel or bladder function.  There is no associated headache.,Brief examination reveals normal motor examination with no pronator drift and no incoordination.  Normal gait.  Cranial nerves are intact.  Sensory examination reveals normal facial sensation.  She has normal and symmetrical light touch, temperature, and pinprick in the upper extremities.  In the lower extremities she has a feeling of dysesthesia in the lateral aspect of the left calf into the lateral aspect of the left foot.  In this area she has normal light touch and pinprick.  She describes it as a strange unusual sensation.,NERVE CONDUCTION STUDIES: , Motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in the left arm and leg.,NEEDLE EMG: , Needle EMG was performed in the left leg, lumbosacral paraspinal, right tibialis anterior, and right upper thoracic paraspinal muscles using a disposable concentric needle.  It revealed normal insertional activity, no spontaneous activity, and normal motor unit action potential form in all muscles tested.,IMPRESSION: , This electrical study is normal.  There is no evidence for peripheral neuropathy, entrapment neuropathy, plexopathy, or lumbosacral radiculopathy.  EMG was also performed in the right upper thoracic paraspinal where she has experienced a lot of pain since the motor vehicle accident.  This was normal.,Based on her history of sudden onset of left face, arm, and leg weakness as well as a normal EMG and MRI of her spine I am concerned that she had a central event in June of this year.  Symptoms are now very mild, but I have ordered an MRI of the brain with and without contrast and MRA of the head and neck with contrast to further elucidate her symptoms.  Once she has the test done she will phone me and further management will be based on the results.", Neurology,22
"EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.", Consult - History and Phy.,5
"PSYCHOSOCIAL DONOR EVALUATION,Following questions are mostly involved in a psychosocial donor evaluation:,A.  DECISION TO DONATE,What is your understanding of the recipient's illness and why a transplant is needed?,When and how did the subject of donation arise?,What was the recipient's reaction to your offer?,What are your family's feelings about your being a donor?,How did you arrive at the decision to be a donor?,How would your family and friends react if you decided not to be a donor?,How would you feel if you cannot be the donor for any reason?,What is your relationship to the recipient?,How will your relationship with the recipient change if you donate your kidney?,Will your being a donor affect any other relationships in your life?,B. TRANSPLANT ISSUES,Do you have an understanding of the process of transplant?,Do you understand the risk of rejection of your kidney by the recipient at some point after transplant?,Have you thought about how you might feel if the kidney/liver is rejected?,Do you have any doubts or concerns about donating?,Do you understand that there will be pain and soreness after the transplant?,What are your expectations about your recuperation?,Do you need to speak further to any of the transplant team members?,C.  MEDICAL HISTORY,What previous illnesses or surgeries have you had? ,Are you currently on any medications?,Have you ever spoken with a counselor, a therapist or a psychiatrist?,Do you smoke?,In a typical week, how many drinks do you consume?  What drink do you prefer?,What kinds of recreational drugs have you tried?  Have you used any recently?,D. FAMILY AND SUPPORT SYSTEM,With whom do you live?  ,If you are in a relationship:,- length of the relationship:  ,- name of spouse/partner:  ,- age and health of spouse/partner:  ,- children:  ,E. POST-SURGICAL PLANS,With whom will you stay after discharge?  ,What is your current occupation:  ,Do you have the support of your employer?", Nephrology,21
"PREOPERATIVE DIAGNOSES:,1.  Benign prostatic hypertrophy.,2.  Urinary retention.,POSTOPERATIVE DIAGNOSES:,1.  Benign prostatic hypertrophy.,2.  Urinary retention.,PROCEDURE PERFORMED:,1.  Cystourethroscopy.,2.  Transurethral resection of prostate (TURP).,ANESTHESIA:  ,Spinal.,DRAIN: , A #24 French three-way Foley catheter.,SPECIMENS: , Prostatic resection chips.,ESTIMATED BLOOD LOSS:  ,150 cc.,DISPOSITION:  ,The patient was transferred to the PACU in stable condition.,INDICATIONS AND FINDINGS:  ,This is an 84-year-old male with history of BPH and subsequent urinary retention with failure of trial of void, scheduled for elective TURP procedure.,FINDINGS: , At the time of surgery, cystourethroscopy revealed trilobar enlargement of the prostate with prostatic varices of the median lobe.  Cystoscopy showed a few cellules of the bladder with no obvious bladder tumors noted.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to operating room and spinal anesthesia was induced by the Department of Anesthesia.  The patient was prepped and draped in the normal sterile fashion and a #21 French cystoscope inserted into urethra and into the bladder.  Cystoscopy performed with the above findings.  Cystoscope was removed.  A #27 French resectoscope with a #26 cutting loop was inserted into the bladder.  Verumontanum was identified as a landmark and systematic transurethral resection of the prostate tissue was undertaken in an circumferential fashion with good resection of tissue completed.  ________ irrigator was used to evacuate the bladder of prostatic chips.  Resectoscope was then inserted and any residual chips were removed in piecemeal fashion with a resectoscope loop.  Any obvious bleeding from the prostatic fossa was controlled with electrocautery.  Resectoscope was removed.  A #24 French three-way Foley catheter inserted into the urethra and into the bladder.  Bladder was irrigated and connected to three-way irrigation.  The patient was cleaned and sent to recovery in stable condition to be admitted overnight for continuous bladder irrigation and postop monitoring.", Urology,39
"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,15
"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.", Physical Medicine - Rehab,30
"EXAM: , Ultrasound of pelvis.,HISTORY:, Menorrhagia.,FINDINGS: , Uterus is enlarged measuring 11.0 x 7.5 x 11.0 cm.  It appears to be completely replaced by multiple ill-defined fibroids.  The endometrial echo complex was not visualized due to the contents of replacement of the uterus with fibroids.  The right ovary measures 3.9 x 1.9 x 2.3 cm.  The left ovary is not seen.  No complex cystic adnexal masses are identified.,IMPRESSION:  ,Essential replacement of the uterus by fibroids.  It is difficult to measure given their heterogenous and diffuse nature.  MRI of the pelvis could be performed for further evaluation to evaluate for possible uterine fibroid embolization.", Obstetrics / Gynecology,24
"CHIEF COMPLAINT:,  Intractable epilepsy, here for video EEG.,HISTORY OF PRESENT ILLNESS: , The patient is a 9-year-old male who has history of global developmental delay and infantile spasms.  Ultimately, imaging study shows an MRI with absent genu of the corpus callosum and thinning of the splenium of the corpus callosum, showing a pattern of cerebral dysgenesis.  He has had severe global developmental delay, and is nonverbal.  He can follow objects with his eyes, but has no ability to interact with his environment to any great degree.  He has noted if any purposeful use of the hands.  He has abnormal movements constantly, which are more choreiform and dystonic.  He has spastic quadriparesis, which is variable at times.  The patient is unable to sit or stand, and receives all his nutrition via G-tube.,The patient began having seizures in infancy presenting as infantile spasms.  I began seeing him at 20 months of age.  At that point, he had undergone workup in Seattle, Washington and then was seeing Dr. X, child neurologist in Mexico, who started Vigabatrin for infantile spasms.  The patient had benefit from this medication, and was doing well at that time with regard to that seizure type.  He initially was on phenobarbital, which failed to give him benefit.  He continued on phenobarbital; however, for a long period time thereafter.  The patient then began having more tonic seizures after his episodic spasms had subsided, and failed several medication trials including valproic acid, Topamax, and Zonegran at least briefly.  Upon starting Lamictal, he began to have benefit and then actually had 1-year seizure freedom before having an isolated seizure or 2.  Over the next 6 months to a year, he only had few further seizures, and was doing well in a general sense.  It was more recently that he began having new seizure events that have not responded to higher doses of Lamictal up to 15 mg/kg/day.  These events manifest as tonic spells with eye deviation and posturing.  Mother reports flexion of the upper extremities, extension with lower extremities.  During that time, he is not able to cry or say any sounds.  These events last from seconds to minutes, and occur at least multiple times per week.  There are times where he has none for a few days and other times where he has multiple days in a row with events.  He has another event manifesting as flexion of the upper extremities and extension lower extremities where he turns red and cries throughout.  He may vomit after these episodes, then seems to calm down.  It is unclear whether this is a seizure or whether the patient is still responsive.,MEDICATIONS:,  The patient's medications include Lamictal for a total of 200 mg twice a day.  It is a 150 mg tablet and 25 mg tablets.  He is on Zonegran using 25 mg capsules 2 capsules twice daily, and baclofen 10 mg three times day.  He has other medications including the Xopenex and Atrovent.,REVIEW OF SYSTEMS: , At this time is negative any fevers, nausea, vomiting, diarrhea, abdominal complaints, rashes, arthritis, or arthralgias.  No respiratory or cardiovascular complaints.  He has no change in his skills at this point.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a slender male who is microcephalic.  He has EEG electrodes in place and is on the video EEG at that time.,HEENT:  His oropharynx shows no lesions.,NECK:  Supple without adenopathy.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs.,ABDOMEN:  Benign with G-tube in place.,EXTREMITIES:  Reveal no clubbing, cyanosis, or edema.,NEUROLOGICAL:  The patient is alert and has bilateral esotropia.  He is able to fix and follow objects briefly.  He is unable to reach for objects.  He exhibits constant choreiform movements when excited.  These are more prominent in the upper extremities and lower extremities.  He has some dystonic posture with flexion of the wrist and fingers bilaterally.  He also has plantar flexion at the ankles bilaterally.  His cranial nerves reveal that his pupils are equal, round, and reactive to light.  Extraocular movements are intact other than bilateral esotropia.  His face moves symmetrically.  Palate elevates in midline.  Hearing appears intact bilaterally.,Motor exam reveals dystonic and variable tone, overall there is mild in spasticity both upper and lower extremities as described above.  He has clonus at the ankles bilaterally, and some valgus contracture of the ankles.  His sensation is intact to light touch bilaterally.  Deep tendon reflexes are 2 to 3+ bilaterally.,IMPRESSION/PLAN: , This is a 9-year-old male with congenital brain malformation and intractable epilepsy.  He has microcephaly as well as dystonic cerebral palsy.  He had a re-emergence of seizures, which are difficult to classify, although some sound like tonic episodes and others are more concerning for non-epileptic phenomenon, such as discomfort.  He is admitted for video EEG to hopefully capture both of these episodes and further clarify the seizure type or types.  He will remain hospitalized for probably at least 48 hours to 72 hours.  He could be discharged sooner if multiple events are captured.  His medications, we will continue his current dose of Zonegran and Lamictal for now.  Both of these medications are very long acting, discontinuing them while in the hospital may simply result in severe seizures after discharge.", Neurology,22
"PROCEDURE: , Newborn circumcision.,INDICATIONS: , Parental preference.,ANESTHESIA:,  Dorsal penile nerve block.,DESCRIPTION OF PROCEDURE:,  The baby was prepared and draped in a sterile manner.  Lidocaine 1% 4 mL without epinephrine was instilled into the base of the penis at 2 o'clock and 10 o'clock.  The penile foreskin was removed using a XXX Gomco.  Hemostasis was achieved with minimal blood loss.  There was no sign of infection.  The baby tolerated the procedure well.  Vaseline was applied to the penis, and the baby was diapered by nursing staff.", Urology,39
"PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:,  Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:,  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.  His family physician attempted to remove the wire, but it only became deeper in the foot.  The wound eventually healed, but a scar tissue was formed.  The patient has had constant pain with ambulation intermittently since the incident occurred.  He desires attempted surgical removal of the wire.  The risks and benefits of the procedure have been explained to the patient in detail by Dr. X.  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 and placed on the operating table in a supine position with a safety strap placed across his waist for his protection.,A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 12 cc of 0.5% Marcaine plain was used to administer an ankle 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.  The foot was lowered into the operative field and the sterile stockinet was reflected.  Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized.  This was the origin and entry point of the previous puncture wound from the wire.  This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area.  Next, the Xi-scan was draped and brought into the operating room.  A #25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire.  Next, a #10 blade was used to make approximately a 3 cm curvilinear ""S""-shaped incision.  Next, the #15 blade was used to carry the incision through the subcutaneous tissue.  The medial and lateral margins of the incision were undermined.  Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot, the wires seemed to serve no benefit other then helping with the incision planning.  Therefore, they were removed.  Once the wound was opened, a hemostat was used to locate the wire very quickly and the wire was clamped.  A second hemostat was used to clamp the wire.  A #15 blade was used to carefully transect the fatty tissue around the tip of the hemostats, which were visualized in the base of the wound.  The wire quickly came into visualization.  It measured approximately 4 mm in length and was approximately 1 mm in diameter.  The wire was green colored and metallic in nature.  It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification.  The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament.  Next, copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected.  Next, a #3-0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space.  Next, #4-0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique.  The standard postoperative dressing consisting of saline-soaked Owen silk, 4x4s, Kling, Kerlix, and Coban were applied.  The pneumatic ankle tourniquet was released.  There was immediate hyperemic flush to the digits noted.  The patient's anesthesia was reversed.  He tolerated the above anesthesia and procedure without complications.  The patient was transported via cart to the Postanesthesia Care Unit.,Vital signs were stable and vascular status was intact to the right foot.  He was given OrthoWedge shoe.  Ice was applied behind the knee and his right lower extremity was elevated on to pillows.  He was given standard postoperative instructions consisting of rest, ice and elevation to the right lower extremity.  He is to be non-weightbearing for three weeks, at which time, the wound will be evaluated and sutures will be removed.  He is to follow up with Dr. X on 08/22/2003 and was given emergency contact number to call if problems arise.  He was given a prescription for Tylenol #4, #30 one p.o. q.4-6h. p.r.n., pain as well as Celebrex 200 mg #30 take two p.o. q.d. p.c., with 200 mg 12 hours later as a rescue dose.  He was given crutches.  He was discharged in stable condition.", Orthopedic,27
"SUBJECTIVE:,  This 1+ year, black female, new patient in dermatology, sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema.  The patient’s mom is from Tanzania.  The patient has been treated with Elidel cream b.i.d. for six months but apparently this has stopped working now and it seems to make her more dry and plus she has been using some Johnson's Baby Oil on her.  The patient is a well-developed baby.  Appears stated age.  Overall health is good.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has eczema and a positive atopic family history.  No psoriasis.  No known drug allergies.,CURRENT MEDICATIONS:,  None.,PHYSICAL EXAMINATION:, The patient has eczematous changes today on her face, trunk, and extremities.,IMPRESSION:,  Atopic eczema.,TREATMENT:,1.  Discussed condition and treatment with Mom.,2.  Continue bathing twice a week.,3.  Discontinue hot soapy water.,4.  Discontinue Elidel for now.,5.  Add Aristocort cream 0.25%, Polysporin ointment, Aquaphor b.i.d. and p.r.n. itch.  We will see her in one month if not better otherwise on a p.r.n. basis.  Send a letter to ABC Practice program.", Pediatrics - Neonatal,29
"PREOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,POSTOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,PROCEDURE:  ,The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.,FINDINGS: , Normal-appearing thyroid gland with a possible lump in the inferior aspect, there was a parathyroid gland that by frozen section _________  was not thyroid, it was reimplanted to the left lower sternocleidomastoid region.,ESTIMATED BLOOD LOSS:  ,Approximately 10 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS: , None.,DRAINS: , Rubber band drain in the neck.,CONDITION:,  Stable.,PROCEDURE:  ,The patient placed supine under general anesthesia.  First, a shoulder roll was placed, 1% lidocaine and 1:100,000 epinephrine was injected into the old scar, natural skin fold, and Betadine prep.  Sterile dressing was placed.  The laryngeal monitoring was noted to be working fine.  Then, an incision was made in this area in a curvilinear fashion through the old scar, taken through the fat and the platysma level.  The strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid, the thyroid gland was then found.  Then, using bipolar cautery and a Coblation dissector, the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally, the thyroid gland was released, then came into the Berry ligaments.  The Berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels, which were crossed with the Harmonic scalpel and removed.  No bleeding was seen.  There was a small nick in the external jugular vein that was tied with a 4-0 Vicryl suture ligature.  After this was completed, on examining the specimen, there appeared to be a lobule on it and it was sent off as possibly parathyroid, therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature.  After this was completed, no bleeding was seen.  The laryngeal nerve could be seen and intact and then Rubber band  drain was placed throughout the neck along the thyroid bed and 4-0 Vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5-0 nylon was used to close the skin and Mastisol and Steri-Strips were placed along the skin edges and then on awakening, both laryngeal nerves were working normally.  Procedure was then terminated at that time.", Surgery,38
"CHIEF COMPLAINT - REASON FOR VISIT: ,Pelvic Pain and vaginal discharge.,ABNORMAL PAP HISTORY:, Date of abnormal pap:  1998. Findings: High grade squamous intraepithelial lesions. Previous colposcopic exam and biopsies showed mild dysplasia or CIN 1. Patient is sexually active and has had 1 partner. There is no history of STD’s.,PELVIC PAIN HISTORY:, The patient complains of a gradual onset of pelvic pain 1 year ago and states condition is recurrent. Location of pain is left lower quadrant. Severity is moderately severe, intermittent and lasts for 2 hours. Quality of pain is crampy, sharp and variable.  Pain requires NSAIDs. Menstrual quality is light, flow lasts for 7 days and interval lasts for 28 days. There was no radiation of pain.,VAGINITIS HISTORY:, Symptoms have lasted for 2 weeks and persistent.  Discharge appears thin, white and with odor. Denies any itching sensation. Denies irritation. The patient denies any self treatment.,PERSONAL / SOCIAL HISTORY:, Tobacco history: Smoke’s 1 pack of cigarettes per day.  Denies the past history of alcohol. Denies past / present illegal drug use of any kind. Marital Status: Married.,PAST MEDICAL HISTORY:, Negative.,FAMILY MEDICAL HISTORY:, Negative.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, There are no current medications.,PAST SURGICAL HISTORY:, D & C.  1993,REVIEW OF SYSTEMS:,Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,Genitourinary: Patient denies any genitourinary problems.,Gynecological: Refer to current history.,Pulmonary: Denies cough, dyspnea, tachypnea, hemoptysis.,GU: Denies frequency, nocturia and hematuria.,Neuro: Denies any problems, no seizures, no numbness, no dizziness.,PHYSICAL EXAMINATION:,Vital Signs: Weight:  104. BP:  100/70.,Chest: Lungs have equal bilateral expansion and are clear to percussion and auscultation.,Cardiovascular / Heart: Regular heart rate and rhythm without murmur or gallop.,Breast: No palpable masses.  No dimpling or retraction. No discharge. No axillary lymphadenopathy.,Abdomen: Tenderness is located in the left upper quadrant. Tenderness is mild. Bowel sounds are normal. No masses palpated.,Gynecologic: Inspection reveals the external genitalia to be normal anatomically. Cervix appears inflamed, bloody discharge and without aceto-white areas. Vagina appears normal. Vaginal discharge was white and watery.  Uterus is normal anteverted. The uterus is normal size and shape, tender to movement and movable. Bladder not tender. ,Rectal: No additional findings.,LAB / TESTS:, Hgb: 17.1 U/A: pH 6.0, spgr 1.025, trace protein, trace blood,IMPRESSION / DIAGNOSIS,1. Endometritis / Endomyometritis (615.9). ,2. Cervicitis - Endocervicitis (616.0). ,3. Pelvic Pain (625.9).,PLAN:, Pap smear done. Take metronidazole first then the Doxycycline. Return in three weeks for reevaluation.,MEDICATIONS PRESCRIBED: ,Metronidazole 500 mg #14 1 BID for 7 days.  Doxycycline 100 mg #14 1 BID.", Obstetrics / Gynecology,24
"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,25
"PROCEDURES PERFORMED: , Endoscopy.,INDICATIONS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:,  Esophageal ring and active reflux esophagitis.,PROCEDURE: , Informed consent was obtained prior to the procedure from the parents and patient.  The oral cavity is sprayed with lidocaine spray.  A bite block is placed.  Versed IV 5 mg and 100 mcg of IV fentanyl was given in cautious increments.  The GIF-160 diagnostic gastroscope used.  The patient was alert during the procedure.  The esophagus was intubated under direct visualization.  The scope was advanced toward the GE junction with active reflux esophagitis involving the distal one-third of the esophagus noted.  The stomach was unremarkable.  Retroflexed exam unremarkable.  Duodenum not intubated in order to minimize the time spent during the procedure.  The patient was alert although not combative.  A balloon was then inserted across the GE junction, 15 mm to 18 mm, and inflated to 3, 4.7, and 7 ATM, and left inflated at 18 mm for 45 seconds.  The balloon was then deflated.  The patient became uncomfortable and a good-size adequate distal esophageal tear was noted.  The scope and balloon were then withdrawn.  The patient left in good condition.,IMPRESSION: , Successful dilation of distal esophageal fracture in the setting of active reflux esophagitis albeit mild.,PLAN: , I will recommend that the patient be on lifelong proton pump inhibition and have repeat endoscopy performed as needed.  This has been discussed with the parents.  He was sent home with a prescription for omeprazole.", Gastroenterology,14
"PREOPERATIVE DIAGNOSES:,  Empyema of the left chest and consolidation of the left lung.,POSTOPERATIVE DIAGNOSES:,  Empyema of the left chest, consolidation of the left lung, lung abscesses of the left upper lobe and left lower lobe.,OPERATIVE PROCEDURE: , Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.,ANESTHESIA:,  General.,FINDINGS: , The patient has a complex history, which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two CAT scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax.  There was also noted to be some mild infiltrates of the right lung.  The patient had a 30-year history of cigarette smoking.  A chest tube was placed at the other hospital, which produced some brownish fluid that had foul odor, actually what was thought to be a fecal-like odor.  Then an abdominal CT scan was done, which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal CT.  The patient was started on antibiotics and was then taken to the operating room, where there was to be a thoracoscopy performed.  The patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions, but there was bloody mucous in the left main stem bronchus and this was suctioned out.  This was suctioned out with the addition of the use of saline ***** in the bronchus.  Following the bronchoscopy, a double lumen tube was placed, but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day.,The patient was transferred for continued evaluation and treatment.  Today, the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted.  These were suctioned, but it was enough to produce a temporary obstruction of the left mainstem bronchus.  Eventually, the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that.  The chest tube tract, which was about in the sixth or seventh intercostal space, but it was not possible to dissect enough down to get a acceptable visualization through this tract.  A second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity.  Therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout.  Remarkably, the surface of the lower lobe laterally was not completely covered with a fibrotic line, but it was more the line anterior and posterior and more of it over the left upper lobe.  There were many pockets of purulent material, which had a gray-white appearance to it.  There was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe.  The adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time.  There seemed to be an abscess that was about 3 cm in dimension, all the lateral basilar segment of the lower lobe near the area where the chest tube was placed.  Many cultures were taken from several areas.  The most remarkable finding was a large cavity, which was probably about 11 cm in dimension, containing grayish pus and also caseous-like material, it was thought to be perhaps necrotic lung tissue, perhaps a deposit related to tuberculosis in the cavity.,The apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm.,PROCEDURE AND TECHNIQUE:,  With the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner.  The chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract, but then it was necessary to enlarge it slightly in order to get the Thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this.  Therefore, the next incision for Thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved, but it was clear that we would be unable to complete the procedure by thoracoscopy.  Therefore posterolateral thoracotomy incision was made, entering the pleural space and what is probably the sixth intercostal space.  Quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity.  Specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense.  Suture ligatures of Prolene were required.  When the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity, which appeared to be from pulmonary veins and these were sutured with a ""tissue pledget"" of what was probably intercostal nozzle and endothoracic fascia with Prolene sutures.,Also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14-French Foley catheter was passed into the area of the tear and the balloon was inflated, which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the Foley catheter was removed.  The patch was sutured onto the pulmonary artery tear.  A similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity.  Also on the pulmonary artery repair some ***** material was used and also thrombin, Gelfoam and Surgicel.  After reasonably good hemostasis was established pleural cavity was irrigated with saline.  As mentioned, biopsies were taken from multiple sites on the pleura and on the edge and on the lung.  Then two #24 Blake chest tubes were placed, one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk.  One was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex.  These were later connected to water-seal suction at 40 cm of water with negative pressure.,Good hemostasis was observed.  Sponge count was reported as being correct.  Intercostal nerve blocks at probably the fifth, sixth, and seventh intercostal nerves was carried out.  Then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib.  Metallic clip was passed through the rib to facilitate passage of an intracostal suture, but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table, so that pericostal sutures were used with #1 Vicryl.  The chest wall was closed with running #1 Vicryl and then 2-0 Vicryl subcutaneous and staples on the skin.  The chest tubes were connected to water-seal drainage with 40 cm of water negative pressure.  Sterile dressings were applied.  The patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen.  The patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS:,  Herniated nucleus pulposus of L5-S1 on the left.,POSTOPERATIVE DIAGNOSIS: ,Herniated nucleus pulposus of L5-S1 on the left.,PROCEDURE PERFORMED:, Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMENS: , Disc that was not sent to the lab.,DRAINS: , None.,COMPLICATIONS: , None.,SURGICAL PROGNOSIS: , Remains guarded due to her ongoing pain condition and Tarlov cyst at the L5 nerve root distally.,SURGICAL INDICATIONS: , The patient is a 51-year-old female who has had unrelenting low back pain that radiated down her left leg for the past several months.  The symptoms were unrelieved by conservative modalities.  The symptoms were interfering with all aspects of daily living and inability to perform any significant work endeavors.  She is understanding the risks, benefits, potential complications, as well as all treatment alternatives.  She wished to proceed with the aforementioned surgery due to her persistent symptoms.  Informed consent was obtained.,OPERATIVE TECHNIQUE: , The patient was taken to OR room #5 where she was given general anesthetic by the Department of Anesthesia.  She was subsequently placed on the Jackson spinal table with the Wilson attachment in the prone position.  Palpation did reveal the iliac crest and suspected L5-S1 interspace.  Thereafter the lumbar spine was serially prepped and draped.  A midline incision was carried over the spinal process of L5 to S1.  Skin and subcutaneous tissue were divided sharply.  Electrocautery provided hemostasis.  Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia.  Lumbar fascia was identified and the decussation of fibers was identified at the L5-S1 interspace.  On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery.  This revealed the interspace of suspect level of L5-S1 on the left.  A Kocher clamp was placed between the spinous processes of the suspect level of L5-S1.  X-ray did confirm the L5-S1 interval.  Angled curet was utilized to detach the ligamentum flavum from its bony attachments at the superior edge of S1 lamina and the inferior edge of the L5 lamina.  Meticulous dissection was undertaken and the ligamentum flavum was removed.  Laminotomy was created with Kerrison rongeur, both proximally and distally.  The microscope was positioned and the dura was inspected.  A blunt Penfield elevator was then utilized to dissect and identify the L5-S1 nerve root on the left.  It was noted to be tented over a disc extrusion.  The nerve root was protected and medialized.  It was retracted with a nerve root retractor.  This did reveal a subligamentous disc herniation at approximately the L5-S1 disc space and neuroforaminal area.  A #15 Bard-Parker blade was utilized to create an annulotomy.  Medially, disc material was extruding through this annulotomy.  Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace.  Additional disc material was then removed, both to the right and left of the annulotomy.  Up and downbiting pituitary rongeurs were utilized to remove any other loose disc pieces.  Once this was completed, the wound was copiously irrigated with antibiotic solution and suctioned dry.  The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray did confirm this level.  Nerve root was again expected exhibiting the foramina.  A foraminotomy was created with a Kerrison rongeur.  Once this was created, the nerve root was again inspected and deemed free of tension.  It was mobile within the neural foramina.  The wound was again copiously irrigated with antibiotic solution and suctioned dry.  A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura.  Lumbar fascia was then approximated with #1 Vicryl interrupted fashion, subcutaneous tissue with #2-0 Vicryl interrupted fashion, and #4-0 undyed Vicryl was utilized to approximate the skin.  Compression dressing was applied.  The patient was turned, awoken, and noted to be moving all four extremities without apparent deficits.  She was taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded due to her ongoing pain syndrome that has been requiring significant narcotic medications.", Neurosurgery,23
"CHIEF COMPLAINT:,  Dental pain.,HISTORY OF PRESENT ILLNESS:,  This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today.  Presents now for evaluation.,PAST MEDICAL HISTORY: , Remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease.  She has chronic pain in general and is followed by Dr. X.,REVIEW OF SYSTEMS: , Otherwise, unremarkable.  Has not noted any fever or chills.  However she, as mentioned, does note the dental discomfort with increasing swelling and pain.  Otherwise, unremarkable except as noted.,CURRENT MEDICATIONS: , Please see list.,ALLERGIES: , IODINE, FISH OIL, FLEXERIL, BETADINE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile, has stable and normal vital signs.  The patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain.  HEENT:  Unremarkable.  I do not see any obvious facial swelling, but she is definitely tender all in the left mandible region.  There is no neck adenopathy.  Oral mucosa is moist and well hydrated.  Dentition looks to be in reasonable condition.  However, she definitely is tender to percussion on the left lower first premolar.  I do not see any huge cavity or anything like that.  No real significant gingival swelling and there is no drainage noted.  None of the teeth are tender to percussion.,PROCEDURE:,  Dental nerve block.  Using 0.5% Marcaine with epinephrine, I performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia.  I have then written a prescription for penicillin and Vicodin for pain.,IMPRESSION: , ACUTE DENTAL ABSCESS.,ASSESSMENT AND PLAN:  ,The patient needs to follow up with the dentist for definitive treatment and care.  She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics.  However, outpatient followup should be adequate.  She is discharged in stable condition.", Emergency Room Reports,12
"CHIEF COMPLAINT: , Chest pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 40-year-old white male who presents with a chief complaint of ""chest pain"".,The patient is diabetic and has a prior history of coronary artery disease.  The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent.  The severity of the pain has progressively increased.  He describes the pain as a sharp and heavy pain which radiates to his neck & left arm.  He ranks the pain a 7 on a scale of 1-10.  He admits some shortness of breath & diaphoresis.  He states that he has had nausea & 3 episodes of vomiting tonight.  He denies any fever or chills.  He admits prior episodes of similar pain prior to his PTCA in 1995.  He states the pain is somewhat worse with walking and seems to be relieved with rest.  There is no change in pain with positioning.  He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain.  The patient ranks his present pain a 4 on a scale of 1-10.  The most recent episode of pain has lasted one-hour.,The patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed.,REVIEW OF SYSTEMS:,  All other systems reviewed & are negative.,PAST MEDICAL HISTORY:,  Diabetes mellitus type II, hypertension, coronary artery disease, atrial fibrillation, status post PTCA in 1995 by Dr. ABC.,SOCIAL HISTORY: , Denies alcohol or drugs.  Smokes 2 packs of cigarettes per day.  Works as a banker.,FAMILY HISTORY: , Positive for coronary artery disease (father & brother).,MEDICATIONS: , Aspirin 81 milligrams QDay.  Humulin N. insulin 50 units in a.m.  HCTZ 50 mg QDay.  Nitroglycerin 1/150 sublingually PRN chest pain.,ALLERGIES: , Penicillin.,PHYSICAL EXAM: , The patient is a 40-year-old white male.,General:  The patient is moderately obese but he is otherwise well developed & well nourished.  He appears in moderate discomfort but there is no evidence of distress.  He is alert, and oriented to person place and circumstance.  There is no evidence of respiratory distress.  The patient ambulates", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS:,  Subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: , Subglottic stenosis.,OPERATIVE PROCEDURES: , Direct laryngoscopy and bronchoscopy.,ANESTHESIA:,  General inhalation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operative table.  General inhalational anesthesia was administered through the patient's tracheotomy tube.  The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway.  There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds.  The stoma showed some suprastomal fibroma.  The remaining tracheobronchial passages were clear.  The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties.  Bleeding was negligible.  There were no untoward complications.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.", ENT - Otolaryngology,11
"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.", Radiology,33
"HISTORY OF PRESENT ILLNESS:,  The patient has a known case of marginal B-cell lymphoma for which he underwent splenectomy two years ago.  The patient, last year, developed a diffuse large B-cell lymphoma which was treated with CHOP/reduction.  The patient again went into complete remission.  The patient has been doing well until recently, few days ago, late last week, when he developed swelling of the left testicle.  The patient states he has been having fever and chills for the last few days.  The patient felt weak and felt unwell.  The patient with these complaints came to the emergency room.  The patient has been having fever and chills and the patient states that the pain in the left testicle is rather severe.  No history of trauma to the testicle.,PAST MEDICAL HISTORY:,1.  Status post splenectomy.,2.  History of marginal B-cell lymphoma.,3.  History of diffuse large cell lymphoma.,ALLERGIES: , None.,PERSONAL HISTORY: , Used to smoke and drink alcohol but at present does not.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS:,HEENT:  Has slight headache.,CARDIOVASCULAR:  No history of hypertension, MI, etc.,RESPIRATORY:  No history of cough, asthma, TB, shortness of breath.,GI:  Unremarkable.,GU:  As above, has developed painful swelling of the left testicle over the last few days.,ENDOCRINE:  Known case of type II diabetes mellitus.,PHYSICAL EXAMINATION:,HEENT:  No conjunctival pallor or icterus.,NECK:  No adenopathy.  No carotid bruits.,LUNGS:  Clear.,HEART:  No gallop or murmur.,ABDOMEN:", Hematology - Oncology,16
"REASON FOR REFERRAL:,  The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney.  He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION: , Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM: , The patient was brought to the Hospital Emergency Department on 09/30/09 after experiencing an episode of confusion for which he has no recall the previous day.  He has no recollection of the event.  The following information is obtained from his medical record.  On 09/29/09, he reportedly went to a five-hour meeting and stated several times ""I do not feel well"" and looked ""glazed.""  He does not remember anything from midmorning until the middle of the night and when his wife came home, she found him in bed at 6 p.m., which is reportedly unusual.  She thought he was warm and had chills.  He later returned to his baseline.  He was seen by Dr. X in the hospital on 09/30/09 and reported to him at that time that he felt that he had returned entirely to baseline.  His neurological exam at that time was unremarkable aside from missing one of three items on recall for the Mini-Mental Status Examination.  Due to mild memory complaints from himself and his wife, he was referred for more extensive neuropsychological testing.  Note that reportedly when his wife found him in bed, he was shaking and feeling nauseated, somewhat clammy and kept saying that he could not remember anything and he was repeating himself, asking the same questions in an agitated way, so she brought him to the emergency room.  The patient had an episode two years ago of transient loss of memory during which he was staring blankly while sitting at his desk at work and the episode lasted approximately two hours.  He was hospitalized at Hospital at that time as well and evaluation included negative EEG, MRI showing mild atrophy, and a neurological consultation, which did not result in a specific diagnosis, but during this episode he was also reportedly nauseous.  He was also reportedly amnestic for this episode.,In 2004, he had a sense of a funny feeling in his neck and electrodes in his head and had an MRI at that time which showed some small vessel changes.,During this interview, the patient reported that other than a coworker noticing a few careless errors in his completion of some documents and his wife reporting some mild memory changes that he had not noticed any significant decline.  He thought that his memory abilities were similar to those of his peers of his same age.  When I asked about this episode, he said he had no recall of it at all and that he ""felt fine the whole time.""  He appeared to be somewhat questioning of the validity of reports that he was amnestic and confused at that time.  So, The patient reported some age related ""memory lapses"" such as going into a room and forgetting why, sometimes putting something down and forgetting where he had put it.  However, he reported that these were entirely within normal expectations and he denied any type of impairment in his ability to continue to work full-time as a tax attorney other than his wife and one coworker, he had not received any feedback from his children or friends of any problems.  He denied any missed appointments, any difficulty scheduling and maintaining appointments.  He does not have to recheck information for errors.  He is able to complete tasks in the same amount of time as he always has.  He reported that he has not made additional errors in tasks that he completed.  He said he does write everything down, but has always done things that way.  He reported that he works in a position that requires a high level of attentiveness and knowledge and that will become obvious very quickly if he was having difficulties or making mistakes.  He did report some age related changes in attention as well, although very mild and he thought these were normal and not more than he would expect for his age.  He remains completely independent in his ADLs.  He denied any difficulty with driving or maintaining any activities that he had always participated in.  He is also able to handle their finances.  He did report significant stress recently particularly in relation to his work environment.,PAST MEDICAL HISTORY:,  Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia.  Note that due to back pain, he had been taking Percocet daily prior to his hospitalization.,CURRENT MEDICATIONS: , Celebrex 200 mg, levothyroxine 0.025 mg, Vytorin 10/40 mg, lisinopril 10 mg, Coreg 10 mg, glucosamine with chondroitin, prostate 2.2, aspirin 81 mg, and laxative stimulant or stool softener.  Note that medical records say that he was supposed to be taking Lipitor 40 mg, but it is not clear if he was doing so and also there was no specific reason found for why he was taking the levothyroxine.,OTHER MEDICAL HISTORY: , Surgical history is significant for hernia repair in 2007 as well.  The patient reported drinking an occasional glass of wine approximately two days of the week.  He quit smoking cigarettes 25 to 30 years ago and he was diagnosed with cancer.  He denied any illicit drug use.  Please add that his prostatectomy was done in 1993 and nephrectomy in 1983 for carcinoma.  He also had right carpal tunnel surgery in 2005 and has cholelithiasis.  Upon discharge from the hospital, the patient's sleep deprived EEG was recommended.,MRI completed on 09/30/09 showed ""mild cerebral and cerebellar atrophy with no significant interval change from a prior study dated June 15, 2007.  No evidence of acute intracranial processes identified.  CT scan was also unremarkable showing only mild cerebral and cerebellar atrophy.  EEG was negative.  Deferential diagnosis was transient global amnesia versus possible seizure disorder.  Note that he also reportedly has some hearing changes, but has not followed up with an evaluation for hearing aid.,FAMILY MEDICAL HISTORY:, Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85.  In addition, his father had a history of heart disease and passed away at the age of 75.  He has one sister with diabetes and thought his mom might have had diabetes as well.,SOCIAL HISTORY:,  The patient obtained a law degree from the University of Baltimore.  He did not complete his undergraduate degree from the University of Maryland because he was able to transfer his credits in order to attend law school at that time.  He reported that he did not obtain very good grades until he reached law school, at which point he graduated in the top 10 of his class and had no problem passing the Bar.  He thought that effort and motivation were important to his success in his school and he had not felt very motivated previously.  He reported that he repeated math classes ""every year of school"" and attended summer school every year due to that.  He has worked as a tax attorney for the past 48 years and reported having a thriving practice with clients all across the country.  He served also in the U.S.  Coast Guard between 1951 and 1953.  He has been married for the past 36 years to his wife, Linda, who is a homemaker.  They have four children and he reported having good relationship with them.  He described being very active.  He goes for dancing four to five times a week, swims daily, plays golf regularly and spends significant amounts of time socializing with friends.,PSYCHIATRIC HISTORY: , The patient denied any history of psychological or psychiatric treatment.  He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test", Neurology,22
"GENERAL:,  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: , Negative rash, negative jaundice.,HEMATOPOIETIC: , Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: , Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:,  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS: , Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  ,Negative postnasal drip, negative sore throat.,CARDIOVASCULAR: , Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:,  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL: , Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY: , Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.,MUSCULOSKELETAL:,  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC: , See psychiatric evaluation.,ENDOCRINE: , No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.", General Medicine,15
"PROBLEMS AND ISSUES:,1.  Headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment.,2.  Some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercise daily.,HISTORY OF PRESENT ILLNESS: , The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness.  I obtained and documented a full history and physical examination.  I reviewed the new patient questionnaire, which she completed prior to her arrival today.  I also reviewed the results of tests, which she had brought with her.,Briefly, she is a 60-year-old woman initially from Ukraine, who had headaches since age 25.  She recalls that in 1996 when her husband died her headaches became more frequent.  They were pulsating.  She was given papaverine, which was successful in reducing the severity of her symptoms.  After six months of taking papaverine, she no longer had any headaches.  In 2004, her headaches returned.  She also noted that she had ""zig-zag lines"" in her vision.  Sometimes she would not see things in her peripheral visions.  She had photophobia and dizziness, which was mostly lightheadedness.  On one occasion she almost had a syncope.  Again she has started taking Russian medications, which did help her.  The dizziness and headaches have become more frequent and now occur on average once to twice per week.  They last two hours since she takes papaverine, which stops the symptoms within 30 minutes.,PAST MEDICAL HISTORY: ,Her past medical history is significant for injury to her left shoulder, gastroesophageal reflux disorder, diabetes, anxiety, and osteoporosis.,MEDICATIONS:,  Her medications include hydrochlorothiazide, lisinopril, glipizide, metformin, vitamin D, Centrum multivitamin tablets, Actos, lorazepam as needed, Vytorin, and Celexa.,ALLERGIES: , She has no known drug allergies.,FAMILY HISTORY:  ,There is family history of migraine and diabetes in her siblings.,SOCIAL HISTORY: , She drinks alcohol occasionally.,REVIEW OF SYSTEMS: , Her review of systems was significant for headaches, pain in her left shoulder, sleeping problems and gastroesophageal reflex symptoms.  Remainder of her full 14-point review of system was unremarkable.,PHYSICAL EXAMINATION:,  On examination, the patient was pleasant.  She was able to speak English fairly well.  Her blood pressure was 130/84.  Heart rate was 80.  Respiratory rate was 16.  Her weight was 188 pounds.  Her pain score was 0/10.  Her general exam was completely unremarkable.  Her neurological examination showed subtle weakness in her left arm due to discomfort and pain.  She had reduced vibration sensation in her left ankle and to some degree in her right foot.  There was no ataxia.  She was able to walk normally.  Reflexes were 2+ throughout.,She had had a CT scan with constant, which per Dr. X's was unremarkable.  She reports that she had a brain MRI two years ago which was also unremarkable.,IMPRESSION AND PLAN:,  The patient is a delightful 60-year-old chemist from Ukraine who has had episodes of headaches with nausea, photophobia, and dizziness since her 20s.  She has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms.  Her diagnosis is consistent with vestibular migraine.  I do not see evidence of multiple sclerosis, Ménière's disease, or benign paroxysmal positional vertigo.,I talked to her in detail about the importance of following a migraine diet.  I gave her instructions including a list of foods times, which worsen migraine.  I reviewed this information for more than half the clinic visit.  I would like to start her on amitriptyline at a dose of 10 mg at time.  She will take Motrin at a dose of 800 mg as needed for her severe headaches.,She will make a diary of her migraine symptoms so that we can find any triggering food items, which worsen her symptoms.  I encouraged her to walk daily in order to improve her fitness, which helps to reduce migraine symptoms.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS:,  Macular edema, right eye.,POSTOPERATIVE DIAGNOSIS:  ,Macular edema, right eye.,TITLE OF OPERATION: , Insertion of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the usual manner for a local eye procedure.  Initially, a 5 cc retrobulbar injection of 2% Xylocaine was done.  Then, a lid speculum was inserted and the conjunctiva was incised 4 mm posterior to the limbus.  A 2-0 silk traction suture was placed around the insertion of the lateral rectus muscle and, with gentle traction, the temporal one-half of the globe was exposed.  The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 Dacron.  The placement was confirmed with indirect ophthalmoscopy.  Next, the eye was irrigated with Neosporin and the conjunctiva was closed with 6-0 plain catgut.  The intraocular pressure was found to be within normal limits.  An eye patch was applied and the patient was sent to the Recovery Room in good condition.  A lateral canthotomy had been done.", Ophthalmology,26
"PREOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,POSTOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,OPERATIONS:,1.  Wound debridement x2, including skin, subcutaneous, and muscle.,2.  Insertion of tissue expander to the medial wound.,3.  Insertion of tissue expander to the lateral wound.,COMPLICATIONS: , None.,TOURNIQUET: , None.,ANESTHESIA:  ,General.,INDICATIONS: , This patient developed a compartment syndrome.  She underwent 4 compartment fasciotomy with dual incision on medial and lateral aspect of the right lower leg.  She was doing very well and was obviously improving.,The swelling was reduced.  A compartment pressure had obviously improved based on examination.  She was therefore indicated for placement of tissue expander for ventral wound closure.  The risks of procedure as well as alternatives of this procedure were discussed at length with the patient and he understood them well.  Risks and benefits were all discussed, risk of bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgery, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  She understood them well.  All questions were answered, and she signed the consent for the procedure as described.,DESCRIPTION OF THE PROCEDURE:,  The patient was placed on the operating table and general anesthesia was achieved.  The medial wound was noted to be approximately 10.5 cm in length x 4 cm.  The lateral wound was noted in approximately 14 cm in length x 5 x 5 cm in width.  Both wounds were then thoroughly debrided.  The debridement of both wounds included skin and subcutaneous tissue and nonviable muscle portion.  This involve very small portion of muscle as well as skin edge and the subcutaneous tissue did require debridement on both sides.  At this point adequate debridement was performed and healthy tissue did appear to be present.  Initially on the medial wound I did place the DermaClose RC continuous external tissue expander.  On the medial wound the 5 skin anchors were placed on each side of the wound and separated appropriately.  I then did place the line loop from the tension controller in a lace like manner through the skin anchors and the tension controller was attached to the middle anchor.  I then did place adequate tension on the sutures.  Continued tension will be noted after engaging the tension controller.  At this point I performed the similar procedure to the lateral wound.  The skin anchors were placed separately and appropriately on either side of the skin margin.  The line loop from the tension controller was placed in lace like manner through the skin anchors.  The tension controller was then attached to the mid anchor and appropriate tension was applied.,It must be noted I did undermine the skin edges both sides of flap from both incision site prior to placement of the skin anchor and adequate mobilization was obtained.  Adequate tension was placed in this region.  A non thick dressing was then applied to the open-wound region and sterile dressing was then applied.  No complications were encountered throughout the procedure and the patient tolerated the procedure well.  The patient was taken to recovery room in stable condition.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Right inguinal hernia. ,POSTOPERATIVE DIAGNOSIS:,  Right direct inguinal hernia. ,PROCEDURE:,  Right direct inguinal hernia repair with PHS mesh system. ,ANESTHESIA:,  General with endotracheal intubation. ,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was administered with endotracheal intubation.  The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion.  An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease.  Dissection was taken down through the skin and subcutaneous tissue.  Scarpa's fascia was divided, and the external ring was located.  The external oblique was divided from the external ring up towards the anterior superior iliac spine.  The cord structures were then encircled.  Careful inspection of the cord structures did not reveal any indirect sac along the cord structures.  I did, however, feel a direct sac with a direct defect.  I opened the floor of the inguinal canal and dissected out the preperitoneal space at the direct sac and cut out the direct sac.  Once I cleared out the preperitoneal space, I placed a PHS mesh system with a posterior mesh into the preperitoneal space, and I made sure that it laid flat along Cooper's ligament and covered the myopectineal orifice.  I then tucked the extended portion of the anterior mesh underneath the external oblique between the external oblique and the internal oblique, and I then tacked the medial portion of the mesh to the pubic tubercle with a 0 Ethibond suture.  I tacked the superior portion of the mesh to the internal oblique and the inferior portion of the mesh to the shelving edge of the inguinal ligament.  I cut a hole in the mesh in order to incorporate the cord structures and recreated the internal ring, making sure that it was not too tight so that it did not strangulate the cord structures.  I then closed the external oblique with a running 3-0 Vicryl.  I closed the Scarpa's with interrupted 3-0 Vicryl, and I closed the skin with a running Monocril.  Sponge, instrument and needle counts were correct at the end of the case.  The patient tolerated the procedure well and without any complications.", Urology,39
"PREOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,POSTOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,PROCEDURE:  ,Closed reduction of mandible fracture with MMF.,ANESTHESIA: , General anesthesia via nasal endotracheal intubation.,FLUIDS: , 2 L of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,HARDWARE: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,CONDITION:  ,The patient was extubated to PACU in good condition.,INDICATIONS FOR PROCEDURE: , The patient is a 17-year-old female who is 2 days status post an altercation in which she sustained multiple blows to the face.  She was worked up on Friday night, 2 days earlier at Hospital, was given palliative treatment and discharged and instructed to follow up as an outpatient with an oral surgeon and given a phone number to call.  The patient was worked up initially.  On initial exam, it was noted that the patient had a left V3 paresthesia.  She had a gross malocclusion.  On the facial CT and panoramic x-ray, it was noted to be a displaced left angle fracture and nondisplaced symphysis fracture.  Alternatives were discussed with the patient and it was determined she would benefit from being taken to the operating room under general anesthesia to have a closed reduction of her fractures.  Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and informed consent was obtained with the patient's mother.,DESCRIPTION OF PROCEDURE:, The patient was taken to the operating room #4 at Hospital and laid in a supine position on the operating room table.  Monitor was attached and general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics.  The patient was prepped and draped in the usual oromaxillofacial surgery fashion.,Surgeon approached the operating table in a sterile fashion.  Approximately 10 mL of 2% lidocaine with 1:100,000 epinephrine was injected into the oral vestibule in a nerve block fashion.  A moistened Ray-Tec sponge was placed in the posterior oropharynx and the mouth was prepped with Peridex mouthrinse, scrubbed with a toothbrush.  The Peridex was evacuated with Yankauer suction.  Erich arch bars were adapted to the maxilla from the first molar to the contralateral first molar and secured with 24-gauge surgical steel wire on the posterior teeth and 26-gauge surgical steel wire on the anterior teeth.  Same was done on the mandible.  The patient was then manipulated up in the maximum intercuspation and noted to be reproducible.  The throat pack was then removed.,The patient was remanipulated up to the maximum intercuspation and secured with interdental elastics.  At this point in time, the procedure was then determined to be over.,The patient was extubated and transferred to the PACU in good condition.", Dentistry,7
"REASON FOR THE CONSULT:,  Nonhealing right ankle stasis ulcer.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers, who was admitted on 01/27/09 for scheduled vascular surgery per Dr. X. I was consulted for nonhealing right ankle stasis ulcer.  There is a concern that the patient had a low-grade fever of 100.2 early this morning.  The patient otherwise feels well.  He was not even aware of the fever.  He does have some ankle pain, worse on the right than the left.  Old medical records were reviewed.  He has multiple hospitalizations for leg cellulitis.  Multiple wound cultures have repeatedly grown Pseudomonas, Enterococcus, and Stenotrophomonas in the past.  Klebsiella and Enterobacter have also grown in the few wound cultures at some point.  The patient has been following up at the wound center as an outpatient and was referred to Dr. X for definitive surgical management.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No malaise.  Positive recent low-grade fevers.  No chills.,HEENT:  No acute change in visual acuity, no diplopia, no acute hearing disturbances, and no sinus congestion.  No sore throat.,CARDIAC:  No chest pain or cough.,GASTROINTESTINAL:  No nausea, vomiting or diarrhea.,All other systems were reviewed and were negative.,PAST MEDICAL HISTORY:  ,Hypertension, exploratory laparotomy in 2004 for abdominal obstruction, cholecystectomy in 2005, chronic intermittent bipedal edema, venous insufficiency, chronic recurrent stasis ulcers.,SOCIAL HISTORY: , The patient admits to heavy alcohol drinking in the past, quit several years ago.  He is also a former cigarette smoker, quit several years ago.,ALLERGIES:,  None known.,CURRENT MEDICATIONS:,  Primaxin, daptomycin, clonidine, furosemide, potassium chloride, lisinopril, metoprolol, ranitidine, Colace, amlodipine, zinc sulfate, Lortab p.r.n., multivitamins with minerals.,PHYSICAL EXAMINATION:,CONSTITUTIONAL/VITAL SIGNS:  Heart rate 73, respiratory rate 20, blood pressure 104/67, temperature 98.3, and oxygen saturation 92% on room air.,GENERAL APPEARANCE:  The patient is awake, alert, and not in cardiorespiratory distress.  Height 6 feet 1.5 inches, body weight 125.26 kilos.,EYES:  Pink conjunctivae, anicteric sclerae.  Pupils equal, brisk reaction to light.,EARS, NOSE, MOUTH AND THROAT:  Intact gross hearing.  Moist oral mucosa.  No oral lesions.,NECK:  No palpable neck masses.  Thyroid is not enlarged on inspection.,RESPIRATORY:  Regular inspiratory effort.  No crackles or wheezes.,CARDIOVASCULAR:  Regular cardiac rhythm.  No thrills or rubs.,GASTROINTESTINAL:  Normoactive bowel sounds.  Soft.  No guarding or rigidity.,LYMPHATIC:  No cervical lymphadenopathy.,MUSCULOSKELETAL:  Good range of motion of upper and lower extremities.,SKIN:  There is hyperpigmentation involving the distal calf of both legs.  There is an open wound on the right medial,malleolar area measuring 9 x 5cm with minimal serous drainage.  Periwound is hyperpigmented with a hint of erythema extending proximally to the medial aspect, distal third of the right lower leg.  There is warmth, but minimal tenderness on palpation of this area.  There is also a wound on the right lateral malleolar area measuring 4 x 3 cm, another open wound on the left medial malleolar area measuring 7 x 4 cm.  Wound edges are poorly defined.,PSYCHIATRIC:  Appropriate mood and affect, oriented x3.  Fair judgment and insight.,LABORATORY RESULTS: , White blood cell count from 01/28/09 is 5.8 with 64% neutrophils, H&H 11.3/33.8, and platelet count 176,000.  BUN and creatinine 9.2/0.52.  Albumin 3.6, AST 25, ALT 9, alk phos 87, and total bilirubin 0.6.  One wound culture from right leg wound culture from 01/27/09 noted with young growth.  Left leg wound culture from 01/27/09 also with young growth.,RADIOLOGY:,  Chest x-ray done on 01/28/09 showed chronic bibasilar subsegmental atelectasis likely related to elevated hemidiaphragm secondary to chronic ileus.  No absolute findings.,IMPRESSION:,1.  Fevers.,2.  Right leg/ankle cellulitis.,3.  Chronic recurrent bilateral ankle venous ulcers.,4.  Multiple previous wound cultures positive for Pseudomonas, Enterococcus, and Stenotrophomonas.,5.  Hypertension.,RECOMMENDATIONS:,1.  We have ordered 2 sets of blood cultures.,2.  Agree with daptomycin and Primaxin IV.,3.  Follow up result of wound cultures.,4.  I will order an MRI of the right ankle to check for underlying osteomyelitis.,Additional ID recommendations as appropriate upon followup.", General Medicine,15
"PREOPERATIVE DIAGNOSIS:  ,Tailor's bunion and neuroma of the second and third interspace of the left foot.,POSTOPERATIVE DIAGNOSIS:, Tailor's bunion and neuroma of the second and third interspace, left foot.,PROCEDURE PERFORMED:,1.  Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.,2.  Excision of nerve lesion with implantation of the muscle belly of the left second interspace.,3.  Excision of nerve lesion in the left third interspace.,ANESTHESIA:  ,Monitored IV sedation with local.,HISTORY:  ,This is a 37-year-old female who presents to ABCD's preoperative holding area, n.p.o. since mid night, last night for surgery of her painful left second and third interspaces and her left fifth metatarsal.  The patient has attempted conservative correction and injections with minimal improvement.  The patient desires surgical correction at this time.  The patient states that her pain has been increasingly worsening with activity and with time and it is currently difficult for her to ambulate and wear shoes.  At this time, the patient desires surgical intervention and correction.  The risks versus benefits of the procedure have been explained to the patient in detail by Dr. X and consent was obtained.,PROCEDURE IN DETAIL: , After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was taken to the Operating Suite via cart and placed on the operating table in the supine position.  A safety strap was placed across her waist for protection.,Next, a pneumatic ankle tourniquet was applied around her left ankle over copious amounts of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of a mixture of 4.5 cc of 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1 cc of Solu-Medrol per 10 cc dose was administered to the patient for local anesthesia.  The foot was then prepped and draped in the usual sterile orthopedic manner.  The foot was then elevated and a tourniquet was then placed at 230 mmHg after applying Esmarch bandage.  The foot was then lowered down the operative field and sterile stockinet was draped.  The stockinet was then reflected.  Attention was then directed to the second intermetatarsal interspace.  After testing the anesthesia, a 4 cm incision was placed using a #10 blade over the dorsal surface of the foot in the second intermetatarsal space beginning from proximal third of the metatarsals distally to and beyond the metatarsal head.  Then, using #15 blade the incision was deepened through the skin into the subcutaneous tissue.  Care was taken to identify and avoid or to cauterize any local encountered vascular structures.  Incision was deepened using the combination of blunt and dull dissection using Mayo scissors, hemostat, and a #15 blade.  The incision was deepened distally down to the level of the deep transverse metatarsal ligament which was reflected and exposure of the intermetatarsal space was appreciated.  The individual branches of the plantar digital nerve were identified extending into the second and third digits plantarly.  These endings were dissected distally and cut at their most distal portions.  Following this, the nerve was dissected proximally into the common nerve and dissected proximally into the proximal portion of the intermetatarsal space.  Using careful meticulous dissection, there was noted to a be a enlarged bulbous mass of fibers and nerve tissue embedded with the adipose tissue.  This was also cut and removed.  The proximal portion of the nerve stump was identified and care was taken to suture this into the lumbrical muscle to leave no free nerve ending exposed.  Following this, the interspace was irrigated with copious amounts of sterile saline and interspace explored for any other portions of nerve which may been missed on the previous dissection.  It was noted that no other portions of the nerve were detectable and the proximal free nerve ending was embedded and found to be ________ the lumbrical muscle belly.  Following this, the interspace was packed using iodoform gauze packing and was closed in layers with the packing extruding from the wound.  Attention was then directed to the third interspace where in a manner as mentioned before.  A dorsal linear incision which measured 5 cm was made over the third interspace extending from the proximal portion of the metatarsal distally to the metatarsal head.  Like before, using a combination of blunt and dull dissection, with sharp dissection the incision was deepened down with care taken to cauterize all retracting vascular structures which were encountered.,The incision was deepened down to the level of the subcutaneous tissue and then down deeper to the interspace of the third and fourth metatarsal.  The dissection was deepened distally down to the level of the transverse intermetatarsal ligament, where upon this was reflected and the nerve fibers to the third and fourth digit plantarly were identified.  These were once again dissected distally out and transected at their most distal portions.  Care was then taken to dissect the nerve proximally into the proximal metatarsal region.  No other branches of the nerve were identified and the nerve in its entirety along with fibrous tissue encountered in the area was removed.  The proximal portion of the nerve which remained was not large enough to suture into lumbrical muscle as was done in the previous interspace.  Half of the nerve was transected proximally as was feasible and no exposed ending was noted.  Incision was then flushed and irrigated using sterile saline.  Following this, the incision wound was packed with iodoform gauze packed and closed in layers using as before #4-0 Vicryl and #4-0 nylon suture.,Following this, attention was directed to the fifth metatarsal head where a lateral 4 cm incision was placed along the lateral distal shaft and head of the fifth metatarsal using a fresh #10 blade.  The incision was then deepened using #15 blade down to the level of the subcutaneous tissue.  Care was taken to reflect any neurovascular structures which were encountered.  Following this the incision was deepened down to the level of the periosteum and periosteum was reflected, using the sharp dissection, to expose the head of the metatarsal along with the neck region.  After adequate exposure of the fifth metatarsal head was achieved, an oblique incision directed from distal lateral to proximal medial in a sagittal plane was performed and the head of the fifth metatarsal was shifted medially.  Following this, an OrthoSorb pin was retrograded through the fifth metatarsal head into the neck of the fifth metatarsal and was cut off first with the lateral surfaces of bone.  OrthoSorb pin was noted to be intact and the fifth metatarsal head was in good alignment and position.  Following this, the sagittal saw and the #138 blade were used to provide rasping and smoothing of the sharp acute edges of bone laterally.  Following this, the periosteum was closed using #4-0 Vicryl and the skin was closed in layers using #4-0 Vicryl and closed with running subcuticular #4-0 Monocryl suture.  Upon completion of this, the foot was noted to be in good position with good visual alignment of the fifth metatarsal head and digit.  The incisions in foot were then ________ draped in the normal manner using Owen silk, 4 x 4s, Kling, and Kerlix and covered with Coban bandage.  The tourniquet was then deflated with the total tourniquet time of 103 minutes at 230 mmHg and immediate hyperemia was noted to end digits one through five of the left foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  The patient tolerated the procedure well without any complications.  The patient was then given prescriptions for Vicoprofen #30 and Augmentin #14 to be taken twice daily.  The patient was instructed to followup with Dr. X after the weekend on Tuesday in his office.  The patient also given postoperative instructions and was placed in a postoperative shoe and instructed to limit weightbearing to the heel only, ice and elevate her foot 20 minutes every hour as tolerated.  The patient also instructed to take her medications and prescriptions as directed.  She was given the emergency contact numbers.  Postoperative x-rays were taken and the patient was discharged home in stable condition upon conclusion of this.", Orthopedic,27
"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,24
"CC:, Headache.,HX:, 63 y/o RHF first seen by Neurology on 9/14/71 for complaint of episodic vertigo. During that evaluation she described a several year history of ""migraine"" headaches. She experienced her first episode of vertigo in 1969. The vertigo (clockwise) typically began suddenly after lying down, and was not associated with nausea/vomiting/headache. The vertigo had not been consistently associated with positional change and could last hours to days.,On 3/15/71, after 5 day bout of vertigo, right ear ache, and difficulty ambulating (secondary to the vertigo) she sought medical attention and underwent an audiogram which reportedly showed a 20% decline in low tone acuity AD. She complained of associated tinnitus which she described as a ""whistle."" In addition, her symptoms appeared to worsen with changes in head position (i.e. looking up or down). The symptoms gradually resolved and she did well until 8/71 when she experienced a 19-day episode of vertigo, tinnitus and intermittent headaches. She was seen 9/14/71, in Neurology, and admitted for evaluation.,Her neurologic exam at that time was unremarkable except for prominent bilateral systolic carotid bruits. Cerebral angiogram revealed an inoperable 7 x 6cm AVM in the right parietal region. The AVM was primarily fed by the right MCA. Otolaryngologic evaluation concluded that she probably also suffered from Meniere's disease.,On 10/14/74 she underwent a 21 day admission for SAH secondary to right parietal AVM.,On 11/23/91 she was admitted for left sided weakness (LUE > LLE), headache, and transient visual change. Neurological exam confirmed left sided weakness, and dysesthesia of the LUE only. Brain CT confirmed a 3 x 4 cm left parietal hemorrhage. She underwent unsuccessful embolization. Neuroradiology had planned to do 3 separate embolizations, but during the first, via the left MCA, they were unable to cannulate many of the AVM vessels and abandoned the procedure. She recovered with residual left hemisensory loss.,In 12/92 she presented with an interventricular hemorrhage and was managed conservatively and refused any future neuroradiologic intervention.,In 1/93 she reconsidered neurointerventional procedure and was scheduled for evaluation at the Barrows Neurological Institute in Phoenix, AZ.", Radiology,33
"PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis. ,PROCEDURE: , Laparoscopic appendectomy. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation.  His abdomen was prepped and draped in a standard, sterile surgical fashion.  A Foley catheter was placed for bladder decompression.  Marcaine was injected into his umbilicus.  A small incision was made.  A Veress needle was introduced in his abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus.  A 5-mm port was then placed just to the right side of the umbilicus.  Another 5-mm port was placed just suprapubic in the midline.  Upon inspection of the cecum, I was able find an inflamed and indurated appendix.  I was able to clear the mesentery at the base of the appendix between the appendix and the cecum.  I fired a white load stapler across the appendix at its base and fired a grey load stapler across the mesentery, and thereby divided the mesentery and freed the appendix.  I put the appendix in an Endocatch bag and removed it through the umbilicus.  I irrigated out the abdomen.  I then closed the fascia of the umbilicus with interrupted 0 Vicryl suture utilizing Carter-Thomason and closed the skin of all incisions with a running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.", Surgery,38
"TITLE OF OPERATION:,1.  Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture including skin, muscle, and bone using a Synthes 3.5 mm locking plate on the lateral malleolus and two Synthes 4.5 mm cannulated screws medial malleolus.,2.  Closed reduction and screw fixation of right femoral neck fracture using one striker Asnis 8.0 mm cannulated screw and two 6.5 mm cannulated screws.,3.  Retrograde femoral nail using a striker T2 retrograde nail 10 x 340 with a 10 mm INCAP and two 5 mm distal locking screws and two 5 mm proximal locking screws.,4.  Irrigation and debridement of right knee.,5.  Irrigation and debridement of right elbow abrasions.,PREOP DIAGNOSIS:,1.  Right open ankle fracture.,2.  Right femoral shaft fracture.,3.  Right femoral neck fracture.,4.  Right open knee.,5.  Right elbow abrasions.,POSTOP DIAGNOSIS:,1.  Right open ankle fracture.,2.  Right femoral shaft fracture.,3.  Right femoral neck fracture.,4.  Right open knee.,5.  Right elbow abrasions.,INTRAVENOUS FLUIDS: , 650 packed red blood cells.,TOURNIQUET TIME: , 2 hours.,URINE OUTPUT:  ,1600 cubic centimeters.,ESTIMATED BLOOD LOSS: , 250 cubic centimeters.,COMPLICATIONS:,  None.,PLAN:,  non-weightbearing right lower extremity, clindamycin x 48 hours.,OPERATIVE NARRATIVE:,  The patient is a 53-year-old female who is a pedestrian struck, in a motor vehicle accident and sustained numerous injuries.  She sustained a right open ankle fracture, right femur fracture, right femoral neck fracture, right open knee, and right elbow abrasions.  Given the emergent nature of the right femoral neck fracture and her young age as well as the open fracture, it was decided to proceed with an urgent operative intervention.  The risks of surgery were discussed in detail and the consents were signed.  The operative site was marked.  The patient was taken to the operating room where she was given preoperative clindamycin.  The patient had then general anesthetic performed by anesthesia.,A well-padded side tourniquet was placed.  Attention was turned to the right ankle first.  The large medical laceration was extended and the tissues were debrided.  All dirty of the all injured bone, muscle, and tissues were debrided.  Wound was then copiously irrigated with 8 liters of normal saline.  At this point, the medial malleolus fracture was identified and was reduced.  This was then fixed in with two 4.5 mm cannulated Synthes screws.,Next, the attention was turned to lateral malleolus.  Incision was made over the distal fibula.  It was carried down sharply through the skin in the subcutaneous issues.  Care was taken to preserve the superficial peroneal nerve.  The fracture was identified, and there was noted to be very comminuted distal fibula fracture.  The fracture was reduced and confirmed with fluoroscopy.  A 7 hole Synthes 3.5 mm locking plate was placed.  This was placed in a bridging fashion with three screws above and three screws below the fracture.  Appropriate reduction was confirmed under fluoroscopy.  A cotton test was performed, and the ankle did not open up.  Therefore, it was decided not to proceed with syndesmotic screw.,Next, the patient was then placed in the fracture table and all extremities were well padded.  All prominences were padded.  The right leg was then prepped and draped in usual sterile fashion.  A 2-cm incision was made just distal to the greater trochanter.  This was carried down sharply through the skin to the fascia.  The femur was identified.  The guidewire for a striker Asnis 6.5 mm screw was placed in the appropriate position.  The triangle guide was then used to ensure appropriate triangular formation of the remainder of the screws.  A reduction of the fracture was performed prior to placing all the guide wires.  A single 8 mm Asnis screw was placed inferiorly followed by two 6.5 mm screws superiorly.,Next, the abrasions on the right elbow were copiously irrigated.  The necrotic and dead tissue was removed.  The abrasions did not appear to enter the joints.  They were wrapped with Xeroform 4 x 4 x 4 Kerlix and Ace wrap.,Next, the lacerations of the anterior knee were connected and were extended in the midline.  They were carried down sharply to the skin and the retinacular issues to the joint.  The intercondylar notch was identified.  A guide wire for the striker T2 retrograde nail was placed and localized with fluoroscopy.  The opening reamer was used following the bolted guide wire was then passed.  The femur was then sequentially reamed using the flexible reamers.  A T2 retrograde nail 10 x 340 was then passed.  Two 5 mm distal locking screws and two 5 mm proximal locking screws were then placed.,Prior to reaming and passing the retrograde nail, the knee was copiously irrigated with 8 liters of normal saline.  Any dead tissues in the knee were identified and were debrided using rongeurs and curettes.,The patient was placed in the AO splints for the right ankle.  The wounds were dressed with Xeroform 4 x 4 x 4s and IO band.  The care was then transferred for the patient to Halstead Service.,The plan will be non-weightbearing right lower extremity and antibiotics for 48 hours.,Dr. X was present and scrubbed for the entirety of the procedure.", Orthopedic,27
"PREOPERATIVE DIAGNOSIS: , Bladder tumor.,POSTOPERATIVE DIAGNOSIS: , Bladder tumor.,PROCEDURE PERFORMED: , Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Bladder tumor and specimen from base of bladder tumor.,DRAINS: , A 22-French 3-way Foley catheter, 30 mL balloon.,ESTIMATED BLOOD LOSS:,  Minimal.,INDICATIONS FOR PROCEDURE: , This is a 74-year-old male who presented with microscopic and an episode of gross hematuria.  He underwent an IVP, which demonstrated enlarged prostate and normal upper tracts.  Cystoscopy in the office demonstrated a 2.5- to 3-cm left lateral wall bladder tumor.  He is brought to the operating room for transurethral resection of that bladder tumor.,DESCRIPTION OF OPERATION: , After preoperative counseling of the patient and his wife, the patient was taken to the operating room and administered a spinal anesthetic.  He was placed in lithotomy position and prepped and draped in the usual fashion.  Using the visual obturator, the resectoscope was then inserted per urethra into the bladder.  The bladder was inspected confirming previous cystoscopic findings of a 2.5- to 3-cm left lateral wall bladder tumor away from the ureteral orifice.  Using the resectoscope loop, the tumor was then resected down to its base in a stepwise fashion.  Following completion of resection down to the base, the bladder was _______ free of tumor specimen.  The resectoscope was then reinserted and the base of the bladder tumor was then resected to get the base of the bladder tumor specimen, this was sent as a separate pathological specimen.  Hemostasis was assured with electrocautery.  The base of the tumor was then fulgurated again and into the periphery out in the normal mucosa surrounding the base of the bladder tumor.  Following completion of the fulguration, there was good hemostasis.  The remainder of the bladder was without evidence of significant abnormality.  Both ureteral orifices were visualized and noted to drain freely of clear urine.  The bladder was filled and the resectoscope was removed.  A 22-French 3-way Foley catheter was inserted per urethra into the bladder.  The balloon was inflated to 30 mL.  The catheter with sterile continuous irrigation and was noted to drain clear irrigant.  The patient was then removed from lithotomy position.  He was in stable condition.", Surgery,38
"DESCRIPTION OF PROCEDURE: , After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table.  Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty.  The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally.  Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants.  A lens ring was secured to the eye using 7-0 Vicryl suture.", Ophthalmology,26
"PREOPERATIVE DIAGNOSIS:  ,1.  Right cubital tunnel syndrome.,2.  Right carpal tunnel syndrome.,3.  Right olecranon bursitis.,POSTOPERATIVE DIAGNOSIS:,  ,1.  Right cubital tunnel syndrome.,2.  Right carpal tunnel syndrome.,3.  Right olecranon bursitis.,PROCEDURES:,  ,1.  Right ulnar nerve transposition.,2.  Right carpal tunnel release.,3.  Right excision of olecranon bursa.,ANESTHESIA:,  General.,BLOOD LOSS:,  Minimal.,COMPLICATIONS:,  None.,FINDINGS: , Thickened transverse carpal ligament and partially subluxed ulnar nerve.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  After uneventful general anesthesia was obtained, his right arm was sterilely prepped and draped in normal fashion.  After elevation and exsanguination with an Esmarch, the tourniquet was inflated.  The carpal tunnel was performed first with longitudinal incision in the palm carried down through the skin and subcutaneous tissues.  The palmar fascia was divided exposing the transverse carpal ligament, which was incised longitudinally.  A Freer was then inserted beneath the ligament, and dissection was carried out proximally and distally.,After adequate release has been formed, the wound was irrigated and closed with nylon.  The medial approach to the elbow was then performed and the skin was opened and subcutaneous tissues were dissected.  A medial antebrachial cutaneous nerve was identified and protected throughout the case.  The ulnar nerve was noted to be subluxing over the superior aspect of the medial epicondyle and flattened and inflamed.  The ulnar nerve was freed proximally and distally.  The medial intramuscular septum was excised and the flexor carpi ulnaris fascia was divided.  The intraarticular branch and the first branch to the SCU were transected; and then the nerve was transposed, it did not appear to have any significant tension or sharp turns.  The fascial sling was made from the medial epicondyle and sewn to the subcutaneous tissues and the nerve had good translation with flexion and extension of the elbow and not too tight.  The wound was irrigated.  The tourniquet was deflated and the wound had excellent hemostasis.  The subcutaneous tissues were closed with #2-0 Vicryl and the skin was closed with staples.  Prior to the tourniquet being deflated, the subcutaneous dissection was carried out over to the olecranon bursa, where the loose fragments were excised with a rongeurs as well as abrading the ulnar cortex and excision of hypertrophic bursa.  A posterior splint was applied.  Marcaine was injected into the incisions and the splint was reinforced with tape.  He was awakened from the anesthesia and taken to recovery room in a stable condition.  Final needle, instrument, and sponge counts were correct.", Orthopedic,27
"CC: ,Headache.,HX: ,This 37y/o LHM was seen one month prior to this presentation for HA, nausea and vomiting. Gastrointestinal evaluation at that time showed no evidence of bowel obstruction and he was released home. These symptoms had been recurrent since onset.,At presentation he complained of mild blurred vision (OU), difficulty concentrating and HA which worsened upon sitting up. The headaches were especially noticeable in the early morning. He described them as non-throbbing headaches. They begin in the bifrontal region and radiate posteriorly. They occurred up to 6 times/day. The HA improved with lying down or dropping the head down between the knees towards the floor. The headaches were associated with blurred vision, nausea,vomiting, photophobia, and phonophobia. He denied any scotomata or positive visual phenomena. He denies any weakness, numbness, tingling, dysarthria or diplopia. His weight has fluctuated from 163# to 148# over the past 3 months and at present he weighs 154#. His appetite has been especially poor in the past month.,MEDS:,Sulfasalazine qid. Tylenol 650mg q4hours.,PMH:, 1)Ulcerative Colitis dx 1989. 2)HTN 3) occasional HAs since the early 1980s which are different in character and much less severe than his current HAs. They were not associated with nausea, vomiting, photophobia, phonophobia or difficulty thinking.,FHX:, MGF with h/o stroke. Mother and Father were healthy. No h/o of migraine in family.,SHX:, Single. Works as a newpaper printing press worker. Denies tobacco, ETOH or illicit drug use, but admits he was a heavy drinker until the last 1970s when he quit.,EXAM: ,BP159/92 HR 48 (sitting): BP126/70 HR48 (supine). RR14 36.2C,MS: A&O to person, place and time. Speech clear. Appears uncomfortable but acts appropriately and cooperatively. No difficulty with short and long term memory.,CN: Grad 2-3 papilledema OS; Grade 1 papilledema (@2 o'clock) OD. Pupils 4/4 decreasing to 2/2 on exposure to light. Bilateral horizontal sustained nystagmus on right and leftward gaze. Bilateral vertical sustained nystagmus on up and downward gaze. Face symmetric with full movement and PP sensation. Tongue midline with full ROM. Gag and SCM were intact bilaterally.,Motor: Full strength throughout with normal muscle bulk and tone.,Sensory: Unremarkable.,Coord: Mild dysynergia on FNF movements in BUE. HNS and RAM were unremarkable.,Station: Unsteady with and without eyes open on Romberg test. No drift in any particular direction.,Gait: Wide based, ataxic and to some degree magnetic and apraxic.,Gen Exam: Unremarkable.,COURSE:, Urinalysis revealed 1-2RBC, 2-3WBC and bacteria were noted. Repeat Urinalysis was negative the next day. PT, PTT, CXR and GS were normal. CBC revealed 10.4WBC with 7.1Granulocytes. HCT, 10/18/95, revealed hydrocephalus. MRI, 10/18/95, revealed ventriculomegaly of the lateral, 3rd and 4th ventricles. There was enhancement of the meninges about the prepontine cisterna and internal auditory canals, and enhancement of a scar or inflammed lining of the foramen of Magendie. These changes were felt suggestive of bacterial or granulomatous meningitis. The patient underwent ventriculostomy on 10/19/94. CSF taken on 10/19/94 via V-P shunt insertion revealed: 22 WBC (21 lymphocytes, 1 monocyte), 380 RBC, Glucose 58, Protein 29, GS negative, Cultures (bacterial, fungal, AFB) negative, Cryptococcal Antigen and India Ink were negative. Numerous CSF samples were taken from the lumbar region and shunt reservoir and these were consistantly unremarkable except for an occasional CSF protein of up to 99mg/dl. Serum and CSF toxoplasma titers and ACE levels were negative on multiple occasions. VDRL and HIV testing was unremarkable. 10/27/94 and 10/31/94 CSF cultures taken from the cervical region eventually grew non-encapsulated crytococcus neoformans. The patient was treated with amphotericin and showed some improvement. However, scarring had probably occurred by then and the V-P shunt was left in place.", Radiology,33
"PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, left.,POSTOPERATIVE DIAGNOSES:,1.  Sixty-percent rotator cuff tear, joint side.,2.  Impingement syndrome.,ANESTHESIA: , General,NAME OF OPERATION:,1.  Arthroscopic subacromial decompression.,2.  Repair of rotator cuff through mini-arthrotomy.,FINDINGS AT OPERATION: , The patient's glenohumeral joint was completely clear, other than obvious tear of the rotator cuff.  The midportion of this appeared to be complete, but for the most part, this was about a 60% rupture of the tendon.  This was confirmed later when the bursal side was opened up.  Note, the patient also had abrasion of the coracoacromial ligament under the anterolateral edge of the acromion.  He did not have any acromioclavicular joint pain or acromioclavicular joint disease noted.,PROCEDURE:,  He was given an anesthetic, examined, prepped, and draped in a sterile fashion in a beach-chair position.  The shoulder was instilled with fluid from posteriorly, followed by the arthroscope.  The shoulder was instilled with fluid from posteriorly, followed by the arthroscope.  Arthroscopy was then carried out in standard fashion using a 30-degree Dionic scope.  With the scope in the posterior portal, the above findings were noted, and an anterior portal was established.  A curved shaver was placed for debridement of the tear.  I established this was about a 60-70% tear with a probable complete area of tear which was very small.  There were no problems at the biceps or the rest of the joint.  The subacromial space showed findings, as noted above, and a thorough subacromial decompression was carried out with a Bovie, rotary shaver, and bur.  I did not debride the acromioclavicular joint.  The lateral portal was then extended to a mini-arthrotomy, and subacromial space was entered by blunt dissection through the deltoid.  The area of weakness of the tendon was found, and was transversely cut, and findings were confirmed.  The diseased tissue was removed, and the greater tuberosity was abraded with a rongeur.  Tendon-to-tendon repair was then carried out with buried sutures of 2-0 Ethibond, giving a very nice repair.  The shoulder was carried through a range of motion.  I could see no evidence of impingement.  Copious irrigation was carried out.  The deltoid deep fascia was anatomically closed, as was the superficial fascia.  The subcutaneous tissue and skin were closed in layers.  A sterile dressing was applied.  The patient appeared to tolerate the procedure well.", Orthopedic,27
"CHIEF COMPLAINT: , Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 45-year-old white male who was admitted with acute back pain.  The patient reports that he had chronic problem with back pain for approximately 20 years, but it has gotten progressively worse over the last 3 years.  On 08/29/2007, the patient had awoken and started his day as he normally does, but midday, he reports that he was in such severe back pain and he was unable to walk or stand upright.  He was seen at ABCD Hospital Emergency Room, was evaluated and admitted.  He was treated with IV analgesics as well as Decadron, after being evaluated by Dr. A.  It was decided that the patient could benefit from physical therapy, since he was unable to perform ADLs, and was transferred to TCU at St. Joseph Health Services on 08/30/2007.  He had been transferred with diagnosis of a back pain secondary to intravertebral lumbar disk disease, secondary to degenerative changes.  The patient reports that he has had a "" bulging disk"" for approximately 1 year.  He reports that he has history of testicular cancer in the distant past and the most recent bone scan was negative.  The bone scan was done at XYZ Hospital, ordered by Dr. B, the patient's oncologist.,ALLERGIES: , PENICILLIN, AMOXICILLIN, CEPHALOSPORIN, DOXYCYCLINE, IVP DYE, IODINE, and SULFA, all cause HIVES.,Additionally, the patient reports that he has HIVES when he comes in contact with SAP FROM THE MANGO TREE, and therefore, he avoids any mango product at all.,PAST MEDICAL HISTORY: , Status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, GERD, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY: , The patient is employed in the finance department.  He is a nonsmoker.  He does consume alcohol on the weekend as much as 3 to 4 alcoholic beverages per day on the weekends.  He denies any IV drug use or abuse.,REVIEW OF SYSTEMS: , No chills, fever, shakes or tremors.  Denies chest pain palpitations, hemoptysis, shortness of breath, nausea, vomiting, diarrhea, constipation or hematemesis.  The patient reports that his last bowel movement was on 08/30/2007.  No urological symptoms such as dysuria, frequency, incomplete bladder emptying or voiding difficulties.  The patient does report that he has occasional intermittent ""numbness and tingling"" of his hands bilaterally as he has a history of bilateral carpal tunnel syndrome.  He denies any history of seizure disorders, but he did report that he had some momentary dizziness earlier, but that has since resolved.,PHYSICAL EXAMINATION:,VITAL SIGNS:  At the time of admission, temperature 98, blood pressure 176/97, pulse 86, respirations 20, and 95% O2 saturation on room air.  The patient weighs 260 pounds and is 5 feet and 10 inches tall by his report.,GENERAL:  The patient appears to be comfortable, in no acute distress.,HEENT:  Normocephalic.  Sclerae are nonicteric.  EOMI.  Tongue is at midline and no evidence of thrush.,NECK:  Trachea is at the midline.,LYMPHATICS:  No cervical or axillary nodes palpable.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Regular rate and rhythm.  Normal S1 and S2.,ABDOMEN:  Obese, softly protuberant, and nontender.,EXTREMITIES:  There is no clubbing, cyanosis or edema.  There is no calf tenderness bilaterally.  Bilateral strength is 5/5 for the upper extremities bilaterally and he has 5/5 of left lower extremity.  The right lower extremity is 4-5/5.,MENTAL STATUS:  He is alert and oriented.  He was pleasant and cooperative during the examination.,ASSESSMENT:,1.  Acute on chronic back pain.  The patient is admitted to the TCU at St. Joseph Health Services for rehabilitation therapy.  He will be seen in consultation by Physical Therapy and Occupational Therapy.  He will continue a tapering dose of Decadron over the next 10 to 14 days and a tapering schedule has been provided, also Percocet 5/325 mg 1 to 2 tablets q.i.d. p.r.n. for pain.,2.  Status post right orchiectomy secondary to testicular cancer, stable at this time.  We will attempt to obtain copy of the most recent bone scan performed at XYZ Hospital ordered by Dr. B.,3.  Gastroesophageal reflux disease, irritable bowel syndrome, and gastrointestinal prophylaxis.  Colace 100 mg b.i.d., lactulose will be used on a p.r.n. basis, and Protonix 40 mg daily.,4.  Deep vein thrombosis prophylaxis will be maintained by the patient, continue to engage in his therapies including ambulating in the halls and doing leg exercises as well.,5.  Obesity.  As mentioned above, the patient's weighs 260 pounds with a height of 5 feet and 10 inches, and we had discussed possible weight loss plan, which he is interested in pursuing and a dietary consult has been requested.", Orthopedic,27
"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy of 39 weeks.,2.  Herpes simplex virus, positive by history.,3.  Hepatitis C, positive by history with low elevation of transaminases.,4.  Cephalopelvic disproportion.,5.  Asynclitism.,6.  Postpartum macrosomia.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy of 39 weeks.,2.  Herpes simplex virus, positive by history.,3.  Hepatitis C, positive by history with low elevation of transaminases.,4.  Cephalopelvic disproportion.,5.  Asynclitism.,6.  Postpartum macrosomia.,7.  Delivery of viable 9 lb female neonate.,PROCEDURE PERFORMED: , Primary low transverse cervical cesarean section.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , About 600 cc.,Baby is doing well.  The patient's uterus is intact, bladder is intact.,HISTORY: , The patient is an approximately 25-year-old Caucasian female with gravida-4, para-1-0-2-1.  The patient's last menstrual period was in December of 2002 with a foreseeable due date on 09/16/03 confirmed by ultrasound.,The patient has a history of herpes simplex virus to which there is no active prodromal and no evidence of lesions.  The patient has a history of IVDA and contracted hepatitis C with slightly elevated liver transaminases.  The patient had been seen through our office for prenatal care.  The patient is on Valtrex.  The patient was found to be 3 cm about 40%, 0 to 9 engaged.  Bag of waters was ruptured.  She was on Pitocin.  She was contracting appropriately for a couple of hours or so with appropriate ________.  There was no cervical change noted.  Most probably because there was a sink vertex and that the head was too large to descend into the pelvis.  The patient was advised of this and we recommended cesarean section.  She agreed.  We discussed the surgery, foreseeable risks and complications, alternative treatment, the procedure itself, and recovery in layman's terms.  The patient's questions were answered.  I personally made sure that she understood every aspect of the consent and that she was comfortable with the understanding of what would transpire.,PROCEDURE:  ,The patient was then taken back to operative suite.  She was given anesthetic and sterilely prepped and draped.  Pfannenstiel incision was used.  A second knife was used to carry the incision down to the anterior rectus fascia.  Anterior rectus fascia was incised in the midline and carried bilaterally and the fascia was lifted off the underlying musculature.  The rectus muscles were separated.  The patient's peritoneum tented up towards the umbilicus and we entered the abdominal cavity.  There was a very thin lower uterine segment.  There seemed to be quite a large baby.  The patient had a small nick in the uterus.  Following the blunt end of the bladder knife going through the innermost layer of the myometrium and into the endometrial cavity, clear amniotic fluid was obtained.  A blunt low transverse cervical incision was made.  Following this, we placed a ________ on the very large fetal head.  The head was delivered following which we were able to deliver a large baby girl, 9 lb, good at tone and cry.  The patient then underwent removal of the placenta after the cord blood and ABG were taken.  The patient's uterus was examined.  There appeared to be no retained products.  The patient's uterine incision was reapproximated and sutured with #0 Vicryl in a running non-interlocking fashion, the second imbricating over the first.  The patient's uterus was hemostatic.  Bladder flap was reapproximated with #0 Vicryl.  The patient then underwent an irrigation at every level of closure and the patient was quite hemostatic.  We reapproximated the rectus musculature with care being taken not to incorporate any underlying structures.  The patient had three interrupted sutures of this.  The fascia was reapproximated with two stitches of #0 Vicryl going from each apex towards the midline.  The Scarpa's fascia was reapproximated with #0 gut.  There was noted no fascial defects and the skin was closed with #0 Vicryl.,Prior to closing the abdominal cavity, the uterus appeared to be intact and bladder appeared to have clear urine and appeared to be intact.  The patient was hemostatic.  All counts were correct and the patient tolerated the procedure well.  We will see her back in recovery.", Surgery,38
"SUBJECTIVE:,  The patient is brought in by an assistant with some of his food diary sheets.  They wonder if the patient needs to lose anymore weight.,OBJECTIVE:,  The patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month.  He has lost a total of 34-1/2 pounds.  I praised this.  I went over his food diary and praised all of his positive food choices reported, especially his use of sugar-free Kool-Aid, sugar-free pudding, and diet pop.  I encouraged him to continue all of that, as well as his regular physical activity.,ASSESSMENT:,  The patient is losing weight at an acceptable rate.  He needs to continue keeping a food diary and his regular physical activity.,PLAN:,  The patient plans to see Dr. XYZ at the end of May 2005.  I recommended that they ask Dr. XYZ what weight he would like for the patient to be at.  Follow up will be with me June 13, 2005.", Diets and Nutritions,9
"EXAM: , Lumbar spine CT without contrast.,HISTORY: , Back pain after a fall.,TECHNIQUE:,  Noncontrast axial images were acquired through the lumbar spine. Coronal and sagittal reconstruction views were also obtained.,FINDINGS: , There is no evidence for acute fracture or subluxation.  There is no spondylolysis or spondylolisthesis.  The central canal and neuroforamen are grossly patent at all levels.  There are no abnormal paraspinal masses. There is no wedge/compression deformity.  There is intervertebral disk space narrowing to a mild degree at L2-3 and L4-5.,Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta, which is not dilated.  There was incompletely visualized probable simple left renal cyst, exophytic at the lower pole.,IMPRESSION:,1.  No evidence for acute fracture or subluxation.,2.  Mild degenerative changes.,3.  Probable left simple renal cyst.,", Radiology,33
"HISTORY: , Patient is a 21-year-old white woman who presented with a chief complaint of chest pain.  She had been previously diagnosed with hyperthyroidism.  Upon admission, she had complaints of constant left sided chest pain that radiated to her left arm.  She had been experiencing palpitations and tachycardia.  She had no diaphoresis, no nausea, vomiting, or dyspnea.,She had a significant TSH of 0.004 and a free T4 of 19.3.  Normal ranges for TSH and free T4 are 0.5-4.7 µIU/mL and 0.8-1.8 ng/dL, respectively.  Her symptoms started four months into her pregnancy as tremors, hot flashes, agitation, and emotional inconsistency.  She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards.  She complained of sweating, but has experienced no diarrhea and no change in appetite.  She was given isosorbide mononitrate and IV steroids in the ER.,FAMILY HISTORY:,  Diabetes, Hypertension, Father had a Coronary Artery Bypass Graph (CABG) at age 34.,SOCIAL HISTORY:,  She had a baby five months ago.  She smokes a half pack a day.  She denies alcohol and drug use.,MEDICATIONS:,  Citalopram 10mg once daily for depression; low dose tramadol PRN pain.,PHYSICAL EXAMINATION: , Temperature 98.4; Pulse 123; Respiratory Rate 16; Blood Pressure 143/74.,HEENT:  She has exophthalmos and could not close her lids completely.,Cardiovascular:  tachycardia.,Neurologic:  She had mild hyperreflexiveness.,LAB:,  All labs within normal limits with the exception of Sodium 133, Creatinine 0.2, TSH 0.004, Free T4 19.3 EKG showed sinus tachycardia with a rate of 122.  Urine pregnancy test was negative.,HOSPITAL COURSE: , After admission, she was given propranolol at 40mg daily and continued on telemetry.  On the 2nd day of treatment, the patient still complained of chest pain.  EKG again showed tachycardia.  Propranolol was increased from 40mg daily to 60mg twice daily., A I-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90% at 4 hours and 94% at 24 hours.  The normal range for 4-hour uptake is 5-15% and 15-25% for 24-hour uptake.  Endocrine consult recommended radioactive I-131 for treatment of Graves disease.,Two days later she received 15.5mCi of I-131.  She was to return home after the iodine treatment.  She was instructed to avoid contact with her baby for the next week and to cease breast feeding.,ASSESSMENT / PLAN:,1. Treatment of hyperthyroidism.  Patient underwent radioactive iodine 131 ablation therapy.,2. Management of cardiac symptoms stemming from hyperthyroidism.  Patient was discharged on propranolol 60mg, one tablet twice daily.,3. Monitor patient for complications of I-131 therapy such as hypothyroidism.  She should return to Endocrine Clinic in six weeks to have thyroid function tests performed.  Long-term follow-up includes thyroid function tests at 6-12 month intervals.,4. Prevention of pregnancy for one year post I-131 therapy.  Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive, taken one tablet daily.,5. Monitor ocular health.  Patient was given methylcellulose ophthalmic, one drop in each eye daily.  She should follow up in 6 weeks with the Ophthalmology clinic.,6. Management of depression.  Patient will be continued on citalopram 10 mg.", Endocrinology,13
"PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE:,  Stable, extubated, and transferred to the recovery room in stable condition.,INDICATIONS FOR PROCEDURE:  ,The patient is a 10-month-old baby with a history of a bilateral cleft of the lip and palate.  The patient has undergone cleft lip repair, and she is here today for her cleft palate operation.  We have discussed with the mother the nature of the procedure, risks, and benefits; the risks included but not limited to the risk of bleeding, infection, dehiscence, scarring, the need for future revision surgeries.  We will proceed with surgery.,DETAILS OF THE PROCEDURE:,  The patient was taken into the operating room, placed in the supine position, and general anesthetic was administered.  A prophylactic dose of antibiotics was given.  The patient proceeded to have bilateral PE tube placement by Dr. X, from Ear, Nose, and Throat Surgery.  After he was done with his procedure, the head of the bed was turned 90 degrees.  The patient was positioned with a shoulder roll and doughnut.  A Dingman retractor was placed.  The operative area was infiltrated with lidocaine with epinephrine 1:200,000, a total of 3 mL, and then, I proceeded with the prepping and draping.  The patient was prepped and draped.  I proceeded to do the palate repair.  The nature of the palate repair was done in the same way on the both sides.  I will describe one side.  The other side was done exactly in the same manner.  The 2 hemiuvulas are placed, holding from a single hook and infiltrated with lidocaine with epinephrine 1:200,000, triangle in the nasal mucosa was previously marked.  This triangle of nasal mucosa was removed and excised.  This was done on both uvulas.  Then, an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa.  A 1-mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better.  Once the incision was done up to the level of the hard palate, the muscle was dissected off the surrounding tissue, 2 mm from the nasal and the oral mucosa.  Then, I proceeded to place an incision at the alveolopalatal junction with the help of 15-blade.  The incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap.  Then the flap was lifted up with the help of a freer, and then the remaining of the incision medially was completed.  Hemostasis was achieved with help of electrocautery and Surgicel.  The mucoperiosteal flap was retracted posteriorly with the help of a freer elevator.  The greater auricular foramen was exposed, and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap.  Then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle.  The pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially.  This procedure was done on both sides in the same manner, and then __________ dissection was done including dissection of the hard palate from the nasal mucosa, it was evident that the nasal mucosa would not reach medially to be placed together.  At this point, the decision was made to proceed with vomer flaps.  The flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book.  The incision was done with a 15C blade.  The vomer flaps were dissected, and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate.  This was approximated on both sides with 5-0 chromic running and interrupted stitches, and I proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5-0 chromic and a 4-0 chromic.  Then 2 stitches of 4-0 Vicryl were applied to the soft palate in the Delaire manner through the full thickness of the mucosa and muscle on one side, on the other side, and then coming back on the mucosa to evert the edges of the soft palate.  The remaining part of the soft palate was placed together with 4-0 Vicryl and 4-0 chromic interrupted stitches.  The throat pack was removed.  The palate was cleaned.  The Dingman retractor was removed, and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2-0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of Tegaderm.  The patient tolerated the procedure without complications.  BSS is applied to the eye after removing the Tegaderm.  I was present and participated in all aspects of the procedure.  The sponge, needle, and instrument count were completed at the end of the procedure.  The patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Mesothelioma.,POSTOPERATIVE DIAGNOSIS:,  Mesothelioma.,OPERATIVE PROCEDURE: , Placement of Port-A-Cath, left subclavian vein with fluoroscopy.,ASSISTANT:,  None.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , The patient is a 74-year-old gentleman who underwent right thoracoscopy and was found to have biopsy-proven mesothelioma.  He was brought to the operating room now for Port-A-Cath placement for chemotherapy.  After informed consent was obtained with the patient, the patient was taken to the operating room, placed in supine position.  After induction of general endotracheal anesthesia, routine prep and drape of the left chest, left subclavian vein was cannulated with #18 gauze needle, and guidewire was inserted.  Needle was removed.  Small incision was made large enough to harbor the port.  Dilator and introducers were then placed over the guidewire.  Guidewire and dilator were removed, and a Port-A-Cath was introduced in the subclavian vein through the introducers.  Introducers were peeled away without difficulty.  He measured with fluoroscopy and cut to the appropriate length.  The tip of the catheter was noted to be at the junction of the superior vena cava and right atrium.  It was then connected to the hub of the port.  Port was then aspirated for patency and flushed with heparinized saline and summoned to the chest wall.  Wounds were then closed.  Needle count, sponge count, and instrument counts were all correct.", Surgery,38
"CHIEF COMPLAINT:, Right-sided weakness.,HISTORY OF PRESENT ILLNESS:, The patient was doing well until this morning when she was noted to have right-sided arm weakness with speech difficulties. She was subsequently sent to ABC Medical Center for evaluation and treatment. At ABC, the patient was seen by Dr. H including labs and a head CT which is currently pending. The patient has continued to have right-sided arm and hand weakness, and has difficulty expressing herself. She does seem to comprehend words. The daughter states the patient is in the Life Care Center, and she believes this started this morning. The patient denies headache, visual changes, chest pain and shortness of breath. These changes have been constant since onset this morning, have not improved or worsened, and the patient notes no modifying factors.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Medications are taken from the paperwork from Life Care Center and include: Lortab 3-4 times a day for pain, Ativan 0.25 mg by mouth every 12 hours p.r.n. pain, Depakote ER 250 mg p.o. q nightly, Actos 15 mg p.o. t.i.d., Lantus 35 units subcu q nightly, Glipizide 10 mg p.o. q day, Lanoxin 0.125 mg p.o. q day, Lasix 40 mg p.o. q day, Lopressor 50 mg p.o. b.i.d., insulin sliding scale, Lunesta 1 mg p.o. q nightly, Sorbitol 15 mg p.o. q day, Zoloft 50 mg p.o. q nightly, Dulcolax as needed for constipation.,PAST MEDICAL HISTORY:, Significant for moderate to severe aortic stenosis, urinary tract infection, hypertension, chronic kidney disease (although her creatinine is near normal).,SOCIAL HISTORY:, The patient lives at Life Care Center. She does not smoke, drink or use intravenous drugs.,FAMILY HISTORY:, Negative for cerebrovascular accident or cardiac disease.,REVIEW OF SYSTEMS:, As in HPI. Patient and daughter also deny weight loss, fevers, chills, sweats, nausea, vomiting, abdominal pain. She has had some difficulty expressing herself, but seems to comprehend speech as above. The patient has had a history of chronic urinary tract infections and her drainage is similar to past episodes when she has had such infection.,PHYSICAL EXAMINATION:,VITAL SIGNS: The patient is currently with a temperature of 99.1, blood pressure 138/59, pulse 69, respirations 15. She is 95% on room air.,GENERAL: This is a pleasant elderly female who appears stated age, in mild distress.,HEENT: Oropharynx is dry.,NECK: Supple with no jugular venous distention or thyromegaly.,RESPIRATORY: Clear to auscultation. No wheezes, rubs or crackles.,CARDIOVASCULAR: A 4/6 systolic ejection murmur best heard at the 2nd right intercostal space with radiation to the carotids.,ABDOMEN: Soft. Normal bowel sounds.,EXTREMITIES: No clubbing, cyanosis or edema. She does have bilateral above knee amputations.,NEUROLOGIC: Strength 2/5 in her right hand, 4/5 in her left hand. She does have mild right facial droop and an expressive aphasia.,VASCULAR: The patient has good capillary refill in her fingertips.,LABORATORY DATA:, BUN 52, creatinine 1.3. Normal coags. Glucose 220. White blood cell count 10,800. Urinalysis has 608 white cells, 625 RBCs. Head CT is currently pending. EKG shows normal sinus rhythm with mild ST-depression and biphasic T-waves diffusely.,ASSESSMENT AND PLAN:,1. Right-sided weakness with an expressive aphasia, at this time concerning for a left-sided middle cerebral artery cerebrovascular accident/transient ischemic attach given the patient's serious vascular disease. At this point we will hydrate, treat her urinary tract infection, check an MRI, ultrasound of her carotids, and echocardiogram to reevaluate valvular and left ventricular function. Start antiplatelet therapy and ask Neuro to see the patient.,2. Urinary tract infection. Will treat with ceftriaxone, check urine culture data and adjust as needed.,3. Dehydration. Will hydrate with IV fluids and follow p.o. intake while holding diuretics.,4. Diabetes mellitus type 2 uncontrolled. Her sugar is 249. We will continue Lantus insulin and sliding scale coverage, and check hemoglobin A1c to gauge prior control.,5. Prophylaxis. Will institute low molecular weight heparin and follow activity levels.", General Medicine,15
"PREOPERATIVE DIAGNOSES:,1.  Chronic renal failure.,2.  Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,POSTOPERATIVE DIAGNOSIS:,1.  Chronic renal failure.,2.  Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,PROCEDURE PERFORMED:,1.  Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula.,2.  Revision of distal anastomosis with 7 mm interposition Gore-Tex graft.,ANESTHESIA:,  General with controlled ventillation.,GROSS FINDINGS: , The patient is a 58-year-old black male with chronic renal failure.  He undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level.  There is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite, placed in supine position.  General anesthetic was administered.  Left arm was prepped and draped in appropriate manner.  A Pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue.  Utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop.  Transverse graftotomy was created.  A #4 Fogarty catheter passed proximally and distally restoring inflow and meager inflow.  A fistulogram was performed and the above findings were noted.  In a retrograde fashion, the proximal anastomosis was patent.  There was no narrowing within the forearm graft.  Both veins were flushed with heparinized saline and controlled with a vascular clamp.  A longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia.  Utilizing both blunt and sharp dissection, the brachial vein as well as distal anastomosis was isolated.  The distal anastomosis amputated off the fistula and oversewn with continuous running #6-0 Prolene suture tied upon itself.  The vein was controlled with vascular clamps.  Longitudinal venotomy created along the anteromedial wall.  A 7 mm graft was brought on to the field and this was cut to shape and size.  This was sewed to the graft in an end-to-side fashion with U-clips anchoring the graft at the heel and toe with interrupted #6-0 Prolene sutures.  Good backflow bleeding was confirmed.  The vein flushed with heparinized saline and graft was controlled with vascular clamp.  The end of the insertion graft was cut to shape in length and sutured to the graft in an end-to-end fashion with continuous running #6-0 Prolene suture.  Good backflow bleeding was confirmed.  The graftotomy was then closed with interrupted #6-0 Prolene suture.  Flow through the fistula was permitted, a good flow passed.  The wound was copiously irrigated with antibiotic solution.  Sponge, needles, instrument counts were correct.  All surgical sites were inspected.  Good hemostasis was noted.  The incision was closed in layers with absorbable sutures.  Sterile dressing was applied.  The patient tolerated the procedure well and returned to the recovery room in apparent stable condition.", Surgery,38
"CHIEF COMPLAINT: , Iron deficiency anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 19-year-old woman, who was recently hospitalized with iron deficiency anemia.  She was seen in consultation by Dr. X.  She underwent a bone marrow biopsy on 07/21/10, which showed a normal cellular marrow with trilineage hematopoiesis.  On 07/22/10, her hemoglobin was 6.5 and therefore she was transfused 2 units of packed red blood cells.  Her iron levels were 5 and her percent transferrin was 2.  There was no evidence of hemolysis.  Of note, she had a baby 5 months ago; however she does not describe excessive bleeding at the time of birth.  She currently has an IUD, so she is not menstruating.  She was discharged from the hospital on iron supplements.  She denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.  She specifically denies melena or hematochezia.,CURRENT MEDICATIONS: , Iron supplements and Levaquin.,ALLERGIES: , Penicillin.,REVIEW OF SYSTEMS:,  As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:  ,She is status post birth of a baby girl 5 months ago.  She is G1, P1.  She is currently using an IUD for contraception.,SOCIAL HISTORY: , She has no tobacco use.  She has rare alcohol use.  No illicit drug use.,FAMILY HISTORY: , Her maternal grandmother had stomach cancer.  There is no history of hematologic malignancies.,PHYSICAL EXAM:,GEN:", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS:,  Diarrhea, suspected irritable bowel.,POSTOPERATIVE DIAGNOSIS:,  Normal colonoscopy., PREMEDICATIONS: , Versed 5 mg, Demerol 75 mg IV.,REPORTED PROCEDURE:,  The rectal exam revealed no external lesions.  The prostate was normal in size and consistency.,The colonoscope was inserted into the cecum with ease.  The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, and rectum were normal.  The scope was retroflexed in the rectum and no abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,  Normal colonoscopy - no evidence of inflammatory disease, polyp, or other neoplasm.  These findings are certainly consistent with irritable bowel syndrome.", Surgery,38
"PRE AND POSTOPERATIVE DIAGNOSIS:,  Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR.  After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted.  At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position.  The patient's posterior cervical area was then prepped and draped in the usual sterile fashion.  At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine.  A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated.  After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken.  This showed the spinous process to be at the C4 level.  Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified.  After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken.  This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time.  At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina.  The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe.  This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur.  However, progress was limited because of thickness of the bone.  Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area.  After the bone had been thinned out, further bone was removed using the Kerrison rongeur.  At this point the nerve root was visually inspected and observed to be decompressed.  However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade.  Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery.  After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin.  Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches.  The subcutaneous layer was then reapproximated using 000 Dexon.  The skin was reapproximated using a running 000 nylon.  Sterile dressings were applied.  The patient was then extubated in the OR and transferred to the Recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  minimal.", Surgery,38
"CHIEF COMPLAINT: , Possible exposure to ant bait.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it.  It had 11 mL of this fluid in it.  She spilled it on her, had it on her hands.  Parents were not sure whether she ingested any of it.  So, they brought her in for evaluation.  They did not note any symptoms of any type.,PAST MEDICAL HISTORY: , Negative.  Generally very healthy.,REVIEW OF SYSTEMS: , The child has not been having any coughing, gagging, vomiting, or other symptoms.  Acting perfectly normal.  Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes.  They did not witness that she ingested any, but did not see anything her mouth.,MEDICATIONS: , None.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  Stable vital signs and normal pulse oximetry.  GENERAL:  The child is very active, cheerful youngster, in no distress whatsoever.  HEENT:  Unremarkable.  Oral mucosa is clear, moist, and well hydrated.  I do not see any evidence of any sort of liquid on the face.  Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso.  Apparently, she had some on her hands that has been wiped off.,EMERGENCY DEPARTMENT COURSE:,  I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case.,IMPRESSION: , Exposure to ant bait.,PLAN: , At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely.  She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation.  So, the patient is discharged in stable condition.", Emergency Room Reports,12
"SUBJECTIVE: , This patient presents to the office today because of some problems with her right hand.  It has been going tingling and getting numb periodically over several weeks.  She just recently moved her keyboard down at work.  She is hoping that will help.  She is worried about carpal tunnel.  She does a lot of repetitive type activities.  It is worse at night.  If she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her.  It involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand.  She has some pain in her thumb as well.  She thinks that could be arthritis.,OBJECTIVE: , Weight 213.2 pounds, blood pressure 142/84, pulse 92, respirations 16.  General:  The patient is nontoxic and in no acute distress.  Musculoskeletal:  The right hand was examined.  It appears to be within normal limits and the appearance is similar to the left hand.  She has good and equal grip strength noted bilaterally.  She has negative Tinel's bilaterally.  She has a positive Phalen's test.  The fingers on the right hand are neurovascularly intact with a normal capillary refill.,ASSESSMENT:  ,Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist.  I suspect carpal tunnel syndrome.,PLAN:  ,The patient is going to use Anaprox double strength one pill every 12 hours with food as well as a cock-up wrist splint.  We are going to try this for two weeks and if the condition is still present, then we are going to proceed with EMG test at that time.  She is going to let me know.  While she is here, I am going to also get her the blood test she needs for her diabetes.  I am noting that her blood pressure is elevated, but improved from the last visit.  I also noticed that she has lost a lot of weight.  She is working on diet and exercise and she is doing a great job.  Right now for the blood pressure we are going to continue to observe as she carries forward additional measures in her diet and exercise to lose more weight and I expect the blood pressure will continue to improve.", Neurology,22
, Gastroenterology,14
"SUBJECTIVE:,  He is a 29-year-old white male who is a patient of Dr. XYZ and he comes in today complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.  He says that he has been stung by wasps before and had similar reactions.  He just said that he wanted to catch it early before he has too bad of a severe reaction like he has had in the past.  He has had a lot of swelling, but no anaphylaxis-type reactions in the past; no shortness of breath or difficultly with his throat feeling like it is going to close up or anything like that in the past; no racing heart beat or anxiety feeling, just a lot of localized swelling where the sting occurs.,OBJECTIVE:,Vitals:  His temperature is 98.4.  Respiratory rate is 18.  Weight is 250 pounds.,Extremities:  Examination of his right hand and forearm reveals that he has an apparent sting just around his wrist region on his right hand on the medial side as well as significant swelling in his hand and his right forearm; extending up to the elbow.  He says that it is really not painful or anything like that.  It is really not all that red and no signs of infection at this time.,ASSESSMENT:,  Wasp sting to the right wrist area.,PLAN:,1.  Solu-Medrol 125 mg IM X 1.,2.  Over-the-counter Benadryl, ice and elevation of that extremity.,3.  Follow up with Dr. XYZ if any further evaluation is needed.", SOAP / Chart / Progress Notes,35
"PREOPERATIVE DIAGNOSES:,  Menorrhagia and dysmenorrhea.,POSTOPERATIVE DIAGNOSES: , Menorrhagia and dysmenorrhea.,PROCEDURE: , Laparoscopic supracervical hysterectomy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 100 mL.,FINDINGS: , An 8-10 cm anteverted uterus, right ovary with a 2 cm x 2 cm x 2 cm simple cyst containing straw colored fluid, a normal-appearing left ovary, and normal-appearing tubes bilaterally.,SPECIMENS:  ,Uterine fragments.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , The patient was brought to the OR where general endotracheal anesthesia was obtained without difficulty.  The patient was placed in dorsal lithotomy position.  Examination under anesthesia revealed an anteverted uterus and no adnexal masses.  The patient was prepped and draped in normal sterile fashion.  A Foley catheter was placed in the patient's bladder.  The patient's cervix was visualized with speculum.  A single-tooth tenaculum was placed on the anterior lip of the cervix.  A HUMI uterine manipulator was placed through the internal os of the cervix and the balloon was inflated.  The tenaculum and speculum were then removed from the vagina.  Attention was then turned to the patient's abdomen where a small infraumbilical incision was made with scalpel.  Veress needle was placed through this incision and the patient's abdomen was inflated to a pressure of 15 mmHg.  Veress needle was removed and then 5-mm trocar was placed through the umbilical incision.  Laparoscope was placed through this incision and the patient's abdominal contents were visualized.  A 2nd trocar incision was placed in the midline 2 cm above the symphysis pubis and a 5-mm trocar was placed through this incision on direct visualization for laparoscope.  A trocar incision was made in the right lower quadrant.  A 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  A ___ trocar incision was made in the left lower quadrant and a 2nd 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  The patient's abdominal and pelvic anatomy were again visualized with the assistance of a blunt probe.  The Gyrus cautery was used to cauterize and cut the right and left round ligaments.  The anterior leaf of the broad ligament was bluntly dissected and cauterized and cut in an inferior fashion towards lower uterine segment.  The right uteroovarian ligament was cauterized and cut using the Gyrus.  The uterine vessels were then bluntly dissected.  The Gyrus was then used to cauterize the right uterine vessels.  Gyrus was then used on the left side to cauterize and cut the left round ligament.  The anterior leaf of the broad ligament on the left side was bluntly dissected, cauterized, and cut.  Using the Gyrus, the left uteroovarian ligament was cauterized and cut and the left uterine vessels were then bluntly dissected.  The left uterine vessels were then cauterized and cut using the Gyrus.  At this point, as the uterine vessels had been cauterized on both sides, the uterine body exhibited blanching.  At this point, the Harmonic scalpel hook was used to amputate the uterine body from the cervix at the level just below the uterine vessels.  The HUMI manipulator was removed prior to amputation of the uterine body.  After the uterine body was detached from the cervical stump, morcellation of the uterine body was performed using the uterine morcellator.  The uterus was removed in a piecemeal fashion through the right lower quadrant trocar incision.  Once, all fragments of the uterus were removed from the abdominal cavity, the pelvis was irrigated.  The Harmonic scalpel was used to cauterize the remaining endocervical canal.  The cervical stump was also cauterized with the Harmonic scalpel and good hemostasis was noted at the cervical stump and also at the sites of all pedicles.  The Harmonic scalpel was then used to incise the right ovarian simple cyst.  The right ovarian cyst was then drained yielding straw-colored fluid.  The site of right ovarian cystotomy was noted to be hemostatic.  The pelvis was again inspected and noted to be hemostatic.  The ureters were identified on both sides and noted to be intact throughout the visualized course.  All instruments were then removed from the patient's abdomen and the abdomen was deflated.  The fascial defects at the 10-mm trocar sites were closed using figure-of-8 sutures of 0-Vicryl and skin incisions were closed with a 4-0 Vicryl in subcuticular fashion.  The cervix was then visualized with the speculum.  Good hemostasis at the site of tenaculum insertion was obtained using silver nitrate sticks.  All instruments were removed from the patient's vagina and the patient was placed in normal supine position.,Sponge, lap, needle, and instrument counts were correct x2.  The patient was awoken from anesthesia and then transferred to the recovery room in stable condition.", Obstetrics / Gynecology,24
"GENERAL REVIEW OF SYSTEMS,General:  No fevers, chills, or sweats.  No weight loss or weight gain.,Cardiovascular:  No exertional chest pain, orthopnea, PND, or pedal edema.  No palpitations.,Neurologic:  No paresis, paresthesias, or syncope.,Eyes:  No double vision or blurred vision.,Ears:  No tinnitus or decreased auditory acuity.,ENT:  No allergy symptoms, such as rhinorrhea or sneezing.,GI:  No indigestion, heartburn, or diarrhea.  No blood in the stools or black stools.  No change in bowel habits.,GU:  No dysuria, hematuria, or pyuria.  No polyuria or nocturia.  Denies slow urinary stream.,Psych:  No symptoms of depression or anxiety.,Pulmonary:  No wheezing, cough, or sputum production.,Skin:  No skin lesions or nonhealing lesions.,Musculoskeletal:  No joint pain, bone pain, or back pain.  No erythema at the joints.,Endocrine:  No heat or cold intolerance.  No polydipsia.,Hematologic:  No easy bruising or easy bleeding.  No swollen lymph nodes.,PHYSICAL EXAM,Vital: Blood pressure today was *, heart rate *, respiratory rate *.,Ears:  TMs intact bilaterally.  Throat is clear without hyperemia.,Mouth:  Mucous membranes normal.  Tongue normal.,Neck:  Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation; no dullness to percussion.,Heart:  Revealed a regular rhythm, normal S1 and S2.  No murmurs, clicks or gallops.,Abdomen:  Soft to palpation without guarding or rebound.  No masses or hepatosplenomegaly palpable.  Bowel sounds are normoactive.,Extremities:  bilaterally symmetrical.  Peripheral pulses 2+ in all extremities.  No pedal edema.,Neurologic examination:  Essentially intact including cranial nerves II through XII intact bilaterally.  Deep tendon reflexes 2+ and symmetrical.,Genitalia:  Bilaterally descended testes without tenderness or masses.  No hernias palpable.  Rectal examination revealed normal sphincter tone, no rectal mass.  Prostate was *.  Stool was Hemoccult negative.", General Medicine,15
"PREOPERATIVE DIAGNOSES:,1.  Hoarseness.,2.  Bilateral true vocal cord lesions.,3.  Leukoplakia.,POSTOPERATIVE DIAGNOSES:,1.  Hoarseness.,2.  Bilateral true vocal cord lesions.,3.  Leukoplakia.,PROCEDURE PERFORMED:  ,Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS:,  Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:  The patient is a 33-year-old Caucasian male with a history of chronic hoarseness and bilateral true vocal cord lesions, and leukoplakia discovered on a fiberoptic nasal laryngoscopy in the office.  Discussed risks, complications, and consequences of a surgical biopsy of the left true vocal cord and consent was obtained.,PROCEDURE: , The patient was brought to operative suite by anesthesia, placed on the operating table in supine position.  After this, the patient was placed under general endotracheal intubation anesthesia and the operative table was turned 90 degrees by the Department of Anesthesia.  A shoulder roll was then placed followed by the patient being placed in reverse Trendelenburg.,After this, a mouthguard was placed in the upper teeth and a Dedo laryngoscope was placed in the patient's oral cavity and advanced through the oral cavity in the oropharynx down into the hypopharynx.  The patient's larynx was then brought into view with the true vocal cords hidden underneath what appeared to be redundant false vocal cords.  The left true vocal cord was then first addressed and appeared to have an extensive area of leukoplakia extending from the posterior one-third up to the anterior third.  The false vocal cord also appeared to be very full on the left side along with fullness in the subglottic region.  The patient's anterior commissure appeared to be clear.  The false cord on the right side also appeared to be very redundant and overshadowing the true vocal cord.  Once the true vocal cord was retracted laterally, there was revealed a second area of leukoplakia involving the right true vocal cord in the anterior one-third aspect.  The patient's subglottic region was very edematous and with redundant mucosal tissue.  The areas of leukoplakia appeared to be cobblestoned in appearance, irregularly bordered, and very hard to the touch.  The left true vocal cord was then first addressed, was stripped from posteriorly to anteriorly utilizing a #45 laryngeal forceps.  After this, the patient had pressure placed upon this area with tropical adrenaline and a rectal swab to maintain hemostasis.  The specimen was passed off the field and was sent to Pathology for evaluation.  Hemostasis was maintained on the left side.  Prior to taking this biopsy, the Louie arm was attached to the laryngoscope and then suspended on the Mayo stand.  The Zeiss operating microscope was then brought into view to directly visualize the vocal cords.  The biopsies were taken under direct visualization utilizing the Zeiss operating microscope.  After the specimen was taken and the laryngoscope was desuspended from the Mayo stand and Louie arm was removed, the scope was then pulled more cephalad and the piriform sinuses, valecula, and base of the tongue were all directly visualized, which appeared normal except for the left base of tongue appeared to be full.  This area was biopsied multiple times with a straight laryngeal forceps and passed off the field and sent to Pathology as specimen.  The scope was then pulled back into the superior aspect of hypopharynx into the oropharynx and the oral cavity demonstrated no signs of any gross lesions.  A bimanual examination was then performed, which again demonstrated a fullness on the left base of tongue region with no signs of any other gross lesions.  There were no signs of any palpable cervical lymphadenopathy.  The tooth guard was removed and the patient was then turned back to anesthesia.  The patient did receive intraoperatively 10 mg of Decadron.  The patient tolerated the procedure well and was extubated in the operating room.,The patient was transferred to recovery room in stable condition and tolerated the procedure well.  The patient will be sent home with prescriptions for Medrol DOSEPAK, Tylenol with Codeine, Elixir, and amoxicillin 250 mg per 5 cc.", ENT - Otolaryngology,11
"PREOPERATIVE DIAGNOSIS:,  Low Back Syndrome - Low back pain with left greater than right lower extremity radiculopathy.,POSTOPERATIVE DIAGNOSIS:,  Same.,PROCEDURE:,1.  Nerve root decompression at L45 on the left side.,2.  Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.,3.  Interpretation of radiograph.,ANESTHESIA: , IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:,  None.,COMPLICATIONS:,  None.,INDICATION FOR PROCEDURE: , Severe and excruciating pain in the lumbar spine and lower extremity.  MRI shows disc pathology as well as facet arthrosis.,SUMMARY OF PROCEDURE: , The patient was admitted to the operating room, consent was obtained and signed.  The patient was taken to the Operating room and was placed in the prone position.  Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring.  After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral region was prepped and draped in sterile fashion with Betadine and four sterile towels.  After the towels were places then sterile drapes were placed on top of that.,After which time the Epimed catheter was then placed, this was done by first repositioning the C-Arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at L5, verifying the sacral hiatus.  The skin over the sacral hiatus was then injected with 1% Lidocaine and an #18-gauge needle was used for skin puncture.  The #18-gauge needle was inserted off of midline.  A #16-gauge RK needle was then placed into the skin puncture and using the paramedian approach and loss-of-resistance technique the needle was placed.  Negative aspiration was carefully performed.  Omnipaque 240 dye was then injected through the #16-gauge RK needle.  The classical run off was noted.  A filling defect was noted @ L45 nerve root on the left side.  After which time 10 cc of 0.25% Marcaine/Triamcinolone (9/1 mixture) was then infused through the 16 R-K Needle.  Some additional lyses of adhesions were visualized as the local anesthetic displaced the Omnipaque 240 dye using this barbotage technique.,An Epimed Tun-L catheter was then inserted through the #16-gauage R-K needle and threaded up to the L45 interspace under continuous fluoroscopic guidance.  As the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized.  The tip of the catheter was noted to be @ L45 level on the left side.  After this the #16-gauge RK needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the L45 nerve root region on the left side.  After this was successfully done, the catheter was then secured in place; this was done with Neosporin ointment, a Split 2x2, Op site and Hypofix tape.  The catheter was then checked with negative aspiration and the Omnipaque 240 dye was then injected.  The classical run off was noted in the lumbar region.  Some lyses of adhesions were also visualized at this time with barbotage technique.  Good dye spread was noted to extend one level above and one level below the L45 nerve root and bilateral spread was noted.  Nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect.  After which time negative aspiration was again performed through the Epimed® Tun-L catheter and then 10 cc of solution was then infused through the catheter, this was done over a 10-minute period with initial 3 cc test dose.  Approximately 3 minutes elapsed and then the remaining 7 cc were infused (Solution consisting of 8 cc of 0.25% Marcaine, 2 cc of Triamcinolone and 1 cc of Wydase.)  The catheter was then capped with a bacterial filter.  The patient was noted to have tolerated the procedure well without any complications.,Interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed.  A filling defect was seen at the L45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure.  This verified positive nerve root decompression.  The tip of the Epimed Tun L catheter was noted to be at L45 level on the left side.  Positive myelogram without dural puncture was noted during this procedure; no sub-dural spread of Omnipaque 240 dye was noted.  This patient did not report any problems and reported pain reduction.", Surgery,38
"PROCEDURE PERFORMED: , Umbilical hernia repair.,PROCEDURE:,  After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine.  The patient was prepped and draped in the usual sterile manner.,A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.  The sac was cleared of overlying adherent tissue, and the fascial defect was delineated.  The fascia was cleared of any adherent tissue for a distance of 1.5 cm from the defect.  The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures.  The umbilicus was then re-formed using 4-0 Vicryl to tack the umbilical skin to the fascia.,The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The skin was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.", Urology,39
"DISCHARGE DIAGNOSIS:,1.  Respiratory failure improved.,2.  Hypotension resolved.,3.  Anemia of chronic disease stable.,4.  Anasarca improving.,5.  Protein malnourishment improving.,6.  End-stage liver disease.,HISTORY AND HOSPITAL COURSE:  ,The patient was admitted after undergoing a drawn out process with a small bowel obstruction.  His bowel function started to improve.  He was on TPN prior to coming to Hospital.  He has remained on TPN throughout his time here, but his appetite and his p.o. intake have improved some.  The patient had an episode while here where his blood pressure bottomed out requiring him to spend multiple days in the Intensive Care Unit on dopamine.  At one point, we were unsuccessful at weaning him off the dopamine, but after approximately 11 days, he finally started to tolerate weaning parameters, was successfully removed from dopamine, and has maintained his blood pressure without difficulty.  The patient also was requiring BiPAP to help with his oxygenation and it appeared that he developed a left-sided pneumonia.  This has been treated successfully with Zyvox and Levaquin and Diflucan.  He seems to be currently doing much better.  He is only using BiPAP in the evening.  As stated above, he is eating better.  He had some evidence of redness and exquisite swelling around his genital and lower abdominal region.  This may be mainly dependent edema versus anasarca.  The patient has been diuresed aggressively over the last 4 to 5 days, and this seems to have made some improvement in his swelling.  This morning, the patient denies any acute distress.  He states he is feeling good and understands that he is being discharged to another facility for continued care and rehabilitation.  He will be discharged to Garden Court skilled nursing facility.,DISCHARGE MEDICATIONS/INSTRUCTIONS:,  He is going to be going with Protonix 40 mg daily, metoclopramide 10 mg every 6 hours, Zyvox 600 mg daily for 5 days, Diflucan 150 mg p.o. daily for 3 days, Bumex 2 mg p.o. daily, Megace 400 mg p.o. b.i.d., Ensure 1 can t.i.d. with meals, and MiraLax 17 gm p.o. daily.  The patient is going to require physical therapy to help with assistance in strength training.  He is also going to need respiratory care to work with his BiPAP.  His initial settings are at a rate of 20, pressure support of 12, PEEP of 6, FIO2 of 40%.  The patient will need a sleep study, which the nursing home will be able to set up.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On the day of discharge, heart rate 99, respiratory rate 20, blood pressure 102/59, temperature 98.2, O2 sat 97%.,GENERAL:  A well-developed white male who appears in no apparent distress.,HEENT:  Unremarkable.,CARDIOVASCULAR:  Positive S1, S2 without murmur, rubs, or gallops.,LUNGS:  Clear to auscultation bilaterally without wheezes or crackles.,ABDOMEN:  Positive for bowel sounds.  Soft, nondistended.  He does have some generalized redness around his abdominal region and groin.  This does appear improved compared to presentation last week.  The swelling in this area also appears improved.,EXTREMITIES:  Show no clubbing or cyanosis.  He does have some lower extremity edema, 2+ distal pedal pulses are present.,NEUROLOGIC:  The patient is alert and oriented to person and place.  He is alert and aware of surroundings.  We have not had any difficulties with confusion here lately.,MUSCULOSKELETAL:  The patient moves all extremities without difficulty.  He is just weak in general.,LABORATORY DATA: , Lab work done today shows the following:  White count 4.2, hemoglobin 10.2, hematocrit 30.6, and platelet count 184,000.  Electrolytes show sodium 139, potassium 4.1, chloride 98, CO2 26, glucose 79, BUN 56, and creatinine 1.4.  Calcium 8.8, phosphorus is a little high at 5.5, magnesium 2.2, albumin 3.9.,PLAN:  ,Discharge this gentleman from Hospital and admit him to Garden Court SNF where they can continue with his rehab and conditioning.  Hopefully, long-term planning will be discharge home.  He has a history of end-stage liver disease with cirrhosis, which may make him a candidate for hospice upon discharge.  The family initially wanted to bring the patient home, but he is too weak and requires too much assistance to adequately consider this option at this time.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS:,  Cecal polyp.,POSTOPERATIVE DIAGNOSIS: , Cecal polyp.,PROCEDURE: , Laparoscopic resection of cecal polyp.,COMPLICATIONS: , None., ,ANESTHESIA:  ,General oral endotracheal intubation.,PROCEDURE:,  After adequate general anesthesia was administered the patient's abdomen was prepped and draped aseptically.  Local anesthetic was infiltrated into the right upper quadrant where a small incision was made.  Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.  A bladed 11-mm port was inserted without difficulty.  Pneumoperitoneum was obtained using C02.  Under direct vision 2 additional, non-bladed, 11-mm trocars were placed, one in the left lower quadrant and one in the right lower quadrant.  There was some adhesion noted to the anterior midline which was taken down using the harmonic scalpel.  The cecum was visualized and found to have tattoo located almost opposite the ileocecal valve.  This was in what appeared to be an appropriate location for removal of this using the Endo GIA stapler without impinging on the ileocecal valve or the appendiceal orifice.  The appendix was somewhat retrocecal in position but otherwise looked normal.  The patient was also found to have ink marks in the peritoneal cavity diffusely indicating possible extravasation of dye.  There was enough however in the wall to identify the location of the polyp.  The lesion was grasped with a Babcock clamp and an Endo GIA stapler used to fire across this transversely. The specimen was then removed through the 12-mm port and examined on the back table.  The lateral margin was found to be closely involved with the specimen so I did not feel that it was clear.  I therefore lifted the lateral apex of the previous staple line and created a new staple line extending more laterally around the colon.  This new staple line was then opened on the back table and examined.  There was some residual polypoid material noted but the margins this time appeared to be clear.  The peritoneal cavity was then lavaged with antibiotic solution.  There were a few small areas of bleeding along the staple line which were treated with pinpoint electrocautery.  The trocars were removed under direct vision.  No bleeding was noted.  The bladed trocar site was closed using a figure-of-eight O Vicryl suture.  All skin incisions were closed with running 4-0 Monocryl subcuticular sutures.  Mastisol and Steri-Strips were placed followed by sterile Tegaderm dressing.  The patient tolerated the procedure well without any complications.", Surgery,38
"PREOPERATIVE DIAGNOSES:,  Menorrhagia and dysmenorrhea.,POSTOPERATIVE DIAGNOSES: , Menorrhagia and dysmenorrhea.,PROCEDURE: , Laparoscopic supracervical hysterectomy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 100 mL.,FINDINGS: , An 8-10 cm anteverted uterus, right ovary with a 2 cm x 2 cm x 2 cm simple cyst containing straw colored fluid, a normal-appearing left ovary, and normal-appearing tubes bilaterally.,SPECIMENS:  ,Uterine fragments.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , The patient was brought to the OR where general endotracheal anesthesia was obtained without difficulty.  The patient was placed in dorsal lithotomy position.  Examination under anesthesia revealed an anteverted uterus and no adnexal masses.  The patient was prepped and draped in normal sterile fashion.  A Foley catheter was placed in the patient's bladder.  The patient's cervix was visualized with speculum.  A single-tooth tenaculum was placed on the anterior lip of the cervix.  A HUMI uterine manipulator was placed through the internal os of the cervix and the balloon was inflated.  The tenaculum and speculum were then removed from the vagina.  Attention was then turned to the patient's abdomen where a small infraumbilical incision was made with scalpel.  Veress needle was placed through this incision and the patient's abdomen was inflated to a pressure of 15 mmHg.  Veress needle was removed and then 5-mm trocar was placed through the umbilical incision.  Laparoscope was placed through this incision and the patient's abdominal contents were visualized.  A 2nd trocar incision was placed in the midline 2 cm above the symphysis pubis and a 5-mm trocar was placed through this incision on direct visualization for laparoscope.  A trocar incision was made in the right lower quadrant.  A 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  A ___ trocar incision was made in the left lower quadrant and a 2nd 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  The patient's abdominal and pelvic anatomy were again visualized with the assistance of a blunt probe.  The Gyrus cautery was used to cauterize and cut the right and left round ligaments.  The anterior leaf of the broad ligament was bluntly dissected and cauterized and cut in an inferior fashion towards lower uterine segment.  The right uteroovarian ligament was cauterized and cut using the Gyrus.  The uterine vessels were then bluntly dissected.  The Gyrus was then used to cauterize the right uterine vessels.  Gyrus was then used on the left side to cauterize and cut the left round ligament.  The anterior leaf of the broad ligament on the left side was bluntly dissected, cauterized, and cut.  Using the Gyrus, the left uteroovarian ligament was cauterized and cut and the left uterine vessels were then bluntly dissected.  The left uterine vessels were then cauterized and cut using the Gyrus.  At this point, as the uterine vessels had been cauterized on both sides, the uterine body exhibited blanching.  At this point, the Harmonic scalpel hook was used to amputate the uterine body from the cervix at the level just below the uterine vessels.  The HUMI manipulator was removed prior to amputation of the uterine body.  After the uterine body was detached from the cervical stump, morcellation of the uterine body was performed using the uterine morcellator.  The uterus was removed in a piecemeal fashion through the right lower quadrant trocar incision.  Once, all fragments of the uterus were removed from the abdominal cavity, the pelvis was irrigated.  The Harmonic scalpel was used to cauterize the remaining endocervical canal.  The cervical stump was also cauterized with the Harmonic scalpel and good hemostasis was noted at the cervical stump and also at the sites of all pedicles.  The Harmonic scalpel was then used to incise the right ovarian simple cyst.  The right ovarian cyst was then drained yielding straw-colored fluid.  The site of right ovarian cystotomy was noted to be hemostatic.  The pelvis was again inspected and noted to be hemostatic.  The ureters were identified on both sides and noted to be intact throughout the visualized course.  All instruments were then removed from the patient's abdomen and the abdomen was deflated.  The fascial defects at the 10-mm trocar sites were closed using figure-of-8 sutures of 0-Vicryl and skin incisions were closed with a 4-0 Vicryl in subcuticular fashion.  The cervix was then visualized with the speculum.  Good hemostasis at the site of tenaculum insertion was obtained using silver nitrate sticks.  All instruments were removed from the patient's vagina and the patient was placed in normal supine position.,Sponge, lap, needle, and instrument counts were correct x2.  The patient was awoken from anesthesia and then transferred to the recovery room in stable condition.", Surgery,38
, Obstetrics / Gynecology,24
"PREOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,OPERATIONS PERFORMED:,  Endoscopic carpal tunnel release.,ANESTHESIA:,  I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:,  Zero.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mm/Hg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal-based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A proximal forearm fasciotomy was performed under direct vision.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.  Hamate sounds were then used to palpate the hook of hamate.  The endoscopic instrument was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision.  After complete division o the transverse carpal ligament, the instrument was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch.  Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.", Surgery,38
"She started her periods at age 13.  She is complaining of a three-month history of lower abdominal pain for which she has been to the emergency room twice.  She describes the pain as bilateral, intermittent, and non-radiating.  It decreases slightly when she eats and increases with activity.  She states the pain when it comes can last for half-a-day.  It is not associated with movement, but occasionally the pain was so bad that it was associated with vomiting.  She has tried LactAid, which initially helped, but then the pain returned.  She has tried changing her diet and Pepcid AC.  She was seen at XYZ where blood work was done.  At that time, she had a normal white count and a normal H&H.  She was given muscle relaxants, which did not work.,Approximately two weeks ago, she was seen in the emergency room at XYZ where a pelvic ultrasound was done.  This showed a 1.9 x 1.4-cm cyst on the right with no free fluid.  The left ovary and uterus appeared normal.  Two days later, the pain resolved and she has not had a recurrence.  She denies constipation and diarrhea.  She has had some hot flashes, but has not taken her temperature.,In addition, she states that her periods have been very irregular coming between four and six weeks.  They are associated with cramping which she is not happy about.,She has never had a pelvic exam.  She states she is not sexually active and declined having her mother leave the room, so she was not questioned regarding this without her mother present.  She is very interested in not having pain with her periods and if this was a cyst that caused her pain, she is interested in starting birth control pills to prevent this from happening again.,PAST MEDICAL HX:  ,Pneumonia in 2002, depression diagnosed in 2005, and seizures as an infant.,PAST SURGICAL HX:  ,Plastic surgery on her ear after a dog bite in 1997.,MEDICATIONS:  ,Zoloft 50 mg a day and LactAid.,ALLERGIES:  ,NO KNOWN DRUG ALLERGIES.,SOCIAL HX: , She enjoys cooking and scrapbooking.  She does have a boyfriend; again she states she is not sexually active.  She also states that she exercises regularly, does not smoke cigarettes, use drugs, or drink alcohol.,FAMILY HX: , Significant for her maternal grandfather with adult-onset diabetes, a maternal grandmother with hypertension, mother with depression, and a father who died of colon cancer at 32 years of age.  She also has a paternal great grandfather who was diagnosed with colon cancer.,PE: , VITALS: Height: 5 feet 5 inches.  Weight: 190 lb.  Blood Pressure: 120/88.  GENERAL: She is well-developed, well-nourished with normal habitus and no deformities.  NECK: Without thyromegaly or lymphadenopathy.  LUNGS: Clear to auscultation bilaterally.  HEART: Regular rate and rhythm without murmurs.  ABDOMEN: Soft, nontender, and nondistended.  There is no organomegaly or lymphadenopathy.  PELVIC: Deferred.,A/P: , Abdominal pain, unclear etiology.  I expressed my doubt that her pain was secondary to this 1.9-cm ovarian cyst given the fact that there was no free fluid surrounding this.  However, given that she has irregular periods and they are painful for her, I think it is reasonable to start her on a low-dose birth control pill.  She has no personal or familial contraindications to start this.  She was given a prescription for Lo/Ovral, dispensed 30 with refill x 4.  She will come back in six weeks for blood pressure check as well as in six months to followup on her pain and her bleeding patterns.,If she should have the recurrence of her pain, I have advised her to call.", Consult - History and Phy.,5
"INDICATIONS: , The patient is a 22-year-old female with past medical history of syncope.  The patient is also complaining of dizziness.  She was referred here by Dr. X for tilt table.,TECHNIQUE: , Risks and benefits explained to the patient.  Consent obtained.  She was lying down on her back for 20 minutes and her blood pressure was 111/75 and heart rate 89.  She was standing up on the tilt tablet for 20 minutes and her heart rate went up to 127 and blood pressure was still in 120/80.  Then, the patient received sublingual nitroglycerin 0.4 mg.  The patient felt dizzy at that time and heart rate was in the 120 and blood pressure was 110/50.  The patient felt nauseous and felt hot at that time.  She did not pass out.,COMPLICATIONS:,  None.,Tilt table was then terminated.,SUMMARY:,  Positive tilt table for vasovagal syncope with significant increase of heart rate with minimal decrease of blood pressure.,RECOMMENDATIONS: , I recommend followup in the office in one week and she will need Toprol-XL 12.5 mg every day if symptoms persist.", Cardiovascular / Pulmonary,3
"SPECIMENS:,1.  Pelvis-right pelvic obturator node.,2.  Pelvis-left pelvic obturator node.,3.  Prostate.,POST-OPERATIVE DIAGNOSIS: , Adenocarcinoma of prostate, erectile dysfunction.,DIAGNOSTIC OPINION:,1.  Adenocarcinoma, Gleason score 9, with tumor extension to periprostatic tissue, margin involvement, and tumor invasion to seminal vesicle, prostate.,2.  No evidence of metastatic carcinoma, right pelvic obturator lymph node.,3.  Metastatic adenocarcinoma, left obturator lymph node; see description.,CLINICAL HISTORY: , None listed.,GROSS DESCRIPTION:,Specimen #1 labeled ""right pelvic obturator lymph nodes"" consists of two portions of adipose tissue measuring 2.5 x 1x 0.8 cm and 2.5 x 1x 0.5 cm.  There are two lymph nodes measuring 1 x 0.7 cm and 0.5 x 0.5 cm.  The entire specimen is cut into several portions and totally embedded.,Specimen #2 labeled ""left pelvic obturation lymph nodes"" consists of an adipose tissue measuring 4 x 2 x 1 cm.  There are two lymph nodes measuring 1.3 x 0.8 cm and 1 x 0.6 cm.  The entire specimen is cut into 1 cm.  The entire specimen is cut into several portions and totally embedded.,Specimen #3 labeled ""prostate"" consists of a prostate.  It measures 5 x 4.5 x 4 cm.  The external surface shows very small portion of seminal vesicles attached in both sides with tumor induration.  External surface also shows tumor induration especially in right side.  External surface is stained with green ink.  The cut surface shows diffuse tumor induration especially in right side.  The tumor appears to extend to excision margin.  Multiple representative sections are made.,MICROSCOPIC DESCRIPTION:,Section #1 reveals lymph node.  There is no evidence of metastatic carcinoma.,Section #2 reveals lymph node with tumor metastasis in section of large lymph node as well as section of small lymph node.,Section #3 reveals adenocarcinoma of prostate.  Gleason's score 9 (5+4).  The tumor shows extension to periprostatic tissue as well as margin involvement.  Seminal vesicle attached to prostate tissue shows tumor invasion.  Dr. XXX reviewed the above case.  His opinion agrees with the above diagnosis.,SUMMARY:,A.  Adenocarcinoma of prostate, Gleason's score 9, with both lobe involvement and seminal vesicle involvement (T3b).,B.  There is lymph node metastasis (N1).,C.  Distant metastasis cannot be assessed (MX).,D.  Excision margin is positive and there is tumor extension to periprostatic tissue.", Lab Medicine - Pathology,19
"SUBJECTIVE:,  This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.  The patient states that her husband has been diagnosed with high blood cholesterol as well.  She wants some support with some dietary recommendations to assist both of them in healthier eating.  The two of them live alone now, and she is used to cooking for large portions.  She is having a hard time adjusting to preparing food for the two of them.  She would like to do less food preparation, in fact.  She is starting a new job this week.,OBJECTIVE:,  Her reported height is 5 feet 4 inches.  Today’s weight was 170 pounds.  BMI is approximately 29.  A diet history was obtained.  I instructed the patient on a 1200 calorie meal plan emphasizing low-saturated fat sources with moderate amounts of sodium as well.  Information on fast food eating was supplied, and additional information on low-fat eating was also supplied.,ASSESSMENT:,  The patient’s basal energy expenditure is estimated at 1361 calories a day.  Her total calorie requirement for weight maintenance is estimated at 1759 calories a day.  Her diet history reflects that she is making some very healthy food choices on a regular basis.  She does emphasize a lot of fruits and vegetables, trying to get a fruit or a vegetable or both at most meals.  She also is emphasizing lower fat selections.  Her physical activity level is moderate at this time.  She is currently walking for 20 minutes four or five days out of the week but at a very moderate pace with a friend.  We reviewed the efforts at weight reduction identifying 3500 calories in a pound of body fat and the need to gradually and slowly chip away at this number on a long-term basis for weight reduction.  We discussed the need to reduce calories from what her current patterns are and to hopefully increase physical activity slightly as well.  We discussed menu selection, as well as food preparation techniques.  The patient appears to have been influenced by the current low-carb, high-protein craze and had really limited her food selections based on that.  I was able to give her some more room for variety including some moderate portions of potatoes, pasta and even on occasion breading her meat as long as she prepares it in a low-fat fashion which was discussed.,PLAN:,  Recommend the patient increase the intensity and the duration of her physical activity with a goal of 30 minutes five days a week working at a brisk walk.  Recommend the patient reduce calories by 500 daily to support a weight loss of one pound a week.  This translates into a 1200-calorie meal plan.  I encouraged the patient to keep food records in order to better track calories consumed.  I recommended low fat selections and especially those that are lower in saturated fats.  Emphasis would be placed on moderating portions of meat and having more moderate snacks between meals as well.  This was a one-hour consultation.  I provided my name and number should additional needs arise.", Consult - History and Phy.,5
"PRESENTATION: , Patient, 13 years old, comes to your office with his mother complaining about severe ear pain.  He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,HISTORY OF PRESENT ILLNESS:  ,Patient reports that he felt good after taking antibiotics with each earache episode and has recently started on the wrestling team.  Mom reports that patient has been afebrile with each of the earache episodes, and he has not had upper respiratory symptoms.  Patient denies any head trauma associated with wrestling practice.,BIRTH AND DEVELOPMENTAL HISTORY:,  Patient's mother reports a normal pregnancy with no complications, having received prenatal care from 12 weeks.  Vaginal delivery was uneventful with a normal perinatal course.  Patient sat alone at 6 months, crawled at 9 months, and walked at 13 months.  His verbal and motor developmental milestones were as expected.,FAMILY/SOCIAL HISTORY: , Patient lives with both parents and two siblings (brother - age 11 years, sister - age 15 years).  He reports enjoying school, remains active in scouts, and is very excited about being on the wresting team.  Mom reports that he has several friends, but she is concerned about the time required for the wrestling team.  Patient is in 8th grade this year and an A/B student.  Both siblings are healthy.  His Dad has hypertension and has frequent heartburn symptoms that he treats with over-the-counter (OTC) medications.  Mom is healthy and has asthma.,PAST MEDICAL HISTORY:  ,Patient has been seen in the clinic yearly for well child exams.  He has had no major illnesses or hospitalizations.  He had one emergency room visit 2 years ago for a knee laceration.  Patient has been healthy except for the past year when he had two episodes of otitis media not associated with respiratory infections.  He received antibiotic therapy (amoxicillin) for the otitis media and both episodes resolved without problems.  Patient's Mom states that he takes no prescribed medications or OTC medications, but he admits that he has been taking his dad's OTC Pepcid AE sometimes when he gets heartburn.  Upon further examination, he reports taking Pepcid when he eats pizza or Mexican food.  He does complain of sore throats sometimes and often feels burning in his throat when he goes to sleep at night after a late evening snack.,NUTRITIONAL HISTORY: , Patient eats cereal bars or pop tarts with milk for breakfast most days.  He takes his lunch (usually a sandwich and chips or yogurt and fruit) for lunch.  Mom or his sister cooks supper in the evening.  The family goes out to eat once or twice a week and he only gets ""fast food"" once or twice a week according to his Mom.  He says he eats ""a lot"" especially after a wrestling meet.,PHYSICAL EXAM:,Height/weight:  Patient weighs 109 pounds (60th percentile) and is 69 inches tall (93rd percentile).  He is following the growth pattern he established in infancy.,Vital signs:  BP 110/60, T 99.2, HR 70, R 16.,General:  Alert, cooperative but a bit shy.,Neuro:  DTRs symmetric, 2+, negative Romberg, able to perform simple calculations without difficulty, short-term memory intact.  He responds appropriately to verbal and visual cues, and movements are smooth and coordinated.,HEENT:  Normocephalic, PEERLA, red reflex present, optic disk and ocular vessels normal.  TMs deep red, dull, landmarks obscured, full bilaterally.  Post auricular and submandibular nodes on left are palpable and slightly tender.,Lungs:  CTA, breath sounds equal bilaterally, excursion and chest configuration normal.,Cardiac:  S1, S2 split, no murmurs, pulses equal bilaterally.,Abdomen:  Soft, rounded, reports no epigastric tenderness but states that heartburn begins in epigastric area and rises to throat.  Bowel sounds active in all quadrants.  No hepatosplenomegaly or tenderness.  No CVA tenderness.,Musculoskeletal:  Full range of motion, all extremities.  Spine straight, able to perform jumping jacks and duck walk without difficulty.,Genital:  Normal male, Tanner stage 4.  Rectal exam - small amount of soft stool, no fissures or masses.,LABS:  ,Stool negative for blood and H. pylori antigen.  Normal CBC and urinalysis.  A barium swallow and upper GI was scheduled for the following week.  It showed marked GE reflux.,ASSESSMENT: , The differential diagnoses for patient included (a) chronic otitis media/treatment failure, (b) peptic ulcer disease/gastritis, (c) gastro esophageal reflux disease (GERD) or carbonated beverage syndrome, (d) trauma.,CHRONIC OTITIS MEDIA. , Chronic otitis media due to a penicillin resistant organism would be the obvious diagnosis in this case.  It is rare for an adolescent to have otitis media with no precipitating factor (such as being on a swim team or otherwise exposed to unusual organisms or in an unusual environment).  It is certainly unusual for him to have three episodes in 1 year.,PEPTIC ULCER DISEASE.,  There were no symptoms of peptic ulcer disease, a negative H. pylori screen and lack of pain made this diagnosis less likely.  Trauma.  Trauma was a possibility, particularly since adolescent males frequently minimize symptoms especially if they might limit participation in a sport but patient maintained that he had not had an event where he struck his head or neck and that he always wore his helmet with ear padding.,GERD.,  The history of ""heartburn"" relieved by his father's medication was striking.  The positive study supported the diagnosis of GERD, which was severe and chronic enough to cause irritation of the mucosal surfaces exposed to the gastric juices and edema, inflammation in the inner ears.,PLAN:,  Patient and his Mom agreed to a trial of omeprazole 20 mg at bedtime for 2 weeks.  Patient was to keep a diary of any episodes of heartburn, including what foods seemed to aggravate it.  The clinician asked him to avoid using any antacid products in the meantime to gage the effectiveness of the medication.  He was also given a prescription for 10 days of Augmentin99 and a follow-up appointment for 2 weeks.  At his follow-up appointment he reported one episode after he ate a whole large pizza after wrestling practice but said it went away pretty quickly after he took his medication.  A 6-month follow up appointment was scheduled.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,POSTOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,OPERATION PERFORMED: , Open repair of right pectoralis major tendon.,ANESTHESIA:,  General with an interscalene block.,COMPLICATIONS:,  None.,Needle and sponge counts were done and correct.,INDICATION FOR OPERATION:  ,The patient is a 26-year-old right hand dominant male who works in sales, who was performing heavy bench press exercises when he felt a tearing burning pain severe in his right shoulder.  The patient presented with mild bruising over the proximal arm of the right side with x-ray showing no fracture.  Over concerns for pectoralis tendon tear, he was sent for MRI evaluation where a complete rupture of a portion of the pectoralis major tendon was noted.  Due to the patient's young age and active lifestyle surgical treatment was recommended in order to obtain best result.  The risks and benefits of the procedure were discussed in detail with the patient including, but not limited to scarring, infection, damage to blood vessels and nerves, re-rupture, need further surgery, loss of range of motion, inability to return to heavy activity such as weight lifting, complex usual pain syndrome, and deep vein thrombosis as well as anesthetic risks.  Understanding all risks and benefits, the patient desires to proceed with surgery as planned.,FINDINGS:,1.  Following deltopectoral approach to the right shoulder, the pectoralis major tendon was encountered.  The clavicular head was noted to be intact.  There was noted to be complete rupture of the sternal head of the pectoralis major tendon with an oblique-type tear having some remaining cuff on the humerus and some tendon attached to the retracted portion.,2.  Following freeing of adhesions using tracks and sutures, the pectoralis major tendon was able to reapproximated to its insertion site on the humerus just lateral to the biceps.,3.  A soft tissue repair was performed with #5 FiberWire suture and a single suture anchor of 5 x 5 bioabsorbable anchor was placed in order to decrease tension at the repair site.  Following repair of soft tissue and using the bone anchor, there was noted to be good apposition of the tendon with edges and a solid repair.,OPERATIVE REPORT IN DETAIL: , The patient was identified in the preop holding area.  His right shoulder was identified, marked his appropriate surgical site after verification with the patient.  He was then taken to the operating room where he was transferred to the operative table in supine position and placed under general anesthesia by anesthesiology team.  He then received prophylactic antibiotics.  A time-out was then undertaken verifying the correct patient, extremity, surgery performed, administration of antibiotics, and the availability of equipment.  At this point, the patient was placed to a modified beech chair position with care taken to ensure all appropriate pressure points were padded and there was no pressure over the eyes.  The right upper extremity was then prepped and draped in the usual sterile fashion.  Preoperative markings were still visible at this point.  A deltopectoral incision was made utilizing the inferior portion.  Dissection was carried down.  The deltoid was retracted laterally.  The clavicular head of the pectoralis major was noted to be intact with the absence of the sternal insertion.  There was a small cuff of tissue left on the proximal humerus associated with the clavicular head.  Gentle probing medially revealed the end of the sternal retracted portion, traction sutures of #5 Ethibond were used in this to allow for retraction and freeing from light adhesion.  This allowed reapproximation of the retracted tendon to the tendon stump.  At this point, a repair using #5 FiberWire was then performed of the pectoralis major tendon back to stump on the proximal humerus noting good apposition of the tendon edges and no gapping of the repair site.  At this point, a single metal suture anchor was attempted to be implanted just lateral to the insertion of the pectoralis in order to remove tension off the repair site; however, the inserted device attached to the metal anchor broke during insertion due to significant hardness of the bone.  For this reason, the starting hole was tapped and a 5x5 bioabsorbable anchor was placed, doubly loaded.  The sutures were then weaved through the lateral aspect of the torn tendon and a modified Krackow type performed and sutured thereby relieving tension off the soft tissue repair.  At this point, there was noted to be excellent apposition of the soft tissue ends and a solid repair to gentle manipulation.  Aggressive external rotation was not performed.  The wound was then copiously irrigated.  The cephalic vein was not injured during the case.  The skin was then closed using a 2-0 Vicryl followed by a 3-0 subcuticular Prolene suture with Steri-Strips.  Sterile dressing was then placed.  Anesthesia was then performed, interscalene block.  The patient was then awakened from anesthesia and transported to postanesthesia care in stable condition in a shoulder immobilizer with the arm adducted and internally rotated.,Plan for this patient, the patient will remain in the shoulder immobilizer until followup visit in approximately 10 days.  We will then start a gentle Codman type exercises and having limited motion until the 4-6 week point based on the patient's progression.", Orthopedic,27
"DELIVERY NOTE: , This is a 30-year-old G7, P5 female at 39-4/7th weeks who presents to Labor and Delivery for induction for history of large babies and living far away.  She was admitted and started on Pitocin.  Her cervix is 3 cm, 50% effaced and -2 station.  Artificial rupture of membrane was performed for clear fluid.  She did receive epidural anesthesia.  She progressed to complete and pushing.  She pushed to approximately one contraction and delivered a live-born female infant at 1524 hours.  Apgars were 8 at 1 minute and 9 at 5 minutes.  Placenta was delivered intact with three-vessel cord.  The cervix was visualized.  No lacerations were noted.  Perineum remained intact.  Estimated blood loss is 300 mL.  Complications were none.  Mother and baby remained in the birthing room in good condition.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , External iliac artery stenosis supplying recently transplanted kidney with renovascular hypertension and impaired renal function.,POSTOPERATIVE DIAGNOSIS:,  External iliac artery stenosis supplying recently transplanted kidney with renovascular hypertension and impaired renal function.,PROCEDURES:,1.  Placement of right external iliac artery catheter via left femoral approach.,2.  Arteriography of the right iliac arteries.,3.  Primary open angioplasty of the right iliac artery using an 8 mm diameter x 3 cm length angioplasty balloon.,3.  Open stent placement in the right external iliac artery for inadequate angiographic result of angioplasty alone.,ANESTHESIA: , Local with intravenous sedation.,INDICATION FOR PROCEDURE:,  He is a 67-year-old white male who is well known to me.  He had severe peripheral vascular disease and recently underwent a kidney transplant.  He has had some troubles with increasing serum creatinine and hypertension.  Duplex suggests a high-grade iliac stenosis just proximal to his transplant kidney.  He is brought to the operating room for arteriography and potential treatment of this.,DESCRIPTION OF PROCEDURE: , The patient was brought to operating room #14.  A condom catheter was put in place.  Preoperative antibiotics were administered.  The patient's left arm was prepped and draped in the usual sterile fashion.  An incision was made over his brachial artery after anesthetizing the skin.  His brachial artery was dissected free and looped with vessel loops.  Under direct vision, it was punctured with an 18-gauge needle and a short 3J guidewire and 6-French sheath put in place.  A 3J guidewire was then introduced after the administration of intravenous heparin and advanced into the descending thoracic aorta.  This was then advanced down into the right common iliac artery.  The catheter was placed over this and arteriography performed.  After adjusting the image intensifier to unfold the origin of the renal artery from the iliac system.  We were able to demonstrate an approximately 60-70% stenosis of the external iliac artery.  Immediately preceding the origin of the artery for the transplant kidney, which appeared to be widely patent.  We elected to try and treat this.  With catheter support a magic torque guidewire was advanced through the stenosis and into the common femoral artery.  An 8 mm diameter x 3 cm length angioplasty balloon was positioned across the stenosis and inflated.  This inflation was held for one minute.  This was then deflated and a catheter positioned again in the proximal common iliac artery.  For this application, we used a guide catheter that would allow us to inject contrast without losing our wire purchase.  This showed an improvement in the stenosis, but a residual stenosis of at least 30% and we elected to stent this.  An 8 mm diameter x 3 cm length stent was chosen and placed just proximal to the origin of the renal artery.  After this was completed, the stent introduction balloon was removed and the catheter replaced.  Repeat angiography showed a widely patent segment with no evidence of any residual stenosis.  There was no evidence of any dissection or damage to the renal artery.  We interpreted this as satisfactory procedure.  Guidewires and sheaths were removed.  The brachial artery was repaired with two interrupted sutures of 7-0 Prolene.  The wound was irrigated and the subcutaneous tissue closed with a running suture of Vicryl.  The skin was reapproximated with a running intracuticular suture of Monocryl.  Steri-Strips and sterile occlusive dressing were applied and the patient was taken to the recovery room in stable condition.  Estimated blood loss for the procedure was less than 50 mL.  Total contrast employed was 37.5 mL.  Total fluoroscopy time was 12 minutes and 43 seconds.", Surgery,38
"INTERVAL HISTORY:,  ABC who is 10 years of age and carries a diagnosis of cystic fibrosis, seen in the clinic today for routine follow-up visit.  He was accompanied by his adopted mother.  He is attending the fourth grade and has not missed significant days for illness.  He has a chronic cough that has been slightly increased for the prior 4 days.  Sputum is not produced.  Sinuses are described as clear.  He is an eager eater, eating a regular diet of increased calorie and protein.  He also was taking Resource just for kid juice boxes as well as chocolate milkmaid with half-and-half.  Belly complaints are denied.  He has 2 to 3 bowel movements per day.  He does need a flu vaccine.,MEDICATIONS: , Albuterol premix via nebulizer as needed, albuterol MDI 2 puffs b.i.d., therapy Vest daily, Creon 20 two with meals and snacks,  A-dec 2 tablets daily, Prevacid 15 mg daily, Advair 100/50 one inhalation twice daily, and MiraLax p.r.n.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Respiratory rate 20 and pulse 91.  Temperature is 100.0 per tympanic membrane.  Oximetry is 98% on room air.  Height is 128 cm, which is an increase of 1.0 cm from prior visit.  Weight is 24.5 kg, which is an increase of 500 grams from prior visit.,GENERAL:  He is a cooperative school-aged boy in no apparent distress.,HEENT:  Tympanic membranes clear, throat with minimal postnasal drip.,CHEST:  Significant for 1+ hyperinflation.  Lungs are auscultated with good air entry and clear breath sounds.,CARDIAC:  Regular sinus rhythm without murmur.,ABDOMEN:  Palpated as soft, without hepatosplenomegaly.,EXTREMITIES:  Not clubbed.,CHART REVIEW: , This chart was thoroughly reviewed prior to this conference by X, RN, BSN.  Review of chart indicates that mother has good adherence to treatment plan indicated by medications being refilled in a timely fashion as well as clinic contact documented with appropriate concerns.,DISCUSSION:  PHYSICIAN: , X did note that mother reported that the patient had discontinued the Pulmozyme due to CCS reasons.  He is not sure what this would be since CCS Pulmozyme is a covered benefit on CCS for children with cystic fibrosis.  This situation will be looked into with the hope of restarting soon.  Other than that the patient seems to be doing well.  A flu shot was given.,NURSE: , X, RN, BSN, did note that the patient was doing quite well.  Reinforcement of current medication regime was supplied.  No other needs identified at this time.,RESPIRATORY CARE: , X, RCP, did review appropriate sequencing of medications with the patient and family.  Once again, she was concerned the lack of Pulmozyme due to mom stating CCS issues.  At this time, they have increased the Vest use to twice daily and are doing 30-minute treatments.,DIETICIAN: , X, RD, CDE, notes that the patient is 89% of his ideal body weight, which is a nutritional failure per cystic fibrosis guidelines.  This is despite the fact that he has an excellent appetite.  Mom reports he is taking his enzymes consistently as well as vitamins.  He does have problems meeting his goal for resource drinks per day.  Since the patient has been struggling to gain weight this past year, we will need to monitor his nutritional status and weight trend very closely.  A variety of additional high calorie items were discussed with mom.,SOCIAL WORK: , X, LCSW, notes that mom has recently gradually from respiratory therapy school and has accepted a position here at Children's Hospital.  The patient is doing well in school.  With the exception of issues with CCS authorization, there appears to be no pressing social needs at this time.,IMPRESSION: , ,1.  Cystic fibrosis.,2.  Poor nutritional status.,PLAN:  ,1.  Give flu vaccine 0.5 mg IM now, this was done.,2.  Continue all other medications and treatment.,3.  Evaluate/investigate rationale for no authorization of Pulmozyme with CCS.,4.  Needs to augment current high-calorie diet to give more nutrition.  To follow advice by a dietician.,5.  Continue all the medication treatments before.,6.  To continue off and ongoing psychosocial nutritional counseling as necessary.", Cardiovascular / Pulmonary,3
"EXAM: , Five views of the right knee.,HISTORY: , Pain.  The patient is status-post surgery, he could not straighten his leg, pain in the back of the knee.,TECHNIQUE:,  Five views of the right knee were evaluated.  There are no priors for comparison.,FINDINGS: , Five views of the right knee were evaluated and they reveal there is no evidence of any displaced fractures, dislocations, or subluxations.  There are multiple areas of growth arrest lines seen in the distal aspect of the femur and proximal aspect of the tibia.  There is also appearance of a high-riding patella suggestive of patella alta.,IMPRESSION:,1.  No evidence of any displaced fractures, dislocations, or subluxations.,2.  Growth arrest lines seen in the distal femur and proximal tibia.,3.  Questionable appearance of a slightly high-riding patella, possibly suggesting patella alta.", Orthopedic,27
"PREOPERATIVE DIAGNOSES: , Chronic otitis media and tonsillar adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES:,  Chronic otitis media and tonsillar adenoid hypertrophy.,PROCEDURES:,  Bilateral myringotomy and tube placement, tonsillectomy and adenoidectomy.,INDICATIONS FOR PROCEDURE: , The patient is a 3-1/2-year-old child with history of recurrent otitis media as well as snoring and chronic mouth breathing.  Risks and benefits of surgery including risk of bleeding, general anesthesia, tympanic membrane perforation as well as persistent recurrent otitis media were discussed with the patient and parents and informed consent was signed by the parents.,FINDINGS:  ,The patient was brought to the operating room, placed in supine position, given general endotracheal anesthesia.  The left ear was then draped in a clean fashion.  Under microscopic visualization, the ear canal was cleaned of the wax.  Myringotomy incision was made in the anterior inferior quadrant.  There was no fluid in the middle ear space.  A Micron Bobbin tube was easily placed.  Floxin drops were placed in the ear.  The same was performed on the right side with similar findings.  The patient was then turned to be placed in Rose position.  The patient draped in clean fashion.  A small McIvor mouth gag was used to hold open the oral cavity.  The soft palate was palpated.  There was no submucous cleft felt.  Using a 1:1 mixture of 1% Xylocaine with 1:100,000 epinephrine and 0.25% Marcaine, both tonsillar pillars and the fossae injected with approximately 7 mL total.  Using a curved Allis the right tonsil was grasped and pulled medially.  Tonsil was dissected off the tonsillar fossa using a Coblator.  The left tonsil was removed in the similar fashion.  Hemostasis then achieved in tonsillar fossa using the Coblator on coagulation setting.  The soft palate was then retracted using red rubber catheter.  Under mirror visualization, the patient was found to have enlarged adenoids.  The adenoids were removed using the Coblator.  Hemostasis was also achieved using the Coblator on coagulation setting.  The rubber catheter was then removed.  Reexamining the oropharynx, small bleeding points were cauterized with the Coblator.  Stomach contents were then aspirated with saline sump.  The patient was woken up from anesthesia, extubated and brought to recovery room in stable condition.  There were no intraoperative complications.  Needle and sponge correct.  Estimated blood loss minimal.", ENT - Otolaryngology,11
"REASON FOR CONSULT: , Medical management, status post left total knee arthroplasty.,PAST MEDICAL HISTORY:,1.  Polyarthritis.,2.  Acromegaly.,3.  Hypothyroidism.,4.  Borderline hypertension.,5.  Obesity.,PAST SURGICAL HISTORY: , Hernia repair, resection of tumor, right thumb arthrodesis, carpal tunnel decompression, bilateral hip replacement, right total knee replacement about 2 months ago, open reduction of left elbow fracture.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS:  No fever or recent general malaise.,ENT:  Not remarkable.,RESPIRATORY:  No cough or shortness of breath.,CARDIOVASCULAR:  The patient denies any heart problems.  No orthopnea.  No palpitations.  No syncopal episodes.,GASTROINTESTINAL:  No nausea.  No vomiting.  No history of GI bleed.,GENITOURINARY:  No dysuria, no hematuria.,ENDOCRINE:  The patient is status post pituitary tumor resection and is on supplemental hormone.,MEDICATIONS:  Depo-Testosterone 200 mg IM q.3 weekly, prednisone 1 tablet p.o. daily, octreotide IM on a monthly basis, morphine extended release 50 mg p.o. b.i.d., Synthroid 100 mcg p.o. daily, desmopressin 1 tablet p.o. every bedtime, aspirin/oxycodone on a p.r.n. basis, aspirin on p.r.n. basis.,ALLERGIES: , IBUPROFEN AND TYLENOL.,SOCIAL HISTORY: , The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION,GENERAL:  Obese, 57-year-old gentleman, not in acute distress.,VITAL SIGNS:  Blood pressure of 105/55, pulse is 90.  He is afebrile.  O2 saturation is 95% on room air.,HEAD AND NECK:  Face symmetrical.  Cranial nerves are intact.  No distended neck veins.  No palpable neck masses.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  The left knee is in closed dressing.  The lower extremities are still numb from spinal anesthesia.,ASSESSMENT AND PLAN:,1.  Polyarthritis, status post left total knee replacement.  The patient tolerated the procedure well.,2.  Acromegaly, status post pituitary resection.  Continue supplemental hormones.,3.  Borderline hypertension, blood pressure is under control with monitoring.,4.  Deep venous thrombosis prophylaxis as per surgeon.,5.  Anemia due to repeated blood loss with monitor hemoglobin and hematocrit.", Orthopedic,27
"EXAM:,  Bilateral carotid ultrasound.,REASON FOR EXAM: , Headache.,TECHNIQUE:  ,Color grayscale and Doppler analysis is employed.,FINDINGS:,  On the grayscale images, the right common carotid artery demonstrates patency with mild intimal thickening only.  At the level of the carotid bifurcation, there is heterogeneous hard plaque present, but without grayscale evidence of greater than 50% stenosis.  Right common carotid waveform is normal with a peak systolic velocity of 0.474 m/second and an end-diastolic velocity of 0.131 m/second.  The right ECA is patent as well with the velocity measurement 0.910 m/second.,The right internal carotid artery at the bifurcation demonstrates plaque formation, but no evidence of greater than 50% stenosis.  Proximal peak systolic velocity in the internal carotid artery is 0.463 m/second with proximal end-diastolic velocity of 0.170.  The mid internal carotid peak systolic velocity is 0.564 m/second, and mid ICA end-diastolic velocity is 0.199 m/second.  Right ICA distal PSV 0.580 m/second, right ICA distal EDV 0.204 m/second.  Vertebral flow is antegrade on the right at 0.469 m/second.,On the left, the common carotid artery demonstrates intimal thickening, but is otherwise patent.  At the level of the bifurcation, however, there is more pronounced plaque formation with approximately 50% stenosis by the grayscale analysis.  See the velocity measurements below:,Left carotid ECA measurement 0.938 m/second.  Left common carotid PSV 0.686 m/second, and left common carotid end-diastolic velocity 0.137 m/second.,Left internal carotid artery again demonstrates prominent focus of hard plaque with up to at least 50% stenosis.  This should be further assessed with CTA for more precise measurement.  The left proximal ICA/PSV 0.955 m/second, left proximal ICA/EDV 0.287 m/second.  There is spectral broadening in the proximal aspect of the carotid waveform.  The left carotid ICA mid PSV 0.895, left carotid ICA mid EDV 0.278 with also spectral broadening present.,The left distal ICA/PSV 0.561, left distal ICA/EDV 0.206, again the spectral broadening present.  Vertebral flow is antegrade at 0.468 m/second.,IMPRESSION: , The study demonstrates bilateral hard plaque at the bifurcation, left greater than right.  There is at least 50% stenosis of the left internal carotid artery at its bifurcation and a followup CTA is recommended for further assessment.", Radiology,33
"HISTORY:  ,A is 12-year-old female who comes today for follow-up appointment and a CCS visit.  She has the diagnosis of discoid lupus and we have been following her for her conditions, her treatments, and also to watch her for any development of her systemic lupus.  A has been doing well with just Plaquenil alone and mother said that during the summer, the rash gets brighter, but now that it is getting darker and she is at school, the rash is starting to become lighter again.  She has been using her cream, which is hydrocortisone at night and applying it with no problems.  She denies any hair losses, denies any decrease in appetite, actually, she has been gaining some weight.  She denies any ulcerations in her mouth, eye problems, or any lumps in her body.  She denies any fevers or any problems with the urine.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Today temperature is 100.1, weight is 73.5 kg, blood pressure is 121/61, height is 158, and pulse is 84.,GENERAL:  She is alert, active, and oriented in no distress.,HEENT:  She had a head full of hair with no bald spots.  She has a macular rash on her cheeks bilaterally with hyperpigmented circles.  No scales, no excoriations, and no palpable erythema.  Oral mucosa is clear with no ulcerations.,NECK:  Soft with no masses.  She does have acanthosis nigricans on the base of the neck.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm with no murmur.,ABDOMEN:  Soft and nontender with no visceromegaly.,MUSCULOSKELETAL:  Shows no limitation, swelling, or tenderness in any of her joints.,SKIN:  Shows a discoid rash with macules approximately 1 cm in diameter in different shapes and size, but most of them are about 1 cm in diameter, which are hyperpigmented.  No erythema, no purpura, no petechiae, and no raised borders.  They look more like cigarette points.  She has this in her upper extremities especially in the forearms and also on her lower extremities, on the legs, but just very few lesions and very light.  She has some periungual erythema, as well as some palmar erythema, but this is minimal.,LABORATORY DATA:,  Laboratories today done, we have a CBC with a white blood cell count of 7.9, hemoglobin is 14.3, platelet count is 321,000, sed rate is only 11, and CMP shows no abnormalities.  Pending is antinuclear antibody complement level.,ASSESSMENT: , She is 12-year-old with discoid lupus on the control with optimal regimen.  We are going to switch her to Protopic at night, especially in the face.  Continue on Plaquenil, get some laboratories and wait for the results.  Diet evaluation today because of the gaining weight and acanthosis nigricans, and will see her back in about 3 months for follow-up.  Future plans will be depending on whether or not she evolves into a full-blown lupus.  I discussed the plan with her mother and they had no further questions.", Rheumatology,34
"PREOPERATIVE DIAGNOSES,1.  EMG-proven left carpal tunnel syndrome.,2.  Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3.  Dupuytren's nodule in the palm.,POSTOPERATIVE DIAGNOSES,1.  EMG-proven left carpal tunnel syndrome.,2.  Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3.  Dupuytren's nodule in the palm.,PROCEDURE: , Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.,ANESTHESIA: , Local plus IV sedation (MAC).,ESTIMATED BLOOD LOSS:  ,Zero.,SPECIMENS:  ,None.,DRAINS: , None.,PROCEDURE DETAIL: , Patient brought to the operating room.  After induction of IV sedation the left hand was anesthetized suitable for carpal tunnel release; 10 cc of a mixture of 1% Xylocaine and 0.5% Marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery.  Routine prep and drape was employed.  Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet and tourniquet inflated to 250 mmHg pressure.  Hand was positioned palm up in the lead hand-holder.  A short curvilinear incision about the base of the thenar eminence was made.  Skin was sharply incised.  Sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin.  Care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm.  Proximally the antebrachial fascia was released for a distance of 2-3 cm proximal to the wrist crease to insure complete decompression of the median nerve.  Retinacular flap was retracted radially to expose the contents of the carpal canal.  Median nerve was identified, seen to be locally compressed with moderate erythema and mild narrowing.  Locally adherent tenosynovium was present and this was carefully dissected free.  Additional tenosynovium was dissected from the flexor tendons, individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal.  Epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium.  When this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5-0 nylon horizontal mattress sutures.  A syringe with 3 cc of Kenalog-10 and 3 cc of 1% Xylocaine using a 25 gauge short needle was then selected; 1 cc of this mixture was injected into the third finger A1 and A2 pulley tendon sheaths using standard trigger finger injection technique; 1 cc was injected into the fourth finger A1/A2 pulley tendon sheath using standard tendon sheath injection technique; 1 cc was injected into the Dupuytren's nodule in the midpalm to relieve local discomfort.  Routine postoperative hand dressing with well-padded, well-molded volar plaster splint and lightly compressive Ace wrap was 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 medication is Darvocet-N 100, 30 tablets, one to two PO q.4h. p.r.n.  Patient asked to begin gentle active flexion, extension and passive nerve glide exercises beginning 24-48 hours after surgery.  She was asked to keep the dressings clean, dry and intact and follow up in my office.", Surgery,38
"S:,  XYZ is in today not feeling well for the last three days.  She is a bit sick with bodyaches.  She is coughing.  She has a sore throat, especially when she coughs.  Her cough is productive of green colored sputum.  She has had some chills.  No vomiting.  No diarrhea.  She is sleeping okay.  She does not feel like she needs anything for the cough.  She did call in yesterday, and got a refill of her Keflex.  She took two Keflex this morning and she is feeling a little bit better now.  She is tearful, just tired of feeling ran down.,O:,  Vital signs as per chart.  Respirations 15.  Exam:  Nontoxic.  No acute distress.  Alert and oriented.  HEENT:  TMs are clear bilaterally without erythema or bulging.  Clear external canals.  Clear tympanic.  Conjunctivae are clear.  Clear nasal mucosa.  Clear oropharynx with moist mucous membranes.  NECK is soft and supple without lymphadenopathy.  LUNGS are coarse with no severe rhonchi or wheezes.  HEART is regular rate and rhythm without murmur.  ABDOMEN is soft and nontender.,Chest x-ray reveals no obvious consolidation or infiltrates.  We will send the x-ray for over-read.,Influenza test is negative.  Rapid strep screen is negative.,A:,  Bronchitis/URI.,P: , ,1.  Motrin as needed for fever and discomfort.,2.  Push fluids.,3.  Continue on the Keflex.,4.  Follow up with Dr. ABC if symptoms persist or worsen, otherwise as needed.", General Medicine,15
"ADMITTING DIAGNOSES:,1.  Fever.,2.  Otitis media.,3.  Possible sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-month-old male who was seen in the office 1 day prior to admission.  He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough, nasal congestion, and rhinorrhea and no history of rashes.  He has been taking Tylenol and Advil to help decrease the fevers, but the fever has continued to rise.  He was noted to have some increased workup of breathing and parents returned to the office on the day of admission.,PAST MEDICAL HISTORY: , Significant for being born at 33 weeks' gestation with a birth weight of 5 pounds and 1 ounce.,PHYSICAL EXAMINATION: , On exam, he was moderately ill appearing and lethargic.  HEENT:  Atraumatic, normocephalic.  Pupils are equal, round, and reactive to light.  Tympanic membranes were red and yellow, and opaque bilaterally.  Nares were patent.  Oropharynx was slightly moist and pink.  Neck was soft and supple without masses.  Heart is regular rate and rhythm without murmurs.  Lungs showed increased workup of breathing, moderate tachypnea.  No rales, rhonchi or wheezes were noted.  Abdomen:  Soft, nontender, nondistended.  Active bowel sounds.  Neurologic exam showed good muscle strength, normal tone.  Cranial nerves II through XII are grossly intact.,LABORATORY FINDINGS: , He had electrolytes, BUN and creatinine, and glucose all of which were within normal limits.  White blood cell count was 8.6 with 61% neutrophils, 21% lymphocytes, 17% monocytes, suggestive of a viral infection.  Urinalysis was completely unremarkable.  Chest x-ray showed a suboptimal inspiration, but no evidence of an acute process in the chest.,HOSPITAL COURSE: , The patient was admitted to the hospital and allowed a clear liquid diet.  Activity is as tolerates.  CBC with differential, blood culture, electrolytes, BUN, and creatinine, glucose, UA, and urine culture all were ordered.  Chest x-ray was ordered as well with 2 views to evaluate for a possible pneumonia.  Pulse oximetry checks were ordered every shift and as needed with O2 ordered per nasal cannula if O2 saturations were less that 94%.  Gave D5 and quarter of normal saline at 45 mL per hour, which was just slightly above maintenance rate to help with hydration.  He was given ceftriaxone 500 mg IV once daily to treat otitis media and possible sepsis, and I will add Tylenol and ibuprofen as needed for fevers.  Overnight, he did have his oxygen saturations drop and went into oxygen overnight.  His lungs remained clear, but because of the need for O2, we instituted albuterol aerosols every 6 hours to help maintain good lung function.  The nurses were instructed to attempt to wean O2 if possible and advance the diet.  He was doing clear liquids well and so I saline locked to help to accommodate improve the mobility with the patient.  He did well the following evening with no further oxygen requirement.  He continued to spike fevers but last fever was around 13:45 on the previous day.  At the time of exam, he had 100% oxygen saturations on room air with temperature of 99.3 degrees F. with clear lungs.  He was given additional dose of Rocephin when it was felt that it would be appropriate for him to be discharged that morning.,CONDITION OF THE PATIENT AT DISCHARGE: , He was at 100% oxygen saturations on room air with no further dips at night.  He has become afebrile and was having no further increased work of breathing.,DISCHARGE DIAGNOSES:,1.  Bilateral otitis media.,2.  Fever.,PLAN:  ,Recommended discharge.  No restrictions in diet or activity.  He was continued Omnicef 125 mg/5 mL one teaspoon p.o. once daily and instructed to follow up with Dr. X, his primary doctor, on the following Tuesday.  Parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy.", Discharge Summary,10
"DIAGNOSIS: , Low back pain and degenerative lumbar disk.,HISTORY:,  The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease.  The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms.  The patient states that this occurred in October 2008 as well as November 2008.  The patient has a history of low back pain, secondary to a fall that originally occurred in 2006.  The patient states that she slipped on a newly waxed floor and fell on her tailbone and low back region.  The patient then had her second fall in March 2006.  The patient states that she was qualifying on the range with a handgun and lost her footing and states that she fell more due to weakness in her lower extremities rather than loss of balance.,PAST MEDICAL HISTORY:,  Past medical history is significant for allergies and thyroid problems.,PAST SURGICAL HISTORY: , The patient has a past surgical history of appendectomy and hysterectomy.,MEDICATIONS:,1.  TriCor.,2.  Vytorin.,3.  Estradiol.,4.  Levothyroxine.,5.  The patient is also taking ibuprofen 800 mg occasionally as needed for pain management.  The patient states she rarely takes this and does not like to take pain medication if at all possible.  The patient states that she has had uncomplicated pregnancies in the past.,SOCIAL HISTORY:,  The patient states she lives in a single-level home with her husband, who is in good health and is able to assist with any tasks or activities the patient is having difficulty with.  The patient rates her general health as excellent and denies any smoking and reports very occasional alcohol consumption.  The patient does state that she has completed exercises on a daily basis of one to one and a half hours a day.  However, has not been able to complete these exercise routine since approximately June 2008, secondary to back pain.  The patient is working full-time as a project manager, and is required to do extensive walking at various periods during a workday.,MEDICAL IMAGING:,  The patient states that she has had an MRI recently performed; however, the results are not available at the time of the evaluation.  The patient states she is able to bring the report in upon next visit.,SUBJECTIVE:  ,The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse.  The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region.  Aggravating factors include stairs and prolonged driving, as well as general limitations with home tasks and projects.  The patient states she is a very active individual and is noticing extreme limitations with ability to complete home tasks and projects she used to be able to complete.,NEUROLOGICAL SYMPTOMS:,  The patient reports having occasional shooting pains into the lower extremities.  However, these are occurring less frequently and is now occurring more frequently in the right versus the left lower extremity when they do occur.,FUNCTIONAL ACTIVITIES AND HOBBIES: , Include exercising and general activities.,PATIENT'S GOAL: , The patient would like to improve her overall body movements and return to daily exercise routine as able and well maintaining safety.,OBJECTIVE: , Upon observation, the patient ambulates independently without the use of assistive device.  However, does present with mild limp and favoring the left lower extremity after extensive standing and walking activity.  The patient does have mild difficulty transferring from the seated position to standing.  However, once is upright, the patient denies any increased pain or symptoms.,ACTIVE RANGE OF MOTION OF LUMBAR SPINE:  ,Forward flexion is 26 cm, fingertip to floor, lateral side bend, fingertip to floor is 52.5 cm bilaterally.,STRENGTH: , Strength is grossly 4/5.  The patient denies any significant tenderness to palpation.  However, does have mild increase in tenderness on the right versus left.  A six-minute walk test revealed painful symptoms and achiness occurring after approximately 400 feet of walking.  The patient was able to continue; however, stopped after 700 feet.  There were two minutes remaining in the six-minute walk test.  The patient does have tight hamstrings as well as a negative slump test.,ASSESSMENT: , The patient would benefit from skilled physical therapy intervention in order to address the following problem list.,PROBLEM LIST:,1.  Increased pain.,2.  Decreased ability to complete tasks and hobbies.,3", Orthopedic,27
"PREOP DIAGNOSES:,1.  Left pilon fracture.,2.  Left great toe proximal phalanx fracture.,POSTOP DIAGNOSES:,1.  Left pilon fracture.,2.  Left great toe proximal phalanx fracture.,OPERATION PERFORMED:,1.  External fixation of left pilon fracture.,2.  Closed reduction of left great toe, T1 fracture.,ANESTHESIA:  ,General.,BLOOD LOSS:  ,Less than 10 mL.,Needle, instrument, and sponge counts were done and correct.,DRAINS AND TUBES: , None.,SPECIMENS:,  None.,INDICATION FOR OPERATION:  ,The patient is a 58-year-old female who was involved in an auto versus a tree accident on 6/15/2009.  The patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time.  The patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness.  She underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the Medicine Service following this and she was appropriate for surgical intervention.  Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.  The patient had swollen lower extremities, however, compartments were soft and she had no sign of compartment syndrome.  Risks and benefits of procedure were discussed in detail with the patient and her husband.  All questions were answered, and consent was obtained.  The risks including damage to blood vessels and nerves with painful neuroma or numbness, limb altered function, loss of range of motion, need for further surgery, infection, complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery.,FINDINGS:,1.  There was a comminuted distal tibia fracture with a fibular shaft fracture.  Following traction, there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula, the fracture fragments were out to length.,2.  The base of her proximal phalanx fracture was assessed and reduced with essentially no articular step-off and approximately 1-mm displacement.  As the reduction was stable with buddy taping, no pinning was performed.,3.  Her compartments were full, but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed.,OPERATIVE REPORT IN DETAIL:  ,The patient was identified in the preoperative holding area.  The left leg was identified and marked at the surgical site of the patient.  She was then taken to the operating room where she was transferred to the operating room in the supine position, placed under general anesthesia by the anesthesiology team.  She received Ancef for antibiotic prophylaxis.  A time-out was then undertaken verifying the correct patient, extremity, visibility of preoperative markings, availability of equipment, and administration of preoperative antibiotics.  When all was verified by the surgeon, anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion.  At this point, intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site.  A single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 Schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length, but not overly distract the fracture and restore coronal and sagittal alignment as much as able.  When this was adequate, the fixator apparatus was locked in place, and x-ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture.  Attention was then turned to the left great toe, where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive.  X-rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture.  At this point, the pins were cut short and capped to protect the sharp ends.  The stab wounds for the Schantz pin and cross pin were covered with gauze with Betadine followed by dry gauze, and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition.  Please note there was no break in sterile technique throughout the case.,PLAN:  ,The patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication.  She will maintain her buddy taping in regards to her great toe fracture.", Surgery,38
"HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall.  Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock.  When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped.  Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker.  An ECG this morning showing normal sinus rhythm with frequent APCs.  Her potassium at that time was 3.1.  She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior.  She denies any chest pain nor shortness of breath prior to or since the fall.  She states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,PAST CARDIAC HISTORY: , She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure.  On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement.  She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative.  She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant.  She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker.  She does have a history of significant hypertension in the past.  She has had dizzy spells and denies clearly any true syncope.  She has had bradycardia in the past from beta-blocker therapy.,MEDICATIONS ON ADMISSION:,1.  Multivitamin p.o. daily.,2.  Aspirin 325 mg once a day.,3.  Lisinopril 40 mg once a day.,4.  Felodipine 10 mg once a day.,5.  Klor-Con 20 mEq p.o. b.i.d.,6.  Omeprazole 20 mg p.o. daily presumably for GERD.,7.  MiraLax 17 g p.o. daily.,8.  Lasix 20 mg p.o. daily.,ALLERGIES: , PENICILLIN.  IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST.,FAMILY HISTORY:,  She states her brother died of an MI suddenly in his 50s.,SOCIAL HISTORY: , She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs.  She is retired from Morse Chain and delivering newspapers.  She is widowed.  She lives alone but has family members who live either on her property or adjacent to it.,REVIEW OF SYSTEMS: , She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers.  She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use.  She does note occasional peripheral edema.  She is not aware of prior history of MI.  She denies diabetes.  She does have a history of GERD.  She notes feeling depressed at times because of living alone.  She denies rheumatologic conditions including psoriasis or lupus.  Remainder of review of systems is negative times 15 except as described above.,PHYSICAL EXAM:  ,Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%.  On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive.  HEENT:  Shows cranium is  normocephalic and atraumatic.  She has moist mucosal membranes.  Neck veins were not distended.  There are no carotid bruits.  Lungs:  Clear to auscultation anteriorly without wheezes.  She is relatively immobile because of her left hip fracture.  Cardiac Exam:  S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound.  There is also a soft holosystolic murmur heard.  There is no rub or gallop.  PMI is nondisplaced.  Abdomen is soft and nondistended.  Bowel sounds present.  Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema.  Pulses appear grossly intact.  Affect is appropriate.  Visible skin warm and perfused.  She is not able to move because of left hip fracture easily in bed.,DIAGNOSTIC STUDIES/LAB DATA: , Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob.  No clear pulmonary vascular congestion.  Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06.  Troponin was 0.03 followed by 0.18.  INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,EKGs are reviewed.  Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes.  She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior.  Followup EKG done this morning shows normal sinus rhythm with frequent APCs.,IMPRESSION:  ,She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery.  Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected.  There has been no atrial fibrillation documented.  I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath.  She actually describes feeling good exercise capacity prior to this fall.  Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that.  Continued optimization of electrolytes.  The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil.  The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery.  I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge.  Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist.", General Medicine,15
"PREOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,POSTOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,OPERATION PERFORMED: , Left neck dissection.,ANESTHESIA:  ,General endotracheal.,INDICATIONS: , The patient is a very nice gentleman, who has had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.  He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound, which are suspicious for recurrent cancer.  Left neck dissection is indicated.,DESCRIPTION OF OPERATION: , The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, the table was then turned.  A shoulder roll placed under the shoulders and the face was placed in an extended fashion.  The left neck, chest, and face were prepped with Betadine and draped in a sterile fashion.  A hockey stick skin incision was performed, extending a previous incision line superiorly towards the mastoid cortex through skin, subcutaneous tissue and platysma with Bovie electrocautery on cut mode.  Subplatysmal superior and inferior flaps were raised.  The dissection was left lateral neck dissection encompassing zones 1, 2A, 2B, 3, and the superior portion of 4.  The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck.  This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles, stripped from the carotid artery, the X cranial nerve, the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr. X in the paratracheal region.  The submandibular gland was removed as well.  The X, XI, and XII cranial nerves were preserved.  The internal jugular vein and carotid artery were preserved as well.  Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure.  There were two obviously positive nodes in this neck dissection.  One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2.  A #10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2-0 silk ligature.  The wound was closed in layers using a 3-0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples.  A fluff and Kling pressure dressing was then applied.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.", ENT - Otolaryngology,11
"CC: , ""Five years ago, I stopped drinking and since that time, I have had severe depression.  I was doing okay when I stopped my medications in April for a few weeks, but then I got depressed again.  I started lithium three weeks ago."",HPI:  ,The patient is a 45-year-old married white female without children currently working as a billing analyst for Northwest Natural.  The patient has had one psychiatric hospitalization for seven days in April of 1999.  The patient now presents with recurrent depressive symptoms for approximately four months.  The patient states that she has decreased energy, suicidal ideation, suicide plan, feelings of guilt, feelings of extreme anger, psychomotor agitation, and increased appetite.  The patient states her sleep is normal and her ability to concentrate is normal.  The patient states that last night she had an argument with her husband in which he threaten to divorce her.  The patient went into the rest room, tried to find a razor blade, could not find one but instead found a scissor and cut her arm moderately with some moderate depth.  She felt better after doing so and put a bandage over the wound and did not report to her husband or anybody else what she had done.  The patient reports that she has had increased tension with her husband as of recent.  She notes that approximately a week ago she struck her husband several times.  She states that he has never hit her but instead pushed her back after she was hitting him.  She reports no history of abuse in the past.  The patient identifies recent stressors as having ongoing conflict at work with her administrator with them ""cracking down on me."" The patient also notes that her longstanding therapy will be temporarily interrupted by the therapist having a child.  She states that her recent depression seems to coincide with her growing knowledge that her therapist was pregnant.  The patient states that she has a tremendous amount of anger towards her therapist for discontinuing or postponing treatment.  She states that she feels ""abandoned."" The patient notes that it does raise issues with her past, where she had a child at the age of 17 who she gave away for adoption and a second child that she was pregnant by the age of 42 that she aborted at the request of her husband.  The patient states she saw her therapist most recently last Friday.  She sees the therapy weekly and indicates the therapy helps, although she is unable to specify how.  When asked for specifics of what she has learned from the therapy, the patient was unable to reply.  It appears that she is very concrete and has difficulty with symbolization and abstractions and self-observation.  The patient reports that at her last visit her therapist was concerned that she may be suicidal and was considering hospitalization.  The patient, at that point, stated that she would be safe through Monday despite having made a gesture last night.  At present, the patient's mood is reactive and for much of the session she appears angry and irritated with me but at the end of the session, after I have given her my assessment, she appears calmed and not depressed.  When asked if she is suicidal at present, she states no.  The patient does not want to go into the hospital.  The patient also indicates at the end of the session she felt hopeful.  The patient reports her current sleep is about eight hours per night.  She states that longest she has been able to stay awake in the past has been 24 hours.  She states that during periods where she feels up she sleeps perhaps six hours per night.  The patient reports no spending sprees and no reports no sexual indiscretions.  The patient states that her sexuality does increase when she is feeling better but not enormously so.  The patient denies any history of delusions or hallucinations.  The patient denies any psychosis.  The patient states that she does have mood swings and that the upstate lasts for a couple of weeks at longest.  She states that more predominately she has depression.  The patient states that she does not engage in numerous projects when she is in an upstate although does imagine doing so.  The patient notes that suicidality and depression seems to often arise around disputes with her husband and/or feelings of abandonment.  The patient indicates some satisfaction when she is called on her behavior ""I need to answer for my actions."" The patient gives a substantial history of alcohol abuse lasting up to about five years ago when she was hospitalized.  Most typically, the patient will drink at least a bottle of wine per day.  The patient has attended AA but at present going once a week, although she states that she is not engaged as she has been in the past; and when asked if she may be in early relapse, she indicates that yes that is a very real possibility.  The patient states she is not working through any of the steps at present.,PPH: , The patient denies any sexual abuse as a child.  She states that she was disciplined primarily by her father with spankings.  She states that on occasion her mother would use a belt to spank her or with her hand or with a spoon.  The patient has been seeing Dr. A for the past five years.  Prior to that she was admitted to a hospital for her suicide attempt.  The patient also has one short treatment experienced with the Day Treatment Program here in Portland.  The patient states that it was not useful as it focused on group work with pts that she did not feel any similarity with.  The patient, also as a child, had a history of cutting behaviors.  The patient was admitted to the hospital after lacerating her arm.,MEDICAL HISTORY:  ,The patient has hypothyroidism and last had her TSH drawn a week ago but does not know the results.  Janet Green is her primary physician.  The patient also has had herniated disc in the neck and a sinus inflammation, both of which were treated surgically.,CURRENT MEDICATIONS: , The patient currently is taking Synthroid 75 mcg per day and lithium 1200 mg p.o. q.d. The patient started the lithium approximately three weeks ago and has not had a recent lithium level or kidney function test.,ALLERGIES: , No known drug allergies.,SUBSTANCE HISTORY: , The patient has been sober for five years.  She drank one bottle of wine per day as per HPI.  History of drinking for approximately 25 years.  The patient does not currently have a sponsor.  The patient experimented with amphetamines, cocaine, marijuana approximately 16 years ago.,SOCIAL HISTORY: , The patient's mother is age 66, father is age 70, and she has a brother age 44.  Her brother has been incarcerated numerous times for assaults and has difficulty with anger and rage.  He made a suicide attempt at age 17.  The patient's father is a machinist who she describes as somewhat narcissistic and with alcohol abuse problem.  He also has arthritis.  The patient's mother is arthritic.  She states that her mother stopped working at middle age after being laid off and appears somewhat reclusive.,EDUCATIONAL HISTORY: , The patient was educated through high school and has two years of Night College.  The patient states that she grew up and was raised in Portland but notes her childhood was primarily lonely.  She states she was unliked and unpopular child because she was ""shy"" and ""not smart enough."" The patient denies having secrets.  The patient reports that this is her second marriage, which has lasted two years.  Her first marriage lasted I believe it was five years.  The patient also had a relationship in recovery for four years, which ended after they went ""different directions."",MSE:,  The patient is middle-aged white female, dressed in a red sweater with a white shirt, full patterned skirt, and open sandals.  The patient is suspicious and somewhat confrontative early in the session.  She asked me regarding my cancellation policy, why I require seven days and not 24 hours.  The patient also is irritated with paper required of her.  Psychomotor is increased slightly.  The patient makes strong eye contact.  Speech is normal rate, rhythm, and volume.  Mood is ""irritated."" Affect is irritated, angry, demanding, attempting to wrest control from me, depressed, frustrated.  Thought is directed.  Content is nondelusional.  There are no auditory and no visual hallucinations.  The patient has no homicidal ideation.  The patient does endorse suicidal ideations.  Regarding plan, the patient notes that cutting herself hurts too much therefore she would like to take some benzodiazepines or barbiturates but has access to none.  The patient states that she will not try to hurt herself currently and that she poses no risk at present.  The patient notes that she does not want to go to the hospital at present.  The patient is alert and oriented x 3.  Recall is three for three at five minutes.  Proverbs are concrete.  She has fair impulse control, poor judgment, and poor insight.,FORMULATION:  ,The patient is a 45-year-old married white female with no children now presenting with recurrent depressive symptoms and active suicidal ideation and planning.  The patient reports longstanding depressive symptoms that were subthreshold punctuated by periods of more severe depression.  The patient also reports some up periods, which do not meet most criteria for a bipolar disorder or manic states.  The patient notes that current depression started with approximately the same time that she became aware that her therapist was pregnant.  She notes that the current depression is atypical in that it is primarily anger based and she does not have the typical hypersomnia that she gets.  The patient reports being unable to express anger to her therapist and being unable to discuss her feeling regarding the pregnancy.  The patient also states that she feels abandoned with the upcoming discontinuation of treatment while the therapist is giving birth and thereafter.  Symptoms are consistent with a longstanding dysthymia and reoccurring depression.  In addition, diagnosis is highly complicated by presence of a strong personality disorder component, most likely borderline personality disorder.  This latter diagnosis seems to be the most active at this time with the patient acutely reacting to perceived therapist's absence and departure.  This is exacerbated by instability in the patient's marital life.,DIAGNOSIS:,Axis I:  Dysthymia.  Major depression, moderate severity, recurrent, with partial remission.,Axis II:  Borderline personality disorder.,Axis III:  Hypothyroidism and cervical disc herniation and sinus surgery.,Axis IV:  Medical access.  Marital discord.,Axis V:  A GAF of 30.,PLAN:  ,The patient is unlikely to have bipolar disorder.  We will recommend the patient's thyroid be rechecked to ensure she is currently euthymic.  We would recommend continued weekly or twice weekly insight oriented psychotherapy with aggressive exploration of the patient's reaction to her therapist's departure.  We would also recommend dialectical behavioral therapy while the therapist is on leave.  We would recommend continued treatment with SSRIs for dysthymia and depression.  We would suggest prescribing long acting antidepressant such as Prozac, given the patient's ambivalence regarding medications.  Prozac should be pushed to minimum of 40 mg, which the patient has already tolerated in the past, but most likely up to 60 or 80 mg.  We might also supplement the Prozac with a (anti-sleep medication).,Time spent with the patient was 1.5 hours.", Psychiatry / Psychology,32
"HOSPITAL COURSE:,  The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation.  Mother had two previous C-sections.  Baby was born at 5:57 on 07/30/2006.  Mother received ampicillin 2 g 4 hours prior to delivery.  Mother came with preterm contractions, with progressive active labor in spite of the terbutaline and magnesium sulfate.  Baby was born with Apgar scores of 8 and 9 at delivery.  Fluid was cleared.  Nuchal cord x1.  Prenatal was at ABC Valley.  Prenatal labs were O positive, antibody negative, rubella immune, RPR nonreactive.  Baby was suctioned on perineum with good support.  The baby was admitted to the NICU for prematurity and to rule out sepsis.  Baby's cry was good.  Color, tone, and __________ mild retractions.  CBC, CRP, blood cultures were done.  IV fluids of D10 at a rate of 6 mL an hour.  Ampicillin and gentamicin were started via protocol.  At the time of admission, the patient was stable on room air and has feeding issues.  Baby was fed EBM 22 and NeoSure per os.  Ampicillin and gentamicin were started per protocol but were discontinue when blood cultures came out negative after 48 hours.  The patient continues on feeding issues, will not suck properly, was kept in the NICU, and put on OG tube for a couple of days after which p.o. feeds were advanced.  Also, the baby was able to suck properly and was tolerating feeds.  The baby was fed EBM 22 and NeoSure was added a day before discharge.  At the time of discharge, baby was stable on room air, baby was tolerated p.o. foods and was sucking properly, was taking ad lib feeds and gaining weight.,ADMISSION DIAGNOSES:,  Respiratory distress, rule out sepsis and prematurity.,DISCHARGE DIAGNOSES:,  Stable, ex-34-week preemie.,Pediatrician after discharge will be Dr. X.,DISCHARGE INSTRUCTIONS: , To follow up with Dr. X in 2 to 3 days, an appointment was made for 08/14/2006.  CPR teaching was completed on 08/11/2006 to parents.  Formula feeding schedule with breast and NeoSure 2 to 3 ounces per feed.  Ad lib feeding on demand.", Discharge Summary,10
"CHIEF COMPLAINT: , ""Bloody bump on penis."",HISTORY OF PRESENT ILLNESS: , This is a 29-year-old African-American male who presents to the Emergency Department today with complaint of a bleeding bump on his penis.  The patient states that he has had a large bump on the end of his penis for approximately a year and a half.  He states that it has never bled before.  It has never caused him any pain or has never been itchy.  The patient states that he is sexually active, but has been monogamous with the same person for the past 13 years.  He states that he believes that his sexual partner is monogamous as well and reciprocates in this practice.  The patient does state that last night he was ""trying to get some,"" meaning that he was engaging in sexual intercourse, at which time this bump bent backwards and ripped a portion of the skin on the tip of his penis.  The patient said that there is a large amount of blood from this injury.  This happened last night, but he was embarrassed to come to the Emergency Department yesterday when it was bleeding.  The patient has been able to get the bleeding to stop, but the large bump is still located on the end of his penis, and he is concerned that it will rip off, and does want it removed.  The patient denies any drainage or discharge from his penis.  He denies fevers or chills recently.  He also denies nausea or vomiting.  The patient has not had any discharge from his penis.  He has not had any other skin lesions on his penis that are new to him.  He states that he has had numerous bumps along the head of his penis and on the shaft of his penis for many years.  The patient has never had these checked out.  He denies fevers, chills, or night sweats.  He denies unintentional weight gain or loss.  He denies any other bumps, rashes, or lesions throughout the skin on his body.,PAST MEDICAL HISTORY:  ,No significant medical problems.,PAST SURGICAL HISTORY: , Surgery for excision of a bullet after being shot in the back.,SOCIAL HABITS: , The patient denies illicit drug usage.  He occasionally smokes tobacco and drinks alcohol.,MEDICATIONS: , None.,ALLERGIES: , No known medical allergies.,PHYSICAL EXAMINATION:  ,GENERAL:  This is an African-American male who appears his stated age of 29 years.  He is well nourished, well developed, in no acute distress.  The patient is pleasant.  He is sitting on a Emergency Department gurney.,VITAL SIGNS:  Temperature 98.4 degrees Fahrenheit, blood pressure of 139/78, pulse of 83, respiratory rate of 18, and pulse oximetry of 98% on room air.,HEART:  Regular rate and rhythm.  Clear S1, S2.  No murmur, rub, or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales, or rhonchi.,ABDOMEN:  Soft, nontender, nondistended, and positive bowel sounds throughout.,GENITOURINARY:  The patient's external genitalia is markedly abnormal.  There is a large pedunculated mass dangling from the glans of the penis at approximately the urethral meatus.  This pedunculated mass is approximately 1.5 x 2 cm in size and pedunculated by a stalk that is approximately 2 mm in diameter.  The patient appears to have condylomatous changes along the glans of the penis and on the shaft of the penis as well.  There are no open lesions at this point.  There is a small tear of the skin where the mass attaches to the glans near the urethral meatus.  Bleeding is currently stanch, and there is no sign of secondary infection at this time.  Bilateral testicles are descended and normal without pain or mass bilaterally.  There is no inguinal adenopathy.,EXTREMITIES:  No edema.,SKIN:  Warm, dry, and intact.  No rash or lesion.,DIAGNOSTIC STUDIES:  ,Non-emergency department courses.  It is thought that this patient should proceed directly with a referral to Urology for excision and biopsy of this mass.,ASSESSMENT AND PLAN: , Penile mass.  The patient does have a large pedunculated penile mass.  He will be referred to the urologist who is on-call today.  The patient will need this mass excised and biopsied.  The patient verbalized understanding the plan of followup and is discharged in satisfactory condition from the ER.,", Emergency Room Reports,12
"EXAM: , Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.,REASON FOR EXAM: , Abnormal stress test and episode of shortness of breath.,PROCEDURE: , Right common femoral artery, 6-French sheath, JL4, JR4, and pigtail catheters were used.,FINDINGS:,1.  Left main is a large-caliber vessel.  It is angiographically free of disease,,2.  LAD is a large-caliber vessel.  It gives rise to two diagonals and septal perforator.  It erupts around the apex.  LAD shows an area of 60% to 70% stenosis probably in its mid portion.  The lesion is a type A finishing before the takeoff of diagonal 1.  The rest of the vessel is angiographically free of disease.,3.  Diagonal 1 and diagonal 2 are angiographically free of disease.,4.  Left circumflex is a small-to-moderate caliber vessel, gives rise to 1 OM.  It is angiographically free of disease.,5.  OM-1 is angiographically free of disease.,6.  RCA is a large, dominant vessel, gives rise to conus, RV marginal, PDA and one PL.  RCA has a tortuous course and it has a 30% to 40% stenosis in its proximal portion.,7.  LVEDP is measured 40 mmHg.,8.  No gradient between LV and aorta is noted.,Due to contrast concern due to renal function, no LV gram was performed.,Following this, right common femoral angiogram was performed followed by StarClose closure of the right common femoral artery.,IMPRESSION:,1.  60% to 70% mid left anterior descending stenosis.,2.  Mild 30% to 40% stenosis of the proximal right coronary artery.,3.  Status post StarClose closure of the right common femoral artery.,PLAN:  ,Plan will be to perform elective PCI of the mid LAD.", Cardiovascular / Pulmonary,3
"PROCEDURE:,1.  Implantation, dual chamber ICD.,2.  Fluoroscopy.,3.  Defibrillation threshold testing.,4.  Venography.,PROCEDURE NOTE: , After informed consent was obtained, the patient was taken to the operating room.  The patient was prepped and draped in a sterile fashion.  Using modified Seldinger technique, the left subclavian vein was attempted to be punctured but unsuccessfully.  Approximately 10 cc of intravenous contrast was injected into the left upper extremity peripheral vein.  Venogram was then performed.  Under fluoroscopy via modified Seldinger technique, the left subclavian vein was punctured and a guidewire was passed through the vein into the superior vena cava, then the right atrium and then into the inferior vena cava.  A second guidewire was placed in a similar fashion.  Approximately a 5 cm incision was made in the left upper anterior chest.  The skin and subcutaneous tissue was dissected out of the prepectoral fascia.  Both guide wires were brought into the pocket area.  A sheath was placed over the lateral guidewire and fluoroscopically guided to the vena cava.  The dilator and guidewire were removed.  A Fixation ventricular lead, under fluoroscopic guidance, was placed through the sheath into the superior vena cava, right atrium and then right ventricle.  Using straight and curved stylettes, it was placed in position and screwed into the right ventricular apex.  After pacing and sensing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscle with Ethibond suture.  A guide sheath was placed over the guidewire and fluoroscopically placed in the superior vena cava.  The dilator and guidewire were removed.  An Active Fixation atrial lead was fluoroscopically passed through the sheath, into the superior vena cava and then the right atrium.  Using straight and J-shaped stylettes, it was placed in the appropriate position and screwed in the right atrial appendage area.  After significant pacing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscles with Ethibond suture.  The tract was flushed with saline solution.  A Medtronic pulse generator was attached to both the leads and fixed to the pectoral muscle with Ethibond suture.  Deep and superficial layers were closed with 3-0 Vicryl in a running fashion.  Steri-strips were placed over the incision.  Tegaderm was placed over the Steri-strips.  Pressure dressing was applied to the pocket area.", Cardiovascular / Pulmonary,3
"PROCEDURE:,  Circumcision.,ANESTHESIA: , EMLA.,FINDINGS: , Normal penis.  The foreskin was normal in appearance and measured 1.6 cm.  There was no bleeding at the circumcision site.,PROCEDURE:,  Patient was placed on the circumcision restraint board.  EMLA had been applied approximately 90 minutes before.  A time-out was completed satisfactorily per protocol.  The area was prepped with Betadine.  The foreskin was grasped with sterile clamps and was dissected away from the corona and the glans penis with blunt dissection.  A Mogen clamp was applied to the cervix.  The excess foreskin was excised with the scalpel.  The clamp was removed.  At this point, the procedure was terminated.  Sterile Vaseline and gauze was applied to the glans penis.  There were no complications.  There was minimal blood loss.", Surgery,38
"INDICATION FOR STUDY: , Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.,MEDICATIONS:,  Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.,BASELINE EKG: , Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.,EXERCISE RESULTS:,1.  The patient exercised for 3 minutes stopping due to fatigue.  No chest pain.,2.  Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate.  Blood pressure rose from 150/88 to 210/100.  There was a slight increase in her repolorization abnormalities in a non-specific pattern.,NUCLEAR PROTOCOL:  ,Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.,NUCLEAR RESULTS:,1.  Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition.  The resting images showed decreased uptake in the anterior wall.  However the apex is spared of this defect.  There is no significant change between rest and stress images.  The sum score is 0.,2.  The Gated SPECT shows moderate LVH with slightly low EF of 48%.,IMPRESSION:,1.  No evidence of exercise induced ischemia at a high myocardial workload.  This essentially excludes obstructive CAD as a cause of her elevated troponin.,2.  Mild hypertensive cardiomyopathy with an EF of 48%.,3.  Poor exercise capacity due to cardiovascular deconditioning.,4.  Suboptimally controlled blood pressure on today's exam.", Radiology,33
"PREOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,POSTOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,PROCEDURE PERFORMED: , Open reduction and internal fixation (ORIF) of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.,ANESTHESIA: , General nasotracheal.,ESTIMATED BLOOD LOSS: , 125 mL.,FLUIDS GIVEN: , 1 L of crystalloids.,SPECIMEN: , Soft tissue from the fracture site sent for histologic diagnosis.,CULTURES: , Also sent for Gram stain, aerobic and anaerobic, culture and sensitivity.,INDICATIONS FOR THE PROCEDURE: , The patient is a 79-year-old male, who fell in his hometown, following an episode of syncope.  He sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in the above-mentioned fracture.  He was admitted to hospital in Harleton, Texas, where his initial evaluation showed the rib fractures have also showed a nodule on his right upper lobe as well as a mediastinal mass.  His mandible fracture was not noted initially.  The patient also has a history of prostate cancer and a renal cell carcinoma.  The patient at that point underwent a bronchoscopy with a biopsy of the mediastinal mass and the results of that biopsy are still pending.  The patient later saw a local oral surgeon.  He diagnosed his mandible fracture and advised him to seek treatment in Houston.  He presented to my office for evaluation on January 18, 2010, and he was found to have an extremely atrophic mandible with a fracture in the left parasymphysis region involving a failed dental implant, which had been placed approximately 15 years ago.  The patient had significant discomfort and could eat foods and drink fluids with difficulty.  Due to the nature of his fracture and the complex medical history, he was sent to the hospital for admission and following cardiac clearance, he was scheduled for surgery today.,PROCEDURE IN DETAIL: , The patient was taken to the operating room, and placed in a supine position.  Following a nasal intubation and induction of general anesthesia, the surgeon then scrubbed, gowned, and gloved in the normal sterile fashion.  The patient was then prepped and draped in a manner consistent with sterile procedures.  A marking pen was first used to outline the incision in the submental region and it was extended from the left mandibular body to the right mandibular body region, approximately 1.5 cm medial to the inferior border of the mandible.  A 1 mL of lidocaine 1% with 1:100,000 epinephrine was then infiltrated along the incision and then a 15-blade was used to incise through the skin and subcutaneous tissue.  A combination of sharp and blunt dissection was then used to carry the dissection superiorly to the inferior border of the mandible.  Electrocautery as well as 4.0 silk ties were used for hemostasis.  A 15-blade was then used to incise the periosteum along the inferior border of the mandible and it was reflected exposing the mandible as well as the fracture site.  The fracture site was slightly distracted allowing access to the dental implant within the bone and it was easily removed from the wound.  Cultures of this site were also obtained and then the granulation tissue from the wound was also curetted free of the wound and sent for a histologic diagnosis.  Manipulation of the mandible was then used to achieve an anatomic reduction and then an 11-hole Synthes reconstruction plate was then used to stand on the fracture site.  Since there was an area of weakness in the right parasymphysis region, in the location of another dental implant, the bone plate was extended posterior to that site.  When the plate was adapted to the mandible, it was then secured to the bone with 9 screws, each being 2 mm in diameter and each screw was placed bicortically.  All the screws were also locking screws.  Following placement of the screws, there was felt to be excellent stability of the fracture, so the wound was irrigated with a copious amount of normal saline.  The incision was closed in multiple layers with 4.0 Vicryl in the muscular and subcutaneous layers and 5.0 nylon in the skin.  A sterile dressing was then placed over the incision.  The patient tolerated the procedure well and was taken to the recovery room with spontaneous respirations and stable vital signs.  Estimated blood loss is 125 mL.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,PROCEDURE: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Patient is a pleasant 31-year-old gentleman who presented to the hospital with acute onset of right lower quadrant pain.  History as well as signs and symptoms are consistent with acute appendicitis as was his CAT scan.  I evaluated the patient in the emergency room and recommended that he undergo the above-named procedure.  The procedure, purpose, risks, expected benefits, potential complications, alternative forms of therapy were discussed with him and he was agreeable with surgery.,FINDINGS: , Patient was found to have acute appendicitis with an inflamed appendix, which was edematous, but essentially no suppuration.,TECHNIQUE:  ,The patient was identified and then taken into the operating room, where after induction of general endotracheal anesthesia, the abdomen was prepped with Betadine solution and draped in sterile fashion.  An infraumbilical incision was made and carried down by blunt dissection to the level of the fascia, which was grasped with an Allis clamp and two stay sutures of 2-0 Vicryl were placed on either side of the midline.  The fascia was tented and incised and the peritoneum entered by blunt finger dissection.  A Hasson cannula was placed and a pneumoperitoneum to 15 mmHg pressure was obtained.  Patient was placed in the Trendelenburg position, rotated to his left, whereupon under direct vision, the 12-mm midline as well as 5-mm midclavicular and anterior axillary ports were placed.  The appendix was easily visualized, grasped with a Babcock's.  A window was created in the mesoappendix between the appendix and the cecum and the Endo GIA was introduced and the appendix was amputated from the base of the cecum.  The mesoappendix was divided using the Endo GIA with vascular staples.  The appendix was placed within an Endo bag and delivered from the abdominal cavity.  The intra-abdominal cavity was irrigated.  Hemostasis was assured within the mesentery and at the base of the cecum.  All ports were removed under direct vision and then wounds were irrigated with saline antibiotic solution.  The infraumbilical defect was closed with a figure-of-eight 0 Vicryl suture.  The remaining wounds were irrigated and then everything was closed subcuticular with 4-0 Vicryl suture and Steri-Strips.  Patient tolerated the procedure well, dressings were applied, and he was taken to recovery room in stable condition.", Surgery,38
"EXAM: , Bilateral lower extremity ultrasound for deep venous thrombus.,REASON FOR EXAM: , Lower extremity edema bilaterally.,TECHNIQUE: , Colored, grayscale, and Doppler imaging is all employed.,FINDINGS: , This examination is limited.  There is prominent edema bilaterally and there is large body habitus.  These two limit assessment especially of the right lower extremity.,As visualized, there is no gross evidence of DVT.  The right leg grayscale images are limited.  No obvious clot identified on the color flow or Doppler images.  The left leg is better visualized than the right, but again is limited.  No definite clot is seen.,IMPRESSION: , Limited study secondary to body habitus and edema.  No obvious DVT as visualized.", Radiology,33
"PROCEDURES: , Left heart catheterization, left ventriculography, and left and right coronary arteriography.,INDICATIONS: , Chest pain and non-Q-wave MI with elevation of troponin I only.,TECHNIQUE:  ,The patient was brought to the procedure room in satisfactory condition.  The right groin was prepped and draped in routine fashion.  An arterial sheath was inserted into the right femoral artery.,Left and right coronary arteries were studied with a 6FL4 and 6FR4 Judkins catheters respectively.  Cine coronary angiograms were done in multiple views.,Left heart catheterization was done using the 6-French pigtail catheter.  Appropriate pressures were obtained before and after the left ventriculogram, which was done in the RAO view.,At the end of the procedure, the femoral catheter was removed and Angio-Seal was applied without any complications.,FINDINGS:,1.  LV is normal in size and shape with good contractility, EF of 60%.,2.  LMCA normal.,3.  LAD has 20% to 30% stenosis at the origin.,4.  LCX is normal.,5.  RCA is dominant and normal.,RECOMMENDATIONS: , Medical management, diet, and exercise.  Aspirin 81 mg p.o. daily, p.r.n. nitroglycerin for chest pain.  Follow up in the clinic.", Cardiovascular / Pulmonary,3
"EXAM:,  Mammographic screening FFDM,HISTORY: , 40-year-old female who is on oral contraceptive pills.  She has no present symptomatic complaints.  No prior history of breast surgery nor family history of breast CA.,TECHNIQUE: , Standard CC and MLO views of the breasts.,COMPARISON: , This is the patient's baseline study.,FINDINGS: , The breasts are composed of moderately to significantly dense fibroglandular tissue.  The overlying skin is unremarkable.,There are a tiny cluster of calcifications in the right breast, near the central position associated with 11:30 on a clock.,There are benign-appearing calcifications in both breasts as well as unremarkable axillary lymph nodes.,There are no spiculated masses or architectural distortion.,IMPRESSION:,  Tiny cluster of calcifications at the 11:30 position of the right breast.  Recommend additional views; spot magnification in the MLO and CC views of the right breast.,BIRADS Classification 0 - Incomplete,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.", Obstetrics / Gynecology,24
"TITLE OF OPERATION: , Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.,INDICATIONS FOR SURGERY:  ,Please refer to medical record, but in short, the patient is a 43-year-old male known to me, status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.  Risks and benefits of surgery were explained in detail including risk of bleeding, infection, stroke, heart attack, paralysis, need for further surgery, hardware failure, persistent symptoms, and death.  This list was inclusive, but not exclusive.  An informed consent was obtained after all patient's questions were answered.,PREOPERATIVE DIAGNOSIS:  ,Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,POSTOPERATIVE DIAGNOSIS: , Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,ANESTHESIA: , General anesthesia and endotracheal tube intubation.,DISPOSITION: , The patient to PACU with stable vital signs.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room.  After adequate general anesthesia with endotracheal tube intubation was obtained, the patient was placed prone on the Jackson table.  Lumbar spine was shaved, prepped, and draped in the usual sterile fashion.  An incision was carried out from L4 to S1.  Hemostasis was obtained with bipolar and Bovie cauterization.  A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4, L5, and sacrum.  At this time, laminectomy was carried out of L5-S1.  Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space.  At this time, the disk was entered with a #15 blade and bipolar.  The disk was entered with straight up and down-biting pituitaries, curettes, and the high speed drill and we were able to takedown calcified herniated disk.  We were able to reestablish the disk space, it was very difficult, required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal, very carefully holding the spinal canal out of harm's way as well as the exiting nerve root.  Once this was done, we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic.  At this time, Dr. X will dictate the posterolateral fusion, pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound.  There were no complications.", Surgery,38
"NUCLEAR CARDIOLOGY/CARDIAC STRESS REPORT,INDICATION FOR STUDY: , Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.,PROCEDURE: , The patient was studied in the resting state following intravenous delivery of adenosine triphosphate at 140 mcg/kg/min delivered over a total of 4 minutes.  At completion of the second minute of infusion, the patient received technetium Cardiolite per protocol.  During this interval, the blood pressure 150/86 dropped to near 136/80 and returned to near 166/84 at completion.  No diagnostic electrocardiographic abnormalities were elaborated during this study.,REGIONAL MYOCARDIAL PERFUSION WITH ADENOSINE PROVOCATION: , Scintigraphic study reveals at this time multiple fixed defects in perfusion suggesting indeed multivessel coronary artery disease, yet no active ischemia at this time.  A fixed defect is seen in the high anterolateral segment.  A further fixed perfusion defect is seen in the inferoapical wall extending from close to the septum.  There is no evidence for active ischemia in either distribution.  Lateral wall moving towards the apex of the left ventricle is further involved from midway through the ventricle moving upward and into the high anterolateral vicinity.  When viewed from the vertical projection, the high septal wall is preserved with significant loss of the mid anteroapical wall moving to the apex and in a wraparound fashion in the inferoapical wall.  A limited segment of apical myocardium is still viable.,No gated wall motion study was obtained.,CONCLUSIONS:  ,Cardiolite perfusion findings support multivessel coronary artery disease and likely previous multivessel infarct as has been elaborated above.  There is no indication for active ischemia at this time.", Radiology,33
"CHIEF COMPLAINT:,  Right middle finger triggering and locking, as well as right index finger soreness at the PIP joint.,HISTORY OF OCCUPATIONAL INJURY OR ILLNESS:,  The patient has been followed elsewhere, and we reviewed his records.  Essentially, he has had a trigger finger and a mucocyst, and he has had injections.  This has been going on for several months.  He is now here for active treatment because the injections were not helpful, nonoperative treatment has not worked, and he would like to move forward in order to prevent this from keeping on locking and causing his pain.  He is referred over here for evaluation regarding that.,SIGNIFICANT PAST MEDICAL AND SURGICAL HISTORY:,General health/review of systems:  See H&P. ,Allergies:  See H&P.,Medications:  See H&P.,Social History:  See H&P.,Family History:  See H&P.,Previous Hospitalizations:  See H&P.,CLINICAL ASSESSMENT AND FINDINGS:,Musculoskeletal:  Shows point tenderness to palpation to the right middle finger A1 pulley.  The right index finger has some small soreness at the PIP joint, but at this time no obvious mucocyst.  He has flexion/extension of his fingers intact.  There is no crepitation at the wrist, forearm, elbow or shoulder with full range of motion.  Contralateral arm exam for comparison reveals no focal findings.,Neurological:  APB, EPL and first dorsal interosseous 5/5.,LABORATORY, RADIOGRAPHIC, AND/OR IMAGING TESTS ORDERS & RESULTS:,Special lab studies:  ,CLINICAL IMPRESSION:,1.  Tendinitis, left middle finger.,2.  PIP joint synovitis and mucocyst, but controlled on nonoperative treatment.,3.  Middle finger trigger, failed nonoperative treatment, requiring a trigger finger release to the right middle finger.,EVALUATION/TREATMENT PLAN:,  Risks, benefits and alternatives were discussed.  All questions were answered.  No guarantees were made.  We will schedule for surgery.  We would like to move forward in order to help him significantly improve since he has failed injections.  All questions were answered.  Followup appointment was given.", Orthopedic,27
"PREOPERATIVE DIAGNOSIS:,  Plantar fascitis, left foot.,POSTOPERATIVE DIAGNOSIS: , Plantar fascitis, left foot.,PROCEDURE PERFORMED: , Partial plantar fasciotomy, left foot.,ANESTHESIA:,  10 cc of 0.5% Marcaine plain with TIVA.,HISTORY:  ,This 35-year-old Caucasian female presents to ABCD General Hospital with above chief complaint.  The patient states she has extreme pain with plantar fascitis in her left foot and has attempted conservative treatment including orthotics without long-term relief of symptoms and desires surgical treatment.  The patient has been NPO since mid night.  Consent is signed and in the chart.  No known drug allergies.,Details Of Procedure:  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on the operating table in supine position with a safety belt across the stomach.  Copious amounts of Webril were placed on the left ankle followed by blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was injected into the surgical site both medially and laterally across the plantar fascia.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  An Esmarch bandage was applied for exsanguination and the pneumatic ankle tourniquet was inflated to 250 mmHg.  The foot was then reflected on the operating, stockinet reflected, and the foot cleansed with a wet and dry sponge.  Attention was then directed to the plantar medial aspect of the left heel.  An approximately 0.75 cm incision was then created in the plantar fat pad over the area of maximal tenderness.,The incision was then deepened with a combination of sharp and blunt dissection until the plantar fascia was palpated.  A #15 blade was then used to transect the medial and central bands of the plantar fascia.  Care was taken to preserve the lateral fibroids.  The foot was dorsiflexed against resistance as the fibers were released and there was noted to be increased laxity after release of the fibers on the plantar aspect of the foot indicating that plantar fascia has in fact been transacted.  The air was then flushed with copious amounts of sterile saline.  The skin incision was then closed with #3-0 nylon in simple interrupted fashion.  Dressings consisted of #0-1 silk, 4 x 4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted throughout all digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to the PACU with vital signs stable and vascular status intact to the left foot.  Intraoperatively, an additional 80 cc of 1% lidocaine was injected for additional anesthesia in the case.  The patient is to be nonweightbearing on the left lower extremity with crutches.  The patient is given postoperative pain prescriptions for Vicodin ES, one q3-4h. p.o. p.r.n. for pain as well as Celebrex 200 mg one p.o. b.i.d.  The patient is to follow-up with Dr. X as directed.", Surgery,38
"SUBJECTIVE:,  Patient presents with Mom for first visit to the office for two week well-child check.  Mom has no concerns stating that patient has been doing well overall since dismissal from the hospital.  Nursing every two to three hours with normal voiding and stooling pattern.  She does have a little bit of some gas and Mom has been using Mylicon drops which are helpful.  She is burping well, hiccuping, sneezing and burping appropriately.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development.  See Denver II form in the chart.,PAST MEDICAL HISTORY:,  Mom reports uncomplicated pregnancy and delivery with prenatal care provided by Dr. Hoing.  Delivery at Newton Medical Center at 39 weeks, 5 days gestation.  Birth weight was 3160 g.  Length 49.5 cm.  Head circumference 33 cm.  Infant was delivered to 22-year-old A-positive mom who is G1 P0, now P1.  Infant did well after delivery and was dismissed to home with Mom the following day.  No other hospitalizations.  No surgeries.,ALLERGIES: , None.,MEDICATIONS:,  Gas drops p.r.n.,FAMILY HISTORY: , Significant for cardiovascular problems and hypertension as well as diabetes mellitus on the maternal side of the family.  History of cancer and asthma on the paternal side of the family.  Mom unsure of what type of cancer.,SOCIAL HISTORY:,  Patient lives at home with 22-year-old mother Aubrey Mizel and her parents Bud and Sue Mizel in Newton, Kansas.  Father of the baby, Shivanka Silva age 30, is a full-time student at WSU in Wichita, Kansas and does help with care of the newborn.  There is no smoking in the home.  Family does have one pet dog in home.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs:  Weight 7 pounds, 1-1/5 ounces.  Height 21 inches.  Head circumference 35.8 cm.  Temperature 97.7.,General:  Well-developed, well-nourished, cooperative, alert and interactive 2-week-old female in no acute distress.,HEENT:  Atraumatic, normocephalic.  Anterior fontanel soft and flat.  Pupils equal, round and reactive.  Sclerae clear.  Red reflex present bilaterally.  TMs clear bilaterally.  Oropharynx:  Mucous membranes moist and pink.,Neck:  Supple, no lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze or crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No masses or organomegaly.  Healing umbilicus.,GU:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.  Negative Ortolani and Barlow maneuver.,Back:  Straight.  No scoliosis.  Some increased pigment over the sacrum.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.,ASSESSMENT/PLAN:,1. Well 2-week-old mixed race Caucasian and Middle Eastern descent female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations and visitation schedule.  Gave two week well-child check handout to Mom.  Plan follow up for the one month well-child check or as needed for acute care.  Mom will call for feeding problems, breathing problems or fever.  Otherwise, plan to see at one month.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS:,  Obstructive sleep apnea.,POSTOPERATIVE DIAGNOSIS:  ,Obstructive sleep apnea.,PROCEDURE PERFORMED:,1.  Tonsillectomy.,2.  Uvulopalatopharyngoplasty.,ANESTHESIA:,  General endotracheal tube.,BLOOD LOSS: , Approximately 50 cc.,INDICATIONS: , The patient is a 41-year-old gentleman with a history of obstructive sleep apnea who has been using CPAP, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea.,PROCEDURE: , After all risks, benefits, and alternatives have been discussed with the patient, informed consent was obtained.  The patient was brought to the operative suite where he was placed in supine position and general endotracheal tube intubation was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away and a shoulder roll was placed and a McIvor mouthgag was inserted into the oral cavity.  Correct inspection and palpation did not reveal evidence of a bifid uvula or submucosal clots.  Attention was directed first to the right tonsil in which a curved Allis forceps was applied to the superior pole.  The needle-tip Bovie cautery was used to incise the mucosa of the anterior tonsillar pillar.  Once the tonsillar pillar was identified and the superior pole was released, the curved forceps with a straight Allis forceps and the dissection was carried down inferiorly, dissecting the tonsil free from all fascial attachments.  Once the tonsil was delivered from the oral cavity, hemostasis was obtained within the tonsillar fossa utilizing suction cautery.,Attention was then directed over to the left tonsil in which a similar procedure was performed.  Once all bleeding was controlled, the mucosa of both the hard and soft palate was anesthetized with a mixture of 1% lidocaine and 1:50000 epinephrine solution.  Now attention was directed to the posterior pillars.  A hemostat was used to clamp the posterior pillar, which was then taken down with Metzenbaum scissors.  The posterior pillar was then approximated to the anterior pillar with the use of #3-0 PDS suture so as to create a box shaped soft palate.  Now, the uvula was reflected onto the soft palate and #12 blade scalpel was used to incise the mucosa of the soft palate extending down onto the uvula.  The mucosa was dissected off with the use of Potts scissors.  Now the uvula was reflected onto the soft palate and sutured down in place with use of #3-0 PDS suture approximated with deep muscle layers.  Now the mucosa of the soft palate and the uvula were approximated with interrupted #3-0 PDS sutures.  Finally, #4-0 Vicryl sutures were placed intermittently between the PDS to further secure the uvula, which had been reflected onto the soft palate.  A final #3-0 PDS suture was used to further approximate the anterior and posterior tonsil pillars.  Final inspection did not reveal any further bleeding.  The mouth was then irrigated with saline and suctioned.  At this point, the procedure was complete.  He was awakened and taken to recovery room in stable condition.  He will be admitted as an observation patient to the Telemetry Floor for routine postoperative management.  Of note, IV Decadron was administered during the procedure.", ENT - Otolaryngology,11
"PREOPERATIVE DIAGNOSIS: , Hemangioma, nasal tip.,POSTOPERATIVE DIAGNOSIS:,  Hemangioma, nasal tip.,PROCEDURE PERFORMED:  ,1.  Debulking of hemangioma of the nasal tip through an open rhinoplasty approach.,2.  Rhinoplasty.,ESTIMATED BLOOD LOSS:  ,Minimal.,FINDINGS: , Large hemangioma involving the midline of the columella separated the lower lateral cartilages at a level of the columella and the nasal domes.,CONDITION:  ,Condition of the patient at end of the procedure stable, transferred to recovery room.,INDICATIONS FOR THE PROCEDURE: , The patient is a 2-year-old female with a history of a nasal tip hemangioma.  The hemangioma has involved at her upper tongue.  There has not been any change in the last 6 months.  We have discussed with the parents the situation and decided to proceed with the debulking of the nasal tip hemangioma.  They understand the nature of the incision, the nature of the surgery, and the possibility of future revision surgeries.  They understand the risk of bleeding, infection, dehiscence, scarring, need for future revision surgery, and minor asymmetry.  They wished to proceed with surgery.,Because of the procedure, informed consent is obtained.  The patient is taken to operating room and placed in the supine position.  General anesthetic is administrated to an oroendotracheal tube.  The face is prepped and draped in the usual manner.  The incision is designed to the lower aspect of the hemangioma, which corresponds to the columella and upper lip junction and then the remaining of the incision is designed as an open rhinoplasty with bilateral rim incisions.  The area is infiltrated with lidocaine with epinephrine.  We waited 7 minutes for the hemostatic effect and proceeded with the incision.  The incision was then done with a 15 C blade starting at the columella and then going laterally to the level of the rim and the double hook is placed at the level of the dome and the intracartilage incision is done through the mucosa, then extended laterally and upward to follow the lower lateral cartilage.  This is done in both sides.  Further incision is done.  A small tenotomy scissors is used and with the help of retraction of the lower lateral cartilage, the hemangioma is separated gently from the lower lateral cartilage on both sides and I proceeded to leave that the central part of the incision lifting up the entire columella to the level of the nasal tip.  The hemangioma is removed and is found to be involving the medial aspects of both medial crura.  This gently separated from the medial crura and from the soft tissue care is taken not to remove the entire hemangioma from the skin as the nose not to devascularize the distal columella portion.  Hemostasis is achieved with electrocautery.  Then, we proceed to place some interdomal stitches with the help of a 6-0 clear nylon and intercrural stitches are placed and then an interdomal stitch, a single one was placed.  The skin is redraped and the nose found to have satisfactory shape.  The columellar piece was tailored on the lateral aspect corresponding to rim incisions to match the newly created width of the columella.  Portions of skin and hemangioma are taken laterally on both sides of the columella distally.  The skin was closed with 6-0 mild chromic stitches, including the portion at the level of the columella and rim incisions medially.  The remaining of the internal incisions are closed with 5-0 chromic interrupted stitches.  The nose is irrigated and suctioned.  The patient tolerated the procedure without complications.  I was present and participated in all aspects of the procedure.  Sponge and instrument count were complete at the end of the procedure.", Surgery,38
"HISTORY OF PRESENT ILLNESS: ,The patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom.  At that time, he reports both legs gave away on him and he fell.  He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.  He was able to get up shortly after falling and according to the patient and his son, subsequently returned back to normal.,He was then well until the 3rd of July 2008 when his legs again gave way on him.  This was not preceded by lightheadedness.  He was rushed to the hospital and was found to have pneumonia, and the fall was blamed on the pneumonia.  He started using a walker from that time, prior to that he was able to walk approximately two miles per day.  He again had a fall in August of 2008 after his legs gave way.  Again, there was no lightheadedness associated with this.  He was again found to have pneumonia and again was admitted to hospital after which he went to rehabilitation and was able to use his walker again after this.  He did not, however, return to the pre-July baseline.  In October of 2008, after another fall, he was found to have pneumonia again and shingles.  He is currently in a Chronic Rehabilitation Unit.  He cannot use a walker and uses a wheelchair for everything.  He states that his hands have been numb, involving all the fingers of both hands for the past three weeks.  He is also losing muscle bulk in his hands and has noticed some general weakness of his hands.  He does, however, note that strength in his hands has not been normal since July 2008, but it is clearly getting worse.  He has been aware of some fasciculations in his legs starting in August 2008, these are present both in the lower legs and the thighs.  He does not report any cramps, problems with swallowing or problems with breathing.  He reports that he has had constipation alternating with diarrhea, although there has been no loss of control of either his bowel or bladder.  He has had some problems with blood pressure drops, and does feel presyncopal when he stands.  He also reports that he has no feeling in his feet, and that his feet feel like sponges.  This has been present for about nine months.  He has also lost joint position sense in his feet for approximately nine months.,PAST MEDICAL HISTORY:,1.  Pneumonia.  He has had recurrent episodes of pneumonia, which started at approximately age 20.  These have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year.  He is usually treated with antibiotics and then discharged.  There is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia.,2.  He has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement.  The patient does not have any history of diabetes and does not report any other medical problems.  He has lost approximately 18 pounds in the past month.,3.  He had an appendectomy in the 1940s.,4.  He had an ankle resection in 1975.,SOCIAL HISTORY:  ,The patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars.  He has not smoked for the past 27 years.  He hardly ever uses alcohol.  He is currently retired.,FAMILY HISTORY: , There is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases.  His aunt has a history of type II diabetes.,CURRENT MEDICATIONS: , Fludrocortisone 0.1 mg p.o. q.d., midodrine 5 mg p.o. q.i.d., Cymbalta 30 mg p.o. per day, Prilosec 20 mg p.o. per day, Lortab 10 mg p.o. per day, Amoxil 500 mg p.o. per day, vitamin B12 1000 mcg weekly, vitamin D 1000 units per day, Metamucil p.r.n., enteric-coated aspirin once a day, Colace 200 mg p.o. q.d., Senokot three tablets p.o. p.r.n., Reglan 10 mg p.o. q.6h., Xanax 0.25 mg p.o. q.8h. p.r.n., Ambien 5 mg p.o. q.h.s. p.r.n. and Dilaudid 2 mg tablets p.o. q.3h. p.r.n., Protonix 40 mg per day, and Megace 400 mg per day.,ALLERGIES:,  He has no medication or food allergies.,REVIEW OF SYSTEMS:,  Please see the health questionnaire and clinical notes from today.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS:  BP was 137/60, P was 89, and his weight could not be measured because he was in a wheelchair.  His pain score was 0.,APPEARANCE:  No acute distress.  He is pleasant and well-groomed.,HEENT:  Atraumatic, normocephalic.  No carotid bruits appreciated.,LUNGS:  There were few coarse crackles in both lung bases.,CARDIOVASCULAR:  Revealed a normal first and second heart sound, with no third or fourth heart sound and no murmurs.  The pulse was regular and of normal volume.,ABDOMEN:  Soft with no masses and normal bowel sounds.  There were no carotid bruits.,EXTREMITIES:  No contractures appreciated.,NEUROLOGICAL EXAM:,MSE:  His orientation, language, calculations, 100-7 tests were all normal.  There was atrophy and fasciculations in both the arms and legs.,CRANIAL NERVES:  Cranial nerve examination was normal with the exception that there was some mild atrophy of his tongue and possible fasciculations.  His palatal movement was normal and gag reflex was normal.,MOTOR:  Strength was decreased in all muscle groups as follows:  Deltoid 4/4, biceps 4+/4+, triceps 5/5, wrist extensors 4+/4+, finger extensors 4-/4-, finger flexors 4-/4-, interossei 4-/4-, hip flexors 4+/4+, hip extensors 4+/4+, knee extensors 4/4, and knee flexors 4/4.  Foot dorsiflexion, plantar flexion, eversion, toe extension and toe flexion was all 0 to 1.  There was atrophy in both hands and general atrophy of the lower limb muscles.  The feet were both cold and showed dystrophic features.  Fasciculations were present mainly in the hands.  There was evidence of dysmetria and past pointing in the left hand.,REFLEXES:  Reflexes were 0 in all sites in the arms and legs.  The jaw reflex was 2+.  Vibration was severely decreased at the elbow and wrist and was absent in the fingers.  Vibration was absent in the toes and ankle bilaterally and was severely decreased at the knee.  Joint position sense was absent in the toes and severely decreased in the fingers.  Pin perception was absent in the feet and was decreased to the upper thighs.  Pin was decreased or absent in the fingers and decreased above the elbows.  The same distribution of sensory loss was found with monofilament testing.,COORDINATION:  Coordination was barely normal in the right hand.  Rapid alternating movements were decreased in the left hand greater than the right hand.  The patient was unable to stand and therefore gait, Romberg's test and balance could not be assessed.,DIAGNOSTIC STUDIES: , Previous diagnostic studies and patient reports.  There were extensive patient reports, all of which were reviewed.  A previous x-ray study of the lateral chest performed in October 2008 showed poor inspiration with basilar atelectasis and an infiltrate.  An x-ray of the cervical, thoracic and lumbar spine showed some evidence of lumbar spinal stenosis.  A CTA of the neck with and without contrast performed in November 2008 showed minor stenosis in the left carotid, a mild hard and soft plaque in the right carotid with approximately 55% stenosis.  The posterior circulation showed a slightly dominant right vertebral artery with no stenosis.  There was no significant stenosis, but there was minor extracranial stenosis noted.  An MRI of the brain with and without contrast performed in November 2008 showed no evidence of an acute infarct, major vascular occlusion, and no abnormal enhancement with gadolinium administration.  There was also no significant sinusitis or mastoiditis.  This was an essentially normal brain MRI.  A CBC performed in January 2009 showed an elevated white cell count of 11.3, a low red cell count of 3.43, elevated MCH of 32.4 and the rest of the study was normal.  An electrolyte study performed in January 2009 showed a sodium which was low at 127, a calcium which was low at 8.3, and a low protein of 5.2 and albumin of 3.1.  The glucose was 86.  TSH performed in January 2009 was 1.57, which is within the normal range.  Vitamin B12 was greater than a 1000, which is normal and the folate was 18.2, which was normal.  A myocardial stress study performed in December 2008 showed normal myocardial perfusion with Persantine Cardiolite SPECT.  The ECG was non-diagnostic.  There was normal regional wall motion of the left ventricle.  The left ventricular ejection fraction was 68%, which is within the normal range for males.  A CT of the lumbar spine without contrast performed in December 2008 showed a broad-based disc bulge at L1-L2, L2-L3, L3-L4 and L4-L5.  At L5-S1, in addition to the broad-based disc bulge, there was also an osteophyte complex and evidence of flavum hypertrophy without canal stenosis.  There was severe bilateral neural foraminal stenosis at L5-S1 and moderate neural foraminal stenosis at L1-L4.  An echocardiogram was performed in November 2008 and showed mild left atrial enlargement, normal left ventricular systolic function, mild concentric left ventricular hypertrophy, scleral degenerative changes in the aortic and mitral apparatus, mild mitral regurgitation, mild tricuspid regurgitation and mild to moderate aortic regurgitation.,DIAGNOSTIC IMPRESSION:  ,The patient presents with a severe neuropathy with marked large fiber sensory as well as motor findings.  He is diffusely weak as well as atrophic in all muscle groups both in his upper and lower extremities, although he is disproportionately weak in his lower extremities.  His proprioceptive and vibratory loss is severe in both the distal upper and lower extremities, signifying that he either has a severe sensory neuropathy or has involvement of the dorsal root ganglia.  According to the history, which was carefully checked, the initial onset of these symptoms goes back one and a half years, although there has only been significant progression in his condition since July 2008.  As indicated below, further diagnostic studies including a detailed nerve conduction and EMG test today showed evidence of a severe sensory, motor, and axonal neuropathy and in addition there was evidence of a diffuse polyradiculopathy.  There was no involvement of the tongue on EMG.  The laboratory testing as indicated below failed to show a specific cause for the neuropathy.  We are still, however, waiting for the paraneoplastic antibodies, which were send out lab to the Mayo Clinic.  This type of very severe sensorimotor neuropathy with significant proprioceptive loss may be seen in several conditions including peripheral nerve vasculitis due to a variety of disorders such as SLE, Sjogren's, rheumatoid arthritis, and mixed connective tissue disease.  In addition, it may also be seen with certain toxins, particularly chemotherapeutic agents.  The patient did not receive any of these.  It may also be seen as part of a paraneoplastic syndrome.  Although the patient does not have any specific clinical symptoms of a cancer, it is noted that he has had an 18-pound weight loss in the past month and does have a remote history of smoking.  We have requested that he obtain a CT of his chest, abdomen and pelvis while he is in Acute Rehabilitation.  The verbal reports of these possibly did not show any evidence of a cancer.  We did also request that he obtain a gallium scan to see if there was any evidence of an unsuspected neoplasm.  The patient did undergo a nerve and muscle biopsy, this was a radial nerve and biceps muscle biopsy from the left arm.  This showed evidence of severe axonal loss.  There was no evidence of a vasculitis.  The vessels did show some mild intimal changes that would be consistent with atherosclerosis.  There were a few perivascular changes; however, there was no clear evidence of a necrotizing vasculitis even on multiple sections.  The muscle biopsy showed severe muscle fiber atrophy, with evidence of fiber grouping.  Again, there was no evidence of inflammation or vasculitis.  Evaluation so far has also shown no evidence of an amyloid neuropathy, no evidence of a monoclonal gammopathy, of sarcoidosis, and again there is no past history of a significant toxin or infective cause for the neuropathy.  Specifically, there is no history of HIV exposure.  We would await the results of the gallium scan and of the paraneoplastic antibodies to see if these are helpful in making a diagnosis.  At this point, because of the severity and the axonal nature of the neuropathy, there is no specific therapy that will reverse the course of the illness, unless we find a specific etiology that can be stopped or reversed.  I have discussed these issues at length with the patient and with his son.  We also addressed whether or not there might be a previously undiagnosed inherited neuropathy.  I think this is unlikely given the short history and the rapid progression of the disorder.,There is also no family history that we can detect a neuropathy, and the patient does not have the typical phenotype for a chronic inherited neuropathy such as Charcot-Marie-Tooth disease type 2.  However, since I have only seen the patient on one occasion and do not know what his previous examination showed two years ago, I cannot be certain that there may not have been the presence of a neuropathy preceding this.,PLAN:,1.  Nerve conduction and EMG will be performed today.  The results were indicated above.,2.  The following laboratory studies were requested including electrolytes, CBC, thyroid function tests, B12, ANA, C-reactive protein, complement, cryoglobulins, double-stranded DNA antibodies, folate level, hemoglobin A1c, immunofixation electrophoresis, P-ANCA, C-ANCA, protein electrophoresis, rheumatoid factor, paraneoplastic antibody studies requested from the Mayo Clinic, B12.  These studies showed minor changes, which included a low sodium level of 129 as previously noted, a low creatinine of 0.74, low calcium of 8.6, low total protein of 5.7.  The B12 was greater than 2000.  The immunoelectrophoresis, ANA, double-stranded DNA, ANCA, hemoglobin A1c, folate, cryoglobulins, complement, C-reactive protein were all normal or negative.  The B12 level was greater than 2000.  Liver function tests were normal.  The glucose was 90.  ESR was 10.  Hemoglobin A1c was 5.5.,3.  A left radial sensory and left biceps biopsy were requested and have been performed and interpreted as indicated above.,4.  CT of chest, abdomen and pelvis.,5.  Whole body gallium scan for evidence of an underlying neoplasm.,6.  The patient will go to the Rehabilitation Facility for Acute Rehabilitation and Training.,7.  We have not made any changes to his medication.  He does have some mild orthostatic changes; however, he is adequately controlled with midodrine at a dose of 2.5 mg three times a day as needed up to 5 mg four times a day.  Usually, he uses a lower dose of 2.5 three times a day to 5 mg three times a day.,8.  Followup will be as determined by the family.", Neurology,22
"HISTORY OF PRESENT ILLNESS:,  This is a 53-year-old widowed woman, she lives at ABC Hotel.  She presented with a complaint of chest pain, evaluations revealed severe aortic stenosis.  She has been refusing cardiac catheter and she may well need aortic valve replacement.  She states that she does not want heart surgery or valve replacement.  She has a history of bipolar disorder and has been diagnosed at times with schizophrenia.  She is on Depakote 500 mg three times a day and Geodon 80 mg twice a day.  The patient receives mental health care through the XYZ Health System and there is a psychiatrist who makes rounds at the ABC Hotel.  She denies hallucinations, psychosis, paranoia, and suicidal ideation at this time.  States that she does not want surgery because the chest pain that was a presenting complaint has gone away that she did not feel her problem is severe enough to require surgery, and medical records does show in this obese individual that cardiac surgery would present substantial risks and for this individual with the chronic mental illness and behavioral problems of a chronic nature, surgery does present some additional risks.  The patient notes that she has a long history of substance abuse, primarily inhalation of paint vapors that she had more than 100 incarcerations in the XYZ County Jail related to offenses related to her lifestyle at that time such as shoplifting, violation of orders to abstain from substance abuse and the longest confinement of these was 100 days.,The patient is able to write a fairly reasonable explanation for why she does not want to pursue medical care.,PAST AND DEVELOPMENTAL HISTORY: , She was born in XYZ.  She is a high-school graduate from ABCD High School.  She did have an abusive childhood.  She is married four times.  She notes she developed depression when a number of her children died.,PHYSICAL EXAMINATION:  ,GENERAL: , This is an obese woman in bed.  She is somewhat restless and moving during the interview.,VITAL SIGNS,:  Temperature of 97.3, pulse 70, respirations 18, blood pressure 113/68, and oxygen saturation 94% on 3 L of oxygen.,PSYCHIATRY:  ,Speech is normal, rate, volume, grammar, and vocabulary consistent with her educational level.  There is no overt thought disorder.  She does not appear psychotic.  She is not suicidal on formal testing.  She gives the date as Sunday, 05/19/2007 when it is the 20th and 207 when it is 2007.  She is oriented to place.  She can memorize four times, repeats two at five minutes, gets the other two with category hints, this places short-term memory in normal limits.  She had difficulty with serial three subtractions, counting on her fingers and had difficulty naming the months in reverse order stating, ""December, November, September, October, June, July, August, September,"" but recognizes this was not right and then said, ""March, April, May.""  She is able to name objects appropriately.,LABORATORY DATA: , Chest x-ray showing no acute changes.  Carotid duplex shows no stenosis.  Electrolytes and liver function tests are normal.  TSH normal.  Hematocrit 31%.  Triglycerides 152.,DIAGNOSES:  ,1.  Bipolar disorder, apparently stable on medications.,2.  Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.,3.  Aortic stenosis.,4.  Sleep apnea.,5.  Obesity.,6.  Anemia.,7.  Gastroesophageal reflux disease.,RECOMMENDATIONS:,  It is my impression at present that the patient retains ability to make decisions on her own behalf.  Given this lady's underlying mental problems, I would recommend that her treating physicians discuss her circumstances with physicians who round on her at the ABC Hotel.  While she may well need surgery and cardiac catheter, she may be more willing to accept this in the context of some continued encouragement from care providers who usually provide care for her.  She clearly at this time wants to leave this hospital; she normally gets her care through XYZ Health.  Again, in summary, I would consider her to retain the ability to make decisions on her own behalf.,Please feel free to contact me at digital pager if additional information is needed.", Psychiatry / Psychology,32
"PREOPERATIVE DIAGNOSES:,1.  Cardiac tamponade.,2.  Status post mitral valve repair.,POSTOPERATIVE DIAGNOSES:,1.  Cardiac tamponade.,2.  Status post mitral valve repair.,PROCEDURE PERFORMED: , Mediastinal exploration with repair of right atrium.,ANESTHESIA: , General endotracheal.,INDICATIONS: , The patient had undergone mitral valve repair about seven days ago.  He had epicardial pacing wires removed at the bedside.  Shortly afterwards, he began to feel lightheaded and became pale and diaphoretic.  He was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires.  He was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s-70s.,DETAILS OF PROCEDURE:  ,The patient was taken emergently to the operating room and placed supine on the operating room table.  His chest was prepped and draped prior to induction under general anesthesia.  Incision was made through the previous median sternotomy chest incision.  Wires were removed in the usual manner and the sternum was retracted.  There were large amounts of dark blood filling the mediastinal chest cavity.  Large amounts of clot were also removed from the pericardial well and chest.  Systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation.  This was repaired with two horizontal mattress pledgeted #5-0 Prolene sutures.  An additional #0 silk tie was also placed around the base of the atrial appendage for further hemostasis.  No other sites of bleeding were identified.  The mediastinum was then irrigated with copious amounts of antibiotic saline solution.  Two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart, as well as straight mediastinal chest tube.  The sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running Vicryl sutures.  The skin was then closed with a running subcuticular stitch.  The patient was then taken to the Intensive Care Unit in a critical but stable condition.", Surgery,38
"PREOPERATIVE DIAGNOSIS (ES):,1. Cholelithiasis.,2. Cholecystitis.,POSTOPERATIVE DIAGNOSIS (ES):,1. Acute perforated gangrenous cholecystitis.,2. Cholelithiasis.,PROCEDURE:,1. Attempted laparoscopic cholecystectomy.,2. Open cholecystectomy.,ANESTHESIA:, General endotracheal anesthesia.,COUNTS:, Correct.,COMPLICATIONS:, None apparent.,ESTIMATED BLOOD LOSS:, 275 mL.,SPECIMENS:,1. Gallbladder.,2. Lymph node.,DRAINS:, One 19-French round Blake.,DESCRIPTION OF THE OPERATION:, After consent was obtained and the patient was properly identified, the patient was transported to the operating room and after induction of general endotracheal anesthesia, the patient was prepped and draped in a normal sterile fashion.,After infiltration with local, a vertical incision was made at the umbilicus and utilizing graspers, the underlying fascia was incised and was divided sharply. Dissecting further, the peritoneal cavity was entered. Once this done, a Hasson trocar was secured with #1 Vicryl and the abdomen was insufflated without difficulty. A camera was placed into the abdomen and there was noted to be omentum overlying the subhepatic space. A second trocar was placed in the standard fashion in the subxiphoid area; this was a 10/12 mm non-bladed trocar. Once this was done, a grasper was used to try and mobilize the omentum and a second grasper was added in the right costal margin; this was a 5-mm port placed, it was non-bladed and placed in the usual fashion under direct visualization without difficulty. A grasper was used to mobilize free the omentum which was acutely friable and after a significant time-consuming effort was made to mobilize the omentum, it was clear that the gallbladder was well incorporated by the omentum and it would be unsafe to proceed with a laparoscopy procedure and then the procedure was converted to open.,The trocars were removed and a right subcostal incision was made incorporating the 10/12 subxiphoid port. The subcutaneous space was divided with electrocautery, as well as the muscles and fascia. The Bookwalter retraction system was then set up and retractors were placed to provide exposure to the right subhepatic space. Then utilizing a right-angle and electrocautery, the omentum was freed from the gallbladder. An ensuing retrograde cholecystectomy was performed, in which, electrocautery and blunt dissection were used to mobilize the gallbladder from the gallbladder fossa; this was done down to the infundibulum. After meticulous dissection, the cystic artery was identified and it was ligated between 3-0 silks. Several other small ties were placed on smaller bleeding vessels and the cystic duct was identified, was skeletonized, and a 3-0 stick tie was placed on the proximal portion of it. After it was divided, the gallbladder was freed from the field.,Once this was done, the liver bed was inspected for hemostasis and this was achieved with electrocautery. Copious irrigation was also used. A 19-French Blake drain was placed in Morrison's pouch lateral to the gallbladder fossa and was secured in place with 2-0 nylon; this was a 19-French round Blake. Once this was done, the umbilical port was closed with #1 Vicryl in an interrupted fashion and then the wound was closed in two layers with #1 Vicryl in an interrupted fashion. The skin was closed with and absorbable stitch.,The patient was then awakened from anesthesia, extubated, and transported to the recovery room in stable condition.", Gastroenterology,14
"GENERAL: , Well developed, well nourished, alert, in no acute distress.  GCS 50, nontoxic.,VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature * degrees F.  Pulse oximetry *%.,HEENT: , Eyes: Lids and conjunctiva.  No lesions.  Pupils equal, round, reactive to light and accommodation.  Irises symmetrical, undilated.  Funduscopic exam reveals no hemorrhages or discopathy.  Ears, Nose, Mouth, and throat:  External ears without lesions.  Nares patent.  Septum midline.  Tympanic membranes without erythema, bulging or retraction.  Canals without lesion.  Hearing is grossly intact.  Lips, teeth, gums, palate without lesion.  Posterior oropharynx:  No erythema.  No tonsillar enlargement, crypt formation or abscess.,NECK:  ,Supple and symmetric.  No masses. Thyroid midline, non enlarged.  No JVD.  Neck is nontender.  Full range of motion without pain.,RESPIRATORY: , Good respiratory effort.  Clear to auscultation.  Clear to percussion.  Chest:  Symmetrical rise and fall.  Symmetrical expansion.  No egophony or tactile fremitus.,CARDIOVASCULAR:,  Regular rate and rhythm.  No murmur, gallops, clicks, heaves or rub.  Cardiac palpation within normal limits.  Pulses equal at carotid.  Femoral and pedal pulses:  No peripheral edema.,GASTROINTESTINAL:  ,No tenderness or mass.  No hepatosplenomegaly.  No hernia.  Bowel sounds equal times four quadrants.  Abdomen is nondistended.  No rebound, guarding, rigidity or ecchymosis.,MUSCULOSKELETAL: , Normal gait and station.  No pathology to digits or nails.  Extremities move times four.  No tenderness or effusion.  Range of motion adequate.  Strength and tone equal bilaterally, stable.,BACK: , Nontender on midline.  Full range of motion with flexion, extension and sidebending.,SKIN:,  Inspection within normal limits.  Well hydrated.  No diaphoresis.  No obvious wound.,LYMPH:,  Cervical lymph nodes.  No lymphadenopathy.,NEUROLOGICAL:  ,Cranial nerves II-XII grossly intact.  DTRs symmetric 2 out of 4 bilateral upper and lower extremity, elbow, patella and ankle.  Motor strength 4/4 bilateral upper and lower extremity.  Straight leg raise is negative bilaterally.,PSYCHIATRIC: , Judgment and insight adequate.  Alert and oriented times three.  Memory and mood within normal limits.  No delusions, hallucinations.  No suicidal or homicidal ideation.", Office Notes,25
"TECHNICAL SUMMARY: , The patient was recorded from 2:15 p.m. on 08/21/06 through 1:55 p.m. on 08/25/06.  The patient was recorded digitally using the 10-20 system of electrode placement.  Additional temporal electrodes and single channels of EOG and EKG were also recorded.  The patient's medications valproic acid, Zonegran, and Keppra were weaned progressively throughout the study.,The occipital dominant rhythm is 10 to 10.5 Hz and well regulated.  Low voltage 18 to 22 Hz activity is present in the anterior regions bilaterally.,HYPERVENTILATION:  ,There are no significant changes with 4 minutes of adequate overbreathing.,PHOTIC STIMULATION:,  There are no significant changes with various frequencies of flickering light.,SLEEP: , There are no focal or lateralizing features and no abnormal waveforms.,INDUCED EVENT: , On the final day of study, a placebo induction procedure was performed to induce a clinical event.  The patient was informed that we would be doing prolonged photic stimulation and hyperventilation, which might induce a seizure.  At 1:38 p.m., the patient was instructed to begin hyperventilation.  Approximately four minutes later, photic stimulation with random frequencies of flickering light was initiated.  Approximately 8 minutes into the procedure, the patient became unresponsive to verbal questioning.  Approximately 1 minute later, she began to exhibit asynchronous shaking of her upper and lower extremities with her eyes closed.  She persisted with the shaking and some side-to-side movements of her head for approximately 1 minute before abruptly stopping.  Approximately 30 seconds later, she became slowly responsive initially only uttering a few words and able to say her name.  When asked what had just occurred, she replied that she was asleep and did not remember any event.  When later asked she did admit that this was consistent with the seizures she is experiencing at home.,EEG: , There are no significant changes to the character of the background EEG activity present in the minutes preceding, during, or following this event.  Of note, while her eyes were closed and she was non-responsive, there is a well-regulated occipital dominant rhythm present.,IMPRESSION:,  The findings of this patient's 95.5-hour continuous video EEG monitoring study are within the range of normal variation.  No epileptiform activity is present.  One clinical event was induced with hyperventilation and photic stimulation.  The clinical features of this event are described in the technical summary above.  There was no epileptiform activity associated with this event.  This finding is consistent with a non-epileptic pseudoseizure.", Radiology,33
"CHIEF COMPLAINT:,  Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD.  He sustained an injury from the patellar from a boat while in the water.  He was air lifted actually up to XYZ Hospital and underwent extensive surgery.  He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area.  In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue.  He has some drainage from these areas.  There are no signs and symptoms of infection.  He is referred to us to help him get those areas under control.,PAST MEDICAL HISTORY:,  Essentially negative other than he has had C. difficile in the recent past.,ALLERGIES:,  None.,MEDICATIONS: , Include Cipro and Flagyl.,PAST SURGICAL HISTORY: , Significant for his trauma surgery noted above.,FAMILY HISTORY: , His maternal grandmother had pancreatic cancer.  Father had prostate cancer.  There is heart disease in the father and diabetes in the father.,SOCIAL HISTORY:,  He is a non-cigarette smoker and non-ETOH user.  He is divorced.  He has three children.  He has an attorney.,REVIEW OF SYSTEMS:,CARDIAC:  He denies any chest pain or shortness of breath.,GI:  As noted above.,GU:  As noted above.,ENDOCRINE:  He denies any bleeding disorders.,PHYSICAL EXAMINATION:,GENERAL:  He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant 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, S4, or gallop.  There is no murmur.,ABDOMEN:  Soft.  It is nontender.  There is no mass or organomegaly.,GU:  Unremarkable.,RECTAL:  Deferred.,EXTREMITIES:  His right lower extremity is unremarkable.  Peripheral pulse is good.  His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed.  The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side.  There is one small area right essentially within the graft site, and there is one small area down lower on the calf area.  The patient has an external fixation on that comes out laterally on his left thigh.  Those pin sites look clean.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION: , Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,PLAN:,  Plan would be for chemical cauterization of these areas.  Series of treatment with chemical cauterization till these are closed.", Surgery,38
"PAST MEDICAL HISTORY:  Include:,1.  Type II diabetes mellitus.,2.  Hypertension.,3.  Hyperlipidemia.,4.  Gastroesophageal reflux disease.,5.  Renal insufficiency.,6.  Degenerative joint disease, status post bilateral hip and bilateral knee replacements.,7.  Enterocutaneous fistula.,8.  Respiratory failure.,9.  History of atrial fibrillation.,10.  Obstructive sleep apnea.,11.  History of uterine cancer, status post total hysterectomy.,12.  History of ventral hernia repair for incarcerated hernia.,SOCIAL HISTORY:  The patient has been admitted to multiple hospitals over the last several months.,FAMILY HISTORY:  Positive for diabetes mellitus type 2 in both mother and her sister.,MEDICATIONS:  Currently include,,1.  Albuterol inhaler q.4 h.,2.  Paradox swish and spit mouthwash twice a day.,3.  Digoxin 0.125 mg daily.,4.  Theophylline 50 mg q.6 h.,5.  Prozac 20 mg daily.,6.  Lasix 40 mg daily.,7.  Humulin regular high dose sliding scale insulin subcu. q.6 h.,8.  Atrovent q.4 h.,9.  Lantus 12 units subcu. q.12 h.,10.  Lisinopril 10 mg daily.,11.  Magnesium oxide 400 mg three times a day.,12.  Metoprolol 25 mg twice daily.,13.  Nitroglycerin topical q.6 h.,14.  Zegerid 40 mg daily.,15.  Simvastatin 10 mg daily.,ALLERGIES:  Percocet, Percodan, oxycodone, and Duragesic.,REVIEW OF SYSTEMS:  The patient currently denies any pain, denies any headache or blurred vision.  Denies chest pain or shortness of breath.  She denies any nausea or vomiting.  Otherwise, systems are negative.,PHYSICAL EXAM:,General:  The patient is awake, alert, and oriented.  She is in no apparent respiratory distress.,Vital Signs:  Temperature 97.6, blood pressure is 139/53, pulse 100, respirations 24.  The patient has a tracheostomy in place.  She will also have an esophageal gastric tube in place.,Cardiac:  Regular rate and rhythm without audible murmurs, rubs or gallops.  Lungs are clear to auscultation bilaterally with slightly diminished breath sounds on the bases.  No adventitious sounds are noted.,Abdomen:  Obese.  There is an open wound on the ventral abdomen overlying the midline abdominal incision from previous surgery.  The area is covered with bandage with serosanguineous fluid.  Abdomen is nontender to palpation.  Bowel sounds are heard in all 4 quadrants.,Extremities:  Bilateral lower extremities are edematous and very cool to touch.,LABORATORY DATA:  Pending.  Capillary blood sugars thus far have been 132 and 135.,ASSESSMENT:  This is an 80-year-old female with an unfortunate past medical history with recent complications of sepsis and respiratory failure who is now receiving tube feeds.,PLAN:  For her diabetes mellitus, we will continue the patient on her current regimen of Lantus 12 units subcu. q.12 h. and Regular Insulin at a high dose sliding scale every 6 hours.  The patient had been previously controlled on this.  We will continue to check her sugars every 6 hours and adjust insulin as necessary.", General Medicine,15
"PREOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,POSTOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,PROCEDURES:,  Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.,ANESTHESIA: , General.,TOURNIQUET TIME:  ,Thirty-seven minutes.,MEDICATIONS: , The patient also received 30 mL of 0.5% Marcaine local anesthetic at the end of the case.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,INTRAOPERATIVE FINDINGS: , The patient had a loose body that was found in the suprapatellar pouch upon entry of the camera.  This loose body was then subsequently removed.  It measured 24 x 14 mm.  This was actually the OCD lesion seen on the MRI that had come from the weightbearing surface of just the lateral posterior aspect of the medial femoral condyle,HISTORY AND PHYSICAL: , The patient is 13-year-old male with persistent left knee pain.  He was initially seen at Sierra Pacific Orthopedic Group where an MRI demonstrated unstable OCD lesion of the left knee.  The patient presented here for a second opinion.  Surgery was recommended grossly due to the instability of the fragment.  Risks and benefits of surgery were discussed.  The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure to relieve pain or restore the articular cartilage, possible need for other surgical procedures, and possible early arthritis.  All questions were answered and parents agreed to the above plan.,DESCRIPTION OF PROCEDURE:  ,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 nonsterile tourniquet was placed on the upper aspect of the patient's left thigh.  The extremity was then prepped and draped in standard surgical fashion.  The standard portals were marked on the skin.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  The portal incisions were then made by an #11 blade.  Camera was inserted into the lateral joint line.  There was a noted large cartilage loose body in the suprapatellar pouch.  This was subsequently removed with extension of the anterolateral portal.  Visualization of the rest of the knee revealed significant synovitis.  The patient had a large cartilage defect in the posterolateral aspect of the medial femoral condyle.  The remainder of the knee demonstrated no other significant cartilage lesions, loose bodies, plica or meniscal pathology.  ACL was also visualized to be intact in the intracondylar notch.,Attention was then turned back to the large defect.  The loose cartilage was debrided using a shaver.  Microfracture technique was then performed to 4 mm depth at 2 to 3 mm distances.  Tourniquet was released at the end of the case to ensure that there was fat and bleeding at the microfracture sites.  All instruments were then removed.  The portals were closed using #4-0 Monocryl.  A total of 30 mL of 0.5% Marcaine was injected into the knee.  Wounds were then cleaned and dried, and dressed in Steri-Strips, Xeroform, 4 x 4s, and bias.  The patient was then placed in a knee immobilizer.  The patient tolerated the procedure well.  The tourniquet was released at 37 minutes.  He was taken to recovery in stable condition.,POSTOPERATIVE PLAN: , The loose cartilage fragment was given to the family.  The intraoperative findings were relayed with intraoperative photos.  There was a large deficit in the weightbearing portion of medial femoral condyle.  His prognosis is guarded given the fact of the fragile lesion and location, but in advantages of his age and his rehab potential down the road, if the patient still has symptoms, he may be a candidate for osteochondral autograft, a procedure which is not performed at Children's or possible cartilaginous transplant.  All questions were answered.  The patient will follow up in 10 days, may wet the wound in 5 days.", Orthopedic,27
"PREOPERATIVE DIAGNOSES:,1.  Clinical stage T2, NX, MX transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2.  New right hydronephrosis.,POSTOPERATIVE DIAGNOSES:,1.  Clinical stage T4a, N3, M1 transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2.  New right hydronephrosis.,3.  Carcinoid tumor of the small bowel.,TITLE OF OPERATION: , Exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an Indiana pouch.,ANESTHESIA: , General endotracheal and epidural.,INDICATIONS: , This patient is a 65-year-old white male, who was diagnosed with a high-grade invasive bladder cancer in June 2005.  During the course of his workup of transurethral resection, he had a heart attack when he was taken off Plavix after having had a drug-eluting stent placed in.  He recovered from this and then underwent chemotherapy and radiation therapy with a brief response documented by cystoscopy and biopsy after which he had another ischemic event.  The patient has been followed regularly by myself and Dr. X and has been continuously free of diseases since that time.  In that interval, he had a coronary artery bypass graft and was taken off of Plavix.  Most recently, he had a PET CT, which showed new right hydronephrosis and a followup cystoscopy, which showed a new abnormality in the right side of his bladder where he previously had the tumor resected and treated.  I took him to the operating room and extensively resected this area with findings of a high-grade muscle invasive bladder cancer.  We could not identify the right ureteral orifice, and he had a right ureteral stent placed.  Metastatic workup was negative and Cardiology felt he was at satisfactory medical risk for surgery and he was taken to the operating room this time for planned salvage cystoprostatectomy.  He was interested in orthotopic neobladder, and I felt like that would be reasonable if resecting around the urethra indicated the tissue was healthier.  Therefore, we planned on an Indiana pouch continent cutaneous diversion.,OPERATIVE FINDINGS:  ,On exploration, there were multiple abnormalities outside the bladder as follows:  There were at least three small lesions within the distal small bowel, the predominant one measured about 1.5 cm in diameter with a white scar on the surface.  There were two much smaller lesions also with a small white scar, with very little palpable mass.  The larger of the two was resected and found to be a carcinoid tumor.  There also were changes in the small bowel mesentry that looked inflammatory and biopsies of this showed only fibrous tissue and histiocytes.  The small bowel mesentry was fairly thickened at the base, but no discrete abnormality noted.,Both common iliac and lymph node samples were very thickened and indurated, and frozen section of the left showed cancer cells that were somewhat degenerative suggesting a chemotherapy and radiation therapy effect; viability was unable to be determined.  There was a frozen section of the distal right external iliac lymph node that was negative.  The bladder was very thickened and abnormal suggesting extensive cancer penetrating just under the peritoneal surface.  The bladder was fairly stuck to the pelvic sidewall and anterior symphysis pubis requiring very meticulous resection in order to get it off of these structures.  The external iliac lymph nodes were resected on both sides of the obturator; the lymph packet, however, was very stuck and adherent to the pelvic sidewall, and I elected not to remove that.  The rest of the large bowel appeared normal.  There were no masses in the liver, and the gallbladder was surgically absent.  There was nasogastric tube in the stomach.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operative suite, and after adequate general endotracheal and epidural anesthesia obtained, having placed in the supine position and flexed over the anterior superior iliac spine, his abdomen and genitalia were sterilely prepped and draped in usual fashion.  The radiologist placed a radial arterial line and an intravenous catheter.  Intravenous antibiotics were given for prophylaxis.  We made a generous midline skin incision from high end of the epigastrium down to the symphysis pubis, deepened through the rectus fascia, and the rectus muscles separated in the midline.  Exploration was carried out with the findings described.  The bladder was adherent and did appear immobile.  Moist wound towels and a Bookwalter retractor was placed for exposure.  We began by assessing the small and large bowel with the findings in the small bowel as described.  We subsequently resected the largest of the lesions by exogenous wedge resection and reanastomosed the small bowel with a two-layer running 4-0 Prolene suture.  We then mobilized the cecum and ascending colon and hepatic flexure after incising the white line of Toldt and mobilized the terminal ileal mesentery up to the second and third portion of the duodenum.  The ureters were carefully dissected out and down deep in the true pelvis.  The right ureter was thickened and hydronephrotic with a stent in place and the left was of normal caliber.  I kept the ureters intact until we were moving the bladder off as described above.  At that point, we then ligated the ureters with the RP-45 vascular load and divided it.,We then established the proximal ____________ laterally to both genitofemoral nerves and resected the precaval and periaortic lymph nodes.  The common iliac lymph nodes remained stuck to the ureter.  Frozen section with the findings described on the left.,I then began the dissection over the right external iliac artery and vein and had a great deal of difficulty dissecting distally.  I was, however, able to establish the distal plane of dissection and a large lymph node was present in the distal external iliac vessels.  Clips were used to control the lymphatics distally.  These lymph nodes were sent for frozen section, which was negative.  We made no attempt to circumferentially mobilize the vessels, but essentially, swept the tissue off of the anterior surface and towards the bladder and then removed it.  The obturator nerve on the right side was sucked into the pelvic sidewall, and I elected not to remove those.  On the left side, things were a little bit more mobile in terms of the lymph nodes, but still the obturator lymph nodes were left intact.,We then worked on the lateral pedicles on both sides and essentially determined that I can take these down.  I then mobilized the later half of the symphysis pubis and pubic ramus to get distal to the apical prostate.  At this point, I scrubbed out of the operation, talked to the family, and indicated that I felt the cystectomy was more palliative than therapeutic, and I reiterated his desire to be free of any external appliance.,I then proceeded to take down the lateral pedicles with an RP-45 stapler on the right and clips distally.  The endopelvic fascia was incised.  I then turned my attention posteriorly and incised the peritoneum overlying the anterior rectal wall and ramus very meticulously dissected the rectum away from the posterior Denonvilliers fascia.  I intentionally picked down those two pedicles lateral to the rectum between the clips and then turned my attention retropubically.  I was able to pass a 0 Vicryl suture along the dorsal venous complex, tied this, and then, sealed and divided the complex with a LigaSure and oversewed it distally with 2-0 Vicryl figure-of-eight stitch.  I then divided the urethra distal to the apex of the prostate, divided the Foley catheter between the clamps and then the posterior urethra.  I then was able to take down the remaining distal attachments of the apex and took the dissection off the rectum, and the specimen was then free of all attachments and handed off the operative field.  The bivalved prostate appeared normal.  We then carefully inspected the rectal wall and noted to be intact.  The wound was irrigated with 1 L of warm sterile water and a meticulous inspection made for hemostasis and a dry pack placed in the pelvis.,We then turned our attention to forming the Indiana pouch.  I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon.  The colon was divided proximal to the middle colic using a GIA-80 stapler.  I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum.  The mesentery was then sealed with a LigaSure device and divided, and the bowel was divided with a GIA-60 stapler.  We then performed a side-to-side ileo-transverse colostomy using a GIA-80 stapler, closing the open end with a TA 60.  The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,We then removed the staple line along the terminal ileum, passed a 12-French Robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the GIA-60 stapler.  The ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by Rowland, et al, and following this, passage of an 18-French Robinson catheter was associated with the characteristic ""pop,"" indicating that we had adequately plicated the ileocecal valve.,As the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy.  We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 Vicryl sutures.  The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb-75.  Between the staple lines, Vicryl sutures were placed and the defects closed with 3-0 Vicryl suture ligatures.,We then turned our attention to forming the ileocolonic anastomosis.  The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 Vicryl sutures, and this was stented with a Cook 8.4-French ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture.  The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis.  We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture.  A 24-French Malecot catheter was placed through the cecum and secured with a chromic suture.  The staple lines were then buried with a running 3-0 Vicryl two-layer suture and the open end of the pouch closed with a TA 60 Polysorb suture.  The pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,We then made a final inspection for hemostasis.  The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures.  We then matured our stoma through the umbilicus.  We removed the plug of skin through the umbilicus and delivered the ileal segment through this.  A portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures.  We left an 18-French Robinson through the stoma and secured this to the skin with silk sutures.  The Malecot and stents were also secured in a similar fashion.,The stoma was returned to the umbilicus after resecting the terminal ileum.,We then placed a large JP drain into both obturator fossae and brought it up the right lower quadrant.  Rectus fascia was closed with buried #2 Prolene stitch anchoring a new figure of 8 at each end tying the two stitches above and in the middle and underneath the fascia.  Interrupted stitches were placed as well.  The subcutaneous tissue was irrigated and skin closed with surgical clips.  The estimated blood loss was 2500 mL.  The patient received 5 units of packed red blood cells and 4 units of FFP.  The patient was then awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.", Urology,39
"PREPROCEDURE DIAGNOSIS: , Complete heart block.,POSTPROCEDURE DIAGNOSIS:  ,Complete heart block.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of a dual-chamber pacemaker.,2.  Fluoroscopic guidance for implantation of a dual-chamber pacemaker.,FLUOROSCOPY TIME: , 2.6 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Versed 2.5 mg.,2.  Fentanyl 150 mcg.,3.  Benadryl 50 mg.,CLINICAL HISTORY: , the patient is a pleasant 80-year-old female who presented to the hospital with complete heart block.  She has been referred for a pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to implantation of a dual-chamber pacemaker were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  After achieving appropriate anesthesia, percutaneous access of the left axillary vein was then performed under fluoroscopy.  A guide wire was advanced into the vein.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Hemostasis was achieved with electrocautery.  Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision.  A pocket was then fashioned in the medial direction.  Using the previously placed wire, a 7-French side-arm sheath was advanced over the wire into the left axillary vein.  The dilator was then removed over the wire.  A second wire was then advanced into the sheath into the left axillary vein.  The sheath was then removed over the top of the two wires.  One wire was then pinned to the drape.  Using the remaining wire, a 7 French side-arm sheath was advanced back into the left axillary vein.  The dilator and wire were removed.  A passive pacing lead was then advanced down into the right atrium.  The peel-away sheath was removed.  The lead was then passed across the tricuspid valve and positioned in the apical location.  Adequate pacing and sensing functions were established.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  With the remaining wire, a 7-French side-arm sheath was advanced over the wire into the axillary vein.  The wire and dilating sheaths were removed.  An active pacing lead was then advanced down into the right atrium.  The peel-away sheath was removed.  Preformed J stylet was then advanced into the lead.  The lead was positioned in the appendage location.  Lead body was then turned, and the active fix screw was fixed to the tissue.  Adequate pacing and sensing function were established.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was then washed with antibiotic-impregnated saline.  Pulse generator was obtained and connected securely to the leads.  The leads were then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  Sponge and needle counts were correct at the end of the procedure.  No acute complications were noted.,DEVICE DATA,1.  Pulse generator, manufacturer Boston Scientific, model # 12345, serial #1234.,2.  Right atrial lead, manufacturer Guidant, model #12345, serial #1234.,3.  Right ventricular lead, manufacturer Guidant, model #12345, serial #1234.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 534 ohms.  P waves measured at 1.2 millivolts.  Pacing threshold 1.0 volt at 0.5 milliseconds.,2.  Right ventricular lead impedance 900 ohms.  R-waves measured 6.0 millivolts.  Pacing threshold 1.0 volt at 0.5 milliseconds.,DEVICE SETTINGS: , DDD 60 to 130.,CONCLUSIONS,1.  Successful implantation of a dual-chamber pacemaker with adequate pacing and sensing function.,2.  No acute complications.,PLAN,1.  The patient will be taken back to her room for continued observation.  She can be dismissed in 24 hours provided no acute complications at the discretion of the primary service.,2.  Chest x-ray to rule out pneumothorax and verified lead position.,3.  Completion of the course of antibiotics.,4.  Home dismissal instructions provided in written format.,5.  Device interrogation in the morning.,6.  Wound check in 7 to 10 days.,7.  Enrollment in device clinic.", Cardiovascular / Pulmonary,3
"REASON FOR REFERRAL:,  The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the ""early stages of a likely dementia"" and was thereafter terminated from her position as a psychiatric nurse.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.  Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning.  The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION:  ,Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  The patient reported that she had worked as a nurse supervisor for Hospital Center for four years.  She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work.  She continues to receive some compensation through FMLA hours.  She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services.  She said that these 90 days are up around the end of November.  She said the reason for her dismissal was performance complaints.  She said that they began ""as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off.  She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays.  She described it as a very chaotic and hectic work environment in which she was often putting in extra time.  She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time.  Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D.  He completed a Comprehensive Independent Medical Evaluation on 08/14/2009.  She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore.  Please note that we do not have copies of any of her work-related correspondence.  The patient never received a copy of the neuropsychological evaluation because she was told that it was ""too derogatory.""  A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation.  To summarize, the results indicated ""diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history.  This suggests that her intellectual functioning has declined.""  It concluded that ""results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy…  The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing.  The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other.  Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits.  His neurological examination on 09/23/2009 was unremarkable.  The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting.  A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions.  Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING:  ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her.  When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills.  She also denied any problems with attention and concentration or forgetfulness or memory problems.  She continues to independently perform all activities of daily living.  She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning.  She reported that if her children had noticed anything they definitely would have brought it to her attention.  She said that she does not currently have a lawyer and does not intend to return to her previous physician.  She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application.  Other current symptoms include excessive fatigue.  She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia.  She also reported having fallen approximately five times within the past year.  She said that this typically occurs when she is climbing up steps and is usually related to her right foot ""like dragging.""  Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis.  She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body.  Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal.  She denied any significant medical conditions during childhood.  As mentioned, she now has a history of fibromyalgia.  She also experiences some restriction in the range of motion with her right arm.  MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7.  MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon.  As mentioned, she was diagnosed with chronic fatigue syndrome in 1991.  She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control.  She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974.  Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007.  She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night.  She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:,  NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs.  She drinks two to four cups of coffee per day.,SOCIAL HISTORY:  ,The patient was born and raised in North Carolina.  She was the sixth of nine siblings.  Her father was a chef.  He completed third grade and died at 60 due to complications of diabetes.  Her mother is 93 years old.  Her last job was as a janitor.  She completed fourth grade.  She reported that she has no cognitive problems at this time.  Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression.  The patient completed a Bachelor of Science in Nursing through State University in 1979.  She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems.  She was married for two years.  Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse.  She has two children ages 43 and 30.  Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York.  In school, the patient reported obtaining primarily A's and B's.  She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling.  The patient worked for Hospital Center for four years.  Prior to that, she worked for an outpatient mental health center for 2-1/2 years.  She was reportedly either terminated or laid off and was unsure of the reason for that.  Prior to that, she worked for Walter P. Carter Center reportedly for 21 years.  She has also worked as an OB nurse in the past.  She reported that other than the two instances reported above, she had never been terminated or fired from a job.  In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue.  She was also taking Prozac during that time.  She then began taking Prozac again when she started working at secondary to stress with the work situation.  She reported a chronic history of mild sadness or depression, which was relatively stable.  When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things.  She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test", Neurology,22
"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 30 and 4/7th weeks.,2.  Previous cesarean section x2.,3.  Multiparity.,4.  Request for permanent sterilization.,POSTOPERATIVE DIAGNOSIS:,1.  Intrauterine pregnancy at 30 and 4/7th weeks.,2.  Previous cesarean section x2.,3.  Multiparity.,4.  Request for permanent sterilization.,5.  Breach presentation in the delivery of a liveborn female neonate.,PROCEDURES PERFORMED:,1.  Repeat low transverse cesarean section.,2.  Bilateral tubal ligation (BTL).,TUBES: , None.,DRAINS: , Foley to gravity.,ESTIMATED BLOOD LOSS: , 600 cc.,FLUIDS:,  200 cc of crystalloids.,URINE OUTPUT:,  300 cc of clear urine at the end of the procedure.,FINDINGS:,  Operative findings demonstrated a wire mesh through the anterior abdominal wall and the anterior fascia.  There were bowel adhesions noted through the anterior abdominal wall.  The uterus was noted to be within normal limits.  The tubes and ovaries bilaterally were noted to be within normal limits.  The baby was delivered from the right sacral anterior position without any difficulty.  Apgars 8 and 9.  Weight was 7.5 lb.,INDICATIONS FOR THIS PROCEDURE:  ,The patient is a 23-year-old G3 P 2-0-0-2 with reported 30 and 4/7th weeks' for a scheduled cesarean section secondary to repeat x2.  She had her first C-section because of congenial hip problems.  In her second C-section, baby was breached, therefore, she is scheduled for a third C-section.  The patient also requests sterilization.  Therefore, she requested a tubal ligation.,PROCEDURE: , After informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where a spinal with Astramorph anesthesia was obtained without any difficulty.  She was placed in the dorsal supine position with a leftward tilt and prepped and draped in the usual sterile fashion.  A Pfannenstiel skin incision was made removing the old scar with a first knife and then carried down to the underlying layer of fascia with a second knife.  The fascia was excised in the midline extended laterally with the Mayo scissors.  The superior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply with the Metzenbaum scissors.  There was noted dense adhesions at this point as well as a wire mesh was noted.  The anterior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply as well as bluntly.  The rectus muscle superiorly was opened with a hemostat.  The peritoneum was identified and entered bluntly digitally.  The peritoneal incision was then extended superiorly up to the level of the mesh.  Then, inferiorly using the knife, the adhesions were taken down and the bladder was identified and the peritoneum incision extended inferiorly to the level of the bladder.  The bladder blade was inserted and vesicouterine peritoneum was identified and tented up with Allis clamps and bladder flap was created sharply with the Metzenbaum scissors digitally.  The bladder blade was then reinserted to protect the bladder and the uterine incision was made with a first knife and then extended laterally with the Bandage scissors.  The amniotic fluid was noted to be clear.  At this point, upon examining the intrauterine contents, the baby was noted to be breached.  The right foot was identified and then the baby was delivered from the double footling breach position without any difficulty.  The cord was clamped and the baby was then handed off to awaiting pediatricians.  The placenta cord gases were obtained and the placenta was then manually extracted from the uterus.  The uterus was exteriorized and cleared of all clots and debris.  Then, the uterine incision was then closed with #0 Vicryl in a double closure stitch fashion, first layer in locking stitch fashion and the second layer an imbricating layer.  Attention at this time was turned to the tubes bilaterally.,Both tubes were isolated and followed all the way to the fimbriated end and tented up with the Babcock clamp.  The hemostat was probed through the mesosalpinx in the avascular area and then a section of tube was clamped off with two hemostats and then transected with the Metzenbaum scissors.  The ends was then burned with the cautery and then using a #2-0 Vicryl suture tied down.  Both tube sections were noted to be hemostatic and the tubes were then sent to pathology for review.  The uterus was then replaced back into the abdomen.  The gutters were cleared of all clots and debris.  The uterine incision was then once again inspected and noted to be hemostatic.  The bladder flap was then replaced back into the uterus with #3-0 interrupted sutures.  The peritoneum was then closed with #3-0 Vicryl in a running fashion.  Then, the area at the fascia where the mesh had been cut and approximately 0.5 cm portion was repaired with #3-0 Vicryl in a simple stitch fashion.  The fascia was then closed with #0 Vicryl in a running fashion.  The subcutaneous layer and Scarpa's fascia were repaired with a #3-0 Vicryl.  Then, the skin edges were reapproximated using sterile clips.  The dressing was placed.  The uterus was then cleared of all clots and debris manually.  Then, the patient tolerated the procedure well.  Sponge, lap, and needle, counts were correct x2.  The patient was taken to recovery in sable condition.  She will be followed up throughout her hospital stay.", Surgery,38
"CC:, Confusion and slurred speech.,HX , (primarily obtained from boyfriend): This 31 y/o RHF experienced a ""flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found ""passed out"" in bed, and when awoken appeared confused, and lethargic. She apparently recovered within 24 hours. For two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). She left a stove on.,She began slurring her speech 2 days prior to admission. On the day of presentation she developed right facial weakness and began stumbling to the right. She denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. There was no history of illicit drug/ETOH use or head trauma.,PMH:, Migraine Headache.,FHX: , Unremarkable.,SHX: ,Divorced. Lives with boyfriend. 3 children alive and well. Denied tobacco/illicit drug use. Rarely consumes ETOH.,ROS:, Irregular menses.,EXAM: ,BP118/66.  HR83. RR 20. T36.8C.,MS: Alert and oriented to name only. Perseverative thought processes. Utilized only one or two word answers/phrases. Non-fluent. Rarely followed commands. Impaired writing of name.,CN: Flattened right nasolabial fold only.,Motor: Mild weakness in RUE manifested by pronator drift. Other extremities were full strength.,Sensory: withdrew to noxious stimulation in all 4 extremities.,Coordination: difficult to assess.,Station: Right pronator drift.,Gait: unremarkable.,Reflexes: 2/2BUE, 3/3BLE, Plantars were flexor bilaterally.,General Exam: unremarkable.,INITIAL STUDIES:, CBC, GS, UA, PT, PTT, ESR, CRP, EKG were all unremarkable. Outside HCT showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified).,COURSE: ,MRI Brian Scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left MCA distribution suggesting slow flow. The latter suggested a vasculopathy such as Moya Moya, or fibromuscular dysplasia. HIV, ANA, Anti-cardiolipin Antibody titer, Cardiac enzymes, TFTs, B12, and cholesterol studies were unremarkable.,She underwent a cerebral angiogram on 2/12/92. This revealed an occlusion of the left MCA just distal to its origin. The distal distribution of the left MCA filled on later films through collaterals from the left ACA. There was also an occlusion of the right MCA just distal to the temporal branch. Distal branches of the right MCA filled through collaterals from the right ACA. No other vascular abnormalities were noted. These findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as Moya Moya disease. She was subsequently given this diagnosis. Neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. She had long latencies responding and understood only simple questions. Affect was blunted and there was distinct lack of concern regarding her condition. She was subsequently discharged home on no medications.,In 9/92 she was admitted for sudden onset right hemiparesis and mental status change. Exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. OB/GYN exam including cervical biopsy, and abdominal/pelvic CT scanning revealed stage IV squamous cell cancer of the cervix. She died 9/24/92 of cervical cancer.", Neurology,22
"PREOPERATIVE DIAGNOSIS:,  Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,POSTOPERATIVE DIAGNOSIS: , Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,PROCEDURE PERFORMED:,1.  Anterior cervical discectomy, C4-C5 and C5-C6.,2.  Arthrodesis, C4-C5 and C5-C6.,3.  Partial corpectomy, C5.,4.  Machine bone allograft, C4-C5 and C5-C6.,5.  Placement of anterior cervical plate with a Zephyr C4 to C6.,6.  Fluoroscopic guidance.,7.  Microscopic dissection.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , 60 mL.,COMPLICATIONS: , None.,INDICATIONS:,  This is a patient who presents with progressive weakness in the left upper extremity as well as imbalance.  He has also noted to have cord signal at the C4-C5 level secondary to a very large disc herniation that came behind the body at C5 as well and as well as a large disc herniation at C5-C6.  Risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed.  He understood and wished to proceed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in the supine position.  Preoperative antibiotics were given.  The patient was placed in the supine position with all pressure points noted and well padded.  The patient was prepped and draped in standard fashion.  An incision was made approximately above the level of the cricoid.  Blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially.  We then placed needle into the disc spaces and was found to be at C5-C6.  Distracting pins were placed in the body of C4 and in to the body of C6.  The disc was then completely removed at C4-C5.  There was very significant compression of the cord.  This was carefully removed to avoid any type of pressure on the cord.  This was very severe and multiple free fragments were noted.  This was taken down to the level of ligamentum.  Both foramen were then also opened.  Other free fragments were also found behind the body of C5, part of the body of C5 was taken down to assure that all of these were removed.  The exact same procedure was done at C5-C6; however, if there were again free fragments noted, there was less not as severe compression at the C4-C5 area.  Again part of the body at C5 was removed to make sure that there was no additional constriction.  Both nerve roots were then widely decompressed.  Machine bone allograft was placed into the C4-C5 as well as C5-C6 and then a Zephyr plate was placed in the body of C4 and to the body of C6 with a metal pin placed into the body at C5.  Excellent purchase was obtained.  Fluoroscopy showed good placement and meticulous hemostasis was obtained.  Fascia was closed with 3-0 Vicryl, subcuticular 3-0 Dermabond for skin.  The patient tolerated the procedure well and went to recovery in good condition.", Orthopedic,27
"GENERAL: , A well-developed infant in no acute respiratory distress.,VITAL SIGNS:  ,Initial temperature was XX, pulse XX, respirations XX.  Weight XX grams, length XX cm, head circumference XX cm.,HEENT:  ,Head is normocephalic with anterior fontanelle open, soft, and non-bulging.  Eyes:  Red reflex elicited bilaterally.  TMs occluded with vernix and not well visualized.  Nose and throat are patent without palatal defect.,NECK: , Supple without clavicular fracture.,LUNGS:,  Clear to auscultation.,HEART:,  Regular rate without murmur, click, or gallop present.  Pulses are 2/4 for brachial and femoral.,ABDOMEN:,  Soft with bowel sounds present.  No masses or organomegaly.,GENITALIA: , Normal.,EXTREMITIES: , Without evidence of hip defects.,NEUROLOGIC:  ,The infant has good Moro, grasp, and suck reflexes.,SKIN: , Warm and dry without evidence of rash.", General Medicine,15
"HISTORY:,  A is here for a follow up appointment at our Pediatric Rheumatology Clinic as well as the CCS Clinic.  A is a 17-year-old male with oligoarticular arthritis of his right knee.  He had a joint injection back in 03/2007 and since then he has been doing relatively well.  He is taking Indocin only as needed even though he said he has pain regularly, and he said that his knee has not changed since the beginning, but he said he only takes the medicine when he has pain, which is not every day, but almost every day.  He denies any swelling more than what it was before, and he denies any other joints are affected at this moment.  Denies any fevers or any rashes.,PHYSICAL EXAMINATION:,  On physical examination, his temperature is 98.6, weight is 104.6 kg; which is 4.4 kg less than before, 108/70 is his blood pressure, weight is 91.0 kg, and his pulse is 80.  He is alert, active, and oriented in no distress.  He has no facial rashes, no lymphadenopathy, no alopecia.  Funduscopic examination is within normal limit.  He has no cataracts and symmetric pupils to light and accommodation.  His chest is clear to auscultation.  The heart has a regular rhythm with no murmur.  The abdomen is soft and nontender with no :  visceromegaly.  Musculoskeletal examination showed good range of motion of all his upper extremities with no swelling or tenderness.  Lower extremities:  He still has some weakness of the knees, hip areas, and the calf muscles.  He does have minus/plus swelling of the right knee with a very hypermobile patella.  There is no limitation in his range of motion, and the swelling is very minimal with some mild tenderness.,In terms of his laboratories, they were not done today.,ASSESSMENT: , This is a 17-year-old male with oligoarticular arthritis.  He is HLA-B27 negative.,PLAN:,  In terms of the plan, I discussed with him what things he should be taking and the fact that since he has persistent symptoms, he should be on medication every day.  I am going to switch him to Indocin 75 mg SR just to give more sustained effect to his joints, and if he does not respond to this or continue with the symptoms, we may need to get an MRI.  We will see him back in three months.  He was evaluated by our physical therapist, who gave him some recommendations in terms of exercise for his lower extremities.  Future plans for A may include physical therapy and more stronger medications as well as imaging studies with an MRI.  Today he received his flu shot.  Discussed this with A and his aunt and they had no further questions.", Rheumatology,34
"PROCEDURE: , Medial branch rhizotomy, lumbosacral.,INFORMED CONSENT:,  The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,SEDATION: , The patient was given conscious sedation and monitored throughout the procedure.  Oxygenation was given.  The patient's oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs.,PROCEDURE:  ,The patient remained awake throughout the procedure in order to interact and give feedback.  The x-ray technician was supervised and instructed to operate the fluoroscopy machine.  The patient was placed in the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.  With fluoroscopy, a Teflon coated needle, ***, was gently guided into the region of the Medial Branch nerves from the Dorsal Ramus of ***.  Specifically, each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra, or for sacral vertebrae at the lateral-superior border of the posterior sacral foramen.  Needle localization was confirmed with AP and lateral radiographs.,The following technique was used to confirm placement at the Medial Branch nerves.  Sensory stimulation was applied to each level at 50 Hz; paresthesias were noted at,*** volts.  Motor stimulation was applied at 2 Hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted at *** volts.,Following this, the needle Trocar was removed and a syringe containing 1% lidocaine was attached.  At each level, after syringe aspiration with no blood return, 1cc 1% lidocaine was injected to anesthetize the Medial Branch nerve and surrounding tissue.  After completion of each nerve block a lesion was created at that level with a temperature of 85 degrees Celsius for 90 seconds.  All injected medications were preservative free.  Sterile technique was used throughout the procedure.,COMPLICATIONS:,  None.  No complications.,The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.", Surgery,38
"PREOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,POSTOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,OPERATION PERFORMED: , Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.,ANESTHESIA:  ,General.,CLINICAL NOTE: , This is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal.  Procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required.  Alternative of fully laparoscopic are open surgery or watching the lesion.,DESCRIPTION OF OPERATION:  ,In the right flank-up position, table was flexed.  He had a Foley catheter in place.  Incision was made from just above the umbilicus, about 5.5 cm in diameter.  The umbilical hernia was taken down.  An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin.  A liver retractor was placed to this.,The colon was reflected medially by incising the white line of Toldt.  The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly.  The vena cava was identified.  The main renal vein was identified.  Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided.  Coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and Bovie.  The harmonic scalpel was utilized superiorly and laterally.  Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided.  Specimen was placed in a collection bag, removed intact.,Hemostasis was excellent.,The umbilical hernia had been completely taken down.  The edges were freshened up.  Vicryl #1 was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar.,Skin closed with clips.,He tolerated the procedure well.  All sponge and instrument counts were correct.  Estimated blood loss less than 100 mL.,The patient was awakened, extubated, and returned to recovery room in satisfactory condition.", Gastroenterology,14
"CC:, Falling.,HX:, This 67y/o RHF was diagnosed with Parkinson's Disease in 9/1/95, by a local physician. For one year prior to the diagnosis, the patient experienced staggering gait, falls and episodes of lightheadedness. She also noticed that she was slowly ""losing"" her voice, and that her handwriting was becoming smaller and smaller. Two months prior to diagnosis, she began experienced bradykinesia, but denied any tremor. She noted no improvement on Sinemet, which was started in 9/95. At the time of presentation, 2/13/96, she continued to have problems with coordination and staggering gait. She felt weak in the morning and worse as the day progressed. She denied any fever, chills, nausea, vomiting, HA, change in vision, seizures or stroke like events, or problems with upper extremity coordination.,MEDS:, Sinemet CR 25/100 1tab TID, Lopressor 25mg qhs, Vitamin E 1tab TID, Premarin 1.25mg qd, Synthroid 0.75mg qd, Oxybutynin 2.5mg has, isocyamine 0.125mg qd.,PMH:, 1) Hysterectomy 1965. 2) Appendectomy 1950's. 3) Left CTR 1975 and Right CTR 1978. 4) Right oophorectomy 1949 for ""tumor."" 5) Bladder repair 1980 for unknown reason. 6) Hypothyroidism dx 4/94. 7) HTN since 1973.,FHX: ,Father died of MI, age 80. Mother died of MI, age73. Brother died of Brain tumor, age 9.,SHX: ,Retired employee of Champion Automotive Co.,Denies use of TOB/ETOH/Illicit drugs.,EXAM: ,BP (supine)182/113 HR (supine)94. BP (standing)161/91 HR (standing)79. RR16 36.4C.,MS: A&O to person, place and time. Speech fluent and without dysarthria. No comment regarding hypophonia.,CN: Pupils 5/5 decreasing to 2/2 on exposure to light. Disks flat. Remainder of CN exam unremarkable.,Motor: 5/5 strength throughout. NO tremor noted at rest or elicited upon movement or distraction,Sensory: Unremarkable PP/VIB testing.,Coord: Did not show sign of dysmetria, dyssynergia, or dysdiadochokinesia. There was mild decrement on finger tapping and clasping/unclasping hands (right worse than left).,Gait: Slow gait with difficulty turning on point. Difficulty initiating gait. There was reduced BUE swing on walking (right worse than left).,Station: 3-4step retropulsion.,Reflexes: 2/2 and symmetric throughout BUE and patellae. 1/1 Achilles. Plantar responses were flexor.,Gen Exam: Inremarkable. HEENT: unremarkable.,COURSE:, The patient continued Sinemet CR 25/100 1tab TID and was told to monitor orthostatic BP at home. The evaluating Neurologist became concerned that she may have Parkinsonism plus dysautonomia.,She was seen again on 5/28/96 and reported no improvement in her condition. In addition she complained of worsening lightheadedness upon standing and had an episode, 1 week prior to 5/28/96, in which she was at her kitchen table and became unable to move. There were no involuntary movements or alteration in sensorium/mental status. During the episode she recalled wanting to turn, but could not. Two weeks prior to 5/28/96 she had an episode of orthostatic syncope in which she struck her head during a fall. She discontinued Sinemet 5 days prior to 5/28/96 and felt better. She felt she was moving slower and that her micrographia had worsened. She had had recent difficulty rolling over in bed and has occasional falls when turning. She denied hypophonia, dysphagia or diplopia.,On EXAM: BP (supine)153/110 with HR 88. BP (standing)110/80 with HR 96. (+) Myerson's sign and mild hypomimia, but no hypophonia. There was normal blinking and EOM. Motor strength was full throughout. No resting tremor, but mild postural tremor present. No rigidity noted. Mild decrement on finger tapping noted. Reflexes were symmetric. No Babinski signs and no clonus. Gait was short stepped with mild anteroflexed posture. She was unable to turn on point. 3-4 step Retropulsion noted. The Parkinsonism had been unresponsive to Sinemet and she had autonomic dysfunction suggestive of Shy-Drager syndrome. It was recommended that she liberalize dietary salt use and lie with head of the bed elevate at 20-30 degrees at night. Indomethacin was suggested to improve BP in future.", Radiology,33
"REASON FOR REFERRAL: , Elevated BNP.,HISTORY OF PRESENT ILLNESS:,  The patient is a 95-year-old Caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's BNP level was high, for which Cardiology consult was requested.  The patient denies any chest pain or shortness of breath.  Chest x-ray and CAT scan shows possible pneumonia.  The patient denies any prior history of coronary artery disease but has a history of hypertension.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  At this time, he is on:,1.  Atrovent and albuterol nebulizers.,2.  Azithromycin.,3.  Potassium chloride 10 mEq p.o. daily.,4.  Furosemide 20 mg IV daily.,5.  Enoxaparin 40 mg daily.,6.  Lisinopril 10 mg p.o. daily.,7.  Ceftriaxone.,PAST MEDICAL HISTORY: , History of hypertension.,PAST SURGICAL HISTORY:,  History of abdominal surgery.,SOCIAL HISTORY: , He does not smoke.  Drinks occasionally.,FAMILY HISTORY:  ,Noncontributory.,REVIEW OF SYSTEMS: , Denies chest pain, PND, or orthopnea.  He has cough.  No fever.  No abdominal pain.  No syncope, near-syncope, or palpitation.  All other systems were reviewed.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable, not in distress.,VITAL SIGNS:  His blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.,HEENT:  Atraumatic, normocephalic.  Eyes PERRLA.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Clear.,HEART:  S1 and S2, regular.  No S3.  No S4.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,DIAGNOSTIC DATA:,  EKG shows sinus tachycardia, nonspecific ST-T changes, nonspecific intraventricular conduction delay.  CT chest shows bilateral pleural effusion, compressive atelectasis, pneumonic infiltrate noted in the right lower lobe.  Loculated pleural effusion in the left upper lobe.  No PE.  Chest x-ray shows bilateral lower lobe patchy opacities concerning for atelectasis or pneumonia.,LABORATORY DATA: , Sodium 139, potassium 4.1, BUN 26, creatinine 0.9, BNP 331, troponin less than 0.05.  White cell count 7.1, hemoglobin 11.5, hematocrit 35.2, platelet 195,000.,ASSESSMENT:,1.  Pneumonia.,2.  Diastolic heart failure, not contributing to his present problem.,3.  Hypertension, controlled.,4.  History of falls.,PLAN: , We will continue IV low-dose diuretics, continue lisinopril, continue IV antibiotics.  No further cardiac workup at this time.", Consult - History and Phy.,5
"OPERATION,1.  Ivor-Lewis esophagogastrectomy.,2.  Feeding jejunostomy.,3.  Placement of two right-sided #28-French chest tubes.,4.  Right thoracotomy.,ANESTHESIA:  ,General endotracheal anesthesia with a dual-lumen tube.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Prior to administration of general anesthesia, the patient had an epidural anesthesia placed.  In addition, he had a dual-lumen endotracheal tube placed.  The patient was placed in the supine position to begin the procedure.  His abdomen and chest were prepped and draped in the standard surgical fashion.  After applying sterile dressings, a #10-blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus.  Dissection was carried down through the linea using Bovie electrocautery.  The abdomen was opened.  Next, a Balfour retractor was positioned as well as a mechanical retractor.  Next, our attention was turned to freeing up the stomach.  In an attempt to do so, we identified the right gastroepiploic artery and arcade.  We incised the omentum and retracted it off the stomach and gastroepiploic arcade.  The omentum was divided using suture ligature with 2-0 silk.  We did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2-0 silk.  Next, we turned our attention to performing a Kocher maneuver.  This was done and the stomach was freed up.  We took down the falciform ligament as well as the caudate attachment to the diaphragm.  We enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest.  We also did a portion of the esophageal dissection from the abdomen into the chest area.  The esophagus and the esophageal hiatus were identified in the abdomen.  We next turned our attention to the left gastric artery.  The left gastric artery was identified at the base of the stomach.  We first took the left gastric vein by ligating and dividing it using 0 silk ties.  The left gastric artery was next taken using suture ligature with silk ties followed by 2-0 stick tie reinforcement.  At this point the stomach was freely mobile.  We then turned our attention to performing our jejunostomy feeding tube.  A 2-0 Vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of Treitz.  We then used Bovie electrocautery to open the jejunum at this site.  We placed a 16-French red rubber catheter through this site.  We tied down in place.  We then used 3-0 silk sutures to perform a Witzel.  Next, the loop of jejunum was tacked up to the abdominal wall using 2-0 silk ties.  After doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately, we turned our attention to closing the abdomen.  This was done with #1 Prolene.  We put in a 2nd layer of 2-0 Vicryl.  The skin was closed with 4-0 Monocryl.,Next, we turned our attention to performing the thoracic portion of the procedure.  The patient was placed in the left lateral decubitus position.  The right chest was prepped and draped appropriately.  We then used a #10 blade scalpel to make an incision in a posterolateral, non-muscle-sparing fashion.  Dissection was carried down to the level of the ribs with Bovie electrocautery.  Next, the ribs were counted and the 5th interspace was entered.  The lung was deflated.  We placed standard chest retractors.  Next, we incised the peritoneum over the esophagus.  We dissected the esophagus to just above the azygos vein.  The azygos vein, in fact, was taken with 0 silk ligatures and reinforced with 2-0 stick ties.  As mentioned, we dissected the esophagus both proximally and distally down to the level of the hiatus.  After doing this, we backed our NG tube out to above the level where we planned to perform our pursestring.  We used an automatic pursestring and applied.  We then transected the proximal portion of the stomach with Metzenbaum scissors.  We secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus.  The pursestring was then tied down without difficulty.  Next, we tabularized our stomach using a #80 GIA stapler.  After doing so, we chose a portion of the stomach more distally and opened it using Bovie electrocautery.  We placed our EEA stapler through it and then punched out through the gastric wall.  We connected our anvil to the EEA stapler.  This was then secured appropriately.  We checked to make sure that there was appropriate muscle apposition.  We then fired the stapler.  We obtained 2 complete rings, 1 of the esophagus and 1 of the stomach, which were sent for pathology.  We also sent the gastroesophageal specimen for pathology.  Of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins.  We then turned our attention to closing the gastrostomy opening.  This was closed with 2-0 Vicryl in a running fashion.  We then buttressed this with serosal 3-0 Vicryl interrupted sutures.  We returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it.  Next, we placed two #28-French chest tubes, 1 anteriorly and 1 posteriorly, taking care not to place it near the anastomosis.  We then closed the chest with #2 Vicryl in an interrupted figure-of-eight fashion.  The lung was brought up.  We closed the muscle layers with #0 Vicryl followed by #0 Vicryl; then we closed the subcutaneous layer with 2-0 Vicryl and the skin with 4-0 Monocryl.  Sterile dressing was applied.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was extubated in the operating room and transferred to the ICU in good condition.", Surgery,38
"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,38
"REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.", Hematology - Oncology,16
"PREOPERATIVE DIAGNOSIS:,  Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE:,  Right carpal tunnel release.,ANESTHESIA:,  Bier block to the right hand.,TOTAL TOURNIQUET TIME: , 20 minutes.,COMPLICATIONS: , None.,DISPOSITION: , Stable to PACU.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,GROSS OPERATIVE FINDINGS:,  We did find a compressed right median nerve upon entering the carpal tunnel, otherwise, the structures of the carpal canal are otherwise unremarkable.  No evidence of tumor was found.,BRIEF HISTORY OF PRESENT ILLNESS:  ,This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.,PROCEDURE: , The patient was taken to the operative room and placed in the supine position.  The patient underwent a Bier block by the Department of Anesthesia on the upper extremity.  The upper extremity was prepped and draped in usual sterile fashion and left free.  Attention was drawn then to the palm of the hand.  We did identify area of incision that we would make, which was located over the carpal tunnel.,Approximately, 1.5 cm incision was made using a #10 blade scalpel.  Dissection was carried through the skin and fascia over the palm down to the carpal tunnel taking care during dissection to avoid any branches of nerves.  Carpal tunnel was then entered and the rest of the transverse carpal ligament was incised sharply with a #10 scalpel.  We inspected the median nerve and found that it was flat and compressed from the transverse carpal ligament.  We found no evidence of tumor or space occupying lesion in the carpal tunnel.  We then irrigated copiously.  Tourniquet was taken down at that time and pressure was held.  There was no evidence of obvious bleeders.  We approximated the skin with nylon and placed a postoperative dressing with a volar splint.  The patient tolerated the procedure well.  She was placed back in the gurney and taken to PACU.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,POSTOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,PROCEDURE PERFORMED: ,Removal of bilateral #32-French chest tubes with closure of wound.,COMPLICATIONS:,  None.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old African-American male who has been in the intensive care unit for over a month with bilateral chest tubes for chronic draining pleural effusions with serous drainage.  A decision was made to proceed with removal of these chest tubes and because of the fistulous tracts, this necessitated to close the wounds with sutures.  The patient was agreeable to proceed.,OPERATIVE PROCEDURE:  ,The patient was prepped and draped at the bedside over both chest tube sites.  The pressures applied over the sites and the skin was closed with interrupted #3-0 Ethilon sutures.  The skin was then cleansed and Vaseline occlusive dressing was applied over the sites.  The same procedure was performed on the other side.  The chest tubes were removed on full inspiration.  Vital signs remained stable throughout the procedure.  The patient will remain in the intensive care unit for continued monitoring.,", Surgery,38
"NAME OF PROCEDURES,1.  Selective coronary angiography.,2.  Left heart catheterization.,3.  Left ventriculography.,PROCEDURE IN DETAIL:  ,The right groin was sterilely prepped and draped in the usual fashion.  The area of the right coronary artery was anesthetized with 2% lidocaine and a 4-French sheath was placed.  Conscious sedation was obtained using a combination of Versed 1 mg and fentanyl 50 mcg.  A left #4, 4-French, Judkins catheter was placed and advanced through the ostium of the left main coronary artery.  Because of difficulty positioning the catheter, the catheter was removed and a 6-French sheath was placed and a 6-French #4 left Judkins catheter was placed.  This was advanced through the ostium of the left main coronary artery where selective angiograms were performed.  Following this, the 4-French right Judkins catheter was placed and angiograms of the right coronary were performed.  A pigtail catheter was placed and a left heart catheterization was performed, followed by a left ventriculogram.  The left heart pullback was performed.  The catheter was removed and a small injection of contrast was given to the sheath.  The sheath was removed over a wire and an Angio-Seal was placed.  There were no complications.  Total contrast media was 200 mL of Optiray 350.  Fluoroscopy time 5.3 minutes.  Total x-ray dose is 1783 mGy.,HEMODYNAMICS:  ,Rhythm is sinus throughout the procedure.  LV pressure of 155/22 mmHg, aortic pressure of 160/80 mmHg.  LV pullback demonstrates no gradient.,The right coronary artery is a nondominant vessel and free of disease.  This also gives rise to the conus branch and two RV free wall branches.  The left main has minor plaquing in the inferior aspect measuring no more than 10% to 15%.  This vessel then bifurcates into the LAD and circumflex.  The circumflex is a large caliber vessel and is dominant.  This vessel gives rise to a large first marginal artery, a moderate sized second marginal branch, and additionally gives rise to a large third marginal artery and the PDA.  There was a very eccentric and severe stenosis in the proximal circumflex measuring approximately 90% in severity.  The origin of the first marginal artery has a severe stenosis measuring approximately 90% in severity.  The distal circumflex has a 60% lesion just prior to the origin of the third marginal branch and PDA.,The proximal LAD is ectatic.  The LAD gives rise to a large first diagonal artery that has a 90% lesion in its origin and a subtotal occlusion midway down the diagonal.  Distal to the origin of this diagonal branch, there is another area of ectasia in the LAD, followed by an area of stenosis that in some views is approximately 50% in severity.,The left ventriculogram demonstrates hypokinesis of the distal half of the inferior wall.  The overall ejection fraction is preserved.  There is moderate dilatation of the aortic root.  The calculated ejection fraction is 63%.,IMPRESSION,1.  Left ventricular dysfunction as evidenced by increased left ventricular end diastolic pressure and hypokinesis of the distal inferior wall.,2.  Coronary artery disease with high-grade and complex lesion in the proximal portion of the dominant large circumflex coronary artery.  There is subtotal stenosis at the origin of the first obtuse marginal artery.,3.  A 60% stenosis in the distal circumflex.,4.  Ectasia of the proximal left anterior descending with 50% stenosis in the mid left anterior descending.,5.  Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.", Surgery,38
"PRINCIPAL DIAGNOSIS: , Mullerian adenosarcoma.  ,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old presenting with a large mass aborted through the cervix.,PHYSICAL EXAM:,CHEST:  Clear.  There is no heart murmur.,ABDOMEN:  Nontender.,PELVIC:  There is a large mass in the vagina.  ,HOSPITAL COURSE: , The patient went to surgery on the day of admission.  The postoperative course was marked by fever and ileus.  The patient regained bowel function.  She was discharged on the morning of the seventh postoperative day.,OPERATIONS: , July 25, 2006:  Total abdominal hysterectomy, bilateral salpingo-oophorectomy.,DISCHARGE CONDITION: , Stable.,  ,PLAN: , The patient will remain at rest initially with progressive ambulation thereafter.  She will avoid lifting, driving, stairs, or intercourse.  She will call me for fevers, drainage, bleeding, or pain.  Family history, social history, and psychosocial needs per the social worker.  The patient will follow up in my office in one week.,PATHOLOGY:,  Mullerian adenosarcoma.,MEDICATIONS:,  Percocet 5, #40, one q.3 h. p.r.n. pain.", Discharge Summary,10
"PREOPERATIVE DIAGNOSES:,  Bilateral mammary hypertrophy with breast asymmetry, right breast larger than left.,POSTOPERATIVE DIAGNOSES:,  Bilateral mammary hypertrophy with breast asymmetry, right breast larger than left.,OPERATION:,  Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple-areolar complex with resection of 947 g in the larger right breast and 758 g in the smaller left breast.,ANESTHESIA:  ,General endotracheal anesthesia.,PROCEDURE IN DETAIL:  ,The patient was placed in the supine position under the effects of general endotracheal anesthesia.  The breasts were prepped and draped with DuraPrep and iodine solution and then draped in appropriate sterile fashion.  Markings were then made in the standing position preoperatively.  The nipple areolar complex was drawn at the level of the anterior projection of the inframammary fold along the central margin of the breast.  A McKissock ring was utilized as a pattern.  It was centered over the new nipple position and the medial and lateral flaps were drawn tangential to the pigmented areola at a 40-degree angle.  Medial and lateral flaps were drawn 8 cm in length.  At the most medial and lateral extremity inframammary folds, a line was drawn to the lower level at the medial and lateral flaps.  On the left side, the epithelialization was performed about the 45-mm nipple-areolar complex within the confines of the superior-medially based dermal parenchymal pedicle.  Resection of the skin, subcutaneous tissue, and glandular tissue was performed along the inframammary fold, and then cut was made medially and laterally.  The resection medially was perpendicular to the chest wall down to the areolar tissue overlying the pectoralis major muscle, and laterally, the resection was performed tangential to the chest wall, skin, subcutaneous tissue, and glandular tissue towards the axillary tail.  The pedicle was thinned as well, so it was 2-cm thick beneath the nipple-areolar complex and they were medially 4-cm thick at its base.  On the right side, 947 g of breast tissue was removed.  Hemostasis was achieved with electrocautery.  Identical procedure was performed on the opposite left side, again with a superiorly and inferiorly based dermal parenchymal pedicle with deepithelialization about the 45-mm diameter nipple-areolar complex.  Resection of the skin, subcutaneous tissue, and glandular tissue was performed medially down to the chest overlying the pectoralis major muscle and laterally tangential to the chest wall towards the axillary tail setting the pedicle as well beneath the nipple areolar complex.  Hemostasis was achieved with electrocautery.  With pedicle on the left, the breast issue on the left side was weighed at 758 g.  Hemostasis was achieved with cautery.  The patient was placed in the sitting position with wound partially closed and there appeared to be excellent symmetry between the right and left sides.  The nipple-areolar complex was transposed within the position and the medial and lateral flaps were brought together beneath the transposed nipple-areolar complex.  Closure was performed with interrupted 3-0 PDS suture for deep subcutaneous tissue and dermis.  Skin was closed with running subcuticular 4-0 Monocryl suture.  A Jackson-Pratt drain had been placed prior to final closure and secured with a 4-0 silk suture.  The wound had been irrigated prior to final closure as well with bacitracin irrigation solution prior to final cauterization.  Closure was performed with an anchor-shaped closure around the nipple-areolar complex, vertically of inframammary folds and across the inframammary folds.  Dressing was applied.  The suture line was treated with Dermabond.  The patient returned to the recovery room with 2 Jackson-Pratt drains, 1 on each side and IV Foley catheter with instructions to be seen in my office in 2 days.  The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.", Cosmetic / Plastic Surgery,6
"REASON FOR CONSULTATION:,  Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.  No symptoms of chest pain or shortness of breath.,His history from cardiac standpoint as mentioned below.,CORONARY RISK FACTORS: , History of hypertension, history of diabetes mellitus, nonsmoker.  Cholesterol elevated.  History of established coronary artery disease in the family and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.,MEDICATIONS:,1.  Metformin.,2.  Prilosec.,3.  Folic acid.,4.  Flomax.,5.  Metoprolol.,6.  Crestor.,7.  Claritin.,ALLERGIES:,  DEMEROL, SULFA.,PERSONAL HISTORY: , He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use.,PAST MEDICAL HISTORY:,  Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer.  Symptoms of shortness of breath, fatigue, and tiredness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills except for recent fever and rigors.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea and vomiting.  No hematemesis or melena.,UROLOGICAL:  Frequency, urgency.,MUSCULOSKELETAL:  No muscle weakness.,SKIN:  None significant.,NEUROLOGICAL:  No TIA or CVA.  No seizure disorder.,PSYCHOLOGICAL:  No anxiety or depression.,ENDOCRINE:  As above.,HEMATOLOGICAL:  None significant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic, normocephalic.,NECK:  Veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft, nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Benign.,EKG: ", Cardiovascular / Pulmonary,3
"PROCEDURE: , Colonoscopy.,INDICATIONS: , Hematochezia, Personal history of colonic polyps.,MEDICATIONS:,  Midazolam 2 mg IV, Fentanyl 100 mcg IV,PROCEDURE:,  A History and Physical has been performed, and patient medication allergies have been reviewed.  The patient's tolerance of previous anesthesia has been reviewed.  The risks and benefits of the procedure and the sedation options and risks were discussed with the patient.  All questions were answered and informed consent was obtained.  Mental Status Examination:  alert and oriented.  Airway Examination:  normal oropharyngeal airway and neck mobility.  Respiratory Examination:  clear to auscultation.  CV Examination:  RRR, no murmurs, no S3 or S4.  ASA Grade Assessment:  P1 A normal healthy patient.  After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.  The anesthesia plan was to use conscious sedation.  Immediately prior to administration of medications, the patient was re-assessed for adequacy to receive sedatives.  The heart rate, respiratory rate, oxygen saturations, blood pressure, adequacy of pulmonary ventilation, and response to care were monitored throughout the procedure.  The physical status of the patient was re-assessed after the procedure.  After I obtained informed consent, the scope was passed under direct vision.  Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.  The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & IC valve.  The quality of the prep was good.  The patient tolerated the procedure well.,FINDINGS:,1.  A sessile, non-bleeding polyp was found in the rectum.  The polyp was 5 mm in size.  Polypectomy was performed with a saline injection-lift technique using the snare.  Resection and retrieval were complete.  Estimated blood loss was minimal.,2.  One pedunculated, non-bleeding polyp was found in the sigmoid colon.  The polyp was 7 mm in size.  Polypectomy was performed with a hot forceps.  Resection and retrieval were complete.  Estimated blood loss was minimal.,3.  Multiple large-mouthed diverticula were found in the descending colon.,4.  Internal, non-bleeding, prolapsed with spontaneous reduction (grade II) hemorrhoids were found on retroflexion.,IMPRESSION:,1.  One 5 mm benign appearing polyp in the rectum.  Resected and retrieved.,2.  One 7 mm polyp in the sigmoid colon.  Resected and retrieved.,3.  Diverticulosis.,4.  Internal hemorrhoids were found.,RECOMMENDATION:,1.  High fiber diet.,2.  Await pathology results.,3.  Repeat colonoscopy for surveillance in 3 years.,4.  The findings and recommendations were discussed with the patient.,CPT CODE(S):,45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare,technique.,45384, 59, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot,biopsy forceps or bipolar cautery.,45381, 59, Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.,ICD9 CODE(S):,211.4, Benign neoplasm of rectum and anal canal.,211.3, Benign neoplasm of colon.,562.10, Diverticulosis of colon (without mention of hemorrhage).,455.2, Internal hemorrhoids with other complication,578.1, Blood in stool.,v12.72, Personal history of colonic polyps.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,POSTOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,OPERATIONS PERFORMED,1.  Left hip arthroscopic debridement.,2.  Left hip arthroscopic femoral neck osteoplasty.,3.  Left hip arthroscopic labral repair.,ANESTHESIA: , General.,OPERATION IN DETAIL: , The patient was taken to the operating room, where he underwent general anesthetic.  His bilateral lower extremities were placed under traction on the Hana table.  His right leg was placed first.  The traction post was left line, and the left leg was placed in traction.  Sterile Hibiclens and alcohol prep and drape were then undertaken.  A fluoroscopic localization was undertaken.  Gentle traction was applied.  Narrow arthrographic effect was obtained.  Following this, the ProTrac portal was made under the fluoro visualization, and then, a direct anterolateral portal made and a femoral neck portal made under direct visualization.  The diagnostic arthroscopy showed the articular surface to be intact with a moderate anterior lip articular cartilage delamination injury that propagated into the acetabulum.  For this reason, the acetabular articular cartilage was taken down and stabilized.  This necessitated takedown of the anterior lip of the acetabulum and subsequent acetabular osteoplasty debridement with associated labral repair.  The labrum was repaired using absorbable Smith & Nephew anchors with a sliding SMC knot.  After stabilization of the labrum and the acetabulum, the ligamentum teres was assessed and noted to be stable.  The remnant articular surface of the femoral artery and acetabulum was stable.  The posterior leg was stable.  The traction was left half off, and the anterolateral aspect of the head and neck junction was identified.  A stable femoral neck decompression was accomplished starting laterally and proceeding anteriorly.  This terminated with the hip coming out of traction and indeterminable flexion.  A combination of burs and shavers was utilized to perform a stable femoral neck osteoplasty decompression.  The decompression was completed with thorough irrigation of the hip.  The cannula was removed, and the portals were closed using interrupted nylon.  The patient was placed into a sterile bandage and anesthetized intraarticularly with 10 mL of ropivacaine subcutaneously with 20 mL of ropivacaine and at this point was taken to the recovery room.  He tolerated the procedure very well with no signs of complications.", Surgery,38
"ADMISSION DIAGNOSIS: , Microinvasive carcinoma of the cervix.,DISCHARGE DIAGNOSIS: , Microinvasive carcinoma of the cervix.,PROCEDURE PERFORMED: , Total vaginal hysterectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old, white female, gravida 7, para 5, last period mid March, status post tubal ligation.  She had an abnormal Pap smear in the 80s, which she failed to followup on until this year.  Biopsy showed a microinvasive carcinoma of the cervix and a cone biopsy was performed on 02/12/2007 also showing microinvasive carcinoma with a 1 mm invasion.  She has elected definitive therapy with a total vaginal hysterectomy.  She is aware of the future need of Pap smears.,PAST MEDICAL HISTORY: , Past history is significant for seven pregnancies, five term deliveries, and significant past history of tobacco use.,PHYSICAL EXAMINATION: , Physical exam is within normal limits with a taut normal size uterus and a small cervix, status post cone biopsy.,LABORATORY DATA AND DIAGNOSTIC STUDIES: , Chest x-ray was clear.  Discharge hemoglobin 10.8.,HOSPITAL COURSE: , She was taken to the operating room on 04/02/2007 where a total vaginal hysterectomy was performed under general anesthesia.  There was an incidental cystotomy at the time of the creation of the bladder flap.  This was repaired intraoperatively without difficulty.  Postoperative, she did very well.  Bowel and bladder function returned quickly.  She is ambulating well and tolerating a regular diet.,Routine postoperative instructions given and understood.  Followup will be in ten days for a cystogram and catheter removal with followup in the office at that time. ,DISCHARGE MEDICATIONS:,  Vicodin, Motrin, and Macrodantin at bedtime for urinary tract infection suppression.  ,DISCHARGE CONDITION: , Good.,Final pathology report was free of residual disease.", Obstetrics / Gynecology,24
"ADMITTING DIAGNOSIS:,  Intrauterine pregnancy at term with previous cesarean.,SECONDARY DIAGNOSIS: , Desired sterilization.,DISCHARGE DIAGNOSES,1.  Intrauterine pregnancy at term with previous cesarean.,2.  Desired sterilization.,3.  Status post repeat low transverse cesarean and bilateral tubal ligation.,HISTORY: , The patient is a 35-year-old gravida 2, para 1-0-0-1 with intrauterine pregnancy on 08/30/09.  Pregnancy was uncomplicated.  She opted for a scheduled elective C-section and sterilization without any trial of labor.  All routine screening labs were normal and she underwent a high-resolution ultrasound during pregnancy.,PAST MEDICAL HISTORY: , Significant for postpartum depression after her last baby as well as a cesarean.,ALLERGIES:,  SHE HAS SEASONAL ALLERGIES.,MEDICATIONS:,  She is taking vitamins and iron.,PHYSICAL EXAMINATION,GENERAL:  An alert gravid woman in no distress.,ABDOMEN:  Gravid, nontender, non-irritable, with an infant in the vertex presentation.  Estimated fetal weight was greater than 10 pounds.,HOSPITAL COURSE:  ,On the first hospital day, the patient went to the operating room where repeat low transverse cesarean and tubal ligation were performed under spinal anesthesia with delivery of a viable female infant weighing 7 pounds 10 ounces and Apgars of 9 and 9.  There was normal placenta, normal pelvic anatomy.  There was 600 cc estimated blood loss.  Patient recovered uneventfully from her anesthesia and surgery.  She was able to ambulate and void.  She tolerated regular diet.  She passed flatus.  She was breast-feeding.  Postoperative hematocrit was 31.  On the second postoperative day, the patient was discharged home in satisfactory condition.,DISCHARGE MEDICATIONS: , Motrin and Percocet for pain.  Paxil for postpartum depression.  She was instructed to do no lifting, straining, or driving, to put nothing in the vagina and to see me in two weeks or with signs of severe pain, heavy bleeding, fever, or other problems.", Discharge Summary,10
"CHIEF COMPLAINT:  ,Leaking nephrostomy tube.,HISTORY OF PRESENT ILLNESS: , This 61-year-old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube.  The leaking began this a.m.  The patient denies any pain, does not have fever and has no other problems or complaints.  The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.  The patient states he feels like his usual self and has no other problems or concerns.  The patient denies any fever or chills.  No nausea or vomiting.  No flank pain, no abdominal pain, no chest pain, no shortness of breath, no swelling to the legs.,REVIEW OF SYSTEMS: , Review of systems otherwise negative and noncontributory.,PAST MEDICAL HISTORY: , Metastatic prostate cancer, anemia, hypertension.,MEDICATIONS: , Medication reconciliation sheet has been reviewed on the nurses' note.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a nonsmoker.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 97.7 oral, blood pressure 150/85, pulse is 91, respirations 16, oxygen saturation 97% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed, appears to be healthy, calm, comfortable, no acute distress, looks well.  HEENT:  Eyes are normal with clear sclerae and cornea.  NECK:  Supple, full range of motion.  CARDIOVASCULAR:  Heart has regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  No dependent edema.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, nondistended.  No rebound or guarding.  Normal benign abdominal exam.  MUSCULOSKELETAL:  The patient has nontender back and flank.  No abnormalities noted to the back other than the bilateral nephrostomy tubes.  The nephrostomy tube left has no abnormalities, no sign of infection.  No leaking of urine, nontender, nephrostomy tube on the right has a damp dressing, which has a small amount of urine soaked into it.  There is no obvious active leak from the ostomy site.  No sign of infection.  No erythema, swelling or tenderness.  The collection bag is full of clear urine.  The patient has no abnormalities on his legs.  SKIN:  No rashes or lesions.  No sign of infection.  NEUROLOGIC:  Motor and sensory are intact to the extremities.  The patient has normal ambulation, normal speech.  PSYCHIATRIC:  Alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC AND LYMPHATIC:  No bleeding or bruising.,EMERGENCY DEPARTMENT COURSE:,  Reviewed the patient's admission record from one month ago when he was admitted for the placement of the nephrostomy tubes, both Dr. X and Dr. Y have been consulted and both had recommended nephrostomy tubes, there was not the name mentioned as to who placed the nephrostomy tubes.  There was no consultation dictated for this and no name was mentioned in the discharge summary, paged Dr. X as this was the only name that the patient could remember that might have been involved with the placement of the nephrostomy tubes.  Dr. A responded to the page and recommended __________ off a BMP and discussing it with Dr. B, the radiologist as he recalled that this was the physician who placed the nephrostomy tubes, paged Dr. X and received a call back from Dr. X.  Dr. X stated that he would have somebody get in touch with us about scheduling a time for which they will change out the nephrostomy tube to a larger and check a nephrogram at that time that came down and stated that they would do it at 10 a.m. tomorrow.  This was discussed with the patient and instructions to return to the hospital at 10 a.m. to have this tube changed out by Dr. X was explained and understood.,DIAGNOSES:,1.  WEAK NEPHROSTOMY SITE FOR THE RIGHT NEPHROSTOMY TUBE.,2.  PROSTATE CANCER, METASTATIC.,3.  URETERAL OBSTRUCTION.,The patient on discharge is stable and dispositioned to home.,PLAN: , We will have the patient return to the hospital tomorrow at 10 a.m. for the replacement of his right nephrostomy tube by Dr. X.  The patient was asked to return in the emergency room sooner if he should develop any new problems or concerns.", Consult - History and Phy.,5
"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,24
"INDICATION: , Bradycardia and dizziness.,COMMENTS:,1.  The patient was monitored for 24 hours.,2.  The predominant rhythm was normal sinus rhythm with a minimum heart rate of 56 beats per minute and the maximum heart rate of 114 beats per minute and a mean heart rate of 86 beats per minute.,3.  There were occasional premature atrial contractions seen, no supraventricular tachycardia was seen.,4.  There was a frequent premature ventricular contraction seen.  Between 11:00 a.m. and 11:15 a.m. the patient was in ventricular bigemini and trigemini most of the time.  During rest of the monitoring period, there were just occasional premature ventricular contractions seen.  No ventricular tachycardia was seen.,5.  There were no pathological pauses noted.,6.  The longest RR interval was 1.1 second.,7.  There were no symptoms reported.", Cardiovascular / Pulmonary,3
"ADMITTING DIAGNOSIS: , Kawasaki disease.,DISCHARGE DIAGNOSIS:,  Kawasaki disease, resolving.,HOSPITAL COURSE:,  This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.  When he was sent to the hospital, he had a fever of 102.  Subsequently, the patient was evaluated and based on the criteria, he was started on high dose of aspirin and IVIG.  Echocardiogram was also done, which was negative.  IVIG was done x1, and between 12 hours of IVIG, he spiked fever again; it was repeated twice, and then after second IVIG, he did not spike any more fever.  Today, his fever and his rash have completely resolved.  He does not have any conjunctivitis and no redness of mucous membranes.  He is more calm and quite and taking good p.o.; so with a very close followup and a cardiac followup, he will be sent home.,DISCHARGE ACTIVITIES:,  Ad-lib.,DISCHARGE DIET: , PO ad-lib.,DISCHARGE MEDICATIONS: , Aspirin high dose 340 mg q.6h. for 1 day and then aspirin low dose 40 mg q.d. for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p.o. once a day.  He will be followed by his primary doctor in 2 to 3 days.  Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG, all the live virus vaccine, and if he gets any rashes, any fevers, should go to primary care doctor as soon as possible.", Allergy / Immunology,0
"MEDICATIONS:,  None.,DESCRIPTION OF THE PROCEDURE:,  After informed consent was obtained, the patient was placed in the left lateral decubitus position and the Olympus video colonoscope was inserted through the anus and advanced in retrograde fashion for a distance of *** cm to the proximal descending colon and then slowly withdrawn.  The mucosa appeared normal.  Retroflex examination of the rectum was normal.", Surgery,38
"OBSERVATIONS: , FEV1 is 3.76, 103% predicted.  FVC is 4.98, 110% predicted.  Ratio is 75.  FEF 25-75 is 3.053, 82% predicted, postbronchodilator improves by 35%.  DLCO is 35, 121% predicted.  Residual volume is 3.04, 139% predicted.  Total lung capacity is 8.34, 120% predicted.,Flow volume loop reviewed.,INTERPRETATION:,  Mild restrictive airflow limitation.  Clinical correlation is recommended.", Cardiovascular / Pulmonary,3
"ADMITTING DIAGNOSES:,  Solitary left kidney with obstruction, and hypertension, and chronic renal insufficiency.,DISCHARGE DIAGNOSES: , Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.,PROCEDURES: , Cystoscopy under anesthesia, ureteroscopy, an attempted tube placement, stent removal with retrograde pyelography, percutaneous tube placement, and nephrostomy by Radiology.,PERTINENT LABORATORIES: , Creatinine of 1.4.  During the hospitalization it was decreased to 0.8 and Pseudomonas urinary tract infection, positive culture sensitive to ceftazidime and ciprofloxacin.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 3-1/2-year-old boy with a solitary kidney, had a ureteropelvic junction repair performed by Dr. Y, in the past, unfortunately, it was thought still be obstructed.  A stent was placed approximately 6 weeks ago after urethroscopic placement with some difficulty.  Plan was to remove the stent.  At the time of removal, we were unable to place another tube within the collecting system, and the patient was admitted for percutaneous nephrostomy placement.  He has had no recent cold or flu.  He has problems with hypertension for which he is on enalapril at home in addition to his Macrodantin prophylaxis.,PAST MEDICAL HISTORY: , The patient has no known allergies.  Multiple urinary tract infection, solitary kidney, and previous surgeries as mentioned above.,REVIEW OF SYSTEMS:,  A 14-organ system review of systems is negative except for the history of present illness.  He also has history of being a 34-week preemie twin.,ALLERGIES: , No known allergies.,FAMILY HISTORY: , Unremarkable without any bleeding or anesthetic problems.,SOCIAL HISTORY: , The patient lives at home with his parents, 2 brothers, and a sister.,IMMUNIZATIONS:,  Up-to-date.,MEDICATIONS: , On admission was Macrodantin, hydralazine, and enalapril.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an active little boy.,HEENT:  The head and neck exam was grossly normal.  He had no oral, ocular, or nasal discharge.,LUNGS:  Exam was normal without wheezing.,HEART:  Without murmur or gallops.,ABDOMEN:  Soft, without mass or tenderness with a well-healed flank incision.,GU:  Uncircumcised male with bilaterally descended testes.,EXTREMITIES:  He has full range of motion in all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,BACK:  He has normal back.  Normal gait.,HOSPITAL COURSE: , The patient was admitted to the hospital after inability to place a ureteral stent via ureteroscopy and cystoscopy.  He was made NPO.  He had a fever at first time with elevated creatinine.  He was also evaluated and treated by Dr. X, for fluid management, hypertensive management, and gave him some hydralazine and Lasix to improve his urine output, in addition to manage his blood pressure.  Once the percutaneous tube was placed, we found that his urine culture grew Pseudomonas, so he was kept on Fortaz, and was switched over to ciprofloxacin without difficulty.  He, otherwise, did well with continuing decrease his creatinine at the time of discharge to home.,The patient was discharged home in stable condition with ciprofloxacin, enalapril, and recommendation for followup in Urology in 1 to 2 weeks for the surgical correction in 2 to 3 weeks of repeat pyeloplasty or possible ureterocalicostomy.  The patient had draining nephrostomy tube without difficulty.,", Urology,39
"PREOPERATIVE DIAGNOSIS:,  Ruptured globe with full-thickness corneal laceration OX.,POSTOPERATIVE DIAGNOSIS: , Ruptured globe with full-thickness corneal laceration OX.,PROCEDURE:  ,Ruptured globe with full-thickness corneal laceration repair OX.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe with full-thickness corneal laceration of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, astigmatism, cataract, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure and 0.12 forceps and a Superblade were used to create a paracentesis at approximately 11 o'clock. Viscoat was injected through the paracentesis to fill the anterior chamber. The Viscoat cannula was used to sweep the incarcerated iris tissue from the wound. More Viscoat was injected to deepen the anterior chamber. A 10-0 nylon suture was used to place four sutures to close the corneal laceration. BSS was then injected to fill the anterior chamber and a small leak was noted at the inferior end of the wound. A fifth 10-0 nylon suture was then placed. The wound was packed and found to be watertight. The sutures were rotated, the wound was again checked and found to be watertight. A small amount of Viscoat was, again, injected to deepen the anterior chamber and the wound was swept to be sure there was no incarcerated uveal tissue. Several drops were placed in the XXX eye including Ocuflox, Pred Forte, Timolol 0.5%, Alphagan and Trusopt. An eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia. (S)he was taken to the recovery area in good condition. There were no complications.", Ophthalmology,26
"CHIEF COMPLAINT: , Nausea and feeling faint.,HPI:  ,The patient is a 74-year-old white female brought in by husband.  The patient is a vague historian at times.  She reports her appetite has been fair over the last several days.  Today, she complains of some nausea.  She feels weak.  No other specific complaints.,REVIEW OF SYSTEMS:  ,The patient denies fever, chills, sweats, ear pain, URI symptoms, cough, dyspnea, chest pain, vomiting, diarrhea, abdominal pain, melena, hematochezia, urinary symptoms, headache, neck pain, back pain, weakness or paresthesias in extremities.,CURRENT MEDICATIONS:  ,Diovan, estradiol, Norvasc, Wellbutrin SR inhaler, and home O2.,ALLERGIES: , MORPHINE CAUSES VOMITING.,PAST MEDICAL HISTORY:  ,COPD and hypertension.,HABITS:  ,Tobacco use, averages two cigarettes per day.  Alcohol use, denies.,LAST TETANUS IMMUNIZATION: , Not sure.,LAST MENSTRUAL PERIOD: , Status post hysterectomy.,SOCIAL HISTORY:  ,The patient is married and retired.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 98.2, pulse is 105, respirations 20, and BP 137/80.  GENERAL:  A well developed, well nourished, alert, cooperative, nontoxic, and appears hydrated.  SKIN:  Warm, dry, and good color.  EYES:  EOMI.  PERRL.  MOUTH:  Clear.  Mucous membranes moist.  NECK:  Supple.  No JVD.  LUNGS:  Reveal faint expiratory wheeze heard in the posterior lung fields.  HEART:  Slightly tachycardic without murmur.  ABDOMEN:  Soft, positive bowel sounds, and nontender.  No rebound or guarding is appreciated.  BACK:  No CVA tenderness.  EXTREMITIES:  Moves all four extremities.  No pretibial edema.  NEURO:  Cranial nerves II to XII, motor, and cerebellar are grossly intact and nonfocal.,LABORATORY STUDIES: , WBC 9200, differential with 82 neutrophils, 8 lymphocytes, 6 monocytes, and 4 eosinophils.  Hemoglobin 10.7 and hematocrit 31.2 both are decreased.  Comprehensive medical profile normal except for decreased sodium of 129, decreased chloride of 92, calcium decreased 8.4, total protein decreased 6.1, and albumin decreased 3.2.  Amylase and lipase both normal.  Clean catch urinalysis is unremarkable.  Review of EMR indicates on 05/09/06 hemoglobin was 12.1, on 05/10/07 hemoglobin was 9.9, and today hemoglobin is 10.7.  It seems to indicate that the patient had previous problems with anemia.,RADIOLOGY STUDIES: , Chest x-ray indicates chronic changes, reviewed by me, official report is pending.,ED STUDIES: , O2 sat on room air is 92%, which is satisfactory for this patient with COPD.  Monitor indicates sinus tachycardia at rate 103.  No ectopy.,ED COURSE:  ,The patient was assessed for orthostatic vital sign changes and none were detected by the nurse.  The patient was given albuterol unit dose small volume nebulizer treatment.  Repeat lung exam reveals resolution of expiratory wheezing.  The patient later had normal saline lock started by the nurse.  She was given IV fluids of normal saline 1L wide open over approximately one hour.  She was able to void urine indicating that she is well hydrated.  Rectal examination was performed with female nurse in attendance.  Good sphincter tone.  No masses.  The rectal secretions were heme negative.  The patient was reassessed.  She feels slightly better.  Monitor now shows normal sinus rhythm, rate 81, no ectopy.  Blood pressure is 136/66.  The patient is stable and will be discharged.,MEDICAL DECISION MAKING: , This patient presents with the above history.  Laboratory evaluation today indicates the following problems, anemia and hyponatremia.  This could contribute the patient's feelings of tiredness and not feeling well.  There is no evidence of rectal bleeding at this time.  The patient was advised that she needs to follow up with Dr. X to further investigate these problems.  The patient is hemodynamically stable and will be discharged.,ASSESSMENT:,1.  Acute tiredness.,2.  Anemia of unknown etiology.,3.  Acute hyponatremia.,PLAN:  ,The patient is advised to put salt on her food for the next week.  Should be given discharge instruction sheet for anemia.  Recommend follow up with personal physician, Dr. X in two to three days for recheck.  Return to ED sooner if condition changes or worsen anyway.  Discharged in stable condition.", Emergency Room Reports,12
"CC:, Found unresponsive.,HX: ,  39 y/o RHF complained of a severe HA at 2AM 11/4/92. It was unclear whether she had been having HA prior to this. She took an unknown analgesic, then vomited, then lay down in bed with her husband. When her husband awoke at 8AM he found her unresponsive with ""stiff straight arms"" and a ""strange breathing pattern."" A Brain CT scan revealed a large intracranial mass. She was intubated and hyperventilated to ABG (7.43/36/398). Other local lab values included: WBC 9.8, RBC 3.74, Hgb 13.8, Hct 40.7, Cr 0.5, BUN 8.5, Glucose 187, Na 140, K 4.0, Cl 107. She was given Mannitol 1gm/kg IV load, DPH 20mg/kg IV load, and transferred by helicopter to UIHC.,PMH:, 1)Myasthenia Gravis for 15 years, s/p Thymectomy,MEDS:, Imuran, Prednisone, Mestinon, Mannitol, DPH, IV NS,FHX/SHX:, Married. Tobacco 10 pack-year; quit nearly 10 years ago. ETOH/Substance Abuse unknown.,EXAM:, 35.8F, 99BPM, BP117/72, Mechanically ventilated at a rate of 22RPM on !00%FiO2. Unresponsive to verbal stimulation. CN: Pupils 7mm/5mm and unresponsive to light (fixed). No spontaneous eye movement or blink to threat. No papilledema or intraocular hemorrhage noted. Trace corneal reflexes bilaterally. No gag reflex. No oculocephalic reflex. MOTOR/SENSORY: No spontaneous movement. On noxious stimulation (Deep nail bed pressure) she either extended both upper extremities (RUE>LUE), or withdrew the stimulated extremity (right > left). Gait/Station/Coordination no tested. Reflexes: 1+ on right and 2+ on left with bilateral Babinski signs.,HCT 11/4/92: Large heterogeneous mass in the right temporal-parietal region causing significant parenchymal distortion and leftward subfalcine effect . There is low parenchymal density within the white matter. A hyperdense ring lies peripherally and may represent hemorrhage or calcification. The mass demonstrates inhomogeneous enhancement with contrast.,COURSE:, Head of bed elevated to 30 degrees, Mannitol and DPH were continued. MRI of Brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures. She underwent surgical resection of the tumor. Pathological analysis was consistent with adenocarcinoma. GYN exam, CT Abdomen and Pelvis, Bone scan were unremarkable. CXR revealed an right upper lobe lung nodule. She did not undergo thoracic biopsy due to poor condition. She received 3000 cGy cranial XRT in ten fractions and following this was discharged to a rehabilitation center.,In March, 1993 the patient exhibited right ptosis, poor adduction and abduction OD, 4/4 strength in the upper extremities and 5-/5- strength in the lower extremities. She was ambulatory with an ataxic gait.,She was admitted on 7/12/93 for lower cervical and upper thoracic pain, paraparesis and T8 sensory level. MRI brainstem/spine on that day revealed decreased T1 signal in the C2, C3, C6 vertebral bodies, increased T2 signal in the anterior medulla, and tectum, and spinal cord (C7-T3). Following injection of Gadolinium there was diffuse leptomeningeal enhancement from C7-T7 These findings were felt consistent with metastatic disease including possible leptomeningeal spread. Neurosurgery and Radiation Oncology agreed that the patients symptoms could be due to either radiation injury and/or metastasis. The patient was treated with Decadron and analgesics and discharged to a hospice center (her choice). She died a few months later.", Radiology,33
"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.", Consult - History and Phy.,5
"HISTORY:,  The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.  He had undergone staged repair beginning on 04/21/1997 with a right modified Blalock-Taussig shunt followed on 09/02/1999 with a bilateral bidirectional Glenn shunt, and left pulmonary artery to main pulmonary artery pericardial patch augmentation.  These procedures were performed at Medical College Hospital.  Family states that they moved to the United States.  Evaluation at the Children's Hospital earlier this year demonstrated complete occlusion of the right bidirectional Glenn shunt as well as occlusion of the proximal right pulmonary artery.  He was also found to have elevated Glenn pressures at 22 mmHg, transpulmonary gradient axis of 14 mmHg.  The QP:QS ratio of 0.6:1.  A large decompressing venous collateral was also appreciated.  The patient was brought back to cardiac catheterization in an attempt to reconstitute the right caval pulmonary anastomosis and to occlude the venous collateral vessel.,DESCRIPTION OF PROCEDURE: , After sedation and local Xylocaine anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 6-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava into the right-sided atrium pulmonary veins and the right ventricle.,Using a 6-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta and ascending aorta.  A separate port of arterial access was obtained in the left femoral artery utilizing a 5-French sheath.,Percutaneous access into the right jugular vein was attempted, but unsuccessful.  Ultrasound on the right neck demonstrated a complete thrombosis of the right internal jugular vein.  Using percutaneous technique and a 5-French sheath, 5-French wedge catheter was inserted into the left internal jugular vein and advanced along the left superior vena cava across the left caval-pulmonary anastomosis into the main pulmonary artery and left pulmonary artery with aid of guidewire.  This catheter then also advanced into the bridging innominate vein.  The catheter was then exchanged over wire for a 4-French Bernstein catheter, which was advanced to the blind end of the right superior vena cava.  A balloon wedge angiogram of the right lower pulmonary vein demonstrated back filling of a small right lower pulmonary artery.  There was no vascular continuity to the stump of the right Glenn.  The jugular venous catheter and sheaths were exchanged over a wire for a 6-French flexor sheath, which was advanced to the proximal right superior vena cava.  The Bernstein catheter was then reintroduced using a Terumo guidewire.  Probing of the superior vena cava facilitated access into the right lower pulmonary artery.  The angiogram in the right pulmonary artery showed a diminutive right lower pulmonary artery and severe long segment proximal stenosis.  The distal pulmonary measured approximately 5.5 to 60 mm in diameter with a long segment stenosis measuring approximately 31 mm in length.  The length of the obstruction was balloon dilated using ultra-thin SD 4 x 2 cm balloon catheter with complete disappearance of the waist.  This facilitated advancement of a flexor sheath into the proximal portion of the stenosis.  A PG 2960 BPX Genesis stent premounted on a 6 mm OptiProbe.  A balloon catheter was advanced across the area of narrowing and inflated with a near-complete disappearance of proximal waist.  Angiogram demonstrated a good stent apposition to the caval wall.  Further angioplasty was then performed utilizing an ultra-thin SDS 8 x 3 cm balloon catheter inflated to 19 atmospheres pressure with complete disappearance of a distinct proximal waist.  Angiogram demonstrated wide patency of reconstituted right caval pulmonary anastomosis though there was no flow seen to the right upper pulmonary artery.  The balloon wedge angiograms were then obtained in the right upper pulmonary veins suggesting the presence of right upper pulmonary artery and not contiguous with the right lower pulmonary artery.  Bernstein catheter was advanced into the main pulmonary artery where a wire probing of the stump of the proximal right pulmonary artery facilitated access to the right upper pulmonary artery.  Angiogram demonstrated severe long segment stenosis of the proximal right pulmonary artery.  Angioplasty of the right pulmonary was then performed using the OptiProbe 6-mm balloon catheter inflated to 16 atmospheres pressure with disappearance of a distinct waist.  Repeat angiogram showed improvement in caliber of right upper pulmonary artery with filling defect of the proximal right pulmonary artery.  The proximal right pulmonary artery was then dilated and stent implanted using a PG 2980 BPX Genesis stent premounted on 8-mm OptiProbe balloon catheter and implanted with complete disappearance of the waist.  Distal right upper pulmonary artery was then dilated and stent implanted utilizing a PG 1870 BPX Genesis stent premounted on 7-mm OptiProbe balloon catheter.  Repeat angiograms were then performed.  Attention was then directed to the large venous collateral vessel arising from the left superior vena cava with a contrast filling of a left-sided azygos vein.  A selective angiogram demonstrated a large azygos vein of the midsection measuring approximately 9.4 mm in diameter.  An Amplatzer 12 mm vascular plug was loaded on the delivery catheter and advanced through the flexor sheath into the azygos vein.  Once stable device was confirmed, the device was released from the delivery catheter.  The 4-French Bernstein catheter was then reintroduced and 5 inch empirical 0.038 inch, 10 cm x 8 mm detachable coils were then implanted above the vascular plug filling the proximal azygos vein.  A pigtail catheter was then introduced into the left superior vena cava for final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the coronary sinus of pulmonary veins, the innominate vein, superior vena cava, the main pulmonary artery, and azygos vein.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:,  Oxygen consumption was assumed to be normal mixed venous saturation, but was low due to systemic arterial desaturation of 79%.  The pulmonary veins were fully saturated with partial pressure of oxygen ranging between 120 and 169 mmHg in 30% oxygen.  Remaining saturations reflected complete admixture.  There was increased saturation in the left pulmonary artery due to aortopulmonary collateral flow.  Phasic right atrial pressures were normal with an A-wave somewhat to the normal right ventricular end-diastolic pressure of 9 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending, descending pressures were similar and normal.  Mean Glenn pressures at initiation of the case were slightly elevated at 14 mmHg with a transpulmonary gradient of 9 mmHg.  The calculated systemic flow was a normal pulmonary flows reduced with a QP:QS ratio of 0.6:1.  The pulmonary vascular resistance was elevated at 4.4 Woods units.  Following stent implantation in the right caval pulmonary anastomosis and right pulmonary artery, there was a slight increase in the Glenn venous pressures to 16 mmHg.  Following embolization of the azygos vein, there was increase in systemic arterial saturation to 84% and increase in mixed venous saturation.  There was similar increase in Glenn pressures to 28 mmHg with a transpulmonary gradient of 14 mmHg.  There was an increase in arterial pressure.  The calculated systemic flow increased from 3.1 liters /minute/meter squared to 4.3 liters/minute/meter squared.  Angiogram within the innominate vein following stent implantation demonstrated appropriate stent position without significant distortion of the innominate vein or proximal cava.  There appeared unobstructed contrast flow to the right lower pulmonary artery of a 1-mmHg mean pressure gradient.  There was absence of contrast filling of the right middle and right upper pulmonary artery.  Final angiogram with a contrast injection in the left superior vena cava showed a forward flow through the right Glenn, a good contrast filling of the right lower pulmonary artery, and a widely patent left Glenn negative contrast washout of the proximal right pulmonary artery and left pulmonary artery presumably due to aortopulmonary collateral flow.  Contrast injection within the right upper pulmonary artery following the stent implantation demonstrated widely patent proximal right pulmonary artery along the length of the implanted stents though with retrograde contrast flow.,INITIAL DIAGNOSES:  ,1.  Asplenia syndrome.,2.  Dextrocardia bilateral superior vena cava.,3.  Atrioventricular septal defect.,4.  Total anomalous pulmonary venous return to the right-sided atrium.,5.  Double outlet right ventricle with malposed great vessels.,6.  Severe pulmonary stenosis.,7.  Separate hepatic venous drainage into the atria.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Right modified Blalock-Taussig shunt.,2.  Bilateral bidirectional Glenn shunt.,3.  Patch augmentation of the main pulmonary to left pulmonary artery.,CURRENT DIAGNOSES:  ,1.  Obstructed right caval pulmonary anastomosis.,2.  Obstructed right proximal pulmonary artery.,3.  Venovenous collateral vessel.,CURRENT INTERVENTION:  ,1.  Balloon dilation of the right superior vena cava and stent implantation.,2.  Balloon dilation of the proximal right pulmonary artery, stent implantation.,3.  Embolization of venovenous collateral vessel.,MANAGEMENT: , The case will be discussed in Combined Cardiology Cardiothoracic Surgery case conference.  A repeat catheterization is recommended in 3 months to assess for right pulmonary artery growth and to assess candidacy for Fontan completion.  The patient will be maintained on anticoagulant medications of aspirin and Plavix.  Further cardiology care will be directed by Dr. X.", Cardiovascular / Pulmonary,3
"HISTORY:,  Smoking history zero.,INDICATION: , Dyspnea with walking less than 100 yards.,PROCEDURE:,  FVC was 59%.  FEV1 was 61%.  FEV1/FVC ratio was 72%. The predicted was 70%.  The FEF 25/75% was 45%, improved from 1.41 to 2.04 with bronchodilator, which represents a 45% improvement.  SVC was 69%. Inspiratory capacity was 71%.  Expiratory residual volume was 61%.  The TGV was 94%.  Residual volume was 113% of its predicted.  Total lung capacity was 83%.  Diffusion capacity was diminished.,IMPRESSION:,1.  Moderate restrictive lung disease.,2.  Some reversible small airway obstruction with improvement with bronchodilator.,3.  Diffusion capacity is diminished, which might indicate extrapulmonary restrictive lung disease.,4.  Flow volume loop was consistent with the above and no upper airway obstruction.,", Cardiovascular / Pulmonary,3
"EXAM: , Cardiac catheterization and coronary intervention report.,PROCEDURES:,1.  Left heart catheterization, coronary angiography, left ventriculography.,2.  PTCA/Endeavor stent, proximal LAD.,INDICATIONS: , Acute anterior ST-elevation MI.,ACCESS: , Right femoral artery 6-French.,MEDICATIONS:,1.  IV Valium.,2.  IV Benadryl.,3.  Subcutaneous lidocaine.,4.  IV heparin.,5.  IV ReoPro.,6.  Intracoronary nitroglycerin.,ESTIMATED BLOOD LOSS: , 10 mL.,CONTRAST:  ,185 mL.,COMPLICATIONS: , None.,PROCEDURE: , The patient was brought to the cardiac catheterization laboratory with acute ST-elevation MI and EKG.  She was prepped and draped in the usual sterile fashion.  The right femoral region was infiltrated with subcutaneous lidocaine, adequate anesthesia was obtained.  The right femoral artery was entered with _______ modified Seldinger technique and a J wire was passed.  The needle was exchanged for 6 French sheath.  The wire was removed.  The sheath was washed with sterile saline.  Following this, the left coronary was attempted to be cannulated with an XP catheter, however, the catheter folded on itself and could not reach the left main, this was removed.  A second 6-French JL4 guiding catheter was then used to cannulate the left main and initial guiding shots demonstrated occlusion of the proximal LAD.  The patient had an ACT check, received additional IV heparin and IV ReoPro.  The lesion was crossed with 0.014 BMW wire and redilated with a 2.5 x 20-mm balloon at nominal pressures.  The balloon was deflated and angiography demonstrated establishment of flow.  Following this, the lesion was stented with a 2.5 x 18-mm Endeavor stent at 10 atmospheres.  The balloon was deflated, reinflated at 12 atmospheres, deflated and removed.  Final angiography demonstrated excellent clinical result.  Additional angiography was performed with a wire out.  Following this, the wire and the catheter was removed.  Following this, the right coronary was selectively cannulated with diagnostic catheter and angiographic views were obtained in multiple views.  This catheter was removed.  The pigtail catheter was placed in the left ventricle and left ventriculography was performed with pullback pressures across the aortic valve.  At the end of procedure, wires and catheter were removed.  Right femoral angiography was performed and a right femoral Angio-Seal kit was deployed at the right femoral arteriotomy site.  There was no hematoma.  Peripheral pulses _______ procedure.  The patient tolerated the procedure well.  Symptoms of chest pain resolved at the end of the procedure with no complications.,RESULTS:,1.  Coronary angiography.,A.  Left main free of obstruction.,B.  LAD, subtotal proximal stenosis.,C.  Circumflex large vessel with three large obtuse marginal branches.  No high-grade obstruction, evidence of minimal plaquing.,D.  Right coronary 70% mid vessel stenosis and 50% mid to distal stenosis before giving rise to a right dominant posterior lateral and posterior descending artery.,2.  Left ventriculogram.  Left ventricular ejection fraction estimated at 45% to 50%.  There was an akinetic apical wall.,3.  Hemodynamics.  Aortic pressure 145/109, left ventricular pressure 147/13, left ventricular end-diastolic pressure 34 mmHg.,IMPRESSION:,1.  Acute ST-elevation myocardial infarction, culprit lesion, left anterior descending occlusion.,2.  Two-vessel coronary disease.,3.  Mild-to-moderate impaired LV systolic function.,4.  Successful stent left anterior descending, 100% occlusion, 0% residual stenosis.,PLAN:  ,Overnight observation in ICU.  Start aspirin, Plavix, beta-blocker and ACE inhibitor.  Check serial cardiac enzymes.  Further recommendations to follow.  Check fasting lipid panel, in addition add a statin.  Further recommendations to follow.", Surgery,38
"PREOPERATIVE DIAGNOSES:,  Empyema of the left chest and consolidation of the left lung.,POSTOPERATIVE DIAGNOSES:,  Empyema of the left chest, consolidation of the left lung, lung abscesses of the left upper lobe and left lower lobe.,OPERATIVE PROCEDURE: , Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.,ANESTHESIA:,  General.,FINDINGS: , The patient has a complex history, which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two CAT scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax.  There was also noted to be some mild infiltrates of the right lung.  The patient had a 30-year history of cigarette smoking.  A chest tube was placed at the other hospital, which produced some brownish fluid that had foul odor, actually what was thought to be a fecal-like odor.  Then an abdominal CT scan was done, which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal CT.  The patient was started on antibiotics and was then taken to the operating room, where there was to be a thoracoscopy performed.  The patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions, but there was bloody mucous in the left main stem bronchus and this was suctioned out.  This was suctioned out with the addition of the use of saline ***** in the bronchus.  Following the bronchoscopy, a double lumen tube was placed, but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day.,The patient was transferred for continued evaluation and treatment.  Today, the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted.  These were suctioned, but it was enough to produce a temporary obstruction of the left mainstem bronchus.  Eventually, the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that.  The chest tube tract, which was about in the sixth or seventh intercostal space, but it was not possible to dissect enough down to get a acceptable visualization through this tract.  A second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity.  Therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout.  Remarkably, the surface of the lower lobe laterally was not completely covered with a fibrotic line, but it was more the line anterior and posterior and more of it over the left upper lobe.  There were many pockets of purulent material, which had a gray-white appearance to it.  There was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe.  The adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time.  There seemed to be an abscess that was about 3 cm in dimension, all the lateral basilar segment of the lower lobe near the area where the chest tube was placed.  Many cultures were taken from several areas.  The most remarkable finding was a large cavity, which was probably about 11 cm in dimension, containing grayish pus and also caseous-like material, it was thought to be perhaps necrotic lung tissue, perhaps a deposit related to tuberculosis in the cavity.,The apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm.,PROCEDURE AND TECHNIQUE:,  With the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner.  The chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract, but then it was necessary to enlarge it slightly in order to get the Thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this.  Therefore, the next incision for Thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved, but it was clear that we would be unable to complete the procedure by thoracoscopy.  Therefore posterolateral thoracotomy incision was made, entering the pleural space and what is probably the sixth intercostal space.  Quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity.  Specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense.  Suture ligatures of Prolene were required.  When the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity, which appeared to be from pulmonary veins and these were sutured with a ""tissue pledget"" of what was probably intercostal nozzle and endothoracic fascia with Prolene sutures.,Also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14-French Foley catheter was passed into the area of the tear and the balloon was inflated, which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the Foley catheter was removed.  The patch was sutured onto the pulmonary artery tear.  A similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity.  Also on the pulmonary artery repair some ***** material was used and also thrombin, Gelfoam and Surgicel.  After reasonably good hemostasis was established pleural cavity was irrigated with saline.  As mentioned, biopsies were taken from multiple sites on the pleura and on the edge and on the lung.  Then two #24 Blake chest tubes were placed, one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk.  One was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex.  These were later connected to water-seal suction at 40 cm of water with negative pressure.,Good hemostasis was observed.  Sponge count was reported as being correct.  Intercostal nerve blocks at probably the fifth, sixth, and seventh intercostal nerves was carried out.  Then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib.  Metallic clip was passed through the rib to facilitate passage of an intracostal suture, but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table, so that pericostal sutures were used with #1 Vicryl.  The chest wall was closed with running #1 Vicryl and then 2-0 Vicryl subcutaneous and staples on the skin.  The chest tubes were connected to water-seal drainage with 40 cm of water negative pressure.  Sterile dressings were applied.  The patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen.  The patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition.", Surgery,38
"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.,5
"ADMISSION DIAGNOSIS:,1. Respiratory arrest.,2 . End-stage chronic obstructive pulmonary disease.,3. Coronary artery disease.,4. History of hypertension.,DISCHARGE DIAGNOSIS:,1. Status post-respiratory arrest.,2. Chronic obstructive pulmonary disease.,3. Congestive heart failure.,4. History of coronary artery disease.,5. History of hypertension.,SUMMARY:,  The patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be intubated shortly after admission to the emergency room. The patient’s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999. The patient has recently been admitted to the hospital with pneumonia and respiratory failure. The patient has been smoking up until three to four months previously. On the day of admission, the patient had the sudden onset of severe dyspnea and called an ambulance. The patient denied any gradual increase in wheezing, any increase in cough, any increase in chest pain, any increase in sputum prior to the onset of his sudden dyspnea.,ADMISSION PHYSICAL EXAMINATION:,GENERAL: Showed a well-developed, slightly obese man who was in extremis.,NECK: Supple, with no jugular venous distension.,HEART: Showed tachycardia without murmurs or gallops.,PULMONARY: Status showed decreased breath sounds, but no clear-cut rales or wheezes.,EXTREMITIES: Free of edema.,HOSPITAL COURSE:,  The patient was admitted to the Special Care Unit and intubated. He received intravenous antibiotic therapy with Levaquin. He received intravenous diuretic therapy. He received hand-held bronchodilator therapy. The patient also was given intravenous steroid therapy with Solu-Medrol. The patient’s course was one of gradual improvement, and after approximately three days, the patient was extubated. He continued to be quite dyspneic, with wheezes as well as basilar rales. After pulmonary consultation was obtained, the pulmonary consultant felt that the patient’s overall clinical picture suggested that he had a,significant element of congestive heart failure. With this, the patient was placed on increased doses of Lisinopril and Digoxin, with improvement of his respiratory status. On the day of discharge, the patient had minimal basilar rales; his chest also showed minimal expiratory wheezes; he had no edema; his heart rate was regular; his abdomen was soft; and his neck veins were not distended. It was, therefore, felt that the patient was stable for further management on an outpatient basis.,DIAGNOSTIC DATA:,  The patient’s admission laboratory data was notable for his initial blood gas, which showed a pH of 7.02 with a pCO2 of 118 and a pO2 of 103. The patient’s electrocardiogram showed nonspecific ST-T wave changes. The patent’s CBC showed a white count of 24,000, with 56% neutrophils and 3% bands.,DISPOSITION:,  The patient was discharged home.,DISCHARGE INSTRUCTIONS:,  His diet was to be a 2 grams sodium, 1800 calorie ADA diet. His medications were to be Prednisone 20 mg twice per day, Theo-24 400 mg per day, Furosemide 40 mg 1-1/2 tabs p.o. per day; Acetazolamide 250 mg one p.o. per day, Lisinopril 20 mg. one p.o. twice per day, Digoxin 0.125 mg one p.o. q.d., nitroglycerin paste 1 inch h.s., K-Dur 60 mEq p.o. b.i.d. He was also to use a Ventolin inhaler every four hours as needed, and Azmacort four puffs twice per day. He was asked to return for follow-up with Dr. X in one to two weeks. Arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge.", Cardiovascular / Pulmonary,3
"HISTORY AND PHYSICAL:  ,The patient is a 13-year-old, who has a history of Shone complex and has a complete heart block.  He is on the pacemaker.  He had a coarctation of the aorta and that was repaired when he was an infant.  He was followed in our Cardiology Clinic here and has been doing well.  However last night, he was sleeping, and he states he felt as if he has having a dream, and there was thunder in this dream, which woke him up.  He then felt that his defibrillator was going off and this has continued and feels like his heart rate is not normal.  Thus, his dad put him in the car and transported him here.  He has been evaluated here.  He had some scar tissue at one point when the internal pacemaker was not working properly and had to have that replaced.  It was 2 a.m. when he woke, and again, he was brought here by private vehicle.  He was well prior to going to bed.  No cough, cold, runny nose, fever.  No trauma has been noted.,PAST MEDICAL HISTORY:,  Shone complex, pacemaker dependent.,MEDICATIONS: , He is on no medications at this time.,ALLERGIES:,  He has no allergies.,IMMUNIZATIONS:,  Up to date.,SOCIAL HISTORY: , He lives with his parents.,FAMILY HISTORY: , Negative.,REVIEW OF SYSTEM: , Twelve asked, all negative, except as noted above.,PHYSICAL EXAMINATION:,GENERAL:  This is an awake, alert male, who appears to be in mild distress.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular movements are intact.  His TMs are clear.  His nares are clear.  The mucous membranes are pink and moist.  Throat is clear.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Clear.,HEART:  Shows bradycardia at 53.  He has good distal pulses.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding, no rebound.  No rashes are seen.,HOSPITAL COURSE:,  Initial blood pressure is 164/90.  He was moved in room 1.  He was placed on nasal cannula.  Pulse ox was 100%, which is normal.  We placed him on a monitor.  We did an EKG; it has not appear to be capturing his pacemaker at this time.  Shortly after the patient's arrival, the Medtronic technician came and worked out his pacemaker.  Medtronic representative informed me that the lead that he has in place has been recalled because it has been prone to microfractures, oversensing, and automatic defibrillation.  As noted, he was transferred to room 1, placed on a monitor, pulse ox.  An IV was placed.  A standard blood work was sent.  A chest x-ray was done showing normal heart size, lead appeared to be in placed.  There was no evidence of pulmonary edema.  His pacemaker did not appear to be capturing.  We placed him on transthoracic leads.  However, it is difficult to get good placement with these because of the area where his pacemaker was placed.  The Medtronic technician initially turned off his defibrillation mode and turned down his sensor.  However, we could not get our transthoracic pacer to capture his heart.  When the Medtronic representative turned off the pacemaker, the heart rate seemed to drop into the 40s.  The patient appeared to be in pain.  We placed it back on a rate of 60 at that time.  He has remained in sinus bradycardia, but no evidence of ectopic beats.  No widening of his QRS complex.  I spoke with Cardiology.  Cardiology service has come in, has evaluated him at bedside with me.  Again, we turned up the transthoracic pacer, but it is again not seem to be picking up, and his heart rate is still going with the Medtronic's internal pacemaker.  So with the ICU physician on call, Dr. X, he has agreed with taking this young man to the ICU.,An hour after presentation here, the ICU was ready for bed.  I accompanied the patient up to the ICU.  He remained awake and alert.  Initially, he was complaining of a lot of chest pain.  Once the defibrillator was turned off, he had no more pain.  He was transported to the Pediatrics PICU and delivered in stable condition.,LABORATORY DATA: , CBC was normal.  Chem-20 was normal as well.,IMPRESSION:  ,Complete heart block with pacemaker malfunction.,PLAN:  ,He is admitted to the ICU.,TIME SEEN: , Critical care time outside billable procedures was 45 minutes with this patient.  I should note that a 12-lead EKG was done here showing sinus bradycardia, normal intervals otherwise.", Cardiovascular / Pulmonary,3
"SUBJECTIVE:,  The patient comes back to see me today.  She is a pleasant 77-year-old Caucasian female who had seen Dr. XYZ with right leg pain.  She has a history of prior laminectomy for spinal stenosis.  She has seen Dr. XYZ with low back pain and lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, and clinical right L2 radiculopathy, which is symptomatic.  Dr. XYZ had performed two right L2-L3 transforaminal epidural injections, last one in March 2005.  She was subsequently seen and Dr. XYZ found most of her remaining symptoms are probably coming from her right hip.  An x-ray of the hip showed marked degenerative changes with significant progression of disease compared to 08/04/2004 study.  Dr. XYZ had performed right intraarticular hip injection on 04/07/2005.  She was last seen on 04/15/2005.  At that time, she had the hip injection that helped her briefly with her pain.  She is not sure whether or not she wants to proceed with hip replacement.  We recommend she start using a cane and had continued her on some pain medicines.,The patient comes back to see me today.  She continues to complain of significant pain in her right hip, especially with weightbearing or with movement.  She said she had made an appointment to see an orthopedic surgeon in Newton as it is closer and more convenient for her.  She is taking Ultracet or other the generic it sounds like, up to four times daily.  She states she can take this much more frequently as she still has significant pain symptoms.  She is using a cane to help her ambulate.,PAST MEDICAL HISTORY:,  Essentially unchanged from her visit of 04/15/2005.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant Caucasian female.,Vital Signs:  Height is 5 feet 4 inches.  Weight is 149 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Musculoskeletal:  Examination shows some mild degenerative joint disease of both knees with grade weakness of her right hip flexors and half-grade weakness of her right hip adductors and right quadriceps, as compared to the left.  Straight leg raises are negative bilaterally.  Posterior tibials are palpable bilaterally.,Skin and Lymphatics:  Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers.  No significant lymphadenopathy noted.,Spine:  Examination shows lumbar scoliosis with surgical scar with no major tenderness.  Spinal movements are limited but functional.,Neurological:  She is alert and oriented with appropriate mood and affect.  She has normal tone and coordination.  Reflexes are 2+ and symmetrical.  Sensations are intact to pinprick.,FUNCTIONAL EXAMINATION:,  Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1.  Degenerative disk disease of the right hip, symptomatic.,2.  Low back syndrome, lumbar spinal stenosis, clinically right L2 radiculopathy, stable.,3.  Low back pain with lumbar scoliosis post laminectomy syndrome, stable.,4.  Facet and sacroiliac joint syndrome on the right, stable.,5.  Post left hip arthroplasty.,6.  Chronic pain syndrome.,RECOMMENDATIONS:,  The patient is symptomatic primarily on her right hip and is planning on seeing an orthopedic surgeon for possible right hip replacement.  In the interim, her Ultracet is not quite taking care of her pain.  I have asked her to discontinue it and we will start her on Tylenol #3, up to four times a day.  I have written a prescription for this for 120 tablets and two refills.  The patient will call for the refills when she needs them.  I will plan further follow up in six months, sooner if needed.  She voiced understanding and is in agreement with this plan.  Physical exam findings, history of present illness and recommendations were performed with and in agreement with Dr. Goel's findings.", Orthopedic,27
"SUBJECTIVE: , The patient is a 20-year-old Caucasian male admitted via ABCD Hospital Emergency Department for evaluation of hydrocarbon aspiration.  The patient ingested ""tiki oil"" (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission.  He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting.  He was seen in the ABCD Hospital Emergency Department, toxic appearing with an abnormal chest x-ray demonstrating bilateral lower lobe infiltrates, greater on the right.  He had a temperature of 38.3 with tachycardia approximating 130.  White count was 59,300 with a marked left shift.  Arterial blood gases showed pH 7.48, pO2 79, and pCO2 35.  He was admitted for further medical management.,PAST MEDICAL HISTORY:,  Aplastic crisis during childhood requiring splenectomy and a cholecystectomy at age 9.,DRUG ALLERGIES: , NONE KNOWN.,CURRENT MEDICATIONS: , None.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,The patient works at a local Christmas tree farm.  He smokes cigarettes approximately one pack per day.,REVIEW OF SYSTEMS:,  Ten-system review significant for nausea, vomiting, fever, hemoptysis, and pleuritic chest pain.,PHYSICAL EXAMINATION,GENERAL:  A toxic-appearing 20-year-old Caucasian male, in mild respiratory distress.,VITAL SIGNS:  Blood pressure 122/74, pulse 130 and regular, respirations 24, temperature 38.3, and oxygen saturation 93%.,SKIN:  No rashes, petechiae or ecchymoses.,HEENT:  Within normal limits.  Pupils are equally round and reactive to light and accommodation.  Ears clean.  Throat clean.,NECK:  Supple without thyromegaly.  Lymph nodes are nonpalpable.,CHEST:  Decreased breath sounds bilaterally, greater on the right, at the right base.,CARDIAC:  No murmur or gallop rhythm.,ABDOMEN:  Mild direct diffuse tenderness without rebound.  No detectable masses, pulsations or organomegaly.,EXTREMITIES:  No edema.  Pulses are equal and full bilaterally.,NEUROLOGIC:  Nonfocal.,DATABASE: , Chest x-ray, bilateral lower lobe pneumonia, greater on the right.  EKG, sinus tachycardia, rate of 130, normal intervals, no ST changes.  Arterial blood gases on 2 L of oxygen, pH 7.48, pO2 79, and pCO2 35.,BLOOD STUDIES: , Hematocrit is 43, WBC 59,300 with a left shift, and platelet count 394,000.  Sodium is 130, potassium 3.8, chloride 97, bicarbonate 24, BUN 14, creatinine 0.8, random blood sugar 147, and calcium 9.4.,IMPRESSION,1.  Hydrocarbon aspiration.,2.  Bilateral pneumonia with pneumonitis secondary to aspiration.,3.  Asplenic patient.,PLAN,1.  ICU monitoring.,2.  O2 protocol.,3.  Hydration.,4.  Antiemetic therapy.,5.  Parenteral antibiotics.,6.  Prophylactic proton pump inhibitors.,The patient will need ICU monitoring and Pulmonary Medicine evaluation pending clinical course.,", Emergency Room Reports,12
"CHIEF COMPLAINT:,  The patient comes for her first Pap smear, complaining of irregular periods.,HISTORY OF PRESENT ILLNESS:,  The patient wishes to discuss considering something to help with her menstrual cramping and irregular periods.  She notes that her periods are out of weck.  She says that she has cramping and pain before her period starts.  Sometimes, she is off her period for two weeks and then she bleeds for two whole weeks.  She usually has her periods lasting seven days, usually comes on the 19th of each month and now it seems to have changed.  The cramping is worse.  She said her flow has increased.  She has to change her pad every half to one hour and uses a super tampon sometimes.  She usually has four days of hard flow and then she might have 10 days where she will have to wear a mini pad.  She also notes that her headaches have been worsening a little bit.  She has had quite a bit of stress.  She had a headache on Wednesday again after having had one on the weekend.  She said she usually only has an occasional headache and that is not too bad but now she has developed what she would consider to be a migraine and she has not had serious headaches like this and it seems to be worsening and coming a little bit more regularly, and she has not figure out what to do to get rid of them.  She avoids caffeine.  She only eats chocolate when she is near her period and she usually drinks one can of cola a day.,MEDICATIONS: , None.,ALLERGIES:,  None.,SOCIAL HISTORY:,  She is a nonsmoker.  She is not sexually active.,PAST MEDICAL HISTORY:,  She has had no surgery or chronic illnesses.,FAMILY HISTORY:,  Mother has hypertension, depression.  Father has had renal cysts and sometimes some stomach problems.  Both of her parents have problems with their knees.,REVIEW OF SYSTEMS:,  Patient denies headache or trauma.  No blurred or double vision.  Hearing is fine, no tinnitus or infection.  Infrequent sore throat, no hoarseness or cough.,HEENT:  See HPI.,Neck:  No stiffness, pain or swelling.,Respiratory:  No shortness of breath, cough or hemoptysis.  She is a nonsmoker.,Cardiovascular:  No chest pain, ankle edema, palpitations or hypertension.,GI:  No nausea, vomiting, diarrhea, constipation, melena or jaundice.,GU:  No dysuria, frequency, urgency or stress incontinence.,Locomotor:  No weakness, joint pain, tremor or swelling.,GYN:  See HPI.,Integumentary:  Patient performs self-breast examinations and denies any breast masses or nipple discharge.  No recent skin or hair changes.,Neuropsychiatric:  Denies depression, anxiety, tearfulness or suicidal thought.,PHYSICAL EXAMINATION:,VITALS:  Height 64.5 inches.  Weight:  162 pounds.  Blood pressure 104/72.  Pulse:  72.  Respirations:  16.  LMP:  08/21/04.  Age:  19.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.,Neck:  Full range of motion.  No lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation and percussion.,Heart:  Normal sinus rhythm, no murmur.,Integumentary:  Breasts are without masses, tenderness, nipple retraction or discharge.  Reviewed self-breast examination.  No axillary nodes are palpable.,Abdomen:  Soft.  Liver, spleen, and kidneys are not palpable.  No masses felt, nontender.  Femoral pulses strong and equal.,Back:  No CVA or spinal tenderness.  No deformity noted.,Pelvic:  BUS negative.  Vaginal mucosa pink, scanty discharge.  Cervix without lesion.  Pap was taken.  Uterus normal size.  Adnexa:  No masses.  She does have some pain on palpation of the uterus.,Rectal:  Good sphincter tone.  No masses.  Stool is guaiac negative.,Extremities:  No edema.  Pulses strong and equal.  Reflexes are intact.,Rectal:  No mass.,ASSESSMENT:,  Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.,PLAN:,  We will evaluate with a CBC, urinalysis and culture, and TSH.  The patient has what she describes as migraine headaches of a new onset.  Because of the pelvic pain, dysmenorrhea, and menorrhagia, we will also evaluate with a pelvic sonogram.  We will evaluate with a CT scan of the brain with and without contrast.  We will try Anaprox DS one every 12 hours for the headache.  At this point, she could also use that for menstrual cramping.  Prescription written for 20 tablets.  If her lab findings, sonographic findings, and CT of the brain are normal, we would consider trying birth control pills to regulate her periods and reduce the cramping and excessive flow.  The lab x-ray and urinalysis results will be reported to her as soon as they are available.", Consult - History and Phy.,5
"The patient presented in the early morning hours of February 12, 2007, with contractions.  The patient was found to be in false versus early labor and managed as an outpatient.  The patient returned to labor and delivery approximately 12 hours later with regular painful contractions.  There was minimal cervical dilation, but 80% effacement by nurse examination.  The patient was admitted.  Expected management was utilized initially.  Stadol was used for analgesia.  Examination did not reveal vulvar lesions.  Epidural was administered.  Membranes ruptured spontaneously.  Cervical dilation progressed.  Acceleration-deceleration complexes were seen.  Overall, fetal heart tones remained reassuring during the progress of labor.  The patient was allowed to ""labor down"" during second stage.  Early decelerations were seen as well as acceleration-deceleration complexes.  Overall, fetal heart tones were reassuring.  Good maternal pushing effort produced progressive descent.,Spontaneous controlled sterile vaginal delivery was performed without episiotomy and accomplished without difficulty.  Fetal arm was wrapped at the level of the neck with the fetal hand and also at the level of the neck.  There was no loop or coil of cord.  Infant was vigorous female sex.  Oropharynx was aggressively aspirated.  Cord blood was obtained.  Placenta delivered spontaneously.,Following delivery, uterus was explored without findings of significant tissue.  Examination of the cervix did not reveal lacerations.  Upper vaginal lacerations were not seen.  Multiple first-degree lacerations were present.  Specific locations included the vestibula at 5 o'clock, left labia minora with short extension up the left sulcus, right anterior labia minora at the vestibule, and midline of the vestibule.  All mucosal lacerations were reapproximated with interrupted simple sutures of 4-0 Vicryl with the knots being buried.  Post-approximation examination of the rectum showed smooth, intact mucosa.  Blood loss with the delivery was 400 mL.,Plans for postpartum care include routine postpartum orders.  Nursing personnel will be notified of Gilbert's syndrome.", Surgery,38
"HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging.  She was doing well until about 2 days ago, when she developed gagging.  No vomiting.  No fever.  She has history of constipation.  She normally passes stool every two days after giving an enema.  No rectal bleeding.  She was brought to the Hospital with some loose stool.  She was found to be dehydrated.  She was given IV fluid bolus, but then she started bleeding from G-tube site.  There was some fresh blood coming out of the G-tube site.  She was transferred to PICU.  She is hypertensive.  Intensivist Dr. X requested me to come and look at her, and do upper endoscopy to find the site of bleeding.,PAST MEDICAL HISTORY: , PEHO syndrome, infantile spasm, right above knee amputation, developmental delay, G-tube fundoplication.,PAST SURGICAL HISTORY: , G-tube fundoplication on 05/25/2007.  Right above knee amputation.,ALLERGIES:,  None.,DIET: , She is NPO now, but at home she is on PediaSure 4 ounces 3 times a day through G-tube, 12 ounces of water per day.,MEDICATIONS: , Albuterol, Pulmicort, MiraLax 17 g once a week, carnitine, phenobarbital, Depakene and Reglan.,FAMILY HISTORY:,  Positive for cancer.,PAST LABORATORY EVALUATION: , On 12/27/2007; WBC 9.3, hemoglobin 7.6, hematocrit 22.1, platelet 132,000.  KUB showed large stool with dilated small and large bowel loops.  Sodium 140, potassium 4.4, chloride 89, CO2 21, BUN 61, creatinine 2, AST 92 increased, ALT 62 increased, albumin 5.3, total bilirubin 0.1.  Earlier this morning, she had hemoglobin of 14.5, hematocrit 41.3, platelets 491,000.  PT 58 increased, INR 6.6 increased, PTT 75.9 increased.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99 degrees Fahrenheit, pulse 142 per minute, respirations 34 per minute, weight 8.6 kg.,GENERAL:  She is intubated.,HEENT:  Atraumatic.  She is intubated.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Distended.  Decreased bowel sounds.,GENITALIA:  Grossly normal female.,CNS:  She is sedated.,IMPRESSION: , A 3-year-old female patient with history of passage of blood through G-tube site with coagulopathy.  She has a history of G-tube fundoplication, developmental delay, PEHO syndrome, which is progressive encephalopathy optic atrophy.,PLAN:  ,Plan is to give vitamin K, FFP, blood transfusion.  Consider upper endoscopy.  Procedure and informed consent discussed with the family.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,POSTOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,6.  Grade 1+ rectocele.,PROCEDURE PERFORMED:  ,D&C and hysteroscopy.,COMPLICATIONS: , None.,HISTORY: , The patient is a 48-year-old para 2, vaginal delivery.  She has heavy periods lasting 7 to 14 days with spotting in between her periods.  The patient's uterus is 12.2 x 6.2 x 5.3 cm.  Her endometrial thickness is 2 cm.  Her adnexa is within normal limits.  The patient and I had a long discussion.  Consent was reviewed in layman's terms.  The patient understood the foreseeable risks and complications, the alternative treatments and procedure itself and recovery.  Questions were answered.  The patient was taken back to the operative suite.  The patient underwent pelvic examination and then carefully placed in dorsal lithotomy position.  The patient had excellent femoral pulses and there was no excessive extension or hyperflexion of the lower extremities.  The patient's history is that she is at risk for development of condyloma.  The patient's husband was found to have a laryngeal papillomatosis.  She has had a laparotomy, which is an infraumbilical incision appendectomy, a laparoscopy, and bilateral tubal ligation.  Her uterus appears to be mobile by 12-week size.  There is a good descend.  There appears to be no adnexal abnormalities.  Uterus is 12-week sized and has fibroids, it is boggy and probably has a component of adenomyosis.  The patient's cervix was dilated without difficulty utilizing Circon ACMI hysteroscope with a 12-degree lens.  The patient underwent hysteroscopy.  The outflow valve was opened at all times.  The inflow valve was opened just to achieve appropriate distension.  The patient did have no evidence of trauma of the cervix.  No Trendelenburg as we were in room #9.  The patient also had the bag held two fingerbreadths above the level of the heart.  The patient was seen.  There is a 2 x 3 cm focal thickening of the posterior wall of the uterus' endometrial lining, a more of a polypoid nature.  The patient also has one in the fundal area.  The thickened tissue was removed via sharp curettage.  Therefore, we reinserted the hysteroscope.  It appeared that there was an appropriate curettage and that all areas of suspicion were indeed removed.  The patient's procedure was ended with specimen being obtained and sent to Department of Pathology.  We will follow her up in the office.", Obstetrics / Gynecology,24
"HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia.  He states that he was in his usual state of health when he awoke one morning in January 2009.  He had double vision.  He states when he closed each eye, the double vision dissipated.  The double vision entirely dissipated within one hour.  He was able to drive.  However, the next day he woke up and he had double vision again.  Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe.  He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation.  He was seen by a primary care physician who sent him for an ophthalmologic evaluation.  He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm.  The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia.  Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together.  He still does not drive.  He also is not working due to the double vision.  There is no temporal fluctuation to the double vision.  More recently, over the past month, he has developed right supraorbital pain.  It actually feels like there is pain under his right lid.  He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system.  Dr. X saw the patient on February 2, 2009, when he was in the emergency department.  He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side.  MRV was negative and MRI of the brain with and without contrast was also negative.  He also had an MRI of the orbit with and without contrast that was normal.  His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis.  He had left gaze diplopia.  The pupils were equal, round, and reactive to light.  His neurological examination was otherwise entirely normal.  According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil.  There was also right medial rectus as well as possibly other extraocular abnormalities.  I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history.  He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:,  He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.  He was an IT software developer, but he has been out of work for several months.  He smokes less than a pack of cigarettes daily.  He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s.  His father had colon cancer.  He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  BP 124/76", Neurology,22
"3-DIMENSIONAL SIMULATION,This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures.  This optimizes the chance of controlling tumor while diminishing the acute and long-term side effects.  With conformal 3-dimensional simulation, there is extended physician, therapist, and dosimetrist effort and time expended.  The patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized.  Preliminary filed sizes and arrangements, including gantry angles, collimator angles, and number of fields are conceived.  Radiographs are taken and these films are approved by the physician.  Appropriate marks are placed on the patient's skin or on the  immobilization device.,The patient is transferred to the diagnostic facility and placed on a flat CT scan table.  Scans are performed through the targeted area.  The scans are evaluated by the radiation oncologist and the tumor volume, target volume, and critical structures are outlined on the CT images.  The dosimetrist then evaluates the slices in the treatment-planning computer with appropriately marked structures.  This volume is reconstructed in a virtual 3-dimensional space utilizing the beam's-eye view features.  Appropriate blocks are designed.  Multiplane computerized dosimetry is performed throughout the volume.  Field arrangements and blocking are modified as necessary to provide coverage of the target volume while minimizing dose to normal structures.,Once appropriate beam parameters and isodose distributions have been confirmed on the computer scan, the individual slices are then reviewed by the physician.  The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician.  Once these are approved, physical blocks or multi-leaf collimator equivalents will be devised.  If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where computer designed fields are re-simulated.,In view of the extensive effort and time expenditure required, this procedure justifies the special procedure code, 77470.", Hematology - Oncology,16
"PREOPERATIVE DIAGNOSES:,1. Squamous cell carcinoma of the head and neck.,2. Ethanol and alcohol abuse.,POSTOPERATIVE DIAGNOSES:,1. Squamous cell carcinoma of the head and neck.,2. Ethanol and alcohol abuse.,PROCEDURE:,1. Failed percutaneous endoscopic gastrostomy tube placement.,2. Open Stamm gastrotomy tube.,3. Lysis of adhesions.,4. Closure of incidental colotomy.,ANESTHESIA:, General endotracheal anesthesia.,IV FLUIDS:, Crystalloid 1400 ml.,ESTIMATED BLOOD LOSS:, Thirty ml.,DRAINS:, Gastrostomy tube was placed to Foley.,SPECIMENS:, None.,FINDINGS:, Stomach located high in the peritoneal cavity. Multiple adhesions around the stomach to the diaphragm and liver.,HISTORY: ,The patient is a 59-year-old black male who is indigent, an ethanol and tobacco abuse. He presented initially to the emergency room with throat and bleeding. Following evaluation by ENT and biopsy, it was determined to be squamous cell carcinoma of the right tonsil and soft palate, The patient is to undergo radiation therapy and possibly chemotherapy and will need prolonged enteral feeding with a bypass route from the mouth. The malignancy was not obstructing. Following obtaining informed consent for percutaneous endoscopic gastrostomy tube with possible conversion to open procedure, we elected to proceed following diagnosis of squamous cell carcinoma and election for radiation therapy.,DESCRIPTION OF PROCEDURE:, The patient was placed in the supine position and general endotracheal anesthesia was induced. Preoperatively, 1 gram of Ancef was given. The abdomen was prepped and draped in the usual sterile fashion. After anesthesia was achieved, an endoscope was placed down into the stomach, and no abnormalities were noted. The stomach was insufflated with air and the endoscope was positioned in the midportion and directed towards the anterior abdominal wall. With the room darkened and intensity turned up on the endoscope, a light reflex was noted on the skin of the abdominal wall in the left upper quadrant at approximately 2 fingerbreadths inferior from the most inferior rib. Finger pressure was applied to the light reflex with adequate indentation on the stomach wall on endoscopy. A 21-gauge 1-1/2 inch needle was initially placed at the margin of the light reflex, and this was done twice. Both times it was not visualized on the endoscopy. At this point, repositioning was made and, again, what was felt to be adequate light reflex was obtained, and the 14-gauge angio catheter was placed. Again, after two attempts, we were unable to visualize the needle in the stomach endoscopically. At this point, decision was made to convert the procedure to an open Stamm gastrostomy.,OPEN STAMM GASTROSTOMY: ,A short upper midline incision was made and deepened through the subcutaneous tissues. Hemostasis was achieved with electrocautery. The linea alba was identified and incised, and the peritoneal cavity was entered. The abdomen was explored. Adhesions were lysed with electrocautery under direct vision. The stomach was identified, and a location on the anterior wall near the greater curvature was selected. After lysis of adhesions was confirmed, we sufficiently moved the original chosen site without tension. A pursestring suture of #3-0 silk was placed on the interior surface of the stomach, and a second #3-0 pursestring silk stitch was placed exterior to that pursestring suture. An incision was then made at the location of the anterior wall which was near the greater curvature and was dissected down to the anterior abdominal wall. A Vanderbilt was used to pass through the abdominal wall in through the skin and then returned to the level of the skin and pulled the Bard feeding tube through the anterior wall into the field. An incision in the center of the pursestring suture on the anterior surface of the stomach was then made with electrocautery. The interior pursestring suture was sutured into place in such a manner as to inkwell the stomach around the catheter. The second outer concentric pursestring suture was then secured as well and tied to further inkwell the stomach. The stomach was then tacked to the anterior abdominal wall at the catheter entrance site with four #2-0 silk sutures in such a manner as to prevent leakage or torsion. The catheter was then secured to the skin with two #2-0 silk sutures. Hemostasis was checked and the peritoneal cavity was washed out and brought to the surgical field. Prior to the initiation of the gastrotomy, the bowel was run and at that time there was noted to be one incidental colotomy. This was oversewn with three #4-0 silk Lembert sutures. At the completion of the operation, the fascia was closed with #1 interrupted Vicryl suture, and the skin was closed with staples. The patient tolerated the procedure well and was taken to the postanesthesia care unit in stable condition.", Gastroenterology,14
"PREOPERATIVE DIAGNOSES,1.  Cervical spinal stenosis, C3-c4 and C4-C5.,2.  Cervical spondylotic myelopathy.,POSTOPERATIVE DIAGNOSES,1.  Cervical spinal stenosis, C3-C4 and C4-C5.,2.  Cervical spondylotic myelopathy.,OPERATIVE PROCEDURES,1.  Radical anterior discectomy, C3-C4 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63075).,2.  Radical anterior discectomy C4-C5 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63076).,3.  Anterior cervical fusion, C3-C4 (CPT 22554),4.  Anterior cervical fusion, C4-C5 (CPT 22585).,5.  Utilization of allograft for purposes of spinal fusion (CPT 20931).,6.  Application of anterior cervical locking plate C3-C5 (CPT 22845).,ANESTHESIA:,  General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,250 cc.,OPERATIVE INDICATIONS:  ,The patient is a 50-year-old gentleman who presented to the hospital after a fall, presenting with neck and arm pain as well as weakness.  His MRI confirmed significant neurologic compression in the cervical spine, combined with a clinical exam consistent with radiculopathy, myelopathy, and weakness.  We discussed the diagnosis and the treatment options.  Due to the severity of his neurologic symptoms as well as the amount of neurologic compression seen radiographically, I recommended that he proceed with surgical intervention as opposed to standard nonsurgical treatment such as physical therapy, medications, and steroid injections.  I explained the surgery itself which will be to remove pressure from the spinal cord via anterior cervical discectomy and fusion at C3-C4 and C4-C5.  We reviewed the surgery itself as well as risks including infection and blood vessels or nerves, leakage of spinal fluid, weakness or paralysis, failure of the pain to improve, possible worsening of the pain, failure of the neurologic symptoms to improve, possible worsening of the neurologic symptoms, and possible need for further surgery including re-revision and/or removal.  Furthermore I explained that the fusion may not become solid or that the hardware could break.  We discussed various techniques available for obtaining fusion and I recommended allograft and plate fixation.  I explained the rationale for this as well as the options of using his own bone.  Furthermore, I explained that removing motion at the fusion sites will transfer stress to other disc levels possibly accelerating there degeneration and causing additional symptoms and/or necessitating additional surgery in the future.,OPERATIVE TECHNIQUE: , After obtaining the appropriate signed and informed consent, the patient was taken to the operating room, where he underwent general endotracheal anesthesia without complications.  He was then positioned supine on the operating table, and all bony prominences were padded.  Pulse oximetry was maintained on both feet throughout the case.  The arms were carefully padded and tucked at his sides.  A roll was placed between the shoulder blades.  The areas of the both ears were sterilely prepped and cranial tongs were applied in routine fashion.  Ten pounds of traction was applied.  A needle was taped to the anterior neck and an x-ray was done to determine the appropriate level for the skin incision.  The entire neck was then sterilely prepped and draped in the usual fashion.,A transverse skin incision was made and carried down to the platysma muscle.  This was then split in line with its fibers.  Blunt dissection was carried down medial to the carotid sheath and lateral to the trachea and esophagus until the anterior cervical spine was visualized.  A needle was placed into a disc and an x-ray was done to determine its location.  The longus colli muscles were then elevated bilaterally with the electrocautery unit.  Self-retaining retractors were placed deep to the longus colli muscle in an effort to avoid injury to the sympathetic chains.,Radical anterior discectomies were performed at C3-C4 and C4-C5.  This included complete removal of the anterior annulus, nucleus, and posterior annulus.  The posterior longitudinal ligament was removed as were the posterior osteophytes.  Foraminotomies were then accomplished bilaterally.  Once all of this was accomplished, the blunt-tip probe was used to check for any residual compression.  The central canal was wide open at each level as were the foramen.,A high-speed bur was used to remove the cartilaginous endplates above and below each interspace.  Bleeding cancellous bone was exposed.  The disc spaces were measured and appropriate size allografts were placed sterilely onto the field.  After further shaping of the grafts with the high-speed bur, they were carefully impacted in to position.  There was good juxtaposition against the bleeding decorticated surfaces and good distraction of each interspace.  All weight was then removed from the crania tongs.,The appropriate size anterior cervical locking plate was chosen and bent into gentle lordosis.  Two screws were then placed into each of the vertebral bodies at C3, C4, and C5.  There was excellent purchase.  A final x-ray was done confirming good position of the hardware and grafts.  The locking screws were then applied, also with excellent purchase.,Following a final copious irrigation, there was good hemostasis and no dural leaks.  The carotid pulse was strong.  A drain was placed deep to the level of the platysma muscle and left at the level of the hardware.  The wounds were then closed in layers using 4-0 Vicryl suture for the platysma muscle, 4-0 Vicryl suture for the subcutaneous tissue, and 4-0 Vicryl suture in a subcuticular skin closure.  Steri-Strips were placed followed by application of a sterile dressing.  The drain was hooked to bulb suction.  A Philadelphia collar was applied.,The cranial tongs were carefully removed.  The soft tissue overlying the puncture site was massaged to free it up from the underlying bone.  There was good hemostasis.,The patient was then carefully returned to the supine position on his hospital bed where he was reversed and extubated and taken to the recovery room having tolerated the procedure well.", Orthopedic,27
"HISTORY OF PRESENT ILLNESS: , The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat.  She had an EGD and colonoscopy with Dr. ABC a few days prior to this admission.  Colonoscopy did reveal diverticulosis and EGD showed retained bile and possible gastritis.  Biopsies were done.  The patient presented to our emergency room for worsening abdominal pain as well as swelling of the right lower leg.,PAST MEDICAL HISTORY: , Extensive and well documented in prior charts.,PHYSICAL EXAMINATION: , Abdomen was diffusely tender.  Lungs clear.  Blood pressure 129/69 on admission.  At the time of admission, she had just a trace of bilateral lower edema.,LABORATORY STUDIES: , White count 6.7, hemoglobin 13, hematocrit 39.3.  Potassium of 3.2 on 08/15/2007.,HOSPITAL COURSE: , Dr. ABC apparently could not advance the scope into the cecum and therefore warranted a barium enema.  This was done and did not really show what the cecum on the barium enema.  There was some retained stool in that area and the patient had a somewhat prolonged hospital course on the remaining barium from the colon.  She did have some enemas.  She had persistent nausea, headache, neck pain throughout this hospitalization.  Finally, she did improve enough to the point where she could be discharged home.,DISCHARGE DIAGNOSIS: , Nausea and abdominal pain of uncertain etiology.,SECONDARY DIAGNOSIS:  ,Migraine headache.,COMPLICATIONS:  ,None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN:  ,Follow up with me in the office in 5 to 7 days to resume all pre-admission medications.  Diet and activity as tolerated.", General Medicine,15
"HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old gentleman who has a history of sick sinus syndrome for which he has St. Jude permanent pacemaker.  Pacemaker battery has reached end of life and the patient is dependent on his pacemaker with 100% pacing in the right ventricle.  He also has a fairly advanced degree of Alzheimer's dementia and is living in an assisted care facility.  The patient is unable to make his own health care decision and his daughter ABC has medical power of attorney.  The patient's dementia has resulted in the patient's having sufficient and chronic anger and his daughter that he refuses to speak with her, refuses to be in a same room with her.  For this reason the Casa Grande Regional Medical Center would obtain surgical and anesthesia consent from the patient's daughter in the fashion keeps the patient and daughter separated.  Furthermore it is important to note that his degree of dementia has disabled the patient to adequately self monitor his status following surgery for significant changes and to seek appropriate medical care, hence he will be admitted after the pacemaker exchange.,PAST MEDICAL HISTORY:,1.  Sick sinus syndrome, pacemaker dependence with 100% with right ventricular pacing.,2.  Dementia of Alzheimer's disease.,3.  Gastroesophageal reflux disease.,4.  Multiple pacemaker implantation and exchanges.,FAMILY HISTORY: , Unobtainable.,SOCIAL HISTORY: , The patient resides full time at ABC supervised living facility.  He is nonsmoker, nondrinker.  He uses wheelchair and moves himself about with his feet.  He is independent of activities of daily living and dependent on independent activities of daily living.,ALLERGIES TO MEDICATIONS: , No known drug allergies.,MEDICATIONS:  ,Omeprazole 20 mg p.o. daily, furosemide 20 mg p.o. daily, citalopram 20 mg p.o. daily, loratadine 10 mg p.o. p.r.n.,REVIEW OF SYSTEMS: , A 10 systems review negative for chest pain, pressure, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, syncope, near-syncopal episodes.  Negative for recent falls.  Positive for significant memory loss.  All other review of systems is negative.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an 85-year-old gentleman in no acute distress, sitting in the wheelchair.,VITAL SIGNS:  Blood pressure is 118/68, pulse is 80 and regular, respirations 16, weight is 200 pounds, oxygen saturation is 90% on room air.,HEENT:  Head atraumatic and normocephalic.  Eyes, pupils are equal and reactive to light and accommodate bilaterally, free from focal lesions.  Ears, nose, mouth, and throat.,NECK:  Supple.  No lymphadenopathy, thyromegaly, or thyroid masses appreciated.,CARDIOVASCULAR:  No JVD or no jugular venous distention.  No carotid bruits bilaterally.  Pacemaker pocket right upper thorax with healed surgical incisions.  S1 and S2 are normal.  No S3 or S4.  There are no murmurs.  No heaves or thrills, gout, or gallops.  Trace edema at dorsum of his feet and ankles.  Femoral pulses are present without bruits, posterior tibial pulses would be palpable bilaterally.,RESPIRATORY:  Breath sounds are clear but diminished throughout AP diameters expanded.  The patient speaks in full sentences.  No wheezing, no accessory muscles used for breathing.,GASTROINTESTINAL:  Abdomen is soft and nontender.  Bowel sounds are active in all 4 quadrants.  No palpable pulses.  No abdominal bruit is appreciated.  No hepatosplenomegaly.,GENITOURINARY:  Nonfocal.,MUSCULOSKELETAL:  Muscle strength in lower extremities is 4/5 bilaterally.  Upper extremities are 5/5 bilaterally with adequate range of motion.,SKIN:  Warm and dry.  No obvious rashes, lesions, or ulcerations. ,NEUROLOGIC:  Alert, not oriented to place and date.  His speech is clear.  There are no focal motor or sensory deficits.,PSYCHIATRIC:  Talkative, pleasant affect with limited impulse control, severe short-term memory loss.,LABORATORY DATA:,  Blood work dated 12/15/08, white count 4.7, hemoglobin 11.9, hematocrit 33.9, and platelets 115,000.  BUN 19, creatinine 1.15, glucose 94, potassium 4.5, sodium 140, and calcium 8.6.,DIAGNOSTIC DATA:,  St. Jude pacemaker interrogation dated 11/10/08 shows single chamber pacemaker and VVIR mode, implant date 08/2000, 100% paced in right ventricle, battery status is ERI.  A 12-lead ECG 12/15/08 shows 100% paced rhythm with rate of 80.  No Q waves at the baseline of atrial fibrillation.  Last measured ejection fraction 40% 12/08 with no significant decompensation.,IMPRESSION/PLAN:,1.  Sick sinus syndrome.,2.  Atrial fibrillation.,3.  Pacemaker dependent.,4.  Mild cardiomyopathy with ejection fraction 40% and no significant decompensation.,5.  Pacemaker battery end of life requiring exchange.,6.  Dementia of Alzheimer's disease with short and long term memory dysfunction.  The dementia disables the patient from recognizing changes in his health status in knowing if he needed to seek appropriate health care.  Dementia also renders the patient incapable informed consent, schedule the patient for pacemaker.  I explain the patient and reimplantation with any device in the surgical suite.  He will require anesthesia assistance for adequate sedation as the patient possesses behavioral risk secondary to his advanced dementia.,7.  Admit the patient after surgery for postoperative care and monitoring.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS:,  Phimosis.,POSTOPERATIVE DIAGNOSES:,  Phimosis.,OPERATIONS:,  Circumcision.,ANESTHESIA: , LMA.,EBL:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , This is a 3-year-old male, who was referred to us from Dr. X's office with phimosis.  The patient had spraying of urine and ballooning of the foreskin with voiding.  The urine seemed to have collected underneath the foreskin and then would slowly drip out.  Options such as dorsal slit, circumcision, watchful waiting by gently pulling the foreskin back were discussed.  Risk of anesthesia, bleeding, infection, pain, scarring, and expected complications were discussed.  The patient's family understood all the complications and wanted to proceed with the procedure.  Consent was obtained using interpreter.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR and anesthesia was applied.  The patient was placed in supine position.  The patient was prepped and draped in usual sterile fashion.  All the penile adhesions were released prior to the prepping.  The extra foreskin was marked off, 1 x 3 Gamco clamp was used.  Hemostasis was obtained after removing the extra foreskin using the Gamco clamp.,Using 5-0 Monocryl, 4 quadrant stitches were placed and horizontal mattress suturing was done.  There was excellent hemostasis.  Dermabond was applied.  The patient was brought to recovery at the end of the procedure in stable condition.", Surgery,38
"DIAGNOSES ON ADMISSION,1.  Cerebrovascular accident (CVA) with right arm weakness.,2.  Bronchitis.,3.  Atherosclerotic cardiovascular disease.,4.  Hyperlipidemia.,5.  Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1.  Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2.  Old coronary infarct, anterior aspect of the right external capsule.,3.  Acute bronchitis with reactive airway disease.,4.  Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5.  Atherosclerotic cardiovascular disease.,6.  Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room.  Plavix was started  in addition to baby aspirin.  He was kept on oral Zithromax for his cough.  He was given Xopenex treatment, because of his respiratory distress.  Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid.  Dr. X saw him in consultation and recommended CT angiogram.  This showed no significant obstructive lesion other than what was known on the ultrasound.  Head MRI was done and revealed the above findings.  The patient was begun on PT and improved.  By discharge, he had much improved strength in his right arm.  He had no further progressions.  His cough improved with oral Zithromax and nebulizer treatments.  His platelets also improved as well.  By discharge, his platelets was up to 107,000.  His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential.  Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate.  Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1.  PT/INR on admission was 1.03, PTT 34.7.  At the time of discharge, the patient's cough was much improved.  His right arm weakness has much improved.  His lung examination has just occasional rhonchi.  He was changed to a metered dose inhaler with albuterol.  He is being discharged home.  An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation.  He will follow up in my office in 1 week.  He is to start PT and OT as an outpatient.  He is to avoid driving his car.  He is to notify, if further symptoms.  He has 2 more doses of Zithromax at home, he will complete.  His prognosis is good.", Discharge Summary,10
"PREOPERATIVE DIAGNOSES:,1.  Metatarsus primus varus with bunion deformity, right foot.,2.  Hallux abductovalgus with angulation deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Metatarsus primus varus with bunion deformity, right foot.,2.  Hallux abductovalgus with angulation deformity, right foot.,PROCEDURES:,1.  Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot.,2.  Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.,ANESTHESIA:,Local infiltrate with IV sedation.,INDICATION FOR SURGERY: , The patient has had a longstanding history of foot problems.  The foot problem has been progressive in nature and has not been responsive to conservative treatment.  The preoperative discussion with the patient included the alternative treatment options.,The procedure was explained in detail and risk factors such as infection, swelling, scarred tissue; numbness, continued pain, recurrence, and postoperative management were explained in detail.  The patient has been advised, although no guaranty for success could be given, most patients have improved function and less pain.  All questions were thoroughly answered.  The patient requested surgical repair since the problem has reached a point that interferes with her normal daily activities.  The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF PROCEDURE:  ,The patient was brought to the operating room and placed in a supine position.  No tourniquet was utilized.  IV sedation was administered and during that time local anesthetic consisting of approximately 10 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site.  The lower extremity was prepped and draped in the usual sterile manner.  Balanced anesthesia was obtained.,PROCEDURE #1: , Distal metaphyseal osteotomy with internal screw fixation with bunionectomy, right foot.  A dorsal curvilinear incision medial to the extensor hallucis longus tendon was made, extending from the distal third of the shaft of the first metatarsal to a point midway on the shaft of the proximal phalanx.  Care was taken to identify and retract the vital structures and when necessary, vessels were ligated via electrocautery.  Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and then down to the capsular and periosteal layer, which was visualized.  A linear periosteal capsular incision was made in line with the skin incision.  The capsular tissue and periosteal layer were underscored, free from its underlying osseous attachments, and they refracted to expose the osseous surface.  Inspection revealed increased first intermetatarsal angle and hypertrophic changes to the first metatarsal head.  The head of the first metatarsal was dissected free from its attachment medially and dorsally, delivered dorsally and may be into the wound.,Inspection revealed the first metatarsophalangeal joint surface appeared to be in satisfactory condition.  The sesamoid was in satisfactory condition.  An oscillating saw was utilized to resect the hypertrophic portion of the first metatarsal head to remove the normal and functional configuration.  Care was taken to preserve the sagittal groove.  The rough edges were then smoothed with a rasp.,Attention was then focused on the medial mid portion of the first metatarsal head where a K-wire access guide was positioned to define the apex and direction of displacement for the capital fragment.  The access guide was noted to be in good position.  A horizontally placed, through-and-through osteotomy with the apex distal and the base proximal was completed.  The short plantar arm was from the access guide to proximal plantar and the long dorsal arm was from the access guide to proximal dorsal.  The capital fragment was distracted off the first metatarsal, moved laterally to decrease the intermetatarsal angle to create a more anatomical and functional position of the first metatarsal head.  The capital fragment was impacted upon the metatarsal.,Inspection revealed satisfactory reduction of the intermetatarsal angle and good alignment of the capital fragment.  It was then fixated with 1 screw.  A guide pin was directed from the dorsal aspect of the capital fragment to the plantar aspect of the shaft and first metatarsal in a distal dorsal to proximal plantar direction.  The length was measured, __________ mm cannulated cortical screw was placed over the guide pin and secured in position.  Compression and fixation were noted to be satisfactory.  Inspection revealed good fixation and alignment at the operative site.  Attention was then directed to the medial portion of the distal third of the shaft of the first metatarsal where an oscillating saw was used to resect the small portion of the bone that was created by shifting the capital fragment laterally.  All rough edges were rasped smooth.  Examination revealed there was still lateral deviation of the hallux.  A second procedure, the reposition osteotomy of the proximal phalanx with internal screw fixation to correct angulation deformity was indicated., ,PROCEDURE #2:,  Reposition osteotomy with internal screw fixation to correct angulation deformity, proximal phalanx, right hallux.  The original skin incision was extended from the point just distal to the interphalangeal joint.  All vital structures were identified and retracted.  Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and down to the periosteal layer, which was underscored, free from its underlying osseous attachments and reflected to expose the osseous surface.  The focus of the deformity was noted to be more distal on the hallux.  Utilizing an oscillating saw, a more distal, wedge-shaped transverse oblique osteotomy was made with the apex being proximal and lateral and the base medial distal was affected.  The proximal phalanx was then placed in appropriate alignment and stabilized with a guide pin, which was then measured, __________ 14 mm cannulated cortical screw was placed over the guide pin and secured into position.,Inspection revealed good fixation and alignment at the osteotomy site.  The alignment and contour of the first way was now satisfactorily improved.  The entire surgical wound was flushed with copious amounts of sterile normal saline irrigation.  The periosteal and capsular layer was closed with running sutures of #3-0 Vicryl.  The subcutaneous tissue was closed with #4-0 Vicryl and the skin edges coapted well with #4-0 nylon with running simples, reinforced with Steri-Strips.,Approximately 6 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine plain was locally infiltrated proximal to the operative site for postoperative anesthesia.  A dressing consisting of Adaptic and 4 x 4 was applied to the wound making sure the hallux was carefully splinted, followed by confirming bandages and an ACE wrap to provide mild compression.  The patient tolerated the procedure and anesthesia well and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by the normal capillary fill time.,A walker boot was dispensed and applied.  The patient should wear it when walking or standing., ,The next office visit will be in 4 days.  The patient was given prescriptions for Percocet 5 mg #40 one p.o. q.4-6h. p.r.n. pain, along with written and oral home instructions.  The patient was discharged home with vital signs stable in no acute distress.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  Right undescended testicle.,POSTOPERATIVE DIAGNOSIS:,  Right undescended testicle.,OPERATIONS:,1.  Right orchiopexy.,2.  Right herniorrhaphy.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Sac.,BRIEF HISTORY: , This is a 10-year-old male who presented to us with his mom with consultation from Craig Connor at Cottonwood with right undescended testis.  The patient and mother had seen the testicle in the right hemiscrotum in the past, but the testicle seemed to be sliding.  The testis was identified right at the external inguinal ring.  The testis was unable to be brought down into the scrotal sac.  The patient could have had sliding testicle in the past and now the testis has become undescended as the child has grown.  Options such as watchful waiting and wait for puberty to stimulate the descent of the testicle, HCG stimulation, orchiopexy were discussed.  Risk of anesthesia, bleeding, infection, pain, hernia, etc. were discussed.  The patient and parents understood and wanted to proceed with right orchiopexy and herniorrhaphy.,PROCEDURE IN DETAIL: , The patient was brought to the OR, anesthesia was applied.  The patient was placed in supine position.  The patient was prepped and draped in the inguinal and scrotal area.  After the patient was prepped and draped, an inguinal incision was made on the right side about 1 cm away for the anterior superior iliac spine going towards the external ring over the inguinal canal.  The incision came through the subcutaneous tissue and external oblique fascia was identified.  The external oblique fascia was opened sharply and was taken all the way down towards the external ring.  The ilioinguinal nerve was identified right underneath the external oblique fascia, which was preserved and attention was drawn throughout the entire case to ensure that it was not under any tension or pinched or got hooked in the suture.  After dissecting proximally, the testis was identified in the distal end of the inguinal canal.  The testis was pulled up.  The cremasteric muscle was divided and dissection was carried all the way up to the internal inguinal ring.  There was very small hernia, which was removed and was tied at the base.  PDS suture was used to tie this hernia sac all the way up to the base.  There was a Y right at the vas and cord indicating there was enough length into the scrotal sac.  The testis was easily brought down into the scrotal sac.  One centimeter superior scrotal incision was made and a Dartos pouch was created.  The testicle was brought down into the pouch and was placed into the pouch.  Careful attention was done to ensure that there was no torsion of the cord.  The vas was medial all the way throughout and the cord was lateral all the way throughout.  The epididymis was in the posterolateral location.  The testicle was pexed using 4-0 Vicryl into the scrotal sac.  Skin was closed using 5-0 Monocryl.  The external oblique fascia was closed using 2-0 PDS.  Attention was drawn to re-create the external inguinal ring.  A small finger was easily placed in the external inguinal ring to ensure that there was no tightening of the cord.  Marcaine 0.25% was applied, about 15 mL worth of this was applied for local anesthesia.  After closing the external oblique fascia, the Scarpa was brought together using 4-0 Vicryl and the skin was closed using 5-0 Monocryl in subcuticular fashion.  Dermabond and Steri-Strips were applied.,The patient was brought to recovery room in stable condition at the end of the procedure.,Please note that the testicle was viable.  It was smaller than the other side, probably by 50%.  There were no palpable testicular masses.  Plan was for the patient to follow up with us in about 1 month.  The patient was told not to do any heavy lifting for at least 3 months, okay to shower in 48 hours.  No tub bath for 2 months.  The patient and family understood all the instructions.", Surgery,38
"PREPROCEDURE DIAGNOSIS: , Abdominal pain, diarrhea, and fever.,POSTPROCEDURE DIAGNOSIS: , Pending pathology.,PROCEDURES PERFORMED: , Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.", Gastroenterology,14
"PREOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1.  Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS:  ,Approximately 1000 cc.,CELL SAVER RETURNED:  ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain.  He had previous lumbar laminectomy at L4-L5.  He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable.  He is suffering from neurogenic claudication.  He was unresponsive to extensive conservative treatment.  He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia.  He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded.  His lumbar spine was then sterilely prepped and draped in the usual fashion.  A previous midline incision was extended from approximate level of L3 to S1.  This was in the midline.  Skin and subcutaneous tissue were debrided sharply.  Electrocautery provided hemostasis.  ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia.  The lumbar fascia was identified and split in the midline.  Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1.  Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4.  Once this was completed, a self-retaining retractor was then placed.  With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable.  These were readily mobile with digital palpation.  A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1.  This bone was morcellized and placed on the back table for utilization for bone grafting.  The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1.  Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained.  Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1.  The microscope was utilized during this portion of procedure for visualization.  There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure.  Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5.  Once this was identified, foraminotomies were created to allow additional mobility.  The wound was then copiously irrigated with antibiotic solution and suctioned dry.  Working type screws, provisional titanium screws were then placed at L4-l5.  This was to allow distraction and reduction of the spondylolisthesis.  These were placed in the pedicles of L4 and L5 under direct intensification.  The position of the screws were visualized, both AP and lateral images.  They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5.  This allowed for additional decompression of the L5 and L4 nerve roots.  Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed.  Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval.  This was taken in sequence up to a 13 mm space.  This was then reduced to a 11 mm as it was much more anatomic in nature.  Once this was completed, the spacers were then placed on the left side and distraction obtained.  Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally.  Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried.  A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft.  There were impacted at the interspace of L4-L5 under direct image intensification.  Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried.  The provisional screws and plates were removed.  This allowed for additional compression along L4-L5 with the cage instrumentation.  Permanent screws were then placed at L4, L5, and S1 bilaterally.  This was performed under direct image intensification.  The position was verified in both AP and lateral images.  Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally.  A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1.  Appropriate cross connecters were applied and the construct was placed over the pedicle screws.  They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra.  Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory.  All connections were tightened and retightened in Torque 2 specifications.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The dura was inspected and noted to be free of tension.  At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors.  An 8-inch Hemovac drain was placed exiting the wound.  The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin.  The remainder of the Hemovac was assembled.  Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape.  He was turned and taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded.", Surgery,38
"PREOPERATIVE DIAGNOSIS:  ,Cervical spondylosis and herniated nucleus pulposus of C4-C5.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis and herniated nucleus pulposus of C4-C5.,TITLE OF OPERATION:,  Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,OPERATIVE PROCEDURE IN DETAIL: , After identification, the patient was taken to the operating room and placed in supine position.  Following the induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  A shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position.  A preoperative x-ray was obtained to identify the operative level and neck position.  An incision was marked at the C4-C5 level on the right side.  The incision was opened with #10 blade knife.  Dissection was carried down through subcutaneous tissues using Bovie electrocautery.  The platysma muscle was divided with the cautery and mobilized rostrally and caudally.  The anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection.  The avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia.  This was opened with scissors and dissected rostrally and caudally with the peanut dissectors.  The operative level was confirmed with an intraoperative x-ray.  The longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator.  The anterior longitudinal ligament was then taken down with the insulated Bovie electrocautery tip exposing the vertebral bodies of C4 and C5.  Self-retaining retractor was placed in submuscular position, and distraction pins were placed in the vertebral bodies of C4 and C5, and distraction was instituted.  We then incise the annulus of C4-C5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes.  Operating microscope was draped and brought into play.  Dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went.  We now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally.  Bone was then removed with 2 mm Kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm Kerrison punch.  There was a transligamentous disc herniation, which was removed during this process.  We then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent.  Cord was seen to be pulsating freely behind the dura.  There appeared to be no complications and the decompression appeared adequate.  We now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the C5 vertebral body.  An 8 mm lordotic trial was used and appeared perfect.  We then used a corticocancellous 8 mm lordotic graft.  This was tapped into position.  Distraction was released, appeared to be in excellent position.  We then positioned an 18 mm Vector plate over the inner space.  Intraoperative x-ray was obtained with the stay screw in place; plates appeared to be in excellent position.  We then use a 14 mm self-tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion.  All of the screws locked to the plate and this was confirmed on visual inspection.  Intraoperative x-ray was again obtained.  Construct appeared satisfactory.  Attention was then directed to closure.  The wound was copiously irrigated.  All of the self-retaining retractors were removed.  Bleeding points were controlled with bone wax and bipolar electrocautery.  The platysma layer was now closed with interrupted 3-0 Vicryl sutures.  The skin was closed with running 3-0 Vicryl subcuticular stitch.  Steri-Strips were applied.  A sterile bandage was applied.  All sponge, needle, and cottonoid counts were reported as correct.  The patient tolerated the procedure well.  He was subsequently extubated in the operating room and transferred to PACU in satisfactory condition.", Surgery,38
"CHIEF COMPLAINT:,  Arm and leg jerking.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.  Mom denies any apnea, perioral cyanosis, or color changes.  These movements are without any back arching.  They mainly occur during sleep, so mom is unaware of any eye rolling.  Mom is able to wake the patient up during this periods and stop the patient's extremity movements.,Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast.  She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours.  She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day.,REVIEW OF SYSTEMS:,  Negative fever, negative fussiness, tracks with her eyes, some sneezing and hiccups.  This patient has developed some upper airway congestion in the past day.  She has not had any vomiting or diarrhea.  Per mom, she does not spit up, and mom is also unable to notice any relationship between these movements and feeds.  This patient has not had any rashes.  Mom was notified by the nurses at birth that her temperature may be low of approximately 97.5 degrees Fahrenheit.  Otherwise, the above history of present illness and other review of systems negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pound 11 ounce baby, ex-41-weeker born via vaginal delivery without vacuum assist or forceps.  There were no complications during pregnancy such as diabetes or hypertension.  Prenatal care started at approximately 3 weeks, and mom maintained all visits.  She also denies any smoking, alcohol, or drug use during the pregnancy.  Mom was GBS status positive, but denies any other infections such as urinary tract infections.  She did not have any fever during labor and received inadequate intrapartum antibiotics prophylaxis.  After delivery, this patient did not receive antibiotics secondary to ""borderline labs.""  She was jaundiced after birth and received photo treatments.  Her discharge bilirubin level was approximately 11.  Mom and child stayed in the hospital for approximately 3-1/2 days.,Mom denies any history of sexually transmitted disease in her or dad.  She specifically denies any blistering, herpetic genital lesions.  She does have a history though of human papillomavirus warts (vaginal), removed 20 years ago.,PAST SURGICAL HISTORY:,  Negative.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , None.,SOCIAL HISTORY: , At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister.  All the residents at home are sick currently with cold, cough, runny nose, except for mom.  At home also live 2 dogs and 2 outside cats.  Mom denies any recent travel history, especially during the recent holidays and no smoke exposures.,FAMILY HISTORY:,  Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently.  The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia.  The maternal grandmother is notable for hypertension and diabetes.  There are no other children in the family who see a specialist or no child death less than 1 year of age.,PHYSICAL EXAMINATION:", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,POSTOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,PROCEDURES PERFORMED:,1.  Right McBride bunionectomy.,2.  Right basilar wedge osteotomy with OrthoPro screw fixation.,ANESTHESIA: , Local with IV sedation.,HEMOSTASIS: , With pneumatic ankle cuff.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in a supine position.  The right foot was prepared and draped in usual sterile manner.  Anesthesia was achieved utilizing a 50:50 mixture of 2% lidocaine plain with 0.5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint.  Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg.  At this time, attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made.  The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure.  The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection.  Using a microsagittal saw, the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp.  At this time, attention was directed to the first inner space using sharp and blunt dissection.  Dissection was carried down to the underling level of the adductor hallucis tendon, which was isolated and freed from its phalangeal, sesamoidal, and metatarsal attachments.  The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0.5 cm to help prevent any re-fibrous attachment.  At this time, the lateral release was stressed and was found to be complete.  The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0.5-cm resection.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw.  The area was again copiously flushed and inspected for any abnormalities and/or prominences and none were noted.  At this time, attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length.  The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption.  At this time, there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint.  At this time, 0.5 cm was measured distal to that lateral measurement and using microsagittal saw, a wedge osteotomy was taken from the base with the apex of the osteotomy being medial, taking care to keep the medial cortex intact as a hinge.  The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3.0 x 22 mm.  The screw was placed following proper technique.  The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing.  A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy.  The packing of the cancellous bone was held in place with bone wax.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed.  At this time, a deep closure was achieved utilizing #2-0 Vicryl suture, subcuticular closure was achieved using #4-0 Vicryl suture, and skin repair was achieved at both surgical sites with #5-0 nylon suture in a running interlocking fashion.  The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site.  At this time, the surgical site was postoperatively injected with 0.5 Marcaine plain as well as dexamethasone 4 mg primarily.  The surgical sites were then dressed with sterile Xeroform, sterile 4x4s, cascading, and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion.  The tourniquet was dropped and color and temperature of all digits returned to normal.  The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition.,The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions, problems, or concerns at any time with the numbers provided.  The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot.,", Surgery,38
"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Arrest of dilation. ,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Arrest of dilation.,PROCEDURE PERFORMED:,  Primary low-transverse cesarean section.,ANESTHESIA: , Epidural.,ESTIMATED BLOOD LOSS: , 1000 mL.,COMPLICATIONS: , None.,FINDINGS:  ,Female infant in cephalic presentation, OP position, weight 9 pounds 8 ounces.  Apgars were 9 at 1 minute and 9 at 5 minutes.  Normal uterus, tubes, and ovaries were noted.,INDICATIONS:  ,The patient is a 20-year-old gravida 1, para 0 female, who presented to labor and delivery in early active labor at 40 and 6/7 weeks gestation.  The patient progressed to 8 cm, at which time, Pitocin was started.  She subsequently progressed to 9 cm, but despite adequate contractions, arrested dilation at 9 cm.  A decision was made to proceed with a primary low transverse cesarean section.,The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and possible need for further surgery.  Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where epidural anesthesia was found to be adequate.  The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a left-ward tilt.  A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie.  The fascia was incised in the midline and extended laterally using Mayo scissors.  Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors.  Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors.  The rectus muscles were dissected in the midline.,The peritoneum was bluntly dissected, entered, and extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was inserted.  The vesicouterine peritoneum was identified with pickups and entered sharply using Metzenbaum scissors.  This incision was extended laterally and the bladder flap was created digitally.  The bladder blade was reinserted.  The lower uterine segment was incised in a transverse fashion using the scalpel and extended using manual traction.  Clear fluid was noted.  The infant was subsequently delivered atraumatically.  The nose and mouth were bulb suctioned.  The cord was clamped and cut.  The infant was subsequently handed to the awaiting nursery nurse.  Next, cord blood was obtained per the patient's request for cord blood donation, which took several minutes to perform.  Subsequent to the collection of this blood, the placenta was removed spontaneously intact with a 3-vessel cord noted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was repaired in 2 layers using 0 chromic suture.  Hemostasis was visualized.  The uterus was returned to the abdomen.,The pelvis was copiously irrigated.  The uterine incision was reexamined and was noted to be hemostatic.  The rectus muscles were reapproximated in the midline using 3-0 Vicryl.  The fascia was closed with 0 Vicryl, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples.  Sponge, lap, and instrument counts were correct x2.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  Ectopic left testis.,POSTOPERATIVE DIAGNOSIS: , Ectopic left testis.,PROCEDURE PERFORMED: , Left orchiopexy.,ANESTHESIA: , General.  The patient did receive Ancef.,INDICATIONS AND CONSENT: , This is a 16-year-old African-American male who had an ectopic left testis that severed approximately one-and-a-half years ago.  The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle.  The risks, benefits, and alternatives of the proposed procedure were discussed with the patient.  Informed consent was on the chart at the time of procedure.,PROCEDURE DETAILS:  ,The patient did receive Ancef antibiotics prior to the procedure.  He was then wheeled to the operative suite where a general anesthetic was administered.  He was prepped and draped in the usual sterile fashion and shaved in the area of the intended procedure.  Next, with a #15 blade scalpel, an oblique skin incision was made over the spermatic cord region.  The fascia was then dissected down both bluntly and sharply and hemostasis was maintained with Bovie electrocautery.  The fascia of the external oblique, creating the external ring was then encountered and that was grasped in two areas with hemostats and sized with Metzenbaum scissors.  This was then continued to open the external ring and was then carried cephalad to further open the external ring, exposing the spermatic cord.  With this accomplished, the testis was then identified.  It was located over the left pubic tubercle region and soft tissue was then meticulously dissected and cared to avoid all vascular and testicular structures.,The cord length was then achieved by applying some tension to the testis and further dissecting any of the fascial adhesions along the spermatic cord.  Once again, meticulous care was maintained not to involve any neurovascular or contents of the testis or vas deferens.  Weitlaner retractor was placed to provide further exposure.  There was a small vein encountered posterior to the testis and this was then hemostated into place and cut with Metzenbaum scissors and doubly ligated with #3-0 Vicryl.  Again hemostasis was maintained with ligation and Bovie electrocautery with adequate mobilization of the spermatic cord and testis.  Next, bluntly a tunnel was created through the subcutaneous tissue into the left empty scrotal compartment.  This was taken down to approximately the two-thirds length of the left scrotal compartment.  Once this tunnel has been created, a #15 blade scalpel was then used to make transverse incision.  A skin incision through the scrotal skin and once again the skin edges were grasped with Allis forceps and the dartos was then entered with the Bovie electrocautery exposing the scrotal compartment.  Once this was achieved, the apices of the dartos were then grasped with hemostats and supra-dartos pouch was then created using the Iris scissors.  A dartos pouch was created between the skin and the supra-dartos, both cephalad and caudad to the level of the scrotal incision.  A hemostat was then placed from inferior to superior through the created tunnel and the testis was pulled through the created supra-dartos pouch ensuring that anatomic position was in place, maintaining the epididymis posterolateral without any rotation of the cord.  With this accomplished, #3-0 Prolene was then used to tack both the medial and lateral aspects of the testis to the remaining dartos into the tunica vaginalis.  The sutures were then tied creating the orchiopexy.  The remaining body of the testicle was then tucked into the supra-dartos pouch and the skin was then approximated with #4-0 undyed Monocryl in a horizontal mattress fashion interrupted sutures.  Once again hemostasis was maintained with Bovie electrocautery.  Finally the attention was made towards the inguinal incision and this was then copiously irrigated and any remaining bleeders were then fulgurated with Bovie electrocautery to make sure to avoid any neurovascular spermatic structures.  External ring was then recreated and grasped on each side with hemostats and approximated with #3-0 Vicryl in a running fashion cephalad to caudad.  Once this was created, the created ring was inspected and there was adequate room for the cord.  There appeared to be no evidence of compression.  Finally, subcutaneous layer with sutures of #4-0 interrupted chromic was placed and then the skin was then closed with #4-0 undyed Vicryl in a running subcuticular fashion.  The patient had been injected with bupivacaine prior to closing the skin.  Finally, the patient was cleansed.,The scrotal support was placed and plan will the for the patient to take Keflex one tablet q.i.d. x7 days as well as Tylenol #3 for severe pain and Motrin for moderate pain as well as applying ice packs to scrotum.  He will follow up with Dr. X in 10 to 14 days.  Appointment will be made.", Surgery,38
"EXAM: , Dobutamine Stress Test.,INDICATION: , Chest pain.,TYPE OF TEST: , Dobutamine stress test, as the patient was unable to walk on a treadmill, and allergic to adenosine.,INTERPRETATION: , Resting heart rate of 66 and blood pressure of 88/45.  EKG, normal sinus rhythm.  Post dobutamine increment dose, his peak heart rate achieved was 125, which is 87% of the target heart rate.  Blood pressure 120/42.  EKG remained the same.  No symptoms were noted.,IMPRESSION:,1. Nondiagnostic dobutamine stress test.,2. Nuclear interpretation as below.,NUCLEAR INTERPRETATION: , Resting and stress images were obtained with 10.8, 30.2 mCi of tetrofosmin injected intravenously by standard protocol.  Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect.  Gated and SPECT revealed normal wall motion and ejection fraction of 75%.  End-diastolic volume was 57 and end-systolic volume of 12.,IMPRESSION:,1. Normal nuclear myocardial perfusion scan.,2. Ejection fraction of 75% by gated SPECT.", Radiology,33
"HISTORY: , The patient is scheduled for laparoscopic gastric bypass.  The patient has been earlier seen by Dr. X, her physician.  She has been referred to us from Family Practice.  In short, she is a 33-year-old lady with a BMI of 43, otherwise healthy with unsuccessful nonsurgical methods of weight loss. ,She was on laparoscopic gastric bypass for weight loss. ,She meets the National Institute of Health Criteria.  She is very well educated and motivated and has no major medical contraindications for the procedure.,PHYSICAL EXAMINATION:,  On physical examination today, she weighs 216 pounds with a BMI of 43.5, pulse is 96, temperature is 97.6, blood pressure is 122/80.  Lungs are clear.  Abdomen is soft, nontender.  There is stigmata for morbid obesity.  She has cesarean section scars in the lower abdomen with no herniation. ,DISCUSSION: , I had a long talk with the patient about laparoscopic gastric bypass, possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines.  I also explained to her complications including rare cases of death secondary to DVT, PE, leak , peritonitis, sepsis, shock, multisystem organ failure, need for re-operation including for leak or bleeding, gastrostomy or jejunostomy for feeding, rare case of respiratory failure requiring mechanical ventilation, etc., with myocardial infarction, pneumonia, atelectasis in the postoperative period were also discussed. ,Short-term complications of gastric bypass including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or anti-inflammatory drug intake which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which were discussed.  The patient would alert us for earlier intervention.  Symptomatic gallstone formation secondary to rapid weight loss were also discussed.  How to avoid it by taking ursodiol were also discussed.  Long-term complications of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, need for major lifestyle and exercise and habit changes, avoiding pregnancy in the first two years, etc., were all stressed.  The patient understands.  She wants to go to surgery. ,In preparation of surgery, she will undergo very low-calorie diet through Medifast to decrease the size of the liver to make laparoscopic approach more successful and also to optimize her cardiopulmonary and metabolic comorbidities.  She will also see a psychologist, nutritionist, and exercise physiologist for a multidisciplinary effort for short and long-term success for weight loss surgery.  I will see her two weeks before the plan of surgery for further discussion and any other questions at that point of time.", Consult - History and Phy.,5
"PROCEDURE:, Esophagogastroduodenoscopy with biopsy and snare polypectomy.,INDICATION FOR THE PROCEDURE:, Iron-deficiency anemia.,MEDICATIONS:, MAC.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, and aspiration.,PROCEDURE:, After informed consent and appropriate sedation, the upper endoscope was inserted into the oropharynx down into the stomach and beyond the pylorus and the second portion of the duodenum. The duodenal mucosa was completely normal. The pylorus was normal. In the stomach, there was evidence of diffuse atrophic-appearing nodular gastritis. Multiple biopsies were obtained. There also was a 1.5-cm adenomatous appearing polyp along the greater curvature at the junction of the body and antrum. There was mild ulceration on the tip of this polyp. It was decided to remove the polyp via snare polypectomy. Retroflexion was performed, and this revealed a small hiatal hernia in the distal esophagus. The Z-line was identified and was unremarkable. The esophageal mucosa was normal.,FINDINGS:,1. Hiatal hernia.,2. Diffuse nodular and atrophic appearing gastritis, biopsies taken.,3. A 1.5-cm polyp with ulceration along the greater curvature, removed.,RECOMMENDATIONS:,1. Follow up biopsies.,2. Continue PPI.,3. Hold Lovenox for 5 days.,4. Place SCDs.", Surgery,38
"CC:, Decreasing visual acuity.,HX: ,This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS, and is now blind in that eye. She denied any other symptomatology. Denied HA.,PMH:, 1) depression. 2) Blind OS,MEDS:, None.,SHX/FHX: ,unremarkable for cancer, CAD, aneurysm, MS, stroke. No h/o Tobacco or ETOH use.,EXAM:, T36.0, BP121/85, HR 94, RR16,MS: Alert and oriented to person, place and time. Speech fluent and unremarkable.,CN: Pale optic disks, OU. Visual acuity: 20/70 (OD) and able to detect only shadow of hand movement (OS). Pupils were pharmacologically dilated earlier. The rest of the CN exam was unremarkable.,MOTOR: 5/5 throughout with normal bulk and tone.,Sensory: no deficits to LT/PP/VIB/PROP.,Coord: FNF-RAM-HKS intact bilaterally.,Station: No pronator drift. Gait: ND,Reflexes: 3/3 BUE, 2/2 BLE. Plantar responses were flexor bilaterally.,Gen Exam: unremarkable. No carotid/cranial bruits.,COURSE:, CT Brain showed large, enhancing 4 x 4 x 3 cm suprasellar-sellar mass without surrounding edema. Differential dx: included craniopharyngioma, pituitary adenoma, and aneurysm. MRI Brain findings were consistent with an aneurysm. The patient underwent 3 vessel cerebral angiogram on 12/29/92. This clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery. Ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis. Emergent HCT showed no evidence of hemorrhage or sign of infarct. Emergent carotid duplex showed no significant stenosis or clot. The patient was left with an expressive aphasia and right hemiparesis. SPECT scans were obtained on 1/7/93 and 2/24/93. They revealed hypoperfusion in the distribution of the left MCA and decreased left basal-ganglia perfusion which may represent in part a mass effect from the LICA aneurysm. She was discharged home and returned and underwent placement of a Selverstone Clamp on 3/9/93. The clamp was gradually and finally closed by 3/14/93. She did well, and returned home. On 3/20/93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia. A HCT then showed SAH around her aneurysm, which had thrombosed. She was place on Nimodipine. Her clinical status improved; then on 3/25/93 she rapidly deteriorated over a 2 hour period to the point of lethargy, complete expressive aphasia, and right hemiplegia. An emergent HCT demonstrated a left ACA and left MCA infarction. She required intubation and worsened as cerebral edema developed. She was pronounced brain dead. Her organs were donated for transplant.", Radiology,33
"CHIEF COMPLAINT:,  Headache.,HPI: , This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan.  He was discharged home with a follow up to neurosurgery on the 14th.  Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery.  He has had headaches since the 13th and complains now of some worsening of his pain.  He denies photophobia, fever, vomiting, and weakness of the arms or legs.,PMH: , As above.,MEDS:,  Vicodin.,ALLERGIES:,  None.,PHYSICAL EXAM:  ,BP 180/110 Pulse 65 RR 18 Temp 97.5.,Mr. P is awake and alert, in no apparent distress.,HEENT:  Pupils equal, round, reactive to light, oropharynx moist, sclera clear.  ,Neck:  Supple, no meningismus.,Lungs:  Clear.,Heart:  Regular rate and rhythm, no murmur, gallop, or rub.  ,Abdomen:  Benign.,Neuro:  Awake and alert, motor strength normal, no numbness, normal gait, DTRs normal.  Cranial nerves normal.  ,COURSE IN THE ED:  ,Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus.  I recommended an LP but he prefers not to have this done.  He received morphine for pain and his headache improved.  I've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram.  He left the ED against my advice.  ,IMPRESSION: , Headache, improved.  Intracranial aneurysm.,PLAN: , The patient will return tomorrow am for his angiogram.", Emergency Room Reports,12
"PREOPERATIVE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Anemia.,3.  Symptomatic fibroid uterus.,POSTOPERATIVE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Anemia.,3.  Symptomatic fibroid uterus.,PROCEDURE: , Total abdominal hysterectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS: , 150 mL.,COMPLICATIONS: , None.,FINDING:  ,Large fibroid uterus.,PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the usual sterile fashion for an abdominal procedure.  A scalpel was used to make a Pfannenstiel skin incision, which was carried down sharply through the subcutaneous tissue to the fascia.  The fascia was nicked in the midline and incision was carried laterally bilaterally with curved Mayo scissors.  The fascia was then bluntly and sharply dissected free from the underlying rectus abdominis muscles.  The rectus abdominis muscles were then bluntly dissected in the midline and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel.  The peritoneum was then bluntly entered and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel.  The O'Connor-O'Sullivan instrument was then placed without difficulty.  The uterus was grasped with a thyroid clamp and the entire pelvis was then visualized without difficulty.  The GIA stapling instrument was then used to separate the infundibulopelvic ligament in a ligated fashion from the body of the uterus.  This was performed on the left infundibulopelvic ligament and the right infundibulopelvic ligament without difficulty.  Hemostasis was noted at this point of the procedure.  The bladder flap was then developed free from the uterus without difficulty.  Careful dissection of the uterus from the pedicle with the uterine arteries and cardinal ligaments was then performed using #1 chromic suture ligature in an interrupted fashion on the left and right side.  This was done without difficulty.  The uterine fundus was then separated from the uterine cervix without difficulty.  This specimen was sent to pathology for identification.  The cervix was then developed with careful dissection.  Jorgenson scissors were then used to remove the cervix from the vaginal cuff.  This was sent to pathology for identification.  Hemostasis was noted at this point of the procedure.  A #1 chromic suture ligature was then used in running fashion at the angles and along the cuff.  Hemostasis was again noted.  Figure-of-eight sutures were then used in an interrupted fashion to close the cuff.  Hemostasis was again noted.  The entire pelvis was washed.  Hemostasis was noted.  The peritoneum was then closed using 2-0 chromic suture ligature in running pursestring fashion.  The rectus abdominis muscles were approximated using #1 chromic suture ligature in an interrupted fashion.  The fascia was closed using 0 Vicryl in interlocking running fashion.  Foundation sutures were then placed in an interrupted fashion for further closing the fascia.  The skin was closed with staple gun.  Sponge and needle counts were noted to be correct x2 at the end of the procedure.  Instrument count was noted to be correct x2 at the end of the procedure.  Hemostasis was noted at each level of closure.  The patient tolerated the procedure well and went to recovery room in good condition.", Obstetrics / Gynecology,24
"PREOPERATIVE DIAGNOSIS: , Anemia.,PROCEDURE:,  Upper gastrointestinal endoscopy.,POSTOPERATIVE DIAGNOSES:,1.  Severe duodenitis.,2.  Gastroesophageal junction small ulceration seen.,3.  No major bleeding seen in the stomach.,PROCEDURE IN DETAIL: , The patient was put in left lateral position.  Olympus scope was inserted from the mouth, under direct visualization advanced to the upper part of the stomach, upper part of esophagus, middle of esophagus, GE junction, and some intermittent bleeding was seen at the GE junction.  Advanced into the upper part of the stomach into the antrum.  The duodenum showed extreme duodenitis and the scope was then brought back.  Retroflexion was performed, which was normal.  Scope was then brought back slowly.  Duodenitis was seen and a little bit of ulceration seen at GE junction.,FINDING: , Severe duodenitis, may be some source of bleeding from there, but no active bleeding at this time.", Surgery,38
"EXAM: , Cervical, lumbosacral, thoracic spine flexion and extension.,HISTORY: , Back and neck pain.,CERVICAL SPINE,FINDINGS:  ,AP, lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable.", Radiology,33
"HISTORY: , This child is seen for a sports physical.,NUTRITIONAL HISTORY:,  She takes meats, vegetables, and fruits.  Eats well.  Has may be 1 to 2 cups a day of milk.  Her calcium intake could be better.  She does not drink that much pop but she likes koolaid.  Her stools are normal.  Brushes her teeth.  Sees a dentist.,DEVELOPMENTAL HISTORY: , She did well in school last year.  Hearing and vision, no problems.  She wears corrective lenses.  She will be in 8th grade and involved in volleyball, basketball, and she will be moving to Texas.  She did go to Burton this last year.  She also plays clarinet, and will be involved also in cheerleading.  She likes to swim in the summer time.  Her menarche was January 2004.  It occurs every 7 weeks.  No particular problems at this time.,OTHER ACTIVITIES:  ,TV time about 2 to 3 hours a day.  She does not use drugs, alcohol, or smoke, and denies sexual activity.,MEDICATIONS:,  Advair 250/50 b.i.d., Flonase b.i.d., Allegra q.d.  120 mg, Xopenex and albuterol p.r.n.,ALLERGIES:,  No known drug allergies.,OBJECTIVE:,Vital Signs:  Blood pressure:  98/60.  Temperature:  96.6 tympanic.  Weight:  107 pounds, which places her at approximately the 60th percentile for weight and the height is about 80th percentile at 64-1/2 inches.  Her body mass index is 18.1, which is 40th percentile.  Pulse:  68.,HEENT:  Normocephalic.  Fundi benign.  Pupils are equal and reactive to light and accommodation.  Conjunctivae were non-injected.  Her pupils were equal, and reactive to light and accommodation.  No strabismus.  She wears glasses.  Her vision was 20/20 in both eyes.  TMs are bilaterally clear.  Nonerythematous.  Hearing in the ears, she was able to pass 40 decibel to 30 decibel.  With the right ear, she has some problems, but the left ear she passed.  Throat was clear.  Nonerythematous.  Good dentition.,Neck:  Supple.  Thyroid normal sized.  No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Respiratory:  Clear.  No wheezes and no crackles.  No tachypnea and no retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal.  No murmur.,Abdomen:  Soft.  No organomegaly and no masses.  No hepatosplenomegaly.,GU:  Normal female genitalia.  Tanner stage III in breast and pubic hair development and she was given a breast exam.  Negative for any masses.,Skin:  Without rash.,Extremities:  Deep tendon reflexes 2+/4+ bilaterally and equal.,Neurological:  Romberg negative.,Back:  No scoliosis.,She had good circumduction at the shoulder joints and duck walk is normal.,ASSESSMENT:,  Sports physical with normal growth and development.,PLAN:,  If problems continue, she will need to have her hearing rechecked.  Hopefully in the school, there will be a screening mat.  She received her first hepatitis A vaccine and she needs to have a booster in 6 to 12 months.  We reviewed her immunizations for tetanus and her last acellular DPT was 11/25/1996.  When she goes to Texas, Mom has an appointment already to see an allergist but she needs to find a primary care physician and we will ask for record release.  We talked about her menarche.  Recommended the exam of the breast regularly.  Talked about other anticipatory guidance including sunscreen, use of seat belts, and drugs, alcohol, and smoking, and sexual activity and avoidance at her age and to continue on her present medications.  She also has had problems with her ankles in the past.  She had no limitation here, but we gave her some ankle strengthening exercise handouts while she was in the office.", Pediatrics - Neonatal,29
"PREOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,POSTOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,ANESTHESIA:,  General.,PROCEDURE: , Excision of recurrent pyogenic granuloma.,INDICATIONS: , The patient is 12-year-old young lady, who has a hand-sized congenital vascular malformation on her left lateral thigh below the greater trochanter, which was described by her parents as a birthmark.  This congenital cutaneous vascular malformation faded substantially over the first years of her life and has regressed to a flat, slightly hyperpigmented lesion.  Although no isolated injury event can be recalled, the patient has developed a pyogenic granuloma next to the distal portion of this lesion on her mid thigh, and it has been treated with topical cautery in her primary care doctor's office, but with recurrence.  She is here today for excision.,OPERATIVE FINDINGS: , The patient had what appeared to be a classic pyogenic granuloma arising from this involuted vascular malformation.,DESCRIPTION OF OPERATION:  ,The patient came to the operating room, had an uneventful induction of general anesthesia.  We conducted a surgical time-out, reiterated her important and unique identifying information and confirmed that the excision of the left thigh pyogenic granuloma was the procedure planned for today.  Preparation and draping was __________ ensued with a chlorhexidine based prep solution.  The pyogenic granuloma was approximately 6 to 7 mm in greatest dimension and to remove it required creating an elliptical incision of about 1 to 1.2 cm.  This entire area was infiltrated with 0.25% Marcaine with dilute epinephrine to provide a wide local field block and then an elliptical incision was made with a #15 scalpel blade, excising the pyogenic granuloma, its base, and a small rim of surrounding normal skin.  Some of the abnormal vessels in the dermal and subdermal layer were cauterized with the needle-tip electrocautery pencil.  The wound was closed in layers with a deep dermal roll of 5-0 Monocryl stitches supplemented by 5-0 intradermal Monocryl and Steri-Strips for final skin closure.  The patient tolerated the procedure well.  This nodule was submitted to pathology for confirmation of its histology as a pyogenic granuloma.  Blood loss was less than 5 mL and there were no complications.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,OPERATION PERFORMED: , Thoracic right-sided discectomy at T8-T9.,BRIEF HISTORY AND INDICATION FOR OPERATION: , The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.  She has failed conservative measures and sought operative intervention for relief of her symptoms.  For details of workup, please see the dictated operative report.,DESCRIPTION OF OPERATION:  ,Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic.  She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected.  Second check was made prior to prepping and draping.  Following this, we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8-T9 level.  We then made an approach through a midline incision and came out over the pars.  We dissected down carefully to identify the pars.  We then went on the outside of the pars and identified the foramen and then we took another series of x-rays to confirm the T8-T9 level.  We did this under live fluoroscopy.  We confirmed T8-T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well.  We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars.  The pars was then drilled out.  We identified the disc even further and found the disc herniation material that was under the spinal cord.  We then took a combination of small pituitaries and removed the disc material without difficulty.  Once we had disc material out, we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further.  Once we had done that, we inspected up by the nerve root, found some more disc material there and removed that as well.  We could trace the nerve root out freely and easily.  We made sure there was no evidence of further disc material.  We used an Epstein curette and placed a nerve hook under the nerve root.  The Epstein curette removed some more disc material.  Once we had done this, we were satisfied with the decompression.  We irrigated the wound copiously to make sure there is no further disc material and then ready for closure.  We did place some steroid over the nerve root and readied for closure.  Hemostasis was meticulous.  The wound was closed with #1 Vicryl suture for the fascial layer, 2 Vicryl suture for the skin, and Monocryl and Steri-Strips applied.  Dressing was applied.  The patient was awoken from anesthesia and taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  150 mL.,COMPLICATIONS: , None.,DISPOSITION:,  To PACU in stable condition having tolerated the procedure well, to mobilize routinely when she is comfortable to go to her home.", Orthopedic,27
"CERVICAL FACET JOINT INJECTION WITH CONTRAST.,PREPROCEDURE PREPARATION:,  After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form. the patient was placed in the prone position and standard ASA monitors applied.  Intravenous access was established and IV sedation was used.  For further details of IV sedation and infusion, please refer to anesthesia notes.  Fluoroscopy was used to identify the appropriate anatomy and symptomatic facet joints.  The skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure.,PROCEDURE DETAILS:,  The patient was laid supine.  Appropriate view of facet joints was achieved by placing pillow below the shoulder and turning the head.  The neck was aseptically prepared.  1% lidocaine was used for local infiltration and subsequently a 25-gauge spinal needle was passed down to the C4-5 facet joint under fluoroscopic control.  Positioning was checked and 0.2 mL of dye was injected.  Acceptable dye pattern was seen.  Subsequent 1 mL of a mixture of 0.5 mL of 1% lidocaine and 0.5 mL of Celestone was injected after aspiration and the patient was monitored.  Needle was removed and same procedure carried out on the other side.  Postprocedure, no complications were noted.", Pain Management,28
"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.", Orthopedic,27
"PREOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,POSTOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,PROCEDURE PERFORMED: , YAG laser capsulotomy, right eye.,INDICATIONS: , This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane.  The patient is being brought in for YAG capsular discission.,PROCEDURE: , The patient was seated at the YAG laser, the pupil having been dilated with 1%  Mydriacyl, and Iopidine was instilled.  The Abraham capsulotomy lens was then positioned and applications of laser energy in the pattern indicated on the outpatient note were applied.  A total of", Ophthalmology,26
"PREOPERATIVE DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,FINAL DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,4.  Acute and chronic adenoiditis.,OPERATIONS PERFORMED,1.  Bilateral myringotomies.,2.  Placement of ventilating tubes.,3.  Nasal endoscopy.,4.  Adenoidectomy.,DESCRIPTION OF OPERATIONS: , The patient was brought to the operating room, endotracheal intubation carried out by Dr. X. Both sides of the patient's nose were then sprayed with Afrin.  Ears were inspected then with the operating microscope.  The anterior inferior quadrant myringotomy incisions were performed.  Then, a modest amount of serous and a trace of mucoid material encountered that was evacuated.  The middle ear mucosa looked remarkably clean.  Armstrong tubes were inserted.  Ciprodex drops were instilled.  Ciprodex will be planned for two postoperative days as well.  Nasal endoscopy was carried out, and evidence of acute purulent adenoiditis was evident in spite of the fact that clinically the patient has shown some modest improvement following cessation of all milk products.  The adenoids were shaved back, flushed with curette through a traditional transoral route with thick purulent material emanating from the crypts, and representative cultures were taken.  Additional adenoid tissue was shaved backwards with the RADenoid shaver.  Electrocautery was used to establish hemostasis, and repeat nasal endoscopy accomplished.  The patient still had residual evidence of inter choanal adenoid tissue, and video photos were taken.  That remaining material was resected, guided by the nasal endoscope using the RADenoid shaver to remove the material and flush with the posterior nasopharynx.  Electrocautery again used to establish hemostasis.  Bleeding was trivial.  Extensive irrigation accomplished.  No additional bleeding was evident.  The patient was awakened, extubated, taken to the recovery room in a stable condition.  Discharge anticipated later in the day on Augmentin 400 mg twice daily, Lortab or Tylenol p.r.n. for pain.  Office recheck would be anticipated if stable and doing well in approximately two weeks.  Parents were instructed to call, however, regarding the outcome of the culture on Monday next week to ensure adequate antibiotic coverage before cessation of the antibiotic.", Surgery,38
"PREOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,POSTOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,PROCEDURE PERFORMED:,1.  Evacuation of epidural hematoma.,2.  Insertion of epidural drain.,ANESTHESIA: , General.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,200 cc.,HISTORY:  ,This is a 64-year-old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction.  She was then transferred to Beaumont Hospital, at which point, she developed a sternal abscess.  The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren, Michigan at which point, she developed a second what was termed minor myocardial infarction.,The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later, brings us to the month of August, at which time she was at home ambulating with a walker or a cane, and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI, which showed record signal change.  The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery, but objectively there was not much improvement.  Approximately 10 days after the surgery, brings us to today's date, the health officer was notified of the patient's labored breathing.  When she examined the patient, she also noted that the patient was unable to move her extremities.  She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic.  I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma.  On clinical examination, there was swelling in the posterior aspect of the neck.  The patient has no active movement in the upper and lower extremity muscle groups.  Reflexes are absent in the upper and lower extremities.  Long track signs are absent.  Sensory level is at the C4 dermatome.  Rectal tone is absent.  I discussed the findings with the patient and also the daughter.  We discussed the possibility of this is permanent quadriplegia, but at this time, the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery.  They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery.,OPERATIVE PROCEDURE:  ,The patient was taken to OR #1 at ABCD General Hospital on a gurney.  Department of Anesthesia administered fiberoptic intubation and general anesthetic.  A Foley catheter was placed in the bladder.  The patient was log rolled in a prone position on the Jackson table.  Bony prominences were well padded.  The patient's head was placed in the prone view anesthesia head holder.  At this point, the wound was examined closely and there was hematoma at the caudal pole of the wound.  Next, the patient was prepped and draped in the usual sterile fashion.  The previous skin incision was reopened.  At this point, hematoma properly exits from the wound.  All sutures were removed and the epidural spaces were encountered at this time.  The self-retaining retractors were placed in the depth of the wound.  Consolidated hematoma was now removed from the wound.  Next, the epidural space was encountered.  There was no additional hematoma in the epidural space or on the thecal sac.  A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac.  The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well.  Next, the wound was irrigated copiously with one liter of saline using a syringe.  The walls of the wound were explored.  There was no active bleeding.  Retractors were removed at this time and even without pressure on the musculature, there was no active bleeding.  A #19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space.  Fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissue with #3-0 Vicryl sutures.  Steri-Strips covered the incision and dressing was then applied over the incision.  The patient was then log rolled in the supine position on the hospital gurney.  She remained intubated for airway precautions and transferred to the recovery room in stable condition.  Once in the recovery room, she was alert.  She was following simple commands and using her head to nod, but she did not have any active movement of her upper or lower extremities.  Prognosis for this patient is guarded.", Neurology,22
"CHIEF COMPLAINT: , Left flank pain and unable to urinate.,HISTORY: , The patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating.  Details are in the history and physical.  She does have a vague history of a bruised left kidney in a motor vehicle accident.  She feels much better today.  I was consulted by Dr. X.,MEDICATIONS:,  Ritalin 50 a day.,ALLERGIES: , To penicillin.,PAST MEDICAL HISTORY: , ADHD.,SOCIAL HISTORY:,  No smoking, alcohol, or drug abuse.,PHYSICAL EXAMINATION: , She is awake, alert, and quite comfortable.  Abdomen is benign.  She points to her left flank, where she was feeling the pain.,DIAGNOSTIC DATA: , Her CAT scan showed a focal ileus in left upper quadrant, but no thickening, no obstruction, no free air, normal appendix, and no kidney stones.,LABORATORY WORK: , Showed white count 6200, hematocrit 44.7.  Liver function tests and amylase were normal.  Urinalysis 3+ bacteria.,IMPRESSION:,1.  Left flank pain, question etiology.,2.  No evidence of surgical pathology.,3.  Rule out urinary tract infection.,PLAN:,1.  No further intervention from my point of view.,2.  Agree with discharge and followup as an outpatient.  Further intervention will depend on how she does clinically.  She fully understood and agreed.", General Medicine,15
"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.,", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,POSTOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,PROCEDURE:  ,Thoracentesis, left.,DESCRIPTION OF PROCEDURE: , The patient was brought to the recovery area of the operating room.  After obtaining the informed consent, the patient's posterior left chest wall was prepped and draped in usual fashion.  Xylocaine 1% was infiltrated above the seventh intercostal space in the midscapular line.  Initially, I tried to use the thoracentesis set after 1% Xylocaine had been infiltrated, but the needle of the system was just too short to reach the pleural cavity due to the patient's very thick chest wall.  Therefore, I had to use a #18 spinal needle, which I had to use almost in its entire length to reach the fluid.  From then on, I proceeded manually to withdraw 2000 mL of a light milky fluid.,The patient tolerated the procedure fairly well, but almost at the end of it she said that she was feeling like fainting and therefore we carefully withdrew the needle.  At that time, it was getting difficult to withdraw fluid anyway and we allowed her to lie down and after a few minutes the patient was feeling fine.  At any rate, we gave her bolus of 250 mL of normal saline and the patient returned to her room for additional hours of observation.  We then thought that if she was doing fine, then we will send her home.,A chest x-ray was performed after the procedure which showed a dramatic reduction of the amount of pleural fluid and then there was no pneumothorax or no other obvious complications of her procedure.,", Surgery,38
"FINDINGS:,Normal foramen magnum.,Normal brainstem-cervical cord junction. There is no tonsillar ectopia. Normal clivus and craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: There is disc desiccation but no loss of disc space height, disc displacement, endplate spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina.,C3-4: There is disc desiccation with a posterior central disc herniation of the protrusion type. The small posterior central disc protrusion measures 3 x 6mm (AP x transverse) in size and is producing ventral thecal sac flattening. CSF remains present surrounding the cord. The residual AP diameter of the central canal measures 9mm. There is minimal right-sided uncovertebral joint arthrosis but no substantial foraminal compromise.,C4-5: There is disc desiccation, slight loss of disc space height with a right posterior lateral pre-foraminal disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis. The disc osteophyte complex measures approximately 5mm in its AP dimension. There is minimal posterior annular bulging measuring approximately 2mm. The AP diameter of the central canal has been narrowed to 9mm. CSF remains present surrounding the cord. There is probable radicular impingement upon the exiting right C5 nerve root.,C5-6: There is disc desiccation, moderate loss of disc space height with a posterior central disc herniation of the protrusion type. The disc protrusion measures approximately 3 x 8mm (AP x transverse) in size. There is ventral thecal sac flattening with effacement of the circumferential CSF cleft. The residual AP diameter of the central canal has been narrowed to 7mm. Findings indicate a loss of the functional reserve of the central canal but there is no cord edema. There is bilateral uncovertebral and apophyseal joint arthrosis with moderate foraminal compromise.,C6-7: There is disc desiccation, mild loss of disc space height with 2mm of posterior annular bulging. There is bilateral uncovertebral and apophyseal joint arthrosis (left greater than right) with probable radicular impingement upon the bilateral exiting C7 nerve roots.,C7-T1, T1-2: There is disc desiccation with no disc displacement. Normal central canal and intervertebral neural foramina.,T3-4: There is disc desiccation with minimal 2mm posterior annular bulging but normal central canal and CSF surrounding the cord.,IMPRESSION:,Multilevel degenerative disc disease with uncovertebral joint arthrosis with foraminal compromise as described above.,C3-4 posterior central disc herniation of the protrusion type but no cord impingement.,C4-5 right posterior lateral disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis with probable radicular impingement upon the right C5 nerve root.,C5-6 degenerative disc disease with a posterior central disc herniation of the protrusion type producing borderline central canal stenosis with effacement of the circumferential CSF cleft indicating a limited functional reserve of the central canal.,C6-7 degenerative disc disease with annular bulging and osseous foraminal compromise with probable impingement upon the bilateral exiting C7 nerve roots.,T3-4 degenerative disc disease with posterior annular bulging.", Neurology,22
"PREOPERATIVE DIAGNOSIS: ,Degenerative arthritis of the left knee.,POSTOPERATIVE DIAGNOSIS:, Degenerative arthritis of the left knee.,PROCEDURE PERFORMED: , Total left knee replacement on 08/19/03.  The patient also underwent a bilateral right total knee replacement in the same sitting and that will be dictated by Dr. X.,TOURNIQUET TIME: , 76 minutes.,BLOOD LOSS: , 150 cc.,ANESTHESIA:  ,General.,IMPLANT USED FOR PROCEDURE:,  NexGen size F femur on the left with #8 size peg tibial tray, a #12 mm polyethylene insert and this a cruciate retaining component.  The patella on the left was not resurfaced.,GROSS INTRAOPERATIVE FINDINGS: , Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau.  The surface of the patella was with a minimal ware and minimal osteophytes and we decided not to resurface the patellar component.,HISTORY:  ,This is a 69-year-old male with complaints of bilateral knee pain for several years and increased intensity in the past several months where it has affected his activities of daily living.  He attempted conservative treatment, which includes anti-inflammatory medications as well as cortisone and Synvisc.  This has only provided him with temporary relief.  It is for that reason, he is elected to undergo the above-named procedure.,All risks as well as complications were discussed with the patient, which include, but are not limited to infection, deep vein thrombosis, pulmonary embolism, need for further surgery, and further pain.  He has agreed to undergo this procedure and a consent was obtained preoperatively.,PROCEDURE: , The patient was wheeled back to operating room #2 at ABCD General Hospital on 08/19/03 and was placed supine on the operating room table.  At this time, a nonsterile tourniquet was placed on the left upper thigh, but not inflated.  An Esmarch was then used to exsanguinate the extremity and the left extremity was then prepped and draped in the usual sterile fashion for this procedure.  The tourniquet was then inflated to 325 mmHg.  At this time, a standard midline incision was made towards the total knee.  We did discuss preoperatively for a possible unicompartmental knee replacement for this patient, but he did have radiographic evidence of chondrocalcinosis of the lateral meniscus.  We did start off with a small midline skin incision in case we were going to do a unicompartmental.  Once we exposed the medial parapatellar mini-arthrotomy and visualized the lateral femoral condyle, we decided that this patient would not be an optimal candidate for unicompartmental knee replacement.  It is for this reason that we extended the incision and underwent with the total knee replacement.  Once the full medial parapatellar arthrotomy was performed with the subperiosteal dissection of the proximal tibia in order to evert the patella.  Once the patella was everted, we then used a drill to cannulate the distal femoral canal in order to place the intramedullary guide.  A Charnley awl was then used to remove all the intramedullary contents and they were removed from the knee.  At this time, a femoral sizer was then placed with reference to the posterior condyles and we measured a size F. Once this was performed, three degrees of external rotation was then drilled into the condyle in alignment with the epicondyles of the femur.  At this time, the intramedullary guide was then inserted and placed in three degrees of external rotation.  Our anterior cutting guide was then placed and an anterior cut was performed with careful protection of the soft tissues.  Next, this was removed and the distal femoral cutting guide was then placed in five degrees of valgus.  This was pinned to the distal femur and with careful protection of the collateral ligaments, a distal femoral cut was performed.  At this time, the intramedullary guide was removed and a final cutting block was placed.  This was placed in the center on the distal femur with 1 mm to 2 mm laterally translated for better patellar tracking.  At this time, the block was pinned and screwed in place with spring pins with careful protection of the soft tissues.  An oscillating saw was then used to resect the posterior and anterior cutting blocks with anterior and posterior chamfer as well as the notch cut.  Peg holes were then drilled.,The block was then removed and an osteotome was then used to remove all the bony cut pieces.  At this time with a better exposure of the proximal tibia, we placed external tibial guide.  This was placed with longitudinal axis of the tibia and carefully positioned in order to obtain an optimal cut for the proximal tibia.  At this time with careful soft tissue retraction and protection, an oscillating saw was used to make a proximal tibial osteotomy.  Prior to the osteotomy, the cut was checked with a depth gauge in order to assure appropriate bony resection.  At this time, a _blunt Kocher and Bovie cautery were used to remove the proximal tibial cut, which had soft tissue attachments.  Once this was removed, we then implanted our trial components of size F to the femur and a size 8 mm tibial tray with 12 mm plastic articulating surface.  The knee was taken through range of motion and revealed excellent femorotibial articulation.  The patella did tend to sublux somewhat laterally with extremes of flexion and it was for this reason, we performed a minimal small incision lateral retinacular release.  Distal lateral patella was tracked more uniformly within the patellar groove of the prosthesis.  At this time, an intraoperative x-ray was performed, which revealed excellent alignment with no varus angulation especially of the whole femur and tibial alignment and tibial cut.  At this time, the prosthesis was removed.  A McGill retractor was then reinserted and replaced peg tibial tray in order to peg the proximal tibia.  Once the drill holes were performed, we then copiously irrigated the wound and then suctioned it dry to get ready and prepped for cementation of the drilled components.  At this time, polymethyl methacrylate cement was then mixed.  The cement was placed on the tibial surface as well as the underneath surface of the component.  The component was then placed and impacted with excess cement removed.  In a similar fashion, the femoral component was also placed.  A 12 mm plastic tray was then placed and the leg held in full extension and compression in order to obtain adequate bony cement content.  Once the cement was fully hardened, the knee was flexed and a small osteotome was used to remove any extruding cement from around the prosthesis of the bone.  Once this was performed, copious irrigation was used to irrigate the wound and the wound was then suctioned dry.  The knee was again taken through range of motion with a 12 mm plastic as well as #14.  The #14 appeared to be a bit too tight especially in extremes of flexion.  We decided to go with a #12 mm polyethylene tray.  At this time, this was placed to the tibial articulation and then left in place.  This was rechecked with careful attention to detail with checking no soft tissue interpositioned between the polyethylene tray and the metal tray of the tibia.  The knee was again taken through range of motion and revealed excellent tracking of the patella with good femur and tibial contact.  A drain was placed and cut to length.,At this time, the knee was irrigated and copiously suction dried.  #1-0 Ethibond suture was then used to approximate the medial parapatellar arthrotomy in figure-of-eight fashion.  A tight capsular closure was performed.  This was reinforced with a #1-0 running Vicryl suture.  At this time, the knee was again taken through range of motion to assure tight capsular closure.  At this time, copious irrigation was used to irrigate the superficial wound.  #2-0 Vicryl was used to approximate the wound with figure-of-eight inverted suture.  The skin was then approximated with staples.  The leg was then cleansed.  Sterile dressing consisting of Adaptic, 4x4, ABDs, and Kerlix roll were then applied.  At this time, the patient was extubated and transferred to recovery in stable condition.  Prognosis is good for this patient.", Surgery,38
"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.", Gastroenterology,14
"PREOPERATIVE DIAGNOSIS: , Sebaceous cyst, right lateral eyebrow.,POSTOPERATIVE DIAGNOSIS:,  Sebaceous cyst, right lateral eyebrow.,PROCEDURE PERFORMED: , Excision of sebaceous cyst, right lateral eyebrow.,ASSISTANT: , None.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE: , Stable.  Transferred to the recovery room.,INDICATIONS FOR PROCEDURE: , The patient is a 4-year-old with a history of sebaceous cyst.  The patient is undergoing PE tubes by Dr. X and I was asked to remove the cyst on the right lateral eyebrow.  I saw the patient in my clinic.  I explained to the mother in Spanish the risk and benefits.  Risk included but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgery.  We will proceed with the surgery.,PROCEDURE IN DETAIL: , The patient was taken into the operating room, placed in the supine position.  General anesthetic was administered.  A prophylactic dose of antibiotic was given.  The patient was prepped and draped in a usual manner.  The procedure began by infiltrating lidocaine with epinephrine around the cyst area.  Then, I proceeded with the help of a 15C blade to make an incision and remove a small wedge of tissue that includes a comedo point.  The incision was done superiorly then inferiorly to a full thickness and to the skin down to the cyst.  The cyst was detached of the surrounding structure with the help of blunt dissection.  Hemostasis was achieved with electrocautery.  The wound was closed with 5-0 Vicryl deep dermal interrupted stitches and Dermabond.  The patient tolerated the procedure well without complications and transferred to recovery room in stable condition.  I was present and participated in all aspects of the procedure.  Sponge, needle, and instrument counts were completed at the end of the procedure.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  Right superior parathyroid adenoma.,POSTOPERATIVE DIAGNOSIS:,  Right superior parathyroid adenoma.,PROCEDURE: , Excision of right superior parathyroid adenoma.,ANESTHESIA:,  Local with 1% Xylocaine and anesthesia standby with sedation.,CLINICAL HISTORY:,  This 80-year-old woman has had some mild dementia.  She was begun on Aricept but could not tolerate that because of strange thoughts and hallucinations.  She was found to be hypercalcemic.  Intact PTH was mildly elevated.  A sestamibi parathyroid scan and an ultrasound showed evidence of a right superior parathyroid adenoma.,FINDINGS AND PROCEDURE:,  The patient was placed on the operating table in the supine position.  A time out was taken so that the anesthesia personnel, nursing personnel, surgical team, and patient could confirm the patient's identity, operative site and operative plan.  The electronic medical record was reviewed as was the ultrasound.  The patient was sedated.  A small roll was placed behind the shoulders to moderately hyperextend the neck.  The head was supported in a foam head cradle.  The neck and chest were prepped with chlorhexidine and isolated with sterile drapes.  After infiltration with 1% Xylocaine with epinephrine along the planned incision, a transverse incision was made in the skin crease a couple of centimeters above the clavicular heads and carried down through the skin, subcutaneous tissue, and platysma.  The larger anterior neck veins were divided between 4-0 silk ligatures.  Superior and inferior flaps were developed in the subplatysmal plane using electrocautery and blunt dissection.  The sternohyoid muscles were separated in the midline, and the right sternohyoid muscle was retracted laterally.  The right sternothyroid muscle was divided transversely with the cautery.  The right middle thyroid vein was divided between 4-0 silk ligatures.  The right thyroid lobe was rotated leftward.  Posterior to the mid portion of the left thyroid lobe, a right superior parathyroid adenoma of moderate size was identified.  This was freed up and its pedicle was ligated with small Hemoclips and divided and the gland was removed.  It was sent for weight and frozen section.  It weighed 960 mg and on frozen section was consistent with a parathyroid adenoma.,Prior to the procedure, a peripheral blood sample had been obtained and placed in a purple top tube labeled ""pre-excision.""  It was our intention to monitor intraoperative intact parathyroid hormone 10 minutes after removal of this parathyroid adenoma.  However, we could not obtain 3 cc of blood from either the left foot or the left arm after multiple attempts, and therefore, we decided that the chance of cure of hyperparathyroidism by removal of this parathyroid adenoma was high enough and the improvement in that chance of cure marginal enough that we would terminate the procedure without monitoring PTH.  The neck was irrigated with saline and hemostasis found to be satisfactory.  The sternohyoid muscles were reapproximated with interrupted 4-0 Vicryl.  The platysma was closed with interrupted 4-0 Vicryl, and the skin was closed with subcuticular 5-0 Monocryl and Dermabond.  The patient was awakened and taken to the recovery area in satisfactory condition having tolerated the procedure well.", Surgery,38
"The patient presented in the early morning hours of February 12, 2007, with contractions.  The patient was found to be in false versus early labor and managed as an outpatient.  The patient returned to labor and delivery approximately 12 hours later with regular painful contractions.  There was minimal cervical dilation, but 80% effacement by nurse examination.  The patient was admitted.  Expected management was utilized initially.  Stadol was used for analgesia.  Examination did not reveal vulvar lesions.  Epidural was administered.  Membranes ruptured spontaneously.  Cervical dilation progressed.  Acceleration-deceleration complexes were seen.  Overall, fetal heart tones remained reassuring during the progress of labor.  The patient was allowed to ""labor down"" during second stage.  Early decelerations were seen as well as acceleration-deceleration complexes.  Overall, fetal heart tones were reassuring.  Good maternal pushing effort produced progressive descent.,Spontaneous controlled sterile vaginal delivery was performed without episiotomy and accomplished without difficulty.  Fetal arm was wrapped at the level of the neck with the fetal hand and also at the level of the neck.  There was no loop or coil of cord.  Infant was vigorous female sex.  Oropharynx was aggressively aspirated.  Cord blood was obtained.  Placenta delivered spontaneously.,Following delivery, uterus was explored without findings of significant tissue.  Examination of the cervix did not reveal lacerations.  Upper vaginal lacerations were not seen.  Multiple first-degree lacerations were present.  Specific locations included the vestibula at 5 o'clock, left labia minora with short extension up the left sulcus, right anterior labia minora at the vestibule, and midline of the vestibule.  All mucosal lacerations were reapproximated with interrupted simple sutures of 4-0 Vicryl with the knots being buried.  Post-approximation examination of the rectum showed smooth, intact mucosa.  Blood loss with the delivery was 400 mL.,Plans for postpartum care include routine postpartum orders.  Nursing personnel will be notified of Gilbert's syndrome.", Obstetrics / Gynecology,24
"PREOPERATIVE DIAGNOSIS: , Fracture dislocation, C2.,POSTOPERATIVE DIAGNOSIS:  ,Fracture dislocation, C2.,OPERATION PERFORMED,1.  Open reduction and internal fixation (ORIF) of comminuted C2 fracture.,2.  Posterior spinal instrumentation C1-C3, using Synthes system.,3.  Posterior cervical fusion C1-C3.,4.  Insertion of morselized allograft at C1to C3.,ANESTHESIA:,  GETA.,ESTIMATED BLOOD LOSS:,  100 mL.,COMPLICATIONS: , None.,DRAINS: , Hemovac x1.,Spinal cord monitoring is stable throughout the entire case.,DISPOSITION:,  Vital signs are stable, extubated and taken back to the ICU in a satisfactory and stable condition.,INDICATIONS FOR OPERATION:,  The patient is a middle-aged female, who has had a significantly displaced C2 comminuted fracture.  This is secondary to a motor vehicle accident and it was translated appropriately 1 cm.  Risks and benefits have been conferred with the patient as well as the family, they wish to proceed.  The patient was taken to the operating room for a C1-C3 posterior cervical fusion, instrumentation, open reduction and internal fixation.,OPERATION IN DETAIL: , After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #5.  The patient was placed in the usual supine position and intubated and under general anesthesia without any difficulties.  Spinal cord monitoring was induced.  No changes were seen from the beginning to the end of the case.,Mayfield tongues were placed appropriately.  This was placed in line with the pinna of the ear as well as a cm above the tip of the earlobes.  The patient was subsequently rolled onto the fluoroscopic OSI table in the usual prone position with chest rolls.  The patient's Mayfield tongue was fixated in the usual standard fashion.  The patient was subsequently prepped and draped in the usual sterile fashion.  Midline incision was extended from the base of the skull down to the C4 spinous process.  Full thickness skin fascia developed.  The fascia was incised at midline and the posterior elements at C1, C2, C3, as well as the inferior aspect of the occiput was exposed.  Intraoperative x-ray confirmed the level to be C2.,Translaminar screws were placed at C2 bilaterally.  Trajectory was completed with a hand drill and sounded in all four quadrants to make sure there was no violation of pedicles and once this was done, two 3.5 mm translaminar screws were placed bilaterally at C2.  Good placement was seen both in the AP and lateral planes using fluoroscopy.  Facet screws were then placed at C3.  Using standard technique of Magerl, starting in the inferomedial quadrant 14 mm trajectories in the 25-degree caudad-cephalad direction as well as 25 degrees in the medial lateral direction was made.  This was subsequently sounded in all four quadrants to make sure that there is no elevation of the trajectory.  A 14 x 3.5 mm screws were then placed appropriately.  Lateral masteries at C1 endplate were placed appropriately.  The medial and lateral borders were demarcated with a Penfield.  The great occipital nerve was retracted out the way.  Starting point was made with a high-speed power bur and midline and lateral mass bilaterally.  Using a 20-degree caudad-cephalad trajectory as well as 10-degree lateral-to-medial direction, the trajectory was completed in 8 mm increments, this was subsequently sounded in all four quadrants to make sure that there was no violation of the pedicle wall of the trajectory.  Once this was done, 24 x 3.5 mm smooth Schanz screws were placed appropriately.  Precontoured titanium rods were then placed between the screws at the C1, C2, C3 and casts were placed appropriately.  Once this was done, all end caps were appropriately torqued.  This completed the open reduction and internal fixation of the C2 fracture, which showed perfect alignment.  It must be noted that the reduction was partially performed on the table using lateral fluoroscopy prior to the instrumentation, almost reducing the posterior vertebral margin of the odontoid fracture with the base of the C2 access.  Once the screws were torqued bilaterally, good alignment was seen both in the AP and lateral planes using fluoroscopy, this completed instrumentation as well as open reduction and internal fixation of C2.  The cervical fusion was completed by decorticating the posterior elements of C1, C2, and C3.  Once this was done, the morselized allograft 30 mL of cortical cancellous bone chips with 10 mL of demineralized bone matrix was placed over the decorticated elements.  The fascia was closed using interrupted #1 Vicryl suture figure-of-8.  Superficial drain was placed appropriately.  Good alignment of the instrumentation as well as of the fracture was seen both in the AP and lateral planes.  The subcutaneous tissues were closed using a #2-0 Vicryl suture.  The dermal edges were approximated using staples.  The wound was then dressed sterilely using Bacitracin ointment, Xeroform, 4x4s, and tape, and the drain was connected appropriately.  The patient was subsequently released with a Mayfield contraption and rolled on to the stretcher in the usual supine position.  Mayfield tongues were subsequently released.  No significant bleeding was appreciated.  The patient was subsequently extubated uneventfully and taken back to the recovery room in satisfactory and stable condition.  No complications arose.", Orthopedic,27
"PREOPERATIVE DIAGNOSIS:  ,Right ureteropelvic junction obstruction.,POSTOPERATIVE DIAGNOSES:,1.  Right ureteropelvic junction obstruction.,2.  Severe intraabdominal adhesions.,3.  Retroperitoneal fibrosis.,PROCEDURES PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Attempted laparoscopic pyeloplasty.,3.  Open laparoscopic pyeloplasty.,ANESTHESIA:,  General.,INDICATION FOR PROCEDURE:  ,This is a 62-year-old female with a history of right ureteropelvic junction obstruction with chronic indwelling double-J ureteral stent.  The patient presents for laparoscopic pyeloplasty.,PROCEDURE: , After informed consent was obtained, the patient was taken to the operative suite and administered general anesthetic.  The patient was sterilely prepped and draped in the supine fashion after building up the right side of the OR table to aid in the patient's positioning for bowel retraction.  Hassan technique was performed for the initial trocar placement in the periumbilical region.  Abdominal insufflation was performed.  There were significant adhesions noted.  A second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a Harmonic scalpel was placed through this and adhesiolysis was performed for approximately two-and-half hours, also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus, an additional 5 mm port in the right upper quadrant subcostal and midclavicular.  After adhesions were taken down, the ascending colon was mobilized by incising the white line of Toldt and mobilizing this medially.  The kidney was able to be palpated within Gerota's fascia.  The psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter.  The uterus was grasped with a Babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction.  The renal pelvis was also identified and dissected free.  There was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes.  We were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open.  An incision was made from the right upper quadrant port extending towards the midline.  This was carried down through the subcutaneous tissue, anterior fascia, muscle layers, posterior fascia, and peritoneum.  A Bookwalter retractor was placed.  The renal pelvis and the ureter were again identified.  Fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and Bovie cautery.  The tissue was sent down to Pathology for analysis.  Please note that upon entering the abdomen, all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted.  Ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place.  The renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue.  At this point, the indwelling double-J ureteral stent was removed.  At this time, the ureter was spatulated laterally and at the apex of this spatulation a #4-0 Vicryl suture was placed.  This was brought up to the deepened portion of the pyelotomy and cystic structures were approximated.  The back wall of the ureteropelvic anastomosis was then approximated with running #4-0 Vicryl suture.  At this point, a double-J stent was placed with a guidewire down into the bladder.  The anterior wall of the uteropelvic anastomosis was then closed again with a #4-0 running Vicryl suture.  Renal sinus fat was then placed around the anastomosis and sutured in place.  Please note in the inferior pole of the kidney, there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue.  This was repaired with horizontal mattress sutures #2-0 Vicryl.  FloSeal was placed over this and the renal capsule was placed over this.  A good hemostasis was noted.  A #10 Blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis.  The initial trocar incision was closed with #0 Vicryl suture.  The abdominal incision was also then closed with running #0 Vicryl suture incorporating all layers of muscle and fascia.  The Scarpa's fascia was then closed with interrupted #3-0 Vicryl suture.  The skin edges were then closed with staples.  Please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator.  We placed the patient on IV antibiotics and pain medications.  We will obtain KUB and x-rays for stent placement.  Further recommendations to follow.", Urology,39
"EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months. Received for second opinion. Study performed on 10/04/05.,FINDINGS:,The patient was scanned in a 1.5 Tesla magnet.,There is a flat undersurface of the acromion (Type I) morphology, with anterior downsloping orientation.,There is inflammation of the anterior rotator interval capsule with peritendinous edema involving the intracapsular long biceps tendon best appreciated on the (axial gradient echo T2 series #3 images #6-9). There is edema with thickening of the superior glenohumeral ligament (axial T2 series #3 image #7). There is flattening of the long biceps tendon as it enters the bicipital groove (axial T2 series #3 image #9-10), but no subluxation. The findings suggest early changes of a “hidden” lesion.,Normal biceps labral complex and superior labrum, and there is no demonstrated superior labral tear.,There is minimal tendinitis with intratendinous edema of the insertion of the subscapularis tendon (axial T2 series #3 image #10). There is minimal fluid within the glenohumeral joint capsule within normal physiologic volume limits.,Normal anterior and posterior glenoid labra.,Normal supraspinatus, infraspinatus, and teres minor tendons.,Normal muscles of the rotator cuff and there is no muscular atrophy.,There is minimal fluid loculated within the labral ligamentous capsular complex along the posterior-superior labrum (sagittal T2 series #7 image #5; coronal T2 series #5 image #7), but there is no demonstrated posterior-superior labral tear or paralabral cyst or ganglion.,Normal acromioclavicular articulation.,IMPRESSION:,Inflammation of the anterior rotator interval capsule with interstitial edema of the superior glenohumeral ligament.,Flattening of the long biceps tendon as it enters the bicipital groove, but no subluxation. Findings suggest early changes of a hidden lesion.,Mild tendinitis of the distal insertion of the subscapularis tendon, but no tendon tear.,Normal supraspinatus, infraspinatus, and teres minor tendons and muscular complexes.,Type I morphology with an anterior downsloping orientation of the acromion, but no inferior acromial osteophyte.", Radiology,33
"CHIEF COMPLAINT:,  ""I took Ecstasy."",HISTORY OF PRESENT ILLNESS: , This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.  The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis.  Mother called the EMS service when the patient vomited.  On arrival here, the patient states that she no longer has any nausea and that she feels just fine.  The patient states she feels wired but has no other problems or complaints.  The patient denies any pain.  The patient does not have any auditory of visual hallucinations.  The patient denies any depression or suicidal ideation.  The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself.  The patient denies any homicidal ideation.  The patient denies any recent illness or recent injuries.  The mother states that the daughter appears to be back to her usual self now.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No recent illness.  No fever or chills.  HEENT:  No headache.  No neck pain.  No vision change or hearing change.  No eye or ear pain.  No rhinorrhea.  No sore throat.  CARDIOVASCULAR:  No chest pain.  No palpitations or racing heart.  RESPIRATIONS:  No shortness of breath.  No cough.  GASTROINTESTINAL: One episode of nonbloody, nonbilious emesis this morning without any nausea since then.  The patient denies any abdominal pain.  No change in bowel movements.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No dizziness, syncope, or near syncope.  PSYCHIATRIC:  The patient denies any depression, suicidal ideation, homicidal ideation, auditory hallucinations or visual hallucinations.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  None.,PAST SURGICAL HISTORY: , Appendectomy when she was 9 years old.,CURRENT MEDICATIONS: , Birth control pills.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies smoking cigarettes.  The patient does drink alcohol and also uses illicit drugs.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure 140/86, pulse is 79, respirations 16, oxygen saturation 100% on room air and is interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, and well developed, appears to be healthy.  The patient is calm and comfortable, in no acute distress and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctiva bilaterally.  The patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally.  No evidence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Ears are normal without any sign of infection.  Mouth and oropharynx are normal without any signs of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +3 and bounding.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, normal and benign.  MUSCULOSKELETAL:  No abnormalities noted in back, arms, or legs.  The patient is normal use of her extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact in all extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  The patient does not have any smell of alcohol and does not exhibit any clinical intoxication.  The patient is quite pleasant, fully cooperative.  HEMATOLOGIC/LYMPHATIC: NO lymphadenitis is noted.  No bruising is noted.,DIAGNOSES:,1.  ECSTASY INGESTION.,2.  ALCOHOL INGESTION.,3.  VOMITING SECONDARY TO STIMULANT ABUSE.,CONDITION UPON DISPOSITION: , Stable disposition to home with her mother.,PLAN:,  I will have the patient followup with her physician at the ABC Clinic in two days for reevaluation.  The patient was advised to stop drinking alcohol, and taking Ecstasy as this is not only in the interest of her health, but was also illegal.  The patient is asked to return to the emergency room should she have any worsening of her condition, develop any other problems or symptoms of concern.", Consult - History and Phy.,5
"ADMITTING DIAGNOSES,1.  Acute gastroenteritis.,2.  Nausea.,3.  Vomiting.,4.  Diarrhea.,5.  Gastrointestinal bleed.,6.  Dehydration.,DISCHARGE DIAGNOSES,1.  Acute gastroenteritis, resolved.,2.  Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.,BRIEF H&P AND HOSPITAL COURSE: , This patient is a 56-year-old male, a patient of Dr. X with 25-pack-year history, also a history of diabetes type 2, dyslipidemia, hypertension, hemorrhoids, chronic obstructive pulmonary disease, and a left lower lobe calcified granuloma that apparently is stable at this time.  This patient presented with periumbilical abdominal pain with nausea, vomiting, and diarrhea for the past 3 days and four to five watery bowel movements a day with symptoms progressively getting worse.  The patient was admitted into the ER and had trop x1 done, which was negative and ECG showed to be of normal sinus rhythm.,Lab findings initially presented with a hemoglobin of 13.1, hematocrit of 38.6 with no elevation of white count.  Upon discharge, his hemoglobin and hematocrit stayed at 10.9 and 31.3 and he was still having stool guaiac positive blood, and a stool study was done which showed few white blood cells, negative for Clostridium difficile and moderate amount of occult blood and moderate amount of RBCs.  The patient's nausea, vomiting, and diarrhea did resolve during his hospital course.  Was placed on IV fluids initially and on hospital day #2 fluids were discontinued and was started on clear liquid diet and diet was advanced slowly, and the patient was able to tolerate p.o. well.  The patient also denied any abdominal pain upon day of discharge.  The patient was also started on prednisone as per GI recommendations.  He was started on 60 mg p.o.  Amylase and lipase were also done which were normal and LDH and CRP was also done which are also normal and LFTs were done which were also normal as well.,PLAN: , The plan is to discharge the patient home.  He can resume his home medications of Prandin, Actos, Lipitor, Glucophage, Benicar, and Advair.  We will also start him on a tapered dose of prednisone for 4 weeks.  We will start him on 15 mg p.o. for seven days.  Then, week #2, we will start him on 40 mg for 1 week.  Then, week #3, we will start him on 30 mg for 1 week, and then, 20 mg for 1 week, and then finally we will stop.  He was instructed to take tapered dose of prednisone for 4 weeks as per the GI recommendations.", Discharge Summary,10
"EXAM: , CT of the abdomen and pelvis without contrast.,HISTORY: , Lower abdominal pain.,FINDINGS:,  Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis.  There is a 1.6 cm nodular density at the left posterior sulcus.,Noncontrast technique limits evaluation of the solid abdominal organs.  Cardiomegaly and atherosclerotic calcifications are seen.,Hepatomegaly is observed.  There is calcification within the right lobe of the liver likely related to granulomatous changes.  Subtle irregularity of the liver contour is noted, suggestive of cirrhosis.  There is splenomegaly seen.  There are two low-attenuation lesions seen in the posterior aspect of the spleen, which are incompletely characterized that may represent splenic cyst.  The pancreas appears atrophic.  There is a left renal nodule seen, which measures 1.9 cm with a Hounsfield unit density of approximately 29, which is indeterminate.,There is mild bilateral perinephric stranding.  There is an 8-mm fat density lesion in the anterior inner polar region of the left kidney, compatible in appearance with angiomyolipoma.  There is a 1-cm low-attenuation lesion in the upper pole of the right kidney, likely representing a cyst, but incompletely characterized on this examination.  Bilateral ureters appear normal in caliber along their visualized course.  The bladder is partially distended with urine, but otherwise unremarkable.,Postsurgical changes of hysterectomy are noted.  There are pelvic phlebolith seen.  There is a calcified soft tissue density lesion in the right pelvis, which may represent an ovary with calcification, as it appears continuous with the right gonadal vein.,Scattered colonic diverticula are observed.  The appendix is within normal limits.  The small bowel is unremarkable.  There is an anterior abdominal wall hernia noted containing herniated mesenteric fat.  The hernia neck measures approximately 2.7 cm.  There is stranding of the fat within the hernia sac.,There are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis.  Degenerative changes of the spine are observed.,IMPRESSION:,1.  Anterior abdominal wall hernia with mesenteric fat-containing stranding, suggestive of incarcerated fat.,2.  Nodule in the left lower lobe, recommend follow up in 3 months.,3.  Indeterminate left adrenal nodule, could be further assessed with dedicated adrenal protocol CT or MRI.,4.  Hepatomegaly with changes suggestive of cirrhosis.  There is also splenomegaly observed.,5.  Low-attenuation lesions in the spleen may represent cyst, that are incompletely characterized on this examination.,6.  Fat density lesion in the left kidney, likely represents angiomyolipoma.,7.  Fat density soft tissue lesion in the region of the right adnexa, this contains calcifications and may represent an ovary or possibly dermoid cyst.", Nephrology,21
"PROCEDURES:, Cystourethroscopy and transurethral resection of prostate.,COMPLICATIONS:, None.,ADMITTING DIAGNOSIS:, Difficulty voiding.,HISTORY:, This 67-year old Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction.  Physical examination revealed normal heart and lungs.  Abdomen was negative for abnormal findings.  ,LABORATORY DATA:, BUN 19 and creatinine 1.1.  Blood group was A, Rh positive, Hemoglobin 13, Hematocrit 32.1, Prothrombin time 12.6 seconds, PTT 37.1.  Discharge  hemoglobin 11.4, and hematocrit 33.3.  Chest x-ray calcified old granulomatous disease, otherwise normal.  EKG was normal.  ,COURSE IN THE HOSPITAL:, The patient had a cysto and TUR of the prostate.  Postoperative course was uncomplicated. The pathology report is pending at the time of dictation.  He is being discharged in satisfactory condition with a good urinary stream, minimal hematuria, and on Bactrim DS one a day for ten days with a standard postprostatic surgery instruction sheet.  ,DISCHARGE DIAGNOSIS: , Enlarged prostate with benign bladder neck obstruction.  ,To be followed in my office in one week and by Dr. ABC next available as an outpatient.", Urology,39
"GENERAL:  ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX.  Height XXX, weight XXX.,HEAD: , Normocephalic.  Negative lesions, negative masses.,EYES: , PERLA, EOMI.  Sclerae clear.  Negative icterus, negative conjunctivitis.,ENT:,  Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates.  Negative ear obstructions, negative exudates.  Negative inflammation in external auditory canals.  Negative throat inflammation or masses.,SKIN: , Negative rashes, negative masses, negative ulcers.  No tattoos.,NECK:,  Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,HEART:,  Regular rate and rhythm.  Negative rubs, negative gallops, negative murmurs.,LUNGS:,  Clear to auscultation.  Negative rales, negative rhonchi, negative wheezing.,ABDOMEN: , Soft, nontender, adequate bowel sounds.  Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,EXTREMITIES: , Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing.  Pulses adequate bilaterally.,MUSCULOSKELETAL:,  Negative muscle atrophy, negative masses.  Strength adequate bilaterally.  Negative movement restriction, negative joint crepitus, negative deformity.,NEUROLOGIC: , Cranial nerves I through XII intact.  Negative gait disturbance.  Balance and coordination intact.  Negative Romberg, negative Babinski.  DTRs equal bilaterally.,GENITOURINARY:  ,Deferred.,", General Medicine,15
"PREOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,POSTOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,PROCEDURE PERFORMED:  ,Debridement left ischial ulcer.,ANESTHESIA: ,Local MAC.,INDICATIONS:,  This is a 27-year-old white male patient, with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic.  The patient has a nonhealing decubitus ulcer in the left ischial region, which is quite deep.  It appears to be right down to the bone.  MRI shows findings suggestive of osteomyelitis.  The patient is being brought to operating room for debridement of this ulcer.  Procedure, indication, and risks were explained to the patient.  Consent obtained.,PROCEDURE IN DETAIL: ,The patient was put in right lateral position and left buttock and ischial region was prepped and draped.  Examination at this time showed fair amount of chronic granulation tissue and scarred tissue circumferentially as well as the base of this decubitus ulcer.  This was sharply excised until bleeding and healthy tissue was obtained circumferentially as well as the base.  The ulcer does not appear to be going into the bone itself as there was a covering on the bone, which appears to be quite healthy, normal and bone itself appeared solid.,I did not rongeur the bone.  The deeper portion of the excised tissue was also sent for tissue cultures.  Hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated Kerlix.  Sterile dressing was applied.  The patient transferred to recovery room in stable condition.", Surgery,38
"LONG-TERM GOALS:,  Both functional and cognitive-linguistic ability to improve safety and independence at home and in the community.  This goal has been met based on the patient and husband reports the patient is able to complete all activities, which she desires to do at home.  During the last reevaluation, the patient had a significant progress and all cognitive domains evaluated, which are attention, memory, executive functions, language, and visuospatial skill.  She continues to have an overall mild cognitive-linguistic deficit, but this is significantly improved from her initial evaluation, which showed severe impairment., ,The patient does no longer need a skilled speech therapy because she has accomplished all of her goals and her progress has plateaued.  The patient and her husband both agreed with the patient's discharge.", Discharge Summary,10
"ADMITTING DIAGNOSIS: , Intractable migraine with aura.,DISCHARGE DIAGNOSIS:,  Migraine with aura.,SECONDARY DIAGNOSES:,1.  Bipolar disorder.,2.  Iron deficiency anemia.,3.  Anxiety disorder.,4.  History of tubal ligation.,PROCEDURES DURING THIS HOSPITALIZATION:,1.  CT of the head with and without contrast, which was negative.,2.  An MRA of the head and neck with and without contrast also negative.,3.  The CTA of the neck also read as negative.,4.  The patient also underwent a lumbar puncture in the Emergency Department, which was grossly unremarkable though an opening pressure was not obtained.,HOME MEDICATIONS:,1.  Vicodin 5/500 p.r.n.,2.  Celexa 40 mg daily.,3.  Phenergan 25 mg p.o. p.r.n.,4.  Abilify 10 mg p.o. daily.,5.  Klonopin 0.5 mg p.o. b.i.d.,6.  Tramadol 30 mg p.r.n.,7.  Ranitidine 150 mg p.o. b.i.d.,ALLERGIES:,  SULFA drugs.,HISTORY OF PRESENT ILLNESS: , The patient is a 25-year-old right-handed Caucasian female who presented to the emergency department with sudden onset of headache occurring at approximately 11 a.m. on the morning of the July 31, 2008.  She described the headache as worse in her life and it was also accompanied by blurry vision and scotoma.  The patient also perceived some swelling in her face.  Once in the Emergency Department, the patient underwent a very thorough evaluation and examination.  She was given the migraine cocktail.  Also was given morphine a total of 8 mg while in the Emergency Department.  For full details on the history of present illness, please see the previous history and physical.,BRIEF SUMMARY OF HOSPITAL COURSE:  ,The patient was admitted to the neurological service after her headache felt to be removed with the headache cocktail.  The patient was brought up to 4 or more early in the a.m. on the August 1, 2008 and was given the dihydroergotamine IV, which did allow some minimal resolution in her headache immediately.  At the time of examination this morning, the patient was feeling better and desired going home.  She states the headache had for the most part resolved though she continues to have some diffuse trigger point pain.,PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE: , General physical exam was unremarkable.  HEENT:  Pupils were equal and respond to light and accommodation bilaterally.  Extraocular movements were intact.  Visual fields were intact to confrontation.  Funduscopic exam revealed no disc pallor or edema.  Retinal vasculature appeared normal.  Face is symmetric.  Facial sensation and strength are intact.  Auditory acuities were grossly normal.  Palate and uvula elevated symmetrically.  Sternocleidomastoid and trapezius muscles are full strength bilaterally.  Tongue protrudes in midline.  Mental status exam: revealed the patient alert and oriented x 4.  Speech was clear and language is normal.  Fund of knowledge, memory, and attention are grossly intact.  Neurologic exam:  Vasomotor system revealed full power throughout.  Normal muscle tone and bulk.  No pronator drift was appreciated.  Coordination was intact to finger-to-nose, heel-to-shin and rapid alternating movement.  No tremor or dysmetria.  Excellent sensory.  Sensation is intact in all modalities throughout. The patient does have notable trigger points diffusely including the occiput, trapezius bilaterally, lumbar, back, and sacrum.  Gait was assessed, the patient's routine and tandem gait were normal.  The patient is able to balance on heels and toes.  Romberg is negative.  Reflexes are 2+ and symmetric throughout.  Babinski reflexes are plantar.,DISPOSITION:,  The patient is discharged home.,INSTRUCTIONS FOR FOLLOWUP:  ,The patient is to followup with her primary care physician as needed.", Discharge Summary,10
"DIAGNOSES:,1.  Juvenile myoclonic epilepsy.,2.  Recent generalized tonic-clonic seizure.,MEDICATIONS:,1.  Lamictal 250 mg b.i.d.,2.  Depo-Provera.,INTERIM HISTORY: , The patient returns for followup.  Since last consultation she has tolerated Lamictal well, but she has had a recurrence of her myoclonic jerking.  She has not had a generalized seizure.  She is very concerned that this will occur.  Most of the myoclonus is in the mornings.  Recent EEG did show polyspike and slow wave complexes bilaterally, more prominent on the left.  She states that she has been very compliant with the medications and is getting a good amount of sleep.  She continues to drive.,Social history and review of systems are discussed above and documented on the chart.,PHYSICAL EXAMINATION: , Vital signs are normal.  Pupils are equal and reactive to light.  Extraocular movements are intact.  There is no nystagmus.  Visual fields are full.  Demeanor is normal.  Facial sensation and symmetry is normal.  No myoclonic jerks noted during this examination.  No myoclonic jerks provoked by tapping on her upper extremity muscles.  Negative orbit.  Deep tendon reflexes are 2 and symmetric.  Gait is normal.  Tandem gait is normal.  Romberg negative.,IMPRESSION AND PLAN:,  Recurrence of early morning myoclonus despite high levels of Lamictal.  She is tolerating the medication well and has not had a generalized tonic-clonic seizure.  She is concerned that this is a precursor for another generalized seizure.  She states that she is compliant with her medications and has had a normal sleep-wake cycle.,Looking back through her notes, she initially responded very well to Keppra, but did have a breakthrough seizure on Keppra.  This was thought secondary to severe insomnia when her baby was very young.  Because she tolerated the medication well and it was at least partially affective, I have recommended adding Keppra 500 mg b.i.d.  Side effect profile of this medication was discussed with the patient.,I will see in followup in three months.", Neurology,22
"CHIEF COMPLAINT:,  Headache.,HPI: , This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan.  He was discharged home with a follow up to neurosurgery on the 14th.  Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery.  He has had headaches since the 13th and complains now of some worsening of his pain.  He denies photophobia, fever, vomiting, and weakness of the arms or legs.,PMH: , As above.,MEDS:,  Vicodin.,ALLERGIES:,  None.,PHYSICAL EXAM:  ,BP 180/110 Pulse 65 RR 18 Temp 97.5.,Mr. P is awake and alert, in no apparent distress.,HEENT:  Pupils equal, round, reactive to light, oropharynx moist, sclera clear.  ,Neck:  Supple, no meningismus.,Lungs:  Clear.,Heart:  Regular rate and rhythm, no murmur, gallop, or rub.  ,Abdomen:  Benign.,Neuro:  Awake and alert, motor strength normal, no numbness, normal gait, DTRs normal.  Cranial nerves normal.  ,COURSE IN THE ED:  ,Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus.  I recommended an LP but he prefers not to have this done.  He received morphine for pain and his headache improved.  I've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram.  He left the ED against my advice.  ,IMPRESSION: , Headache, improved.  Intracranial aneurysm.,PLAN: , The patient will return tomorrow am for his angiogram.", Neurology,22
"CC: ,Falling to left.,HX:, 26y/oRHF fell and struck her head on the ice 3.5 weeks prior to presentation. There was no associated loss of consciousness. She noted a dull headache and severe sharp pain behind her left ear 8 days ago. The pain lasted 1-2 minutes in duration. The next morning she experienced difficulty walking and consistently fell to the left. In addition the left side of her face had become numb and she began choking on food. Family noted her pupils had become unequal in size. She was seen locally and felt to be depressed and admitted to a psychiatric facility. She was subsequently transferred to UIHC following evaluation by a local ophthalmologist.,MEDS:, Prozac and Ativan (both recently started at the psychiatric facility).,PMH: ,1) Right esotropia and hyperopia since age 1year. 2) Recurrent UTI.,FHX:, Unremarkable.,SHX:, Divorced. Lives with children. No spontaneous abortions. Denied ETOH/Tobacco/Illicit Drug use.,EXAM:, BP 138/110.  HR 85.  RR 16.  Temp 37.2C.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, repetition.,CN: Pupils 4/2 decreasing to 3/1 on exposure to light. Optic Disks flat. VFFTC. Esotropia OD, otherwise EOM full. Horizontal nystagmus on leftward gaze. Decreased corneal reflex, OS. Decreased PP/TEMP sensation on left side of face. Light touch testing normal. Decreased gag response on left. Uvula deviates to right. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: Decreased PP and TEMP on right side of body. PROP/VIB intact.,Coord: Difficulty with FNF/HKS/RAM on left. Normal on right side.,Station: No pronator drift. Romberg test not noted.,Gait: unsteady with tendency to fall to left.,Reflexes: 3/3 throughout BUE and Patellae. 2+/2+ Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese. In no acute distress. Otherwise unremarkable.,HEENT: No carotid/vertebral/cranial bruits.,COURSE:, PT/PTT, GS, CBC, TSH, FT4 and Cholesterol screen were all within normal limits. HCT on admission was negative. MRI Brain (done locally 2/2/93) was reviewed and a left lateral medullary stroke was appreciated. The patient underwent a cerebral angiogram on 2/3/93 which revealed significant narrowing of the left vertebral artery beginning at C2 and extending to and involving the basilar artery. There is severe, irregular narrowing of the horizontal portion above the posterior arch of C1. The findings were felt consistent with a left vertebral artery dissection. Neuro-opthalmology confirmed a left Horner's pupil by clinical exam and history. Cookie swallow study was unremarkable. The Patient was placed on Heparin then converted to Coumadin. The PT on discharge was 17.,She remained on Coumadin for 3 months and then was switched to ASA for 1 year. An Otolaryngologic evaluation on 10/96 noted true left vocal cord paralysis with full glottic closure. A prosthesis was made and no surgical invention was done.", Radiology,33
"PREOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE:  ,Open carpal tunnel release.,COMPLICATIONS:  ,None.,PROCEDURE IN DETAIL:  ,After administering appropriate antibiotics and general anesthesia the Left upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the 4th ray.  The dissection was carried down to the superficial aponeurosis, which was cut.  The distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with scissors.,After irrigating the wound with copious amounts of normal saline, the skin was repaired with 4-0 nylon interrupted stitches.,Marcaine with epinephrine was injected into the wound, which was then dressed and splinted.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.", Surgery,38
"HISTORY OF PRESENT ILLNESS: , This 40-year-old white single man was hospitalized at XYZ Hospital in the mental health ward, issues were filled up by his sister and his mother.  The issues involved include the fact that for the last 10 years he has been on disability for psychiatric reasons and has been not working, and in the last several weeks to month he began to call his family talking about the fact that he had been sexually abused by brother.  He has been in outpatient therapy with Jeffrey Silverberg for the past 10 years and Mr. Silverberg became concerned about his behavior, called the family and told them to have him put in the hospital, and at one point called the police because the patient was throwing cellphones and having tantrums in his office.,The history includes the fact that the patient is the 3rd of 4 children.  A brother who is approximately 8 years older, sexually abused brother who is 4 years older.  The brother who is 8 years older lives in California and will contact the family, has had minimal contact for many years.,That brother in California is gay.  The brother who is 4 years older, sexually abused, the patient from age 8 to 12 on a regular basis.  He said, he told his mother several years ago, but she did nothing about it.,The patient finished high school and with some struggle completed college at the University of Houston.  He has a sister who is approximately a year and half younger than he is, who was sexually abused by the brothers will, but only on one occasion.  She has been concerned about patient's behavior and was instrumental in having him committed.,Reportedly, the patient ran away from home at the age of 12 or 13 because of the abuse, but was not able to tell his family what happened.,He had no or minimal psychiatric treatment growing up and after completing college worked in retail part time.,He states he injured his back about 10 yeas ago.  He told he had disk problems but never had surgery.  He subsequently was put on psychiatric disability for depression, states he has been unable to get out of bed at times and isolates and keeps to himself.,He has been on a variety of different medications including Celexa 40 mg and ADD medication different times, and reportedly has used amphetamines in the past, although he denies it at this time.  He minimizes any alcohol use which appears not to be a problem, but what does appear to be a problem is he isolates, stays at home, has been in situations where he brings in people he does not know well and he runs the risk of getting himself physically harmed.,He has never been psychiatrically hospitalized before.,MENTAL STATUS EXAMINATION:,  Revealed a somewhat disheveled 40-year-old man who was clearly quite depressed and somewhat shocked at his family's commitment.  He says he has not seen them on a regular basis because every time he sees them he feels hurt and acknowledged that he called up the brother who abused him and told the brother's wife what had happened.  The brother has a child and wife became very upset with him.,Normocephalic.  Pleasant, cooperative, disheveled man with about 37 to 40, thoughts were somewhat guarded.  His affect was anxious and depressed and he denied being suicidal, although the family said that he has talked about it at times.,Recent past memory were intact.,DIAGNOSES:,Axis I:  Major depression rule out substance abuse.,Axis II:  Deferred at this time.,Axis III:  Noncontributory.,Axis IV:  Family financial and social pressures.,Axis V:  Global Assessment of Functioning 40.,RECOMMENDATION:,  The patient will be hospitalized to assess.,Along the issues, the fact that he is been living in disability in the fact that his family has had to support him for all this time despite the fact that he has had a college degree.  He says he has had several part time jobs, but never been able to sustain employment, although he would like to.", Psychiatry / Psychology,32
"HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old woman whom I have been following, who has had angina.  In any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when I spoke to her.  I advised her to call 911, which she did.  While waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain.  By the time she presented here, she is currently pain-free and is feeling well.,PAST CARDIAC HISTORY: , The patient has been having arm pain for several months.  She underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia.  I had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker.  However, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room.  On 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80%  mid LAD lesion, circumflex normal, and RCA totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area.  The decision was made to transfer  her as she may be having collateral insufficiency from the LAD stenosis to the RCA vessel.  She underwent that with drug-eluting stents on 08/16/08, with I believe three or four total placed, and was discharged on 08/17/08.  She had some left arm discomfort on 08/18/08, but this was mild.  Yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin.  This is her usual angina.  She is being admitted with unstable angina post stent.,PAST MEDICAL HISTORY: , Longstanding hypertension, CAD as above, hyperlipidemia, and overactive bladder.,MEDICATIONS:,1.  Detrol LA 2 mg once a day.,2.  Prilosec for GERD 20 mg once a day.,3.  Glucosamine 500/400 mg once a day for arthritis.,4.  Multivitamin p.o. daily.,5.  Nitroglycerin sublingual as available to her.,6.  Toprol-XL 25 mg once a day which I started although she had been bradycardic, but she seems to be tolerating.,7.  Aspirin 325 mg once a day.,8.  Plavix 75 mg once a day.,9.  Diovan 160 mg once a day.,10.  Claritin 10 mg once a day for allergic rhinitis.,11.  Norvasc 5 mg once a day.,12.  Lipitor 5 mg once a day.,13.  Evista 60 mg once a day.,ALLERGIES: , ALLERGIES TO MEDICATIONS ARE NONE.  SHE DENIES ANY SHRIMP OR SEA FOOD ALLERGY.,FAMILY HISTORY: , Her father died of an MI in his 50s and a brother had his first MI and bypass surgery at 54.,SOCIAL HISTORY:  ,She does not smoke cigarettes, abuse alcohol, no use of illicit drugs.  She is divorced and lives alone and is a retired laboratory technician from Cornell Diagnostic Laboratory.,REVIEW OF SYSTEMS:,  She denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08.  No morning headaches or fatigue.  No psychiatric diagnosis.  No psoriasis, no lupus.  Remainder of the review of systems is negative x14 systems except as described above.,PHYSICAL EXAMINATION:,GENERAL:  She is a pleasant elderly woman, currently in no acute distress.,VITAL SIGNS:  Height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 47,  respiratory rate 16, and O2 saturation 100%,HEENT:  Cranium is normocephalic and atraumatic.  She has moist mucosal membranes.,NECK:  Veins are not distended.  There are no carotid bruits.,LUNGS:  Clear to auscultation and percussion without wheezes.,HEART:  S1 and S2, regular rate.  No significant murmurs, rubs or gallops.  PMI nondisplaced.,ABDOMEN:  Soft and nondistended.  Bowel sounds present.,EXTREMITIES:  Without significant clubbing, cyanosis or edema.  Pulses grossly intact.  Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI and there is no evidence of hematoma or bruit and intact distal pulses.,LABORATORY DATA: , EKG reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,Sodium 136, potassium 3.8, chloride 105, and bicarbonate 27.  BUN 16 and creatinine 0.9.  Glucose 110.  Magnesium 2.5.  ALT 107 and AST 65 and these were normal on 08/15/08.  INR is 0.89, PTT 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,IMPRESSION AND PLAN:  ,The patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery.  In any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, I am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy.  We will continue her beta-blocker and I cannot increase the dose because she is bradycardic already.  Aspirin, Plavix, valsartan, Lipitor, and Norvasc.  I am going to add Imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out MI, although there is a little suspicion.  I suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect.  My concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal LV function.  She will continue the glucosamine for her arthritis, Claritin for allergies, and Detrol LA for urinary incontinence.,Total patient care time in the emergency department 75 minutes.  All this was discussed in detail with the patient and her daughter who expressed understanding and agreement.  The patient desires full resuscitation status.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS:,  Severe degenerative joint disease of the right knee.,POSTOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right knee.,PROCEDURE:,  Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella.  All components were cemented with Cobalt G.,ANESTHESIA:,  Spinal.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , Less than 60 minutes.,The patient was taken to the Postanesthesia Care Unit in stable condition.  The patient tolerated the procedure well.,INDICATIONS:  ,The patient is a 51-year-old female complaining of worsening right knee pain.  The patient had failed conservative measures and having difficulties with her activities of daily living as well as recurrent knee pain and swelling.  The patient requested surgical intervention and need for total knee replacement.,All risks, benefits, expectations, and complications of surgery were explained to her in great detail and she signed informed consent.  All risks including nerve and vessel damage, infection, and revision of surgery as well as component failure were explained to the patient and she did sign informed consent.  The patient was given antibiotics preoperatively.,PROCEDURE DETAIL:  ,The patient was taken to the operating suite and placed in supine position on the operating table.  She was placed in the seated position and a spinal anesthetic was placed, which the patient tolerated well.  The patient was then moved to supine position again and a well-padded tourniquet was placed on the right thigh.  Right lower extremity was prepped and draped in sterile fashion.  All extremities were padded prior to this.,The right lower extremity, after being prepped and draped in the sterile fashion, the tourniquet was elevated and maintained for less than 60 minutes in this case.  A midline incision was made over the right knee and medial parapatellar arthrotomy was performed.  Patella was everted.  The infrapatellar fat pad was incised and medial and lateral meniscectomy was performed and the anterior cruciate ligament was removed.  The posterior cruciate ligament was intact.,There was severe osteoarthritis of the lateral compartment on the lateral femoral condyle as well as mild-to-moderate osteoarthritis in the medial femoral compartment as well severe osteoarthritis along the patellofemoral compartment.  The medial periosteal tissue on the proximal tibia was elevated to the medial collateral ligament and medial collateral ligament was left intact throughout the entirety of the case.,At the extramedullary tibial guide, an extended cut was made adjusting for her alignment.  Once this was performed, excess bone was removed.  The reamer was placed along on the femoral canal, after which a 6-degree valgus distal cut was made along the distal femur.  Once this was performed, the distal femoral size in 3 degrees external rotation, 62.5-mm cutting block was placed in 3 degrees external rotation with anterior and posterior cuts as well as anterior and posterior Chamfer cuts remained in the standard fashion.  Excess bone was removed.,Next, the tibia was brought anterior and excised to 71 mm.  It was then punched in standard fashion adjusting for appropriate rotation along the alignment of the tibia.  Once this was performed, a 71-mm tibial trial was placed as well as a 62.5-mm femoral trial was placed with a 12-mm polyethylene insert.,Next, the patella was cut in the standard fashion measuring 31 mm and a patella bed was placed.  The knee was taken for range of motion; had excellent flexion and extension as well as adequate varus and valgus stability.  There was no loosening appreciated.  There is no laxity appreciated along the posterior cruciate ligament.,Once this was performed, the trial components were removed.  The knee was irrigated with fluid and antibiotics, after which the cement was put on the back table, this being Cobalt G, it was placed on the tibia.  The tibial components were tagged in position and placed on the femur.  The femoral components were tagged into position.  All excess cement was removed ___ placement of patella.  It was tagged in position.  A 12-mm polyethylene insert was placed; knee was held in extension and all excess cement was removed.  The cement hardened with the knee in full extension, after which any extra cement was removed.,The wounds were copiously irrigated with saline and antibiotics, and medial parapatellar arthrotomy was closed with #2 Vicryl.  Subcutaneous tissue was approximated with #2-0 Vicryl and the skin was closed with staples.  The patient was awakened from general anesthetic, transferred to the gurney, and taken into postanesthesia care unit in stable condition.  The patient tolerated the procedure well.", Surgery,38
"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.", Surgery,38
"EXAM: , Barium enema.,CLINICAL HISTORY: , A 4-year-old male with a history of encopresis and constipation.,TECHNIQUE:  ,A single frontal scout radiograph of the abdomen was performed.  A rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed via spot fluoroscopic images.  A post-evacuation overhead radiograph of the abdomen was performed.,FINDINGS:,  The scout radiograph demonstrates a nonobstructive gastrointestinal pattern.  There are no suspicious calcifications seen or evidence of gross free intraperitoneal air.  The visualized lung bases and osseous structures are within normal limits.,The rectum and colon is of normal caliber throughout its course.  There is no evidence of obstruction, as contrast is seen to flow without difficulty into the right colon and cecum.  A small amount of contrast is seen to opacify small bowel loops on the post-evacuation image.  There is also opacification of a normal-appearing appendix documented.,IMPRESSION: , Normal barium enema.", Gastroenterology,14
"REASON FOR ADMISSION: , Fever of unknown origin.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old woman with polymyositis/dermatomyositis on methotrexate once a week.  The patient has also been on high-dose prednisone for an urticarial rash.  The patient was admitted because of persistent high fevers without a clear-cut source of infection.  She had been having temperatures of up to 103 for 8-10 days.  She had been seen at Alta View Emergency Department a week prior to admission.  A workup there including chest x-ray, blood cultures, and a transthoracic echocardiogram had all remained nondiagnostic, and were normal.  Her chest x-ray on that occasion was normal.  After the patient was seen in the office on August 10, she persisted with high fevers and was admitted on August 11 to Cottonwood Hospital.  Studies done at Cottonwood:  CT scan of the chest, abdomen, and pelvis.  Results:  CT chest showed mild bibasilar pleural-based interstitial changes.  These were localized to mid and lower lung zones.  The process was not diffuse.  There was no ground glass change.  CT abdomen and pelvis was normal.  Infectious disease consultation was obtained.  Dr. XYZ saw the patient.  He ordered serologies for CMV including a CMV blood PCR.  Next serologies for EBV, Legionella, Chlamydia, Mycoplasma, Coccidioides, and cryptococcal antigen, and a PPD.  The CMV serology came back positive for IgM.  The IgG was negative.  The CMV blood PCR was positive, as well.  Other serologies and her PPD stayed negative.  Blood cultures stayed negative.,In view of the positive CMV, PCR, and the changes in her CAT scan, the patient was taken for a bronchoscopy.  BAL and transbronchial biopsies were performed.  The transbronchial biopsies did not show any evidence of pneumocystis, fungal infection, AFB.  There was some nonspecific interstitial fibrosis, which was minimal.  I spoke with the pathologist, Dr. XYZ and immunopathology was done to look for CMV.  The patient had 3 nucleoli on the biopsy specimens that stained positive and were consistent with CMV infection.  The patient was started on ganciclovir once her CMV serologies had come back positive.  No other antibiotic therapy was prescribed.  Next, the patient's methotrexate was held.,A chest x-ray prior to discharge showed some bibasilar disease, showing interstitial infiltrates.  The patient was given ibuprofen and acetaminophen during her hospitalization, and her fever resolved with these measures.,On the BAL fluid cell count, the patient only had 5 WBCs and 5 RBCs on the differential.  It showed 43% neutrophils, 45% lymphocytes.,Discussions were held with Dr. XYZ, Dr. XYZ, her rheumatologist, and with pathology.,DISCHARGE DIAGNOSES:,1.  Disseminated CMV infection with possible CMV pneumonitis.,2.  Polymyositis on immunosuppressive therapy (methotrexate and prednisone).,DISCHARGE MEDICATIONS:,1.  The patient is going to go on ganciclovir 275 mg IV q.12 h. for approximately 3 weeks.,2.  Advair 100/50, 1 puff b.i.d.,3.  Ibuprofen p.r.n. and Tylenol p.r.n. for fever, and will continue her folic acid.,4.  The patient will not restart for methotrexate for now.,She is supposed to follow up with me on August 22, 2007 at 1:45 p.m.  She is also supposed to see Dr. XYZ in 2 weeks, and Dr. XYZ in 2-3 weeks.  She also has an appointment to see an ophthalmologist in about 10 days' time.  This was a prolonged discharge, more than 30 minutes were spent on discharging this patient.", General Medicine,15
"CHIEF COMPLAINT:,  Itchy rash.,HISTORY OF PRESENT ILLNESS: , This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.  No facial swelling.  No tongue or lip swelling.  No shortness of breath, wheezing, or other associated symptoms.  He cannot think of anything that could have triggered this off.  There have been no changes in his foods, medications, or other exposures as far as he knows.  He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day.,PAST MEDICAL HISTORY: , Negative for chronic medical problems.  No local physician.  Has had previous back surgery and appendectomy, otherwise generally healthy.,REVIEW OF SYSTEMS: , As mentioned denies any oropharyngeal swelling.  No lip or tongue swelling.  No wheezing or shortness of breath.  No headache.  No nausea.  Notes itchy rash, especially on his torso and upper arms.,SOCIAL HISTORY: , The patient is accompanied with his wife.,FAMILY HISTORY: , Negative.,MEDICATIONS: , None.,ALLERGIES: , TORADOL, MORPHINE, PENICILLIN, AND AMPICILLIN.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  He is slightly tachycardic, 105, but stable blood pressure and respiratory rate.  GENERAL:  The patient is in no distress.  Sitting quietly on the gurney.  HEENT:  Unremarkable.  His oral mucosa is moist and well hydrated.  Lips and tongue look normal.  Posterior pharynx is clear.  NECK:  Supple.  His trachea is midline.  There is no stridor.  LUNGS:  Very clear with good breath sounds in all fields.  There is no wheezing.  Good air movement in all lung fields.  CARDIAC:  Without murmur.  Slight tachycardia.  ABDOMEN:  Soft, nontender.  SKIN:  Notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms.  He noted some on his buttocks as well.  Remaining of the exam is unremarkable.,ED COURSE: , The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly.  After about 15-20 minutes he states that itching started to feel better.  The rash has started to fade a little bit and feeling a lot more comfortable.,IMPRESSION:,  ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS.,ASSESSMENT AND PLAN: , The patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess.  He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off.  In the meantime, I think he can be managed with some antihistamine over-the-counter.  He is responding already to Benadryl and the epinephrine that we gave him here.  He is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation.  He is discharged in stable condition.", Consult - History and Phy.,5
"REASON FOR EXAM: , Pregnant female with nausea, vomiting, and diarrhea.,FINDINGS: , The uterus measures 8.6 x 4.4 x 5.4 cm and contains a gestational sac with double decidual sac sign.  A yolk sac is visualized.  What appears to represent a crown-rump length measures 3.3 mm for an estimated sonographic age of 6 weeks 0 days and estimated date of delivery of 09/28/09.,Please note however that no fetal heart tones are seen.  However, fetal heart tones would be expected at this age.,The right ovary measures 3.1 x 1.6 x 2.3 cm.  The left ovary measures 3.3 x 1.9 x 3.5 cm.  No free fluid is detected.,IMPRESSION: , Single intrauterine pregnancy at 6 weeks 0 days with an estimated date of delivery of 09/28/09.  A live intrauterine pregnancy, however, could not be confirmed, as a sonographic fetal heart rate would be expected at this time.  A close interval followup in correlation with beta-hCG is necessary as findings may represent an inevitable abortion.", Obstetrics / Gynecology,24
"PAST MEDICAL HISTORY:  ,She had a negative stress test four to five years ago.  She gets short of breath in walking about 30 steps.  She has had non-insulin dependent diabetes for about eight years now.  She has a left knee arthritis and history of hemorrhoids.,PAST SURGICAL HISTORY: , Pertinent for laparoscopic cholecystectomy, tonsillectomy, left knee surgery, and right breast lumpectomy.,PSYCHOLOGICAL HISTORY: , Negative except that she was rehabilitated for alcohol addiction in 1990.,SOCIAL HISTORY: , The patient is married.  She is an office manager for a gravel company.  Her spouse is also overweight.  She drinks on a weekly basis and she smokes,about two packs of cigarettes over a week's period of time.  She is doing this for about 35 years.,FAMILY HISTORY: , Diabetes and hypertension.,MEDICATIONS:,  Include Colestid 1 g daily, Actos 30 mg daily, Amaryl 2 mg daily, Soma, and meloxicam for her back pain.,ALLERGIES:,  She has no allergies; however, she does get tachycardic with caffeine, Sudafed, or phenylpropanolamine.,REVIEW OF SYSTEMS: , Otherwise, negative.,PHYSICAL EXAM: , This is a pleasant female in no acute distress.  Alert and oriented x 3.  HEENT:  Normocephalic, atraumatic.  Extraocular muscles intact, nonicteric sclerae.  Chest is clear.  Abdomen is obese, soft, nontender and nondistended.  Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: , This is a 51-year-old female with a BMI of 43 who is interested in the Lap-Band as opposed to gastric bypass.  ABC will be asking for a letter of medical necessity from XYZ.  She will also need an EKG and clearance for surgery.  She will also see my nutritionist and social worker and once this is completed, we will submit her to her insurance company for approval.", Bariatrics,2
"SPIROMETRY:,  Spirometry reveals the FVC to be adequate.,FEV1 is also adequate 93% predicted.  FEV1/FVC ratio is 114% predicted which is normal and FEF25 75% is 126% predicted.,After the use of bronchodilator, there is no significant improvement of the abovementioned parameters.,MVV is also normal.,LUNG VOLUMES: , Reveal a TLC to be 80% predicted.  FRC is mildly decreased and RV is also mildly decreased.  RV/TLC ratio is also normal 97% predicted.,DIFFUSION CAPACITY:,  After correction for alveolar ventilation, is 112% predicted which is normal.,OXYGEN SATURATION ON ROOM AIR:,  98%.,FINAL INTERPRETATION: , Pulmonary function test shows mild restrictive pulmonary disease.  There is no significant obstructive disease present.  There is no improvement after the use of bronchodilator and diffusion capacity is normal.  Oxygen saturation on room air is also adequate.  Clinical correlation will be necessary in this case.,", Cardiovascular / Pulmonary,3
"OTITIS MEDIA, is an infection of the middle ear space where the small bones and nerves of the ear connect to the eardrum on one side and the eustachian tube on the other.  The ear infection itself is not contagious but the respiratory infection preceding it is transmittable.  Otitis media is most often seen in infants and young children.  There are several causes including a viral or bacterial infection that spreads to the middle ear by way of the eustachian tubes, nasal allergy drainage blocking the sinuses or eustachian tubes, enlarged adenoids also blocking sinuses or eustachian tubes and eardrum rupture.  Many factors can increase the risk of an ear infection like recent upper respiratory tract illness, crowded living conditions, family history of ear infections, day care, smoking in household, altitude changes, cold weather and genetic factors.,SIGNS AND SYMPTOMS:,*  Irritability.,*  Ear pain, fullness, hearing loss.,*  Infants may pull on ear.,*  Fever.,*  Vomiting.,*  Discharge from ear.,*  Diarrhea.,TREATMENT:,*  Diagnosis is by physical exam and otoscopic exam.  Sometimes fluid from the ear is cultured.,*  Pain relievers, like acetaminophen (Tylenol).  Infant pain relievers are available.,*  Decongestant to relieve symptoms of upper respiratory tract infection.,*  Antibiotics when indicated for bacterial infection such as Amoxicillin or Zithromycin.  Finish ALL antibiotics as prescribed.  Do not stop the medication even if symptoms subside.,*  Avoid swimming until infection goes away.,*  Surgery is sometimes necessary to put in tubes through the eardrum to equalize pressure and drain fluids.,*  Surgery to remove adenoids if they are enlarged.,*  Reduce activity until symptoms subside.,Call doctor's office if symptoms do not improve within 2 days of treatment, and for convulsion, fever, ear swelling, dizziness, twitching facial muscles and severe headache.", ENT - Otolaryngology,11
"DIAGNOSES PROBLEMS:,1.  Orthostatic hypotension.,2.  Bradycardia.,3.  Diabetes.,4.  Status post renal transplant secondary polycystic kidney disease in 1995.,5.  Hypertension.,6.  History of basal cell ganglia cerebrovascular event in 2004 with left residual.,7.  History of renal osteodystrophy.,8.  Iron deficiency anemia.,9.  Cataract status post cataract surgery.,10.  Chronic left lower extremity pain.,11.  Hyperlipidemia.,12.  Status post hysterectomy secondary to uterine fibroids.,PROCEDURES:,  Telemetry monitoring.,HISTORY FINDINGS HOSPITAL COURSE: , The patient was originally hospitalized on 04/26/07, secondary to dizziness and disequilibrium.  Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.  She was transferred briefly to Psychiatry, however, on the second day in Psychiatry, she became very orthostatic and was transferred acutely back to the medicine.  She briefly was on Cymbalta; however, this was discontinued when she was transferred back.  She was monitored back medicine for 24 hours and was given intravenous fluids and these were discontinued.  She was able to maintain her pressures then was able to ambulate without difficulty.  We had wanted to pursue workup for possible causes for autonomic dysfunction; however, the patient was not interested in remaining in the hospital anymore and left really against our recommendations.,DISCHARGE MEDICATIONS:,1.  CellCept - 500 mg twice a daily.,2.  Cyclosporine - 25 mg in the morning and 15 mg in the evening.,3.  Prednisone - 5 mg once daily.,4.  Hydralazine - 10 mg four times a day.,5.  Pantoprazole - 40 mg once daily.,6.  Glipizide - 5 mg every morning.,7.  Aspirin - 81 mg once daily.,FOLLOWUP CARE:  ,The patient is to follow up with Dr. X in about 1 week's time.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,POSTOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,PROCEDURE PERFORMED:,  Subxiphoid pericardiotomy.,ANESTHESIA:,  General via ET tube.,ESTIMATED BLOOD LOSS: , 50 cc.,FINDINGS:,  This is a 70-year-old black female who underwent a transhiatal esophagectomy in November of 2003.  She subsequently had repeat chest x-rays and CT scans and was found to have a moderate pericardial effusion.  She had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic.  Also, during that time, she had become significantly more short of breath.  A dobutamine stress echocardiogram was performed, which was negative with the exception of the pericardial effusions.  She had no tamponade physiology.,INDICATION FOR THE PROCEDURE: , For therapeutic and diagnostic management of this symptomatic pericardial effusion.  Risks, benefits, and alternative measures were discussed with the patient.  Consent was obtained for the above procedure.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion.  A 4 cm incision was created in the midline above the xiphoid.  Dissection was carried down through the fascia and the xiphoid was resected.  The sternum was retracted superiorly the pericardium was identified and pericardial fat was cleared off the pericardium.  An #0 silk suture was then placed into the pericardium with care taken not to enter the underlying heart.,This suture was used to retract the pericardium and the pericardium was nicked with #15 blade under direct visualization.  Serous fluid exited through the pericardium and was sent for culture, cytology, and cell count etc.  A section of pericardium was taken approximately 2 cm x 2 cm x 2 cm and was removed.  The heart was visualized and appeared to be contracting well with no evidence of injury to the heart.  The pericardium was then palpated.  There was no evidence of studding.  A right angle chest tube was then placed in the pericardium along the diaphragmatic of the pericardium and then brought out though a small skin incision in the epigastrium.  It was sewn into place with #0 silk suture.  There was some air leak of the left pleural cavity, so a right angle chest tube was placed in the left pleural cavity and brought out through a skin nick in the epigastrium.  It was sewn in the similar way to the other chest tube.  Once again, the area was inspected and found to be hemostatic and then closed with #0 Vicryl suture for fascial stitch, then #3-0 Vicryl suture in the subcutaneous fat, and then #4-0 undyed Vicryl in a running subcuticular fashion.  The patient tolerated the procedure well.  Chest tubes were placed on 20 cm of water suction.  The patient was taken to PACU in stable condition.", Surgery,38
"HISTORY OF PRESENT ILLNESS: , A 71-year-old female who I am seeing for the first time.  She has a history of rheumatoid arthritis for the last 6 years.  She was followed by another rheumatologist.  She says she has been off and on, on prednisone and Arava.  The rheumatologist, as per the patient, would not want her to be on a long-term medicine, so he would give her prednisone and then switch to Arava and then switch her back to prednisone.  She says she had been on prednisone for the last 6 to 9 months.  She is on 5 mg a day.  She recently had a left BKA and there was a question of infection, so it had to be debrided.  I was consulted to see if her prednisone is to be continued.  The patient denies any joint pains at the present time.  She says when this started she had significant joint pains and was unable to walk.  She had pain in the hands and feet.  Currently, she has no pain in any of her joints.,REVIEW OF SYSTEMS: , Denies photosensitivity, oral or nasal ulcer, seizure, psychosis, and skin rashes.,PAST MEDICAL HISTORY: , Significant for hypertension, peripheral vascular disease, and left BKA.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , Denies tobacco, alcohol or illicit drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS:  BP 130/70, heart rate 80, and respiratory rate 14.,HEENT:  EOMI.  PERRLA.,NECK:  Supple.  No JVD.  No lymphadenopathy.,CHEST:  Clear to auscultation.,HEART:  S1 and S2.  No S3, no murmurs.,ABDOMEN:  Soft and nontender.  No organomegaly.,EXTREMITIES:  No edema.,NEUROLOGIC:  Deferred.,ARTICULAR:  She has swelling of bilateral wrists, but no significant tenderness.,LABORATORY DATA:,  Labs in chart was reviewed.,ASSESSMENT AND PLAN:,  A 71-year-old female with a history of rheumatoid arthritis, on longstanding prednisone.  She is not on DMARD, but as she recently had a surgery followed by a probable infection, I will hold off on that.  As she has no pain, I have decreased the prednisone to 2.5 mg a day starting tomorrow if she is to go back to her nursing home tomorrow.  If in a couple of weeks her symptoms stay the same, then I would discontinue the prednisone.  I would defer that to Dr. X.  If she flares up at that point, prednisone may have to be restarted with a DMARD, so that eventually she could stay off the prednisone.  I discussed this at length with the patient and she is in full agreement with the plan.  I explained to her that if she is to be discharged, if she wishes, she could follow up with me in clinic or if she goes back to Victoria, then see her rheumatologist over there.", Rheumatology,34
"DISCHARGE DISPOSITION:,  The patient was discharged by court as a voluntary drop by prosecution.  This was AMA against hospital advice.,DISCHARGE DIAGNOSES:,AXIS I:  Schizoaffective disorder, bipolar type.,AXIS II:  Deferred.,AXIS III:  Hepatitis C.,AXIS IV:  Severe.,AXIS V:  19.,CONDITION OF PATIENT ON DISCHARGE: , The patient remained disorganized.  The patient was suffering from prolactinemia secondary to medications.,DISCHARGE FOLLOWUP:  ,To be arranged per the patient as the patient was discharged by court.,DISCHARGE MEDICATIONS: , A 2-week supply of the following was phoned into the patient's pharmacy:  Seroquel 25 mg p.o. nightly.  Zyprexa 5 mg p.o. b.i.d.,MENTAL STATUS AT THE TIME OF DISCHARGE:,  Attitude was cooperative.  Appearance showed fair hygiene and grooming.  Psychomotor behavior showed restlessness.  No EPS or TD was noted.  Affect was restricted.  Mood remained anxious and speech was pressured.  Thoughts remained tangential, and the patient endorsed paranoid delusions.  The patient denied auditory hallucinations.  The patient denied suicidal or homicidal ideation, was oriented to person and place.  Overall, insight into her illness remained impaired.,HISTORY AND HOSPITAL COURSE: , The patient is a 22-year-old female with a history of bipolar affective disorder, was initially admitted for evaluation of increasing mood lability, disorganization, and inappropriate behaviors.  The patient reportedly was asking her father to have sex with her and tried to pull down her mother's pants.  The patient took her clothing off, was noted to be very disorganized sexually, and religiously preoccupied, and endorsed auditory hallucinations of voices telling her to calm herself and others.  The patient has a history of depression versus bipolar disorder, last hospitalized in Pierce County in 2008, but without recent treatment.  The patient on admission interview was noted to be labile and disorganized.  The patient was initiated on Risperdal M-Tab 2 mg p.o. b.i.d. for psychosis and mood lability, and also medically evaluated by Rebecca Richardson, MD.  The patient remained labile and suspicious during her hospital stay.  The patient continued to be sexually preoccupied and had poor insight into her need for treatment.  The patient denied further auditory hallucinations.  The patient was treated with Seroquel for persistent mood lability and psychosis.  The patient was noted to develop prolactinemia with Risperdal and this was changed to Zyprexa prior to discharge.  The patient remained disorganized, but was given a voluntary drop by prosecution against medical advice when she went to court on 01/11/2010.  The patient was discharged to return home to her parents and was referred to Community Mental Health Agencies.  The patient was thus discharged in symptomatic condition.", Psychiatry / Psychology,32
"PREOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1.  Excision of mass, left second toe.,2.  Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot.  The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size.  The patient also has history of shave biopsy in the past.  The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses.  The foot was lowered to the operating table.  The stockinet was reflected and the foot was cleansed with wet and dry sponge.  A distal Syme's incision was planned over the distal aspect of the left hallux.  The incision was performed with a #10 blade and deepened with #15 down to the level of bone.  The dorsal skin flap was removed and dissected in toto off of the distal phalanx.  There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx.  The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer.  Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen.  At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx.  The area was inspected for any remaining suspicious tissues.  Any suspicious tissue was removed.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe.  There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe.  A linear incision was made just medial to the tissue mass.  The mass was then dissected from the overlying skin and off of the underlying capsule.  This tissue mass was hard, round, and pearly-gray in appearance.  It does not invade into any other surrounding tissues.  The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon.  Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed.  The patient will be contacted immediately pending the results of pathology.  Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.", Podiatry,31
"PREOPERATIVE DIAGNOSIS: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,POSTOPERATIVE DIAGNOSES: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C3-4.,2.  Arthrodesis with anterior interbody fusion, C3-4.,3.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: , 1800 mL of crystalloids.,URINE OUTPUT:  ,1000 mL.,SPECIMENS: , None.,COMPLICATIONS:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  ,Less than 100 mL.,CONDITION:  ,To postanesthesia care unit extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:  ,This is a case of a very pleasant 32-year-old Caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop.  Since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening.  About two days ago, he started noticing weakness on the left arm.  The patient also noted shuffling gait.  The patient presented to a family physician and was referred to Dr. X for further evaluation.  Dr. X could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an MRI of the brain was essentially unremarkable as well as MRI of the thoracic spine.  MRI of the cervical spine, however, revealed an acute disk herniation at C3-C4 with evidence of stenosis and cord changes.  Based on these findings, I recommended decompression.  The patient was started on Decadron at 10 mg IV q.6h.  Operation, expected outcome, risks, and benefits were discussed with him.  Risks to include but not exclusive of bleeding and infection.  Bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma.  The hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function.  Should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient.  There is also the possibility of infection, which can be superficial and treated with IV and p.o. antibiotics.  However, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation.  This may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed.  There is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele.  This too can compromise airway and may require return to the operating room for repair of the dural tear.  There is also potential risk of injury to the esophagus, the trachea, as well as the carotid.  The patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation.  The patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  No monitoring leads were placed.  The patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders.  Localizing x-ray verified the marker to be right at the C3-4 interspace.  Proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion.  The anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath.  The prevertebral fascia was identified.  Localizing x-ray verified another marker to be at the C3-4 interspace.  Proceeded to strip the longus colli muscles off the vertebral body of C3 and C4 and a self-retaining retractor was then laid out.  There was some degree of anterior osteophyte and this was carefully drilled down with a Midas 5-mm bur.  The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur.  The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4.  There was note of a central disk herniation centrally, but more marked displacement of the cord on the left side.  By careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed.  Hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of Gelfoam on the patient's left because of profuse venous bleeder.  With this completed, the Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant with its interior packed with Vitoss was then tapped into place.  An 18-mm plate was then screwed down with four 14 x 4.0 mm screws.  The area was irrigated with saline, with bacitracin solution.  Postoperative x-ray showed excellent placement of the graft and spinal instrumentation.  A round French 10 JP drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl 4-0 subcuticular stitch for the dermis and Dermabond.  The catheter was anchored to the skin with a nylon 3-0 stitch.  Dressing was placed only on the exit site of the drain.  C-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities.", Neurosurgery,23
"CHIEF COMPLAINT:,  Essential thrombocytosis.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 64-year-old gentleman who I am following for essential thrombocytosis.  He was first diagnosed when he first saw a hematologist on 07/09/07.  At that time, his platelet count was 1,240,000.  He was initially started on Hydrea 1000 mg q.d.  On 07/11/07, he underwent a bone marrow biopsy, which showed essential thrombocytosis.  He was positive for the JAK-2 mutation.  On 11/06/07, his platelets were noted to be 766,000.  His current Hydrea dose is now 1500 mg on Mondays and Fridays and 1000 mg on all other days.  He moved to ABCD in December 2009 in an attempt to improve his wife's rheumatoid arthritis.,Overall, he is doing well.  He has a good energy level, and his ECOG performance status is 0.  He denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Hydrea 1500 mg on Mondays and Fridays and 1000 mg the other days of the week,  Flomax q.d., vitamin D q.d, saw palmetto q.d., aspirin 81 mg q.d., and vitamin C q.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:,  As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post an appendectomy.,2.  Status post a tonsillectomy and adenoidectomy.,3.  Status post bilateral cataract surgery.,4.  BPH.,SOCIAL HISTORY:  ,He has a history of tobacco use, which he quit at the age of 37.  He has one alcoholic drink per day.  He is married.  He is a retired lab manager.,FAMILY HISTORY:  ,There is no history of solid tumor or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:", Hematology - Oncology,16
"CHIEF COMPLAINT:  ,Penile cellulitis status post circumcision.,HISTORY OF PRESENT ILLNESS: , The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge.  The child initially had a newborn circumcision at about 1 week of life and then developed a concealed or buried penis with extra skin and tightness of the skin.  He underwent a second circumcision with a general anesthetic approximately 8 to 9 days ago.  The mother states that on Thursday, he developed fairly significant swelling, scrotum was also swollen, the suprapubic region was swollen, and he was having a purulent discharge and a fairly significant fever to 102 to 103.  He was seen at Hospital, transferred to Children's Hospital for further care.  Since being hospitalized, his cultures apparently have grown Staph but is unknown yet whether it is methicillin-resistant.  He has been placed on clindamycin, and he is now currently afebrile and with marked improvement according to the mother.  I was requested a consultation by Dr. X because of the appearance of penis.  The patient has been voiding without difficulty throughout.,PAST MEDICAL HISTORY: , The patient has no known allergies.  He was a term delivery via vaginal delivery.  Surgeries; he has had 2 circumcisions.  No other hospitalizations.  He has had no heart murmurs, seizures, asthma, or bronchitis.,REVIEW OF SYSTEMS: , A 14-point review of systems was negative with the exception of the penile and scrotal cellulitis and the surgeries as mentioned.  He also had an ear infection about 1 to 2 weeks before his circumcision.,SOCIAL HISTORY: , The patient lives with both parents and no siblings.  There are smokers at home.,MEDICATIONS: , Clindamycin and bacitracin ointment.  Also Bactrim.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight is 14.9 kg.,GENERAL:  The patient was sleepy but easily arousable.,HEAD AND NECK:  Grossly normal.  His neck and chest are without masses.,NARES:  He had some crusted nares; otherwise, no other discharge.,LUNGS:  Clear.,CARDIAC:  Without murmurs or gallops.,ABDOMEN:  Soft without masses or tenderness.,GU:  He has a fairly prominent suprapubic fat pad, and he is quite a large child in any event; however, there were no signs of erythema.  There was some induration around the penis; however, there were no signs of active infection.  He has a buried appearance of the penis after recent circumcision with a normal appearing glans.  The tissue itself, however, was quite dull and is soft or readily retractable at this time.  The scrotum was normal, and there was no erythema, there was no tenderness.  Both testes were descended without hydroceles.,EXTREMITIES:  He has full range of motion of all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,BACK:  Normal.,IMPRESSION/PLAN: , The patient had a recent circumcision with a fairly prominent suprapubic fat pad but also has a penile and suprapubic cellulitis.  This is being treated, but it is most likely Staph and pending sensitivities.  I talked to the mother and told her that at this point the swelling that is present is a mixture of the resolving cellulitis from a suprapubic fat pad.  I recommended that he be treated most likely with Bactrim for a 10-day course at home, bacitracin, or some antibiotics ointment to the penis with each diaper change for the next 2 to 3 weeks with sitz bath once or twice a day.  I told the mother that initially the tissues are going to be quite dull because of the infection and the recent surgery, but she ultimately will have to gently retract the skin to keep it from adhering again because of the prominent suprapubic fat pad, which makes it more likely.  Otherwise, it is a fairly healthy-appearing tissue at the present time and she knows the reasons that he cannot be discharged once the hospitalist service believes that it is appropriate to do so.  He has a scheduled followup appointment with his urologist  and he should keep that appointment or followup sooner if there is any other problem arising.", Urology,39
"HISTORY OF PRESENT ILLNESS: ,This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain.  He states that this began approximately one week ago when he was lifting stacks of cardboard.  The motion that he describes is essentially picking up a stack of cardboard at his waist level, twisting to the right and delivering it at approximately waist level.  Sometimes he has to throw the stacks a little bit as well.  He states he felt a popping sensation on 06/30/04.  Since that time, he has had persistent shoulder pain with lifting activities.  He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder.  He has no upper extremity .  , ,REVIEW OF SYSTEMS: ,Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies.  He denies any chronic cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine abnormalities.  , ,MEDICATIONS: , Claritin for allergic rhinitis.  , ,ALLERGIES: , None.  , ,PHYSICAL EXAMINATION:, Blood pressure 120/90, respirations 10, pulse 72, temperature 97.2.  He is sitting upright, alert and oriented, and in no acute distress.  Skin is warm and dry. Gross neurologic examination is normal.  ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes.  Neck: Full range of motion with no adenopathy or thyromegaly.  Cardiovascular:  Regular rate and rhythm.  Lungs:  Clear.  Abdomen: Soft.", Consult - History and Phy.,5
"FINDINGS:,There are post biopsy changes seen in the retroareolar region, middle third aspect of the left breast at the post biopsy site.,There is abnormal enhancement seen in this location compatible with patient’s history of malignancy.,There is increased enhancement seen in the inferior aspect of the left breast at the 6:00 o’clock, N+5.5 cm position measuring 1.2 cm. Further work-up with ultrasound is indicated.,There are other multiple benign appearing enhancing masses seen in both the right and left breasts.,None of the remaining masses appear worrisome for malignancy based upon MRI criteria.,IMPRESSION:,  BIRADS CATEGORY M/5,There is a malignant appearing area of enhancement in the left breast which does correspond to the patient’s history of recent diagnosis of malignancy.,She has been scheduled to see a surgeon, as well as Medical Oncologist.,Dedicated ultrasonography of the inferior aspect of the left breast should be performed at the 6:00 o’clock, N+5.5 cm position for further evaluation of the mass. At that same time, ultrasonography of the remaining masses should also be performed.,Please note, however that the remaining masses have primarily benign features based upon MRI criteria. However, further evaluation with ultrasound should be performed.", Radiology,33
"NERVE CONDUCTION STUDIES:,  Bilateral ulnar sensory responses are absent.  Bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude.  The left radial sensory response is normal and robust.  Left sural response is absent.  Left median motor distal latency is prolonged with attenuated evoked response amplitude.  Conduction velocity across the forearm is mildly slowed.  Right median motor distal latency is prolonged with a normal evoked response amplitude and conduction velocity.  The left ulnar motor distal latency is prolonged with a severely attenuated evoked response amplitude both below and above the elbow.  Conduction velocities across the forearm and across the elbow are prolonged.  Conduction velocity proximal to the elbow is normal.  The right median motor distal latency is normal with normal evoked response amplitudes at the wrist with a normal evoked response amplitude at the wrist.  There is mild diminution of response around the elbow.  Conduction velocity slows across the elbow.  The left common peroneal motor distal latency evoked response amplitude is normal with slowed conduction velocity across the calf and across the fibula head.  F-waves are prolonged.,NEEDLE EMG: , Needle EMG was performed on the left arm and lumbosacral and cervical paraspinal muscles as well as middle thoracic muscles using a disposable concentric needle.  It revealed spontaneous activity in lower cervical paraspinals, left abductor pollicis brevis, and first dorsal interosseous muscles.  There were signs of chronic reinnervation in triceps, extensor digitorum communis, flexor pollicis longus as well first dorsal interosseous and abductor pollicis brevis muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  A sensory motor length-dependent neuropathy consistent with diabetes.,2.  A severe left ulnar neuropathy.  This is probably at the elbow, although definitive localization cannot be made.,3.  Moderate-to-severe left median neuropathy.  This is also probably at the carpal tunnel, although definitive localization cannot be made.,4.  Right ulnar neuropathy at the elbow, mild.,5.  Right median neuropathy at the wrist consistent with carpal tunnel syndrome, moderate.,6.  A left C8 radiculopathy (double crush syndrome).,7.  There is no evidence for thoracic radiculitis.,The patient has made very good response with respect to his abdominal pain since starting Neurontin.  He still has mild allodynia and is waiting for authorization to get insurance coverage for his Lidoderm patch.  He is still scheduled for MRI of C-spine and T-spine.  I will see him in followup after the above scans.", Physical Medicine - Rehab,30
"PREOPERATIVE DIAGNOSIS:  ,Right ureteropelvic junction obstruction.,POSTOPERATIVE DIAGNOSES:,1.  Right ureteropelvic junction obstruction.,2.  Severe intraabdominal adhesions.,3.  Retroperitoneal fibrosis.,PROCEDURES PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Attempted laparoscopic pyeloplasty.,3.  Open laparoscopic pyeloplasty.,ANESTHESIA:,  General.,INDICATION FOR PROCEDURE:  ,This is a 62-year-old female with a history of right ureteropelvic junction obstruction with chronic indwelling double-J ureteral stent.  The patient presents for laparoscopic pyeloplasty.,PROCEDURE: , After informed consent was obtained, the patient was taken to the operative suite and administered general anesthetic.  The patient was sterilely prepped and draped in the supine fashion after building up the right side of the OR table to aid in the patient's positioning for bowel retraction.  Hassan technique was performed for the initial trocar placement in the periumbilical region.  Abdominal insufflation was performed.  There were significant adhesions noted.  A second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a Harmonic scalpel was placed through this and adhesiolysis was performed for approximately two-and-half hours, also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus, an additional 5 mm port in the right upper quadrant subcostal and midclavicular.  After adhesions were taken down, the ascending colon was mobilized by incising the white line of Toldt and mobilizing this medially.  The kidney was able to be palpated within Gerota's fascia.  The psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter.  The uterus was grasped with a Babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction.  The renal pelvis was also identified and dissected free.  There was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes.  We were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open.  An incision was made from the right upper quadrant port extending towards the midline.  This was carried down through the subcutaneous tissue, anterior fascia, muscle layers, posterior fascia, and peritoneum.  A Bookwalter retractor was placed.  The renal pelvis and the ureter were again identified.  Fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and Bovie cautery.  The tissue was sent down to Pathology for analysis.  Please note that upon entering the abdomen, all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted.  Ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place.  The renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue.  At this point, the indwelling double-J ureteral stent was removed.  At this time, the ureter was spatulated laterally and at the apex of this spatulation a #4-0 Vicryl suture was placed.  This was brought up to the deepened portion of the pyelotomy and cystic structures were approximated.  The back wall of the ureteropelvic anastomosis was then approximated with running #4-0 Vicryl suture.  At this point, a double-J stent was placed with a guidewire down into the bladder.  The anterior wall of the uteropelvic anastomosis was then closed again with a #4-0 running Vicryl suture.  Renal sinus fat was then placed around the anastomosis and sutured in place.  Please note in the inferior pole of the kidney, there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue.  This was repaired with horizontal mattress sutures #2-0 Vicryl.  FloSeal was placed over this and the renal capsule was placed over this.  A good hemostasis was noted.  A #10 Blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis.  The initial trocar incision was closed with #0 Vicryl suture.  The abdominal incision was also then closed with running #0 Vicryl suture incorporating all layers of muscle and fascia.  The Scarpa's fascia was then closed with interrupted #3-0 Vicryl suture.  The skin edges were then closed with staples.  Please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator.  We placed the patient on IV antibiotics and pain medications.  We will obtain KUB and x-rays for stent placement.  Further recommendations to follow.", Nephrology,21
"ADMISSION DIAGNOSIS:,  End-stage renal disease (ESRD).,DISCHARGE DIAGNOSIS: , End-stage renal disease (ESRD).,PROCEDURE:,  Cadaveric renal transplant.,HISTORY OF PRESENT ILLNESS: , This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis since 1993 and is also status post cadaveric kidney transplant in 1996 with chronic rejection.,PAST MEDICAL HISTORY:  ,1.  Diabetes mellitus diagnosed 12 years ago.,2.  Hypertension.,3.  Coronary artery disease with a myocardial infarct in September of 2006.,4.  End-stage renal disease.,PAST SURGICAL HISTORY: , Coronary artery bypass graft x5 in 1995 and cadaveric renal transplant in 1996.,SOCIAL HISTORY:  ,The patient denies tobacco or ethanol use.,FAMILY HISTORY:,  Hypertension.,PHYSICAL EXAMINATION:  ,GENERAL:  The patient was alert and oriented x3 in no acute distress, healthy-appearing male.,VITAL SIGNS:  Temperature 96.6, blood pressure 166/106, heart rate 83, respiratory rate 18, and saturations 96% on room air.,CARDIOVASCULAR:  Regular rate and rhythm.,PULMONARY:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, and nondistended with positive bowel sounds.,EXTREMITIES:  No clubbing, cyanosis, or edema.,PERTINENT LABORATORY DATA: , White blood cell count 6.4, hematocrit 34.6, and platelet count 182.  Sodium 137, potassium 5.4, BUN 41, creatinine 7.9, and glucose 295.  Total protein 6.5, albumin 3.4, AST 51, ALT 51, alk phos 175, and total bilirubin 0.5.,COURSE IN HOSPITAL: , The patient was admitted postoperatively to the surgical intensive care unit.  Initially, the patient had a decrease in hematocrit from 30 to 25.  The patient's hematocrit stabilized at 25.  During the patient's stay, the patient's creatinine progressively decreased from 8.1 to a creatinine at the time of discharge of 2.3.  The patient was making excellent urine throughout his stay.  The patient's Jackson-Pratt drain was removed on postoperative day #1 and he was moved to the floor.  The patient was advanced in diet appropriately.  The patient was started on Prograf by postoperative day #2.  Initial Prograf levels came back high at 18.  The patient's Prograf doses were changed accordingly and today, the patient is deemed stable to be discharged home.  During the patient's stay, the patient received four total doses of Thymoglobulin.  Today, he will complete his final dose of Thymoglobulin prior to being discharged.  In addition, today, the patient has an elevated blood pressure of 198/96.  The patient is being given an extra dose of metoprolol for this blood pressure.  In addition, the patient has an elevated glucose of 393 and for this reason he has been given an extra dose of insulin.  These labs will be rechecked later today and once his blood pressure has decreased to systolic blood pressure less than 116 and his glucose has come down to a more normal level, he will be discharged to home.,DISCHARGE INSTRUCTIONS: , The patient is discharged with instructions to seek medical attention in the event if he develops fevers, chills, nausea, vomiting, decreased urine output, or other concerns.  He is discharged on a low-potassium diet with activity as tolerated.  He is instructed that he may shower; however, he is to undergo no underwater soaking activities for approximately two weeks.  The patient will be followed up in the Transplant Clinic at ABCD tomorrow, at which time, his labs will be rechecked.  The patient's Prograf levels at the time of discharge are pending; however, given that his Prograf dose was decreased, he will be followed tomorrow at the Renal Transplant Clinic.", Nephrology,21
"REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.  Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month.  The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m.  At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements.  Her daughter called 911 and her symptoms seemed to improve.  Then, she began vomiting.  When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI.  I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG.  She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free.  Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer.  In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage.  We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion.  She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1.  Amiodarone 200 mg once a day.,2.  Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES:  ,CODEINE.  NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes.  She uses alcohol.  No use of illicit drugs.  She is divorced and lives with her daughter.  She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS:  ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22.  O2 saturation 100%.  On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization.  HEENT shows the cranium is normocephalic and atraumatic.  She has dry mucosal membrane.  She now has a right facial droop, which per her daughter is new.  Neck veins are not distended.  No carotid bruits visible.  Skin:  Warm, well perfused.  Lungs are clear to auscultation anteriorly.  No wheezes.  Cardiac exam:  S1, S2, regular rate.  No significant murmurs.  PMI is nondisplaced.  Abdomen:  Soft, nondistended.  Extremities:  Without edema, on limited exam.  Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above.  Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds.  Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized.  I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1.  I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2.  Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3.  Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service.  I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.", Hospice - Palliative Care,17
"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.", Surgery,38
"REASON FOR EXAM: , Right-sided abdominal pain with nausea and fever.,TECHNIQUE: , Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN:  ,The liver, spleen, pancreas, gallbladder, adrenal glands, and kidney are unremarkable.,CT PELVIS: , Within the right lower quadrant, the appendix measures 16 mm and there are adjacent inflammatory changes with fluid in the right lower quadrant.  Findings are compatible with acute appendicitis.,The large and small bowels are normal in course and caliber without obstruction.  The urinary bladder is normal.  The uterus appears unremarkable.  Mild free fluid is seen in the lower pelvis.,No destructive osseous lesions are seen.  The visualized lung bases are clear.,IMPRESSION: , Acute appendicitis.", Nephrology,21
"PREOPERATIVE DIAGNOSIS: , Phimosis.,POSTOPERATIVE DIAGNOSIS: , Phimosis.,PROCEDURE: , Reduction of paraphimosis.,ANESTHESIA:  ,General inhalation anesthetic with 0.25% Marcaine, penile block and ring block about 20 mL given.,FLUIDS RECEIVED: , 100 mL.,SPECIMENS:,  No tissues sent to pathology.,COUNTS: , Sponge and needle counts were not necessary.,TUBES/DRAINS: , No tubes or drains were used.,FINDINGS: , Paraphimosis with moderate swelling.,INDICATIONS FOR OPERATION: , The patient is a 15-year-old boy who had acute alcohol intoxication had his foreskin retracted with a Foley catheter placed at another institution.  When they removed the catheter they forgot to reduce the foreskin and he developed paraphimosis.  The plan is for reduction.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, with manual pressure and mobilization of the shaft skin we were able to reduce the paraphimosis.  Using Betadine and alcohol cleanse, we then did a dorsal penile block and a ring block by surgeon with 0.25% Marcaine, 20 mL were given.  He did quite well after the procedure and was transferred to the recovery room in stable condition.", Surgery,38
"Sample Address,Re:  Mrs. Sample Patient,Dear Sample Doctor:,I had the pleasure of seeing your patient, Mrs. Sample Patient , in my office today.  Mrs. Sample Patient is a 48-year-old, African-American female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermittent rectal bleeding.  The patient denies any weight loss, does have a good appetite, no nausea and no vomiting.,PAST MEDICAL HISTORY:,  Significant for hypertension and diabetes.,PAST SURGICAL HISTORY:,  The patient denies any past surgical history.,MEDICATIONS:,  The patient takes Cardizem CD 240-mg.  The patient also takes eye drops.,ALLERGIES:,  The patient denies any allergies.,SOCIAL HISTORY:,  The patient smokes about a pack a day for more than 25 years.  The patient drinks alcohol socially.,FAMILY HISTORY:,  Significant for hypertension and strokes.,REVIEW OF SYSTEMS:,  The patient does have a good appetite and no weight loss.  She does have intermittent rectal bleeding associated with irritation in the rectal area.  The patient denies any nausea, any vomiting, any night sweats, any fevers or any chills.,The patient denies any shortness of breath, any chest pain, any irregular heartbeat or chronic cough.,The patient is chronically constipated.,PHYSICAL EXAMINATION:,  This is a 48 year-old lady who is awake, alert and oriented x 3.  She does not seem to be in any acute distress.  Her vital signs are blood pressure is 130/70 with a heart rate of 75 and respirations of 16.  HEENT is normocephalic, atraumatic.  Sclerae are non-icteric.  Her neck is supple, no bruits, no lymph nodes.  Lungs are clear to auscultation bilaterally, no crackles, no rales and no wheezes.  The cardiovascular system has a regular rate and rhythm, no murmurs.  The abdomen is soft and non-tender.  Bowel sounds are positive and no organomegaly.  Extremities have no edema.,IMPRESSION:,  This is a 48-year-old female presenting with painless rectal bleeding not associated with any weight loss.  The patient is chronically constipated.,1.  Rule out colon cancer.,2.  Rule out colon polyps. ,3.  Rule out hemorrhoids, which is the most likely diagnosis.,RECOMMENDATIONS:,  Because of the patient's age, the patient will need to have a complete colonoscopy exam.,The patient will also need to have a CBC check and monitor.,The patient will be scheduled for the colonoscopy at Sample Hospital and the full report will be forwarded to your office.,Thank you very much for allowing me to participate in the care of your patient.,Sincerely yours,,Sample Doctor, MD", Gastroenterology,14
"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.", Pain Management,28
"DISCHARGE DIAGNOSES:,1.  Central nervous system lymphoma.,2.  Gram-negative bacteremia.,3.  Pancytopenia.,4.  Hypertension.,5.  Perianal rash.,6.  Diabetes mellitus.,7.  Hypoxia.,8.  Seizure prophylaxis.,9.  Acute kidney injury.,PROCEDURES DURING HOSPITALIZATION:,1.  Cycle five high-dose methotrexate.,2.  Rituxan weekly.,3.  Chest x-ray.,4.  Wound consult.,HISTORY OF PRESENT ILLNESS: , Ms. ABC is a pleasant 60-year-old Caucasian female who was diagnosed in April 2008 with diffuse large B-cell lymphoma after she developed visual saltation, changes, and confusion.  Further staging revealed borderline mediastinal pretracheal lymphadenopathy but was otherwise unremarkable.  She began high-dose methotrexate in mid May 2008; courses of methotrexate have been complicated by prolonged methotrexate levels, mental confusion, and mania.  During cycle three, repeat MRI showed interval worsening of disease, and Rituxan was added to her regimen.  Ms. ABC had a repeat MRI on July 24, 2008 prior to this admission, which showed significant improvement in her CNS disease.,HOSPITAL COURSE: , Ms. ABC was admitted to the Hematology B Service under attending Dr. Z.,1.  CNS lymphoma.  Upon admission, she was started on her Rituxan, which she tolerated well.  She was then hydrated with bicarbonate solution to a urine pH of 8.  She received methotrexate 5 g/m2.  24-hour creatinine was 0.9, 48-hour methotrexate level was elevated at 2.08.  This was likely secondary to the need to initiate treatment with antibiotics secondary to infection.  Her leucovorin was increased to 100 mg/m2.  72-hour methotrexate level was 0.58.  96-hour methotrexate was 0.16, and 19-hour was 0.08.  She continued additional four doses of oral leucovorin.  Her creatinine improved.  On day prior to discharge, she received her weekly dose of Rituxan.  She will return for Rituxan next week and then return for an appointment with Dr. X on August 18, 2008 with plans for admission for next cycle of methotrexate.,2.  Gram-negative bacteremia.  On the morning of June 27, 2008, Ms. ABC did spike a fever.  She was started on empiric antibiotics with cefepime and vancomycin.  Cultures were drawn peripherally and from the Port-A-Cath which both grew out Gram-negative rods within 12 hours.  After being initiated on IV antibiotics, she remained afebrile for the remainder of the hospitalization.  Both cultures eventually grew out Proteus mirabilis, which was pansensitive.  She had three additional blood cultures, which were all negative.  On the day prior to discharge, she was transitioned to oral Cipro and remained afebrile.  We had intended to send her home with oral antibiotics; however, by day of discharge, she was pancytopenic and it was decided that she should be discharged to complete a 14-day course of IV antibiotics with cefepime.  She will continue this with the assistance of home health services.  She was advised to follow neutropenic precautions and labs will be followed closely as an outpatient.  She understands if she develops a fever greater than 100.5, she should call to return immediately for admission.,3.  Pancytopenia.  On the day of discharge, the patient was pancytopenic with white count of 0.7, ANC of 500, hemoglobin 8.5, hematocrit 24.8, and platelet count 38, 000.  Her labs will be followed closely as an outpatient.  During the admission, we did obtain a HIT antibody, which was negative.  Heparin was held until this level was returned.  She was placed on Arixtra for prophylaxis against thrombus.  It is thought that her decreasing counts may be secondary to infection; however, if she continues to be pancytopenic, she will have a repeat bone marrow as an outpatient.,4.  Hypertension.  Blood pressure remained stable throughout the admission.  She will continue lisinopril daily.,5.  Perianal rash.  Upon admission, she was found to have worsening of a candidal rash in the perianal region.  A wound consult was obtained.  They recommended Aloe Vesta foam and Silver gel to the area topically.  She was also continued on Diflucan 200 mg daily.  She will complete a 10-day course.,6.  Diabetes mellitus.  At the time of admission, she was found to have hyperglycemia.  She was started on sliding scale insulin and eventually started on long-acting Lantus insulin.  She will be discharged with the regimen of Lantus 35 units at bedtime and continue the sliding scale as needed.,7.  Hypoxia.  She did have evidence of decreased saturations.  There was concern that she may have a pneumonia, which was treated with vancomycin for possible hospital acquired pneumonia; however, upon further review of the blood cultures improved, chest x-ray consistent with atelectasis and normal saturations that this was likely secondary to increased fluids associated with methotrexate and atelectasis from being confined to bed.,8.  Seizure prophylaxis.  She will continue Keppra twice daily.,9.  Acute kidney injury.  She did have a bump in the creatinine when methotrexate level was elevated.  This resolved by the time of discharge.  Creatinine on day of discharge is 0.9.  This will be followed as an outpatient.,DISPOSITION: , To home in stable condition with home health services.,DISCHARGE MEDICATIONS: , See separate sheet attached.,DIET:,  Neutropenic diabetic.,ACTIVITY: , Resume same activity.,FOLLOWUP: , With weekly lab work and plans for admission on August 18, 2008.  Ms. ABC was advised if she has any problems or concerns in the interim and needs to be seen sooner, she should call.", Discharge Summary,10
"PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammertoe, bilateral third, fourth, and fifth toes.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammertoe, bilateral third, fourth, and fifth toes.,PROCEDURE PERFORMED:,1.  Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2.  Proximal interphalangeal joint arthroplasty, bilateral fifth toes.,3.  Distal interphalangeal joint arthroplasty, bilateral third and fourth toes.,4.  Flexor tenotomy, bilateral third toes.,HISTORY:,  This is a 36-year-old female who presented to ABCD preoperative holding area after keeping herself n.p.o. since mid night for surgery on her painful bunion to her right foot and her painful hammertoes to both feet.  The patient has a history of sharp pain, which is aggravated by wearing shoes and ambulation.  She has tried multiple conservative methods and treatment such as wide shoes and accommodative padding, all of which provided inadequate relief.  At this time, she desires attempted surgical correction.  The risks versus benefits of the procedure have been discussed in detail by Dr. Kaczander with the patient and the consent is available on the chart.,PROCEDURE IN DETAIL:,  After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with a safety strap placed across her waist for her protection.,Copious amounts of Webril were applied about both ankles and a pneumatic ankle tourniquet was applied over the Webril.  After adequate IV sedation was administered, a total of 18 cc of a 0.5% Marcaine plain was used to anesthetize the right foot, performing a Mayo block and a bilateral third, fourth, and fifth digital block.  Next, the foot was prepped and draped in the usual aseptic fashion bilaterally.  The foot was elevated off the table and an Esmarch bandage was used to exsanguinate the right foot.  The pneumatic ankle tourniquet was elevated on the right foot to 200 mmHg.  The foot was lowered into operative field and the sterile stockinet was reflected proximally.  Attention was directed to the right first metatarsophalangeal joint, it was found to be contracted and there was lateral deviation of the hallux.  There was decreased range of motion of the first metatarsophalangeal joint.  A dorsolinear incision was made with a #10 blade, approximately 4 cm in length.  The incision was deepened to the subcutaneous layer with a #15 blade.  Any small veins traversing the subcutaneous layer were ligated with electrocautery.  Next, the medial and lateral wound margins were undermined sharply.  Care was taken to avoid the medial neurovascular bundle and the lateral extensor hallucis longus tendon.  Next, the first metatarsal joint capsule was identified.  A #15 blade was used to make a linear capsular incision down to the bone.  The capsular periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound.  The PASA was found to be within normal limits.  There was a hypertrophic medial eminence noted.  A sagittal saw was used to remove the hypertrophic medial eminence.  A 0.045 inch Kirschner wire was placed into the central medial aspect of the metatarsal head as an access guide.  A standard lateral release was performed.  The fibular sesamoid was found to be in the interspace, but was relocated onto the metatarsal head properly.  Next, a sagittal saw was used to perform a long arm Austin osteotomy.  The K-wire was removed.  The capital fragment was shifted laterally and impacted into the head.  A 0.045 inch Kirschner wire was used to temporarily fixate the osteotomy.  A 2.7 x 16 mm Synthes, fully threaded cortical screw was throne using standard AO technique.  A second screw was throne, which was a 2.0 x 12 mm Synthes cortical screw.  Excellent fixation was achieved and the screws tightly perched the bone.  Next, the medial overhanging wedge was removed with a sagittal saw.  A reciprocating rasp was used to smooth all bony prominences.  The 0.045 inch Kirschner wire was removed.  The screws were checked again for tightness and found to be very tight.  The joint was flushed with copious amounts of sterile saline.  A #3-0 Vicryl was used to close the capsular periosteal tissues with simple interrupted suture technique.  A #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted technique.  A #5-0 Monocryl was used to close the skin in a running subcuticular fashion.,Attention was directed to the right third digit, which was found to be markedly contracted at the distal interphalangeal joint.  A #15 blade was used to make two convergent semi-elliptical incisions over the distal interphalangeal joint.  The incision was deepened with a #15 blade.  The wedge of skin was removed in full thickness.  The long extensor tendon was identified and the distal and proximal borders of the wound were undermined.  The #15 blade was used to transect the long extensor tendon, which was reflected proximally.  The distal interphalangeal joint was identified and the #15 blade was placed in the joint and the medial and lateral collateral ligaments were released.  Crown and collar scissors were used to release the planar attachment to the head of the middle phalanx.  Next, a double action bone cutter was used to resect the head of the middle phalanx.  The toe was dorsiflexed and was found to have an excellent rectus position.  A hand rasp was used to smooth all bony surfaces.  The joint was flushed with copious amounts of sterile saline.  The flexor tendon was found to be contracted, therefore, a flexor tenotomy was performed through the dorsal incision.  Next, #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures.  A #4-0 nylon was used to close the skin and excellent cosmetic result was achieved.,Attention was directed to the fourth toe, which was found to be contracted at the distal interphalangeal joint and abducted and varus rotated.  An oblique skin incision with two converging semi-elliptical incisions was created using #15 blade.  The rest of the procedure was repeated exactly the same as the above paragraph to the third toe on the right foot.  All the same suture materials were used.  However, there was no flexor tenotomy performed on this toe, only on the third toe bilaterally.,Attention was directed to the fifth right digit, which was found to be contracted at the proximal interphalangeal joint.  A linear incision approximately 2 cm in length was made with a #15 blade over the proximal interphalangeal joint.  Next, a #15 blade was used to deepen the incision to the subcutaneous layer.  The medial and lateral margins were undermined sharply to the level of the long extensor tendon.  The proximal interphalangeal joint was identified and the tendon was transected with the #15 blade.  The tendon was reflected proximally, off the head of the proximal phalanx.  The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound.  A double action bone nibbler was used to remove the head of the proximal phalanx.  A hand rasp was used to smooth residual bone.  The joint was flushed with copious amounts of saline.  A #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures.  A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress sutures.,A standard postoperative dressing consisting of saline-soaked #0-1 silk, 4 x 4s, Kerlix, Kling, and Coban were applied.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,Attention was directed to the left foot.  The foot was elevated off the table and exsanguinated with an Esmarch bandage and the pneumatic ankle tourniquet was elevated to 200 mmHg.  Attention was directed to the left fifth toe, which was found to be contracted at the proximal interphalangeal joint.  The exact same procedure, performed to the right fifth digit, was performed on this toe, with the same materials being used for suture and closure.,Attention was then directed to the left fourth digit, which was found to contracted and slightly abducted and varus rotated.  The exact same procedure as performed to the right fourth toe was performed, consisting of two semi-elliptical skin incisions in an oblique angle.  The same suture material were used to close the incision.,Attention was directed to the left third digit, which was found to be contracted at the distal interphalangeal joint.  The same procedure performed on the right third digit was also performed.  The same suture materials were used to close the wound and the flexor tenotomy was also performed at this digit.  A standard postoperative dressing was also applied to the left foot consisting of the same materials as described for the right foot.  The pneumatic tourniquet was released and immediate hyperemic flush was noted to the digits.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the foot.  She was given postoperative shoes and will be partial weighbearing with crutches.  She was admitted short-stay to Dr. Kaczander for pain control.  She was placed on Demerol 50 and Vistaril 25 mg IM q3-4h. p.r.n. for pain.  She will have Vicodin 5/500 one to two p.o. q.4-6h. p.r.n. for moderate pain.  She was placed on Subq. heparin and given incentive spirometry 10 times an hour.  She will be discharged tomorrow.  She is to ice and elevate both feet today and rest as much as possible.,Physical Therapy will teach her crutch training today.  X-rays were taken in the postoperative area and revealed excellent position of the screws and correction of bunion deformity as well as the hammertoe deformities.", Surgery,38
"SUBJECTIVE:,  This 32-year-old female comes in again still having not got a primary care physician.  She said she was at Dr. XYZ office today for her appointment, and they cancelled her appointment because she has not gotten her Project Access insurance into affect.  She says that Project Access is trying to find her a doctor.  She is not currently on Project Access, and so she is here to get something for the pain in her foot.  I did notice that she went in to see Dr. XYZ for a primary care physician on 05/14/2004.  She said she does not have a primary care physician.  She was in here just last week and saw Dr. XYZ for back pain and was put on pain medicines and muscle relaxers.  She has been in here multiple times for different kinds of pain.  This pain she is having is in her foot.  She had surgery on it, and she has plates and screws.  She said she was suppose to see Dr. XYZ about getting some of the hardware out of it.  The appointment was cancelled, and that is why she came here.  It started hurting a lot yesterday, but she had this previous appointment with Dr. XYZ so she thought she would take care of it there, but they would not see her.  She did not injure her foot in any way recently.  It is chronically painful.  Every time she does very much exercise it hurts more.  We have x-rayed it in the past.  She has some hardware there.  It does not appear to be grossly abnormal or causing any loosening or problems on x-ray.,PHYSICAL EXAM: , Examination of her foot shows some well-healed surgical scars.  On the top of her foot she has two, and then on the lateral aspect below her ankle she has a long scar.  They are all old, and the surgery was done over a year ago.  She is walking with a very slight limp.  There is no redness.  No heat.  No swelling of the foot or the ankle.  It is mildly tender around the medial side of the foot just inferior to the medial malleolus.  It is not warm or red.,ASSESSMENT:,  Foot pain.,PLAN:,  She has been in here before.  She seems very pleasant.  Thought maybe she certainly might be having some significant pain, so I gave her some Lortab 7.5 to take with a refill.  After she left, I got to thinking about it and looked into her record.  She has been in here multiple times for pain medicine.  She has a primary care physician, and now she is telling us she does not have a primary care physician even though she had seen Dr. XYZ not too long ago.  We called Dr. XYZ office.  Dr. XYZ nurse said that the patient did not have an appointment today.  She has an appointment on June 15, 2004, for a postop check.  They did not tell her they would not see her today because of insurance, so the patient was lying to me.  We will keep that in mind the next time she returns, because she will likely be back.  She did say that Project Access will be approving her insurance next week, so she will be able to see Dr. XYZ soon.", SOAP / Chart / Progress Notes,35
"PREOPERATIVE DIAGNOSIS: , Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:,  Right trigger thumb.,SURGERY: , Release of A1 pulley, CPT code 26055.,ANESTHESIA:,  General LMA.,TOURNIQUET TIME:  ,9 minutes at 200 torr.,FINDINGS:,  The patient was found to have limitations to extension at the IP joint to the right thumb.  He was found to have full extension after release of A1 pulley.,INDICATIONS:,  The patient is 2-1/2-year-old.  He has a history of a trigger thumb.  This was evaluated in the office.  He was indicated for release of A1 pulley to allow for full excursion.  Risks and benefits including recurrence, infection, and problems with anesthesia were discussed at length with the family.  They wanted to proceed.,PROCEDURE:,  The patient was brought into the operating room and placed on the operating table in supine position.  General anesthesia was induced without incident.  He was given a weight-adjusted dose of antibiotics.  The right upper extremity was then prepped and draped in a standard fashion.  Limb was exsanguinated with an Esmarch bandage.  Tourniquet was raised to 200 torr.  Transverse incision was then made at the base of thumb.  The underlying soft tissues were carefully spread in line longitudinally.  The underlying tendon was then identified.  The accompanied A1 pulley was also identified.  This was incised longitudinally using #11 blade.  Inspection of the entire tendon then demonstrated good motion both in flexion and extension.  The leaflets of the pulley were easily identified.,The wound was then irrigated and closed.  The skin was closed using interrupted #4-0 Monocryl simple sutures.  The area was injected with 5 mL of 0.25% Marcaine.  The wound was dressed with Xeroform, dry sterile dressings, hand dressing, Kerlix, and Coban.  The patient was awakened from anesthesia and taken to the recovery room in good condition.  There were no complications.  All instrument, sponge, needle counts were correct at the end of case.,PLAN: , The patient will be discharged home.  He will return in 1-1/2 weeks for wound inspection.", Surgery,38
"CC: ,Episodic confusion.,HX: ,This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The ""stroke"" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week.,PMH:, Bilateral Hearing Loss of unknown etiology, S/P bilateral ear surgery many years ago.,MEDS:, DPH and ASA,SHX/FHX:, 2-4 Beers/day. 1-2 packs of cigarettes per day.,EXAM:, BP 111/68, P 68BPM, 36.8C. Alert and Oriented to person, place and time, 30/30 on mini-mental status test, Speech fluent and without dysarthria. CN: Left superior quandranopia only. Motor: 5/5 strength throughout. Sensory: unremarkable except for mild decreased vibration sense in feet. Coordination: unremarkable. Gait and station testing were unremarkable. He was able to tandem walk without difficulty. Reflexes: 2+ and symmetric throughout. Flexor plantar responses bilaterally.,LAB:, Gen Screen, CBC, PT, PTT all WNL. DPH 4.6mcg/ml.,Review of outside MRI Brain done 1/17/92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus. The area did not enhance with gadolinium contrast.,CXR:, 8/31/92: 5 x 6 mm spiculated opacity in apex right lung.,EEG:, 8/24/92: normal awake and asleep,MRI Brain with/without contrast: 8/31/92: Decreased T1 and increased T2 signal in the right temporal lobe. The lesion increased in size and enhances more greatly when compared to the 1/17/92 MRI exam. There is also edema surrounding the affected area and associated mass effect.,NEUROPSYCHOLOGICAL TESTING:, Low-average digit symbol substitution, mildly impaired verbal learning, and severely defective delayed recall. There was relative preservation of other cognitive functions. The findings were consistent with left mesiotemporal dysfunction.,COURSE: ,Patient underwent right temporal lobectomy on 9/16/92 following initial treatment with Decadron. Pathologic analysis was consistent with a Grade 2 astrocytoma. GFAP staining positive. Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed.", Radiology,33
"PREOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,POSTOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,OPERATION PERFORMED: , Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.,ANESTHESIA:  ,General.,CLINICAL NOTE: , This is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal.  Procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required.  Alternative of fully laparoscopic are open surgery or watching the lesion.,DESCRIPTION OF OPERATION:  ,In the right flank-up position, table was flexed.  He had a Foley catheter in place.  Incision was made from just above the umbilicus, about 5.5 cm in diameter.  The umbilical hernia was taken down.  An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin.  A liver retractor was placed to this.,The colon was reflected medially by incising the white line of Toldt.  The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly.  The vena cava was identified.  The main renal vein was identified.  Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided.  Coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and Bovie.  The harmonic scalpel was utilized superiorly and laterally.  Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided.  Specimen was placed in a collection bag, removed intact.,Hemostasis was excellent.,The umbilical hernia had been completely taken down.  The edges were freshened up.  Vicryl #1 was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar.,Skin closed with clips.,He tolerated the procedure well.  All sponge and instrument counts were correct.  Estimated blood loss less than 100 mL.,The patient was awakened, extubated, and returned to recovery room in satisfactory condition.", Hematology - Oncology,16
, Gastroenterology,14
"CHIEF COMPLAINT: , Both pancreatic and left adrenal lesions.,HISTORY OF PRESENT ILLNESS:,  This 60-year-old white male is referred to us by his medical physician with a complaint of recent finding of a both pancreatic lesion and lesions with left adrenal gland.  The patient's history dates back to at the end of the January of this past year when he began experiencing symptoms consistent with difficulty almost like a suffocating feeling whenever he would lie flat on his back.  He noticed whenever he would recline backwards, he would begin this feeling and it is so bad now that he can barely recline, very little before he has this feeling.  He is now sleeping in an upright position.  He was sent for CAT scan originally of his chest.  The CAT scan of the chest reveals a pneumonitis, but also saw a left adrenal nodule and a small pancreatic lesion.  He was subsequently was sent for a dedicated abdominal CAT scan and MRI.  The CAT scan revealed 1.8-cm lesion of his left adrenal gland, suspected to be a benign adenoma.  The pancreas showed pancreatic lesion towards the mid body tail aspect of the pancreas, approximately 1 cm, most likely of cystic nature.  Neoplasm could not be excluded.  He was referred to us for further assessment.  He denies any significant abdominal pain, any nausea or vomiting.  His appetite is fine.  He has had no significant changes in his bowel habits or any rectal bleeding or melena.  He has undergone a colonoscopy in September of last year and was found to have three adenomatous polyps.  He does have a history of frequent urination.  Has been followed by urologist for this.  There is no family history of pancreatic cancer.  There is a history of gallstone pancreatitis in the patient's sister.,PAST MEDICAL HISTORY:,  Significant for hypertension, type 2 diabetes mellitus, asthma, and high cholesterol.,ALLERGIES: , ENVIRONMENTAL.,MEDICATIONS:,  Include glipizide 5 mg b.i.d., metformin 500 mg b.i.d., Atacand 16 mg daily, metoprolol 25 mg b.i.d., Lipitor 10 mg daily, pantoprazole 40 mg daily, Flomax 0.4 mg daily, Detrol 4 mg daily, Zyrtec 10 mg daily, Advair Diskus 100/50 mcg one puff b.i.d., and fluticasone spray 50 mcg two sprays daily.,PAST SURGICAL HISTORY:,  He has not had any previous surgery.,FAMILY HISTORY: , His brothers had prostate cancer.  Father had brain cancer.  Heart disease in both sides of the family.  Has diabetes in his brother and sister.,SOCIAL HISTORY:,  He is a non-cigarette smoker and non-ETOH user.  He is single and he has no children.  He works as a payroll representative and previously did lot of work in jewelry business, working he states with chemical.,REVIEW OF SYSTEMS: , He denies any chest pain.  He admits to exertional shortness of breath.  He denies any GI problems as noted.  Has frequent urination as noted.  He denies any bleeding disorders or bleeding history.,PHYSICAL EXAMINATION:,GENERAL:  Presents as an obese 60-year-old white male, who appears to be in no apparent 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.,HEART:  There is distant heart sounds.,ABDOMEN:  Obese.  It is soft.  It is nontender.  Examination was done as relatively sitting up as the patient was unable to recline.  Bowel sounds are present.  There is no obvious mass or organomegaly.,GENITALIA:  Deferred.,RECTAL:  Deferred.,EXTREMITIES:  Revealed about 1+ pitting edema.  Bilateral peripheral pulses are intact.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION:,  Both left adrenal and pancreatic lesions.  The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded.  Given the location of these pancreatic lesions in the mid body towards the tail and size of 1 cm, the likelihood is an ERCP will be of no value and the likelihood is that it is too small to biopsy.  We are going to review x-rays with Radiology prior with the patient probably at some point will present for operative intervention.  Prior to that the patient will undergo an esophagogastroduodenoscopy.", Endocrinology,13
"ADMITTING DIAGNOSES,1. Prematurity.,2. Appropriate for gestational age.,3. Maternal group B streptococcus positive culture.,DISCHARGE DIAGNOSES,1. Prematurity, 34 weeks' gestation, now 5 days old.,2. Group B streptococcus exposure, but no sepsis.,3. Physiologic jaundice.,4. Feeding problem.,HISTORY OF ILLNESS:  ,This is a 4-pound female infant born to a 26-year-old gravida 1, now para 1-0-0-1 lady with an EDC of November 19, 2003.  Group B streptococcus culture was positive on September 29, 2003, and betamethasone was given 1 dose prior to delivery.  Mother also received 1 dose of penicillin approximately 1-1/2 hours prior to delivery.  The infant delivered vaginally, had a double nuchal cord and required CPAP and free flow oxygen.  Her Apgars were 8 at 1 minute and 9 at 5 minutes.  At the end of delivery, it was noted there was a partial placental abruptio.,HOSPITAL COURSE:  ,The infant has had a basically uncomplicated hospital course.  She did not require oxygen.  She did have antibiotics, ampicillin and gentamicin for approximately 48 hours to cover for possible group B streptococcus.  The culture was negative and the antibiotics were stopped at 48 hours.,The infant was noted to have physiologic jaundice and her highest bilirubin was 7.1.  She was treated for approximately 24 hours with phototherapy and the bilirubin on October 15, 2003 was 3.4.,FEEDING: , The infant has had some difficulty with feeding, but at the time of discharge, she is taking approximately 30 mL every feeding and is taking Formula or breast milk, that is, ___ 24 calories per ounce.,PHYSICAL EXAMINATION:, ,VITAL SIGNS:  At discharge, reveals a well-developed infant whose temperature is 98.3, pulse 156, respirations 35, her weight is 1779 g (1% below her birthweight).,HEENT:  Head is normocephalic.  Eyes are without conjunctival injection.  Red reflex is elicited bilaterally.  TMs not well visualized.  Nose and throat are patent without palatal defect.,NECK:  Supple without clavicular fracture.,LUNGS:  Clear to auscultation.,HEART:  Regular rate without murmur, click or gallop present.,EXTREMITIES:  Pulses are 2/4 for brachial and femoral.  Extremities without evidence of hip defects.,ABDOMEN:  Soft, bowel sounds present.  No masses or organomegaly.,GENITALIA:  Normal female, but the clitoris is not covered by the labia majora.,NEUROLOGICAL:  The infant has good Moro, grasp, and suck reflexes.,INSTRUCTIONS FOR CONTINUING CARE,The infant will be discharged home.  She will have home health visits one time per week for 3 weeks, and she will be seen in followup at San Juan Pediatrics the week of October 20, 2003.  She is to continue feeding with either breast milk or Formula, that is, ___ to 24 calories per ounce.,CONDITION: , Her condition at discharge is good.", Pediatrics - Neonatal,29
"TITLE OF PROCEDURE: , Insertion of Port-A-Cath via left subclavian vein using fluoroscopy.,PREOPERATIVE DIAGNOSIS:  ,Metastatic renal cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Metastatic renal cell carcinoma.,PROCEDURE IN DETAIL:,  This is a 49-year-old gentleman was referred by Dr. A.  The patient underwent a left nephrectomy for renal cell carcinoma in 1999 in Philadelphia.  He has developed recurrence with metastases to the lung and to bone.,The patient is on dialysis via a right internal jugular PermCath that was placed elsewhere.,In the operating room under monitored anesthesia care with intravenous sedation, the patient was prepped and draped suitably.  Lidocaine 1% with epinephrine was used for local anesthesia and the left subclavian vein was punctured at the first pass without difficulty.  A J-wire was guided into place under fluoroscopic control.  A 7.2-French vortex titanium Port-A-Cath was now anchored in the subcutaneous pocket made just below using 3-0 Prolene.  The attached catheter tunneled, cut to the appropriate length and placed through the sheath that was then peeled away.  Fluoroscopy showed good catheter disposition in the superior vena cava.  The catheter was accessed with a butterfly Huber needle, blood was aspirated easily and the system was then flushed using heparinized saline.  The pocket was irrigated using antibiotic saline and closed with absorbable suture.  The port was left accessed with the butterfly needle after dressings were applied and the patient is to report to Dr. A's office later today for the commencement of chemotherapy.  There were no complications.", Surgery,38
"REASON FOR CONSULTATION:  ,Followup of seizures.,HISTORY OF PRESENT ILLNESS:,  This is a 47-year-old African-American female, well known to the neurology service, who has been referred to me for the first time evaluation of her left temporal lobe epilepsy that was diagnosed in August of 2002.  At that time, she had one generalized tonic-clonic seizure.  Apparently she had been having several events characterized by confusion and feeling unsteady lasting for approximately 60 seconds.  She said these events were very paroxysmal in the sense they suddenly came on and would abruptly stop.  She had two EEGs at that time, one on August 04, 2002 and second on November 01, 2002, both of which showed rare left anterior temporal sharp waves during drowsiness and sleep.  She also had an MRI done on September 05, 2002, with and without contrast that was negative.  Her diagnosis was confirmed by Dr. X at Johns Hopkins Hospital who reviewed her studies as well as examined the patient and felt that actually her history and findings were consistent with diagnosis of left temporal lobe epilepsy.  She was initially started on Trileptal, but had some problems with the medication subsequently Keppra, which she said made her feel bad and subsequently changed in 2003 to lamotrigine, which she has been taking since then.  She reports no seizures in the past several years.  She currently is without complaint.,In terms of seizure risk factors she denies head trauma, history of CNS infection, history of CVA, childhood seizures, febrile seizures.  There is no family history of seizures.,PAST MEDICAL HISTORY: , Significant only for hypertension and left temporal lobe epilepsy.,FAMILY HISTORY: , Remarkable only for hypertension in her father.  Her mother died in a motor vehicle accident.,SOCIAL HISTORY:  ,She works running a day care at home.  She has three children.  She is married.  She does not smoke, use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , Please see note in chart.  Only endorses weight gain and the history of seizures, as well as some minor headaches treated with over-the-counter medications.,CURRENT MEDICATIONS:  ,Lamotrigine 150 mg p.o. b.i.d., verapamil, and hydrochlorothiazide.,ALLERGIES: , Flagyl and aspirin.,PHYSICAL EXAMINATION: , Blood pressure is 138/88, heart rate is 76, respiratory rate is 18, and weight is 224 pounds, pain scale is none.,General Examination:  Please see note in chart, which is essentially unremarkable except mild obesity.,NEUROLOGICAL EXAMINATION: , Again, please see note in chart.  Mental status is normal, cranial nerves are intact, motor is normal bulk and tone throughout with no weakness appreciated in upper and lower extremities bilaterally.  There is no drift and there are no abnormalities to orbit.  Sensory examination, light touch, and temperature intact at all distal extremities.  Cerebellar examination, she has normal finger-to-nose, rapid alternating movements, heel-to-shin, and foot tap.,She rises easily from the chair.  She has normal step, stride, arm swing, toe, heel, and tandem.  Deep tendon reflexes are 2 and equal at biceps, brachioradialis, patella, and 1 at the ankles.,She was seen in the emergency room for chest pain one month ago.  CT of the head was performed, which I reviewed, dated September 07, 2006.  The findings were within the range of normal variation.  There is no evidence of bleeding, mass, lesions, or any evidence of atrophy.,IMPRESSION: , This is a pleasant 47-year-old African-American female with what appears to be cryptogenic left temporal lobe epilepsy that is very well controlled on her current dose of lamotrigine.,PLAN:,1.  Continue lamotrigine 150 mg p.o. b.i.d.,2.  I discussed with the patient the option of a trial of medications.  We need to repeat her EEG as well as her MRI prior to weaning her medications.  The patient wants to continue her lamotrigine at this time.  I concur.,3.  The patient will be following up with me in six months.,", Neurology,22
"PREOPERATIVE DIAGNOSES: , Coronal hypospadias with chordee and asthma.,POSTOPERATIVE DIAGNOSES:,  Coronal hypospadias with chordee and asthma.,PROCEDURE: , Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).,ANESTHETIC: , General inhalational anesthetic with a caudal block.,FLUIDS RECEIVED:  ,300 mL of crystalloid.,ESTIMATED BLOOD LOSS:  ,20 mL.,TUBES/DRAINS:  ,An 8-French Zaontz catheter.,INDICATIONS FOR OPERATION:  ,The patient is a 17-month-old boy with hypospadias abnormality.  The plan is for repair.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, a caudal block was placed.  IV antibiotics were given.  He was then placed in the supine position.  The foreskin was retracted and cleansed.  He was then sterilely prepped and draped.  A stay stitch of 4-0 Prolene was then placed on the glans.  The urethra was calibrated with the lacrimal duct probes to an 8-French.  We then marked out the coronal cuff, the penile shaft skin as well as the glanular plate for future surgery with a marking pen.,We then used a 15-blade knife to circumscribe the penis around the coronal cuff.  We then degloved the penis using the curved tenotomy scissors, and electrocautery was used for hemostasis.  The patient had some splaying of the spongiosum tissue, which was also incised laterally and rotated to make a secondary flap.  Once the penis was degloved, and the excessive chordee tissue was released, we then placed a vessel loop tourniquet around the base of the penis and using IV grade saline injected the penis for an artifical erection.  He was still noted to have chordee, so a midline incision through the Buck fascia was made with a 15-blade knife and Heineke-Mikulicz closure using 5-0 Prolene was then used for the chordee Nesbit tuck.  We repeated the artificial erection and the penis was straight.  We then incised the urethral plate with an ophthalmic blade in the midline, and then elevated the glanular wings using a 15-blade knife to elevate and then incise them.  Using the curved iris scissors, we then also further mobilized the glanular wings.  The 8-French Zaontz was then placed while the tourniquet was still in place into the urethral plate.  The upper aspect of the distal meatus was then closed with an interrupted suture of 7-0 Vicryl, and then using a running subcuticular closure, we closed the urethral plates over the Zaontz catheter.  We then mobilized subcutaneous tissue from the penile shaft skin, and the inner perpetual skin on the dorsum, and then buttonholed the flap, placed it over the head of the penis, and then, used it to cover of the hypospadias repair with tacking sutures of 7-0 Vicryl.  We then rolled the spongiosum flap to cover the distal urethra that was also somewhat dysplastic; 7-0 Vicryl was used for that as well.  5-0 Vicryl was used to roll the glans with 2 deep sutures, and then, horizontal mattress sutures of 7-0 Vicryl were used to reconstitute the glans.  Interrupted sutures of 7-0 Vicryl were used to approximate the urethral meatus to the glans.  Once this was done, we then excised the excessive penile shaft skin, and used the interrupted sutures of 6-0 chromic to attach the penile shaft skin to the coronal cuff.  On the ventrum itself, we used horizontal mattress sutures to close the defect.,At the end of the procedure, the Zaontz catheter was sutured into place with a 4-0 Prolene suture, Dermabond tissue adhesive, and Surgicel was used as a dressing and a second layer of Telfa and clear eye tape was then used to tape it into place.  IV Toradol was given at the procedure.  The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room.", Urology,39
"HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet, right greater than left.  The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion deformity on the right foot and pain localized to the second toe and MTP joint of the right foot as well.  The patient had prior surgery performed approximately 13 years ago.  She states that since the time of the original surgery the deformity has slowly recurred, and she has noticed progressive deformity in the lesser toes at the second and third toes of the left foot and involving the second toe of the right foot.  The patient is employed on her feet as a hospital employee and states that she does wear a functional orthotic which does provide some relief of forefoot pain although not complete.,PAST MEDICAL HISTORY, FAMILY HISTORY, SOCIAL HISTORY & REVIEW OF SYSTEMS:,  See Patient History sheet, which was reviewed with the patient and is signed in the chart.  Past medical history on the patient, past surgical history, current medications, drug-related allergies and social history have all been updated and reviewed, and enclosed in the chart.,PHYSICAL EXAMINATION: , Physical exam reveals a pleasant, 57-year-old female who is 5 feet 4 inches and 150 pounds.  She has palpable pulses.  Neurologic sensation is intact.  Examination of the extremities shows the patient as having well-healed surgical sites from her arthroplasty, second digits bilaterally and prior bunionectomy.  There is a recurrence of bunion deformity noted on both great toes although the patient notes to have reasonably good range of movement.  She has particular pain in the second MTP joint of the right foot and demonstrates a mild claw-toe deformity of the second and third toes to the left foot, and to a lesser degree the second toe to the right.  Gait analysis:  The patient stands and walks with a rather severe pes planus and has generalized hypermobility noted in the feet.,X-RAY INTERPRETATION:,  X-rays taken today; three views to the right foot shows presence of internal K-wire and wire from prior bunionectomy.  Biomechanical analysis shows 15 degree intermetatarsal angle and approximately 45 degree hallux abducto valgus angle.  No evidence of arthrosis in the joint is noted.  Significant shift to the fibular sesamoid is present.,ASSESSMENT:,1.  Recurrent bunion deformity, right forefoot.,2.  Pes planovalgus deformity, bilateral feet.,PLAN/TREATMENT:,1.  Today, we did review remaining treatment options with the patient including the feasibility of conservative versus surgical treatment.  The patient would require an open wedge osteotomy to reduce the intermetatarsal angle with the lateral release and a decompression osteotomy  at the second metatarsal.  Anticipated length of healing was noted for the patient as were potential risks and complications.  The patient ultimately would probably require surgery on her left foot at a later date as well.,2.  The patient will explore her ability to get out of work for the above-mentioned period of time and will be in touch with regards regarding scheduling at a later date.,3.  All questions were answered.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSES: , Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.,POSTOPERATIVE DIAGNOSES:,  Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.,OPERATIVE PROCEDURE: , Coronary artery bypass grafting (CABG) x4.,GRAFTS PERFORMED: , LIMA to LAD, left radial artery from the aorta to the PDA, left saphenous vein graft from the aorta sequential to the diagonal to the obtuse marginal.,INDICATIONS FOR PROCEDURE: , The patient is a 74-year-old gentleman, who presented with six-month history of progressively worsening exertional angina.  He had a positive stress test and cardiac cath showed severe triple-vessel coronary artery disease including left main disease with preserved LV function.  He was advised surgical revascularization of his coronaries.,FINDINGS DURING THE PROCEDURE:  ,The aorta was free of any significant plaque in the ascending portion at the sites of cannulation and cross clamp.  Left internal mammary artery and saphenous vein grafts were good quality conduits.  Radial artery graft was a smaller sized conduit, otherwise good quality.  All distal targets showed heavy plaque involvement with calcification present.  The smallest target was the PDA, which was about 1.5 mm in size.  All the other targets were about 2 mm in size or greater.  The patient came off cardiopulmonary bypass without any problems.  He was transferred on Neo-Synephrine, nitroglycerin, Precedex drips.  Cross clamp time was 102 minutes, bypass time was 120 minutes.,DETAILS OF THE PROCEDURE:  ,The patient was brought into the operating room and laid supine on the table.  After he had been interfaced with the appropriate monitors, general endotracheal anesthesia was induced and invasive monitoring lines including right IJ triple-lumen catheter and Cordis catheter, right radial A-line, Foley catheter, TEE probes were placed and interfaced appropriately.  The patient was then prepped and draped from chin to bilateral ankles including the left forearm in the usual sterile fashion.  Preoperative checkup of the left forearm has revealed good collateral filling from the ulnar with the radial occluded thus indicating good common arch and thus left radial artery was suitable for harvest.,After prepping and draping the patient from the chin to bilateral ankles including left forearm in the usual sterile fashion, proper time-out was conducted and site identification was performed, and subsequently incision was made overlying the sternum and median sternotomy was performed.  Left internal mammary artery was taken down.  Simultaneously, left forearm radial artery was harvested using endoscopic harvesting techniques.  Simultaneously, endoscopic left leg saphenous vein was harvested using endoscopic minimally invasive techniques.  Subsequent to harvest, the incisions were closed in layers during the course of the procedure.,Heparin was given.  Pericardium was opened and suspended.  During the takedown of the left internal mammary artery, it was noted that the left pleural space was globally softened and left lung was adherent to the chest wall and mediastinum globally.  Only a limited dissection was performed to free up the lung from the mediastinal structures to accommodate the left internal mammary artery.,Pericardium was opened and suspended.  Pursestring sutures were placed.  Aortic and venous as well as antegrade and retrograde cardioplegia cannulation was performed and the patient was placed on cardiopulmonary bypass.  With satisfactory flow, the aorta was cross clamped and the heart was arrested using a combination of antegrade and retrograde cold blood cardioplegia.  An initial dose of about 1500 mL was given and this was followed by intermittent doses given both antegrade and retrograde throughout the procedure to maintain a good arrest and to protect the heart.,PDA was exposed first.  The right coronary artery was calcified along its course all the way to its terminal bifurcation.  Even in the PDA, calcification was noted in a spotty fashion.  Arteriotomy on the PDA was performed in a soft area and 1.5 probe was noted to be accommodated in both directions.  End radial to side PDA anastomosis was constructed using running 7-0 Prolene.  Next, the posterolateral obtuse marginal was exposed.  Arteriotomy was performed.  An end saphenous vein to side obtuse marginal anastomosis was constructed using running 7-0 Prolene.  This graft was then apposed to the diagonal and corresponding arteriotomy and venotomies were performed and a diamond shaped side-to-side anastomosis was constructed using running 7-0 Prolene.  Next, a slit was made in the left side of the pericardium and LIMA was accommodated in the slit on its way to the LAD.  LAD was exposed.  Arteriotomy was performed.  An end LIMA to side LAD anastomosis was constructed using running 7-0 Prolene.  LIMA was tacked down to the epicardium securely utilizing its fascial pedicle.,Two stab incisions were made in the ascending aorta and enlarged using 4-mm punch.  Two proximal anastomosis were constructed between the proximal end of the saphenous vein graft and the side of the aorta, and the proximal end of the radial artery graft and the side of the aorta separately using running 6-0 Prolene.  The patient was given terminal dose of warm retrograde followed by antegrade cardioplegia during which de-airing maneuvers were performed.  Following this, the aortic cross clamp was removed and the heart was noted to resume spontaneous coordinated contractile activity.  Temporary V-pacing wires were placed.  Blake drains were placed in the left chest, the right chest, as well as in the mediastinum.  Left chest Blake drain was placed just in the medial section where dissection had been performed.  After an adequate period of rewarming during which time, temporary V-pacing wires were also placed, the patient was successfully weaned off cardiopulmonary bypass without any problems.  With satisfactory hemodynamics, good LV function on TEE and baseline EKG, heparin was reversed using protamine.  Decannulation was performed after volume resuscitation.  Hemostasis was assured.  Mediastinal and pericardial fat and pericardium were loosely reapproximated in the midline and chest was closed in layers using interrupted stainless steel wires to reappose the two sternal halves, heavy Vicryl for musculofascial closure, and Monocryl for subcuticular skin closure.  Dressings were applied.  The patient was transferred to the ICU in stable condition.  He tolerated the procedure well.  All counts were correct at the termination of the procedure.  Cross clamp time was 102 minutes.  Bypass time was 120 minutes.  The patient was transferred on Neo-Synephrine, nitroglycerin, and Precedex drips.", Surgery,38
"PREOPERATIVE DIAGNOSES: , Malnutrition and dysphagia.,POSTOPERATIVE DIAGNOSES: , Malnutrition and dysphagia with two antral polyps and large hiatal hernia.,PROCEDURES: , Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement.,ANESTHESIA: , IV sedation, 1% Xylocaine locally.,CONDITION:,  Stable.,OPERATIVE NOTE IN DETAIL: , After risk of operation was explained to this patient's family, consent was obtained for surgery.  The patient was brought to the GI lab.  There, she was placed in partial left lateral decubitus position.  She was given IV sedation by Anesthesia.  Her abdomen was prepped with alcohol and then Betadine.  Flexible gastroscope was passed down the esophagus, through the stomach into the duodenum.  No lesions were noted in the duodenum.  There appeared to be a few polyps in the antral area, two in the antrum.  Actually, one appeared to be almost covering the pylorus.  The scope was withdrawn back into the antrum.  On retroflexion, we could see a large hiatal hernia.  No other lesions were noted.  Biopsy was taken of one of the polyps.  The scope was left in position.  Anterior abdominal wall was prepped with Betadine, 1% Xylocaine was injected in the left epigastric area.  A small stab incision was made and a large bore Angiocath was placed directly into the anterior abdominal wall, into the stomach, followed by a thread, was grasped with a snare using the gastroscope, brought out through the patient's mouth.  Tied to the gastrostomy tube, which was then pulled down and up through the anterior abdominal wall.  It was held in position with a dressing and a stent.  A connector was applied to the cut gastrostomy tube, held in place with a 2-0 silk ligature.  The patient tolerated the procedure well.  She was returned to the floor in stable condition.", Gastroenterology,14
"REASON FOR NEUROLOGICAL CONSULTATION:,  Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance.,HISTORY OF PRESENT ILLNESS: , The patient is a 62-year-old African-American male with a significant past medical history of diabetes, hypertension, previous stroke in 2002 with minimal residual right-sided weakness as well as two MIs, status post pacemaker insertion who first presented with numbness in his lower extremities in 2001.  He states that since that time these symptoms have been progressive and now involving his legs above his knees as well as his hands.  More recently, he describes a burning sensation along with numbness.  This has become a particular problem and of all the problems he has he feels that pain is his primary concern.  Over the last six months, he has noticed that he cannot feel hot objects in his hands and that objects slip out of his hands.  He denies any weakness per se, just clumsiness and decreased sensation.  He has also been complaining of brief muscle jerks, which occur in both hands and his shoulders.  This has been a fairly longstanding problem, and again has become more prevalent recently.  He does not have any tremor.  He denies any neck pain.  He walks with the aid of a walker because of unsteadiness with gait.,Recently, he has tried gabapentin, but this was not effective for pain control.  Oxycodone helps somewhat and gives him at least three hours pain relief.  Because of the pain, he has significant problems with fractured sleep.  He states he has not had a good night's sleep in many years.  About six months ago, after an MI and pacemaker insertion, he was transferred to a nursing facility.  At that facility, his insulin was stopped.  Since then he has only been on oral medication for his diabetes.  He denies any back pain, neck pain, change in bowel or bladder function, or specific injury pre-dating these symptoms., ,PAST MEDICAL HISTORY: , Diabetes, hypertension, coronary artery disease, stroke, arthritis, GERD, and headaches.,MEDICATIONS: , Trazodone, simvastatin, hydrochlorothiazide, Prevacid, lisinopril, glipizide, and gabapentin.,FAMILY HISTORY: , Discussed above and documented on the chart.,SOCIAL HISTORY: , Discussed above and documented on the chart.  He does not smoke.  He lives in a senior citizens building with daily nursing aids.  He previously was a security guard, but is currently on disability.,REVIEW OF SYSTEMS: , Discussed above and documented on the chart.,PHYSICAL EXAMINATION: , On examination, blood pressure 150/80, pulse of 80, respiratory rate 22, and weight 360 pounds.  Pain scale 7/10.  A full general and neurological examination was performed on the patient and is documented on the chart.,The patient is obese with significant ankle edema.,Neurological examination reveals normal cognitive exam and normal cranial nerve examination.  Motor examination reveals mild atrophy in bilateral FDIs, but still has a strong grip.  Individual muscle strength is close to normal with only subtle weakness found in ankle plantar and dorsiflexion.  Tone and bulk are normal.  Sensory examination reveals a severe decrease to all modalities in his lower extremities from just above the knees distally.  He has no vibration sense at his knees.  Similarly, there is decrease to all sensory modalities in his both upper extremities from just above the wrist distally.  The only reflexes I could obtain with trace reflexes in his biceps.  Remaining reflexes were unelicitable.  No Babinski.  The patient walks normally with the aid of a cane.  He has severe sensory ataxia with inability to walk unaided.  Positive Romberg with eyes open and closed.,IMPRESSION AND PLAN:,1.  Probable painful diabetic neuropathy.  Symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities.  He has relative preservation of motor function.  Because these symptoms are progressive and, by report, he came off his insulin, suggesting somewhat mild diabetes, I would like to rule out other causes of progressive neuropathy.,2.  He has history of myoclonic jerks.  I did not see any on my examination today and I feel that these are benign and probably secondary to his severe insomnia, which he states is secondary to the painful neuropathy.  I would like to rule out other causes such as hepatic encephalopathy., ,I have recommended the following:,1.  EMG/nerve conduction study to assess severity of neuropathy and to characterize neuropathy.,2.  Blood work, looking for other causes of neuropathy and myoclonus, to include CBC, CMP, TSH, LFT, B12, RPR, ESR, Lyme titer, and HbA1c, and ammonia level.,3.  Neurontin and oxycodone have not been effective, and I have recommended Cymbalta starting at 30 mg q.d. for five days and then increasing to 60 mg q.d.  Side effect profile of this medication was discussed with the patient.,4.  I have explained to him that progression of diabetic neuropathy is closely related to diabetic control and I have recommended tight diabetic control.,5.  I will see him at followup at the EMG.", Consult - History and Phy.,5
"An orbital block was done.  An infraorbital block was also performed with a 25 gauge needle.  A skin muscle flap was elevated by sharp dissection down to the orbital rim area.  The herniated periorbital fat was removed by opening the orbital septum with sharp dissection using a 15 blade, teasing the periorbital fat out, cross clamping the fat and removing the fat with a scissor over the clamp.  The clamp was cauterized with needle cautery and then the clamp was scarped with a 15 blade.,The remaining fat was left to fall back into the orbit.  This was done in three compartments, the middle, medial and lateral compartments.  Fat was removed from all three compartments.  Then with the mouth open and the eyes in upward gaze, the lower skin muscle flap was redraped on the eyelids and tailored to fit exactly into place and then sutured into place with multiple 6-0 silk sutures.,Bleeding was minimal.  The patient tolerated the procedure well.", Surgery,38
"OPERATION PERFORMED:,  Full mouth dental rehabilitation in the operative room under general anesthesia.,PREOPERATIVE DIAGNOSIS: , Severe dental caries.,POSTOPERATIVE DIAGNOSES:,1.  Severe dental caries.,2.  Non-restorable teeth.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: , 43 minutes.,BRIEF HISTORY:  ,The patient was first seen by me on 04/26/2007.  She had a history of open heart surgery at 11 months' of age.  She presented with severe anterior caries with most likely dental extractions needed.  Due to her young age, I felt that she would be best served in the safety of the hospital operating room.  After consultation with the mother, she agreed to have her treated in the safety of the hospital operating room at Children's Hospital.,OPERATIVE PREPARATION:  ,This child was brought to Hospital Day Surgery and is accompanied by her mother.  There I met with them and discussed the needs of the child, types of restorations to be performed, the risks and benefits of the treatment as well as the options and alternatives of the treatment.  After all their questions and concerns were addressed, I gave the informed consent to proceed with the treatment.  The patient's history and physical examination was reviewed.  Once she was cleared by Anesthesia and the child was taken back to the operating room.,OPERATIVE PROCEDURE:  ,The patient was placed on the surgical table in the usual supine position with all extremities protected.  Anesthesia was induced by mask.  The patient was then intubated with a nasal endotracheal tube and the tube was stabilized.  The head was wrapped and the eyes were taped shut for protection.  An angiocatheter was placed in the left hand and an IV was started.  The head and neck were draped with sterile towels, and the body was covered with a lead apron and sterile sheath.  A moist continuous throat pack was placed beyond the tonsillar pillars.  Plastic lip and cheek retractors were then placed.  Preoperative clinical photographs were taken.  Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiography.  After the radiographs were taken, the lead shield was removed.  Prophylaxis was then performed using prophy cup and fluoridated prophy paste.  The teeth were then rinsed well and the patient's oral cavity was suctioned clean.  Clinical and radiographic examinations followed and areas of decay were noted.  During the restorative phase, these areas of decay were entered into and removed.  Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it.  Final caries was removed and was confirmed upon reaching hard, firm sounding dentin.  Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement.  Non-restorable primary teeth would be extracted.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  The original treatment plan was verified with the actual treatment provided.  Postoperative clinical photographs were then taken.  The continuous gauze throat pack was removed with continuous suction with visualization.  Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room and taken to the recovery room breathing spontaneously with stable vital signs.,FINDINGS:  ,This young patient presented with mild generalized marginal gingivitis secondary to light generalized plaque accumulation and fair oral hygiene.  All primary teeth were present.  Dental caries were present on the following teeth:  Tooth D, E, F, and G caries on all surfaces; teeth J, lingual caries.  The remainder of her teeth and soft tissues were within normal limits.  The following restorations and procedures were performed:  Tooth D, E, F, and G were extracted and four sutures were placed one at each extraction site and tooth J lingual amalgam.,CONCLUSION:  ,The mother was informed of the completion of the procedure.  She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care.  They will contact to my office in the event of immediate postoperative complications.  After full recovery, she was discharged from the recovery room in the care of her mother.", Dentistry,7
"HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old woman who reports that on the 30th of October 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic.  I do not have the records from this hospital admission, but apparently the epidural was administered for approximately 14 to 18 hours.  She was sitting up during the epidural.,She did not notice any difference in her lower extremities at the time she had the epidural; however, she reports that she was extremely sleepy and may not have been aware of any change in strength or sensation in her lower extremities at that time.  She delivered on the 31st of October, by Cesarean section, because she had failed to progress and had pyrexia.,She also had a Foley catheter placed at that time.  On the 1st of November 2008, they began to mobilize her and it was at that time that she first noticed that she could not walk.  She was aware that she could not move her legs at all, and then within a few days, she was aware that she could move toes in the left foot but could not move her right foot at all.  Since that time, there has been a gradual improvement in strength to the point that she now has limited movement in her left leg and severely restricted movement in her right leg.  She is not able to walk by herself, and needs assistance to stand.  She was discharged from hospital after the Cesarean section on the 3rd of November.  Unfortunately, we do not have the records and we do not know what the discussion was between the anesthesiologist and the patient at the time of discharge.  She was then seen at ABC Hospital on November 05, 2008.  She had an MRI scan of her spine, which showed no evidence of an abnormality, specifically there were no cord changes and no evidence of a hematoma.  She also had an EMG study at that time by Dr. X, which was abnormal but not diagnostic and this was repeated again in December.  At the present time, she also complains of a pressure in both her legs and in her thighs.  She complains that her right foot hurts and that she has some hyperesthesia there.  She has been taking gabapentin to try to reduce the discomfort, although she is on a very low dose and the effect is minimal.  She has no symptoms in her arms, her bowel and bladder function is normal, and her bulbar function is normal.  There is no problem with her vision, swallowing, or respiratory function.,PAST MEDICAL HISTORY: , Unremarkable except as noted above.  She has seasonal allergies.,CURRENT MEDICATIONS:,  Gabapentin 300 mg b.i.d., Centrum once a day, and another multivitamin.,ALLERGIES: , She has no medication allergies, but does have seasonal allergies.,FAMILY HISTORY: , There is a family history of diabetes and hypertension.  There is no family history of a neuropathy or other neurological disease.  She has one child, a son, born on October 31, 2008.,SOCIAL HISTORY: , The patient is a civil engineer, who currently works from home.  She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby.  She does not smoke and does not drink and has never done either.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS:  P 74, BP 144/75, and a pain score of 0.,GENERAL:  Her general physical examination was unremarkable.,CARDIOVASCULAR:  Normal first and second heart sound, regular pulse with normal volume.,RESPIRATORY:  Unremarkable, both lung bases were clear, and respiration was normal.,GI:  Unremarkable, with no organomegaly and normal bowel sounds.,NEUROLOGICAL EXAM:,MSE:  The patient's orientation was normal, fund of knowledge was normal, memory was normal, speech was normal, calculation was normal, and immediate and long-term recall was normal.  Executive function was normal.,CRANIAL NERVES:  The cranial nerve examination II through XII was unremarkable.  Both disks were normal, with normal retina.  Pupils were equal and reactive to light.  Eye movements were full.  Facial sensation and strength was normal.  Bulbar function was normal.  The trapezius had normal strength.,MOTOR:  Muscle tone showed a slight increase in tone in the lower extremities, with normal tone in the upper extremities.  Muscle strength was 5/5 in all muscle groups in the upper extremities.  In the lower extremities, the hip flexors were 1/5 bilaterally, hip extensors were 1/5 bilaterally, knee extension on the right was 1/5 and on the left was 3-/5, knee flexion was 2/5 on the right and 3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 on the left, foot plantar flexion was 4-/5 on the right and 4+/5 on the left, toe extension was 0/5 on the right and 4-/5 on the left, toe flexion was 4-/5 on the right and 4+/5 on the left.,REFLEXES:  Reflexes in the upper extremities were 2+ bilaterally.  In the lower extremities, they were 0 bilaterally at the knee and ankles.  The abdominal reflexes were present above the umbilicus and absent below the umbilicus.  The plantar responses were mute.  The jaw reflex was normal.,SENSATION:  Vibration was moderately decreased in the right great toe and was mildly decreased in the left great toe.  There was a sensory level to light touch at approximately T7 posteriorly and approximately T9 anteriorly.  There was a range of sensation, but clearly there was a decrease in sensation below this level but not complete loss of sensation.  To pain, the sensory level is even less clear, but appeared to be at about T7 on the right side.  In the lower extremities, there was a slight decrease in pin and light touch in the right great toe compared to the left.  There was no evidence of allodynia or hyperesthesia.  Joint position sense was mildly reduced in the right toe and normal on the left.,COORDINATION:  Coordination for rapid alternating movements and finger-to-nose testing was normal.  Coordination could not be tested in the lower extremities.,GAIT:  The patient was unable to stand and therefore we were unable to test gait or Romberg's.  There was no evidence of focal back tenderness.,REVIEW OF OUTSIDE RECORDS: , I have reviewed the records from ABC Hospital, including the letter from Dr. Y and the EMG report dated 12/17/2008 from Dr. X. The EMG report shows evidence of a lumbosacral polyradiculopathy below approximately T6.  The lower extremity sensory responses are essentially normal; however, there is a decrease in the amplitude of the motor responses with minimal changes in latency.  I do have the MRI of lumbar spine report from 11/06/2008 with and without contrast.  This showed a minimal concentric disc bulge of L4-L5 without disc herniation, but was otherwise unremarkable.  The patient brought a disc with a most recent MRI study; however, we were unable to open this on our computers.  The verbal report is that the study was unremarkable except for some gadolinium enhancement in the lumbar nerve roots.  A Doppler of the lower extremities showed no evidence of deep venous thrombosis in either lower extremity.  Chest x-ray showed some scoliosis on the lumbar spine, curve to the left, but no evidence of other abnormalities.  A CT pelvis study performed on November 07, 2008 showed some nonspecific fluid in the subcutaneous fat of the back, posterior to L4 and L5 levels; however, there were no pelvic masses or other abnormalities.  We were able to obtain an update of the report from the MRI of the lumbar spine with and without contrast dated 12/30/2008.  The complete study included the cervical, thoracic, and lumbar spine.  There was diffuse enhancement of the nerve roots of the cauda equina that had increased in enhancement since prior exam in November.  It was also reported that the patient was given intravenous methylprednisolone and this had had no effect on strength in her lower extremities.,IMPRESSION: , The patient has a condition that is temporarily related to the epidural injection she was given at the end of October 2008, prior to her Cesarean section.  It appears she became aware of weakness within two days of the administration of the epidural, she was very tired during the epidural and may have missed some change in her neurological function.  She was severely weak in both lower extremities, slightly worse on the right than the left.  There has been some interval improvement in her strength since the beginning of November 2008.  Her EMG study from the end of December is most consistent with a lumbosacral polyradiculopathy.  The MRI findings of gadolinium enhancement in the lumbar nerve roots would be most consistent with an inflammatory radiculitis most likely related to the epidural anesthesia or administration of the epidural.  There had been no response to IV methylprednisolone given to her at ABC.  The issue of having a lumbar puncture to look for evidence of inflammatory cells or an elevated protein had been discussed with her at both ABC and by myself.  The patient did not wish to consider a lumbar puncture because of concerns that this might worsen her condition.  At the present time, she is able to stand with aid but is unable to walk.  There is no evidence on her previous EMG of a demyelinating neuropathy.,RECOMMENDATIONS:,1.  The diagnostic issues were discussed with the patient at length.  She is informed that this is still early in the course of the problem and that we expect her to show some improvement in her function over the next one to two years, although it is unclear as to how much function she will regain.,2.  She is strongly recommended to continue with vigorous physical therapy, and to continue with the plan to mobilize her as much as possible, with the goal of trying to get her ambulatory.  If she is able to walk, she will need bilateral AFOs for her ankles, to improve her overall mobility.  I am not prescribing these because at the present time she does not need them.,3.  We discussed increasing the dose of gabapentin.  The paresthesias that she has may indicate that she is actually regaining some sensory function, although there is a concern that as recovery continues, she may be left with significant neuropathic pain.  If this is the case, I have advised her to increase her gabapentin dose from 300 mg b.i.d. gradually up to 300 mg four times a day and then to 600 mg to 900 mg four times a day.  She may need other neuropathic pain medications as needed.  She will determine whether her current symptoms are significant enough to require this increase in dosage.,4.  The patient will follow up with Dr. Y and his team at ABC Hospital.  She will also continue with physical therapy within the ABC system.", Neurology,22
"SUBJECTIVE:,  His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it.  The patient started improving his diet when he received the letter explaining his lipids are elevated.  He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc.  He has started packing his lunch three to four times per week instead of eating out so much.  He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time.  He is in training for a triathlon.  He says he is already losing weight due to his efforts.,OBJECTIVE:,  Height:  6 foot 2 inches.  Weight:  204 pounds on 03/07/05.  Ideal body weight:  190 pounds, plus or minus ten percent.  He is 107 percent standard of midpoint ideal body weight.  BMI:  26.189.  A 48-year-old male.  Lab on 03/15/05:  Cholesterol:  251.  LDL:  166.  VLDL:  17.  HDL:  68.  Triglycerides:  87.  I explained to the patient the dietary guidelines to help improve his lipids.  I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight.  I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read.  I encouraged him to continue as he is doing.,ASSESSMENT:,  Basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories.  His 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake.  He needs to continue as he is doing.  He verbalized understanding and seemed receptive.,PLAN:,  The patient plans to recheck his lipids through Dr. XYZ  I gave him my phone number and he is to call me if he has any further questions regarding his diet.", SOAP / Chart / Progress Notes,35
"PREOPERATIVE DIAGNOSES:,1.  Dysphagia.,2.  Right parapharyngeal hemorrhagic lesion.,POSTOPERATIVE DIAGNOSES:,1.  Dysphagia with no signs of piriform sinus pooling or aspiration.,2.  No parapharyngeal hemorrhagic lesion noted.,3.  Right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.,PROCEDURE PERFORMED: ,Fiberoptic nasolaryngoscopy.,ANESTHESIA: , None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 93-year-old Caucasian male who was admitted to ABCD General Hospital on 08/07/2003 secondary to ischemic ulcer on the right foot.  ENT was asked to see the patient regarding postop dysphagia with findings at that time of the consultation on 08/17/03 with a fiberoptic nasolaryngoscopy, a right parapharyngeal hemorrhagic lesion possibly secondary to LMA intubation.  The patient subsequently resolved with his dysphagia and workup of Speech was obtained, which showed no aspiration, no pooling, minimal premature spillage with solids, but good protection of the airway.  This is a reevaluation of the right parapharyngeal hemorrhagic lesion that was noted prior.,PROCEDURE DETAILS: ,The patient was brought in the semi-Fowler's position, a fiberoptic nasal laryngoscope was then passed into the patient's right nasal passage, all the way to the nasopharynx.  The scope was then flexed caudally and advanced slowly through the nasopharynx into the oropharynx, and down to the hypopharynx.  The patient's oro and nasopharynx all appeared normal with no signs of any gross lesions, edema, or ecchymosis.,Within the hypopharynx although there was an area of fullness and on the right side around the level of the thyroid cartilage cornu that seemed to be prominent and within the lumen of the hypopharynx.  There were no signs of any obstruction.  The epiglottis, piriform sinuses, vallecula, and base of tongue all appeared normal with no signs of any gross lesions.  The patient with excellent phonation with good glottic closure upon phonation and no signs of any aspiration or pooling of secretions.  The scope was then pulled out and the patient tolerated the procedure well.  At this time, we will follow up as an outpatient and possibly there is a need for a microscopic suspension direct laryngoscopy for evaluation of this right parapharyngeal lesion.", ENT - Otolaryngology,11
"TECHNIQUE: , Sequential axial CT images were obtained through the cervical spine without contrast.  Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures.  ,FINDINGS: , The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture, dislocation, or spondylolisthesis.  The vertebral body heights and disc spaces are maintained.  The central canal is patent.  The pedicles and posterior elements are intact.  The paravertebral soft tissues are within normal limits.  The atlanto-dens interval and the dens are intact.  The visualized lung apices are clear.,IMPRESSION: , No acute abnormalities.", Neurology,22
"PREOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.,POSTOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.  Significant coronary artery disease, very severe PAD.,PROCEDURES PERFORMED:,1.  Right common femoral artery cannulation.,2.  Conscious sedation using IV Versed and IV fentanyl.,3.  Retrograde bilateral coronary angiography.,4.  Abdominal aortogram with pelvic runoff.,5.  Left external iliac angiogram with runoff to the patient's left foot.,6.  Left external iliac angiogram with runoff to the patient's right leg.,7.  Right common femoral artery angiogram runoff to the patient's right leg.,PROCEDURE IN DETAIL:,  The patient was taken to the cardiac catheterization laboratory after having a valid consent.  He was prepped and draped in the usual sterile fashion.,After local infiltration with 2% Xylocaine, the right common femoral artery was entered percutaneously and a 4-French sheath was placed over the artery.  The arterial sheath was flushed throughout the procedure.,Conscious sedation was obtained using IV Versed and IV fentanyl.,With the help of a Wholey wire, a 4-French 4-curve Judkins right coronary artery catheter was advanced into the ascending aorta.  The wire was removed, the catheter was flushed.  The catheter was engaged in the left main.  Injections were performed at the left main in different views.  The catheter was then exchanged for an RCA catheter, 4-French 4-curve which was advanced into the ascending aorta with the help of a J-wire.  The wire was removed, the catheter was flushed.  The catheter was engaged in the RCA.  Injections were performed at the RCA in different views.,The catheter was then exchanged for a 5-French Omniflush catheter, which was advanced into the abdominal aorta with the help of a regular J-wire.  The wire was removed.  The catheter was flushed.  Abdominal aortogram was then performed with runoff to the patient's pelvis.,The Omniflush catheter was then retracted into the aortic bifurcation.  Through the Omniflush catheter, a Glidewire was then advanced distally into the left SFA.  The Omniflush was then removed.  Through the wire, a Royal Flush catheter was then advanced into the left external iliac.  The wire was removed.  Left external iliac angiogram was performed with runoff to the patient's left foot _______ was then performed.  The catheter was then retracted into the left common iliac.  Angiograms were performed of the left common iliac with runoff to the patient's left groin.  The catheter was then positioned at the level of the right common iliac.  Angiogram of the right common iliac with runoff to the patient's right leg was then performed.  The catheter was then removed with the help of a J-wire.  The J-wire was left in the abdominal aorta.  Hand injection was performed of the right common femoral artery in 2 locations with runoff to the patient's right leg.,The wire was then removed.  The arterial sheath was then removed after being flushed.  Hemostasis was obtained using hand compression.,The patient tolerated the procedure well and had no complications.  At the end of the procedure, palpable right common femoral pulses were noted as well as 1+ right PT pulse.,Hemodynamic Findings:,  Aortic pressure 140/70.,ANGIOGRAPHIC FINDINGS: , Left main with calcification 25% to 40% lesion.,The left main is very short.,LAD with calcification 25% to 40% proximal lesion.,D1 has 25% lesion.  No in-stent restenosis was noted in D1.,D2 and D3 are very small with luminal irregularities.,Circumflex artery was diseased throughout the vessel.  The circumflex artery has an ostium of 60% to 75% lesion distally and the circumflex has a 75% lesion.,OM1 has 25% to 40% lesion.  These OMs are small with luminal irregularities.,RCA has 25% to 50% lesion, distally, the RCA has luminal irregularities.,Left ventriculography was not done.,ABDOMINAL AORTOGRAM:,  Right renal artery with luminal irregularities.  Left renal artery with luminal irregularities.  The abdominal aorta has 25% lesion.,Right common iliac has a 25% to 50% lesion as well as a distal 75% lesion.,The right external iliac has a proximal 75% lesion.,The distal part of the right external iliac as well as the right common femoral appears to be occlusive by the 5-French sheath.,The right SFA was visualized, although not very well.,Left common iliac with 25% to 50% lesion.  Left external iliac with 25% to 40% lesion.  Left common femoral with 25% to 40% lesion.  Left SFA with 25% lesion.  Left popliteal with wall luminal irregularities.,Three-vessel runoff is noted at the level of the left knee and at the level of the left ankle.,Conclusions:  Severe coronary artery disease.  Very severe peripheral arterial disease.,PLAN: , Because of the anatomic distribution of the coronary artery disease, for now we will continue medical treatment for CAD.  We will proceed with revascularization of the right external iliac as well as right common femoral.  Discontinue tobacco.", Cardiovascular / Pulmonary,3
"SUBJECTIVE:,  The patient is a 68-year-old white female who presents for complete physical, Pap and breast exam.  Her last Pap smear was 05/02/2002.  Her only complaint is that she has had some occasional episodes of some midchest pain that seems to go to her back, usually occurs at rest.  Has awakened her at night on occasion and only last about 15 to 20 minutes.  Denies nausea, vomiting, diaphoresis or shortness of breath with it.  This has not happened in almost two months.  She had a normal EKG one year ago.  Otherwise, has been doing quite well.  Did quite well with her foot surgery with Dr. Clayton.,PAST MEDICAL HISTORY:,  Reactive airway disease; rheumatoid arthritis, recent surgery on her hands and feet; gravida 4, para 5, with one set of twins, all vaginal deliveries; iron deficiency anemia; osteoporosis; and hypothyroidism.,MEDICATIONS:,  Methotrexate 2.5 mg five weekly, Fosamax 70 mg weekly, folic acid daily, amitriptyline 15 mg daily, Synthroid 0.088 mg daily, calcium two in the morning and two at noon, multivitamin daily, baby aspirin daily and Colace one to three b.i.d.,ALLERGIES:,  None.,SOCIAL HISTORY:,  She is married.  Denies tobacco, alcohol and drug use.  She is not employed outside the home.,FAMILY HISTORY: , Unremarkable.,REVIEW OF SYSTEMS:,  HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional and psychiatric are all negative except for HPI.,OBJECTIVE:,Vital Signs:  Weight 146.  Blood pressure 100/64.  Pulse 80.  Respirations 16.  Temperature 97.7.,General:  She is a well-developed, well-nourished white female in no acute distress.,HEENT:  Grossly within normal limits.,Neck:  Supple.  No lymphadenopathy.  No thyromegaly.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Positive bowel sounds, soft and nontender.  No hepatosplenomegaly.,Breasts:  No nipple discharge.  No lumps or masses palpated.  No dimpling of the skin.  No axillary lymph nodes palpated.  Self-breast exam discussed and encouraged.,Pelvic:  Normal female genitalia.  Atrophic vaginal mucosa.  No cervical lesions.  No cervical motion tenderness.  No adnexal tenderness or masses palpated.,Rectal:  Normal sphincter tone.  No stool present in the vault.  No rectal masses palpated.,Extremities:  No cyanosis, clubbing or edema.  She does have obvious rheumatoid arthritis of her hands.,Neurologic:  Grossly intact.,ASSESSMENT/PLAN:,1.  Chest pain.  The patient will evaluate when it happens next; what she has been eating, what activities she has been performing.  She had normal ECG one year ago.  In fact this does not sound cardiac in nature.  We will not do further cardiac workup at this time.  Did discuss with her she may be having some GI reflux type symptoms.,2.  Hypothyroidism.  We will recheck TSH to make sure she is on the right amount of medication at this time, making adjustments as needed.,3.  Rheumatoid arthritis.  Continue her methotrexate as prescribed by Dr. Mortensen, and follow up with Dr. XYZ as needed.,4.  Osteoporosis.  It is time for her to have a repeat DEXA at this time and that will be scheduled.,5.  Health care maintenance, Pap smear was obtained today.  The patient will be scheduled for mammogram.", Consult - History and Phy.,5
"FAMILY HISTORY: , Her father died at the age of 80 from prostate cancer.  Her mother died at the age of 67.  She did abuse alcohol.  She had a brother died at the age of 70 from bone and throat cancer.  She has two sons, ages 37 and 38 years old who are healthy.  She has two daughters, ages 60 and 58 years old, both with cancer.  She describes cancer hypertension, nervous condition, kidney disease, lung disease, and depression in her family.,SOCIAL HISTORY: , She is married and has support at home.  Denies tobacco, alcohol, and illicit drug use.,ALLERGIES: , Aspirin.,MEDICATIONS:  ,The patient does not list any current medications.,PAST MEDICAL HISTORY: , Hypertension, depression, and osteoporosis.,PAST SURGICAL HISTORY: , She has had over her over her lifetime four back surgeries and in 2005 she had anterior cervical discectomy and fusion of C3 through C7 by Dr. L.  She is G10, P7, no cesarean sections.,REVIEW OF SYSTEMS: , HEENT:  Headaches, vision changes, dizziness, and sore throat.  GI:  Difficulty swallowing.  Musculoskeletal:  She is right-handed with joint pain, stiffness, decreased range of motion, and arthritis.  Respiratory:  Shortness of breath and cough.  Cardiac:  Chest pain and swelling in her feet and ankle.  Psychiatric:  Anxiety and depression.  Urinary:  Negative and noncontributory.  Hem-Onc:  Negative and noncontributory.  Vascular:  Negative and noncontributory.  Genital:  Negative and noncontributory.,PHYSICAL EXAMINATION:,  On physical exam, she is 5 feet tall and currently weighs 110 pounds; weight one year ago was 145 pounds.  BP 138/78, pulse is 64.  General:  A well-developed, well-nourished female, in no acute distress.  HEENT exam, head is atraumatic and normocephalic.  Eyes, sclerae are anicteric.  Teeth, she does have some poor dentition.  She does say that she needs some of her teeth pulled on her lower mouth.  Cranial nerves II, III, IV, and VI, vision is intact and visual fields are full to confrontation.  EOMs are full bilaterally.  Pupils are equal, round, and reactive to light.  Cranial nerves V and VII, normal facial sensation and symmetrical facial movements.  Cranial nerve VIII, hearing is intact, although decreased bilaterally right worse than left.  Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.  Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance.  Cardiac, regular rate and rhythm.  Chest and lungs are clear bilaterally.  Skin is warm and dry.  Normal turgor and texture.  No rashes or lesions are noted.  General musculoskeletal exam reveals no gross deformity, fasciculations, and atrophy.  Peripheral vascular, no cyanosis, clubbing, or edema.  She does have some tremoring of her bilateral upper arms as she said.  Strength testing reveals difficulty when testing due to the fact that the patient does have a lot of pain, but she seems to be pretty equal in the bilateral upper extremities with no obvious weakness noted.  She is about 4+/5 in the deltoids, biceps, triceps, wrist flexors, wrist extensors, dorsal interossei, and grip strength.,It is much more painful for her on the left.  Deep tendon reflexes are 2+ bilaterally only at biceps, triceps, and brachioradialis, knees, and ankles.  No ankle clonus is elicited.  Hoffmann's is negative bilaterally.  Sensation is intact.  She ambulates with slow short steps.  No spastic gait is noted.  She has appropriate station and gait with no assisted devices, although she states that she is supposed to be using a cane.  She does not bring one in with her today.,FINDINGS: , Patient brings in cervical spine x-rays and she has had an MRI taken but does not bring that in with her today.  She will obtain that and x rays, which showed at cervical plate C3, C4, C5, C6, and C7 anteriorly with some lifting with the most lifted area at the C3 level.  No fractures are noted.,ASSESSMENT: , Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.,PLAN:,  We went ahead and obtained an EKG in the office today, which demonstrated normal sinus rhythm.  She went ahead and obtained her x-rays and will pick her MRI and return to the office for surgical consultation with Dr. L first available.  She would like the plate removed, so that she can eat and drink better, so that she can proceed with her shoulder surgery.  All questions and concerns were addressed with her.  Warning signs and symptoms were gone over with her.  If she should have any further questions, concerns, or complications, she will contact our office immediately; otherwise, we will see her as scheduled.  I am quite worried about the pain that she is having in her arms, so I would like to see the MRI as well.  Case was reviewed and discussed with Dr. L.", SOAP / Chart / Progress Notes,35
, Pain Management,28
"HISTORY OF PRESENT ILLNESS:,  A 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache.  Symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved.  She is having some left-sided sinus pressure and actually went to the dentist because her teeth were hurting; however, the teeth were okay.  She continues to have some left-sided jaw pain.  Denies any headache, fever, cough, or sore throat.  She had used Cutivate cream in the past for the atopic dermatitis with good results and is needing a refill of that.  She has also had problems with sinusitis in the past and chronic left-sided headache.,FAMILY HISTORY:,  Reviewed and unchanged.,ALLERGIES: , To cephalexin.,CURRENT MEDICATIONS:,  Ibuprofen.,SOCIAL HISTORY:,  She is a nonsmoker.,REVIEW OF SYSTEMS:,  As above.  No nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,General:  A well-developed and well-nourished female, conscious, alert, and in no acute distress.,Vital Signs:  Weight:  121 pounds.  Temperature:  97.9 degrees.,Skin:  Reveals scattered erythematous plaques with some mild lichenification on the nuchal region and behind the knees.,Eyes:  PERRLA.  Conjunctivae are clear.,Ears:  Left TM with some effusion.  Right TM is clear.  Canals are clear.  External auricles are nontender to manipulation.,Nose:  Nasal mucosa is pink and moist without discharge.,Throat:  Nonerythematous.  No tonsillar hypertrophy or exudate.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.  Respirations are regular and unlabored.,Heart:  Regular rate and rhythm at rate of 100 beats per minute.,ASSESSMENT:,1.  Serous otitis.,2.  Atopic dermatitis.,PLAN:,1.  Nasacort AQ two sprays each nostril daily.,2.  Duraphen II one b.i.d.,3.  Refills Cutivate cream 0.05% to apply to affected areas b.i.d.  Recheck p.r.n.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS:,  Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,POSTOPERATIVE DIAGNOSIS:,  Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,PROCEDURE:,  Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.,ANESTHESIA: , General anesthesia via nasal endotracheal intubation.,FLUIDS: , 1800 mL of LR.,ESTIMATED BLOOD LOSS: , 150 mL.,HARDWARE:  ,A 2.3 titanium locking reconstruction plate from Leibinger on the symphysis and a 2.0 reconstruction plate on the left angle.,SPECIMEN: , None.,COMPLICATIONS: , None.,CONDITION: , The patient was extubated to the PACU, breathing spontaneously in excellent good condition.,INDICATIONS FOR THE PROCEDURE: , The patient is a 55-year-old male that he is 12 hour status post interpersonal violence in which he sustained bilateral mandible fractures and positive loss of consciousness.  He reported to the Hospital the day after his altercation complaining of mall occlusion and sore left shoulder.  He was worked up by the emergency department.  His head CT was cleared and his left shoulder was clear of any fractures or soft tissue damage.  Oral maxillary facial surgery was consulted to manage the mandible fracture.  After review of the CT and examination it was determined that the patient would benefit from open reduction, internal fixation of bilateral mandible fractures.  Risks, benefits, and alternative to treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was brought to the operating room #2 at Hospital.  He was laid in supine position on the operating room table.  ASA monitors were attached and stated general anesthesia was induced with IV anesthetic and maintained with nasal endotracheal intubation and inflation anesthetics.,The patient was prepped and draped in the usual oral maxillofacial surgery fashion.  The surgeon approached the operating room table in a sterile fashion.  Approximately 10 mL of 1% lidocaine with 1:100,000 epinephrine was injected into oral vestibule in a nerve block fashion.  Erich arch bars were adapted to the maxilla and mandible, secured in the posterior teeth with 24-gauge surgical steel wire and 26-gauge surgical steel wire in the anterior.  This was done from second molar to second molar on both the maxilla and the mandible secondary to the patient missing multiple teeth.  The patient was manipulated up into maximum intercuspation.  He has a malocclusion with severe bruxism and so wear facets were lined up.  This was secured with 26-gauge surgical steel wire.  Attention was then directed to the symphysis extraorally.  Approximately 5 mL of 1% lidocaine with epinephrine was injected into the area of incision which paralleled the inferior border of the mandible 2 cm below the inferior border of the mandible.,After waiting appropriate time for local anesthesia using a 15 blade, a skin and platysma incision was made.  Then using a series of blunt and sharp dissections, the dissection was carried to the inferior border of the mandible.  The periosteum was incised and reflected with the periosteal elevator.  The fracture was noted and it was displaced.  Manipulation of the segments and checking with the occlusion intraorally, the fracture was aligned.  This was secured with 7-hole 2.3 titanium locking reconstruction plate with bicortical screws.  The wound was then packed with moist Ray-Tec and attention was directed intraorally to the left angle fracture.  Approximately 5 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the left vestibule.  After waiting appropriate time for local anesthesia to take effect, using Bovie electrocautery, a sagittal split incision was made and the fracture was identified.  It was noted that the fracture went through tooth #17 and this needed to be extracted.  Taking a round bur, a buckle trough was made and the tooth was elevated and removed both distal and mesial roots.  The fracture was then reduced and lateral superior border plate 2-0 4 whole with monocortical screws was placed.  The fracture was noted to be well reduced.  The wound was then irrigated with copious amount of sterile water.  The patient was released for excellent intercuspation.  He was then manipulated up into the occlusion easily.  Wound was then closed with running 3-0 chromic gut suture.  Attention was then directed extraorally.  This was irrigated with copious amount of sterile water and closed in a layer fashion with 3-0 Vicryl, 4-0 Vicryl, and 5-0 Prolene on skin.  Attention was then again directed into the mouth.  The throat pack was removed and orogastric tube was placed and stomach content was evacuated.  The patient was then manipulated back up to maximum intercuspation and secured with interdental elastics and a pressure dressing was applied to the extraoral incisions.  At this point, the procedure was then determined to be over.,The patient was extubated and breathing spontaneously, transported to the PACU in excellent condition.", Surgery,38
"FINDINGS:,There is a large intrasellar mass lesion producing diffuse expansion of the sella turcica. This mass lesions measures approximately 16 x 18 x 18mm (craniocaudal x AP x mediolateral) in size.", Neurology,22
"CHIEF COMPLAINT:,  Weak and shaky.,HISTORY OF PRESENT ILLNESS:,  The patient is a 75-year-old, Caucasian female who comes in today with complaint of feeling weak and shaky.  When questioned further, she described shortness of breath primarily with ambulation.  She denies chest pain.  She denies cough, hemoptysis, dyspnea, and wheeze.  She denies syncope, presyncope, or palpitations.  Her symptoms are fairly longstanding but have been worsening as of late.,PAST MEDICAL HISTORY:,  She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history.  She states that she has underlying history of heart disease but is not able to elaborate to any significant extent.  She also has a history of hypertension and type II diabetes but is not currently taking any medication.  She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections.  Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair.,CURRENT MEDICATIONS:,  She is on two different medications, neither of which she can remember the name and why she is taking it.,ALLERGIES: , She has no known medical allergies.,FAMILY HISTORY:,  Remarkable for coronary artery disease, stroke, and congestive heart failure.,SOCIAL HISTORY:,  She is a widow, lives alone.  Denies any tobacco or alcohol use.,REVIEW OF SYSTEMS:,  Dyspnea on exertion.  No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling.,PHYSICAL EXAMINATION:,General:  She is alert but seems somewhat confused and is not able to provide specific details about her past history.,Vital Signs:  Blood pressure:  146/80.  Pulse:  68.  Weight:  147 pounds.,HEENT:  Unremarkable.,Neck:  Supple without JVD, adenopathy, or bruit.,Chest:  Clear to auscultation.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft.,Extremities:  No edema.,LABORATORY:,  O2 sat 100% at rest and with exertion.  Electrocardiogram was normal sinus rhythm.  Nonspecific S-T segment changes.  Chest x-ray pending.,ASSESSMENT/PLAN:,1.  Dyspnea on exertion, uncertain etiology.  Mother would be concerned about the possibility of coronary artery disease given the patient’s underlying risk factors.  We will have the patient sign a release of records so that we can review her previous history.  Consider setting up for a stress test.,2.  Hypertension, blood pressure is acceptable today.  I am not certain as to what, if the patient’s is on any antihypertensive agents.  We will need to have her call us what the names of her medications, so we can see exactly what she is taking.,3.  History of diabetes.  Again, not certain as to whether the patient is taking anything for this particular problem when she last had a hemoglobin A1C.  I have to obtain some further history and review records before proceeding with treatment recommendations.", Consult - History and Phy.,5
"PROCEDURE: , Right ventricular pacemaker lead placement and lead revision.,INDICATIONS:,  Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.,EQUIPMENT: , A new lead is a Medtronic model #12345, threshold sensing at 5.7, impedance of 1032, threshold of 0.3, atrial threshold is 0.3, 531, and sensing at 4.1.  The original chronic ventricular lead had a threshold of 3.5 and 6 on the can.,ESTIMATED BLOOD LOSS: , 5 mL.,PROCEDURE DESCRIPTION:  ,Conscious sedation with Versed and fentanyl over left subclavicular area with pacemaker pocket was anesthetized with local anesthetic with epinephrine.  The patient received a venogram documenting patency of the subclavian vein.  Skin incision with blunt and sharp dissection.  Electrocautery for hemostasis.  The pocket was opened and the pacemaker was removed from the pocket and disconnected from the leads.  The leads were sequentially checked.  Through the pocket a puncture of the vein with a thin wall needle was made and a long sheath was used to help carry it along the tortuosity of the proximal subclavian and innominate superior vena cava.  Ultimately, a ventricular lead was placed in apex of the right ventricle, secured to base pocket with 2-0 silk suture.  Pocket was irrigated with antibiotic solution.  The pocket was packed with bacitracin-soaked gauze.  This was removed during the case and then irrigated once again.  The generator was attached to the leads, placed in the pocket, secured with 2-0 silk suture and the pocket was closed with a three layer of 4-0 Monocryl.,CONCLUSION:  , Successful replacement of a right ventricular lead secondary to poor lead thresholds in a chronic lead and placement of the previous Vitatron pulse generator model # 12345.", Surgery,38
"TITLE OF OPERATION:  ,1.  Incision and drainage with extensive debridement, left shoulder.,2.  Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component).,3.  Implantation of antibiotic beads, left shoulder.,INDICATION FOR SURGERY: , The patient was seen multiple times preoperatively and found to have findings consistent with a chronic and indolent infections.  Risks and benefits have been discussed with him and his family at length including but not exclusive of continued infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, fractures, loss of bone, medical complications, surgical complications, transfusion related complications, etc.  The patient understood and wished to proceed.,PREOP DIAGNOSIS: , Presumed infection, left total shoulder arthroplasty.,POSTOP DIAGNOSES:  ,1.  Deep extensive infection, left total shoulder arthroplasty.,2.  Biceps tenosynovitis.,3.  Massive rotator cuff tear in left shoulder (full thickness subscapularis tendon rupture 3 cm x 4 cm; supraspinatus tendon rupture 3 cm x 3 cm; infraspinatus tear 2 cm x 2 cm).,DESCRIPTION OF PROCEDURE:  ,The patient was anesthetized in the supine position, a Foley catheter was placed in his bladder.  He was then placed Beach chair position and all bony prominences were well padded.  Pillows were placed around his knees to protect his sciatic nerve.  He was brought to the side of the table and secured with towels and tape.  The head was placed in neutral position with no lateral bending or extension to protect the brachioplexus from any stretch.  Left upper extremity was then prepped and draped in usual sterile fashion.  Unfortunately, preoperative antibiotics were given prior to the procedure.  This occurred due to lack of communication between the surgical staff and the anesthesia staff.  The patient's extremity, however, was prepped a second time with a chlorhexidine prep after he had been draped.  Also, Ioban bandages were placed securely to the skin to prevent any further introduction of infection into his shoulder.,Deltopectoral incision was then made.  The patient's had a cephalic vein, it was identified and protected throughout the case.  It was retracted laterally and once this has been completed, the deltopectoral interval was developed as carefully as possible.  The patient did have significant scar from this point on and did bleed from many surfaces throughout the case.  As a result, he was transfused 1 unit postoperatively.  He did not have any problems during the case except for one small drop of blood pressure.  However this was due primarily because of the extensive scarring of his proximal humerus.  He had scar between the anterior capsular structures and the conjoint tendon.  Also there was significant scar between the deltoid and the proximal humerus.  The deltoid was very carefully and tediously removed from the proximal humerus in order not to damage the axillary nerve.  Once the plane between the deltoid and underlying tissue was found, the proximal humerus was discovered to have a large defect, approximately 4 x 3.  This was covered by rimmed fibrous tissue which was fairly compressible, which felt to be purulent, however, when the needle was stuck into this area, there was no return of fluid.  As a result, this was finally opened and found to have fibrinous exudates which appeared to be old congealed, purulent material.  There was some suggestion of a synovitis type reaction also inside this cystic area.  This was all debrided but was found to track all the way into the proximal humerus from the lateral femoral component and also tracked posteriorly through and around the posterior cortex of the proximal humerus indicating that the infraspinatus probably had some tearing and detachment.  This later proved to be the case and infraspinatus did indeed have a tear 2 cm x 2 cm.  All of the mucinous material and fibrinous material was removed from the proximal humerus.  This was fairly extensive debridement.  All of this was sent to pathology and also sent for culture and sensitivity.  It should be noted that Gram stain became as multiple white blood cells but no organism seen.  The pathology came back as fibrinous material with multiple white cells, also with signs of chronic inflammation consistent with an infection.,Attention was then directed towards the anterior structures to gain access to the joint so that we could dislocate the prosthesis and remove it.  There was also cystic area in the anterior aspect of the shoulder which was fairly fibrinous.  This was also removed.  Once this was removed, though the capsule was found to be very thin, there was essentially no subscapularis tendon whatsoever.  It should also noted the patient's proximal humerus was subluxed superiorly so that there was no supraspinatus tendon present whatsoever.  As a result, the biceps tendon was finally identified just below the pectoralis tendon insertion.  The upper 1 or 2 cm of the pectoralis insertion was released in order to find the biceps.  It was tracked proximally and transverse ligament released.  The biceps tendon was flat and somewhat erythematous.  As a result, it released and tagged with an 0 Vicryl suture.  It was later tenodesed to the conjoint tendon using 2-0 Prolene sutures.  The joint was then entered and noted significant synovitis throughout the entire glenoid.  This was all very carefully removed using a rongeur and sharp dissection.,Next, the humeral component was removed and this was done by attempting to remove it with the slap hammer and device which comes with the Biomet set.  Unfortunately, this device would not hold the proximal humerus and we could not get the component to release.  As a result, bone contact of the metal proximally was released using a straight osteotome.  Once this was completed, another attempt was made to remove the prosthesis but this only resulted in fracture of the proximal humerus through the areas of erosion of the infection and once this has been completed, we abandoned use of that particular device and using a __________ , we were able to hit the prosthesis lip from beneath and essentially remove it.  There was no cement.  There was exudate within the canal which was removed using a curette.,Using fluoroscopy, sequential reamers were placed to a size of 11 distally down the shaft to remove the exudate.  This was also thoroughly irrigated with irrigation antibiotic, and impregnated irrigation to decrease any risk of infection.  It should be noted that the reaming was done fluoroscopically to make sure that there was no penetration of the canal at any point.,The attention was then directed to the glenoid.  The glenoid component was very carefully dissected free and found to be very loose.  It was essentially removed with digital dissection.  There was no remaining cement in the cavity itself.  The patient's glenoid was very carefully debrided.  The glenoid itself was found to be very cup shaped with significant amount of bone loss in the central portion of the canal itself.  This was debrided using rongeurs and curette until there was no purulent exudate present anywhere in the glenoid itself.,Next, the entire wound was irrigated thoroughly with 9 liters of antibiotic impregnated irrigation.  Rather than place a spacer, it was elected to use antiobiotic beads.  This was with antibiotic impregnated cement with one package with 3 gram of vancomycin.  These beads were then connected using Prolene and placed into the glenoid cavity itself, also some were placed in the greater tuberosity region.  These three did not have a Prolene attached to them.  The ones placed down the canal did have a Prolene used as did the ones placed in the cavity of the glenoid itself.,The biceps tendon was then tenodesed under tension to the conjoint tendon.  There was essentially no capsule left purely to close over the proximal humerus.  It was electively the proximal humerus.  A portion of bone intact because it did have some bleeding surfaces.  Deltopectoral was then closed with 0-Vicryl sutures, the deep subcutaneous tissues with 0-Vicryl sutures, superficial subcutaneous tissues with 2-0 Vicryl sutures.  Skin was closed with staples.  A sterile bandage was applied along with a cold therapy device and shoulder immobilizer.  The patient was sent to recovery room in stable and satisfactory condition.,It should be noted that __________ is being requested for this case.  This was a significantly scarred patient which required extra dissection and attention.  Even though this was a standard revision case due to infection, there was a significant more decision making and technical challenges in this case and this was present for typical revision case.  Similarly, this case took approximately 30 to 40% more length of time due to bleeding and the attention to hemostasis.  The blood loss and operative findings indicates that this case was at least 30 to 40% more challenging than a standard total shoulder or revision case.  This is being dictated for insurance purposes only and reflects no inherent difficulties with the case whatsoever.", Orthopedic,27
"ADMISSION DIAGNOSES,1.  Neck pain with right upper extremity radiculopathy.,2.  Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,DISCHARGE DIAGNOSES,1.  Neck pain with right upper extremity radiculopathy.,2.  Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression C4-C5, C5-C6, and C6-C7.,2.  Arthrodesis with anterior interbody fusion C4-C5, C5-C6, and C6-C7.,3.  Spinal instrumentation C4 through C7.,4.  Implant.,5.  Allograft.,COMPLICATIONS:,  None.,COURSE ON ADMISSION: , This is the case of a very pleasant 41-year-old Caucasian female who was seen in clinic as an initial consultation on 09/13/07 complaining of intense neck pain radiating to the right shoulder blade to top of the right shoulder in to the right upper extremity to the patient's hand.  The patient's symptoms have been persistent and had gotten worse with subjective weakness of the right upper extremity since its onset for several weeks now.  The patient has been treated with medications, which has been unrelenting.  The patient had imaging studies that showed evidence of cervical spondylosis with herniated disk and stenosis at C4-C5, C5-C6 and C6-C7.  The patient underwent liver surgery and postoperatively her main issue was that of some degree of on and off right shoulder pain and some operative site soreness, which was treated well with IV morphine.  The patient has resolution of the pain down the arm, but she does have some tingling of the right thumb and right index finger.  The patient apparently is doing well with slight dysphagia, we treated her with Decadron and we will send her home with Medrol.  The patient will have continued pain medication coverage with Darvocet and Flexeril.  The patient will follow up with me as scheduled.  Instructions have been given.", Discharge Summary,10
"PREOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,POSTOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,PROCEDURE PERFORMED: , YAG laser capsulotomy, right eye.,INDICATIONS: , This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane.  The patient is being brought in for YAG capsular discission.,PROCEDURE: , The patient was seated at the YAG laser, the pupil having been dilated with 1%  Mydriacyl, and Iopidine was instilled.  The Abraham capsulotomy lens was then positioned and applications of laser energy in the pattern indicated on the outpatient note were applied.  A total of", Surgery,38
"NERVE CONDUCTION STUDIES:,  Bilateral ulnar sensory responses are absent.  Bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude.  The left radial sensory response is normal and robust.  Left sural response is absent.  Left median motor distal latency is prolonged with attenuated evoked response amplitude.  Conduction velocity across the forearm is mildly slowed.  Right median motor distal latency is prolonged with a normal evoked response amplitude and conduction velocity.  The left ulnar motor distal latency is prolonged with a severely attenuated evoked response amplitude both below and above the elbow.  Conduction velocities across the forearm and across the elbow are prolonged.  Conduction velocity proximal to the elbow is normal.  The right median motor distal latency is normal with normal evoked response amplitudes at the wrist with a normal evoked response amplitude at the wrist.  There is mild diminution of response around the elbow.  Conduction velocity slows across the elbow.  The left common peroneal motor distal latency evoked response amplitude is normal with slowed conduction velocity across the calf and across the fibula head.  F-waves are prolonged.,NEEDLE EMG: , Needle EMG was performed on the left arm and lumbosacral and cervical paraspinal muscles as well as middle thoracic muscles using a disposable concentric needle.  It revealed spontaneous activity in lower cervical paraspinals, left abductor pollicis brevis, and first dorsal interosseous muscles.  There were signs of chronic reinnervation in triceps, extensor digitorum communis, flexor pollicis longus as well first dorsal interosseous and abductor pollicis brevis muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  A sensory motor length-dependent neuropathy consistent with diabetes.,2.  A severe left ulnar neuropathy.  This is probably at the elbow, although definitive localization cannot be made.,3.  Moderate-to-severe left median neuropathy.  This is also probably at the carpal tunnel, although definitive localization cannot be made.,4.  Right ulnar neuropathy at the elbow, mild.,5.  Right median neuropathy at the wrist consistent with carpal tunnel syndrome, moderate.,6.  A left C8 radiculopathy (double crush syndrome).,7.  There is no evidence for thoracic radiculitis.,The patient has made very good response with respect to his abdominal pain since starting Neurontin.  He still has mild allodynia and is waiting for authorization to get insurance coverage for his Lidoderm patch.  He is still scheduled for MRI of C-spine and T-spine.  I will see him in followup after the above scans.", Neurology,22
"PROCEDURES PERFORMED: , Esophagogastroduodenoscopy.,PREPROCEDURE DIAGNOSIS: , Dysphagia.,POSTPROCEDURE DIAGNOSIS: , Active reflux esophagitis, distal esophageal stricture, ring due to reflux esophagitis, dilated with balloon to 18 mm.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives.  Risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications.  Vital signs were monitored by blood pressure, heart rate, and oxygen saturation.  Supplemental O2 given.  Specifics of the procedure discussed.  The procedure was discussed with father and mother as the patient is mentally challenged.  He has no complaints of dysphagia usually for solids, better with liquids, worsening over the last 6 months, although there is an emergency department report from last year.  He went to the emergency department yesterday with beef jerky.,All of this reviewed.  The patient is currently on Cortef, Synthroid, Tegretol, Norvasc, lisinopril, DDAVP.  He is being managed for extensive past history due to an astrocytoma, brain surgery, hypothyroidism, endocrine insufficiency.  He has not yet undergone significant workup.  He has not yet had an endoscopy or barium study performed.  He is developmentally delayed due to the surgery, panhypopituitarism.,His family history is significant for his father being of mine, also having reflux issues, without true heartburn, but distal esophageal stricture.  The patient does not smoke, does not drink.  He is living with his parents.  Since his emergency department visitation yesterday, no significant complaints.,Large male, no acute distress.  Vital signs monitored in the endoscopy suite.  Lungs clear.  Cardiac exam showed regular rhythm.  Abdomen obese but soft.  Extremity exam showed large hands.  He was a Mallampati score A, ASA classification type 2.,The procedure discussed with the patient, the patient's mother.  Risks, benefits, and alternatives discussed.  Potential alternatives for dysphagia, such as motility disorder, given his brain surgery, given the possibility of achalasia and similar discussed.  The potential need for a barium swallow, modified barium swallow, and similar discussed.  All questions answered.  At this point, the patient will undergo endoscopy for evaluation of dysphagia, with potential benefit of the possibility to dilate him should there be a stricture.  He may have reflux symptoms, without complaining of heartburn.  He may benefit from a trial of PPI.  All of this reviewed.  All questions answered.,", Surgery,38
"BILATERAL SCROTAL ORCHECTOMY,PROCEDURE:,:  The patient is placed in the supine position, prepped and draped in the usual manner.  Under satisfactory general anesthesia, the scrotum was approached and through a transverse mid scrotal incision, the right testicle was delivered through the incision.  Hemostasis was obtained with the Bovie and the spermatic cord was identified.  It was clamped, suture ligated with 0 chromic catgut and the cord above was infiltrated with 0.25% Marcaine for postoperative pain relief.  The left testicle was delivered through the same incision.  The spermatic cord was identified, clamped, suture ligated and that cord was also injected with 0.25% percent Marcaine.  The incision was injected with the same material and then closed in two layers using 4-0 chromic catgut continuous for the dartos and interrupted for the skin.  A dry sterile dressing fluff and scrotal support applied over that.  The patient was sent to the Recovery Room in stable condition.", Urology,39
"HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old African-American male previously well known to me.  He has a previous history of aortic valve disease, status post aortic valve replacement on 10/15/2007, for which he has been on chronic anticoagulation.  There is a previous history of paroxysmal atrial fibrillation and congestive heart failure, both of which have been stable prior to this admission.  He has a previous history of transient ischemic attack with no residual neurologic deficits.,The patient has undergone surgery by Dr. X for attempted nephrolithotomy.  The patient has experienced significant postoperative bleeding, for which it has been necessary to discontinue all anticoagulation.  The patient is presently seen at the request of Dr. X for management of anticoagulation and his above heart disease.,PAST MEDICAL AND SURGICAL HISTORY:,1.  Type I diabetes mellitus.,2.  Hyperlipidemia.,3.  Hypertension.,4.  Morbid obesity.,5.  Sleep apnea syndrome.,6.  Status post thyroidectomy for thyroid carcinoma.,REVIEW OF SYSTEMS:,General:  Unremarkable.,Cardiopulmonary:  No chest pain, shortness of breath, palpitations, or dizziness.,Gastrointestinal:  Unremarkable.,Genitourinary:  See above.,Musculoskeletal:  Unremarkable.,Neurologic:  Unremarkable.,FAMILY HISTORY: , There are no family members with coronary artery disease.  His mother has congestive heart failure.,SOCIAL HISTORY:  ,The patient is married.  He lives with his wife.  He is employed as a barber.  He does not use alcohol, tobacco, or illicit drugs.,MEDICATIONS PRIOR TO ADMISSION:,1.  Clonidine 0.3 mg b.i.d.,2.  Atenolol 50 mg daily.,3.  Simvastatin 80 mg daily.,4.  Furosemide 40 mg daily.,5.  Metformin 1000 mg b.i.d.,6.  Hydralazine 25 mg t.i.d.,7.  Diovan 320 mg daily.,8.  Lisinopril 40 mg daily.,9.  Amlodipine 10 mg daily.,10.  Lantus insulin 50 units q.p.m.,11.  KCl 20 mEq daily.,12.  NovoLog sliding scale insulin coverage.,13.  Warfarin 7.5 mg daily.,14.  Levothyroxine 0.2 mg daily.,15.  Folic acid 1 mg daily.,ALLERGIES: , None.,PHYSICAL EXAMINATION:,General:  A well-appearing, obese black male.,Vital Signs:  BP 140/80, HR 88, respirations 16, and afebrile.,HEENT:  Grossly normal.,Neck:  Normal.  Thyroid, normal.  Carotid, normal upstroke, no bruits.,Chest:  Midline sternotomy scar.,Lungs:  Clear.,Heart:  PMI fifth intercostal space mid clavicular line.  Normal S1 and prosthetic S2.  No murmur, rub, gallop, or click.,Abdomen:  Soft and nontender.  No palpable mass or hepatosplenomegaly.", Consult - History and Phy.,5
"EXAM:,  CT examination of the abdomen and pelvis with intravenous contrast.,INDICATIONS:,  Abdominal pain.,TECHNIQUE:  ,CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration.  Oral contrast was not administered.  There was no comparison of studies.,FINDINGS,CT PELVIS:,Within the pelvis, the uterus demonstrates a thickened-appearing endometrium.  There is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology.  There is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid.  Several smaller fibroids were also suspected.,The ovaries are unremarkable in appearance.  There is no free pelvic fluid or adenopathy.,CT ABDOMEN:,The appendix has normal appearance in the right lower quadrant.  There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis.  The small and large bowels are otherwise unremarkable.  The stomach is grossly unremarkable.  There is no abdominal or retroperitoneal adenopathy.  There are no adrenal masses.  The kidneys, liver, gallbladder, and pancreas are in unremarkable appearance.  The spleen contains several small calcified granulomas, but no evidence of masses.  It is normal in size.  The lung bases are clear bilaterally.  The osseous structures are unremarkable other than mild facet degenerative changes at L4-L5 and L5-S1.,IMPRESSION:,1.  Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm.,2.  Multiple uterine fibroids.,3.  Prominent endometrium.,4.  Followup pelvic ultrasound is recommended.", Gastroenterology,14
"LEXISCAN MYOVIEW STRESS STUDY,REASON FOR THE EXAM: , Chest discomfort.,INTERPRETATION: , The patient exercised according to the Lexiscan study, received a total of 0.4 mg of Lexiscan IV injection.  At peak hyperemic effect, 24.9 mCi of Myoview were injected for the stress imaging and earlier 8.2 mCi were injected for the resting and the usual SPECT and gated SPECT protocol was followed and the data was analyzed using Cedars-Sinai software.  The patient did not walk because of prior history of inability to exercise long enough on treadmill.,The resting heart rate was 57 with the resting blood pressure 143/94.  Maximum heart rate achieved was 90 with a maximum blood pressure unchanged.,EKG at rest showed sinus rhythm with no significant ST-T wave changes of reversible ischemia or injury.  Subtle nonspecific in III and aVF were seen.  Maximum stress test EKG showed inverted T wave from V4 to V6.  Normal response to Lexiscan.,CONCLUSION:  ,Maximal Lexiscan perfusion with subtle abnormalities non-conclusive.  Please refer to the Myoview interpretation.,MYOVIEW INTERPRETATION: , The left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end-diastolic volume of 115 and end-systolic of 51.  EF estimated and calculated at 56%.,Cardiac perfusion reviewed, showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring.,IMPRESSION:,1.  Normal stress/rest cardiac perfusion with no indication of ischemia.,2.  Normal LV function and low likelihood of significant epicardial coronary narrowing.,", Radiology,33
"PREOPERATIVE DIAGNOSIS:,  Left distal radius fracture displaced.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture displaced.,SURGERY:  ,Closed reduction and placement of long-arm cast, CPT code 25605.,ANESTHESIA:  ,General LMA.,FINDINGS:  ,The patient was found to have a displaced fracture.  She was found to be in perfect alignment after closed reduction and placement of cast.  The radial deviation was well corrected.,INDICATIONS: , The patient is 5 years old.  She was seen in our office today 1 week after being placed into a cast for a displaced fracture.  She was noted to have significant loss of alignment especially on the lateral view.  She was indicated for closed reduction and placed of the long-arm cast.  Risks and benefits were discussed at length with the family.  They wished to proceed.,PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in supine position.  General anesthesia was induced without incident.  Previous cast was previously removed.  An arm was approached and a closed reduction was performed.  This was checked under AP and lateral projection and was found to be in adequate alignment.  There was very mild residual dorsiflexion deformity noted.,A long-arm cast was then placed with plaster and molding.  Repeat x-rays demonstrated adequate alignment on both views.,The cast was then reinforced with fiberglass.  The patient was awakened from anesthesia and taken to recovery room in good condition.  There were no complications.  All instruments, sponge, and needle counts were correct at the end of case.,PLAN:  ,The patient will be discharged home.  She will return in 3 weeks for cast removal and clinical examination.  She would likely be placed into a wrist-guard at that time.  She has a prescription for Tylenol with codeine elixir.,", Orthopedic,27
"PREOPERATIVE DIAGNOSIS:  ,Persistent abnormal uterine bleeding after endometrial ablation.,POSTOPERATIVE DIAGNOSIS: , Persistent abnormal uterine bleeding after endometrial ablation.,PROCEDURE PERFORMED: , Total abdominal hysterectomy (TAH) with a right salpingo-oophorectomy.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 250 cc.,FLUIDS:  ,1500 cc of crystalloids.,URINE: , 125 cc of clear urine at the end of the procedure.,FINDINGS: , On exam, under anesthesia, an obese female with an enlarged fibroid uterus freely movable on the pelvis.  Operative findings demonstrated the same with normal appearing tubes bilaterally.  The right ovary contained a right ovarian cyst.  The left ovary appeared to be within normal limits.  The peritoneal surfaces were noted to be within normal limits.  The bowel was also noted to be within normal limits.,INDICATIONS FOR THIS PROCEDURE: , The patient is a 44-year-old female who had an endometrial ablation done in May, which showed submucosal fibroids.  She had history of anemia and has been on iron therapy.  She started having bleeding three weeks ago with intermittent bouts of flooding.,She desired permanent and definitive therapy and therefore it was felt very appropriate to take the patient for a total abdominal hysterectomy.  The uterus, cervix, and right tube and ovary was sent to pathology for review.,PROCEDURE: , After informed consent was obtained, all questions were answered to the patient's satisfaction in layman's term.  She was taken to the operating room where a general anesthesia was obtained without any difficulty.  She was examined under anesthesia with noted findings above.  She was placed in a dorsal supine position and prepped and draped in the usual sterile fashion.  The Pfannenstiel skin incision was made with the first knife and was then carried down to the underlying layer of the fascia.  With the second knife, the fascia was excised in the midline and extended laterally with the Mayo scissors.  The superior aspect of the fascial incision was then tented up with the Ochsner clamps and the underlying rectus muscle was dissected off sharply as well as bluntly.  Attention was then turned to the inferior aspect of the fascial incision, which in a similar fashion was tented up and the underlying rectus muscle was dissected off sharply as well as bluntly.  The rectus muscle was then separated in the midline, the peritoneum was identified, entered bluntly and digitally.  Then the peritoneal incision was then extended superior and inferiorly with excellent visualization of the bladder.  The GYN Balfour was then placed.  A Lahey clamp was placed on the fundus of the uterus to pull the uterus into the operative field and the bowel was packed away with moist laparotomy sponges.  Attention was then turned to the round ligaments bilaterally, which were tented up with Allis clamps and then a hemostat was poked through the avascular portion underneath the round ligament and the #O-tie was passed through and then tied down.  Then the round ligament was transected and suture ligated and noted to be hemostatic.  The round ligaments were then skeletonized to create a window in the broad ligament.  The right infundibulopelvic ligament was isolated through the window created from the round ligaments and then the infundibular ligament on the right was loop tied and then doubly clamped with straight Ochsner clamps and then transected and suture ligated with a #0 Vicryl in a Heaney stitch fashion.  It was noted to be hemostatic.  Attention was then turned to the left side, in which the uterovarian vessel was isolated and then tied with an #O-tie and then doubly clamped with straight Ochsner clamps, transected and suture ligated with a #0 Vicryl in a Heaney stitch fashion and noted to be hemostatic.  The vesicouterine peritoneum was then identified, tented up with Allis clamps, and then the bladder flap was created sharply with a Russian and Metzenbaum scissors.  Then the bladder was deflected off of the underlying cervix with blunt dissection with a moist Ray-Tec sponge down to the level of the cervix.,The uterine vessels were skeletonized bilaterally and then clamped with straight Ochsner clamps and transected and suture ligated and noted to be hemostatic.  In the similar fashion, the broad ligament down to the level of the caudal ligament, the uterosacral ligaments was clamped with curved Ochsner clamps and transected and suture ligated, and noted to be hemostatic.  The second Lahey clamp was then placed on the cervix.  The cervix was tented up and the pubocervical vesical fascia was transected with a long knife and then the vagina was entered with a double pointed scissors poked through well protecting posteriorly with a large malleable.  The cuff was then outlined.  The vaginal cuff was grasped with a Ochsner clamp and then the cervix, uterus, and the right tube and ovary were transected using the Jorgenson scissors.  The cuff outlined with Ochsner clamps.  The cuff was then painted with a Betadine soaked Ray-Tec sponge and the sponge was placed over the vagina.  The vaginal cuff was then closed with a #0 Vicryl in a running locked fashion holding on to the beginning end on the right side as well as incorporating the ipsilateral cardinal ligaments into the cuff angles.  A long Allis was then used to grasp the mid portion of the cuff and a #0 Vicryl figure-of-eight stitch was placed in the mid portion of the cuff and tied down.  At this time, the abdomen was copiously irrigated with warm normal saline and noted to be hemostatic.  The suture that was used to close the cuff was then used to come back through the posterior peritoneum grabbing the uterosacral ligaments and the mid portion of the cuff, and then tied down to bring the cuff close and together.  Then, the right round ligament was pulled into the cuff and tied down with the #0 Vicryl that was used as a figure-of-eight stitch in the middle of the cuff.  The left round ligament was too small to reach the cuff.  The abdomen was then again copiously irrigated with warm normal saline and noted to be hemostatic.  The peritoneum was then re-peritonealized with a #3-0 Vicryl in a running fashion.  The GYN Balfour and all packing sponges were removed from the abdomen.  Then the abdomen was then once again copiously irrigated and the cuff and incision sites were once again reinspected and noted to be hemostatic.  The ______ was placed back into the hollow of the sacrum.  The omentum was then pulled over to top of the bowel and then the peritoneum was then closed with a #3-0 Vicryl in a running fashion and then the fascia was closed with #0 Vicryl in a running fashion.  The skin was closed with staples and dressing applied.  The patient was then examined at the end of the procedure.  The Betadine-soaked sponge was removed from the vagina.  The cuff was noted to be intact without bleeding and the patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2 and she was taken to the recovery in stable condition.  The patient will be followed throughout her hospital stay.", Obstetrics / Gynecology,24
"COMPARISON:, None.,MEDICATIONS:, Lopressor 5mg IV at 0920 hours.,HEART RATE: ,Recorded heart rate 55 to 57bpm.,EXAM:,Initial unenhanced axial CT imaging of the heart was obtained with ECG gating for the purpose of coronary artery calcium scoring (Agatston Method) and calcium volume determination.,18 gauge IV Intracath was inserted into the right antecubital vein.,A 20cc saline bolus was injected intravenously to confirm vein patency and adequacy of venous access.,Multi-detector CT imaging was performed with a 64 slice MDCT scanner with images obtained from the mid ascending aorta to the diaphragm at 0.5mm slice thickness during breath-holding.,95 cc of Isovue was administered followed by a 90cc saline “bolus chaser”. Image reconstruction was performed using retrospective cardiac gating. Calcium scoring analysis (Agatston Method and volume determination) was performed.,FINDINGS:,CALCIUM SCORE:  The patient's total Agatston calcium score is: 115. The Agatston score for the individual vessels are: LM: 49. RCA: 1. LAD: 2. CX: 2. Other: 62. The Agatston calcium score places the patient in the 90th percentile, which means 10 percent of the male population in this age group would have a higher calcium score.,QUALITY ASSESSMENT:,  Examination is of good quality with good bolus timing and good demonstration of coronary arteries.,LEFT MAIN CORONARY ARTERY:,  The left main coronary artery has a posteriorly positioned take-off from the valve cusp, with a patent ostium, and it has an extramural (non-malignant) course. The vessel is of moderate size. There is an apparent second ostium, in a more normal anatomic location, but quite small. This has an extramural (non-malignant) course. There is mixed calcific/atheromatous plaque within the distal vessel, as well as positive remodeling. There is no high grade stenosis but a flow-limiting lesion can not be excluded. The vessel trifurcates into a left anterior descending artery, a ramus intermedius and a left circumflex artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  The left anterior descending artery is a moderate-size vessel, with ostial calcific plaque and soft plaque without a high-grade stenosis, but there may be a flow-limiting lesion here. There is a moderate size bifurcating first diagonal branch with ostial calcification, but no flow-limiting lesion. LAD continues as a moderate-size vessel to the posterior apex of the left ventricle.,Ramus intermedius branch is a moderate to large-size vessel with extensive calcific plaque, but no ostial stenosis. The dense calcific plaque limits evaluation of the vessel lumen, and a flow-limiting lesion within the proximal vessel cannot be excluded. The vessel continues as a small vessel on the left lateral ventricular wall.,LEFT CIRCUMFLEX CORONARY ARTERY:, The left circumflex artery is a moderate-size vessel with a normal ostium giving rise to a small OM1 branch and a large OM2 branch supplying much of the posterolateral wall of the left ventricular. The AV-groove branch tapers at the base of the heart. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting stenosis.,RIGHT CORONARY ARTERY:, The right coronary artery is a large vessel with a normal ostium giving rise to a moderate-size acute marginal branch and continuing as a large vessel to the crux of the heart supplying a left posterior descending artery and small posterolateral ventricular branches. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting lesion.,Coronary circulation is right dominant.,FUNCTIONAL ANALYSIS:, End diastolic volume: 106ml End systolic volume: 44ml Ejection fraction: 58 percent,ANATOMIC ANALYSIS:,Normal heart size with no demonstrated ventricular wall abnormalities. There are no demonstrated myocardial,bridges. Normal left atrial appendage with no evidence of thrombosis.,Cardiac valves are normal.,The aortic diameter measures 33mm just distal to the sino-tubular junction. The visualized thoracic aorta appears normal in size.,Normal pericardium without pericardial thickening or effusion.,There is no demonstrated mediastinal or hilar adenopathy. The visualized lung parenchyma is unremarkable.,There are two left and two right pulmonary veins.,IMPRESSION:,Ventricular function: Normal.,Single vessel coronary artery analysis:,LM: There is a posterior origin from the valve cusp. There is mixed calcific/atheromatous plaque and positive remodeling plaque within the LM, and although there is no high grade stenosis, a flow-limiting lesion can not be excluded. In addition, there is an apparent second ostium of indeterminate significance, but both ostia have extramural (non-malignant) courses.,LAD: Dense calcific plaque within the proximal vessel with ostial calcification and possible flow-limiting proximal lesion. There is a ramus branch with dense calcific plaque limiting evaluation of the vessel lumen, but a flow-limiting lesion cannot be excluded here.,CX: Minimal calcific plaque with no flow-limiting lesion.,RCA: Minimal calcific plaque with no flow-limiting lesion.,Coronary artery dominance: Right.", Radiology,33
"MULTISYSTEM EXAM,CONSTITUTIONAL: , The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  The patient appeared alert.,EYES: , The conjunctiva was clear.  The pupil was equal and reactive.  There was no ptosis.  The irides appeared normal.,EARS, NOSE AND THROAT: , The ears and the nose appeared normal in appearance.  Hearing was grossly intact.  The oropharynx showed that the mucosa was moist.  There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK: , The neck was supple.  The thyroid gland was not enlarged by palpation.,RESPIRATORY:  ,The patient's respiratory effort was normal.  Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR: , Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted.  The extremities showed no edema.,BREASTS:  ,Breast inspection showed them to be symmetrical with no nipple discharge.  Palpation of the breasts and axilla revealed no obvious mass that I could appreciate.,GASTROINTESTINAL:  ,The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  Bowel sounds were present.,GU:  ,The external genitalia appeared to be normal.  The pelvic exam revealed no adnexal masses.  The uterus appeared to be normal in size and there was no cervical motion tenderness.,LYMPHATIC:  ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL:  ,The head and neck by inspection showed no obvious deformity.  Again, the extremities showed no obvious deformity.  Range of motion appeared to be normal for the upper and lower extremities.,SKIN:,  Inspection of the skin and subcutaneous tissues appeared to be normal.  The skin was pink, warm and dry to touch.,NEUROLOGIC: , Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.,PSYCHIATRIC:  ,The patient was oriented to time, place and person.  The patient's judgment and insight appeared to be normal.", General Medicine,15
"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,39
"CHIEF COMPLAINT:,  The patient comes for her first Pap smear, complaining of irregular periods.,HISTORY OF PRESENT ILLNESS:,  The patient wishes to discuss considering something to help with her menstrual cramping and irregular periods.  She notes that her periods are out of weck.  She says that she has cramping and pain before her period starts.  Sometimes, she is off her period for two weeks and then she bleeds for two whole weeks.  She usually has her periods lasting seven days, usually comes on the 19th of each month and now it seems to have changed.  The cramping is worse.  She said her flow has increased.  She has to change her pad every half to one hour and uses a super tampon sometimes.  She usually has four days of hard flow and then she might have 10 days where she will have to wear a mini pad.  She also notes that her headaches have been worsening a little bit.  She has had quite a bit of stress.  She had a headache on Wednesday again after having had one on the weekend.  She said she usually only has an occasional headache and that is not too bad but now she has developed what she would consider to be a migraine and she has not had serious headaches like this and it seems to be worsening and coming a little bit more regularly, and she has not figure out what to do to get rid of them.  She avoids caffeine.  She only eats chocolate when she is near her period and she usually drinks one can of cola a day.,MEDICATIONS: , None.,ALLERGIES:,  None.,SOCIAL HISTORY:,  She is a nonsmoker.  She is not sexually active.,PAST MEDICAL HISTORY:,  She has had no surgery or chronic illnesses.,FAMILY HISTORY:,  Mother has hypertension, depression.  Father has had renal cysts and sometimes some stomach problems.  Both of her parents have problems with their knees.,REVIEW OF SYSTEMS:,  Patient denies headache or trauma.  No blurred or double vision.  Hearing is fine, no tinnitus or infection.  Infrequent sore throat, no hoarseness or cough.,HEENT:  See HPI.,Neck:  No stiffness, pain or swelling.,Respiratory:  No shortness of breath, cough or hemoptysis.  She is a nonsmoker.,Cardiovascular:  No chest pain, ankle edema, palpitations or hypertension.,GI:  No nausea, vomiting, diarrhea, constipation, melena or jaundice.,GU:  No dysuria, frequency, urgency or stress incontinence.,Locomotor:  No weakness, joint pain, tremor or swelling.,GYN:  See HPI.,Integumentary:  Patient performs self-breast examinations and denies any breast masses or nipple discharge.  No recent skin or hair changes.,Neuropsychiatric:  Denies depression, anxiety, tearfulness or suicidal thought.,PHYSICAL EXAMINATION:,VITALS:  Height 64.5 inches.  Weight:  162 pounds.  Blood pressure 104/72.  Pulse:  72.  Respirations:  16.  LMP:  08/21/04.  Age:  19.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.,Neck:  Full range of motion.  No lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation and percussion.,Heart:  Normal sinus rhythm, no murmur.,Integumentary:  Breasts are without masses, tenderness, nipple retraction or discharge.  Reviewed self-breast examination.  No axillary nodes are palpable.,Abdomen:  Soft.  Liver, spleen, and kidneys are not palpable.  No masses felt, nontender.  Femoral pulses strong and equal.,Back:  No CVA or spinal tenderness.  No deformity noted.,Pelvic:  BUS negative.  Vaginal mucosa pink, scanty discharge.  Cervix without lesion.  Pap was taken.  Uterus normal size.  Adnexa:  No masses.  She does have some pain on palpation of the uterus.,Rectal:  Good sphincter tone.  No masses.  Stool is guaiac negative.,Extremities:  No edema.  Pulses strong and equal.  Reflexes are intact.,Rectal:  No mass.,ASSESSMENT:,  Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.,PLAN:,  We will evaluate with a CBC, urinalysis and culture, and TSH.  The patient has what she describes as migraine headaches of a new onset.  Because of the pelvic pain, dysmenorrhea, and menorrhagia, we will also evaluate with a pelvic sonogram.  We will evaluate with a CT scan of the brain with and without contrast.  We will try Anaprox DS one every 12 hours for the headache.  At this point, she could also use that for menstrual cramping.  Prescription written for 20 tablets.  If her lab findings, sonographic findings, and CT of the brain are normal, we would consider trying birth control pills to regulate her periods and reduce the cramping and excessive flow.  The lab x-ray and urinalysis results will be reported to her as soon as they are available.", Obstetrics / Gynecology,24
"CHIEF COMPLAINT:,  Chronic otitis media.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth.  There is also associated chronic nasal congestion.  There had been no bouts of spontaneous tympanic membrane perforation, but there had been elevations of temperature up to 102 during the acute infection.  He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia.,ALLERGIES:,  None.,MEDICATIONS:,  None.,FAMILY HISTORY:,  Noncontributory.,MEDICAL HISTORY: , Mild reflux.,PREVIOUS SURGERIES:,  None.,SOCIAL HISTORY: , The patient is not in daycare.  There are no pets in the home.  There is no secondhand tobacco exposure.,PHYSICAL EXAMINATION: , Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present.  Left ear is still little bit black.  Nose, moderate inferior turbinate hypertrophy.  No polyps or purulence.  Oral cavity, oropharynx 2+ tonsils.  No exudates.  Neck, no nodes, masses or thyromegaly.  Lungs are clear to A&P.  Cardiac exam, regular rate and rhythm.  No murmurs.  Abdomen is soft and nontender.  Positive bowel sounds.,IMPRESSION: , Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, and wax accumulation.,PLAN:,  The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia.", Pediatrics - Neonatal,29
"CHIEF COMPLAINT:, Bright red blood per rectum ,HISTORY OF PRESENT ILLNESS: ,This 73-year-old woman had a recent medical history significant for renal and bladder cancer, deep venous thrombosis of the right lower extremity, and anticoagulation therapy complicated by lower gastrointestinal bleeding. Colonoscopy during that admission showed internal hemorrhoids and diverticulosis, but a bleeding site was not identified. Five days after discharge to a nursing home, she again experienced bloody bowel movements and returned to the emergency department for evaluation. ,REVIEW OF SYMPTOMS: ,No chest pain, palpitations, abdominal pain or cramping, nausea, vomiting, or lightheadedness. Positive for generalized weakness and diarrhea the day of admission. ,PRIOR MEDICAL HISTORY:, Long-standing hypertension, intermittent atrial fibrillation, and hypercholesterolemia. Renal cell carcinoma and transitional cell bladder cancer status post left nephrectomy, radical cystectomy, and ileal loop diversion 6 weeks prior to presentation, postoperative course complicated by pneumonia, urinary tract infection, and retroperitoneal bleed. Deep venous thrombosis 2 weeks prior to presentation, management complicated by lower gastrointestinal bleeding, status post inferior vena cava filter placement. ,MEDICATIONS: ,Diltiazem 30 mg tid, pantoprazole 40 mg qd, epoetin alfa 40,000 units weekly, iron 325 mg bid, cholestyramine. Warfarin discontinued approximately 10 days earlier. ,ALLERGIES: ,Celecoxib (rash).,SOCIAL HISTORY:, Resided at nursing home. Denied alcohol, tobacco, and drug use. ,FAMILY HISTORY:, Non-contributory.,PHYSICAL EXAM: ,Temp = 38.3C BP =146/52 HR= 113 RR = 18 SaO2 = 98% room air ,General: Pale, ill-appearing elderly female. ,HEENT: Pale conjunctivae, oral mucous membranes moist. ,CVS: Irregularly irregular, tachycardia. ,Lungs: Decreased breath sounds at the bases. ,Abdomen: Positive bowel sounds, soft, nontender, nondistended, gross blood on rectal exam. ,Extremities: No cyanosis, clubbing, or edema. ,Skin: Warm, normal turgor. ,Neuro: Alert and oriented. Nonfocal. ,LABS: ,CBC: ,WBC count: 6,500 per mL ,Hemoglobin: 10.3 g/dL ,Hematocrit:31.8% ,Platelet count: 248 per mL ,Mean corpuscular volume: 86.5 fL ,RDW: 18% ,CHEM 7: ,Sodium: 131 mmol/L ,Potassium: 3.5 mmol/L ,Chloride: 98 mmol/L ,Bicarbonate: 23 mmol/L ,BUN: 11 mg/dL ,Creatinine: 1.1 mg/dL ,Glucose: 105 mg/dL ,COAGULATION STUDIES: ,PT 15.7 sec ,INR 1.6 ,PTT 29.5 sec ,HOSPITAL COURSE: ,The patient received 1 liter normal saline and diltiazem (a total of 20 mg intravenously and 30 mg orally) in the emergency department. Emergency department personnel made several attempts to place a nasogastric tube for gastric lavage, but were unsuccessful. During her evaluation, the patient was noted to desaturate to 80% on room air, with an increase in her respiratory rate to 34 breaths per minute. She was administered 50% oxygen by nonrebreadier mask, with improvement in her oxygen saturation to 89%. Computed tomographic angiography was negative for pulmonary embolism. ", Emergency Room Reports,12
"SUBJECTIVE:,  The patient is here for a follow-up.  The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d.  Eye report was noted and appreciated.  The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago.  She denied having any trauma.  She states that the pain is bothering her.  She denies having any fevers, chills, or any joint effusion or swelling at this point.  She noted also that there is some increase in her hair loss in the recent times.,OBJECTIVE:,  The patient is alert and oriented.  General physical exam is unremarkable.  Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion.  Hand examination is unremarkable today.  The rest of the musculoskeletal exam is unremarkable.,ASSESSMENT:,  Epicondylitis, both elbows, possibly secondary to lupus flare-up.,PLAN:,  We will inject both elbows with 40-mg of Kenalog mixed with 1 cc of lidocaine.  The posterior approach was chosen under sterile conditions.  The patient tolerated both procedures well.  I will obtain CBC and urinalysis today.  If the patient's pain does not improve, I will consider adding methotrexate to her therapy.,Sample Doctor M.D.", Rheumatology,34
"HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **.  Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound.  ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear.  The baby was vertex presentation.  The baby was dried, stimulated, and bulb suctioned.  Apgar scores of ** at one minute and ** at five minutes.,PAST MEDICAL HISTORY,MATERNAL HISTORY:,  The mother is a **-year-old, G**, P** female with blood type **.  She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative.  Mother was group B strep **.  Mother's past medical history is **.,PRENATAL CARE: , Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits.  She did not smoke, drink alcohol, or use illicit drugs during pregnancy.,SURGICAL HISTORY: , **,MEDICATIONS:,  Medications taken during this pregnancy were **.,ALLERGIES: , **,FAMILY HISTORY: , **,SOCIAL HISTORY: , **,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature **, heart rate **, respiratory rate **.  Dextrose stick **.  Ballard score by the RN is ** weeks.  Birth weight is ** grams, which is the ** percentile for gestational age.  Length is ** centimeters which is ** percentile for gestational age.  Head circumference is ** centimeters which is ** percentile for gestational age.,GENERAL:  **Alert, active, nondysmorphic-appearing infant in no acute distress.,HEENT:  Anterior fontanelle open and flat.  Positive bilateral red reflexes.,Ears have normal shape and position with no pits or tags.  Nares patent.  Palate intact.  Mucous membranes moist.,NECK:  Full range of motion.,CARDIOVASCULAR:  Normal precordium, regular rate and rhythm.  No murmurs.  Normal femoral pulses.,RESPIRATORY;  Clear to auscultation bilaterally.  No retractions.,ABDOMEN:  Soft, nondistended.  Normal bowel sounds.  No hepatosplenomegaly.  Umbilical stump is clean, dry, and intact.,GENITOURINARY:  Normal tanner I **.  Anus patent.,MUSCULOSKELETAL:  Negative Barlow and Ortolani.  Clavicles intact.  Spine straight.  No sacral dimple or hair tuft.  Leg lengths grossly symmetric.  Five fingers on each hand and five toes on each foot.,SKIN:  Warm and pink with brisk capillary refill.  No jaundice.,NEUROLOGICAL:  Normal tone.  Normal root, suck, grasp, and Moro reflexes.  Moves all extremities equally.,DIAGNOSTIC STUDIES,LABORATORY DATA:,  **,ASSESSMENT: , Full term, appropriate for gestational age **.,PLAN:,1.  Routine newborn care.,2.  Anticipatory guidance.,3.  Hepatitis B immunization prior to discharge.,", Pediatrics - Neonatal,29
"PREOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,POSTOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,OPERATIVE PROCEDURE: , Transplant nephrectomy.,DESCRIPTION OF PROCEDURE: , The patient has had rapid deterioration of her kidney function since her transplant at ABCD one year ago.  The patient was recently thought to have obstruction to the transplant and a stent was placed in to the transplant percutaneously, but the ureter was wide open and there was no evidence of obstruction.  Because the kidney was felt to be irretrievably lost and immunosuppression had been withdrawn, it was elected to go ahead and remove the kidney and hopes that her fever and toxic course could be arrested.,With the patient in the supine position, the previously placed nephrostomy tube was removed.  The patient then after adequate prepping and draping, and placing of a small roll under the right hip, underwent an incision in the direction of the transplant incision down through and through all muscle layers and into the preperitoneal space.  The kidney was encountered and kidney was dissected free of its attachments through the retroperitoneal space.  During the course of dissection, the iliac artery and vein were identified as was the native ureter and the patient's ilioinguinal nerve; all these were preserved.  The individual vessels in the kidney were identified, ligated, and incised, and the kidney was removed.  The ureter was encountered during the course of resection, but was not ligated.  The patient's retroperitoneal space was irrigated with antibiotic solution and #19 Blake drain was placed into the retroperitoneal space, and the patient returned to the recovery room in good condition.,ESTIMATED BLOOD LOSS:  900 mL.", Nephrology,21
"SUBJECTIVE:,  Overall, she has been doing well.  Her blood sugars have usually been less than or equal to 135 by home glucose monitoring.  Her fasting blood sugar today is 120 by our Accu-Chek.  She is exercising three times per week.  Review of systems is otherwise unremarkable. ,OBJECTIVE:,  Her blood pressure is 110/60.  Other vitals are stable.  HEENT:  Unremarkable.  Neck:  Unremarkable.  Lungs:  Clear.  Heart:  Regular.  Abdomen:  Unchanged.  Extremities:  Unchanged.  Neurologic:  Unchanged. ,ASSESSMENT:,  ,1.  NIDDM with improved control. ,2.  Hypertension. ,3.  Coronary artery disease status post coronary artery bypass graft. ,4.  Degenerative arthritis. ,5.  Hyperlipidemia. ,6.  Hyperuricemia. ,7.  Renal azotemia. ,8.  Anemia. ,9.  Fibroglandular breasts. ,PLAN:,  We will get follow-up labs today.  We will continue with current medications and treatment.  We will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately Month DD, YYYY.  The patient is advised to proceed with previous recommendations.  She is to follow-up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow-up as directed.", SOAP / Chart / Progress Notes,35
"EXAM: , Barium enema.,CLINICAL HISTORY: , A 4-year-old male with a history of encopresis and constipation.,TECHNIQUE:  ,A single frontal scout radiograph of the abdomen was performed.  A rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed via spot fluoroscopic images.  A post-evacuation overhead radiograph of the abdomen was performed.,FINDINGS:,  The scout radiograph demonstrates a nonobstructive gastrointestinal pattern.  There are no suspicious calcifications seen or evidence of gross free intraperitoneal air.  The visualized lung bases and osseous structures are within normal limits.,The rectum and colon is of normal caliber throughout its course.  There is no evidence of obstruction, as contrast is seen to flow without difficulty into the right colon and cecum.  A small amount of contrast is seen to opacify small bowel loops on the post-evacuation image.  There is also opacification of a normal-appearing appendix documented.,IMPRESSION: , Normal barium enema.", Radiology,33
"CHIEF COMPLAINT:, Bright red blood per rectum ,HISTORY OF PRESENT ILLNESS: ,This 73-year-old woman had a recent medical history significant for renal and bladder cancer, deep venous thrombosis of the right lower extremity, and anticoagulation therapy complicated by lower gastrointestinal bleeding. Colonoscopy during that admission showed internal hemorrhoids and diverticulosis, but a bleeding site was not identified. Five days after discharge to a nursing home, she again experienced bloody bowel movements and returned to the emergency department for evaluation. ,REVIEW OF SYMPTOMS: ,No chest pain, palpitations, abdominal pain or cramping, nausea, vomiting, or lightheadedness. Positive for generalized weakness and diarrhea the day of admission. ,PRIOR MEDICAL HISTORY:, Long-standing hypertension, intermittent atrial fibrillation, and hypercholesterolemia. Renal cell carcinoma and transitional cell bladder cancer status post left nephrectomy, radical cystectomy, and ileal loop diversion 6 weeks prior to presentation, postoperative course complicated by pneumonia, urinary tract infection, and retroperitoneal bleed. Deep venous thrombosis 2 weeks prior to presentation, management complicated by lower gastrointestinal bleeding, status post inferior vena cava filter placement. ,MEDICATIONS: ,Diltiazem 30 mg tid, pantoprazole 40 mg qd, epoetin alfa 40,000 units weekly, iron 325 mg bid, cholestyramine. Warfarin discontinued approximately 10 days earlier. ,ALLERGIES: ,Celecoxib (rash).,SOCIAL HISTORY:, Resided at nursing home. Denied alcohol, tobacco, and drug use. ,FAMILY HISTORY:, Non-contributory.,PHYSICAL EXAM: ,Temp = 38.3C BP =146/52 HR= 113 RR = 18 SaO2 = 98% room air ,General: Pale, ill-appearing elderly female. ,HEENT: Pale conjunctivae, oral mucous membranes moist. ,CVS: Irregularly irregular, tachycardia. ,Lungs: Decreased breath sounds at the bases. ,Abdomen: Positive bowel sounds, soft, nontender, nondistended, gross blood on rectal exam. ,Extremities: No cyanosis, clubbing, or edema. ,Skin: Warm, normal turgor. ,Neuro: Alert and oriented. Nonfocal. ,LABS: ,CBC: ,WBC count: 6,500 per mL ,Hemoglobin: 10.3 g/dL ,Hematocrit:31.8% ,Platelet count: 248 per mL ,Mean corpuscular volume: 86.5 fL ,RDW: 18% ,CHEM 7: ,Sodium: 131 mmol/L ,Potassium: 3.5 mmol/L ,Chloride: 98 mmol/L ,Bicarbonate: 23 mmol/L ,BUN: 11 mg/dL ,Creatinine: 1.1 mg/dL ,Glucose: 105 mg/dL ,COAGULATION STUDIES: ,PT 15.7 sec ,INR 1.6 ,PTT 29.5 sec ,HOSPITAL COURSE: ,The patient received 1 liter normal saline and diltiazem (a total of 20 mg intravenously and 30 mg orally) in the emergency department. Emergency department personnel made several attempts to place a nasogastric tube for gastric lavage, but were unsuccessful. During her evaluation, the patient was noted to desaturate to 80% on room air, with an increase in her respiratory rate to 34 breaths per minute. She was administered 50% oxygen by nonrebreadier mask, with improvement in her oxygen saturation to 89%. Computed tomographic angiography was negative for pulmonary embolism. ", Gastroenterology,14
"PREOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Diabetes.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Diabetes.,OPERATIVE PROCEDURE,Creation of right brachiocephalic arteriovenous fistula.,INDICATIONS FOR THE PROCEDURE,This patient has end-stage renal disease.  Although, the patient is right-handed, preoperative vein mapping demonstrated much better vein in the right arm.  Hence, a right brachiocephalic fistula is being planned.,OPERATIVE FINDINGS,The right cephalic vein at the elbow is chosen to be suitable.  It is slightly sporadic, but of an adequate size.  An end-to-side right brachiocephalic arteriovenous fistula was created.  At completion, there was a great thrill.,OPERATIVE PROCEDURE IN DETAIL,After informed consent was obtained, the patient was taken to the operating room.  The patient was placed in the supine position.  The patient received a regional nerve block.  The patient also received intravenous sedation.  The right arm was prepped and draped in the usual sterile fashion.,We made a small transverse incision in the right cubital fossa.  The cephalic vein was identified and mobilized.  The fascia was incised, and the brachial artery was also identified and mobilized.  The brachial artery was free off significant disease.  A good pulse was noted.  The cephalic vein was mobilized proximally and distally.  The brachial artery was mobilized proximally and distally.  We did not give heparin.  The brachial artery was then clamped proximally and distally.  The cephalic vein was also clamped proximally and distally.  Longitudinal arteriotomy was made in brachial artery, and a longitudinal venotomy was made in the cephalic vein.  We then sewn the vein to the artery in a side-to-side fashion using a running 7-0 Prolene suture.,Just prior to completion of the anastomosis, it was flushed, and the anastomosis was then completed.  A great thrill was noted.  We then ligated the cephalic vein beyond the arteriovenous anastomosis and divided it.  This surrounded the anastomosis as an end-to-side functionally.  A great thrill remained in the fistula.  Hemostasis was secured.  We then closed the wound using interrupted PDS sutures for the fascia and a running 4-0 Monocryl subcuticular suture for the skin.  Sterile dry dressing was applied.,The patient tolerated the procedure well.  There were no operative complications.  The sponge, instrument, and needle counts were correct at the end of the case.  I was present and participated in all aspects of the procedure.  The patient was then transferred to the recovery room in satisfactory condition.  A great thrill was felt in the fistula completion.  There was also a palpable radial pulse distally.", Nephrology,21
"Assessment for peripheral vestibular function follows:,OTOSCOPY:, showed bilateral intact tympanic membranes with central  Weber test and bilateral positive Rinne.,ROMBERG TEST:, maintained postural stability.,FRENZEL GLASSES EXAMINATION:, no spontaneous, end gaze nystagmus.,HEAD SHAKING:, No provocation nystagmus.,DIX-HALLPIKE:, showed no positional nystagmus excluding benign paroxysmal positional vertigo.,VESTIBULOCULAR REFLEX [HALMAGYI TEST]:, showed corrective saccades giving the impression of decompensated vestibular hypofunction.,IMPRESSION: , The patient was advised to continue her vestibular rehabilitation exercises and the additional medical treatment of betahistine at 24 mg dose bid.  ,PLAN:  ,Planned for  electronystagmography to document the degree of vestibular hypofunction.,", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS: , Retained hardware in left elbow.,POSTOPERATIVE DIAGNOSIS:,  Retained hardware in left elbow.,PROCEDURE: , Hardware removal in the left elbow.,ANESTHESIA: , Procedure done under general anesthesia.  The patient also received 4 mL of 0.25% Marcaine of local anesthetic.,TOURNIQUET:  ,There is no tourniquet time.,ESTIMATED BLOOD LOSS:  ,Minimal.,COMPLICATIONS:  ,No intraoperative complications.,HISTORY AND PHYSICAL:  ,The patient is a 5-year, 8-month-old male who presented to me direct from ED with distracted left lateral condyle fracture.  He underwent screw compression for the fracture in October 2007.  The fracture has subsequently healed and the patient presents for hardware removal.  The risks and benefits of surgery were discussed.  The risks of surgery include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion.  All questions were answered and the family agreed to the above plan.,PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  General anesthesia was then administered.  The patient's left upper extremity was then prepped and draped in standard surgical fashion.  Using his previous incision, dissection was carried down through the screw.  A guide wire was placed inside the screw and the screw was removed without incident.  The patient had an extension lag of about 15 to 20 degrees.  Elbow is manipulated and his arm was able to be extended to zero degrees dorsiflex.  The washer was also removed without incident.  Wound was then irrigated and closed using #2-0 Vicryl and #4-0 Monocryl.  Wound was injected with 0.25% Marcaine.  The wound was then dressed with Steri-Strips, Xeroform, 4 x4 and bias.  The patient tolerated the procedure well and subsequently taken to the recovery in stable condition.,DISCHARGE NOTE: , The patient will be discharged on date of surgery.  He is to follow up in one week's time for a wound check.  This can be done at his primary care physician's office.  The patient should keep his postop dressing for about 4 to 5 days.  He may then wet the wound, but not scrub it.  The patient may resume regular activities in about 2 weeks.  The patient was given Tylenol with Codeine 10 mL p.o. every 3 to 4 hours p.r.n.", Orthopedic,27
"PREOPERATIVE DIAGNOSIS: , Foreign body in airway.,POSTOPERATIVE DIAGNOSIS:,  Plastic piece foreign body in the right main stem bronchus.,PROCEDURE: , Rigid bronchoscopy with foreign body removal.,INDICATIONS FOR PROCEDURE: , This patient is 7-month-old baby boy who presented to emergency room today with increasing stridor and shortness of breath according to mom.  The patient had a chest x-ray and based on that there is concern by the Radiology it could be a foreign body in the right main stem.  The patient has been taken to the operating room for rigid bronchoscopy and foreign body removal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, placed supine, put under general mask anesthesia.  Using a 3.5 rigid bronchoscope we visualized between the cords into the trachea.  There were some secretions but that looked okay.  Got down at the level of the carina to see a foreign body flapping in the right main stem.  I then used graspers to grasp to try to pull into the scope itself.  I could not do that, I thus had to pull the scope out along with the foreign body that was held on to with a grasper.  It appeared to be consisting of some type of plastic piece that had broke off some different object.  I took the scope and put it back down into the airway again.  Again, there was secretion in the trachea that we suctioned out.  We looked down into the right bronchus intermedius.  There was no other pathology noted, just some irritation in the right main stem area.  I looked down the left main stem as well and that looked okay as well.  I then withdrew the scope.  Trachea looked fine as well as the cords.  I put the patient back on mask oxygen to wake the patient up.  The patient tolerated the procedure well.", Surgery,38
"PROCEDURES: , Left heart catheterization, left ventriculography, and left and right coronary arteriography.,INDICATIONS: , Chest pain and non-Q-wave MI with elevation of troponin I only.,TECHNIQUE:  ,The patient was brought to the procedure room in satisfactory condition.  The right groin was prepped and draped in routine fashion.  An arterial sheath was inserted into the right femoral artery.,Left and right coronary arteries were studied with a 6FL4 and 6FR4 Judkins catheters respectively.  Cine coronary angiograms were done in multiple views.,Left heart catheterization was done using the 6-French pigtail catheter.  Appropriate pressures were obtained before and after the left ventriculogram, which was done in the RAO view.,At the end of the procedure, the femoral catheter was removed and Angio-Seal was applied without any complications.,FINDINGS:,1.  LV is normal in size and shape with good contractility, EF of 60%.,2.  LMCA normal.,3.  LAD has 20% to 30% stenosis at the origin.,4.  LCX is normal.,5.  RCA is dominant and normal.,RECOMMENDATIONS: , Medical management, diet, and exercise.  Aspirin 81 mg p.o. daily, p.r.n. nitroglycerin for chest pain.  Follow up in the clinic.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,POSTOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,PROCEDURE PERFORMED: , Excision of soft tissue mass, right foot.,HISTORY:  ,The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot.  The patient has had previous injections to the site which have caused the mass to decrease in size, however, the mass continues to be present and is irritated and painful with shoes.  The patient has requested surgical intervention at this time.,PROCEDURE:  ,After an IV was instituted by the Department of Anesthesia, the patient was escorted from the preoperative holding area to the operating room.  The patient was then placed on the operating room table in the supine position and a towel was placed around the patient's abdomen and secured her to the table.  Using copious amounts of Webril, a pneumatic ankle tourniquet was applied to her right ankle.  Using a Skin Skribe, the area of the soft tissue mass was outlined over the dorsum of her foot.  After adequate amount of anesthesia was provided by the Department of Anesthesia, a local ankle block was given using 10 cc of 4.5 mL of 1% lidocaine plain, 4.5 mL of 0.5% Marcaine plain and 1.0 mL of Solu-Medrol and the foot was scrubbed and prepped in a normal sterile orthopedic manner.  Following this, the ankle was elevated and Esmarch bandage applied to exsanguinate the foot and the ankle tourniquet was inflated to 250 mmHg.  The foot was then brought back down to the table using bandage scissors.  The stockinette was reflected and the right foot was exposed.  Using a fresh #10 blade, a curvilinear incision was performed over the dorsum of the right foot.  Then using a #15 blade, the incision was deepened with care taken to identify and avoid or cauterize any bleeders which were noted.  Following this, the incision was deepened using a combination of sharp and blunt dissection and the muscle belly of the extensor digitorum brevis muscle was identified.  Further dissection was then performed in the medial direction in the area of the soft tissue mass.  The intermediate dorsal cutaneous nerve was identified and gently retracted laterally.  Large amounts of adipose tissue were noted medial to the belly of the extensor digitorum brevis muscle.  Using careful dissection, adipose tissue in this area was removed and saved for pathology.  Following removal of adipose tissue in this area and identification of no more adipose tissue, attention was directed lateral to the belly of the extensor digitorum brevis muscle, which was also noted to have large amounts of adipose tissue in this area as well.  Using careful dissection, from the lateral border of the foot as much adipose tissue as possible was removed from this area as well and saved for pathology.  There was noted to be no other fluid-filled masses or lesions identifiable in this area then between the slits of the extensor digitorum brevis muscle, careful dissection was performed to examine the underside of the belly of the muscle as well as structures beneath and no abnormal structures were identified here as well.  Following this, feeling adequately that no other mass remained in the area, the incision was flushed using copious amounts of sterile saline.  The wound was then reinspected and all remaining tissues appeared healthy including the subcutaneous tissue.  The tendon and muscle belly of the extensor digitorum brevis muscle, the nerves of the intermediate dorsal cutaneous nerve and also the medial dorsal cutaneous nerve which were identified medially, all appeared intact.  No deficits were noted.  No abnormal appearing tissue was present within the surgical site.  Following this, the skin edges were reapproximated using #4-0 Vicryl deep closure of the subcutaneous layer was performed.  Then, using #4-0 nylon and simple interrupted suture, the skin was reapproximated and closed with care taken to ensure eversion of the skin edges and good approximation of the borders.  The patient was also given 7 cc of 1% lidocaine plain throughout the procedure to augment local anesthesia.  Following this, the wound was dressed using Xeroform gauze and 4x4s and was dressed using two ABD pads, dorsal and plantar for compression and using Kling, Kerlix and Coban.  The patient then had the ankle tourniquet deflated with a total tourniquet time of 55 minutes at 250 mmHg and immediate hyperemia was noted to digits one through five of the right foot.  The patient tolerated the procedure and anesthesia well and was noted to have vascular status intact.  The patient was then escorted to the Postanesthesia Care Unit where she was placed in a surgical shoe.  The patient was then given postoperative instructions to include ice and elevation to her right foot.  The patient was cleared for ambulation as tolerated, but was instructed that with increased ambulation will come increased swelling and pain.  The patient will follow up with Dr. X in his office on Tuesday, 08/26/03 for further follow up.  The patient was given prescription for Vicoprofen #25 taken one tablet q.4h. p.r.n., moderate to severe pain and also prescription for Keflex #20 500 mg tablets to be taken b.i.d. x10 days.  The patient was given a number for the Emergency Room and instructed to return if any sign or symptom of infection should present and the patient was educated as to the nature of these.  The patient had no further questions and recovered without any complications in the Postanesthesia Care Unit.", Podiatry,31
"PREOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,PROCEDURE PERFORMED,1.  Anterior cervical decompression, C5-C6.,2.  Anterior cervical decompression, C6-C7.,3.  Anterior spine instrumentation.,4.  Anterior cervical spine fusion, C5-C6.,5.  Anterior cervical spine fusion, C6-C7.,6.  Application of machined allograft at C5-C6.,7.  Application of machined allograft at C6-C7.,8.  Allograft, structural at C5-C6.,9.  Allograft, structural at C6-C7.,ANESTHESIA: , General.,PREOPERATIVE NOTE:  ,This patient is a 47-year-old male with chief complaint of severe neck pain and left upper extremity numbness and weakness.  Preoperative MRI scan showed evidence of herniated nucleus pulposus at C5-C6 and C6-C7 on the left.  The patient has failed epidural steroid injections.  Risks and benefits of the above procedure were discussed with the patient including bleeding, infection, muscle loss, nerve damage, paralysis, and death.,OPERATIVE REPORT: , The patient was taken to the OR and placed in the supine position.  After general endotracheal anesthesia was obtained, the patient's neck was sterilely prepped and draped in the usual fashion.  A horizontal incision was made on the left side of the neck at the level of the C6 vertebral body.  It was taken down through the subcutaneous tissues exposing the platysmus muscle.  The platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine.  An #18 gauge needle was placed in the C5-C6 interspace and the intraoperative x-ray confirmed that this was the appropriate level.  Next, the longus colli muscles were resected laterally on both the right and left side, and then a complete anterior cervical discectomy was performed.  The disk was very degenerated and brown in color.  There was an acute disk herniation through posterior longitudinal ligament.  The posterior longitudinal ligament was removed and a bilateral foraminotomy was performed.  Approximately, 5 mm of the nerve root on both the right and left side was visualized.  A ball-ended probe could be passed up the foramen.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates of C5 and C6 were prepared using a high-speed burr and a 6-mm lordotic machined allograft was malleted into place.  There was good bony apposition both proximally and distally.  Next, attention was placed at the C6-C7 level.  Again, the longus colli muscles were resected laterally and a complete anterior cervical discectomy at C6-C7 was performed.  The disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left.  The posterior longitudinal ligament was removed.  A bilateral foraminotomy was performed.  Approximately, 5 mm of the C7 nerve root was visualized on both sides.  A micro nerve hook was able to be passed up the foramen easily.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates at C6-C7 were then prepared using a high-speed burr and then a 7-mm machined lordotic allograft was malleted into place.  There was good bony apposition, both proximally and distally.  Next, a 44-mm Blackstone low-profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws.  Intraoperative x-ray confirmed appropriate positioning of the plate and the graft.  The wound was then copiously irrigated with normal saline and bacitracin.  There was no active bleeding upon closure of the wound.  A small drain was placed deep.  The platysmal muscle was closed with 3-0 Vicryl.  The skin was closed with #4-0 Monocryl.  Mastisol and Steri-Strips were applied.  The patient was monitored throughout the procedure with free-running EMGs and SSEPs and there were no untoward events.  The patient was awoken and taken to the recovery room in satisfactory condition.", Neurosurgery,23
"PREOPERATIVE DIAGNOSIS:,  Aortic stenosis.,POSTOPERATIVE DIAGNOSIS:  ,Aortic stenosis.,PROCEDURES PERFORMED,1.  Insertion of a **-mm Toronto stentless porcine valve.,2.  Cardiopulmonary bypass.,3.  Cold cardioplegia arrest of the heart.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  , 300 cc.,INTRAVENOUS FLUIDS:  , 1200 cc of crystalloid.,URINE OUTPUT:  , 250 cc.,AORTIC CROSS-CLAMP TIME: , **,CARDIOPULMONARY BYPASS TIME TOTAL: , **,PROCEDURE IN DETAIL:,  After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  Next the neck, chest and legs were prepped and draped in the standard surgical fashion.  We used a #10-blade scalpel to make a midline median sternotomy incision.  Dissection was carried down to the left of the sternum using Bovie electrocautery.  The sternum was opened with a sternal saw.  The chest retractor was positioned.  Next, full-dose heparin was given.  The pericardium was opened.  Pericardial stay sutures were positioned.  After obtaining adequate ACT, we prepared to place the patient on cardiopulmonary bypass.  A 2-0 double pursestring of Ethibond suture was placed in the ascending aorta.  Through this was passed an aortic cannula connected to the arterial side of the cardiopulmonary bypass machine.  Next a 3-0 Prolene pursestring was placed in the right atrial appendage.  Through this was passed our venous cannula connected to the venous portion of the cardiopulmonary bypass machine.  A 4-0 U-stitch was placed in the right atrium.  A retrograde cardioplegia catheter was positioned at this site.  Next, scissors were used to dissect out the right upper pulmonary vein.  A 4-0 Prolene pursestring was placed in the right upper pulmonary vein.  Next, a right-angle sump was placed at this position.  We then connected our retrograde cardioplegia catheter to the cardioplegia solution circuit.  Bovie electrocautery was used to dissect the interface between the aorta and pulmonary artery.  The aorta was completely encircled.  Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta.  We then prepared to cross-clamp the aorta.  We went down on our flows and cross-clamped the aorta.  We backed up our flows.  We then gave antegrade and retrograde cold blood cardioplegia solution circuit so as to arrest the heart.  The patient had some aortic insufficiency so we elected, after initially arresting the heart, to open the aorta and transect it and then give direct ostial infusion of cardioplegia solution circuit.  Next, after obtaining complete diastolic arrest of the heart, we turned our attention to exposing the aortic valve, and 4-0 Tycron sutures were placed in the commissures.  In addition, a 2-0 Prolene suture was placed in the aortic wall so as to bring the aortic wall and root up into view.  Next, scissors were used to excise the diseased aortic valve leaflets.  Care was taken to remove all the calcium from the aortic annulus.  We then sized up the aortic annulus which came out to be a **-mm stentless porcine Toronto valve.  We prepared the valve.  Next, we placed our proximal suture line of interrupted 4-0 Tycron sutures for the annulus.  We started with our individual commissural stitches.  They were connected to our valve sewing ring.  Next, we placed 5 interrupted 4-0 Tycron sutures in a subannular fashion at each commissural position.  After doing so, we passed 1 end of the suture through the sewing portion of the Toronto stentless porcine valve.  The valve was lowered into place and all of the sutures were tied.  Next, we gave another round of cold blood antegrade and retrograde cardioplegia.  Next, we sewed our distal suture line.  We began with the left coronary cusp of the valve.  We ran a 5-0 RB needle up both sides of the valve.  Care was taken to avoid the left coronary ostia.  This procedure was repeated on the right cusp of the stentless porcine valve.  Again, care was taken to avoid any injury to the coronary ostia.  Lastly, we sewed our non-coronary cusp.  This was done without difficulty.  At this point we inspected our aortic valve.  There was good coaptation of the leaflets, and it was noted that both the left and the right coronary ostia were open.  We gave another round of cold blood antegrade and retrograde cardioplegia.  The antegrade portion was given in a direct ostial fashion once again.  We now turned our attention to closing the aorta.  A 4-0 Prolene double row of suture was used to close the aorta in a running fashion.  Just prior to closing, we de-aired the heart and gave a warm shot of antegrade and retrograde cardioplegia.  At this point, we removed our aortic cross-clamp.  The heart gradually regained its electromechanical activity.  We placed 2 atrial and 2 ventricular pacing wires.  We removed our aortic vent and oversewed that site with another 4-0 Prolene on an SH needle.  We removed our retrograde cardioplegia catheter.  We oversewed that site with a 5-0 Prolene.  By now, the heart was de-aired and resumed normal electromechanical activity.  We began to wean the patient from cardiopulmonary bypass.  We then removed our venous cannula and suture ligated that site with a #2 silk.  We then gave full-dose protamine.  After knowing that there was no evidence of a protamine reaction, we removed the aortic cannula.  We buttressed that site with a 4-0 Prolene on an SH needle.  We placed a mediastinal chest tube and brought it out through the skin.  We also placed 2 Blake drains, 1 in the left chest and 1 in the right chest, as the patient had some bilateral pleural effusions.  They were brought out through the skin.  The sternum was closed with #7 wires in an interrupted figure-of-eight fashion.  The fascia was closed with #1 Vicryl.  We closed the subcu tissue with 2-0 Vicryl and the skin with 4-0 PDS.", Cardiovascular / Pulmonary,3
"CONFORMAL SIMULATION WITH COPLANAR BEAMS,This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated.  It allows us to highly focus the beam of radiation and shape the beam to the target volume, delivering a homogenous dosage through it while sparing the surrounding, more radiosensitive, normal tissues.  This will allow us to give the optimum chance of tumor control while minimizing the acute and long-term side effects.,A conformal simulation is a simulation which involves extended physician, therapist, and dosimetrist time and effort.  The patient is initially taken into a conventional simulator room, where appropriate markers are placed, and the patient is positioned and immobilized.  One then approximates the field sizes and arrangements (gantry angles, collimator angles, and number of fields).  Radiographs are taken, and these fields are marked on the patient's skin.  The patient is then transferred to the diagnostic facility and placed on a flat CT scan table.  Scans are then performed through the targeted area.  The CT scans are evaluated by the radiation oncologist, and the tumor volume, target volume, and critical structures are outlined on each slice of the CT scan.  The dosimetrist then evaluates each individual slice in the treatment planning computer with the appropriately marked structures.  This volume is then reconstructed in 3-dimensional space.  Utilizing the beam's-eye view features, the appropriate blocks are designed.  Multiplane computerized dosimetry is performed throughout the volume.  Field arrangements and blocking are modified as necessary to provide homogenous coverage of the target volume while minimizing the dose to normal structures.  Once all appropriate beam parameters and isodate distributions have been confirmed on the computer scan, each individual slice is then reviewed by the physician.  The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician.  Once these are approved, Cerrobend blocks will be custom fabricated.,If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where the computer-designed fields are re-simulated.", Hematology - Oncology,16
"ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay.  He had left hip fracture identified on x-rays at that time.  Pain and inability to ambulate brought him in.  He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia.  His medical issues are under good control.  The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03.  The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension.  Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy.  He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions.,PAST MEDICAL HISTORY: , Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation.  Remote history of subdural hematoma precluding the use of Coumadin.  History of depression, panic attacks on Doxepin.  Perioperative anemia.  Swallowing difficulties.,ALLERGIES:,  Zyloprim, penicillin, Vioxx, NSAIDs.,CURRENT MEDICATIONS,1.  Heparin.,2.  Albuterol inhaler.,3.  Combivent.,4.  Aldactone.,5.  Doxepin.,6.  Xanax.,7.  Aspirin.,8.  Amiodarone.,9.  Tegretol.,10.  Synthroid.,11.  Colace.,SOCIAL HISTORY: , Lives in a 1-story home with 1 step down; wife is there.  Speech and language pathology following with current swallowing dysfunction.  He is minimum assist for activities of daily living, bed mobility.,REVIEW OF SYSTEMS:,  Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain.,PHYSICAL EXAMINATION,HEENT:  Oropharynx clear.,CV:  Regular rate and rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended.  Bowel sounds positive.,EXTREMITIES:  Without clubbing, cyanosis, or edema.,NEUROLOGIC:  There are no focal motor or sensory losses to the lower extremities.  Bulk and tone normal in the lower extremities.  Wound site has healed well with staples out.,IMPRESSION ,1.  Status post left hip fracture and hemiarthroplasty.,2.  History of panic attack, anxiety, depression.,3.  Myocardial infarction with stent placement.,4.  Hypertension.,5.  Hypothyroidism.,6.  Subdural hematoma.,7.  Seizures.,8.  History of chronic obstructive pulmonary disease.  Recent respiratory insufficiency.,9.  Renal insufficiency.,10.  Recent pneumonia.,11.  O2 requiring.,12.  Perioperative anemia.,PLAN: , Rehab transfer as soon as medically cleared.", Orthopedic,27
"CHIEF COMPLAINT: , Severe back pain and sleepiness.,The patient is not a good historian and history was obtained from the patient's husband at bedside.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 76-year-old obese Caucasian female with past medical conditions that includes hypertension, history of urinary incontinence, dementia, and chronic back pain, basically brought by the husband to the emergency room because of having excruciating back pain.  As per the husband, the patient has this back pain for about almost 1 year and seeing Dr. X in Neurosurgery and had an epidural injection x2, and then the patient's pain somewhat got better between, but last time the patient went to see Dr. X, the patient given injection and the patient passed out, so the doctor stopped giving any other epidural injection.  The patient has severe pain and all in all, the patient cries at home.  As per the husband, the patient woke up in the morning with severe pain, unable to eat, drink today, and crying in the morning, so brought her to the emergency room for further evaluation.  The patient denied any history of fever, cough, chest pain, diarrhea, dysuria or polyuria.  While I was examining the patient, the patient explained about possible diagnosis and treatment plan and possible nursing home discharge for pain control.  The patient passed out for about 3 to 4 minutes, unable to respond to even painful stimuli.  The patient's heart rate went down to 50s and blood pressure was 92 systolic, so the patient was later on given IV fluid and blood pressure checked.  The patient woke up after 5 to 6 minutes, so the patient was later on evaluated for admission because of near syncopal episode.,PAST MEDICAL CONDITIONS:,  Include hypertension, dementia, urinary incontinence, chronic back pain, and degenerative joint disease of the spine.  No history of diabetes, stroke or coronary artery disease.,SURGICAL HISTORY: , Include left total hip replacement many years ago, history of hysterectomy, and appendectomy in the young age.,ALLERGIES: , DENIED.,CURRENT MEDICATIONS: , According to the list shows the patient takes hydrocodone 10/325 mg every 6 hours, Flexeril 10 mg p.o. at bedtime, and Xanax 0.25 mg p.o. 4 times a day.  The patient also takes Neurontin 200 mg 3 times a day, propranolol 10 mg twice a day, oxybutynin 5 mg p.o. twice a day, Namenda 10 mg p.o. daily, and Aricept 10 mg p.o. daily.,SOCIAL HISTORY: , She lives with her husband, usually walks with a walker and wheelchair-bound, does not walk much as per the husband knows.  No history of alcohol abuse or smoking.,PHYSICAL EXAMINATION:,GENERAL:  Currently lying in the bed without apparent distress, very lethargic.,VITAL SIGNS:  Pulse rate of 55, blood pressure is 92/52, after IV fluid came up to 105/58.,CHEST:  Shows bilateral air entry present, clear to auscultate.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft, nondistended, and nontender.,EXTREMITIES:  Shows the patient's straight leg raising to be only up to 30% causing the patient severe back pain.,IMAGING: , The patient's x-ray of the lumbosacral spine done shows there is a L1 compression fracture with some osteophyte formation in the lumbar spine suggestive of degenerative joint disease.,LABORATORY DATA: , The patient's lab test is not done currently, but previous lab test done in 3/2009 seems to be in acceptable range.,IMPRESSION: , The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes in front of me with a low blood pressure.,1.  Vasovagal syncope versus polypharmacy because of 3 to 4 medications and muscle relaxants.,2.  Osteoporosis of the spine with L1 compression fracture causing the patient severe pain.,3.  Hypertension, now hypotension.,4.  Incontinence of the bladder.,5.  Dementia, most likely Alzheimer type.,PLAN AND SUGGESTION: , Initial plan was to send the patient to the nursing home, but because of the patient's low blood pressure and heart rate low, we will admit the patient to DOU for 23-hour observation, start the patient on IV fluid, normal saline, 20 mEq KCl, and Protonix 40 mg, and we will also continue the patient's Namenda and Aricept.  I will hold the patient's hydrocodone.  I will hold the Flexeril and I will also hold gabapentin at this moment.  We will give the patient's pain control with Percocet and very minimal morphine sulfate as needed.  Also give the patient calcium with vitamin D and physical therapy.  We will also order a blood test and further management will be based on the patient's all test results.  I also explained to the husband that tomorrow if the patient is better and more alert and awake, then we will send her to the nursing care versus home, it depends on the pain control.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS: , Bunion, left foot.,POSTOPERATIVE DIAGNOSIS: ,Bunion, left foot.,PROCEDURE PERFORMED:,1.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation.,2.  Akin osteotomy with internal wire fixation of left foot.,HISTORY: , This 19-year-old Caucasian female presents to ABCD General Hospital with the above chief complaint.  The patient states she has had worsening bunion deformity for as long as she could not remember.  She does have a history of Charcot-Marie tooth disease and desires surgical treatment at this time.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in a Mayo block type fashion surrounding the lower left first metatarsal.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating field.  The stockinette was reflected, the foot was cleansed with a wet and dry sponge.  Approximately 5 cm incision was made dorsomedially over the first metatarsal.,The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  Care was taken to preserve the extensor digitorum longus tendon.  The capsule over the first metatarsal phalangeal then was identified where a dorsal capsular incision was then created down to the level of bone.  Capsule and periosteum was reflected off the first metatarsal head.  At this time, the cartilage was inspected and noted to be white, shiny, and healthy cartilage.  There was noted to be a prominent medial eminence.  Attention was then directed to first interspace where a combination of blunt and sharp dissection was done to perform a standard lateral release.  The abductor tendon attachments were identified and transected.  The lateral capsulotomy was performed.  The extensor digitorum brevis tendon was identified and transected.  Attention was then directed to the prominent medial eminence, which was resected with a sagittal saw.  Intraoperative assessment of pes was performed and pes was noted to be normal.,At this time, a regional incision was carried more approximately about 1.5 cm.  The capsular incision was then extended and the proximal capsule and periosteum were reflected off the first metatarsal.  The first metatarsal cuneiform joint was identified.  A 0.45 K-wire was then inserted into the base of the first metatarsal approximately 1 cm from the first cuneiform joint perpendicular to the weightbearing surface.  This K-wire was used as an access guide for a Juvaro type oblique base wedge osteotomy.  The sagittal saw was then used to creat a closing base wedge osteotomy with the apex being proximal medial.  The osteotomy site was then feathered and tilted with tight estimation of the bony edges.  The cortical hinge was maintained.  A 0.27 x 24 mm screw was then inserted in a standard AO fashion.  At this time, there was noted to be tight compression of the osteotomy site.  A second 2.7 x 16 mm screw was then inserted more distally in the standard AO fashion with compression noted.  The ________ angle was noted to be significantly released.  Reciprocating rasp was then used to smoothen any remaining sharp edges.  The 0.45 k-wire was removed.  The foot was loaded and was noted to fill the remaining abduction of the hallux.  At this time, it was incised to perform an Akin osteotomy.,Original incision was then extended distally approximately 1 cm.  The incision was then deepened down to the level of capsule over the base of the proximal phalanx.  Again care was taken to preserve the extensor digitorum longus tendon.  The capsule was reflected off of the base of the proximal phalanx.  An Akin osteotomy was performed with the apex being lateral and the base being medial.  After where the bone was resected, it was feathered until tight compression was noted without tension at the osteotomy site.  Care was taken to preserve the lateral hinge.  At 1.5 wire passed and a drill was then used to create drill hole proximal and distally to the osteotomy site in order for passage of 28 gauge monofilament wire.  The #28 gauge monofilament wire was passed through the drill hole and tightened down until compression and tight ________ osteotomy site was noted.  The remaining edge of the wire was then buried in the medial most distal drill hole.  The area was then inspected and the foot was noted with significant reduction of the bunion deformity.  The area was then flushed with copious amounts of sterile saline.  Capsule was closed with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl in order to decrease tension of the incision site.  A running #5-0 subcuticular stitch was then performed.  Steri-Strips were applied.  Total of 1 cc dexamethasone phosphate was then injected into the surgical site.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  Posterior splint was then placed on the patient in the operating room.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred back to the PACU with vital signs stable and vascular status intact to the left foot.  The patient was given postoperative instructions to be strictly nonweightbearing on the left foot.  The patient was given postop pain prescriptions for Vicodin and instructed to take one q.4-6h. p.r.n. for pain as well as Naprosyn 500 mg p.o. q. b.i.d.  The patient is to follow-up with Dr. X in his office in four to five days as directed.", Orthopedic,27
"PRE AND POSTOPERATIVE DIAGNOSIS:,  Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR.  After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted.  At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position.  The patient's posterior cervical area was then prepped and draped in the usual sterile fashion.  At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine.  A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated.  After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken.  This showed the spinous process to be at the C4 level.  Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified.  After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken.  This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time.  At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina.  The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe.  This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur.  However, progress was limited because of thickness of the bone.  Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area.  After the bone had been thinned out, further bone was removed using the Kerrison rongeur.  At this point the nerve root was visually inspected and observed to be decompressed.  However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade.  Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery.  After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin.  Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches.  The subcutaneous layer was then reapproximated using 000 Dexon.  The skin was reapproximated using a running 000 nylon.  Sterile dressings were applied.  The patient was then extubated in the OR and transferred to the Recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  minimal.", Orthopedic,27
"ADMISSION DIAGNOSIS: , Right tibial plateau fracture.,DISCHARGE DIAGNOSES: , Right tibial plateau fracture and also medial meniscus tear on the right side.,PROCEDURES PERFORMED:,  Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,CONSULTATIONS: , To rehab, Dr. X and to Internal Medicine for management of multiple medical problems including hypothyroid, diabetes mellitus type 2, bronchitis, and congestive heart failure.,HOSPITAL COURSE: , The patient was admitted and consented for operation, and taken to the operating room for open reduction and internal fixation of right Schatzker III tibial plateau fracture and partial medial meniscectomy performed without incidence.  The patient seemed to be recovering well.  The patient spent the next several days on the floor, nonweightbearing with CPM machine in place, developed a brief period of dyspnea, which seems to have resolved and may have been a combination of bronchitis, thick secretions, and fluid overload.  The patient was given nebulizer treatment and Lasix increased the same to resolve the problem.  The patient was comfortable, stabilized, breathing well.  On day #12, was transferred to ABCD.,DISCHARGE INSTRUCTIONS: , The patient is to be transferred to ABCD after open reduction and internal fixation of right tibial plateau fracture and partial medial meniscectomy.,DIET:,  Regular.,ACTIVITY AND LIMITATIONS: , Nonweightbearing to the right lower extremity.  The patient is to continue CPM machine while in bed along with antiembolic stockings.  The patient will require nursing, physical therapy, occupational therapy, and social work consults.,DISCHARGE MEDICATIONS: , Resume home medications, but increase Lasix to 80 mg every morning, Lovenox 30 mg subcu daily x2 weeks, Vicodin 5/500 mg one to two every four to six hours p.r.n. pain, Combivent nebulizer every four hours while awake for difficulty breathing, Zithromax one week 250 mg daily, and guaifenesin long-acting one twice a day b.i.d.,FOLLOWUP: , Follow up with Dr. Y in 7 to 10 days in office.,CONDITION ON DISCHARGE:,  Stable.", Orthopedic,27
"PREOPERATIVE DIAGNOSIS: , Postmenopausal bleeding.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:  ,Fractional dilatation and curettage.,SPECIMENS: , Endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding.  An office endometrial biopsy was unable to be performed secondary to a stenotic internal cervical os.,FINDINGS: , Examination under anesthesia revealed a retroverted, retroflexed uterus with fundal diameter of 6.5 cm.  The uterine cavity was smooth upon curettage.  Curettings were fairly copious.  Sounding depth was 8 cm.,PROCEDURE:,  The patient was brought to the Operating Room with an IV in place.  The patient was given a general anesthetic and was placed in the lithotomy position.  Examination under anesthesia was completed with findings as noted.  She was prepped and draped and a speculum was placed into the vagina.  ,Tenaculum was placed on the cervix.  The endocervical canal was curetted using a Kevorkian curette, and the sound was used to measure the overall depth of the uterus.  The endocervical canal was dilated without difficulty to a size 16 French dilator.  A small, sharp curette was passed into the uterine cavity and curettings were obtained.,After completion of the curettage, polyp forceps were passed into the uterine cavity.  No additional tissue was obtained.  Upon completion of the dilatation and curettage, minimum blood loss was noted.,The patient was awakened from her anesthetic, and taken to the post anesthesia care unit in stable condition.", Surgery,38
"PREOPERATIVE DIAGNOSES:,1.  Right hyoid mass, rule out carcinomatosis.,2.  Weight loss.,3.  Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1.  Right hyoid mass, rule out carcinomatosis.,2.  Weight loss.,3.  Chronic obstructive pulmonary disease.,4.  Changes consistent with acute and chronic bronchitis.,5.  Severe mucosal irregularity with endobronchial narrowing of the right middle and lower lobes.,6.  Left vocal cord irregularity.,PROCEDURE PERFORMED:  ,Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.,ANESTHESIA: , Demerol 50 mg with Versed 3 mg as well as topical cocaine and lidocaine solution.,LOCATION OF PROCEDURE: , Endoscopy suite #4.,After informed consent was obtained and following the review of the procedure including procedure as well as possible risks and complications were explained and consent was previously obtained, the patient was sedated with the above stated medication and the patient was continuously monitored on pulse oximetry, noninvasive blood pressure, and EKG monitoring.  Prior to starting the procedure, the patient was noted to have a baseline oxygen saturation of 86% on room air.  Subsequently, she was given a bronchodilator treatment with Atrovent and albuterol and subsequent saturation increased to approximately 90% to 91% on room air.,The patient was placed on a supplemental oxygen as the patient was sedated with above-stated medication.  As this occurred, the bronchoscope was inserted into the right naris with good visualization of the nasopharynx and oropharynx.  The cords were noted to oppose bilaterally on phonation.  There was some slight mucosal irregularity noted on the vocal cord on the left side.  Additional topical lidocaine was instilled on the vocal cords, at which point the bronchoscope was introduced into the trachea, which was midline in nature.  The bronchoscope was then advanced to the distal trachea and additional lidocaine was instilled.  At this time, the bronchoscope was further advanced through the main stem and additional lidocaine was instilled.  Bronchoscope was then further advanced into the right upper lobe, which revealed no evidence of any endobronchial lesion.  The mucosa was diffusely friable throughout.  Bronchoscope was then slowly withdrawn into the right main stem and additional lidocaine was instilled.  At this point, the bronchoscope was then advanced to the right bronchus intermedius.  At this time, it was noted that there was severe mucosal irregularities of nodular in appearance significantly narrowing the right lower lobe and right middle lobe opening.  The mucosal area throughout this region was severely friable.  Additional lidocaine was instilled as well as topical epinephrine.  At this time, bronchoscope was maintained in this region and endobronchial biopsies were performed.  At the initial attempt of inserting biopsy forceps, some resistance was noted within the proximal channel at this time making advancement of the biopsy forceps out of the proximal channel impossible.  So the biopsy forceps was withdrawn and the bronchoscope was completely withdrawn and new bronchoscope was then utilized.  At this time, bronchoscope was then reinserted into the right naris and subsequently advanced to the vocal cords into the right bronchus intermedius without difficulty.  At this time, the biopsy forceps were easily passed and visualized in the right bronchus intermedius.  At this time, multiple mucosal biopsies were performed with some mild oozing noted.  Several aliquots of normal saline lavage followed.  After completion of multiple biopsies there was good hemostasis.  Cytology flushing was also performed in this region and subsequently several aliquots of additional normal saline lavage was followed.  Bronchoscope was unable to be passed distally to the base of the segment of the right lower lobe or distal to the further visualized endobronchial anatomy of the right middle lobe subsegments.  The bronchoscope was then withdrawn to the distal trachea.,At this time, bronchoscope was then advanced to the left main stem.  Additional lidocaine was instilled.  The bronchoscope was advanced to the left upper and lower lobe subsegments.  There was no endobronchial lesion visualized.  There is mild diffuse erythema and fibromucosa was noted throughout.  No endobronchial lesion was visualized in the left bronchial system.  The bronchoscope was then subsequently further withdrawn to the distal trachea and readvanced into the right bronchial system.  At this time, bronchoscope was readvanced into the right bronchus intermedius and additional aliquots of normal saline lavage until cleared.  There is no gross bleeding evidenced at this time or diffuse mucosal erythema and edema present throughout.  The bronchoscope was subsequently withdrawn and the patient was sent to recovery room.  During the bronchoscopy, the patient noted ________ have desaturation and required increasing FiO2 with subsequent increased saturation to 93% to 94%.  The patient remained at this level of saturation or greater throughout the remaining of the procedure.,The patient postprocedure relates having some intermittent hemoptysis prior to the procedure as well as moderate exertional dyspnea.  This was confirmed by her daughter and mother who were also present at the bedside postprocedure.  The patient did receive a nebulizer bronchodilator treatment immediately prebronchoscopy and postprocedure as well.  The patient also admitted to continued smoking in spite of all of the above.  The patient was extensively counseled regarding the continued smoking especially with her present symptoms.  She was advised regarding smoking cessation.  The patient was also placed on a prescription of prednisone 2 mg tablets starting at 40 mg a day decreasing every three days to continue to wean off.  The patient was also administered Solu-Medrol 60 mg IV x1 in recovery room.  There was no significant bronchospastic component noted, although because of the severity of the mucosal edema, erythema, and her complaints, short course of steroids will be instituted.  The patient was also advised to refrain from using any aspirin or other nonsteroidal anti-inflammatory medication because of her hemoptysis.  At this time, the patient was also advised that if hemoptysis were to continue or worsen or develop progressive dyspnea, to either contact myself, , or return to ABCD Emergency Room for evaluation of possible admission.  However, the above was reviewed with the patient in great detail as well as with her daughter and mother who were at the bedsite at this time as well.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis, nonperforated.,PROCEDURE PERFORMED:,  Appendectomy.,ANESTHESIA: , General endotracheal.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A transverse right lower quadrant incision was made directly over the point of maximal tenderness.  Sharp dissection utilizing Bovie electrocautery was used to expose the external oblique fascia.  The fascia of the external oblique was incised in the direction of the fibers, and the muscle was spread with a clamp.  The internal oblique fascia was similarly incised and its muscular fibers were similarly spread.  The transversus abdominis muscle, transversalis fascia and peritoneum were incised sharply gaining entrance into the abdominal cavity without incident.  Upon entering the peritoneal cavity, the peritoneal fluid was noted to be clean.,The cecum was then grasped along the taenia with a moist gauze sponge and was gently mobilized into the wound.  After the appendix was fully visualized, the mesentery was divided between Kelly clamps and ligated with 2-0 Vicryl ties.  The base of the appendix was crushed with a clamp and then the clamp was reapplied proximally on the appendix.  The base was ligated with 2-0 Vicryl tie over the crushed area, and the appendix amputated along the clamp.  The stump of the appendix was cauterized and the cecum was returned to the abdomen.,The peritoneum was irrigated with warm sterile saline.  The mesoappendix and cecum were examined for hemostasis which was present.  The wound was closed in layers using 2-0 Vicryl for the peritoneum and 0 Vicryl for the internal oblique and external oblique layers.  The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was placed on the wound.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.", Surgery,38
"PREOPERATIVE DIAGNOSES: , Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,POSTOPERATIVE DIAGNOSES:,  Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,PROCEDURES:  ,1.  Open reduction internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint.,2.  Closed reduction casting of the right forearm.,ANESTHESIA: , Surgery performed under general anesthesia.  Local anesthetic was 10 mL of 0.5% Marcaine.,TOURNIQUET TIME: , On the left was 29 minutes.,COMPLICATIONS:  ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HISTORY AND PHYSICAL:  ,The patient is a 13-year-old right-hand dominant girl, who fell off a swing at school around 1:30 today.  The patient was initially seen at an outside facility and brought here by her father, given findings on x-ray, a closed reduction was attempted on the left elbow.  After the attempted reduction, the patient was noted to have an incarcerated medial epicondyle fracture as well as increasing ulnar paresthesias that were not present prior to the procedure.  Given this finding, the patient needed urgent open reduction and internal fixation to relieve the pressure on the ulnar nerve.  At that same time, the patient's mildly angulated radial shaft fracture will be reduced.  This was explained to the father.  The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for later hardware removal, and possible continuous nerve symptoms.  All questions were answered.  The father agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  The left upper extremity was then prepped and draped in the standard surgical fashion.  Attempts to remove the incarcerated medial epicondyle with supination, valgus stress, and with extension were unsuccessful.  It was decided at this time that she would need open reduction.  The arm was wrapped in Esmarch prior to inflation of the tourniquet to 250 mmHg.  The Esmarch was then removed.  An incision was then made.  Care was taken to avoid any injury to the ulnar nerve.  The medial epicondyle fracture was found incarcerated into the anterior aspect of the joint.  This was easily removed.  The ulnar nerve was also identified, and appeared to be intact.  The medial epicondyle was then transfixed using a guidewire into its anatomic position with the outer cortex over drilled with a 3.2 drill bit, and subsequently a 44-mm 4.5 partially threaded cannulated screw was then placed with a washer to hold the medial epicondyle in place.  After fixation of the fragment, the ulnar nerve was visualized as it traveled around the medial epicondyle fracture with no signs of impingement.  The wound was then irrigated with normal saline and closed using 2-0 Vicryl and 4-0 Monocryl.  The wound was clean and dry, dressed with Steri-Strips and Xeroform.  The area was infiltrated with 0.5% Marcaine.  The patient was then placed in a long-arm posterior well-molded splint with 90 degrees of flexion and neutral rotation.  The tourniquet was released at 30 minutes prior to placement of the dressing, showed no significant bleeding.  Attention was then turned to right side, the arm was then manipulated and a well-molded long-arm cast placed.  The final position in the cast revealed a very small residual volar apex angulation, which is quite acceptable in this age.  The patient tolerated the procedure well, was subsequently extubated and taken to recovery in a stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized for pain control and neurovascular testing for the next 1 to 2 days.  The father was made aware of the intraoperative findings.  All questions answered.", Orthopedic,27
"PREOPERATIVE DIAGNOSIS:,  Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Ruptured appendicitis.,PROCEDURE:,  Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE:,  This patient is a 4-year-old boy with less than 24-hour history of apparent right lower quadrant abdominal pain associated with vomiting and fevers.  The patient has elevated white count on exam and CT scan consistent with acute appendicitis.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's abdomen was prepped and draped in usual sterile fashion.  A periumbilical incision was made.  The fascia was incised.  Peritoneal cavity entered bluntly.  A 10-mm trocar and scope was passed.  Peritoneal cavity was insufflated.  Five-mm ports placed in left lower and hypogastric areas.  On visualization of the right lower quadrant, appendix was visualized stuck against the right anterior abdominal wall, there is obvious site of perforation and leakage of content and pus.  We proceeded to take the mesoappendix down to the base, and once the base was free, we placed GIA stapler across the base, fired the stapler, removed the appendix through the periumbilical port site.  We irrigated and suctioned out the right lower and pelvic areas.  We then removed the ports under direct visualization, closed the periumbilical port site fascia with 0 Vicryl, all skin incisions with 5-0 Monocryl, and dressed with Steri-Strips.  The patient was extubated in the operating table and taken back to recovery room.  The patient tolerated the procedure well.", Surgery,38
"PREOPERATIVE DIAGNOSIS,Left breast mass.,POSTOPERATIVE DIAGNOSIS,Left breast mass.,PROCEDURE PERFORMED,Needle localization and left breast biopsy.,ANESTHESIA,General.,FLUIDS,1000 cc.,ESTIMATED BLOOD LOSS,Minimal.,DRAINS,None.,COMPLICATIONS,None.,SPECIMEN,Breast biopsy specimen with localizing needle.,FINDINGS,Breast tissue surrounding needle localization while no palpable mass.,HISTORY,The patient is a very pleasant 51-year-old African-American female who presented to the office with a mass in the left breast.  She was seen and evaluated.  On routine mammography, revealed a density in the left breast approximately at 4 o'clock position several centimeters lateral to the nipple complex.  She was readmitted for excisional biopsy.,Due to the nonpalpable nature of this lesion, the patient underwent first needle localization of the breast at the  Hospital and was taken to the operating room.,PROCEDURE IN DETAIL,After informed consent was obtained from the patient, the patient taken to the operating room and placed in the supine position on the operating table.  After appropriate general endotracheal anesthesia has been administered to the patient, the left breast was prepped and draped in a standard surgical fashion using Betadine solution.,The localization wire was cut at skin.  The patient had previously had a reduction mammoplasty in the lateral aspect of the transverse where an incision was re-incised to distance of about 4 cm.  The wire was entering the skin about 2 cm above the incision.  Superior skin flap was raised using electrocautery, and the needle localization wire was brought into the incision.  At this point, a core breast tissue of approximately 2 cm surrounding the needle was excised superiorly, inferiorly, medially, and laterally until the tissue specimen was well below the hook of the needle localization wire.,The breast specimen was then removed from breast, and silk sutures were used to mark the superior and lateral margins.  This specimen was then sent for mammography.  Pathologist called in the room to verify that the entire needle localization wire and hook were intact in the specimen.  At this point, the breast cavity was palpated and no other abnormalities were noted.  ,The wound was irrigated.  Bleeding points were easily controlled using electrocautery.  The wound was closed in two layers using 3-0 Vicryl and 4-0 Monocryl suture in a subcuticular fashion.  Benzoin, Steri-Strips, 2 x 2's, Tegaderm were placed.  The patient was aroused from anesthesia and transported to the recovery room in stable condition.  There were no complications.  All instrument, needle, and sponge counts were correct x2 at the end of the case.", Surgery,38
"PREOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,POSTOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,PROCEDURE PERFORMED: , Decompression of the ulnar nerve, left elbow.,ANESTHESIA: , General.,FINDINGS OF THE OPERATION:,  The ulnar nerve appeared to be significantly constricted as it passed through the cubital tunnel.  There was presence of hourglass constriction of the ulnar nerve.,PROCEDURE: , The patient was brought to the operating room and once an adequate general anesthesia was achieved, his left upper extremity was prepped and draped in standard sterile fashion.  A sterile tourniquet was positioned and tourniquet was inflated at 250 mmHg.  Perioperative antibiotics were infused.  Time-out procedure was called.  The medial epicondyle and the olecranon tip were well palpated.  The incision was initiated at equidistant between the olecranon and the medial epicondyle extending 3-4 cm proximally and 6-8 cm distally.  The ulnar nerve was identified proximally.  It was mobilized with a blunt and a sharp dissection proximally to the arcade of Struthers, which was released sharply.  The roof of the cubital tunnel was then incised and the nerve was mobilized distally to its motor branches.  The ulnar nerve was well-isolated before it entered the cubital tunnel.  The arch of the FCU was well defined.  The fascia was elevated from the nerve and both the FCU fascia and the Osborne fascia were divided protecting the nerve under direct visualization.  Distally, the dissection was carried between the 2 heads of the FCU.  Decompression of the nerve was performed between the heads of the FCU.  The muscular branches were well protected.  Similarly, the cutaneous branches in the arm and forearm were well protected.  The venous plexus proximally and distally were well protected.  The nerve was well mobilized from the cubital tunnel preserving the small longitudinal vessels accompanying it.  Proximally, multiple vascular leashes were defined near the incision of the septum into the medial epicondyle, which were also protected.  Once the in situ decompression of the ulnar nerve was performed proximally and distally, the elbow was flexed and extended.  There was no evidence of any subluxation.  Satisfactory decompression was performed.  Tourniquet was released.  Hemostasis was achieved.  Subcutaneous layer was closed with 2-0 Vicryl and skin was approximated with staples.  A well-padded dressing was applied.  The patient was then extubated and transferred to the recovery room in stable condition.  There were no intraoperative complications noted.  The patient tolerated the procedure very well.", Surgery,38
"HISTORY: , The patient is a 52-year-old right-handed female with longstanding bilateral arm pain, which is predominantly in the medial aspect of her arms and hands as well as left hand numbness, worse at night and after doing repetitive work with her left hand.  She denies any weakness.  No significant neck pain, change in bowel or bladder symptoms, change in gait, or similar symptoms in the past.  She is on Lyrica for the pain, which has been somewhat successful.,Examination reveals positive Phalen's test on the left.  Remainder of her neurological examination is normal.,NERVE CONDUCTION STUDIES:  ,The left median motor distal latency is prolonged with normal evoked response amplitude and conduction velocity.  The left median sensory distal latency is prolonged with an attenuated evoked response amplitude.  The right median sensory distal latency is mildly prolonged with a mildly attenuated evoked response amplitude.  The right median motor distal latency and evoked response amplitude is normal.  Left ulnar motor and sensory and left radial sensory responses are normal.  Left median F-wave is normal.,NEEDLE EMG:,  Needle EMG was performed on the left arm, right first dorsal interosseous muscle, and bilateral cervical paraspinal muscles.  It revealed spontaneous activity in the left abductor pollicis brevis muscle.  There is increased insertional activity in the right first dorsal interosseous muscle.  Both interosseous muscles showed signs of reinnervation.  Left extensor digitorum communis muscle showed evidence of reduced recruitment.  Cervical paraspinal muscles were normal.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:  A left median neuropathy at the wrist consistent with carpal tunnel syndrome.  Electrical abnormalities are moderate-to-mild bilateral C8 radiculopathies.  This may be an incidental finding.,I have recommended MRI of the spine without contrast and report will be sent to Dr. XYZ.  She will follow up with Dr. XYZ with respect to treatment of the above conditions.", Radiology,33
"CHIEF COMPLAINT: , This 5-year-old male presents to Children's Hospital Emergency Department by the mother with ""have asthma.""  Mother states he has been wheezing and coughing.  They saw their primary medical doctor.  He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic.  They told to go to the ER if he got worse.  He has had some vomiting and some abdominal pain.  His peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day.,PAST MEDICAL HISTORY:,  Asthma with his last admission in 07/2007.  Also inclusive of frequent pneumonia by report.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , Denied.,MEDICATIONS:  ,Advair, Nasonex, Xopenex, Zicam, Zithromax, prednisone, and albuterol.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY: , Lives at home, here in the ED with the mother and there is no smoking in the home.,FAMILY HISTORY: , No noted exposures.,REVIEW OF SYSTEMS:  ,Documented on the template.  Systems reviewed on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg.  Oxygen saturation low at 91% on room air.,GENERAL:  This is a well-developed male who is cooperative, alert, active with oxygen by facemask.,HEENT:  Head is atraumatic and normocephalic.  Pupils are equal, round, and reactive to light.  Extraocular motions are intact and conjugate.  Clear TMs, nose, and oropharynx.,NECK:  Supple.  Full painless nontender range of motion.,CHEST:  Tight wheezing and retractions heard bilaterally.,HEART:  Regular without rubs or murmurs.,ABDOMEN:  Soft, nontender.  No masses.  No hepatosplenomegaly.,GENITALIA:  Male genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions or rash.,EXTREMITIES:  Moves all extremities without difficulty, nontender.  No deformity.,NEUROLOGIC:  Symmetric face, cooperative, and age appropriate.,MEDICAL DECISION MAKING:,  The differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia.  He is evaluated in the emergency department with continuous high-dose albuterol, Decadron by mouth, pulse oximetry, and close observation.  Chest x-ray reveals bronchial thickening, otherwise no definite infiltrate.  She is further treated in the emergency department with continued breathing treatments.  At 0048 hours, he has continued tight wheezes with saturations 99%, but ED sats are 92% with coughing spells.  Based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma.", Emergency Room Reports,12
"SUBJECTIVE:,  The patient is a 2-year-old little girl who comes in with concerns about stuffiness, congestion and nasal drainage.  She does take Zyrtec on a fairly regular basis.  Mom is having some allergy trouble herself right now.  She does not know her colors.  She knows some of her shapes.  She speaks in sentences.  She is not showing much interest in the potty.  She is in the 80th percentile for height and weight, and still over 95th percentile for head circumference.  Mom has no other concerns.,ALLERGIES:,  Eggs and peanuts.,OBJECTIVE:,General:  Alert, very talkative little girl.,HEENT:  TMs clear and mobile.  Eyes:  PERRL.  Fundi benign.  Pharynx clear.  Mouth moist.  Nasal mucosa is pale with clear discharge.,Neck:  Supple without adenopathy.,Heart:  Regular rate and rhythm without murmur.,Lungs:  Clear.  No tachypnea, wheezing, rales or retractions.,Abdomen:  Soft and nontender without mass or organomegaly.,GU:  Normal female genitalia.  Tanner stage I.,Extremities:  No clubbing, cyanosis or edema.  Pulses 2+ and equal.,Hips:  Intact.,Neurological:  Normal.  DTRs are 2+.  Gait was normal.,Skin:  Warm and dry.  No rashes noted.,ASSESSMENT:,  Allergic rhinitis.  Otherwise healthy 2-year-old young lady.,PLAN:,  In addition to her Zyrtec, I put her on Nasonex spray one spray each nostril daily.  If this works for her, certainly she can do it through the ragweed season.  Otherwise she is doing well.  I talked about ways to improve her potty training.  She is a very good eater.  I will see her yearly or p.r.n.  Unfortunately she is not able to get the flu shot due to her egg allergy.", Consult - History and Phy.,5
"She started her periods at age 13.  She is complaining of a three-month history of lower abdominal pain for which she has been to the emergency room twice.  She describes the pain as bilateral, intermittent, and non-radiating.  It decreases slightly when she eats and increases with activity.  She states the pain when it comes can last for half-a-day.  It is not associated with movement, but occasionally the pain was so bad that it was associated with vomiting.  She has tried LactAid, which initially helped, but then the pain returned.  She has tried changing her diet and Pepcid AC.  She was seen at XYZ where blood work was done.  At that time, she had a normal white count and a normal H&H.  She was given muscle relaxants, which did not work.,Approximately two weeks ago, she was seen in the emergency room at XYZ where a pelvic ultrasound was done.  This showed a 1.9 x 1.4-cm cyst on the right with no free fluid.  The left ovary and uterus appeared normal.  Two days later, the pain resolved and she has not had a recurrence.  She denies constipation and diarrhea.  She has had some hot flashes, but has not taken her temperature.,In addition, she states that her periods have been very irregular coming between four and six weeks.  They are associated with cramping which she is not happy about.,She has never had a pelvic exam.  She states she is not sexually active and declined having her mother leave the room, so she was not questioned regarding this without her mother present.  She is very interested in not having pain with her periods and if this was a cyst that caused her pain, she is interested in starting birth control pills to prevent this from happening again.,PAST MEDICAL HX:  ,Pneumonia in 2002, depression diagnosed in 2005, and seizures as an infant.,PAST SURGICAL HX:  ,Plastic surgery on her ear after a dog bite in 1997.,MEDICATIONS:  ,Zoloft 50 mg a day and LactAid.,ALLERGIES:  ,NO KNOWN DRUG ALLERGIES.,SOCIAL HX: , She enjoys cooking and scrapbooking.  She does have a boyfriend; again she states she is not sexually active.  She also states that she exercises regularly, does not smoke cigarettes, use drugs, or drink alcohol.,FAMILY HX: , Significant for her maternal grandfather with adult-onset diabetes, a maternal grandmother with hypertension, mother with depression, and a father who died of colon cancer at 32 years of age.  She also has a paternal great grandfather who was diagnosed with colon cancer.,PE: , VITALS: Height: 5 feet 5 inches.  Weight: 190 lb.  Blood Pressure: 120/88.  GENERAL: She is well-developed, well-nourished with normal habitus and no deformities.  NECK: Without thyromegaly or lymphadenopathy.  LUNGS: Clear to auscultation bilaterally.  HEART: Regular rate and rhythm without murmurs.  ABDOMEN: Soft, nontender, and nondistended.  There is no organomegaly or lymphadenopathy.  PELVIC: Deferred.,A/P: , Abdominal pain, unclear etiology.  I expressed my doubt that her pain was secondary to this 1.9-cm ovarian cyst given the fact that there was no free fluid surrounding this.  However, given that she has irregular periods and they are painful for her, I think it is reasonable to start her on a low-dose birth control pill.  She has no personal or familial contraindications to start this.  She was given a prescription for Lo/Ovral, dispensed 30 with refill x 4.  She will come back in six weeks for blood pressure check as well as in six months to followup on her pain and her bleeding patterns.,If she should have the recurrence of her pain, I have advised her to call.", Obstetrics / Gynecology,24
"PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,OPERATION PERFORMED: , Excision of nasal tip basal carcinoma.  Total area of excision, approximately 1 cm to 12 mm frozen section x2, final margins clear.,INDICATION: , A 66-year-old female for excision of nasal basal cell carcinoma.  This area is to be excised accordingly and closed.  We had multiple discussions regarding types of closure.,SUMMARY: , The patient was brought to the OR in satisfactory condition and placed supine on the OR table.  Underwent general anesthesia along with Marcaine in the nasal tip areas for planned excision.  The area was injected, after sterile prep and drape, with Marcaine 0.25% with 1:200,000 adrenaline.,The specimen was sent to pathology.  Margins were still positive at the inferior 6 o'clock ***** margin and this was resubmitted accordingly.  Final margins were clear.,Closure consisted of undermining circumferentially.  Advancement closure with dog ear removal distally and proximally was accomplished without difficulty.  Closure with interrupted 5-0 Monocryl running 7-0 nylon followed by Xeroform gauze, light pressure dressing, and Steri-Strips.,The patient is discharged on minocycline and Darvocet-N 100.,NOTE:,  The 2.6 mm loupe magnification was utilized throughout the procedure.  No complications noted with excellent and all clear margins at the termination.  An advancement closure technique was utilized.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Perforated Meckel's diverticulum.,PROCEDURES PERFORMED:,1.  Diagnostic laparotomy.,2.  Exploratory laparotomy.,3.  Meckel's diverticulectomy.,4.  Open incidental appendectomy.,5.  Peritoneal toilet.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:  ,300 ml.,URINE OUTPUT: , 200 ml.,TOTAL FLUID:,  1600 mL.,DRAIN:,  JP x1 right lower quadrant and anterior to the rectum.,TUBES:,  Include an NG and a Foley catheter.,SPECIMENS: , Include Meckel's diverticulum and appendix.,COMPLICATIONS: , Ventilator-dependent respiratory failure with hypoxemia following closure.,BRIEF HISTORY: , This is a 45-year-old Caucasian gentleman presented to ABCD General Hospital with acute onset of right lower quadrant pain that began 24 hours prior to this evaluation.,The pain was very vague and progressed in intensity.  The patient has had anorexia with decrease in appetite.  His physical examination revealed the patient to be febrile with the temperature of 102.4.  He had right lower quadrant and suprapubic tenderness with palpation with Rovsing sign and rebound consistent with acute surgical abdomen.  The patient was presumed acute appendicitis and was placed on IV antibiotics and recommended that he undergo diagnostic laparoscopy with possible open exploratory laparotomy.  He was explained the risks, benefits, and complications of the procedure and gave informed consent to proceed.,OPERATIVE FINDINGS: , Diagnostic laparoscopy revealed purulent drainage within the region of the right lower quadrant adjacent to the cecum and terminal ileum.  There was large amounts of purulent drainage.  The appendix was visualized, however, it was difficult to be visualized secondary to the acute inflammatory process, purulent drainage, and edema.  It was decided given the signs of perforation and purulent drainage within the abdomen that we would convert to an open exploratory laparotomy.  Upon exploration of the ileum, there was noted to be a ruptured Meckel's diverticulum, this was resected.  Additionally, the appendix appeared normal without evidence of perforation and/or edema and a decision to proceed with incidental appendectomy was performed.  The patient was irrigated with copious amounts of warmth normal saline approximately 2 to 3 liters.  The patient was closed and did develop some hypoxemia after closure.  He remained ventilated and was placed on a large amount of ________.  His hypoxia did resolve and he remained intubated and proceed to the Critical Care Complex or postop surgical care.,OPERATIVE PROCEDURE:,  The patient was brought to the operative suite and placed in the supine position.  He did receive preoperative IV antibiotics, sequential compression devices, NG tube placement with Foley catheter, and heparin subcutaneously.  The patient was intubated by the Anesthesia Department.  After adequate anesthesia was obtained, the abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  Utilizing a #10 blade scalpel, an infraumbilical incision was created.  The Veress needle was inserted into the abdomen.  The abdomen was insufflated to approximately 15 mmHg.  A #10 mm ablated trocar was inserted into the abdomen and a video laparoscope was inserted and the abdomen was explored and the above findings were noted.  A right upper quadrant 5 mm port was inserted to help with manipulation of bowel and to visualize the appendix.  Decision was then made to convert to exploratory laparotomy given the signs of acute perforation.  The instruments were then removed.  The abdomen was then deflated.  Utilizing ________ #10 blade scalpel, a midline incision was created from the xiphoid down to level of the pubic symphysis.,The incision was carried down with a #10 blade scalpel and the bleeding was controlled along the way with electrocautery.  The posterior layer of the rectus fascia and peritoneum was opened carefully with the scissors as the peritoneum had already been penetrated during laparoscopy.  Incision was carried down to the midline within the linea alba.  Once the abdomen was opened, there was noted to be gross purulent drainage.  The ileum was explored and there was noted to be a perforated Meckel's diverticulum.  Decision to resect the diverticulum was performed.,The blood supply to the Meckel's diverticulum was carefully dissected free and a #3-0 Vicryl was used to tie off the blood supply to the Meckel's diverticulum.  Clamps were placed to the proximal supply to the Meckel's diverticulum was tied off with #3-0 Vicryl sutures.  The Meckel's diverticulum was noted to be completely free and was grasped anteriorly and utilizing a GIA stapling device, the diverticulum was transected.  There was noted to be a hemostatic region within the transection and staple line looked intact without evidence of perforation and/or leakage.  Next, decision was decided to go ahead and perform an appendectomy.  Mesoappendix was doubly clamped with hemostats and cut with Metzenbaum scissors.  The appendiceal artery was identified and was clamped between two hemostats and transected as well.  Once the appendix was completely freed of the surrounding inflammation and adhesion.  A plain gut was placed at the base of the appendix and tied down.  The appendix was milked distally with a straight stat and clamped approximately halfway.  A second piece of plain gut suture was used to ligate above and then was transected with a #10 blade scalpel.  The appendiceal stump was then inverted with a pursestring suture of #2-0 Vicryl suture.  Once the ________ was completed, decision to place a JP drain within the right lower quadrant was performed.  The drain was positioned within the right lower quadrant and anterior to the rectum and brought out through a separate site in the anterior abdominal wall.  It was sewn in place with a #3-0 nylon suture.  The abdomen was then irrigated with copious amounts of warmed normal saline.  The remainder of the abdomen was unremarkable for pathology.  The omentum was replaced over the bowel contents and utilizing #1-0 PDS suture, the abdominal wall, anterior and posterior rectus fascias were closed with a running suture.  Once the abdomen was completely closed, the subcutaneous tissue was irrigated with copious amounts of saline and the incision was closed with staples.  The previous laparoscopic sites were also closed with staples.  Sterile dressings were placed over the wound with Adaptic and 4x4s and covered with ABDs.  JPs replaced with bulb suction.  NG tube and Foley catheter were left in place.  The patient tolerated this procedure well with exception of hypoxemia which resolved by the conclusion of the case.,The patient will proceed to the Critical Care Complex where he will be closely evaluated and followed in his postoperative course.  To remain on IV antibiotics and we will manage ventilatory-dependency of the patient.", Surgery,38
"PREOPERATIVE DIAGNOSES:,1.  Radiation cystitis.,2.  Refractory voiding dysfunction.,3.  Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,POSTOPERATIVE DIAGNOSES:,1.  Radiation cystitis.,2.  Refractory voiding dysfunction.,3.  Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,TITLE OF OPERATION: , Salvage cystectomy (very difficult due to postradical prostatectomy and postradiation therapy to the pelvis), Indiana pouch continent cutaneous diversion, and omental pedicle flap to the pelvis.,ANESTHESIA: , General endotracheal with epidural.,INDICATIONS:  ,This patient is a 65-year-old white male who in 1998 had a radical prostatectomy.  He was initially dry without pads and then underwent salvage radiation therapy for rising PSA.  After that he began with episodes of incontinence as well as urinary retention requiring catheterization.  One year ago, he was unable to catheterize and was taken to the operative room and had cystoscopy.  He had retained staple removed and a diverticulum identified.  There were also bladder stones that were lasered and removed, and he had been incontinent ever since that time.  He wears 8 to 10 pads per day, and this has affected his quality of life significantly.  I took him to the operating room on January 16, 2008, and found diffuse radiation changes with a small capacity bladder and wide-open bladder neck.  We both felt that his lower urinary tract was not rehabilitatable and that a continent cutaneous diversion would solve the number of problems facing him.  I felt like if we could remove the bladder safely, then this would also provide a benefit.,FINDINGS: , At exploration, there were no gross lesions of the smaller or large bowel.  The bladder was predictably sucked into the pelvic sidewall both inferiorly and laterally.  The opened bladder, which we were able to remove completely, had a wide-open capacious diverticulum in its very distal segment.  Because of the previous radiation therapy and a dissection down to the pelvis, I elected to place an omental pedicle flap to provide additional blood supply for healing as well in the pelvis and also under the pubic bone which was exposed inferiorly due to previous surgery and treatment.,PROCEDURE IN DETAIL:  ,The patient was brought to the operative suite and after adequate general endotracheal and epidural anesthesia obtained, placed in the supine position, flexed over the anterosuperior iliac spine, and his abdomen and genitalia were sterilely prepped and draped in the usual fashion.  A nasogastric tube was placed as well as radial arterial line.  He was given intravenous antibiotics for prophylaxis.  A generous midline skin incision was made from the midepigastrium down to the symphysis pubis, deep into the rectus fascia, the rectus muscle separated in the midline, and exploration carried out with the findings described.  Moist wound towels and a Bookwalter retractor were placed for exposure.  We began by retracting the bowels by mobilizing the cecum and ascending colon and hepatic flexure and elevating the terminal ileum up to the second and third portion of the duodenum.  The ureter was identified as a crisis over the iliac vessels and dissected deep into pelvis and subsequently divided between clips.  An identical procedure was performed in the left side with similar findings and the bowels were packed cephalad.,We began then dissecting the bladder away from the pelvic side walls staying medial to both epigastric arteries.  This was quite challenging because of the previous radiation therapy and radical prostatectomy.  We essentially carved the bladder off of the pelvic sidewall inferiorly as best we could and then we were able to have enough freedom to identify the lateral pedicles, and these were taken between double clips approximately and clipped distally.  We then approached things posteriorly and carefully dissected between the __________ and posterior bladder.  There was some remnant seminal vesicle on the right as well as both remnant ejaculatory duct and we used this to dissect the longus safe plane anterior to the rectum.  We then entered the bladder anteriorly as distal as we could and remove the bladder and what we thought was a bladder neck and this appeared to end in a diverticulum.  We then peeled it off the remaining rectum and passed the specimen off the operative field.  Bladder was irrigated with warm sterile water and a meticulous inspection was made for hemostasis.,We then completely mobilized the omentum off of the proximal transverse colon.  This allowed a generous flap to be able to be laid into the pelvis without tension.,We then turned our attention to forming the Indiana pouch.  I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon.  The colon was divided proximal to the middle colic using a GIA-80 stapler.  I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum.  The mesentery was then sealed with a LigaSure device and divided, and the bowel was divided with a GIA-60 stapler.  We then performed a side-to-side ileo-transverse colostomy using a GIA-80 stapler, closing the open end with a TA 60.  The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,We then removed the staple line along the terminal ileum, passed a 12-French Robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the GIA-60 stapler.  The ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by Rowland, et al, and following this, passage of an 18-French Robinson catheter was associated with the characteristic ""pop,"" indicating that we had adequately plicated the ileocecal valve.,As the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy.  We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 Vicryl sutures.  The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb-75.  Between the staple lines, Vicryl sutures were placed and the defects closed with 3-0 Vicryl suture ligatures.,We then turned our attention to forming the ileocolonic anastomosis.  The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 Vicryl sutures, and this was stented with a Cook 8.4-French ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture.  The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis.  We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture.  A 24-French Malecot catheter was placed through the cecum and secured with a chromic suture.  The staple lines were then buried with a running 3-0 Vicryl two-layer suture and the open end of the pouch closed with a TA 60 Polysorb suture.  The pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,We then made a final inspection for hemostasis.  The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures.  We then matured our stoma through the umbilicus.  We removed the plug of skin through the umbilicus and delivered the ileal segment through this.  A portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures.  We left an 18-French Robinson through the stomag and secured this to the skin with silk sutures.  The Malecot and stents were also secured in a similar fashion.,We matured the stoma to the umbilicus with interrupted chromic stitches.  The stitch was brought out to the right upper quadrant and the Malecot to the left lower quadrant.  A Large JP drain was placed in the pelvis dependent to the omentum pedicle flap as well as the Indiana pouch.,The rectus fascia was closed with a buried #2 Prolene running stitch, tying a new figure-of-eight proximally and distally and meeting in the middle and tying it underneath the fascia.  Subcutaneous tissue was irrigated with saline and skin was closed with surgical clips.  The estimated blood loss was 450 mL, and the patient received no packed red blood cells.  The final sponge and needle count were reported to be correct.  The patient was awakened and extubated, and taken on stretcher to the recovery room in satisfactory condition.", Urology,39
"PREOPERATIVE DIAGNOSIS:, Chronic abdominal pain and heme positive stool.,POSTOPERATIVE DIAGNOSES:,1.  Antral gastritis.,2.  Duodenal polyp.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with photos and antral biopsy.,ANESTHESIA: , Demerol and Versed.,DESCRIPTION OF PROCEDURE: , Consent was obtained after all risks and benefits were described.  The patient was brought back into the Endoscopy Suite.  The aforementioned anesthesia was given.  Once the patient was properly anesthetized, bite block was placed in the patient's mouth.  Then, the patient was given the aforementioned anesthesia.  Once he was properly anesthetized, the endoscope was placed in the patient's mouth that was brought down to the cricopharyngeus muscle into the esophagus and from the esophagus to his stomach.  The air was insufflated down.  The scope was passed down to the level of the antrum where there was some evidence of gastritis seen.  The scope was passed into the duodenum and then duodenal sweep where there was a polyp seen.  The scope was pulled back into the stomach in order to flex upon itself and straightened out.  Biopsies were taken for CLO and histology of the antrum.  The scope was pulled back.  The junction was visualized.  No other masses or lesions were seen.  The scope was removed.  The patient tolerated the procedure well.  We will recommend the patient be on some type of a H2 blocker.  Further recommendations to follow.", Gastroenterology,14
"PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest.  The right groin was prepped and draped in usual manner.  Under 2% lidocaine anesthesia, the right femoral artery was entered.  A 6-French sheath was placed.  The patient was already on anticoagulation.  Selective coronary angiograms were then performed using a left and a 3DRC catheter.  The catheters were reviewed.  The catheters were then removed and an Angio-Seal was placed.  There was some hematoma at the cath site.,RESULTS,1.  The left main was free of disease.,2.  The left anterior descending and its branches were free of disease.,3.  The circumflex was free of disease.,4.  The right coronary artery was free of disease.  There was no gradient across the aortic valve.,IMPRESSION: , Normal coronary angiogram.,", Surgery,38
"PAST MEDICAL HISTORY: , Her medical conditions driving her toward surgery include hypercholesterolemia, hypertension, varicose veins, prior history of stroke.  She denies any history of cancer.  She does have a history of hepatitis which I will need to further investigate.  She complains of multiple joint pains, and heavy snoring.,PAST SURGICAL HISTORY: , Includes hysterectomy in 1995 for fibroids and varicose vein removal.  She had one ovary removed at the time of the hysterectomy as well.,SOCIAL HISTORY:,  She is a single mother of one adopted child.,FAMILY HISTORY:  ,There is a strong family history of heart disease and hypertension, as well as diabetes on both sides of her family.  Her mother is alive.  Her father is deceased from alcohol.  She has five siblings.,MEDICATIONS: , As you know she takes the following medications for her diabetes, insulin 70 units/6 units times four years, aspirin 81 mg a day, Actos 15 mg, Crestor 10 mg and CellCept 500 mg two times a day.,ALLERGIES: , She has no known drug allergies.,PHYSICAL EXAM: , She is a 54-year-old obese female.  She does not appear to have any significant residual deficits from her stroke.  There may be slight left arm weakness.,ASSESSMENT/PLAN:,  We will have her undergo routine nutritional and psychosocial assessment.  I suspect that we can significantly improve the situation with her insulin and oral hypoglycemia, as well as hypertension, with significant weight loss.  She is otherwise at increased risk for future complications given her history, and weight loss will be a good option.  We will see her back in the office once she completes her preliminary workup and submit her for approval to the insurance company.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS AND INDICATIONS:,  Acute non-ST-elevation MI.,POSTOPERATIVE DIAGNOSIS AND SUMMARY:,  The patient presented with an acute non-ST-elevation MI.  Despite medical therapy, she continued to have intermittent angina.  Angiography demonstrated the severe LAD as the culprit lesion.  This was treated as noted above with angioplasty alone as the stent could not be safely advanced.  She has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual LAD lesions as noted above.  She will be continued on her medical therapy.  At age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.,PROCEDURE PERFORMED: , Selective coronary angiography, coronary angioplasty.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position.  The area of the right femoral artery was prepped and draped in a sterile fashion.  Using the percutaneous technique, a 6-French sheath was placed in the right femoral artery under fluoroscopic guidance.  With the guidewire in place, a 5-French JL-4 catheter was used to selectively angiogram the left coronary system.  The catheter was removed.  The sheath flushed.  The 5-French 3DRC catheter was then used to selectively angiogram the right coronary artery.  The cath removed, the sheath flushed.,It was decided that intervention was needed in the severe lesions in the LAD, which appeared to be the culprit lesions for the non-ST elevation-MI.  The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained, we rebolused and the ACT was slightly lower.  We repeated the level and it was slightly higher.  We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV.  Additionally, the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started.,A 6-French CLS 3.5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal.  An Apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated.  Angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent.  The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium.  The balloon was inflated and removed, repeat angiography performed.  We attempted to advance a Driver 2.5 x 24 mm bare metal stent, but I could not advance it beyond the proximal LAD, where there was significant calcification.  The stent was removed.  Attempts to advance the same 2.5 x 15 mm Apex balloon that was previously used were unsuccessful.  It was removed, a new Apex 2.5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed.  Repeat angiography demonstrated no evidence of dissection.  One more attempt was made to advance the Driver 2.5 x 24 mm bare metal stent, but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal.  I felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed.  The guidewires and guide cath were removed.  The sheath flushed and sutured into position.  The patient moved to ICU in stable condition with no chest discomfort at all.,CONTRAST: , Isovue-370, 120 mL.,FLUORO TIME: , 9.4 minutes.,ESTIMATED BLOOD LOSS: , 30 mL.,HEMODYNAMICS:,  Aorta 185/54.,Left ventriculography was not performed.  I did not make an attempt to cross this severely stenotic aortic valve.,The left main is a large vessel, giving rise to LAD and circumflex vessels.  The left main has no significant disease other than calcification in the walls.,The LAD is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal.  The LAD has significant calcification proximally.  There is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent.  This resulted in a 30% residual, mostly eccentric calcified plaque.  Following this, there was a 50% stenosis in the LAD just after the takeoff of the third diagonal.  This was not ballooned.  Beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal.  These 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal.  As noted above, this area was not stented because I could not safely advance the stent.  Note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.,The circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches.  The proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal.  The remainder of the vessel was without significant disease.,The right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch.  The right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch.  The remainder of the right coronary and its branches were without significant disease.", Surgery,38
"REASON FOR VISIT: , The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus.  He is accompanied by his wife and daughter.,HISTORY OF PRESENT ILLNESS:,  I first saw him nearly a year ago on December 20, 2007.  At that time, he had had a traumatic deterioration over the course of approximately eight months.  This included severe cognitive impairment, gait impairment, and incontinence.  He had actually been evaluated at Hospital with CSF drainage via a temporary spinal catheter, but there was no response that was noted.  When I saw him, there were findings consistent with cervical stenosis and I ordered an MRI scan of the cervical spine.  I subsequently referred him to Dr. X, who performed a cervical laminectomy and instrumented fusion on July 16, 2008.  According to his notes this went well.,According to the family, there has not been any improvement.,With regard to the gait and balance, they actually think that he is worse now than he was a year ago.  He is virtually unable to walk at all.  He needs both a walker and support from an assistant to be able to stand or walk.  Therefore, he is always in the wheelchair.,He is completely incontinent.  He never indicates his need to the go to the bathroom.  On the other hand when asked, he will indicate that he needs to go.  He wears a Depends undergarment all the time.,He has no headaches.,His thinking and memory are worse.  For the most part, he is apathetic.  He does not talk very much.  He lives in a skilled nursing facility in the Alzheimer's section.  He does have some daytime activities.  He takes a nap once a day.  He does not read very much.  On the other hand, he did recently exercise the right to vote in the presidential election.  He needs full assistance at the nursing home.,MEDICATIONS:,  From the list by the nursing home are Aricept 10 mg in the evening, carbidopa/levodopa 25/100 mg three times a day, citalopram (Celexa) 40 mg daily, Colace 100 mg twice a day, finasteride (Proscar) 5 mg once a day, Flomax (tamsulosin) 0.4 mg once a day, multivitamin with iron once a day, omeprazole (Prilosec) 20 mg once a day, senna 8.6 mg twice a day, Tylenol 650 mg as needed, and promethazine 25 mg as needed.,PHYSICAL EXAM: , On examination today, this is a pleasant 81-year-old man who is brought back from the clinic waiting area in a wheelchair.  He is well developed, well nourished, and kempt.,Vital Signs:  Temperature 96.7, pulse 62, respirations 16, and blood pressure 123/71.,Head:  The head is normocephalic and atraumatic.,Mental Status:  Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  The Mini-Mental State Exam score was 14/30.  He was not at all oriented.  He did know we were at Sinai Hospital on the second floor.  He could spell 'world' forward, but was mute when asked to spell backwards.  He was mute when asked to recall 3/3 objects for delayed recall.  He could not copy a diagram of intersecting pentagons.  For comparison, the Mini-Mental State exam score last December was 20/30 when attention was tested by having him spell 'world' backwards and 28/30 when tested with serial 7 subtractions.  Additionally, there are times when he stutters or stammers.  I do not see any paraphasic errors.  There is some evidence of ideomotor apraxia.  He is also stimulus bound.  There is a tendency to mimic.,Cranial Nerve Exam:  There is no upgaze that I can elicit today.  The horizontal gaze and down gaze are intact.  This is a change from a year ago.  The muscles of facial expiration are intact as are hearing, head turning, cough, tongue, and palate movement.,Motor Exam:  Normal bulk and strength.  The tone is characterized by paratonia.  There is no atrophy, fasciculations, drift, or tremor.,Sensory Exam:  Intact to light touch.,Cerebellar Exam:  Intact for finger-to-nose testing that he can perform only by mimicking, but not by following verbal commands.,Gait:  Severely impaired.  When in the wheelchair, he leans to one side.  He cannot getup on his own.  He needs assistance.  Once up, he can bear weight, but cannot maintain his balance.  This would amount to a Tinetti score of zero.,REVIEW OF X-RAYS: , I personally reviewed the CT scan of the brain from November 1, 2008 and compared it to the MRI scan from a year ago.  The ventricles appear larger to me now in comparison to a year ago.  The frontal horn span is now 6 cm, whereas previously it was about 5.5 cm.  The 3rd ventricular span is about 15 mm.  There is no obvious atrophy, although there may be some subtle bilateral perisylvian atrophy.  The scan from a year ago showed that there was a patent sylvian aqueduct.,ASSESSMENT:,  The patient has had worsening of his gait, his dementia, and his incontinence.  The new finding for me today is the limited upgaze.  This would be consistent either with progressive supranuclear palsy, which was one of the differential diagnoses a year ago, or it could be consistent with progressive enlargement of the ventricles.,PROBLEMS/DIAGNOSES:,1.  Question of idiopathic normal pressure hydrocephalus (331.5).,2.  Possible supranuclear palsy.,3.  Severe gait impairment.,4.  Urinary urgency and incontinence.,5.  Dementia.,PLAN: , I had a long talk with him and his family.  Even though he has already had a trial of CSF drainage via spinal catheter at Hospital over a year ago, I offered this test to them again.  I do so on the basis that there is further enlargement of the ventricles on the scan.  His family and I discussed the facts that it is not likely to be only hydrocephalus.  Instead we are trying to answer the question of whether hydrocephalus is contributing sufficiently to his symptoms that progressing with shunt surgery would make a difference.  I have advised them to think it over for a day and contact my office to see whether they would wish to proceed.  I gave them a printed prescription of the protocol including its rationale, risks, benefits, and alternatives.  I specifically mentioned the 3% chance of infection, which mean a 97% chance of no infection.", Neurology,22
"PREOPERATIVE DIAGNOSIS: , Postoperative hemorrhage.,POSTOPERATIVE DIAGNOSIS:,  Postoperative hemorrhage.,SURGICAL PROCEDURE:  ,Examination under anesthesia with control of right parapharyngeal space hemorrhage.,ANESTHESIA:  ,General endotracheal technique.,SURGICAL FINDINGS: , Right lower pole bleeder cauterized with electrocautery with good hemostasis.,INDICATIONS FOR SURGERY: , The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy.  Previously, in the day she had undergone a tonsillectomy with adenoidectomy and was recovering without difficulty.  However, in the PACU after a coughing spell she began bleeding from the right oropharynx, and was taken back to the operative suite for control of hemorrhage.,DESCRIPTION OF SURGERY:  ,The patient was placed supine on the operating room table and general anesthetic was administered, once appropriate anesthetic findings achieved the patient was intubated and then prepped and draped in usual sterile manner for a parapharyngeal space hemorrhage.  A Crowe-Davis type mouth gag was introduced in the oropharynx and under operating headlight the oropharynx was clearly visualized.  There was a small bleeder present at the inferior mid pole of the right oropharynx in the tonsillar fossa, this area was cauterized with suction cautery and irrigated.  There was no other bleeding noted.  The patient was repositioned and the mouth gag, the tongue was rotated to the left side of the mouth and the right parapharyngeal space carefully examined.  There was a small amount of oozing noted in the right tonsillar bed, and this was cauterized with suction cautery.  No other bleeding was noted and the patient was recovered from general anesthetic.  She was extubated and left the operating room in good condition to postoperative recovery room area.  Prior to extubation the patient's tonsillar fossa were injected with a 6 mL of 0.25% Marcaine with 1:100,000 adrenalin solution to facilitate postoperative analgesia and hemostasis.", ENT - Otolaryngology,11
"PREOPERATIVE DIAGNOSIS: , Mesothelioma.,POSTOPERATIVE DIAGNOSIS:,  Mesothelioma.,OPERATIVE PROCEDURE: , Placement of Port-A-Cath, left subclavian vein with fluoroscopy.,ASSISTANT:,  None.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , The patient is a 74-year-old gentleman who underwent right thoracoscopy and was found to have biopsy-proven mesothelioma.  He was brought to the operating room now for Port-A-Cath placement for chemotherapy.  After informed consent was obtained with the patient, the patient was taken to the operating room, placed in supine position.  After induction of general endotracheal anesthesia, routine prep and drape of the left chest, left subclavian vein was cannulated with #18 gauze needle, and guidewire was inserted.  Needle was removed.  Small incision was made large enough to harbor the port.  Dilator and introducers were then placed over the guidewire.  Guidewire and dilator were removed, and a Port-A-Cath was introduced in the subclavian vein through the introducers.  Introducers were peeled away without difficulty.  He measured with fluoroscopy and cut to the appropriate length.  The tip of the catheter was noted to be at the junction of the superior vena cava and right atrium.  It was then connected to the hub of the port.  Port was then aspirated for patency and flushed with heparinized saline and summoned to the chest wall.  Wounds were then closed.  Needle count, sponge count, and instrument counts were all correct.", Hematology - Oncology,16
"CLINICAL INDICATION:  ,Normal stress test.,PROCEDURES PERFORMED:,1.  Left heart cath.,2.  Selective coronary angiography.,3.  LV gram.,4.  Right femoral arteriogram.,5.  Mynx closure device.,PROCEDURE IN DETAIL: , The patient was explained about all the risks, benefits, and alternatives of this procedure.  The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in the usual sterile fashion.  After local anesthesia with 2% lidocaine, a 6-French sheath was inserted in the right femoral artery.  Left and right coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheters.  Then, LV gram was performed using 6-French pigtail catheter.  Post LV gram, LV-to-aortic gradient was obtained.  Then, the right femoral arteriogram was performed.  Then, the Mynx closure device was used for hemostasis.  There were no complications.,HEMODYNAMICS: , LVEDP was 9.  There was no LV-to-aortic gradient.,CORONARY ANGIOGRAPHY:,1.  Left main is normal.  It bifurcates into LAD and left circumflex.,2.  Proximal LAD at the origin of big diagonal, there is 50% to 60% calcified lesion present.  Rest of the LAD free of disease.,3.  Left circumflex is a large vessel and with minor plaque.,4.  Right coronary is dominant and also has proximal 40% stenosis.,SUMMARY:,1.  Nonobstructive coronary artery disease, LAD proximal at the origin of big diagonal has 50% to 60% stenosis, which is calcified.,2.  RCA has 40% proximal stenosis.,3.  Normal LV systolic function with LV ejection fraction of 60%.,PLAN: , We will treat with medical therapy.  If the patient becomes symptomatic, we will repeat stress test.  If there is ischemic event, the patient will need surgery for the LAD lesion.  For the time being, we will continue with the medical therapy.,", Surgery,38
"BLEPHAROPLASTY,The patient was prepped and draped.  The upper lid skin was marked out in a lazy S fashion, and the redundant skin marked out with a Green forceps.  Then the upper lids were injected with 2% Xylocaine and 1:100,000 epinephrine and 1 mL of Wydase per 20 mL of solution.,The upper lid skin was then excised within the markings.  Gentle pressure was placed on the upper eyelids, and the fat in each of the compartments was teased out using a scissor and cotton applicator; and then the fat was cross clamped, cut, and the clamp cauterized.  This was done in the all compartments of the middle and medial compartments of the upper eyelid, and then the skin sutured with interrupted 6-0 nylon sutures.  The first suture was placed in the lower eyelid skin picking up the periorbital muscle and then the upper portion of the tarsus and then the upper lid skin.  This created a significant crisp, supratarsal fold.  The upper lid skin was closed in this fashion, and then attention was turned to the lower lid.,An incision was made under the lash line and slightly onto the lateral canthus.  The #15 blade was used to delineate the plane in the lateral portion of the incision, and then using a scissor the skin was cut at the marking.  Then the skin muscle flap was elevated with sharp dissection.  The fat was located and using a scissor the three eyelid compartments were opened.  Fat was teased out, cross clamped, the fat removed, and then the clamp cauterized.  Once this was done the skin was tailored to the lower lid incision site with mouth open and eyes in upward gaze, and then the excess skin removed.  The suture line was sutured with interrupted 6-0 silk sutures.  Once this was done the procedure was finished.,The patient left the OR in satisfactory condition.  The patient was given 50 mg of Demerol IM with 25 mg of Phenergan.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  Complex Regional Pain Syndrome Type I.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1.  Stellate ganglion RFTC (radiofrequency thermocoagulation)  left side.,2.  Interpretation of Radiograph.,ANESTHESIA:  ,IV Sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:,  None.,COMPLICATIONS:,  None.,INDICATIONS: , Patient with reflex sympathetic dystrophy, left side.  Positive for allodynia, pain, mottled appearance, skin changes upper extremities as well as swelling.,SUMMARY OF PROCEDURE: , Patient is admitted to the Operating Room.  Monitors placed, including EKG, Pulse oximeter, and BP cuff.  Patient had a pillow placed under the shoulder blades.  The head and neck was allowed to fall back into hyperextension.  The neck region was prepped and draped in sterile fashion with Betadine and alcohol.  Four sterile towels were placed.  The cricothyroid membrane was palpated, then going one finger's breadth lateral from the cricothyroid membrane and one finger's breadth inferior, the carotid pulse was palpated and the sheath was retracted laterally.  A 22 gauge SMK 5-mm bare tipped needle was then introduced in between the cricothyroid membrane and the carotid sheath and directed inferiomedially.  The needle is advanced prudently through the tissues, avoiding the carotid artery laterally.  The tip of the needle is perceived to intersect with the vertebral body of Cervical #7 and this was visualized by fluoroscopy.  Aspiration was cautiously performed after the needle was retracted approximately 1 mm and held steady with left hand.  No venous or arterial blood return is noted.  No cerebral spinal fluid is noted.  Positive sensory stimulation was elicited using the Radionics unit at 50 Hz from 0-0.1 volts and negative motor stimulation was elicited from 1-10 volts at 2 Hz.  After negative aspiration through the 22 gauge SMK 5mm bare tipped needle is absolutely confirmed, 5 cc of solution (solution consisting of 5 cc of 0.5% Marcaine, 1 cc of triamcinolone) was then injected into the stellate ganglion region.  This was done with intermittent aspiration vigilantly verifying negative aspiration.  The stylet was then promptly replaced and neurolysis (nerve decompression) was then carried out for 60 seconds at 80 degrees centigrade.  This exact same procedure using the exact same protocol was repeated one more time to complete the two lesions of the stellate ganglion.  The patient was immediately placed in the sitting position to reduce any side effect from the stellate ganglion block associated with cephalad spread of the solution.  Pressure was placed over the puncture site for approximately five minutes to eliminate any hemorrhage from blood vessels that may have been punctured and a Band-Aid was placed over the puncture site.  Patient was monitored for an additional ten to fifteen minutes and was noted to have tolerated the procedure well without any adverse sequelae.  Significant temperature elevation was noted on the affected side verifying neurolysis of the ganglion.  ,Interpretation of radiograph reveals placement of the 22-gauge SMK 5-mm bare tipped needle in the region of the stellate ganglion on the affected side.  Four lesions were carried out.", Radiology,33
"PREOPERATIVE DIAGNOSIS: , Ruptured globe with uveal prolapse OX.,POSTOPERATIVE DIAGNOSIS:,  Ruptured globe with uveal prolapse OX.,PROCEDURE:  ,Repair of ruptured globe with repositing of uveal tissue OX.,ANESTHESIA: ,General,SPECIMENS:,  None.,COMPLICATIONS:,  None.,INDICATIONS: , This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE: ,  The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was carefully placed to provide exposure. A two-armed 7 mm scleral laceration was seen in the supranasal quadrant. The laceration involved the sclera and the limbus in this area. There was a small amount of iris tissue prolapsed in the wound. The Westcott scissors and 0.12 forceps were used to carefully dissect the conjunctiva away from the wound to provide exposure. A cyclodialysis spatula was used to carefully reposit the prolapsed iris tissue back into the anterior chamber. The anterior chamber remained formed and the iris tissue easily resumed its normal position. The pupil appeared round. An 8-0 nylon suture was used to close the scleral portion of the laceration. Three sutures were placed using the 8-0 nylon suture. Then 9-0 nylon suture was used to close the limbal portion of the wound. After the wound appeared closed, a Superblade was used to create a paracentesis at approximately 2 o'clock. BSS was injected through the paracentesis to fill the anterior chamber. The wound was checked and found to be watertight. No leaks were observed. An 8-0 Vicryl suture was used to reposition the conjunctiva and close the wound. Three 8-0 Vicryl sutures were placed in the conjunctiva. All scleral sutures were completely covered. The anterior chamber remained formed and the pupil remained round and appeared so at the end of the case. Subconjunctival injections of Ancef and dexamethasone were given at the end of the case as well as Tobradex ointment. The lid speculum was carefully removed. The drapes were carefully removed. Sterile saline was used to clean around the XXX eye as well as the rest of the face. The area was carefully dried and an eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia without difficulty. (S)he was taken to the recovery area in good condition. There were no complications.", Surgery,38
"CHIEF COMPLAINT:,  Decreased ability to perform daily living activity secondary to recent right hip surgery.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 51-year-old white female who is status post right total hip replacement performed on 08/27/2007 at ABCD Hospital by Dr. A.  The patient had an unremarkable postoperative course, except low-grade fever of 99 to 100 postoperatively.  She was admitted to the Transitional Care Unit on 08/30/2007 at XYZ Services.  Prior to her discharge from ABCD Hospital, she had received DVT prophylaxis utilizing Coumadin and Lovenox and the INR goal is 2.0 to 3.0.  She presents reporting that her last bowel movement was on 08/26/2007 prior to surgery.  Otherwise, she reports some intermittent right calf discomfort and some postoperative right hip pain.,ALLERGIES:,  No known drug allergies.,PAST MEDICAL HISTORY:,  Anxiety, depression, osteoarthritis, migraine headaches associated with menstrual cycle, history of sciatic pain in the distant past, history of herniated disc, and status post appendectomy.,MEDICATIONS:  ,Medications taken at home are Paxil, MOBIC, and Klonopin.,MEDICATIONS ON TRANSFER: , Celebrex, Coumadin, Colace, Fiorinal, oxycodone, Klonopin, and Paxil.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY: , The patient is married.  She lives with her husband and is employed as a school nurse for the School Department.  She had quit smoking cigarettes some 25 years ago and is a nondrinker.,REVIEW OF SYSTEMS:,  As mentioned above.  She has a history of migraine headaches associated with her menstrual cycle.  She wears glasses and has a history of floaters.  She reports a low-grade temperature of 99 to 100 postoperatively, mild intermittent cough, scratchy throat, (the symptoms may be secondary to intubation during surgery), intermittent right calf pain, which was described as sharp, but momentary with a negative Homans sign.  The patient denies any cardiopulmonary symptoms such as chest pain, palpitation, pain in the upper neck and down to her arm, difficulty breathing, shortness of breath, or hemoptysis.  She denies any nausea, vomiting, or diarrhea, but reports as being constipated with the last bowel movement being on 08/26/2007 prior to surgery.  She denies urinary symptoms such as dysuria, urinary frequency, incomplete bladder emptying or voiding difficulties.  First day of her last menstrual cycle was 08/23/207 and she reports that she is most likely not pregnant since her husband had a vasectomy years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS:  At the time of admission, temperature 97.7, blood pressure 108/52, heart rate 94, respirations 18, and 95% O2 saturation on room air.,GENERAL:  No acute distress at the time of exam.,HEENT:  Normocephalic.  Sclerae are nonicteric.  EOMI.  Dentition is in good repair.,NECK:  Trachea is at the midline.,LUNGS:  Clear to auscultation.,HEART:  Regular rate and rhythm.,ABDOMEN:  Bowel sounds are heard throughout.  Soft and nontender.,EXTREMITIES:  Right hip incision is clean, intact, and no drainage is noted.  There is diffuse edema, which extends distally.  There is no calf tenderness per se bilaterally and Homans sign is negative.  There is no pedal edema.,MENTAL STATUS:  Alert and oriented x3, pleasant and cooperative during the exam.,LABORATORY DATA: , Initial workup included chemistry panel, which was unremarkable with the exception of a fasting glucose of 122 and an anion gap that was slightly decreased at 6.  The BUN was normal at 8, creatinine was 0.9, INR was 1.49.  CBC, had a white count of 5.7, hemoglobin was 9.2, hematocrit was 26.6, and platelets were 318,000.,IMPRESSION:,1.  Status post right total hip replacement.  The patient is admitted to the TCU at XYZ's Health Services and will be seen in consultation by Physical Therapy and Occupational Therapy.,2.  Postoperative anemia, Feosol 325 mg one q.d.,3.  Pain management.  Oxycodone SR 20 mg b.i.d., and oxycodone IR 5 mg one to two tablets q.4h., p.r.n. pain.  Additionally, she will utilize ice to help decrease edema.,4.  Depression and anxiety, Paxil 40 mg daily, Klonopin 1 mg q.h.s.,5.  Osteoarthritis, Celebrex 200 mg b.i.d.,6.  GI prophylaxis, Protonix 40 mg b.i.d.  Dulcolax suppository and lactulose will be used as a p.r.n. basis and Colace 100 mg b.i.d.,7.  DVT prophylaxis will be maintained with Arixtra 2.5 mg subcutaneously daily until the INR is greater than 1.7 and Coumadin will be adjusted according to the INR.  She will continue on 5 mg every day.,8.  Right leg muscle spasm/calf pain is stable at this time and we will reevaluate on a regular basis.  Monitor for any possibility of DVT.", Discharge Summary,10
"PREOPERATIVE DIAGNOSIS: , Cervical carcinoma in situ.,POSTOPERATIVE DIAGNOSIS: , Cervical carcinoma in situ.,OPERATION PERFORMED:,  Cervical cone biopsy, dilatation & curettage.,SPECIMENS:  ,Cone biopsy, endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with a Pap smear showing probable adenocarcinoma in situ.  The patient was advised to have cone biopsy to fully assess endocervical glands.,FINDINGS: , During the examination, under anesthesia, the vulva, vagina, and cervix were grossly unremarkable.  The uterus was smooth with no palpable cervical nodularity and no adnexal masses were noted.,PROCEDURE: , The patient was brought to the Operating Room with an IV in place.  Anesthetic was administered and she was placed in the lithotomy position.  The patient was prepped and draped after which a weighted speculum was placed in the vagina and a tenaculum was placed on the cervix for traction.  Angle stitches of 0 Vicryl sutures were placed at 3 o'clock and 9 o'clock in the lateral vagina fornices.  The cervix was stained with Lugol's iodine solution. ,After the cervix was stained, a scalpel was used to excise a cone shaped biopsy circumferentially around the cervical os.  The specimen was removed intact, after which the uterine cavity was sounded to a depth of 8 cm.  A Kevorkian curette was used to obtain endocervical curettings.  The cone biopsy site was sutured using a running lock stitch of 0 Vicryl suture.  Upon completion of the suture placement, the endocervical canal was sounded to assure patency.  A prophylactic application of Monsel's solution completed the procedure.  ,The patient was awakened from her anesthetic and taken to the post anesthesia care unit in stable condition.  Final sponge, needle, and instrument counts were.", Obstetrics / Gynecology,24
"Because children need hearing to learn speech, hearing loss from fluid in the middle ear can result in speech delay.  Children begin to speak some words by 18 months.  Children with fluid in both ears can show significant delay in their use of language.  In addition, young children learn to pronounce words by hearing them spoken.  When there is a hearing loss, even a mild one, the spoken words of parents and siblings are distorted to the child with fluid in the ears.  Identification of fluid in the middle ear is important, not only to prevent future speech problems, but to avoid permanent damage to the eardrum and the middle ear.  Most children will have at least one ear infection before the age of four.,With treatment, the ear infections clear up promptly.  Without the follow-up visit, fluid may still be present, even though the child has no complaints or symptoms.  Therefore, it is essential that ear infections be rechecked after initial treatment.  Usually, the presence of fluid results in a ""mild conductive hearing loss."" This could be as much as 30% hearing loss overall.  After the specialist confirms that fluid is present behind both eardrums, further medical treatment is often advised.  This may consist of additional antibiotics, decongestants, and in some cases, nasal sprays.  If fluid has been present for over 12 weeks, surgical drainage of the fluid is often indicated.  The decision to perform surgery should be based on the response to medical treatment, the degree of hearing loss and the appearance of the eardum itself under the surgical microscope.  Surgery which drains fluid involves a small incision in the eardrum, so that the fluid can be gently removed and a tube can be inserted.  The procedure, medically termed a myringotomy and tubes, or tympanostomy and tube, (BMT if Bilateral) or PET (Pressure Equalizing Tubes), is performed on children under general anesthesia.", ENT - Otolaryngology,11
"PREOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,POSTOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,PROCEDURES PERFORMED: , Total hip replacement on the right side using the following components:,1.  Zimmer trilogy acetabular system 10-degree elevated rim located at the 12 o'clock position.,2.  Trabecular metal modular acetabular system 48 mm in diameter.,3.  Femoral head 32 mm diameter +0 mm neck length.,4.  Alloclassic SL offset stem uncemented for taper.,ANESTHESIA: , Spinal.,DESCRIPTION OF PROCEDURE IN DETAIL:,  The patient was brought into the operating room and was placed on the operative table in a lateral decubitus position with the right side up.  After review of allergies, antibiotics were administered and time out was performed.  The right lower extremity was prepped and draped in a sterile fashion.  A 15 cm to 25 cm in length, an incision was made over the greater trochanter.  This was angled posteriorly.  Access to the tensor fascia lata was performed.  This was incised with the use of scissors.  Gluteus maximus was separated.  The bursa around the hip was identified, and the bleeders were coagulated with the use of Bovie.  Hemostasis was achieved.  The piriformis fossa was identified, and the piriformis fossa tendon was elevated with the use of a Cobb.  It was detached from the piriformis fossa and tagged with 2-0 Vicryl.  Access to the capsule was performed.  The capsule was excised from the posterior and superior aspects.  It was released also in the front with the use of a Mayo scissors.  The hip was then dislocated.  With the use of an oscillating saw, the femoral neck cut was performed.  The acetabulum was then visualized and debrided from soft tissues and osteophytes.  Reaming was initiated and completed for a 48 mm diameter cap without complications.  The trial component was put in place and was found to be stable in an anatomic position.  The actual component was then impacted in the acetabulum.  A 10-degree lip polyethylene was also placed in the acetabular cap.  Our attention was then focused to the femur.  With the use of a cookie cutter, the femoral canal was accessed.  The broaching process was initiated for No.4 trial component.  Trialing of the hip with the hip flexed at 90 degrees and internally rotated to 30 degrees did not demonstrate any obvious instability or dislocation.  In addition, in full extension and external rotation, there was no dislocation.  The actual component was inserted in place and hemostasis was achieved again.  The wound was irrigated with normal saline.  The wound was then closed in layers.  Before performing that the medium-sized Hemovac drain was placed in the wound.  The tensor fascia lata was closed with 0 PDS and the wound was closed with 2-0 Monocryl.  Staples were used for the skin.  The patient recovered from anesthesia without complications.,EBL: , 50 mL.,IV FLUIDS: , 2 liters.,DRAINS: , One medium-sized Hemovac.,COMPLICATIONS: , None.,DISPOSITION: , The patient was transferred to the PACU in stable condition.  She will be weightbearing as tolerated to the right lower extremity with posterior hip precautions.  We will start the DVT prophylaxis after the removal of the epidural catheter.", Orthopedic,27
"PREOPERATIVE DIAGNOSIS:  ,Urinary hesitancy and weak stream.,POSTOPERATIVE DIAGNOSES:,1.  Urinary hesitancy and weak stream.,2.  Urethral narrowing.,3.  Mild posterior wall erythema.,PROCEDURE PERFORMED:,1.  Cystourethroscopy.,2.  Urethral dilation.,3.  Bladder biopsy and fulguration.,ANESTHESIA:  ,General.,SPECIMEN:  ,Urine culture sensitivity and cytology and bladder biopsy x1.,DISPOSITION: , To PACU in stable condition.,INDICATIONS AND FINDINGS:  ,This is a 76-year-old female with history of weak stream and history of intermittent catheterization secondary to hypotonic bladder in the past, last cystoscopy approximately two years ago.,FINDINGS AT TIME OF SURGERY:,  Cystourethroscopy revealed some mild narrowing of the urethra, which was easily dilated to #23 French.  A midureteral polyp was noted.  Cystoscopy revealed multiple cellules and mild trabeculation of the bladder.  Posterior wall revealed some mild erythema with some distorted architecture of the bladder mucosa.  No obvious raised bladder tumor was noted.  No foreign bodies were noted.  The ureteral orifices were noted on the trigone just proximal to the bladder neck.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to the operating room, general anesthesia was induced by the Department of Anesthesia.  The patient was prepped and draped in normal sterile fashion and urethral sounds used to dilate the urethra to accommodate #23 French cystoscope.  Cystoscopy was performed in its entirety with the above findings.  The small area of erythema on the posterior wall was biopsied using a flexible biopsy forceps and Bovie cautery was used to cauterize and fulgurate this area.  The bladder was drained, cystoscope was removed, scope was reinserted and bladder was again reexamined.  No evidence of active bleeding noted.  The bladder was drained, cystoscope was removed, and the patient was cleaned and sent to recovery room in stable condition to followup with Dr. X in two weeks.  She is given prescription for Levaquin and Pyridium and given discharge instructions.", Urology,39
"PREOPERATIVE DIAGNOSIS: , Breast assymetry, status post previous breast surgery.,POSTOPERATIVE DIAGNOSIS:  ,Breast assymetry, status post previous breast surgery.,OPERATION: , Capsulotomy left breast, flat advancement V to Y left breast for correction lower pole defect.,ANESTHESIA:,  LMA.,FINDINGS AND PROCEDURE:  ,The patient is a 35-year-old female who presents status post multiple breast surgeries with resultant flatness of the lower pole of the left breast.  The nipple inframammary fold distance is approximately 1.5 cm shorter than the fuller right breast.  The patient has bilateral Mentor-Smooth round moderate projection jell-filled mammary prosthesis, 225 cc.,The patient was marked in the upright position for mobilization of lateral skin flaps and increase in the length of the nipple inframammary fold distance.  She was then brought to the operating room and after satisfactory LMA anesthesia had been induced, the patient was prepped and draped in the usual manger.  The patient received a gram of Kefzol prior to beginning the procedure.  The previous inverted T-scar was excised down to the underlying capsule of the breast implant.  The breast was carefully dissected off of the underlying capsule.  Care being taken to preserve the vascular supply to the skin and breast flap.  When the anterior portion of the breast was dissected free of the underlying capsule, the posterior aspect of the capsule was then dissected off of the underlying pectoralis muscle.  A posterior incision was made on the backside of the capsule at the proximate middle portion of the capsule and then reflected inferiorly thereby creating a superior based capsular flap.  The lateral aspects of the capsule were then opened and the inferior edge of the capsule was then sutured to the underside of the inframammary flap with 2-0 Monocryl statures.  Care was taken to avoid as much exposure of the implant, as well as damage to the implant.  When the flap had been created and advanced, hemostasis was obtained and the area copiously irrigated with a solution of Bacitracin 50,000 units, Kefzol 1 g, gentamicin 80 mg, and 500 cc of saline.  The lateral skin both medially and laterally were then completely freed and the vertical incision of the inverted T was then extended the 2 cm and sutured with a trifurcation suture of 2-0 Biosyn.  This lengthened the vertical portion of the mastopexy scar to allow for descent of the implant and roundness of the inferior pole of the left breast.  The remainder of the inverted T was closed with interrupted sutures of 3 and 2-0 Biosyn and the skin was closed with continuous suture of 5-0 nylon.  Bacitracin and a standard breast dressing were applied.,The anesthesia was terminated and the patient was recovered in the operating room.  Sponge, instrument, needle count reported as corrected.  Estimated blood loss negligible.", Cosmetic / Plastic Surgery,6
"ADMITTING DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,DISCHARGE DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,3.  Pneumonia.,HISTORY OF PRESENT ILLNESS: , The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who presented with a 36-hour presentation of URI symptoms, then had an abrupt onset of cough and increased work of breathing.  Child was brought to Children's Hospital and received nebulized treatments in the ER and the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,He was placed on the hospitalist system and was started on continuous nebulized albuterol secondary to his respiratory distress.  He also received inhaled as well as systemic corticosteroids.  An x-ray was without infiltrate on initial review by the hospitalist, but there was a right upper lobe infiltrate versus atelectasis per the official radiology reading.  The patient was not started on any antibiotics and his fever resolved.  However, the CRP was relatively elevated at 6.7.  The CBC was normal with a white count of 9.6; however, the bands were 84%.  Given these results, which she is to treat the pneumonia as bacterial and discharge the child with amoxicillin and Zithromax.,He was taken off of continuous and he was not on room air all night.  In the morning, he still had some bilateral wheezing, but no tachypnea.,DISCHARGE PHYSICAL EXAMINATION: , ,GENERAL:  No acute distress, running around the room.,HEENT:  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly or masses.,CHEST:  Bilateral basilar wheezing.  No distress.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses.  Nontender to palpation.,GENITOURINARY:  Deferred.,EXTREMITIES:  Warm and well perfused.,DISCHARGE INSTRUCTIONS:,  As follows:,1.  Activity, regular.,2.  Diet is regular.,3.  Follow up with Dr. X in 2 days.,DISCHARGE MEDICATIONS:,1.  Xopenex MDI 2 puffs every 4 hours for 2 days and then as needed for cough or wheeze.,2.  QVAR 40, 2 puffs twice daily until otherwise instructed by the primary care provider.,3.  Amoxicillin 550 mg p.o. twice daily for 10 days.,4.  Zithromax 150 mg p.o. on day 1, then 75 mg p.o. daily for 4 more days.,Total time for this discharge 37 minutes.", Discharge Summary,10
"PREOPERATIVE DIAGNOSES: , Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,POSTOPERATIVE DIAGNOSES:,  Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,PROCEDURE:  ,Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.,ANESTHESIA:  ,General endotracheal anesthetic with a caudal block x2.,FLUIDS RECEIVED:  ,1000 mL crystalloid.,ESTIMATED BLOOD LOSS:  ,Less than 10 mL.,SPECIMENS: , Tissue sent to pathology is a renal biopsy.,ABNORMAL FINDINGS: , A stenotic scarred ureteropelvic junction with dilated ureter and dilated renal pelvis.,TUBES AND DRAINS:  ,A 10-French silicone Foley catheter with 3 mL in balloon and a 4.7-French ureteral double J-stent multilength.,INDICATIONS FOR OPERATION:  ,The patient is a 3-1/2-year-old boy, who has a solitary left kidney with renal insufficiency with creatinine of 1.2, who has had a ureteropelvic junction repair performed by Dr. Chang.  It was subsequently obstructed with multiple episodes of pyelonephritis, two percutaneous tube placements, ureteroscopy with balloon dilation of the system, and continued obstruction.  Plan is for co surgeons due to the complexity of the situation and the solitary kidney to do surgical procedure to correct the obstruction.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operative room.  Surgical consent, operative site, and patient identification were verified.  Dr. X and Dr. Y both agreed upon the procedures in advance.  Dr. Y then, once the patient was anesthetized, requested IV antibiotics with Fortaz, the patient had a caudal block placed, and he was then placed in lithotomy position.  Dr. Y then calibrated the urethra with the bougie a boule to 8, 10, and up to 12 French.  The 9.5-French cystoscope sheath was then placed within the patient's bladder with the offset scope, and his bladder had no evidence of cystitis.  I was able to locate the ureteral orifice bilaterally, although no urine coming from the right.  We then placed a 4-French ureteral catheter into the ureter as far as we could go.  An antegrade nephrostogram was then performed, which shows that the contrast filled the dilated pelvis, but did not go into the ureter.  A retrograde was performed, and it was found that there was a narrowed band across the two.  Upon draining the ureter allowing to drain to gravity, the pelvis which had been clamped and its nephrostomy tube did not drain at all.  Dr. Y then placed a 0.035 guidewire into the ureter after removing the 4-French catheter and then placed a 4.7-French double-J catheter into the ureter as far as it would go allowing it to coil in the bladder.  Once this was completed, we then removed the cystoscope and sheath, placed a 10-French Foley catheter, and the patient was positioned by Dr. X and Dr. Y into the flank position with the left flank up after adequate padding on the arms and legs as well as a brachial plexus roll.  He was then sterilely prepped and draped.  Dr. Y then incised the skin with a 15-blade knife through the old incision and then extended the incision with curved mosquito clamp and Dr. X performed cautery of the areas advanced to be excised.  Once this was then dissected, Dr. Y and Dr. X divided the lumbosacral fascia; at the latissimus dorsi fascia, posterior dorsal lumbotomy maneuver using the electrocautery; and then using curved mosquito clamps __________.  At this point, Dr. X used the cautery to enter the posterior retroperitoneal space through the posterior abdominal fascia.  Dr. Y then used the curved right angle clamp and dissected around towards the ureter, which was markedly adherent to the base of the retroperitoneum.  Dr. X and Dr. Y also needed dissection on the medial and lateral aspects with Dr. Y being on the lateral aspect of the area and Dr. X on the medial to get an adequate length of this.  The tissue was markedly inflamed and had significant adhesions noted.  The patient's spermatic vessels were also in the region as well as the renal vessels markedly scarred close to the ureteropelvic junction.  Ultimately, Dr. Y and Dr. X both with alternating dissection were able to dissect the renal pelvis to a position where Dr. Y put stay sutures and a 4-0 chromic to isolate the four quadrant area where we replaced the ureter.  Dr. X then divided the ureter and suture ligated the base, which was obstructed with a 3-0 chromic suture.  Dr. Y then spatulated the ureter for about 1.5 cm, and the stent was gently delivered in a normal location out of the ureter at the proximal and left alone in the bladder.  Dr. Y then incised the renal pelvis and dissected and opened it enough to allow the new ureteropelvic junction repair to be performed.  Dr. Y then placed interrupted sutures of 5-0 Monocryl at the apex to repair the most dependent portion of the renal pelvis, entered the lateral aspect, interrupted sutures of the repair.  Dr. X then was able to without much difficulty do interrupted sutures on the medial aspect.  The stent was then placed into the bladder in the proper orientation and alternating sutures by Dr. Y and Dr. X closed the ureteropelvic junction without any evidence of leakage.  Once this was complete, we removed the extra stay stitches and watched the ureter lay back into the retroperitoneum in a normal position without any kinking in apparently good position.  This opening was at least 1.5 cm wide.  Dr. Y then placed 2 stay sutures of 2-0 chromic in the lower pole of the kidney and then incised wedge biopsy and excised the biopsy with a 15-blade knife and curved iris scissors for renal biopsy for determination of renal tissue health.  Electrocautery was used on the base.  There was no bleeding, however, and the tissue was quite soft.  Dermabond and Gelfoam were placed, and then Dr. Y closed the biopsy site over with thrombin-Gelfoam using the 2-0 chromic stay sutures.  Dr. X then closed the fascial layers with running suture of 3-0 Vicryl in 3 layers.  Dr. Y closed the Scarpa fascia and the skin with 4-0 Vicryl and 4-0 Rapide respectively.  A 4-0 nylon suture was then placed by Dr. Y around the previous nephrostomy tube, which was again left clamped.  Dermabond tissue adhesive was placed over the incision and then a dry sterile dressing was placed by Dr. Y over the nephrostomy tube site, which was left clamped, and the patient then had a Foley catheter placed in the bladder.  The Foley catheter was then taped to his leg.  A second caudal block was placed for anesthesia, and he is in stable condition upon transfer to recovery room.", Urology,39
"As you know, the patient is a 50-year-old right-handed Caucasian female, who works as an independent contractor and as a human resources consultant.,Her neurological history first begins in December of 1987, when she had a rather sudden onset of slurred speech and the hesitancy when she started to walk.  She had HMO insurance at that time and saw a neurologist, whose name she does not recall.  She thinks that she underwent MRI scan of the brain and possibly visual evoked response and brainstem auditory evoked response tests.  She was told that all the tests were normal and no diagnosis was made.,The slurred speech resolved after a few weeks, but her gait hesitancy persisted for a number of years and then finally partially improved.  She also began to note that she would fatigue after very prolonged walking.,In about 1993, she developed bladder urgency and frequency along with some nocturia.  She saw a urologist and underwent urodynamic testing.  She was diagnosed as having ""overactive bladder"", but the cause of this was never determined.  She was treated with medications, possibly Ditropan, without much benefit.  She also developed a dry mouth from the medication and so she discontinued it.,Also in about 1993, she began to note an uncomfortable ""stiffness"" in her feet and slight swelling of the ankles.  Apparently, the swelling was not visible by others.  She saw multiple physicians and was told that it was ""not arthritis"", but no definite diagnosis was ever established.  She saw at least two rheumatologists on several occasions and blood tests were all normal.  No clear-cut diagnosis was ever made and the patient simply learned to live with these symptoms.,However, over time she noted that the symptoms in her legs seemed to worsen somewhat.  She states from time-to-time she could ""barely walk"".  She felt as if her balance is impaired and she felt as if she were ""walking on stilts"".  She tried arch supports from a podiatrist without any benefit.  She began to tire more easily when walking.,In 2002 she was seen by a podiatrist, who noticed an abnormal gait and recommended that she see a neurologist.,In the fall of 2002, she was seen by Dr. X.  He ordered an MRI scan of her brain and lumbar spine.  He also did some sort of nerve testing and possibly visual evoked response testing.  After reviewing everything, he diagnosed multiple sclerosis.  However, prior to starting her on immunomodulatory therapy, he referred her for a second opinion to Dr. Y, in January of 2003.  Dr. Y confirmed the diagnosis of multiple sclerosis.,The patient then returned to Dr. X and was started on Avonex.  She continued on it for about six months.  However, it made her feel much more stiff and delayed and so she finally stopped it.  She also recalled being tried on baclofen by Dr. X, but again it did not benefit her and made her feel slightly dizzy.  So, she discontinued it also.,At that point in time, she decided to try a program of ""good nutrition, vitamin supplements, and fish oil"".,In December 2004 and extending up to February 2005, she began to note progressively more severe swelling and stiffness in the distal lower extremities.  She began to have to use a cane.  She was seen in neurological consultation by Dr. Z.  She was treated with a Medrol Dosepak.  Her spasticity and swelling seemed to improve dramatically.  However, within about two weeks symptoms were back to baseline.,She was then treated with intravenous Solu-Medrol 500 mg daily for five days followed by a prednisone or Medrol taper (July 2005).  This seemed to be less helpful than the oral steroids, but was partially beneficial.  However, it wore off once again.,A repeat MRI scan of the brain in April 2005 was said to ""look better"".  She was started on Zanaflex for her lower extremity spasticity without benefit.,Finally six days ago, she was restarted on oral prednisone 10 mg tablets.  She takes one-half tablet daily and this again has seemed to reduce the swelling and stiffness in her legs.  She continues on the prednisone in the same dosage for relief of the spasticity.,She has not been on any other immunomodulatory agents.,The patient does note some complaints of mild heat sensitivity and mild easy fatigability.  There is no history of diplopia, dysarthria, aphasia, focal weakness, numbness, paresthesias, cognitive dysfunction, or memory dysfunction.,PAST MEDICAL HISTORY: , Essentially noncontributory.,ALLERGIES:,  The patient is allergic to LOBSTER and VICODIN.  She feels that she is probably allergic to IODINE.,SOCIAL HISTORY:,  She does not smoke.  She takes one glass of wine per day.,PAST SURGICAL HISTORY: , She has not had any prior surgeries.  Her general health has been excellent except for the above-indicated problems.,REVIEW OF OUTSIDE RADIOLOGICAL STUDIES:,  The patient brought with her today MRI scans of the brain, thoracic spine, and lumbosacral spine performed on 11/14/02 on a 1.5-Tesla magnet.  There are numerous T2 hyperintense lesions in the periventricular and subcortical white matter of the brain and at least one lesion is in the corpus callosum.  There appear to be Dawson's fingers.  The MRI of the thoracic and lumbosacral spines did not reveal any significant abnormalities.,Also available are the MRI scans of the brain, cervical spine, thoracic spine, and lumbosacral spine performed on a 0.35-Tesla magnet on 04/22/05.  The MRI of the brain shows that one of the prior lesions has resolved and there appear to be one or two more lesions.,However, the quality of the newer scan is only 0.35-Tesla and is suboptimal.  Visualization of the cord is also suboptimal, but there are no clear-cut extraaxial or complexities of the spinal cord.  It is difficult to be certain that there are no intra-axial lesions, but I could not clearly see one.,PHYSICAL EXAMINATION:,Vital signs:  Blood pressure 151/88, pulse 92, temperature 99.5ºF, and weight 124 lb (dressed).,General:  Well-developed, well-nourished female in no acute distress.,Head:  Normocephalic, without evidence of trauma or bruits.,Neck:  Supple, with full range of motion.  No spasm or tenderness.  Carotid pulsations are of normal volume and contour bilaterally without bruits.  No thyromegaly or adenopathy.,Extremities:  No clubbing, cyanosis, edema, or deformity.  Range of motion full throughout.,NEUROLOGICAL EXAMINATION:,Mental Status:  Awake, alert, oriented to time, place, and person; appropriate.  Recent and remote memory intact.  No evidence of right-left confusion, finger agnosia, dysnomia or aphasia.,CRANIAL NERVES,:,II:  Visual fields full to confrontation.  Fundi benign.,III, IV, VI:  Extraocular movements full throughout, without nystagmus.  No ptosis.  Pupils equal, round and react briskly to light and accommodation.,V:  Normal sensation to light touch and pinprick bilaterally.  Corneal reflexes equal bilaterally.  Motor function normal.,VII:  No facial asymmetry.,VIII:  Hears finger rub bilaterally.  Weber and Rinne tests normal.,IX & X:  Palate elevates symmetrically bilaterally with phonation.  Gag reflex equal bilaterally.,XI:  Sternocleidomastoid and upper trapezius normal tone, bulk and strength bilaterally.,XII:  Tongue midline without atrophy or fasciculations.  Rapid alternating movements normal.  No dysarthria.,Motor:  Tone, bulk, and strength are normal in both upper extremities.  In the lower extremities, there is moderate spasticity on the right and moderately severe spasticity on the left.  There are bilateral Achilles' contractures more so on the left than the right and also a slight left knee flexion contracture.,Strength in the lower extremities is rated as follows on a 5-point scale (right/left):  Iliopsoas 4+/5-, quadriceps 5-/5-, tibialis anterior 4+/4+, and gastrocnemius 5/5.  There are no tremors, fasciculations or abnormal involuntary movements.", Consult - History and Phy.,5
"DATE OF INJURY : October 4, 2000,DATE OF EXAMINATION : September 5, 2003,EXAMINING PHYSICIAN : X Y, MD,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,CHIEF COMPLAINT:  ,Aching and mid back pain.,HISTORY OF PRESENT INJURY: , Based upon the examinee's perspective: ,Mr. Abc is a 52-year-old self-employed, independent consultant for DEMILEE-USA. He is also a mechanical engineer. He reports that he was injured in a motor vehicle accident that occurred in October 4, 2000. At that time, he was employed as a purchasing agent for IBIKEN-USA. On the date of the motor vehicle accident, he was sitting in the right front passenger's seat, wearing seat and shoulder belt safety harnesses, in his 1996 or 1997 Volvo 850 Wagon automobile driven by his son. The vehicle was completely stopped and was ""slammed from behind"" by a van. The police officer, who responded to the accident, told Mr. Abc that the van was probably traveling at approximately 30 miles per hour at the time of impact.,During the impact, Mr. Abc was restrained in the seat and did not contact the interior surface of the vehicle. He experienced immediate mid back pain. He states that the Volvo automobile sustained approximately $4600 in damage.,He was transported by an ambulance, secured by a cervical collar and backboard to the emergency department. An x-ray of the whole spine was obtained, and he was evaluated by a physician's assistant. He was told that it would be ""okay to walk."" He was prescribed pain pills and told to return for reevaluation if he experienced increasing pain.,He returned to the Kaiser facility a few days later, and physical therapy was prescribed. Mr. Abc states that he was told that ""these things can take a long time."" He indicates that after one year he was no better. He then states that after two years he was no better and worried if the condition would never get better.,He indicates he saw an independent physician, a general practitioner, and an MRI was ordered. The MRI study was completed at ABCD Hospital. Subsequently, Mr. Abc returned and was evaluated by a physiatrist. The physiatrist reexamined the original thoracic spine x-rays that were taken on October 4, 2000, and stated that he did not know why the radiologist did not originally observe vertebral compression fractures. Mr. Abc believes that he was told by the physiatrist that it involved either T6-T7 or T7-T8.,Mr. Abc reports that the physiatrist told him that little could be done besides participation in core strengthening. Mr. Abc describes his current exercise regimen, consisting of cycling, and it was deemed to be adequate. He was told, however, by the physiatrist that he could also try a Pilates type of core exercise program.,The physiatrist ordered a bone scan, and Mr. Abc is unsure of the results. He does not have a formal follow up scheduled with Kaiser, and is awaiting re-contact by the physiatrist.,He denies any previous history of symptomatology or injuries involving his back.,CURRENT SYMPTOMS:  ,He reports that he has the same mid back pain that has been present since the original injury. It is located in the same area, the mid thoracic spine area. It is described as a pain and an ache and ranges from 3/10 to 6/10 in intensity, and the intensity varies, seeming to go in cycles. The pain has been staying constant.,When I asked whether or not the pain have improved, he stated that he was unable to determine whether or not he had experienced improvement. He indicates that there may be less pain, or conversely, that he may have developed more of a tolerance for the pain. He further states that ""I can power through it."" ""I have learned how to manage the pain, using exercise, stretching, and diversion techniques."" It is primary limitation with regards to the back pain involves prolonged sitting. After approximately two hours of sitting, he has required to get up and move around, which results in diminishment of the pain. He indicates that prior to the motor vehicle accident, he could sit for significantly longer periods of time, 10 to 12 hours on a regular basis, and up to 20 hours, continuously, on an occasional basis.,He has never experienced radiation of the pain from the mid thoracic spine, and he has never experienced radicular symptoms of radiation of pain into the extremities, numbness, tingling, or weakness.,Again, aggravating activities include prolonged sitting, greater than approximately two hours.,Alleviating activities include moving around, stretching, and exercising. Also, if he takes ibuprofen, it does seem to help with the back pain.,He is not currently taking medications regularly, but list that he takes occasional ibuprofen when the pain is too persistent.,He indicates that he received several physical therapy sessions for treatment, and was instructed in stretching and exercises. He has subsequently performed the prescribed stretching and exercises daily, for nearly three years.,With regards to recreational activities, he states that he has not limited his activities due to his back pain.,He denies bowel or bladder dysfunction.,FILES REVIEW:  ,October 4, 2000: An ambulance was dispatched to the scene of a motor vehicle accident on South and Partlow Road. The EMS crew arrived to find a 49-year-old male sitting in the front passenger seat of a vehicle that was damaged in a rear-end collision and appeared to have minimal damage. He was wearing a seatbelt and he denied loss of consciousness. He also denied a pertinent past medical history. They noted pain in the lower cervical area, mid thoracic and lumbar area. They placed him on a backboard and transported him to Medical Center.,October 4, 2000: He was seen in the emergency department of Medical Center. The provider is described as ""unknown."" The history from the patient was that he was the passenger in the front seat of a car that was stopped and rear-ended. He stated that he did not exit the car because of pain in his upper back. He reported he had been wearing the seatbelt and harness at that time. He denied a history of back or neck injuries. He was examined on a board and had a cervical collar in place. He was complaining of mid back pain. He denied extremity weakness. Sensory examination was intact. There was no tenderness with palpation or flexion in the neck. The back was a little tender in the upper thoracic spine area without visible deformity. There were no marks on the back. His x-ray was described as ""no acute bony process."" Listed visit diagnosis was a sprain-thoracic, and he was prescribed hydrocodone/acetaminophen tablets and Motrin 800 mg tablets.,October 4, 2000: During the visit, a Clinician's Report of Disability document was signed by Dr. M, authorizing time loss from October 4, 2000, through October 8, 2000. The document also advised no heavy lifting, pushing, pulling, or overhead work for two weeks. During this visit, a thoracic spine x-ray series, two views, was obtained and read by Dr. JR. The findings demonstrate no evidence of acute injury. No notable arthritic findings. The pedicles and paravertebral soft tissues appear unremarkable.,November 21, 2000: An outpatient progress note was completed at Kaiser, and the clinician of record was Dr. H. The history obtained documents that Mr. Abc continued to experience the same pain that he first noted after the accident, described as a discomfort in the mid thoracic spine area. It was non-radiating and described as a tightness. He also reported that he was hearing clicking noises that he had not previously heard. He denied loss of strength in the arms. The physical examination revealed good strength and normal deep tendon reflexes in the arms. There was minimal tenderness over T4 through T8, in an approximate area. The visit diagnosis listed was back pain. Also described in the assessment was residual pain from MVA, suspected bruised muscles. He was prescribed Motrin 800 mg tablets and an order was sent to physical therapy. Dr. N also documents that if the prescribed treatment measures were not effective, then he would suggest a referral to a physiatrist. Also, the doctor wanted him to discuss with physical therapy whether or not they thought that a chiropractor would be beneficial.,December 4, 2000: He was seen at Kaiser for a physical therapy visit by Philippe Justel, physical therapist. The history obtained from Mr. Abc is that he was not improving. Symptoms described were located in the mid back, centrally. The examination revealed mild tenderness, centrally at T3-T8, with very poor segmental mobility. The posture was described as rigid T/S in flexion. Range of motion was described as within normal limits, without pain at the cervical spine and thoracic spine. The plan listed included two visits per week for two weeks, for mobilization. It is also noted that the physical therapist would contact the MD regarding a referral to a chiropractor.,December 8, 2000: He was seen at Kaiser for a physical therapy visit by Mr. Justel. It was noted that the subjective category of the document revealed that there was no real change. It was noted that Mr. Abc tolerated the treatment well and that he was to see a chiropractor on Monday.,December 11, 2000: He presented to the Chiropractic Wellness Center. There is a form titled 'Chiropractic Case History,' and it documents that Mr. Abc was involved in a motor vehicle accident, in which he was rear-ended in October. He has had mid back pain since that time. The pain is worsened with sitting, especially at a computer. The pain decreases when he changes positions, and sometimes when he walks. Mr. Abc reports that he occasionally takes 800 mg doses of ibuprofen. He reported he went to physical therapy treatment on two occasions, which helped for a few hours only. He did report that he had a previous history of transitory low back pain.,During the visit, he completed a modified Oswestry Disability Questionnaire, and a WC/PI Subjective Complaint Form. He listed complaints of mid and low back pain of a sore and aching character. He rated the pain at grade 3-5/10, in intensity. He reported difficulty with sitting at a table, bending forward, or stooping. He reported that the pain was moderate and comes and goes.,During the visit at the Chiropractic Wellness Center, a spinal examination form was completed. It documents palpation tenderness in the cervical, thoracic, and lumbar spine area and also palpation tenderness present in the suboccipital area, scalenes, and trapezia. Active cervical range of motion measured with goniometry reveals pain and restriction in all planes. Active thoracic range of motion measured with inclinometry revealed pain and restriction in rotation bilaterally. Active lumbosacral range of motion measured with inclinometry reveals pain with lumbar extension, right lateral flexion, and left lateral flexion.,December 11, 2000: He received chiropractic manipulation treatment, and he was advised to return for further treatment at a frequency of twice a week.,December 13, 2000: He returned to the Chiropractic Wellness Center to see Joe Smith, DC, and it is documented that his middle back was better.,December 13, 2000: A personal injury patient history form is completed at the Chiropractic Wellness Center. Mr. Abc reported that on October 4, 2000, he was driving his 1996 Volvo 850 vehicle, wearing seat and shoulder belt safety harnesses, and completely stopped. He was rear-ended by a vehicle traveling at approximately 30 miles per hour. The impact threw him back into his seat, and he felt back pain and determined that it was not wise to move about. He reported approximate damage to his vehicle of $4800. He reported continuing mid and low back pain, of a dull and semi-intense nature. He reported that he was an export company manager for IBIKEN-USA, and that he missed two full days of work, and missed 10-plus partial days of work. He stated that he was treated initially after the motor vehicle accident at Kaiser and received painkillers and ibuprofen, which relieved the pain temporarily. He specifically denied ever experiencing similar symptoms.,December 26, 2000: A no-show was documented at the Chiropractic Wellness Center.,April 5, 2001: He received treatment at the Chiropractic Wellness Center. He reported that two weeks previously, his mid back pain had worsened.,April 12, 2001: He received chiropractic treatment at the Chiropractic Wellness Center.,April 16, 2001: He did not show up for his chiropractic treatment.,April 19, 2001: He did not show up for his chiropractic treatment.,April 26, 2001: He received chiropractic manipulation treatment at the Chiropractic Wellness Center. He reported that his mid back pain increased with sitting at the computer. At the conclusion of this visit, he was advised to return to the clinic as needed.,September 6, 2002: An MRI of the thoracic spine was completed at ABCD Hospital and read by Dr. RL, radiologist. Dr. D noted the presence of minor anterior compression of some mid thoracic vertebrae of indeterminate age, resulting in some increased kyphosis. Some of the mid thoracic discs demonstrate findings consistent with degenerative disc disease, without a significant posterior disc bulging or disc herniation. There are some vertebral end-plate abnormalities, consistent with small Schmorl's nodes, one on the superior aspect of T7, which is compressed anteriorly, and on the inferior aspect of T6.,May 12, 2003: He was seen at the Outpatient Clinic by Dr. L, internal medicine specialist. He was there for a health screening examination, and listed that his only complaints are for psoriasis and chronic mid back pain, which have been present since a 2000 motor vehicle accident. Mr. Abc reported that an outside MRI showed compression fractures in the thoracic spine. The history further documents that Mr. Abc is an avid skier and volunteers on the ski patrol. The physical examination revealed that he was a middle-aged Caucasian male in no acute distress. The diagnosis listed from this visit is back pain and psoriasis. Dr. L documented that he spent one hour in the examination room with the patient discussing what was realistic and reasonable with regard to screening testing. Dr. L also stated that since Mr. Abc was experiencing chronic back pain, he advised him to see a physiatrist for evaluation. He was instructed to bring the MRI to the visit with that practitioner.,June 10, 2003: He was seen at the Physiatry Clinic by Dr. R, physiatrist. The complaint listed is mid back pain. In the subjective portion of the chart note, Dr. R notes that Mr. Abc is involved in the import/export business, and that he is physically active in cycling, skiing, and gardening. He is referred by Dr. L because of persistent lower thoracic pain, following a motor vehicle accident, on October 4, 2000. Mr. Abc told Dr. R that he was the restrained passenger of a vehicle that was rear-ended at a moderate speed. He stated that he experienced immediate discomfort in his thoracic spine area without radiation. He further stated that thoracic spine x-rays were obtained at the Sunnyside Emergency Room and read as normal. It is noted that Mr. Abc was treated conservatively and then referred to physical therapy where he had a number of visits in late of 2002 and early 2003. No further chart entries were documented about the back problem until Mr. Abc complained to Dr. L that he still had ongoing thoracic spine pain during a visit the previous month. He obtained an MRI, out of pocket, at ABCD Hospital and stated that he paid $1100 for it. Dr. R asked to see the MRI and was told by Mr. Abc that he would have to reimburse or pay him $1100 first. He then told the doctor that the interpretation was that he had a T7 and T8 compression fracture. Mr. Abc reported his improvement at about 20%, compared to how he felt immediately after the accident. He described that his only symptoms are an aching pain that occurs after sitting for four to five hours. If he takes a break from sitting and walks around, his symptoms resolve. He is noted to be able to bike, ski, and be active in his garden without any symptoms at all. He denied upper extremity radicular symptoms. He denied lower extremity weakness or discoordination. He also denied bowel or bladder control or sensation issues. Dr. R noted that Mr. Abc was hostile about the Kaiser health plan and was quite uncommunicative, only reluctantly revealing his history. The physical examination revealed that he moved about the examination room without difficulty and exhibited normal lumbosacral range of motion. There was normal thoracic spine motion with good chest expansion. Neurovascular examination of the upper extremities was recorded as normal. There was no spasticity in the lower extremities. There was no tenderness to palpation or percussion up and down the thoracic spine. Dr. R reviewed the thoracic spine films and noted the presence of ""a little compression of what appears to be T7 and T8 on the lateral view."" Dr. R observed that this was not noted on the original x-ray interpretation. He further stated that the MRI, as noted above, was not available for review. Dr. R assessed that Mr. Abc was experiencing minimal thoracic spine complaints that probably related to the motor vehicle accident three years previously. The doctor further stated that ""the patient's symptoms are so mild as to almost not warrant intervention."" He discussed the need to make sure that Mr. Abc's workstation was ergonomic and that Mr. Abc could pursue core strengthening. He further recommended that Mr. Abc look into participation in a Pilates class. Mr. Abc was insistent, so Dr. R made plans to order a bone scan to further discriminate the etiology of his symptoms. He advised Mr. Abc that the bone scan results would probably not change treatment. As a result of this visit, Dr. R diagnosed thoracic spine pain (724.1) and ordered a bone scan study.", Chiropractic,4
"CC:, Fluctuating level of consciousness.,HX:, 59y/o male experienced a ""pop"" in his head on 10/10/92 while showering in Cheyenne, Wyoming. He was visiting his son at the time. He was found unconscious on the shower floor 1.5 hours later. His son then drove him Back to Iowa. Since then he has had recurrent headaches and fluctuating level of consciousness, according to his wife. He presented at local hospital this AM, 10/13/92. A HCT there demonstrated a subarachnoid hemorrhage. He was then transferred to UIHC.,MEDS:, none.,PMH:, 1) Right hip and clavicle fractures many years ago. 2) All of his teeth have been removed., ,FHX:, Not noted.,SHX:, Cigar smoker. Truck driver.,EXAM: , BP 193/73.  HR 71.  RR 21.  Temp 37.2C.,MS: A&O to person, place and time. No note regarding speech or thought process.,CN: Subhyaloid hemorrhages, OU. Pupils 4/4 decreasing to 2/2 on exposure to light. Face symmetric. Tongue midline. Gag response difficult to elicit. Corneal responses not noted.,MOTOR: 5/5 strength throughout.,Sensory: Intact PP/VIB.,Reflexes: 2+/2+ throughout. Plantars were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, The patient underwent Cerebral Angiography on 10/13/92. This revealed a lobulated aneurysm off the supraclinoid portion of the left internal carotid artery close to the origin of the posterior communication artery. The patient subsequently underwent clipping of this aneurysm. He recovery was complicated severe vasospasm and bacterial meningitis. HCT on 10/19/92 revealed multiple low density areas in the left hemisphere in the LACA-LPCA watershed, left fronto-parietal area and left thalamic region. He was left with residual right hemiparesis, urinary incontinence, some (unspecified) degree of mental dysfunction. He was last seen 2/26/93 in Neurosurgery clinic and had stable deficits.", Radiology,33
"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,14
"PROCEDURE: , Endoscopy.,CLINICAL INDICATIONS: , Intermittent rectal bleeding with abdominal pain.,ANESTHESIA: , Fentanyl 100 mcg and 5 mg of IV Versed.,PROCEDURE:,  The patient was taken to the GI lab and placed in the left lateral supine position.  Continuous pulse oximetry and blood pressure monitoring were in place.  After informed consent was obtained, the video endoscope was inserted over the dorsum of the tongue without difficulty.  With swallowing, the scope was advanced down the esophagus into the body of the stomach.  The scope was further advanced down to the antrum and through the pylorus into the duodenum, which was visualized into its second portion.  It appeared free of stricture, neoplasm, or ulceration.  Samples were obtained from the antrum and prepyloric area to check for Helicobacter, rapid urease, and additional samples were sent to pathology.  Retroflexion view of the fundus of the stomach was normal without evidence of a hiatal hernia.  The scope was then slowly removed.  The distal esophagus appeared benign with a normal-appearing gastroesophageal sphincter and no esophagitis.  The remaining portion of the esophagus was normal.,IMPRESSION:,  Abdominal pain.  Symptoms most consistent with gastroesophageal reflux disease without endoscopic evidence of hiatal hernia.,RECOMMENDATIONS:,  Await results of CLO testing and biopsies.  Return to clinic with Dr. Spencer in 2 weeks for further discussion.", Gastroenterology,14
"PREOPERATIVE DIAGNOSES:  ,1.  Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2.  Cervical stenosis with cord compression, C5-C6 (723.0).,POSTOPERATIVE DIAGNOSES:  ,1.  Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2.  Cervical stenosis with cord compression, C5-C6 (723.0), with surgical findings confirmed.,PROCEDURES:  ,1.  Anterior cervical discectomy at C4-C5, C5-C6, and C6-C7 for neural decompression (63075, 63076, 63076).,2.  Anterior interbody fusion at C4-C5, C5-C6, and C6-C7 (22554, 22585, 22585) utilizing Bengal cages times three (22851).,3.  Anterior instrumentation for stabilization by Slim-LOC plate C4, C5, C6, and C7 (22846); with intraoperative x-ray times two.,ANESTHESIA:,  General.,SERVICE: , Neurosurgery.,OPERATION: , The patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner, and then the prevertebral space was encountered and prominent anterior osteophytes were well visualized once longus colli muscle was cauterized along its mesial border, and self-retaining retractors were placed to reveal the anterior osteophytic spaces.  Large osteophytes were excised with a rongeur at C4-5, C5-C6, and C6-C7 revealing a collapsed disc space and a #11 blade was utilized to create an annulotomy at all three interspaces with discectomies being performed with straight disc forceps removing grossly degenerated and very degenerated discs at C4-C5, then at C5-C6, then at C6-C7 sending specimen for permanent section to Pathology in a routine and separate manner.  Residual disc fragments were drilled away as drilling extended into normal cortical and cancellous elements in order to perform a wide decompression all the way posteriorly to the spinal canal itself finally revealing a ligament, which was removed in a similar piecemeal fashion with 1 and 2-mm micro Kerrison rongeurs also utilizing these instruments to remove prominent osteophytes, widely laterally bilaterally at each interspace with one at C4-C5, more right-sided.  The most prominent osteophyte and compression was at C5-C6 followed by C6-C7 and C4-C5 with a complete decompression of the spinal canal allowing the dura to finally bulge into the interspace at all three levels, once the ligaments were proximally removed as well and similarly a sign of a decompressed status.  The nerve roots themselves were inspected with a double ball dissector and found to be equally decompressed.  The wound was irrigated with antibiotic solution and hemostasis was well achieved with pledgets of Gelfoam subsequently irrigated away.  Appropriate size Bengal cages were filled with the patient's own bone elements and countersunk into position, filled along with fusion putty, and once these were quite tightly applied and checked, further stability was added by the placement of a Slim-LOC plate of appropriate size with appropriate size screws, and a post placement x-ray showed well-aligned elements.,The wound was irrigated with antibiotic solution again and inspected, and hemostasis was completely achieved and finally the wound was closed in a routine closure by approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was sterilely dressed, and incorporated a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in a routine fashion.  At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.", Surgery,38
"PROCEDURE:,  Right sacral alar notch and sacroiliac joint/posterior rami injections with fluoroscopy.,ANESTHESIA:,  Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS:  ,None.,DETAILS OF PROCEDURE: , INT was placed.  The patient was in the operating room with intravenous line in place and intravenous sedation was given.  The patient was in the prone position.  The back was prepped with Betadine.  Under fluoroscopy, the right sacral alar notch was identified and after placement of a 22-gauge, 3-1/2 inch spinal needle in to the notch, negative aspiration was performed and 5 cc of 0.5% Marcaine plus 20 mg of Depo-Medrol was injected.  The needle was then placed in to the right sacroiliac joint (distal third) and the same local anesthetic mixture was injected.  This was repeated for the right sacral alar notch and the right sacroiliac joint (distal third).  The needle was withdrawn.  The above was repeated for the posterior primary rami branch at S2 and S3 by stimulating along the superior lateral wall of the foramen; then followed by steroid injection and coagulation as above.,There were no complications.  Needles removed.  Band-aids were applied over the puncture sites.  The patient was discharged to operating room recovery in stable condition.", Pain Management,28
"CHIEF COMPLAINT:,  Joints are hurting all over and checkup.,HISTORY OF PRESENT ILLNESS:,  A 77-year-old white female who is having more problems with joint pain.  It seems to be all over decreasing her mobility, hands and wrists.  No real swelling but maybe just a little more uncomfortable than they have been.  The Daypro generic does not seem to be helping at all.  No fever or chills.  No erythema.,She actually is doing better.  Her diarrhea now has settled down and she is having less urinary incontinence, less pedal edema.  Blood sugars seem to be little better as well.,The patient also has gotten back on her Zoloft because she thinks she may be depressed, sleeping all the time, just not herself and really is disturbed that she cannot be more mobile in things.  She has had no polyuria, polydipsia, or other problems.  No recent blood pressure checks.,PAST MEDICAL HISTORY:,  Little over a year ago, the patient was found to have lumbar discitis and was treated with antibiotics and ended up having debridement and instrumentation with Dr. XYZ and is doing really quite well.  She had a pulmonary embolus with that hospitalization.,PAST SURGICAL HISTORY:,  She has also had a hysterectomy, salpingoophorectomy, appendectomy, tonsillectomy, two carpal tunnel releases.  She also has had a parathyroidectomy but still has had some borderline elevated calcium.  Also, hypertension, hyperlipidemia, as well as diabetes.  She also has osteoporosis.,SOCIAL HISTORY:,  The patient still smokes about a third of a pack a day, also drinks only occasional alcoholic drinks.  The patient is married.  She has three grown sons, all of which are very successful in professional positions.  One son is a gastroenterologist in San Diego, California.,MEDICATIONS:,  Nifedipine-XR 90 mg daily, furosemide 20 mg half tablet b.i.d., lisinopril 20 mg daily, gemfibrozil 600 mg b.i.d., Synthroid 0.1 mg daily, Miacalcin one spray in alternate nostrils daily, Ogen 0.625 mg daily, Daypro 600 mg t.i.d., also Lortab 7.5 two or three a day, also Flexeril occasionally, also other vitamin.,ALLERGIES: , She had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins.,FAMILY HISTORY:,  As far as heart disease there is none in the family.  As far as cancer two cousins had breast cancer.  As far as diabetes father and grandfather had type II diabetes.  Son has type I diabetes and is struggling with that at the moment.,REVIEW OF SYSTEMS:,General:  No fever, chills, or night sweats.  Weight stable.,HEENT:  No sudden blindness, diplopia, loss of vision, i.e., in one eye or other visual changes.  No hearing changes or ear problems.  No swallowing problems or mouth lesions.,Endocrine:  Hypothyroidism but no polyuria or polydipsia.  She watches her blood sugars.  They have been doing quite well.,Respiratory:  No shortness of breath, cough, sputum production, hemoptysis or breathing problems.,Cardiovascular:  No chest pain or chest discomfort.  No paroxysmal nocturnal dyspnea, orthopnea, palpitations, or heart attacks.,GI:  As mentioned, has had diarrhea though thought to be possibly due to Clostridium difficile colitis that now has gotten better.  She has had some irritable bowel syndrome and bowel abnormalities for years.,GU:  No urinary problems, dysuria, polyuria or polydipsia, kidney stones, or recent infections.  No vaginal bleeding or discharge.,Musculoskeletal:  As above.,Hematological:  She has had some anemia in the past.,Neurological:  No blackouts, convulsions, seizures, paralysis, strokes, or headaches.,PHYSICAL EXAMINATION:,Vital Signs:  Weight is 164 pounds.  Blood pressure:  140/64.  Pulse:  72.  Blood pressure repeated by me with the patient sitting taken on the right arm is 148/60, left arm 136/58; these are while sitting on the exam table.,General:  A well-developed pleasant female who is comfortable in no acute distress otherwise but she does move slowly.,HEENT:  Skull is normocephalic.  TMs intact and shiny with good auditory acuity to finger rub.  Pupils equal, round, reactive to light and accommodation with extraocular movements intact.  Fundi benign.  Sclerae and conjunctivae were normal.,Neck:  No thyromegaly or cervical lymphadenopathy.  Carotids are 2+ and equal bilaterally and no bruits present.,Lungs:  Clear to auscultation and percussion with good respiratory movement.  No bronchial breath sounds, egophony, or rales are present.,Heart:  Regular rhythm and rate with no murmurs, gallops, rubs, or enlargement.  PMI normal position.  All pulses are 2+ and equal bilaterally.,Abdomen:  Obese, soft with no hepatosplenomegaly or masses.,Breasts:  No predominant masses, discharge, or asymmetry.,Pelvic Exam:  Normal external genitalia, vagina and cervix.  Pap smear done.  Bimanual exam shows no uterine enlargement and is anteroflexed.  No adnexal masses or tenderness.  Rectal exam is normal with soft brown stool Hemoccult negative.,Extremities:  The patient does appear to have some doughiness of all of the MCP joints of the hands and the wrists as well.  No real erythema.  There is no real swelling of the knees.  No new pedal edema.,Lymph nodes:  No cervical, axillary, or inguinal adenopathy.,Neurological:  Cranial nerves II-XII are grossly intact.  Deep tendon reflexes are 2+ and equal bilaterally.  Cerebellar and motor function intact in all extremities.  Good vibratory and positional sense in all extremities and dermatomes.  Plantar reflexes are downgoing bilaterally.,LABORATORY:  ,CBC shows a hemoglobin of 10.5, hematocrit 35.4, otherwise normal.  Urinalysis is within normal limits.  Chem profile showed a BUN of 54, creatinine 1.4, glucose 116, calcium was 10.8, cholesterol 198, triglycerides 171, HDL 43, LDL 121, TSH is normal, hemoglobin A1C is 5.3.,ASSESSMENT:,1.  Arthralgias that are suspicious for inflammatory arthritis, but certainly seems to be more active and bothersome.  I think we need to look at this more closely.,2.  Diarrhea that seems to have resolved.  Whether this is related to the above is unclear.,3.  Diabetes mellitus type II, really fairly well controlled.", Consult - History and Phy.,5
"PRECATHETERIZATION DIAGNOSIS (ES):, Hypoplastic left heart, status post Norwood procedure and Glenn shunt.,POSTCATHETERIZATION DIAGNOSIS (ES):,1. Hypoplastic left heart.,A. Status post Norwood.,B. Status post Glenn.,2. Left pulmonary artery hypoplasia.,3. Diminished right ventricular systolic function.,4. Trivial neo-aortic stenosis.,5. Trivial coarctation.,6. Flow to right upper lobe more than left upper lobe from collaterals arising from branches of the aortic arch.,PROCEDURE (S):, Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.,I. PROCEDURES:, XXXXXX was brought to the catheterization lab and was anesthetized by anesthesia. He was intubated. His supplemental oxygen was weaned to 24%, on which all of his hemodynamics were obtained. The patient was prepped and draped in the routine sterile fashion, including both groins and the right neck. Xylocaine was administered in the right femoral area. A 6-French sheath was introduced into the right femoral vein percutaneously without complication. A 4-French sheath was introduced into the right femoral artery percutaneously without complication. A 4-French pigtail catheter was introduced and passed to the abdominal aorta.,Dr. Hayes, using the SiteRite device, introduced a 5-French sheath into the right internal jugular vein without complication.,A 5-French wedge catheter was introduced through the sheath in the right internal jugular vein and was passed to the left pulmonary artery and further to the left pulmonary capillary wedge position. This catheter would not pass to the right pulmonary artery. The wedge catheter was removed. A 5-French IMA catheter was then introduced and passed to the right pulmonary artery. After right pulmonary artery pressure was measured, this catheter was removed.,The 5 wedge catheter was advanced through the right femoral sheath and was passed to the following chambers or vessels: Inferior vena cava, right atrium, left atrium, and right ventricle.,The previously introduced 4 pigtail catheter was advanced to the ascending aorta. Simultaneous right ventricular and ascending aortic pressures were measured. A pullback from ascending aorta to descending aorta was then performed. Simultaneous measurements of right ventricular and descending aortic pressures were measured.,The wedge catheter was removed. A 5-French Berman catheter was advanced down the Glenn shunt to the right pulmonary artery, where a pullback from right pulmonary artery to Glenn shunt was performed. An injection was then performed using Omnipaque 16 mL at 8 mL per second with the Berman catheter positioned in the Glenn shunt. The 5-French Berman was removed.,A 6-French Berman was introduced through the right femoral vein sheath and was advanced to the right ventricle. A right ventriculogram was performed using Omnipaque 18 mL at 12 mL per second. The Berman catheter was pulled back to the inferior vena cava, where an inferior vena cavagram was performed using Omnipaque 10 mL at 8 mL per second.,The 4-French pigtail catheter was advanced to the ascending aorta and an ascending aortogram was performed using Omnipaque 16 mL at 12 mL per second.,Following the ascending angiograms, two kidneys and a bladder were noted. The catheters and sheaths were removed, and hemostasis was obtained by direct pressure. The estimated blood loss was less than 30 mL, and none was replaced. Heparin was administered following placement of all of the sheaths. Pulse oximetry saturation, pulse in the right foot, and EKG were monitored continuously.,II. PRESSURES:,A. Left pulmonary artery, mean of 11; left capillary wedge, mean of 9; main pulmonary artery, mean of 12; right pulmonary artery, mean of 10; descending aorta, 75/45, mean of 57; right atrium, A6 to 9, V6 to 8, mean 7; left atrium, mean 8; inferior vena cava, mean 7.,B. Ascending aorta, 65/35, with a simultaneous right ventricular pressure of 70/10; descending aorta, 60/35, with a right ventricular pressure of 72/10.,C. Pullbacks, left pulmonary artery to main pulmonary artery, mean of 11 to mean of 12; main pulmonary artery to Glenn, mean of 12 to mean of 13; right pulmonary artery to Glenn, mean of 12 to mean of 13; ascending aorta 68/35 to descending aorta 62/35.,INTERPRETATION:, Right and left pulmonary artery pressures are appropriate for this situation. There is a gradient of, at most, 2 mmHg on pullback from both the right and left pulmonary arteries to the Glenn shunt. The left atrial mean pressure is normal. Right ventricular end-diastolic pressure is, at most, slightly elevated. There is a trivial gradient between the right ventricle and ascending aorta consistent with trivial neo-aortic valve stenosis. There is a roughly 10-mm gradient between the right ventricle and descending aorta, consistent with additional coarctation of the aorta. On pullback from ascending to descending aorta, there is a 6-mmHg gradient between the two. Systemic blood pressure is normal.,III. OXIMETRY:, Superior vena cava 65, right pulmonary artery 67, left pulmonary artery 65, left atrium 96, right atrium 87, inferior vena cava 69, aorta 86, right ventricle 83.,INTERPRETATION:, Systemic arteriovenous oxygenation difference is normal, consistent with a normal cardiac output. Left atrial saturation is fairly normal, consistent with normal oxygenation in the lungs. The saturation falls passing from the left atrium to the right atrium and further to the right ventricle, consistent with mixing of pulmonary venous return and inferior vena cava return, as would be expected in this patient.,IV. SPECIAL PROCEDURE (S):, None done.,V. CALCULATIONS:,Please see the calculation sheet. Calculations were based upon an assumed oxygen consumption. The _____ saturation used was 67%, with a pulmonary artery saturation of 65%, a left atrial saturation of 96%, and an aortic saturation of 86%. Using the above information, the pulmonary to systemic flow ratio was 0.6. Systemic blood flow was 5.1 liters per minute per meter squared. Pulmonary blood flow was 3.2 liters per minute per meter squared. Systemic resistance was 9.8 Wood's units times meter squared, which is mildly diminished. Pulmonary resistance was 2.5 Wood's units times meter squared, which is in the normal range.,VI. ANGIOGRAPHY:, The injection to the Glenn shunt demonstrates a wide-open Glenn connection. The right pulmonary artery is widely patent, without stenosis. The proximal portion of the left pulmonary artery is significantly narrowed, but does open up near its branch point. The right pulmonary artery measures 6.5, the left pulmonary artery measures 3.0 mm. The aorta at the diaphragm on a later injection was 5.5 mm. There is a small collateral off the innominate vein passing to the left upper lobe. Flow to both upper lobes is diminished versus lower lung fields. There is normal return of the pulmonary veins from the right, with simultaneous filling of the left atrium and right atrium. There is normal return of the left lower pulmonary vein and left upper pulmonary vein. There is some reflux of dye into the inferior vena cava from the right atrium.,The right ventriculogram demonstrates a heavily pedunculated right ventricle with somewhat depressed right ventricular systolic function. The calculated ejection fraction from the LAO projection is only mildly diminished at 59%. There is no significant tricuspid regurgitation. The neo-aortic valve appears to open well with no stenosis. The ascending aorta is dilated. There is mild narrowing of the aorta at the isthmal area. On some projections, there appears to be a partial duplication of the aortic arch, probably secondary to this patient's style of Norwood reconstruction. There is some filling of the right upper and left upper lobes from collateral blood flow, with the left being more opacified than the right.,The inferior vena cavagram demonstrates normal return of the inferior vena cava to the right atrium.,The ascending aortogram demonstrates trivial aortic insufficiency, which is probably catheter-induced. The coronary arteries are poorly seen. Again, a portion of the aorta appears to be partially duplicated. There is faint opacification of the left upper lung from collateral blood flow. The above-mentioned narrowing of the aortic arch is again noted.", Cardiovascular / Pulmonary,3
"HISTORY OF PRESENT ILLNESS:,  Patient is a 50-year-old white male complaining of continued lower back pain.  Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago.  He states he helped a friend unload a motorcycle from a vehicle two-and-a-half days ago, after which he ""felt it"" in his lower back.  The following day (two days ago), he states he rode to Massachusetts and Maine to pick up clients.  He feels that this aggravated his chronic back pain as well.  He also claims to have a screw in his right hip from a previous surgery to repair a pelvic fracture.  He is being prescribed Ultram, Celebrex, gabapentin, and amitriptyline by his PCP for his chronic back pain.  He states that his PCP has informed him that he does not prescribe opiate medications for chronic back pain.,The patient did self-refer to another physician, who suggested that he follow up at a pain clinic for his chronic back pain to discuss other alternatives, particularly the medications that the patient feels that he needs.  Patient states he did not do this because he was feeling well at that time.,The patient did present to our emergency room last night, at which time he saw Dr. X.  He was given a prescription for 12 Vicodin as well as some to take home last night.  The patient has not picked up his prescription as of yet and informed the triage nurse that he was concerned that he would not have enough to last through the weekend.  Patient states he also has methadone and Darvocet at home from previous prescription and is wondering if he should restart these medicines.  He is on several medications, the list of which is attached to the chart.,MEDICATIONS: , In addition to the aforementioned medications, he is on Cymbalta, pantoprazole, and a multivitamin.,ALLERGIES:,  HE IS ALLERGIC TO RELAFEN (ITCHING).,SOCIAL HISTORY: , The patient is married and lives with his wife.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse is elevated at 105.  Temp and other vitals signs are all within normal limits.,GENERAL:  Patient is a middle-aged white male who is sitting on the stretcher in no acute distress.,BACK:  Exam of the back shows some generalized tenderness on palpation of the musculature surrounding the lumbar spine, more so on the right than on the left.  There is a well-healed upper lumbar incision from his previous L1-L2 fusion.  There is no erythema, ecchymosis, or soft-tissue swelling.  Mobility is generally very good without obvious signs of discomfort.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,MUSCULOSKELETAL:  With the patient supine, there is some discomfort in the lower back with bent-knee flexion of both hips as well as with straight leg abduction of the left leg.  There is some mild discomfort on internal and external rotation of the hips as well.  DTRs are 1+ at the knees and trace at the ankles.,I explained to the patient that he is suffering from a chronic condition and as his PCP has made it clear that he is unwilling to prescribe opiate medication, which the patient feels that he needs, and he is obligated to follow up at the pain clinic as suggested by the other physician even if he is having a ""good day.""  I explained to him that if he did not investigate other alternatives to what his PCP is willing to prescribe, then on a ""bad day,"" he will have nowhere else to turn.  I explained to him that some emergency physicians do chose to use opiates for a short term as Dr. X did last night.  It is unclear if the patient is looking for a different opiate medication, but I do not think it is wise to give him more, particularly as he has not even filled the prescription that was given to him last night.  I did suggest that he not restart his methadone and Darvocet at this time as he is already on five different medications for his back (Celebrex, tramadol, amitriptyline, gabapentin, and the Vicodin that he was given last night).  I did suggest that we could try a different anti-inflammatory if he felt that the Celebrex is not helping.  The patient is agreeable to this.,ASSESSMENT,1.  Lumbar muscle strain.,2.  Chronic back pain.,PLAN: , At this point in time, I felt that it was safe for the patient to transition to heat to his back which he may use as often as possible.  Rx for Voltaren 75 mg tabs, dispensed 20, sig. one p.o. q.12h. for pain instead of Celebrex.  He may continue with his other medications as directed but not the methadone or Darvocet.  I did urge him to reschedule his pain clinic appointment as he was urged to do originally.  If unimproved this week, he should follow up with Dr. Y.", Orthopedic,27
"CHIEF COMPLAINT: , ""Bloody bump on penis."",HISTORY OF PRESENT ILLNESS: , This is a 29-year-old African-American male who presents to the Emergency Department today with complaint of a bleeding bump on his penis.  The patient states that he has had a large bump on the end of his penis for approximately a year and a half.  He states that it has never bled before.  It has never caused him any pain or has never been itchy.  The patient states that he is sexually active, but has been monogamous with the same person for the past 13 years.  He states that he believes that his sexual partner is monogamous as well and reciprocates in this practice.  The patient does state that last night he was ""trying to get some,"" meaning that he was engaging in sexual intercourse, at which time this bump bent backwards and ripped a portion of the skin on the tip of his penis.  The patient said that there is a large amount of blood from this injury.  This happened last night, but he was embarrassed to come to the Emergency Department yesterday when it was bleeding.  The patient has been able to get the bleeding to stop, but the large bump is still located on the end of his penis, and he is concerned that it will rip off, and does want it removed.  The patient denies any drainage or discharge from his penis.  He denies fevers or chills recently.  He also denies nausea or vomiting.  The patient has not had any discharge from his penis.  He has not had any other skin lesions on his penis that are new to him.  He states that he has had numerous bumps along the head of his penis and on the shaft of his penis for many years.  The patient has never had these checked out.  He denies fevers, chills, or night sweats.  He denies unintentional weight gain or loss.  He denies any other bumps, rashes, or lesions throughout the skin on his body.,PAST MEDICAL HISTORY:  ,No significant medical problems.,PAST SURGICAL HISTORY: , Surgery for excision of a bullet after being shot in the back.,SOCIAL HABITS: , The patient denies illicit drug usage.  He occasionally smokes tobacco and drinks alcohol.,MEDICATIONS: , None.,ALLERGIES: , No known medical allergies.,PHYSICAL EXAMINATION:  ,GENERAL:  This is an African-American male who appears his stated age of 29 years.  He is well nourished, well developed, in no acute distress.  The patient is pleasant.  He is sitting on a Emergency Department gurney.,VITAL SIGNS:  Temperature 98.4 degrees Fahrenheit, blood pressure of 139/78, pulse of 83, respiratory rate of 18, and pulse oximetry of 98% on room air.,HEART:  Regular rate and rhythm.  Clear S1, S2.  No murmur, rub, or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales, or rhonchi.,ABDOMEN:  Soft, nontender, nondistended, and positive bowel sounds throughout.,GENITOURINARY:  The patient's external genitalia is markedly abnormal.  There is a large pedunculated mass dangling from the glans of the penis at approximately the urethral meatus.  This pedunculated mass is approximately 1.5 x 2 cm in size and pedunculated by a stalk that is approximately 2 mm in diameter.  The patient appears to have condylomatous changes along the glans of the penis and on the shaft of the penis as well.  There are no open lesions at this point.  There is a small tear of the skin where the mass attaches to the glans near the urethral meatus.  Bleeding is currently stanch, and there is no sign of secondary infection at this time.  Bilateral testicles are descended and normal without pain or mass bilaterally.  There is no inguinal adenopathy.,EXTREMITIES:  No edema.,SKIN:  Warm, dry, and intact.  No rash or lesion.,DIAGNOSTIC STUDIES:  ,Non-emergency department courses.  It is thought that this patient should proceed directly with a referral to Urology for excision and biopsy of this mass.,ASSESSMENT AND PLAN: , Penile mass.  The patient does have a large pedunculated penile mass.  He will be referred to the urologist who is on-call today.  The patient will need this mass excised and biopsied.  The patient verbalized understanding the plan of followup and is discharged in satisfactory condition from the ER.,", Urology,39
"CC:, Transient visual field loss.,HX: ,This 58 y/o RHF had a 2 yr h/o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations. She was evaluated by a local physician several days prior to this presentation (1/7/91), for clumsiness of her right hand and falling. HCT and MRI brain revealed bilateral posterior clinoid masses.,MEDS:, Colace, Quinidine, Synthroid, Lasix, Lanoxin, KCL, Elavil, Tenormin.,PMH: ,1) Obesity.  2) VBG, 1990.  3) A-Fib. 4) HTN.  5) Hypothyroidism.  6) Hypercholesterolemia. 7) Briquet's syndrome: h/o of hysterical paralysis. 8) CLL, dx 1989; in 1992 presented with left neck lymphadenopathy and received 5 cycles of chlorambucil/prednisone chemotherapy; 10/95 parotid gland biopsy was consistent with CLL and she received 5 more cycles of chlorambucil/prednisone; 1/10/96, she received 3000cGy to right parotid mass. 9) SNHL,FHX:, Father died, MI age 61.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM:, Vitals were unremarkable.,The neurologic exam was unremarkable except for obesity and mild decreased PP about the right upper and lower face, diffusely about the left upper and lower face, per neurosurgery notes. The neuro-ophthalmologic exam was unremarkable, per Neuro-ophthalmology.,COURSE:, She underwent Cerebral Angiography on 1/8/91. This revealed a 15x17x20mm LICA paraclinoid/ophthalmic artery aneurysm and a 5x7mm RICA paraclinoid/ophthalmic artery aneurysm. On 1/16/91 she underwent a left frontotemporal craniotomy and exploration of the left aneurysm. The aneurysm neck went into the cavernous sinus and was unclippable so it was wrapped. She has complained of headaches since.", Radiology,33
"EXAM:,  Lexiscan Nuclear Myocardial Perfusion Scan.,INDICATION:,  Chest pain.,TYPE OF TEST:  ,Lexiscan, unable to walk on a treadmill.,INTERPRETATION: , Resting heart rate of 96, blood pressure of 141/76.  EKG, normal sinus rhythm, nonspecific ST-T changes, left bundle branch block.  Post Lexiscan 0.4 mg injected intravenously by standard protocol.  Peak heart rate was 105, blood pressure of 135/72.  EKG remains the same.  No symptoms are noted.,SUMMARY:,1.  Nondiagnostic Lexiscan.,2.  Nuclear interpretation as below.,NUCLEAR MYOCARDIAL PERFUSION SCAN WITH STANDARD PROTOCOL:,  Resting and stress images were obtained with 10.4, 32.5 mCi of tetrofosmin injected intravenously by standard protocol.  Myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake.  There is no evidence of reversible or fixed defect.  Gated SPECT revealed mild global hypokinesis, more pronounced in the septal wall possibly secondary to prior surgery.  Ejection fraction calculated at 41%.  End-diastolic volume of 115, end-systolic volume of 68.,IMPRESSION:,1.  Normal nuclear myocardial perfusion scan.,2.  Ejection fraction 41% by gated SPECT.", Radiology,33
"PREOPERATIVE DIAGNOSIS: , Inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct inguinal hernia.,PROCEDURE PERFORMED:,  Rutkow direct inguinal herniorrhaphy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  General endotracheal anesthesia was induced without incident.  Preoperative antibiotics were given for prophylaxis against surgical infection.  The patient was prepped and draped in the usual sterile fashion.,A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.  The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated.  The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors.  Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was placed around the cord structures at the level of the pubic tubercle.  This Penrose drain was then used to retract the cord structures as needed.  Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and no sac was found.  The hernia was found coming from the floor of the inguinal canal medial to the inferior epigastric vessels.  This was dissected back to the hernia opening.  The hernia was inverted back into the abdominal cavity and a large PerFix plug inserted into the ring.  The plug was secured to the ring by interrupted 2-0 Prolene sutures.,The PerFix onlay patch was then placed on the floor of the inguinal canal and secured in place using interrupted 2-0 Prolene sutures.  By reinforcing the floor with the onlay patch, a new internal ring was thus formed.,The Penrose drain was removed.  The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring.  The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.", Urology,39
"REFERRAL INDICATION,1.  Tachybrady syndrome.,2.  Chronic atrial fibrillation.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of a single-chamber pacemaker.,2.  Fluoroscopic guidance for implantation of single-chamber pacemaker.,FLUOROSCOPY TIME:  ,1.2 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Ancef 1 g.,2.  Benadryl 50 mg.,3.  Versed 3 mg.,4.  Fentanyl 150 mcg.,CLINICAL HISTORY: , The patient is a pleasant 73-year-old female with chronic atrial fibrillation.  She has been found to have tachybrady syndrome, has been referred for pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives of implantation of a single-chamber pacemaker were discussed with the patient.  The patient agreed both verbally and via written consent.  Risks that were discussed included but were not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, need for urgent cardiovascular surgery, and death were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in a fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  Percutaneous access of the left axillary vein was then performed.  A wire was then advanced in the left axillary vein using fluoroscopy.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision and a pocket was fashioned in the medial direction.  Using the previously placed guidewire, a 7-French sidearm sheath was advanced over the wire into the vein.  The dilator and wire were removed.  An active pacing lead was then advanced down in the right atrium.  The peel-away sheath was removed.  Lead was passed across the tricuspid valve and positioned in an apical septal location.  This was an active fixed lead and the screw was deployed.  Adequate pacing and sensing function were established.  The suture sleeve was then advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was washed with antibiotic-impregnated saline.  A pulse generator was obtained and connected securely to the lead.  The lead was then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket.  Pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  No acute complications were noted.,DEVICE DATA,1.  Pulse generator, manufacturer St. Jude model 12345, serial #123456.,2.  Right ventricular lead, manufacturer St. Jude model 12345, serial #ABCD123456.,MEASURED INTRAOPERATIVE DATA:,  Right ventricular lead impedance 630 ohms.  R wave measures 17.5 mV.  Pacing threshold of 0.8 V at 0.5 msec.,DEVICE SETTINGS: , VVI 70 to 120.,CONCLUSIONS,1.  Successful implantation of the single-chamber pacemaker with adequate pacing and sensing function.,2.  No acute complications.,PLAN,1.  The patient will be admitted for overnight observation and dismissed at the discretion of primary service.,2.  Chest x-ray to rule out pneumothorax and verify lead position.,3.  Completion of course of antibiotics.,4.  Device interrogation in the morning.,5.  Home dismissal instructions provided in a written format.,6.  Wound check in 7 to 10 days.,7.  Enrollment in Device Clinic.", Surgery,38
"CLINICAL HISTORY: , A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology.  An abnormal chest radiograph shows right middle lobe infiltrate and collapse.  Patient needs staging CT of chest with contrast.  Right sided supraclavicular and lower anterior cervical adenopathy noted on physical exam.,TECHNIQUE: , Multiple transaxial images utilized in 10 mm sections were obtained through the chest.  Intravenous contrast was administered.,FINDINGS: , There is a large 3 x 4 cm lymph node seen in the right supraclavicular region.  There is a large right paratracheal lymph node best appreciated on image #16 which measures 3 x 2 cm.  A subcarinal lymph node is enlarged also.  It measures 6 x 2 cm.  Multiple pulmonary nodules are seen along the posterior border of the visceral as well as parietal pleura.  There is a pleural mass seen within the anterior sulcus of the right hemithorax as well as the right crus of the diaphragm.  There is also a soft tissue density best appreciated on image #36 adjacent to the inferior aspect of the right lobe of the liver which most likely also represents metastatic deposit.  The liver parenchyma is normal without evidence of any dominant masses.  The right kidney demonstrates a solitary cyst in the mid pole of the right kidney.,IMPRESSION:,1.  Greater than twenty pulmonary nodules demonstrated on the right side to include pulmonary nodules within the parietal as well as various visceral pleura with adjacent consolidation most likely representing pulmonary neoplasm.,2.  Extensive mediastinal adenopathy as described above.,3.  No lesion seen within the left lung at this time.,4.  Supraclavicular adenopathy.", Cardiovascular / Pulmonary,3
"On review of systems, the patient admits to hypertension and occasional heartburn.  She undergoes mammograms every six months, which have been negative for malignancy.  She denies fevers, chills, weight loss, fatigue, diabetes mellitus, thyroid disease, upper extremity trauma, night sweats, DVT, pulmonary embolism, anorexia, bone pain, headaches, seizures, angina, peripheral edema, claudication, orthopnea, PND, coronary artery disease, rheumatoid arthritis, rashes, upper extremity edema, cat scratches, cough, hemoptysis, shortness of breath, dyspnea at two flights of stairs, hoarseness, GI bleeding, change in bowel habits, dysphagia, ulcers, hematuria, or history of TB exposure.  She has had negative PPD.,PAST MEDICAL HISTORY:,  Hypertension.,PAST SURGICAL HISTORY:,  Right breast biopsy - benign.,SOCIAL HISTORY: , She was born and raised in Baltimore.  She has not performed farming or kept birds or cats.,Tobacco: None.,Ethanol: ,Drug Use: ,Occupation:  She is a registered nurse at Spring Grove Hospital.,Exposure: Negative to asbestos.,FAMILY HISTORY:,  Mother with breast cancer.,ALLERGIES: , Percocet and morphine causing temporary hypotension.,MEDICATIONS: , Caduet 10 mg p.o. q.d., Coreg CR 40 mg p.o. q.d., and Micardis HCT 80 mg/12.5 mg p.o. q.d.,PHYSICAL EXAMINATION: ,BP:  133/72", Consult - History and Phy.,5
"SUBJECTIVE:,  The patient's assistant brings in her food diary sheets.  The patient says she stays active by walking at the mall.,OBJECTIVE:,  Weight today is 201 pounds, which is down 3 pounds in the past month.  She has lost a total of 24 pounds.  I praised this and encouraged her to continue.  I went over her food diary.  I praised her three-meal pattern and all of her positive food choices, especially the use of sugar-free Kool-Aid, sugar-free Jell-O, sugar-free lemonade, diet pop, as well as the variety of foods she is using in her three-meal pattern.  I encouraged her to continue all of this.,ASSESSMENT:,  The patient 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.  She needs to continue all this.,PLAN:,  Followup is set for 06/13/05 to check the patient's weight, her food diary, and answer any questions.", SOAP / Chart / Progress Notes,35
"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 38 weeks.,2.  Malpresentation.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 38 weeks.,2.  Malpresentation.,3.  Delivery of a viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cervical cesarean section.,ANESTHESIA: , Spinal with Astramorph.,ESTIMATED BLOOD LOSS: , 300 cc.,URINE OUTPUT:,  80 cc of clear urine.,FLUIDS: , 2000 cc of crystalloids.,COMPLICATIONS: , None.,FINDINGS: , A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g.  No nuchal cord.  No meconium.  Normal uterus, fallopian tubes, and ovaries.,INDICATIONS: , This patient is a 21-year-old gravida 3, para 1-0-1-1 Caucasian female who presented to Labor and Delivery in labor.  Her cervix did make some cervical chains.  She did progress to 75% and -2, however, there was a raised lobular area palpated on the fetal head.  However, on exam unable to delineate the facial structures, but definite fetal malpresentation.  The fetal heart tones did start and it continued to have variable decelerations with contractions overall are reassuring.  The contraction pattern was inadequate.  It was discussed with the patient's family that in light of the physical exam and with the fetal malpresentation that a cesarean section will be recommended.  All the questions were answered.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed in the dorsal lithotomy position with a leftward tilt.  Prior to this, the spinal anesthesia was administered.  The patient was then prepped and draped.  A Pfannenstiel skin incision was made with the first scalpel and carried through to the underlying layer of fascia with the second scalpel.  The fascia was then incised in the midline and extended laterally using Mayo scissors.  The superior aspect of the rectus fascia was then grasped with Ochsners, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors.  The superior portion and inferior portion of the rectus fascia was identified, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors.  The rectus muscle was then separated in the midline.  The peritoneum was then identified, tented up with hemostats and entered sharply with Metzenbaum scissors.  The peritoneum was then gently stretched.  The vesicouterine peritoneum was then identified, tented up with an Allis and the bladder flap was created bluntly as well as using Metzenbaum scissors.  The uterus was entered with the second scalpel and large transverse incision.  This was then extended in upward and lateral fashion bluntly.  The infant was then delivered atraumatically.  The nose and mouth were suctioned.  The cord was then clamped and cut.  The infant was handed off to the awaiting pediatrician.  The placenta was then manually extracted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was then repaired using #0 chromic in a running fashion marking a U stitch.  A second layer of the same suture was used in an imbricating fashion to obtain excellent hemostasis.  The uterus was then returned to the anatomical position.  The abdomen and the gutters were cleared of all clots.  Again, the incision was found to be hemostatic.  The rectus muscle was then reapproximated with #2-0 Vicryl in a single interrupted stitch.  The rectus fascia was then repaired with #0 Vicryl in a running fashion locking the first stitch and first last stitch in a lateral to medial fashion.  This was palpated and the patient was found to be without defect and intact.  The skin was then closed with staples.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She will be followed up as an inpatient with Dr. X.", Obstetrics / Gynecology,24
"PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1.  Lumbar discogram L2-3.,2.  Lumbar discogram L3-4.,3.  Lumbar discogram L4-5.,4.  Lumbar discogram L5-S1.,ANESTHESIA:  ,IV sedation.,PROCEDURE IN DETAIL:  ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table.  The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained.  We then proceeded to prepare the low back with a Betadine solution and draped sterile.  Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space.  A metallic marker was then placed laterally and a needle entrance point was determined.  A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections.  A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus.  We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.", Pain Management,28
"PREOPERATIVE DIAGNOSIS: , Recurrent right inguinal hernia, as well as phimosis.,POSTOPERATIVE DIAGNOSIS:,  Recurrent right inguinal hernia, as well as phimosis.,PROCEDURE PERFORMED: , Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery room in stable condition.,SPECIMEN: , Foreskin.,BRIEF HISTORY: , This patient is a 66-year-old African-American male who presented to Dr. Y's office with recurrent right inguinal hernia for the second time requesting hernia repair.  The procedure was discussed with the patient and the patient opted for laparoscopic repair due to multiple attempts at the open inguinal repair on the right.  The patient also is requesting circumcision with phimosis at the same operating time setting.,INTRAOPERATIVE FINDINGS: , The patient was found to have a right inguinal hernia with omentum and bowel within the hernia, which was easily reduced.  The patient was also found to have a phimosis, which was easily removed.,PROCEDURE:,  After informed consent, the risks and benefits of the procedure were explained to the patient.  The patient was brought to operating suite, after general endotracheal intubation, prepped and draped in the normal sterile fashion.  An infraumbilical incision was made with a #15 Bard-Parker scalpel.  The umbilical skin was elevated with a towel clip and the Veress needle was inserted without difficulty.  Saline drop test proved entrance into the abdominal cavity and then the abdomen was insufflated to sufficient pressure of 15 mmHg.  Next, the Veress was removed and #10 bladed trocar was inserted without difficulty.  The 30-degree camera laparoscope was then inserted and the abdomen was explored.  There was evidence of a large right inguinal hernia, which had omentum as well as bowel within it, easily reducible.  Attention was next made to placing a #12 port in the right upper quadrant, four fingerbreadths from the umbilicus.  Again, a skin was made with a #15 blade scalpel and the #12 port was inserted under direct visualization.  A #5 port was inserted in the left upper quadrant in similar fashion without difficulty under direct visualization.  Next, a grasper with blunt dissector was used to reduce the hernia and withdraw the sac and using an Endoshears, the peritoneum was scored towards the midline and towards the medial umbilical ligament and lateral.  The peritoneum was then spread using the blunt dissector, opening up and identifying the iliopubic tract, which was identified without difficulty.  Dissection was carried out, freeing up the hernia sac from the peritoneum.  This was done without difficulty reducing the hernia in its entirety.  Attention was next made to placing a piece of Prolene mesh, it was placed through the #12 port and placed into the desired position, stapled into place in its medial aspect via the 4 mm staples along the iliopubic tract.  The 4.8 mm staples were then used to staple the superior edge of the mesh just below the peritoneum and then the patient was re-peritonealized, re-approximating edge of the perineum with the 4.8 mm staples.  This was done without difficulty.  All three ports were removed under direct visualization.  No evidence of bleeding and the #10 and #12 mm ports were closed with #0-Vicryl and UR6 needle.  Skin was closed with running subcuticular #4-0 undyed Vicryl.  Steri-Strips and sterile dressings were applied.  Attention was next made to carrying out the circumcision.  The foreskin was retracted back over the penis head.  The desired amount of removing foreskin was marked out with a skin marker.  The foreskin was then put on tension using a clamp to protect the penis head.  A #15 blade scalpel was used to remove the foreskin and sending off as specimen.  This was done without difficulty.  Next, the remaining edges were retracted, hemostasis was obtained with Bovie electrocautery and the skin edges were re-approximated with #2-0 plain gut in simple interrupted fashion and circumferentially.  This was done without difficulty maintaining hemostasis.,A petroleum jelly was applied with a Coban dressing.  The patient tolerated this procedure well and was well and was transferred to recovery after extubation in stable condition.", Surgery,38
"PREOPERATIVE DIAGNOSES:,1.  Need for intravenous access.,2.  Status post fall.,3.  Status post incision and drainage of left lower extremity.,POSTOPERATIVE DIAGNOSES:,1.  Need for intravenous access.,2.  Status post fall.,3.  Status post incision and drainage of left lower extremity.,PROCEDURE PERFORMED: , Insertion of right subclavian central venous catheter.,SECOND ANESTHESIA: , Approximately 10 cc of 1% lidocaine.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE:  ,The patient is a 74-year-old white female who presents to ABCD General Hospital after falling down flight of eleven stairs and sustained numerous injuries.  The patient went to OR today for an I&D of left lower extremity degloving injury.  Orthopedics was planning on taking the patient back for serial debridements and need for reliable IV access is requested.,PROCEDURE: , Informed consent was obtained by the patient and her daughter.  All risks and benefits of the procedure were explained and all questions were answered.  The patient was prepped and draped in the normal sterile fashion.  After landmarks were identified, approximately 5 cc of 1% lidocaine were injected into the skin and subcuticular tissues and the right neck posterior head of the sternocleidomastoid.  Locator needle was used to correctly cannulate the right internal jugular vein.  Multiple attempts were made and the right internal jugular vein was unable to be cannulized.,Therefore, we prepared for a right subclavian approach.  The angle of the clavicle was found and a #22 gauge needle was used to anesthetize approximately 5 cc of 1% lidocaine in skin and subcuticular tissues along with the periosteum of the clavicle.  A Cook catheter needle was then placed and ________ the clavicle in the orientation aimed toward the sternal notch.  The right subclavian vein was then accessed.  A guidewire was placed with a Cook needle and then the needle was subsequently removed and a #11 blade scalpel was used to nick the skin.  A dilator sheath was placed over the guidewire and subsequently removed.  The triple lumen catheter was then placed over the guidewire and advanced to 14 cm.  All ports aspirated and flushed.  Good blood return was noted and all ports were flushed well.  The triple lumen catheter was then secured at 14 cm using #0 silk suture.  A sterile dressing was then applied.  A stat portable chest x-ray was ordered to check line placement.  The patient tolerated the procedure well and there were no complications.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Lumbar stenosis.,POSTOPERATIVE DIAGNOSES:,  Lumbar stenosis and cerebrospinal fluid fistula.,TITLE OF THE OPERATION,1.  Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques.,2.  Repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.,INDICATIONS:,  The patient is an 82-year-old woman who has about a four-month history now of urinary incontinence and numbness in her legs and hands, and difficulty ambulating.  She was evaluated with an MRI scan, which showed a very high-grade stenosis in her lumbar spine, and subsequent evaluation included a myelogram, which demonstrated cervical stenosis at C4-C5, C5-C6, and C6-C7 as well as a complete block of the contrast at L4-L5 and no contrast at L5-S1 either and stenosis at L3-L4 and all the way up, but worse at L3-L4, L4-L5, and L5-S1.  Yesterday, she underwent an anterior cervical discectomy and fusions C4-C5, C5-C6, C6-C7 and had some improvement of her symptoms and increased strength, even in the recovery room.  She was kept in the ICU because of her age and the need to bring her back to the operating room today for decompressive lumbar laminectomy.  The rationale for putting the surgery is close together that she is normally on Coumadin for atrial fibrillation, though she has been cardioverted.  She and her son understand the nature, indications, and risks of the surgery, and agreed to go ahead.,PROCEDURE: , The patient was brought from the Neuro ICU to the operating room, where general endotracheal anesthesia was obtained.  She was rolled in a prone position on the Wilson frame.  The back was prepared in the usual manner with Betadine soak, followed by Betadine paint.  Markings were applied.  Sterile drapes were applied.  Using the usual anatomical landmarks, linear midline incision was made presumed over L4-L5 and L5-S1.  Sharp dissection was carried down into subcutaneous tissue, then Bovie electrocautery was used to isolate the spinous processes.  A Kocher clamp was placed in the anterior spinous ligament and this turned out to be L5-S1.  The incision was extended rostrally and deep Gelpi's were inserted to expose the spinous processes and lamina of L3, L4, L5, and S1.  Using the Leksell rongeur, the spinous processes of L4 and L5 were removed completely, and the caudal part of L3.  A high-speed drill was then used to thin the caudal lamina of L3, all of the lamina of L4 and of L5.  Then using various Kerrison punches, I proceeded to perform a laminectomy.  Removing the L5 lamina, there was a dural band attached to the ligamentum flavum and this caused about a 3-mm tear in the dura.  There was CSF leak.  The lamina removal was continued, ligamentum flavum was removed to expose all the dura.  Then using 4-0 Nurolon suture, a running-locking suture was used to close the approximate 3-mm long dural fistula.  There was no CSF leak with Valsalva.,I then continued the laminectomy removing all of the lamina of L5 and of L4, removing the ligamentum flavum between L3-L4, L4-L5 and L5-S1.  Foraminotomies were accomplished bilaterally.  The caudal aspect of the lamina of L3 also was removed.  The dura came up quite nicely.  I explored out along the L4, L5, and S1 nerve roots after completing the foraminotomies, the roots were quite free.  Further more, the thecal sac came up quite nicely.  In order to ensure no CSF leak, we would follow the patient out of the operating room.  The dural closure was covered with a small piece of fat.  This was all then covered with DuraSeal glue.  Gelfoam was placed on top of this, then the muscle was closed with interrupted 0 Ethibond.  The lumbodorsal fascia was closed with multiple sutures of interrupted 0 Ethibond in a watertight fashion.  Scarpa's fascia was closed with a running 0 Vicryl, and finally the skin was closed with a running-locking 3-0 nylon.  The wound was blocked with 0.5% plain Marcaine.,ESTIMATED BLOOD LOSS:  Estimated blood loss for the case was about 100 mL.,SPONGE AND NEEDLE COUNTS:  Correct.,FINDINGS:  A very tight high-grade stenosis at L3-L4, L4-L5, and L5-S1.  There were adhesions between the dura and the ligamentum flavum owing to the severity and length of the stenosis.,The patient tolerated the procedure well with stable vitals throughout.", Orthopedic,27
"PREOPERATIVE DIAGNOSES:,  Tearing, eyelash encrustation with probable tear duct obstruction bilateral.,POSTOPERATIVE DIAGNOSES:  ,1.  Distal nasolacrimal duct stenosis with obstruction, left eye.,2.  Distal nasolacrimal duct stenosis with obstruction, right eye.,OPERATIVE PROCEDURE: , Bilateral nasolacrimal probing.,ANESTHESIA: , Monitored anesthesia care along with mask sedation.,INDICATIONS FOR SURGERY: , This young infant is a 19-month-old who has had persistent tearing and mild eyelash encrustation of each eye for many months.  Conservative measures at home have failed to completely resolve the symptoms.  He has been placed on previous antibiotics treatment for presumed conjunctivitis.  Please refer to clinic note for more details.  Conservative measures at home have failed to resolve the symptoms.  A nasolacrimal probing was offered as an elective procedure.  Procedure as well as inherent risks, expected outcomes, benefits, and alternatives (including continued observation) were discussed with his mother prior to scheduling surgery.  Again, a description of procedure as well as diagram instruction was provided to mother and father in the morning of the procedure.  The risks as explained included, but were not limited to temporary bleeding, persistent symptoms, recurrence need for further procedure, possible need for future stent placement or repeat probing, and anesthesia risk were all discussed.  Also a rare possibility of errant passage of the nasolacrimal probe was discussed.  Preoperative evaluation and explanation include drying of the nasolacrimal system with an explanation expected outcome/result from surgery.  No guarantees were offered.  Informed consent was signed and placed on the chart.,DESCRIPTION OF PROCEDURE:  ,The patient was identified and the procedure was verified.  Procedure as well as inherent risks were again discussed with parents prior to the procedure.  After anesthesia was induced in the operating room, tetracaine drops were applied to each eye and the pressure of the eyes were checked with Tono-Pen.  The pressure on the right was 17 mmHg and on the left was 16 mmHg.,A punctal dilator was then used to dilate the left superior puncta.  A size 00 Bowman probe was used to navigate the superior puncta and canaliculus with traction of the eyelid temporally.  The probe was advanced until a firm stop of the lacrimal bone was felt.  The probe was rotated in a superior and medial fashion along the brow to allow for navigation through the nasolacrimal sac and duct.  A mild resistance was felt at the distal aspect of the nasolacrimal duct consistent with a location of the valve.  There was also some mild stenosis distally, but not felt significant.  The probe was used to navigate through this mild resistance.  A second Bowman probe was then placed through the left naris and metal on metal contact was felt confirming patency.  Both probes were removed.  The 00 Bowman probe was then used to navigate the inferior puncta canaliculus system.  Patency was confirmed.  The left upper lid was everted and inspected and was found to be normal.,Attention was then turned to the right side where the similar procedure through the right superior puncta was performed.  A punctal dilator was used to dilate the puncta followed by a size 00 Bowman probe.  Again on this side, a size 0 Bowman probe was unable to be placed initially to the superior puncta.  The probe was used to navigate the superior puncta, canaliculus, and then the probe was rotated superomedially and the probe was advanced.  Similar amount of distal stenosis and distal nasolacrimal duct obstruction was felt.  The mild resistance was over come at the approximate location of the valve.  Metal-on-metal feel confirmed patency through the right naris with a second metal probe.  At the completion of the procedure all probes were removed.  Awakened and taken to the postanesthesia recovery unit in good condition having tolerated the procedure well.,Postoperative instructions were provided to the parents by me, and the discharging nurse.  I did advised nasolacrimal massage for the next 7 to 10 days on each side two to three times daily.  Technique explained and demonstrated.  Erythromycin ointment to both eyes twice daily for three days.  Follow up was arranged and he may call with any further questions or concerns.", Surgery,38
"SUBJECTIVE:,  The patient is keeping a food journal that she brought in.  She is counting calorie points, which ranged 26 to 30 per day.  She is exercising pretty regularly.  She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia.  The patient requests information on diabetic exchanges.  She said she is feeling better since she has lost weight.,OBJECTIVE:,Vital Signs:  The patient's weight today is 209 pounds, which is down 22 pounds since I last saw her on 06/07/2004.  I praised her weight loss and her regular exercising.  I looked at her food journal.  I praised her record keeping.  I gave her a list of the diabetic exchanges and explained them.  I also gave her a food dairy sheet so that she could record exchanges.  I encouraged her to continue.,ASSESSMENT:,  The patient seems happy with her progress and she seems to be doing well.  She needs to continue.,PLAN:,  Followup is on a p.r.n. basis.  She is always welcome to call or return.", Consult - History and Phy.,5
"CC:, Stable expressive aphasia and decreased vision.,HX:, This 72y/o woman was diagnosed with a left sphenoid wing meningioma on 6/3/80. She was 59 years old at the time and presented with a 6 month history of increasing irritability and left occipital-nuchal headaches. One month prior to that presentation she developed leftward head turning, and 3 days prior to presentation had an episode of severe dysphasia. A HCT (done locally) revealed a homogenously enhancing lesion of the left sphenoid wing. Skull X-rays showed deviation of the pineal to the right. She was transferred to UIHC and was noted to have a normal neurologic exam (per Neurosurgery note). Angiography demonstrated a highly vascular left temporal/sphenoid wing tumor. She under went left temporal craniotomy and ""complete resection"" of the tumor which on pathologic analysis was consistent with a meningioma.,The left sphenoid wing meningioma recurred and was excised 9/25/84. There was regrowth of this tumor seen on HCT, 1985. A 6/88 HCT revealed the left sphenoid meningioma and a new left tentorial meningioma. HCT in 1989 revealed left temporal/sphenoid, left tentorial, and new left frontal lesions. On 2/14/91 she presented with increasing lethargy and difficulty concentrating. A 2/14/91, HCT revealed increased size and surrounding edema of the left frontal meningioma. The left frontal and temporal meningiomas were excised on 2/25/91. These tumors all recurred and a left parietal lesion developed. She underwent resection of the left frontal meningioma on 11/21/91 due to right sided weakness and expressive aphasia. The weakness partially resolved and though the speech improved following resection it did not return to normal. In May 1992 she experienced 3 tonic-clonic type seizures, all of which began with a Jacksonian march up the RLE then RUE before generalizing. Her Phenobarbital prophylaxis which she had been taking since her 1980 surgery was increased. On 12/7/92, she underwent a left fronto-temporo-parieto-occipital craniotomy and excision of five meningiomas. Postoperatively she developed worsened right sided weakness and expressive aphasia. The weakness and aphasia improved by 3/93, but never returned to normal.", Consult - History and Phy.,5
"GENERAL:,  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: , Negative rash, negative jaundice.,HEMATOPOIETIC: , Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: , Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:,  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS: , Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  ,Negative postnasal drip, negative sore throat.,CARDIOVASCULAR: , Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:,  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL: , Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY: , Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.,MUSCULOSKELETAL:,  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC: , See psychiatric evaluation.,ENDOCRINE: , No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.", Consult - History and Phy.,5
"HISTORY:,  A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis.  The patient was status post coronary artery bypass surgery aortic valve repair at Shadyside Hospital.  The patient subsequently developed CVA.  She also developed thrombosis of the right arm, which ultimately required right hand amputation.  She was stabilized and eventually transferred to HealthSouth for further management.,PHYSICAL EXAMINATION:,Vital Signs:  Pulse of 90 and blood pressure 150/70.,Heart:  Sounds were heard, grade 2/6 systolic murmur at the precordium.,Chest:  Clinically clear.,Abdomen:  Some suprapubic tenderness.  Evidence of right lower arm amputation.,The patient was started on Prevacid 30 mg daily, levothyroxine 75 mcg a day, Toprol 25 mg twice a day, Zofran 4 mg q.6 h, Coumadin dose at 5 mg and was adjusted.  She was given a pain control using Vicodin and Percocet, amiodarone 200 mg a day, Lexapro 20 mg a day, Plavix 75 mg a day, fenofibrate 145 mg, Lasix 20 mg IV twice a day, Lantus 50 units at bedtime and Humalog 10 units a.c. and sliding scale insulin coverage.  Wound care to the right heel was supervised by Dr. X.  The patient initially was fed through NG tube, which was eventually discontinued.  Physical therapy was ordered.  The patient continued to do well.  She was progressively ambulated.  Her meds were continuously adjusted.  The patient's insulin was eventually changed from Lantus to Levemir 25 units twice a day.  Dr. Y also followed the patient closely for left heel ulcer.,LABORATORY DATA: , The latest cultures from left heel are pending.  Her electrolytes revealed sodium of 135 and potassium of 3.2.  Her potassium was switched to K-Dur 40 mEq twice a day.  Her blood chemistries are otherwise closely monitored.  INRs were obtained and were therapeutic.  Throughout her hospitalization, multiple cultures were also obtained.  Urine cultures grew Klebsiella.  She was treated with appropriate antibiotics.  Her detailed blood work is as in the chart.  Detailed radiological studies are as in the chart.  The patient made a steady progress and eventually plans were made to transfer the patient to ABC furthermore aggressive rehabilitation.,FINAL DIAGNOSES:,1.  Atherosclerotic heart disease, status post coronary artery bypass graft.,2.  Valvular heart disease, status post aortic valve replacement.,3.  Right arm arterial thrombosis, status post amputation right lower arm.,4.  Hypothyroidism.,5.  Uncontrolled diabetes mellitus, type 2.,6.  Urinary tract infection.,7.  Hypokalemia.,8.  Heparin-induced thrombocytopenia.,9.  Peripheral vascular occlusive disease.,10.  Paroxysmal atrial fibrillation.,11.  Hyperlipidemia.,12.  Depression.,13.  Carotid stenosis.", Consult - History and Phy.,5
"CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with ""pins & needles"" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.", Neurology,22
"OPERATION,1.  Insertion of a left subclavian Tesio hemodialysis catheter.,2.  Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and MAC anesthesia was administered.  Next, the patient's chest and neck were prepped and draped in the standard surgical fashion.  Lidocaine 1% was used to infiltrate the skin in the region of the procedure.  Next a #18-gauge finder needle was used to locate the left subclavian vein.  After aspiration of venous blood, Seldinger technique was used to thread a J wire through the needle.  This process was repeated.  The 2 J wires and their distal tips were confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next, the subcutaneous tunnel was created.  The distal tips of the individual Tesio hemodialysis catheters were pulled through to the level of the cuff.  A dilator and sheath were passed over the individual J wires.  The dilator and wire were removed, and the distal tip of the Tesio hemodialysis catheter was threaded through the sheath, which was simultaneously withdrawn.  The process was repeated.  Both distal tips were noted to be in good position.  The Tesio hemodialysis catheters were flushed and aspirated without difficulty.  The catheters were secured at the cuff level with a 2-0 nylon.  The skin was closed with 4-0 Monocryl.  Sterile dressing was applied.  The patient tolerated the procedure well and was transferred to the PACU in good condition.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis.  Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:,  Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825).  Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-year-old female who has progressive aging changes of the face and neck.  The patient demonstrates the deformities described above and has requested surgical correction.  The procedure, risks, limitations, and alternatives in this individual case have been very carefully discussed with the patient.  The patient has consented to surgery.,The patient was brought into the operating room and placed in the supine position on the operating table.  An intravenous line was started and anesthesia was maintained throughout the case.  The patient was monitored for cardiac, blood pressure, and oxygen saturation continuously.,The hair was prepared and secured with rubber bands and micropore tape along the incision line.  A marking pen had been used to outline the area of the incisions, which included the preauricular area to the level of the tragus, the post-tragal region, the post auricular region and into the hairline.  In addition, the incision was marked in the temporal area in the event of a temporal lift, then across the coronal scalp for the forehead lift.  The incision was marked in the submental crease for the submental lipectomy and liposuction.  The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline.,The areas to be operated on were injected with 1% Lidocaine containing 1:100,000 Epinephrine.  This provided local anesthesia and vasoconstriction.  The total of Lidocaine used throughout the procedure was maintained at no more than 500mg.,SUBMENTAL SUCTION ASSISTED LIPECTOMY: , The incision was made, as previously outlined, in the submental crease in a transverse direction, through the skin and subcutaneous tissue, and hemostasis was obtained with bipolar cautery.  A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible.  4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly.  The tunnels were enlarged with a 6mm flat liposuction cannula.,Then with the Wells-Johnson liposuction machine 27-29 inches of underwater mercury suction was accomplished in all tunnels.  Care was taken not to turn the opening of the suction cannula up to the dermis, but it was rotated in and out taking a symmetrical amount of fat from each area.  A similar procedure was performed with the 4 mm cannula cleaning the area.  Bilateral areas were palpated for symmetry, and any remaining fat was then suctioned directly.,A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle.  A plication stitch of 3-0 Vicryl was placed.,When a satisfactory visible result had been accomplished from the liposuction, the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion.  5-0 plain catgut was used for closure in a running interlocking fashion.  The wound was cleaned at the end, dried, and Mastisol applied.  Then tan micropore tape was placed for support to the entire area.,FACE LIFT: , After waiting approximately 10-15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal.  A gentle curve was then made, and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region.  A preauricular incision was carried into the natural crease superior to the tragus, curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin.  The incision was made in the temporal area beveling parallel with the hair follicles.  (The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly.),The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid.  The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim.  At the superior level of the zygoma and at the level of the sideburn, dissection was brought more superficially in order to avoid the nerves and vessels in the areas, specifically the frontalis branch of the facial nerve.,The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible.  This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl.  Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS.  The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8-10cm in the neck region.  When the areas of dissection had been connected carefully, hemostasis was obtained and all areas inspected.  At no point were muscle fibers or major vessels or nerves encountered in the dissection.,The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM.  The SMAS flap was then advanced posteriorly and superiorly.  The SMAS was split at the level of the earlobe, and the inferior portion was sutured to the mastoid periosteum.  The excess SMAS was trimmed and excised from the portion anterior to the auricle.  The SMAS was then imbricated with 2-0 Surgidak interrupted sutures.,The area was then inspected for any bleeding points and careful hemostasis obtained.  The flaps were then rotated and advanced posteriorly and then superiorly, and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2-0 Tycron suture.  The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period.  Skin closure was accomplished in the hairbearing areas with 5-0 Nylon in the preauricular tuft and 4-0 Nylon interrupted in the post auricular area.  The pre auricular area was closed first with 5-0 Dexon at the ear lobules, and 6-0 Nylon at the lobules, and 5-0 plain catgut in a running interlocking fashion.  5-0 Plain catgut was used in the post auricular area as well, leaving ample room for serosanguinous drainage into the dressing.  The post tragal incisin was closed with interrupted and running interlocking 5-0 plain catgut.  The exact similar procedure was repeated on the left side.,At the end of this procedure, all flaps were inspected for adequate capillary filling or any evidence of hematoma formation.  Any small amount of fluid was expressed post-auricularly.  A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure.  A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines.,ABD padding over 4X4 gauze was used to cover the pre and post auricular areas.  This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non-constricting but secured fashion.  The entire dressing complex was secured with a pre-formed elastic stretch wrap device.  All branches of the facial nerve were checked and appeared to be functioning normally.,The procedures were completed without complication and tolerated well.  The patient left the operating room in satisfactory condition.  A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to home in satisfactory condition.", Dermatology,8
"PREOPERATIVE DIAGNOSES:,  Left calcaneal valgus split.,POSTOPERATIVE DIAGNOSES:,  Left calcaneal valgus split.,PROCEDURES:  ,1.  Left calcaneal lengthening osteotomy with allograft.,2.  Partial plantar fasciotomy.,3.  Posterior subtalar and tibiotalar capsulotomy.,4.  Short leg cast placed.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME: , 69 minutes.,The patient in local anesthetic of 20 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS:  ,None.,SPECIMENS: , None.,HISTORY AND PHYSICAL: , The patient is a 13-year-old female who had previous bilateral feet correction at 1 year of age.  Since that time, the patient has developed significant calcaneal valgus deformity with significant pain.  Radiographs confirmed collapse of the spinal arch, as well as valgus position of the foot.  Given the patient's symptoms, surgery is recommended for calcaneal osteotomy and Achilles lengthening.  Risks and benefits of surgery were discussed with the mother.  Risks of surgery include risk of anesthesia; infection; bleeding; changes in sensation in most of extremity; hardware failure; need for later hardware removal; possible nonunion; possible failure to correct all the deformity; and need for other surgical procedures.  The patient will need to be strict nonweightbearing for at least 6 weeks and wear a brace for up to 6 months.  All questions were answered and parents agreed to the above surgical plan.,DESCRIPTION OF PROCEDURE: , 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 bump was placed underneath the left buttock.  A nonsterile tourniquet was placed on the upper aspect of the left thigh.  The extremity was then prepped and draped in a standard surgical fashion.  The patient had a previous incision along the calcaneocuboid lateral part of the foot.  This was marked and extended proximally through the Achilles tendon.  Extremity was wrapped in Esmarch.  Tourniquet inflation was noted to be 250 mmHg.  Decision was then made to protect the sural nerve.  There was one sensory nervous branch that did cross the field though it was subsequently sharply ligated because it was in the way.  Dissection was carried down to Achilles tendon, which was subsequently de-lengthened with the distal half performed down the lateral thigh.  Proximal end was tacked with an 0 Ethibond suture and subsequently repaired end-on-end at length with the heel in neutral.  Dissection was then carried on the lateral border of the foot with identification of the peroneal longus and valgus tendons, which were removed from the sheath and retracted dorsally.  At this time, we also noted that calcaneocuboid joint appeared to be fused.  The area between the anterior and middle facets were plicated on fluoroscopy for planned osteotomy.  This was performed with a saw.  After a partial plantar fasciotomy was performed, this was released off an abductor digiti minimi.  The osteotomy was completed with an osteotome and distracted with the lamina spreader.  A tricortical allograft was then shaped and subsequently impacted into this area.  Final positioning was checked with multiple views of fluoroscopy.  It was subsequently fixed using a 0.94 K-wire and drilled from the heel anteriorly.  A pin was subsequently bent and cut short at the level of the skin.  The wound was then irrigated with normal saline.  The Achilles was repaired with this tie.  Please note during the case, it was noted the patient had continued significant stiffness despite the Achilles lengthening.  A posterior capsulotomy of the tibiotalar and subtalar joints were performed with increased 10 degrees of dorsiflexion.  Wound was then closed using #2-0 Vicryl and #4-0 Monocryl.  The surgical field was irrigated with 0.25% Marcaine and subsequently injected with more Marcaine at the end of the case.  The wound was clean and dry and dressed with Steri-Strips and Xeroform.  Skin was dressed with Xeroform and 4 x 4's.  Everything was wrapped with 4 x 4's in sterile Webril.  The tourniquet was released after 69 minutes.  A short-leg cast was then placed with good return of capillary refill to his toes.  The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for elevation, ice packs, neurovascular checks, and pain control.  The patient to be strict nonweightbearing.  We will arrange for her to get a wheelchair.  The patient will then follow up in about 10 to 14 days for a cast check, as well as pain control.  The patient will need an AFO script at that time.  Intraoperative findings are relayed to the parents.", Orthopedic,27
"PREOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,POSTOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,OPERATION PERFORMED:,1.  Bilateral myringotomies.,2.  Insertion of Shepard grommet draining tubes.,ANESTHESIA: , General, by mask.,ESTIMATED BLOOD LOSS: , Less than 1 mL.,COMPLICATIONS:,  None.,FINDINGS:  ,The patient had a long history of persistent recurrent infections and was placed on antibiotics for the same.  At this point in time, he had a small amount of thick mucoid material in both middle ear spaces with middle ear mucosa somewhat inflamed, but no active acute infection at this point in time.,PROCEDURE:,  With the patient under adequate general anesthesia with the mask delivery of anesthesia, he had his ear canals cleaned utilizing an operating microscope and all foul cerumen had been removed from both sides.  Bilateral inferior radial myringotomies were performed, first on the right and then on the left.  Middle ear spaces were suctioned of small amount of thick mucoid material on both sides and then Shepard grommet draining tubes were inserted on either side.  Floxin drops were then instilled bilaterally to decrease any clotting within the tubes, and then cotton ball was placed in the external meatus bilaterally.  At this point, the patient was awakened and returned to the recovery room, satisfactory, with no difficulty encountered.", Surgery,38
"HISTORY OF PRESENT ILLNESS:  ,The patient is a 38-year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration.  The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip.  The pain is located laterally as well as anteriorly into the groin.  She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip.  She is here for evaluation for the first time.  She sought no previous medical attention for this.,PAST MEDICAL HISTORY:  ,Significant for depression and reflux disease.,PAST SURGICAL HISTORY: , Cesarean section x 2.,CURRENT MEDICATIONS: , Listed in the chart and reviewed with the patient.,ALLERGIES:  ,The patient has no known drug allergies.,SOCIAL HISTORY:  ,The patient is married.  She is employed as an office manager.  She does smoke cigarettes, one pack per day for the last 20 years.  She consumes alcohol 3 to 5 drinks daily.  She uses no illicit drugs.  She exercises monthly mainly walking and low impact aerobics.  She also likes to play softball.,REVIEW OF SYSTEMS: , Significant for occasional indigestion and nausea as well as anxiety and depression.  The remainder of the systems negative.,PHYSICAL EXAMINATION: , The patient is 5 foot, 2 inches tall, weighs 155 pounds.  The patient ambulates independently without an assist device with normal stance and gait.  Inspection of the hips reveals normal contour and appearance and good symmetry.  The patient is able to do an active straight leg raise against gravity and against resistance bilaterally.  She has no significant trochanteric tenderness.  She does, however, have some tenderness in the groin bilaterally.  There is no crepitus present with passive or active range of motion of the hips.  She is grossly neurologically intact in the bilateral lower extremities.,DIAGNOSTIC DATA:,  X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip.  There are no acute findings.  No fractures or dislocations.  There are minimal degenerative changes noted in the joint.  There is, however, the suggestion of an exostosis on the superior femoral neck, which could be consistent with femoroacetabular impingement.,IMPRESSION: , Bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on x-rays and her clinical picture is also consistent with possible labral tear.,PLAN:,  After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip.  We will get that done as soon as possible.  In the meantime, she is asked to moderate her activities.  She will follow up as soon as the MRIs are performed.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Right carpal tunnel syndrome.,PROCEDURE PERFORMED: , Right carpal tunnel release.,PROCEDURE NOTE:  ,The right upper extremity was prepped and draped in the usual fashion.  IV sedation was supplied by the anesthesiologist.  A local block using 6 cc of 0.5% Marcaine was used at the transverse wrist crease using a 25 gauge needle, superficial to the transverse carpal ligament.,The upper extremity was exsanguinated with a 6 inch ace wrap.,Tourniquet time was less than 10 minutes at 250 mmHg.,An incision was used in line with the third web space just to the ulnar side of the thenar crease.  It was carried sharply down to the transverse wrist crease.  The transverse carpal ligament was identified and released under direct vision.  Proximal to the transverse wrist crease it was released subcutaneously.  During the entire procedure care was taken to avoid injury to the median nerve proper, the recurrent median, the palmar cutaneous branch, the ulnar neurovascular bundle and the superficial palmar arch.  The nerve appeared to be mildly constricted.  Closure was routine with running 5-0 nylon.  A bulky hand dressing as well as a volar splint was applied and the patient was sent to the outpatient surgery area in good condition.", Surgery,38
"DESCRIPTION:,1.  Normal cardiac chambers size.,2.  Normal left ventricular size.,3.  Normal LV systolic function.  Ejection fraction estimated around 60%.,4.  Aortic valve seen with good motion.,5.  Mitral valve seen with good motion.,6.  Tricuspid valve seen with good motion.,7.  No pericardial effusion or intracardiac masses.,DOPPLER:,1.  Trace mitral regurgitation.,2.  Trace tricuspid regurgitation.,IMPRESSION:,1.  Normal LV systolic function.,2.  Ejection fraction estimated around 60%.,", Radiology,33
"HDR BRACHYTHERAPY,The intracavitary brachytherapy applicator was placed appropriately and secured after the patient was identified.  Simulation films were obtained, documenting its positioning.  The 3-dimensional treatment planning process was accomplished utilizing the CT derived data.  A treatment plan was selected utilizing sequential dwell positions within a single catheter.  The patient was taken to the treatment area.  The patient was appropriately positioned and the position of the intracavitary device was checked.  Catheter length measurements were taken.  Appropriate measurements of the probe dimensions and assembly were also performed.  The applicator was attached to the HDR after-loader device.  The device ran through its checking sequences appropriately and the brachytherapy was then delivered without difficulty or complication.  The brachytherapy source was appropriately removed back to the brachytherapy safe within the device.  Radiation screening was performed with the Geiger-Muller counter both prior to and after the brachytherapy procedure was completed and the results were deemed appropriate.,Following completion of the procedure, the intracavitary device was removed without difficulty.  The patient was in no apparent distress and was discharged home.", Hematology - Oncology,16
"Her axial back pain is greatly improved, but not completely eradicated.  There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption.,PAST MEDICAL HISTORY:,  Significant for anxiety disorder.,PAST SURGICAL HISTORY: , Foot surgery, abdominal surgery, and knee surgery.,CURRENT MEDICATIONS:,  Lipitor and Lexapro.,ALLERGIES: , She is allergic to sulfa medications.,SOCIAL HISTORY: , She is married, retired.  Denies tobacco or ethanol use.,FAMILY HISTORY:,  Father died of mesothelioma.  Mother gastric problems.,REVIEW OF SYSTEMS: , No recent history of night sweats, fevers, weight loss, visual changes, loss of consciousness, convulsion, or dysphagia.  Otherwise, review of systems is unremarkable, and a detailed history can be found in the patient's chart.,PHYSICAL EXAMINATION:,  Physical exam can be found in great detail in the patient's chart.,ASSESSMENT AND PLAN:  ,The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome.  Her lumbar facet joints were denervated approximately 6 months ago.  The denervation procedure helped her axial back pain approximately 40% when standing.  With extension and rotation it helped her axial back pain approximately 70%.  She is now able to swing a golf club.  She was unable to swing a golf club due to the rotational movements before her rhizotomy.  She is currently playing golf.  Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection.,I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p.o. b.i.d.  We will follow her up in 1 month's time.,", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS: , Right inguinal hernia. ,POSTOPERATIVE DIAGNOSIS:,  Right direct inguinal hernia. ,PROCEDURE:,  Right direct inguinal hernia repair with PHS mesh system. ,ANESTHESIA:,  General with endotracheal intubation. ,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was administered with endotracheal intubation.  The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion.  An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease.  Dissection was taken down through the skin and subcutaneous tissue.  Scarpa's fascia was divided, and the external ring was located.  The external oblique was divided from the external ring up towards the anterior superior iliac spine.  The cord structures were then encircled.  Careful inspection of the cord structures did not reveal any indirect sac along the cord structures.  I did, however, feel a direct sac with a direct defect.  I opened the floor of the inguinal canal and dissected out the preperitoneal space at the direct sac and cut out the direct sac.  Once I cleared out the preperitoneal space, I placed a PHS mesh system with a posterior mesh into the preperitoneal space, and I made sure that it laid flat along Cooper's ligament and covered the myopectineal orifice.  I then tucked the extended portion of the anterior mesh underneath the external oblique between the external oblique and the internal oblique, and I then tacked the medial portion of the mesh to the pubic tubercle with a 0 Ethibond suture.  I tacked the superior portion of the mesh to the internal oblique and the inferior portion of the mesh to the shelving edge of the inguinal ligament.  I cut a hole in the mesh in order to incorporate the cord structures and recreated the internal ring, making sure that it was not too tight so that it did not strangulate the cord structures.  I then closed the external oblique with a running 3-0 Vicryl.  I closed the Scarpa's with interrupted 3-0 Vicryl, and I closed the skin with a running Monocril.  Sponge, instrument and needle counts were correct at the end of the case.  The patient tolerated the procedure well and without any complications.", Surgery,38
"REASON FOR VISIT:,  The patient presents for a followup for history of erythema nodosum.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old woman who is attending psychology classes.  She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specific back in Netherlands.  At that point, she had undergone workup which was extensive for secondary diseases associated with erythema nodosum.  Part of her workup included a colonoscopy.  The findings were equivocal characterizes not clearly abnormal biopsies of the terminal ileum.,The skin biopsy, in particular, mentions some fibrosis, basal proliferation, and inflammatory cells in the subcutis.,Prior to the onset of her erythema nodosum, she had a tibia-fibula fracture several years before on the right, which was not temporarily associated with the skin lesions, which are present in both legs anyway.  Even, a jaw cosmetic surgery she underwent was long before she started developing her skin lesions.  She was seen in our clinic and by Dermatology on several occasions.  Apart from the first couple of visits when she presented stating a recurrent skin rash with a description suggestive of erythema nodosum in the lower extremities and ankle and there is discomfort pointing towards a possible inflammatory arthritis and an initial high sed rate of above 110 with an increased CRP.  In the following visits, no evident abnormality has been detected.  In the first visit, here some MTP discomfort detected.  It was thought that erythema nodosum may be present.  However, the evaluation of Dermatology did not concur and it was thought that the patient had venous stasis, which could be related to her prior fracture.  When she was initially seen here, a suspicion of IBD, sarcoid inflammatory arthropathy, and lupus was raised.  She had an equivocal rheumatoid fracture, but her CCP was negative.  She had an ANA, which was positive at 1:40 with a speckled pattern persistently, but the rest of the lupus serologies including double-stranded DNA, RNP, Smith, Ro, La were negative.  Her cardiolipin panel antibodies were negative as well.  We followed the IgM, IgG, and IgA being less than 10.  However, she did have a beta-2 glycoprotein 1 or an RVVT tested and this may be important since she has a livedo pattern.  It was thought that the onset of lupus may be the case.  It was thought that rheumatoid arthritis could not be the case since it is not associated with erythema nodosum.  For the fear of possible lymphoma, she underwent CT of the chest, abdomen, and pelvis.  It was done also in order to rule out sarcoid and the result was unremarkable.  Based on some changes in her bowel habits and evidence of B12 deficiency with a high methylmalonic and high homocystine levels along with a low normal B12 in addition to iron studies consistent with iron deficiency and an initially low MCV, the possibility of inflammatory bowel disease was employed.  The patient underwent an initially unrevealing colonoscopy and a capsule endoscopy, which was normal.  A second colonoscopy was done recently and microscopically no evidence of inflammatory bowel disease was seen.  However, eosinophil aggregations were noted in microscopy and this was told to be consistent with an allergic reaction or an emerging Crohn disease and I will need to discuss with Gastroenterology what is the significance of that.  Her possible B12 deficiency and iron deficiency were never addressed during her stay here in the United States.,In the initial appointment, she was placed on prednisone 40 mg, which was gradually titrated down this led to an exacerbation of her acne.  We decided to take her off prednisone due to adverse effects and start her on colchicine 0.6 mg daily.  While this kept things under control with the inflammatory markers being positive and no overt episodes of erythema nodosum, the patient still complains for sensitivity with less suspicious skin rash in the lower extremities and occasional ankle swelling and pain.  She was reevaluated by Dermatology for that and no evidence of erythema nodosum was felt to be present.  Out plan was to proceed with a DEXA scan, at some point check a vitamin D level, and order vitamin D and calcium over the counter for bone protection purposes.  However, the later was deferred until we have resolved the situation and find out what is the underlying cause of her disease.,Her past medical history apart from the tibia-fibular fracture and the jaw cosmetic surgery is significant for varicella and mononucleosis.,Her physical examination had shown consistently diffuse periarticular ankle edema and also venous stasis changes at least until I took over her care last August.  I have not been able to detect any erythema nodosum, however, a livedo pattern has been detected consistently.  She also has evidence of acne, which does not seem to be present at the moment.  She also was found to have a heart murmur present and we are going to proceed with an echocardiogram placed.,Her workup during the initial appointment included an ACE level, which was normal.  She also had a rather higher sed rate up to 30, but prior to that, per report, it was even higher, above 110.  Her RVVT was normal, her rheumatoid factor was negative.  Her ANA was 1:40, speckled pattern.  The double-stranded DNA was negative.  Her RNP and Smith were negative as well.  RO and LA were negative and cardiolipin antibodies were negative as well.  A urinalysis at the moment was completely normal.  A CRP was 2.3 in the initial appointment, which was high.  A CCP was negative.  Her CBC had shown microcytosis and hypochromia with a hematocrit of 37.7.  This improved later without any evidence of hypochromia, microcytosis or anemia with a hematocrit of 40.3.,The patient returns here today, as I mentioned, complaining of milder bouts of skin rash, which she calls erythema nodosum, which is accompanied by arthralgias, especially in the ankles.  I am mentioning here that photosensitivity rash was mentioned in the past.  She tells me that she had it twice back in Europe after skiing where her whole face was swollen.  Her acne has been very stable after she was taken off prednisone and was started on colchicine 0.6 daily.  Today we discussed about the effect of colchicine on a possible pregnancy.,MEDICATIONS: , Prednisone was stopped.  Vitamin D and calcium over the counter, we need to verify that.  Colchicine 0.6 mg daily which we are going to stop, ranitidine 150 mg as needed, which she does not take frequently.,FINDINGS:,  On physical examination, she is very pleasant, alert, and oriented x 3 and not in any acute distress.  There is some evidence of faint subcutaneous lesions in both shins bilaterally, but with mild tenderness, but no evidence of classic erythema nodosum.  Stasis dermatitis changes in both lower extremities present.  Mild livedo reticularis is present as well.,There is some periarticular ankle edema as well.  Laboratory data from 04/23/07, show a normal complete metabolic profile with a creatinine of 0.7, a CBC with a white count of 7880, hematocrit of 40.3, and platelets of 228.  Her microcytosis and hypochromia has resolved.  Her serum electrophoresis does not show a monoclonal abnormality.  Her vitamin D levels were 26, which suggests some mild insufficiency and she would probably benefit by vitamin D supplementation.  This points again towards some ileum pathology.  Her ANCA B and C were negative.  Her PF3 and MPO were unremarkable.  Her endomysial antibodies were negative.  Her sed rate at this time were 19.  The highest has been 30, but prior to her appointment here was even higher.  Her ANA continues to be positive with a titer of 1:40, speckled pattern.  Her double-stranded DNA is negative.  Her serum immunofixation confirmed the absence of monoclonal abnormality.  Her urine immunofixation was not performed.  Her IgG, IgA, and IgM levels are normal.  Her IgE levels are normal as well.  A urinalysis was not performed this time.  Her CRP is 0.4.  Her tissue transglutaminase antibodies are negative.  Her ASCA is normal and anti-OmpC was not tested.  Gliadin antibodies IgA is 12, which is in the borderline to be considered equivocal, but these are nonspecific.  I am reminding here that her homocystine levels have been 15.7, slightly higher, and that her methylmalonic acid was 385, which is obviously abnormal.  Her B12 levels were 216, which is rather low possibly indicating a B12 deficiency.  Her iron studies showed a ferritin of 15, a saturation of 9%, and an iron of 30.  Her TIBC was 345 pointing towards an iron deficiency anemia.  I am reminding you that her ACE levels in the past were normal and that she has a microcytosis.  Her radiologic workup including a thoracic, abdominal, and pelvic CT did not show any suspicious adenopathy, but only small aortocaval and periaortic nodes, the largest being 8 mm in short axis, likely reactive.  Her pelvic ultrasound showed normal uterus adnexa.  Her bladder was normal as well.  Subcentimeter inguinal nodes were found.  There was no large lytic or sclerotic lesion noted.  Her recent endoscopy was unremarkable, but the microscopy showed some eosinophil aggregation, which may be pointing towards allergy or an evolving Crohn disease.  Her capsule endoscopy was limited secondary to rapid transit.  There was only a tiny mucosal red spot in the proximal jejunum without active bleeding, 2 possible erosions were seen in the distal jejunum and proximal ileum.  However, no significant inflammation or bleeding was seen and this could be small bowel crisis.  Neither evidence of bleeding or inflammation were seen as well.  Specifically, the terminal ileum appeared normal.  Recent evaluation by a dermatologist did not verify the presence of erythema nodosum.,ASSESSMENT:,  This is a 25-year-old woman diagnosed with presumptive erythema nodosum in 2004.  She has been treated with prednisone as in the beginning she had also a wrist and ankle discomfort and high inflammatory markers.  Since I took over her care, I have not seen a clear-cut erythema nodosum being present.  No evidence of synovitis was there.  Her serologies apart from an ANA of 1:40 were negative.  She has a livedo pattern, which has been worrisome.  The issue here was a possibility of inflammatory bowel disease based on deficiency in vitamin B12 as indicated by high methylmalonic and homocystine levels and also iron deficiency.  She also has low vitamin D levels, which point towards terminal ileum pathology as well and she had a history of decreased MCV.  We never received the x-ray of her hands which she had and she never had a DEXA scan.  Lymphoma has been ruled out and we believe that inflammatory bowel disease, after repeated colonoscopies and the capsule endoscopy, has been ruled out as well.  Sarcoid is probably not the case since the patient did not have any lymphadenopathies and her ACE levels were normal.  We are going check a PPD to rule out tuberculosis.  We are going to order an RVVT and glycoprotein beta-1 levels in her workup to make sure that an antiphospholipid syndrome is not present given the livedo pattern.  An anti-intrinsic factor will be added as well.  Her primary care physician needs to workup the possible B12 and iron deficiency and also the vitamin D deficiency.  In the meanwhile, we feel that the patient should stop taking the colchicine and if she has a flare of her disease then she should present to her dermatologist and have the skin biopsy performed in order to have a clear-cut answer of what is the nature of this skin rash.  Regarding her heart murmur, we are going to proceed with an echocardiogram.  A PPD should be placed as well.  In her next appointment, we may fax a requisition for vitamin B replacement.,PROBLEMS/DIAGNOSES:,  1.  Recurrent erythema nodosum with ankle and wrist discomfort, ? arthritis.,2.  Iron deficiencies, according to iron studies.,3.  Borderline B12 with increased methylmalonic acid and homocystine.,4.  On chronic steroids; vitamin D and calcium is needed; she needs a DEXA scan.,5.  Typical ANCA, per records, were not verified here.  ANCA and ASCA were negative and the OmpC was not ordered.,6.  Acne.,7.  Recurrent arthralgia not present.  Rheumatoid factor, CCP negative, ANA 1:40 speckled.,8.  Livedo reticularis, beta 2-glycoprotein was not checked, we are going to check it today.  Needs vaccination for influenza and pneumonia.,9.  Vitamin D deficiency.  She needs replacement with ergocalciferol, but this may point towards ___________ pathology as this was not detected.,10.  Recurrent ankle discomfort which necessitates ankle x-rays.,PLANS:,  We can proceed with part of her workup here in clinic, PPD, echocardiogram, ankle x-rays, and anti-intrinsic factor antibodies.  We can start repleting her vitamin D with __________ weeks of ergocalciferol 50,000 weekly.  We can add an RVVT and glycoprotein to her workup in order to rule out any antiphospholipid syndrome.  She should be taking vitamin D and calcium after the completion of vitamin D replacement.  She should be seen by her primary care physician, have the iron and B12 deficiency worked up.  She should stop the colchicine and if the skin lesion recurs then she should be seen by her dermatologist.  Based on the physical examination, we do not suspect that the patient has the presence of any other disease associated with erythema nodosum.  We are going to add an amylase and lipase to evaluate her pancreatic function, RPR, HIV, __________ serologies.  Given the evidence of possible malabsorption it may be significant to proceed with an upper endoscopy to rule out Whipple disease or celiac disease which can sometimes be associated with erythema nodosum.  An anti-intrinsic factor would be added, as I mentioned.  I doubt whether the patient has Behcet disease given the absence of oral or genital ulcers.  She does not give a history of oral contraceptives or medications that could be related to erythema nodosum.  She does not have any evidence of lupus __________ mycosis.  Histoplasmosis coccidioidomycosis would be accompanied by other symptoms.  Hodgkin disease has probably been ruled out with a CAT scan.  However, we are going to add an LDH in future workup.  I need to discuss with her primary care physician regarding the need for workup of her vitamin B12 deficiency and also with her gastroenterologist regarding the need for an upper endoscopy.  The patient will return in 1 month.", Dermatology,8
"HISTORY:,  The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.  He had undergone staged repair beginning on 04/21/1997 with a right modified Blalock-Taussig shunt followed on 09/02/1999 with a bilateral bidirectional Glenn shunt, and left pulmonary artery to main pulmonary artery pericardial patch augmentation.  These procedures were performed at Medical College Hospital.  Family states that they moved to the United States.  Evaluation at the Children's Hospital earlier this year demonstrated complete occlusion of the right bidirectional Glenn shunt as well as occlusion of the proximal right pulmonary artery.  He was also found to have elevated Glenn pressures at 22 mmHg, transpulmonary gradient axis of 14 mmHg.  The QP:QS ratio of 0.6:1.  A large decompressing venous collateral was also appreciated.  The patient was brought back to cardiac catheterization in an attempt to reconstitute the right caval pulmonary anastomosis and to occlude the venous collateral vessel.,DESCRIPTION OF PROCEDURE: , After sedation and local Xylocaine anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 6-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava into the right-sided atrium pulmonary veins and the right ventricle.,Using a 6-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta and ascending aorta.  A separate port of arterial access was obtained in the left femoral artery utilizing a 5-French sheath.,Percutaneous access into the right jugular vein was attempted, but unsuccessful.  Ultrasound on the right neck demonstrated a complete thrombosis of the right internal jugular vein.  Using percutaneous technique and a 5-French sheath, 5-French wedge catheter was inserted into the left internal jugular vein and advanced along the left superior vena cava across the left caval-pulmonary anastomosis into the main pulmonary artery and left pulmonary artery with aid of guidewire.  This catheter then also advanced into the bridging innominate vein.  The catheter was then exchanged over wire for a 4-French Bernstein catheter, which was advanced to the blind end of the right superior vena cava.  A balloon wedge angiogram of the right lower pulmonary vein demonstrated back filling of a small right lower pulmonary artery.  There was no vascular continuity to the stump of the right Glenn.  The jugular venous catheter and sheaths were exchanged over a wire for a 6-French flexor sheath, which was advanced to the proximal right superior vena cava.  The Bernstein catheter was then reintroduced using a Terumo guidewire.  Probing of the superior vena cava facilitated access into the right lower pulmonary artery.  The angiogram in the right pulmonary artery showed a diminutive right lower pulmonary artery and severe long segment proximal stenosis.  The distal pulmonary measured approximately 5.5 to 60 mm in diameter with a long segment stenosis measuring approximately 31 mm in length.  The length of the obstruction was balloon dilated using ultra-thin SD 4 x 2 cm balloon catheter with complete disappearance of the waist.  This facilitated advancement of a flexor sheath into the proximal portion of the stenosis.  A PG 2960 BPX Genesis stent premounted on a 6 mm OptiProbe.  A balloon catheter was advanced across the area of narrowing and inflated with a near-complete disappearance of proximal waist.  Angiogram demonstrated a good stent apposition to the caval wall.  Further angioplasty was then performed utilizing an ultra-thin SDS 8 x 3 cm balloon catheter inflated to 19 atmospheres pressure with complete disappearance of a distinct proximal waist.  Angiogram demonstrated wide patency of reconstituted right caval pulmonary anastomosis though there was no flow seen to the right upper pulmonary artery.  The balloon wedge angiograms were then obtained in the right upper pulmonary veins suggesting the presence of right upper pulmonary artery and not contiguous with the right lower pulmonary artery.  Bernstein catheter was advanced into the main pulmonary artery where a wire probing of the stump of the proximal right pulmonary artery facilitated access to the right upper pulmonary artery.  Angiogram demonstrated severe long segment stenosis of the proximal right pulmonary artery.  Angioplasty of the right pulmonary was then performed using the OptiProbe 6-mm balloon catheter inflated to 16 atmospheres pressure with disappearance of a distinct waist.  Repeat angiogram showed improvement in caliber of right upper pulmonary artery with filling defect of the proximal right pulmonary artery.  The proximal right pulmonary artery was then dilated and stent implanted using a PG 2980 BPX Genesis stent premounted on 8-mm OptiProbe balloon catheter and implanted with complete disappearance of the waist.  Distal right upper pulmonary artery was then dilated and stent implanted utilizing a PG 1870 BPX Genesis stent premounted on 7-mm OptiProbe balloon catheter.  Repeat angiograms were then performed.  Attention was then directed to the large venous collateral vessel arising from the left superior vena cava with a contrast filling of a left-sided azygos vein.  A selective angiogram demonstrated a large azygos vein of the midsection measuring approximately 9.4 mm in diameter.  An Amplatzer 12 mm vascular plug was loaded on the delivery catheter and advanced through the flexor sheath into the azygos vein.  Once stable device was confirmed, the device was released from the delivery catheter.  The 4-French Bernstein catheter was then reintroduced and 5 inch empirical 0.038 inch, 10 cm x 8 mm detachable coils were then implanted above the vascular plug filling the proximal azygos vein.  A pigtail catheter was then introduced into the left superior vena cava for final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the coronary sinus of pulmonary veins, the innominate vein, superior vena cava, the main pulmonary artery, and azygos vein.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:,  Oxygen consumption was assumed to be normal mixed venous saturation, but was low due to systemic arterial desaturation of 79%.  The pulmonary veins were fully saturated with partial pressure of oxygen ranging between 120 and 169 mmHg in 30% oxygen.  Remaining saturations reflected complete admixture.  There was increased saturation in the left pulmonary artery due to aortopulmonary collateral flow.  Phasic right atrial pressures were normal with an A-wave somewhat to the normal right ventricular end-diastolic pressure of 9 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending, descending pressures were similar and normal.  Mean Glenn pressures at initiation of the case were slightly elevated at 14 mmHg with a transpulmonary gradient of 9 mmHg.  The calculated systemic flow was a normal pulmonary flows reduced with a QP:QS ratio of 0.6:1.  The pulmonary vascular resistance was elevated at 4.4 Woods units.  Following stent implantation in the right caval pulmonary anastomosis and right pulmonary artery, there was a slight increase in the Glenn venous pressures to 16 mmHg.  Following embolization of the azygos vein, there was increase in systemic arterial saturation to 84% and increase in mixed venous saturation.  There was similar increase in Glenn pressures to 28 mmHg with a transpulmonary gradient of 14 mmHg.  There was an increase in arterial pressure.  The calculated systemic flow increased from 3.1 liters /minute/meter squared to 4.3 liters/minute/meter squared.  Angiogram within the innominate vein following stent implantation demonstrated appropriate stent position without significant distortion of the innominate vein or proximal cava.  There appeared unobstructed contrast flow to the right lower pulmonary artery of a 1-mmHg mean pressure gradient.  There was absence of contrast filling of the right middle and right upper pulmonary artery.  Final angiogram with a contrast injection in the left superior vena cava showed a forward flow through the right Glenn, a good contrast filling of the right lower pulmonary artery, and a widely patent left Glenn negative contrast washout of the proximal right pulmonary artery and left pulmonary artery presumably due to aortopulmonary collateral flow.  Contrast injection within the right upper pulmonary artery following the stent implantation demonstrated widely patent proximal right pulmonary artery along the length of the implanted stents though with retrograde contrast flow.,INITIAL DIAGNOSES:  ,1.  Asplenia syndrome.,2.  Dextrocardia bilateral superior vena cava.,3.  Atrioventricular septal defect.,4.  Total anomalous pulmonary venous return to the right-sided atrium.,5.  Double outlet right ventricle with malposed great vessels.,6.  Severe pulmonary stenosis.,7.  Separate hepatic venous drainage into the atria.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Right modified Blalock-Taussig shunt.,2.  Bilateral bidirectional Glenn shunt.,3.  Patch augmentation of the main pulmonary to left pulmonary artery.,CURRENT DIAGNOSES:  ,1.  Obstructed right caval pulmonary anastomosis.,2.  Obstructed right proximal pulmonary artery.,3.  Venovenous collateral vessel.,CURRENT INTERVENTION:  ,1.  Balloon dilation of the right superior vena cava and stent implantation.,2.  Balloon dilation of the proximal right pulmonary artery, stent implantation.,3.  Embolization of venovenous collateral vessel.,MANAGEMENT: , The case will be discussed in Combined Cardiology Cardiothoracic Surgery case conference.  A repeat catheterization is recommended in 3 months to assess for right pulmonary artery growth and to assess candidacy for Fontan completion.  The patient will be maintained on anticoagulant medications of aspirin and Plavix.  Further cardiology care will be directed by Dr. X.", Surgery,38
"ADMISSION DIAGNOSES:,1.  Seizure.,2.  Hypoglycemia.,3.  Anemia.,4.  Hypotension.,5.  Dyspnea.,6.  Edema.,DISCHARGE DIAGNOSES:,1.  Colon cancer, status post right hemicolectomy.,2.  Anemia.,3.  Hospital-acquired pneumonia.,4.  Hypertension.,5.  Congestive heart failure.,6.  Seizure disorder.,PROCEDURES PERFORMED:,1.  Colonoscopy.,2.  Right hemicolectomy.,HOSPITAL COURSE: , The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD, bipolar disorder, and anemia.  She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia.  Regarding the seizure disorder, Neurology was consulted.  Noncontrast CT of the head was negative.  Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d.  Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour.  Her insulin pump had a basal rate of roughly three at night during the feedings.  While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times.  She seemed to tolerate the insulin pump rate well throughout her hospital course.  There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course.,At discharge, her endocrinologist was contacted.  It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m., from 0.8 units per hour from 6 a.m. until 8 a.m., and then at 0.2 units per hour from 8 a.m. until 6 p.m.  The insulin was to be NovoLog.  Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools.  A colonoscopy was performed, which found a mass at the right hepatic flexure.  General Surgery was then consulted and a right hemicolectomy was performed on the patient.  The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour.  Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer.  CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis.  Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia.  She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well.  Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness.  The patient was seen by the Infectious Disease specialist.  The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site.  At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours.  The Bactrim was used to cover the MRSA at the J-tube site.  It was found that MRSA was sensitive to Bactrim.  Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable.  She also received Lipitor for her high cholesterol.  Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night.  The dosage increases can begin on an outpatient basis.,DISCHARGE INSTRUCTIONS/MEDICATIONS: , The patient was discharged to home.  She was told to shy away from strenuous activity.  Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night.  The discharge medications were as follows:,1.  Coreg 12.5 mg p.o. b.i.d.,2.  Lipitor 10 mg p.o. at bedtime.,3.  Nitro-Dur patch 0.3 mg per hour one patch daily.,4.  Phenergan syrup 6.25 mg p.o. q.4h. p.r.n.,5.  Synthroid 0.175 mg p.o. daily.,6.  Zyrtec 10 mg p.o. daily.,7.  Lamictal 100 mg p.o. daily.,8.  Lamictal 150 mg p.o. at bedtime.,9.  Ferrous sulfate drops 325 mg, PEG tube b.i.d.,10.  Nexium 40 mg p.o. at breakfast.,11.  Neurontin 400 mg p.o. t.i.d.,12.  Lasix 40 mg p.o. b.i.d.,13.  Fentanyl 50 mcg patch transdermal q.72h.,14.  Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d.,15.  Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days.,16.  Levaquin 750 mg one tablet p.o. x3 days.,The medications listed above, one listed as p.o. are to be administered via the J-tube.,FOLLOWUP:  ,The patient was instructed to see Dr. X in approximately five to seven days.  She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X.  She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer.  She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes.  We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment.  She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.,CONDITION ON DISCHARGE: , Stable.", Cardiovascular / Pulmonary,3
"HISTORY OF PRESENT ILLNESS:,  This is a 55-year-old female with a history of I-131-induced hypothyroidism years ago who presents with increased weight and edema over the last few weeks with a 25-pound weight gain.  She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder.  She has noticed increasing abdominal girth as well as increasing edema in her legs.  She has been on Norvasc and lisinopril for years for hypertension.  She has occasional sweats with no significant change in her bowel status.  She takes her thyroid hormone apart from her Synthroid.  She had been on generic for the last few months and has had difficulty with this in the past.,MEDICATIONS: , Include levothyroxine 300 mcg daily, albuterol, Asacol, and Prilosec.  Her amlodipine and lisinopril are on hold.,ALLERGIES:,  Include IV DYE, SULFA, NSAIDS, COMPAZINE, and DEMEROL.,PAST MEDICAL HISTORY:,  As above includes I-131-induced hypothyroidism, inflammatory bowel disease with Crohn, hypertension, fibromyalgia, COPD, and disc disease.,PAST SURGICAL HISTORY: , Includes a hysterectomy and a cholecystectomy.,SOCIAL HISTORY: , She does not smoke or drink alcohol.,FAMILY HISTORY: , Positive for thyroid disease but the sister has Graves disease, as well a sister with Hashimoto thyroiditis.,REVIEW OF SYSTEMS: , Positive for fatigue, sweats, and weight gain of 20 pounds.  Denies chest pain or palpitations.  She has some loosening stools, but denies abdominal pain.  Complains of increasing girth and increasing leg swelling.,PHYSICAL EXAMINATION:,GENERAL:  She is an obese female.,VITAL SIGNS:  Blood pressure 140/70 and heart rate 84.  She is afebrile.,HEENT:  She has no periorbital edema.  Extraocular movements were intact.  There was moist oral mucosa.,NECK:  Supple.  Her thyroid gland is atrophic and nontender.,CHEST:  Good air entry.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Benign.,EXTREMITIES:  Showed 1+ edema.,NEUROLOGIC:  She was awake and alert.,LABORATORY DATA:,  TSH 0.28, free T4 1.34, total T4 12.4 and glucose 105.,IMPRESSION/PLAN:,  This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism.  Hypothyroidism is secondary to radioactive iodine for Graves disease many years ago.  She is clinically and biochemically euthyroid.  Her TSH is mildly suppressed, but her free T4 is normal and with her weight gain I will not decrease her dose of levothyroxine.  I will continue on 300 mcg daily of Synthroid.  If she wanted to lose significant weight, I shall repeat thyroid function test in six weeks' time to ensure that she is not hyperthyroid.", Endocrinology,13
"PREOPERATIVE DIAGNOSIS:  ,Symptomatic disk herniation, C7-T1.,FINAL DIAGNOSIS:  ,Symptomatic disk herniation, C7-T1.,PROCEDURES PERFORMED,1.  Anterior cervical discectomy with decompression of spinal cord C7-T1.,2.  Anterior cervical fusion, C7-T1.,3.  Anterior cervical instrumentation, anterior C7-T1.,4.  Insertion of intervertebral device, C7-T1.,5.  Use of operating microscope.,ANESTHESIOLOGY: , General endotracheal.,ESTIMATED BLOOD LOSS:  ,A 30 mL.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room where he was orally intubated by The Anesthesiology Service.  He was placed in the supine position on an OR table.  His arms were carefully taped down.  He was sterilely prepped and draped in the usual fashion.,A 4-cm incision was made obliquely over the left side of his neck.  Subcutaneous tissue was dissected down to the level of the platysma.  The platysma was incised using electrocautery.  Blunt dissection was done to create a plane between the strap muscles and the sternoclavicular mastoid muscle.  This allowed us to get right down on to the anterior cervical spine.  Blunt dissection was done to sweep off the longus colli.  We isolated the C7-T1 interspace.  An x-ray was taken to verify; we were indeed at the C7-T1 interspace.,Shadow-Line retractor was placed as well as Caspar pins.  This provided very, very good access to the C7-T1 disk.,At this point, the operating microscope was brought into the decompression.,A thorough and aggressive C7-T1 discectomy was done using a succession of curettes, pituitary rongeur, 4-mm cutting bur and a #2 Kerrison rongeur.  At the end of the discectomy, the cartilaginous endplates were carefully removed using 4-mm cutting burr.  The posterior longitudinal ligament was carefully resected using #2 Kerrison rongeur.  Left-sided C8 foraminotomy was accomplished using nerve hook and a 2-mm Kerrison rongeur.  At the end of the decompression, there was no further compression on the left C8 nerve root.,A Synthes cortical cancellous ____________ bone was placed in the interspace.  Sofamor Danek Atlantis plate was then placed over the interspace and four screws were placed, two in the body of C7 and two in the body of T1.  An x-ray was taken.  It showed good placement of the plate and screws.,A deep drain was placed.  The platysma layer was closed in running fashion using #1 Vicryl.  Subcutaneous tissue was closed in an interrupted fashion using 2-0 Vicryl.  Skin was closed in a running fashion using 4-0 Monocryl.  Steri-Strips and dressings were applied.  All counts were correct.  There were no complications.", Neurosurgery,23
"PREOPERATIVE DIAGNOSES:,1.  Cellulitis with associated abscess, right foot.,2.  Foreign body, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Cellulitis with associated abscess, right foot.,2.  Foreign body, right foot.,PROCEDURE PERFORMED:,1.  Irrigation debridement.,2.  Removal of foreign body of right foot.,ANESTHESIA:,  Spinal with sedation.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,GROSS FINDINGS: , Include purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old Caucasian male with a history of uncontrolled diabetes mellitus.  The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot.  He notes some itching as well as increasing pain and redness in the right foot and presented to ABCD General Hospital Emergency Room.  He was evaluated by the Emergency Room staff as well as the medical team and the Department of Orthopedics.  It was noted upon x-ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity.  After a long discussion held with the patient, it was elected to proceed with irrigation debridement and removal of the foreign body.,PROCEDURE: , After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the patient, operative surgeon, the Department of Anesthesia and nursing staff.  The patient was then transferred to preoperative area to Operative Suite #5 and placed on the operating table in supine position.  All bony prominences were well padded at this time.  The Department of Anesthesia was administered spinal anesthetic to the patient.  Once this anesthesia was obtained, the patient's right lower extremity was sterilely prepped and draped in the usual sterile fashion.  Upon viewing of the plantar aspect of the foot, there was noted to be a swollen ecchymotic area with a small hole in it, which purulent fluid was coming from.  At this time, after all bony and soft tissue landmarks were identified as well as the localization of the pus, a 2 cm longitudinal incision was made directly over this area, which was located between the second and third metatarsal heads.  Upon incising this, there was a foul smelling purulent fluid, which flowed from this region.  Aerobic and anaerobic cultures were taken as well as gram stain.  The area was explored and it ________ to the dorsum of the foot.  There was no obvious joint involvement.  After all loculations were broken, 3 liters antibiotic-impregnated fluid were pulse-evac through the wound.  The wound was again inspected with no more gross purulent or necrotic appearing tissue.  The wound was then packed with an iodoform gauge and a sterile dressing was applied consisting of 4x4s, floss, and Kerlix covered by an Ace bandage.  At this time, the Department of Anesthesia reversed the sedation.  The patient was transferred back to the hospital gurney to Postanesthesia Care Unit.  The patient tolerated the procedure well and there were no complications.,DISPOSITION:  ,The patient will be followed on a daily basis for possible repeat irrigation debridement.", Orthopedic,27
"INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant.  His mother had premature rupture of membranes on 12/20/08.  She then presented to the Labor and Delivery with symptoms of flu.  The baby was then induced and delivered.  The mother had a history of premature babies in the past.  This baby was doing well, and then, we had a significant increasing oxygen requirement from room air up to 85%.  He is now on 60% FiO2.,PHYSICAL FINDINGS,GENERAL:  He appears to be pink, well perfused, and slightly jaundiced.,VITAL SIGNS:  Pulse 156, 56 respiratory rate, 92% sat, and 59/28 mmHg blood pressure.,SKIN:  He was pink.,He was on the high-frequency ventilator with good wiggle.,His echocardiogram showed normal structural anatomy.  He has evidence for significant pulmonary hypertension.  A large ductus arteriosus was seen with bidirectional shunt.  A foramen ovale shunt was also noted with bidirectional shunt.  The shunting for both the ductus and the foramen ovale was equal left to right and right to left.,IMPRESSION: , My impression is that baby boy, XYZ, has significant pulmonary hypertension.  The best therapy for this is to continue oxygen.  If clinically worsens, he may require nitric oxide.  Certainly, Indocin should not be used at this time.  He needs to have lower pulmonary artery pressures for that to be considered.,Thank you very much for allowing me to be involved in baby XYZ's care.", Pediatrics - Neonatal,29
"HISTORY:  ,We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic.  He was sent here with a chief complaint of joint pain in several joints for few months.  This is a 7-year-old white male who has no history of systemic disease, who until 2 months ago, was doing well and 2 months ago, he started to complain of pain in his fingers, elbows, and neck.  At this moment, this is better and is almost gone, but for several months, he was having pain to the point that he would cry at some point.  He is not a complainer according to his mom and he is a very active kid.  There is no history of previous illness to this or had gastrointestinal problems.  He has problems with allergies, especially seasonal allergies and he takes Claritin for it.  Other than that, he has not had any other problem.  Denies any swelling except for that doctor mentioned swelling on his elbow.  There is no history of rash, no stomach pain, no diarrhea, no fevers, no weight loss, no ulcers in his mouth except for canker sores.  No lymphadenopathy, no eye problems, and no urinary problems.,MEDICATIONS: , His medications consist only of Motrin only as needed and Claritin currently for seasonal allergies and rhinitis.,ALLERGIES: , He has no allergies to any drugs.,BIRTH HISTORY:  ,Pregnancy and delivery with no complications.  He has no history of hospitalizations or surgeries.,FAMILY HISTORY: , Positive for arthritis in his grandmother.  No history of pediatric arthritis.  There is history of psoriasis in his dad.,SOCIAL HISTORY: , He lives with mom, dad, brother, sister, and everybody is healthy.  They live in Easton.  They have 4 dogs, 3 cats, 3 mules and no deer.  At school, he is in second grade and he is doing PE without any limitation.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Temperature is 98.7, pulse is 96, respiratory rate is 24, height is 118.1 cm, weight is 22.1 kg, and blood pressure is 61/44.,GENERAL:  He is alert, active, in no distress, very cooperative.,HEENT:  He has no facial rash.  No lymphadenopathy.  Oral mucosa is clear.  No tonsillitis.  His ear canals are clear and pupils are reactive to light and accommodation.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm and no murmur.,ABDOMEN:  Soft, nontender with no visceromegaly.,MUSCULOSKELETAL:  Shows no limitation in any of his joints or active swelling today.  He has no tenderness either in any of his joints.  Muscle strength is 5/5 in proximal muscles.,LABORATORY DATA:,  Includes an arthritis panel.  It has normal uric acid, sedimentation rate of 2, rheumatoid factor of 6, and antinuclear antibody that is negative and C-reactive protein that is 7.1.  His mother stated that this was done while he was having symptoms.,ASSESSMENT AND PLAN: , This patient may have had reactive arthritis.  He is seen frequently and the patient has family history of psoriatic arthritis or psoriasis.  I do not see any problems at this moment on his laboratories or on his physical examination.  This may have been related to recent episode of viral infection or infection of some sort.  Mother was oriented about the finding and my recommendation is to observe him and if there is any recurrence of the symptoms or persistence of swelling or limitation in any of his joints, I will be glad to see him back.,If you have any question on further assessment and plan, please do no hesitate to contact us.", Rheumatology,34
"Chief Complaint:, coughing up blood and severe joint pain.,History of Present Illness:,  The patient is a 37 year old African American woman with history of chronic allergic rhinitis who presents to an outpatient clinic with severe pain in multiple joints and hemoptysis for 1 day. The patient was at her baseline state of health until 2 months prior to admission when her usual symptoms of allergic rhinitis worsened. In addition to increased nasal congestion and drainage, she also began having generalized fatigue, malaise, and migratory arthralgias involving bilateral wrists, shoulders, elbows, knees, ankles, and finger joints. She also had intermittent episodes of swollen fingers that prevented her from making a fist. Patient denied recent flu-like illness, fever, chills, myalgias, or night sweats. Four weeks after the onset of arthralgias patient developed severe bilateral eye dryness and redness without any discharge. She was evaluated by an ophthalmologist and diagnosed with conjunctivitis. She was given eye drops that did not relieve her eye symptoms. Two weeks prior to admission patient noted the onset of rust colored urine. No bright red blood or clots in the urine. She denied having dysuria, decreased urine output, abdominal pain, flank pain, or nausea/vomiting. Patient went to a community ER, and had a CT Scan of the abdomen that was negative for kidney stones. She was discharged from the ER with Bactrim for possible UTI. During the next week patient had progressively worsening arthralgias to the point where she could hardly walk. On the day of admission, she developed a cough productive of bright red blood associated with shortness of breath and nausea, but no chest pain or dizziness. This prompted the patient to go see her primary care physician. After being seen in clinic, she was transferred to St. Luke’s Episcopal Hospital for further evaluation.,Past Medical History:, Allergic rhinitis, which she has had for many years and treated with numerous medications. No history of diabetes, hypertension, or renal disease. No history tuberculosis, asthma, or upper airway disease.,Past Surgical History:, Appendectomy at age 21. C-Section 8 years ago.,Ob/Gyn: G2P2; last menstrual period 3 weeks ago. Heavy menses due to fibroids.,Social History:, Patient is married and lives with her husband and 2 children. Works in a business office. Denies any tobacco, alcohol, or illicit drug use of any kind. No history of sexually transmitted diseases. Denies exposures to asbestos, chemicals, or industrial gases. No recent travel. No recent sick contacts.,Family History:, Mother and 2 maternal aunts with asthma. No history of renal or rheumatologic diseases.,Medications:, Allegra 180mg po qd, Zyrtec 10mg po qd, Claritin 10mg po qd,No herbal medication use.,Allergies:, No known drug allergies.,Review of systems:, No rashes, headache, photophobia, diplopia, or oral ulcers. No palpitations, orthopnea or PND. No diarrhea, constipation, melena, bright red blood per rectum, or pale stool. No jaundice. Decreased appetite, but no weight loss.,Physical Examination:,VS: T 100.2F BP 132/85 P 111 RR 20 O2 Sat 95% on room air,GEN: Well-developed woman in no apparent distress.,SKIN: No rashes, nodules, ecchymoses, or petechiae.,LYMPH NODES: No cervical, axillary, or inguinal lymphadenopathy.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric sclerae. Erythematous sclerae and pale conjunctivae. Dry mucous membranes. No oropharyngeal lesions. Bilateral tympanic membranes clear. No nasal deformities.,NECK: Supple. No increased jugular venous pressure. No thyromegaly.,CHEST: Decreased breath sounds throughout bilateral lung fields with occasional diffuse crackles. No wheezes or rales.,CV: Tachycardic. Regular rhythm. No murmurs, gallops, or rubs.,ABDOMEN: Soft with normal active bowel sounds. Non-distended and non-tender. No masses palpated. No hepatosplenomegaly.,RECTAL: Brown stool. Guaiac negative.,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally. Tenderness and mild swelling of bilateral wrists, MCPs and PIPs with decreased range of motion and grip function. Bilateral wrists warm without erythema. Bilateral elbows, knees, and ankles tender to palpation with decreased range of motion, but no erythema, warmth, or swelling of these joints.,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation are within normal limits.,STUDIES:,Chest X-ray (10/03):,Suboptimal inspiratory effort. No evidence of pneumonic consolidation, pleural effusion, pneumothorax, or pulmonary edema. Cardiomediastinal silhouette is unremarkable.,CT Scan of Chest (10/03):,Prominence of the bronchovascular markings bilaterally with a nodular configuration. There are mixed ground glass interstitial pulmonary infiltrates throughout both lungs with a perihilar predominance. Aortic arch is of normal caliber. The pulmonary arteries are of normal caliber. There is right paratracheal lymphadenopathy. There is probable bilateral hilar lymphadenopathy. Trachea and main stem bronchi are normal. The heart is of normal size.,Renal Biopsy:,Microscopic Description : Ten glomeruli are present. There are crescents in eight of the glomeruli. Some of the glomeruli show focal areas of apparent necrosis with fibrin formation. The interstitium consists of a fairly dense infiltrate of lymphocytes, plasma cells with admixed eosinophils. The tubules for the most part are unremarkable. No vasculitis is identified.,Immunofluorescence Description : There are no staining for IgG, IgA, IgM, C3, Kappa, Lambda, C1q, or albumin.,Electron Microscopic Description : Mild to moderate glomerular, tubular, and interstitial changes. Mesangium has multifocal areas with increased matrix and cells. There is focal mesangial interpositioning with the filtration membrane. Interstitium has multifocal areas with increased collagen. There are focal areas with interstitial aggregate of fibrin. Within the collagen substrate are infiltrates of lymphocytes, plasma cells, eosinophils, and macrophages. The glomerular sections evaluated show no electron-dense deposits in the filtration membrane or mesangium.,Microscopic Diagnosis: Pauci-immune crescentic glomerulonephritis with eosinophilic interstitial infiltrate.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,POSTOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,PROCEDURE:  ,Closed reduction of mandible fracture with MMF.,ANESTHESIA: , General anesthesia via nasal endotracheal intubation.,FLUIDS: , 2 L of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,HARDWARE: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,CONDITION:  ,The patient was extubated to PACU in good condition.,INDICATIONS FOR PROCEDURE: , The patient is a 17-year-old female who is 2 days status post an altercation in which she sustained multiple blows to the face.  She was worked up on Friday night, 2 days earlier at Hospital, was given palliative treatment and discharged and instructed to follow up as an outpatient with an oral surgeon and given a phone number to call.  The patient was worked up initially.  On initial exam, it was noted that the patient had a left V3 paresthesia.  She had a gross malocclusion.  On the facial CT and panoramic x-ray, it was noted to be a displaced left angle fracture and nondisplaced symphysis fracture.  Alternatives were discussed with the patient and it was determined she would benefit from being taken to the operating room under general anesthesia to have a closed reduction of her fractures.  Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and informed consent was obtained with the patient's mother.,DESCRIPTION OF PROCEDURE:, The patient was taken to the operating room #4 at Hospital and laid in a supine position on the operating room table.  Monitor was attached and general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics.  The patient was prepped and draped in the usual oromaxillofacial surgery fashion.,Surgeon approached the operating table in a sterile fashion.  Approximately 10 mL of 2% lidocaine with 1:100,000 epinephrine was injected into the oral vestibule in a nerve block fashion.  A moistened Ray-Tec sponge was placed in the posterior oropharynx and the mouth was prepped with Peridex mouthrinse, scrubbed with a toothbrush.  The Peridex was evacuated with Yankauer suction.  Erich arch bars were adapted to the maxilla from the first molar to the contralateral first molar and secured with 24-gauge surgical steel wire on the posterior teeth and 26-gauge surgical steel wire on the anterior teeth.  Same was done on the mandible.  The patient was then manipulated up in the maximum intercuspation and noted to be reproducible.  The throat pack was then removed.,The patient was remanipulated up to the maximum intercuspation and secured with interdental elastics.  At this point in time, the procedure was then determined to be over.,The patient was extubated and transferred to the PACU in good condition.", Surgery,38
"REASON FOR CONSULT:,  Depression.,HPI:,  The patient is an 87-year-old white female admitted for low back pain status post hip fracture sustained a few days before Thanksgiving in 2006.  The patient was diagnosed and treated for a T9 compression fraction with vertebroplasty.  Soon after discharge, the patient was readmitted with severe mid low back pain and found to have a T8 compression fracture.  This was also treated with vertebroplasty.  The patient is now complaining of back pain that fluctuates at time, acknowledging her pain medication works but not all the time.  Her pain is in her upper back around her shoulder blades.  The patient says lying down with the heated pad lessens the pain and that any physical activity increases it.  MRI on January 29, 2007, was positive for possible meningioma to the left of anterior box.,The patient reports of many depressive symptoms, has lost all interest in things she used to do (playing cards, reading).  Has no energy to do things she likes, but does participate in physical therapy, cries often and what she believes for no reason.  Does not see any future for herself.  Reports not being able to concentrate on anything saying she gets distracted by thoughts of how she does not want to live anymore.  Admits to decreased appetite, feeling depressed, and always wanting to be alone.  Claims that before her initial hospitalization for her hip fracture, she was highly active, enjoyed living independently at Terrace.  Denies suicidal ideations and homicidal ideations, but that she did not mind dying, and denies any manic symptoms including decreased need to sleep, inflated self-worth, and impulsivity.  Denies auditory and visual hallucinations.  No paranoid, delusions, or other abnormalities of thought content.  Denies panic attacks, flashbacks, and other feelings of anxiety.  Does admit to feeling restless at times.  Is concerned with her physical appearance while in the hospital, i.e., her hair looking ""awful."",PAST MEDICAL HISTORY:,  Hypertension, cataracts, hysterectomy, MI, osteoporosis, right total knee replacement in April 2004, hip fracture, and newly diagnosed diabetes.  No history of thyroid problems, seizures, strokes, or head injuries.,CURRENT MEDICATIONS:,  Norvasc 10 mg p.o. daily, aspirin 81 mg p.o. daily, Lipitor 20 mg p.o. daily, Klonopin 0.5 mg p.o. b.i.d., digoxin 0.125 mg p.o. daily, Lexapro 10 mg p.o. daily, TriCor 145 mg p.o. each bedtime, Lasix 20 mg p.o. daily, Ismo 20 mg p.o. daily, lidocaine patch, Zestril, Prinivil 40 mg p.o. daily, Lopressor 75 mg p.o. b.i.d., Starlix 120 mg p.o. t.i.d., Pamelor 25 mg p.o. each bedtime, polyethylene glycol 17 g p.o. every other day, potassium chloride 20 mEq p.o. t.i.d., Norco one tablet p.o. q.4h. p.r.n., Zofran 4 mg IV q.6h.,HOME MEDICATIONS:,  Unknown.,ALLERGIES:,  CODEINE (HALLUCINATIONS).,FAMILY MEDICAL HISTORY:,  Unremarkable.,PAST PSYCHIATRIC HISTORY:,  Unremarkable.  Never taken any psychiatric medications or have ever had a family member with psychiatric illness.,SOCIAL/DEVELOPMENTAL HISTORY:,  Unremarkable childhood.  Married for 40 plus years, widowed in 1981.  Worked as administrative assistant in UTMB Hospitals VP's office.  Two children.  Before admission, lived in the Terrace Independent Living Center.  Was happy and very active while living there.  Had friends in the Terrace and would not mind going back there after discharge.  Occasional glass of wine at dinner.  Denies ever using illicit drugs and tobacco.,MENTAL STATUS EXAM:,  The patient is an 87-year-old white female with appropriate appearance, wearing street clothes while lying in bed with her eyes tightly closed.  Slight decrease in motor activity.  Normal eye contact.  Speech, low volume and rate.  Good articulation and inflexion.  Normal concentration.  Mood, labile, tearful at times, depressed, then euthymic.  Affect, mood congruent, full range.  Thought process, logical and goal directed.  Thought content, no delusions, suicidal or homicidal ideations.  Perception, no auditory or visual hallucinations.  Sensorium, alert, and oriented x3.  Memory, fair.  Information and intelligence, average.  Judgment and insight, fair.,MINI MENTAL STATUS EXAM,:  A 28/30.  Could not remember two out of the three recalled words.,ASSESSMENT:,  The patient is an 87-year-old white female with recent history of hip fracture and two thoracic compression fractures.  The patient reports being high functioning prior to admission and says her depression symptoms have occurred while being in the hospital.,Axis I:  Major depression disorder.,Axis II:  Deferred.,Axis III:  Osteoporosis, hypertension, hip fracture, possible diabetes, meningioma, MI, and right total knee replacement.,Axis IV:  Lives independently at Terrace, difficulty walking, hospitalization.,Axis V:  45.,PLAN:,  Continue Lexapro 10 mg daily and Pamelor 25 mg each bedtime monitor for adverse effects of TCA and worsening of depressive symptoms.  Discussed about possible inpatient psychiatric care.,Thank you for the consultation.", Psychiatry / Psychology,32
"TITLE OF OPERATION:,  Lateral and plantar condylectomy, fifth left metatarsal.,PREOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,POSTOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,ANESTHESIA:  ,Monitored anesthesia care with 10 mL of 1:1 mixture of both 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:,  30 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED: , 3-0 Vicryl and 4-0 Vicryl.,INJECTABLES:,  Ancef 1 g IV 30 minutes preoperatively.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room and placed on the operating table in a supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites.  The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg.  The left foot was then prepped, scrubbed, and draped in a normal sterile technique.  The left ankle tourniquet was inflated.  Attention was then directed on the dorsolateral aspect of the fifth left metatarsophalangeal joint where a 4-cm linear incision was placed over the fifth left metatarsophalangeal joint parallel and lateral to the course of the extensor digitorum longus to the fifth left toe.  The incision was deepened through the subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the fifth left metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the soft tissue attachments through the fifth left metatarsal head were mobilized.  The lateral and plantar aspect of the fifth left metatarsal head were adequately exposed and using the sagittal saw a lateral and plantar condylectomy of the fifth left metatarsal head were then achieved.  The bony prominences were removed and passed off the operating table to be sent to pathology for identification.  The remaining sharp edges of the fifth left metatarsal head were then smoothened with the use of a dental rasp.  The area was copiously flushed with saline.  Then, 3-0 Vicryl and 4-0 Vicryl suture materials were used to approximate the periosteal, capsular, and subcutaneous tissues respectively.  The incision was reinforced with Steri-Strips.  Range of motion of the fifth left metatarsophalangeal joint was tested and was found to be excellent and uninhibited.  The patient's left ankle tourniquet at this time was deflated.  Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff.  The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage and the patient's left foot was placed in a surgical shoe.  The patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels.  The patient was given pain medications and instructions on how to control her postoperative course.  She was discharged from Hospital according to nursing protocol and was will follow up with Dr. X in one week's time for her first postoperative appointment.", Surgery,38
"REASON FOR CONSULTATION:,  Newly diagnosed cholangiocarcinoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009.  Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis.  Common bile duct was noted to be 10 mm in size on that ultrasound.  She then underwent a CT scan of the abdomen in July 2010, which showed intrahepatic ductal dilatation with the common bile duct size being 12.7 mm.  She then underwent an MRI MRCP, which was notable for stricture of the distal common bile duct.  She was then referred to gastroenterology and underwent an ERCP.  On August 24, 2010, she underwent the endoscopic retrograde cholangiopancreatography.  She was noted to have a stricturing mass of the mid-to-proximal common bile duct consistent with cholangiocarcinoma.  A temporary biliary stent was placed across the biliary stricture.  Blood work was obtained during the hospitalization.  She was also noted to have an elevated CA99.  She comes in to clinic today for initial Medical Oncology consultation.  After she sees me this morning, she has a follow-up consultation with a surgeon.,PAST MEDICAL HISTORY:  ,Significant for hypertension and hyperlipidemia.  In July, she had eye surgery on her left eye for a muscle repair.  Other surgeries include left ankle surgery for a fractured ankle in 2000.,CURRENT MEDICATIONS: , Diovan 80/12.5 mg daily, Lipitor 10 mg daily, Lutein 20 mg daily, folic acid 0.8 mg daily and multivitamin daily.,ALLERGIES:  ,No known drug allergies.,FAMILY HISTORY: , Notable for heart disease.  She had three brothers that died of complications from open heart surgery.  Her parents and brothers all had hypertension.  Her younger brother died at the age of 18 of infection from a butcher's shop.  He was cutting Argentinean beef and contracted an infection and died within 24 hours.  She has one brother that is living who has angina and a sister who is 84 with dementia.  She has two adult sons who are in good health.,SOCIAL HISTORY: , The patient has been married to her second husband for the past ten years.  Her first husband died in 1995.  She does not have a smoking history and does not drink alcohol.,REVIEW OF SYSTEMS:  ,The patient reports a change in her bowels ever since she had the stent placed.  She has noted some weight loss, but she notes that that is due to not eating very well.  She has had some mild fatigue, but prior to her diagnosis she had absolutely no symptoms.  As mentioned above, she was noted to have abnormal alkaline phosphatase and total bilirubin, AST and ALT, which prompted the followup.  She has had some difficulty with her vision that has improved with her recent surgical procedure.  She denies any fevers, chills, night sweats.  She has had loose stools.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:", Consult - History and Phy.,5
"EXAMINATION: , Cardiac catheterization.,PROCEDURE PERFORMED: , Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.,INDICATION: , Syncope with severe aortic stenosis.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained from the patient, the patient was brought to the cardiac catheterization laboratory in a post observed state.  The right groin was prepped and draped in the usual sterile fashion.  After adequate conscious sedation and local anesthesia was obtained, a 6-French sheath was placed in the right common femoral artery and a 8-French sheath was placed in the right common femoral vein.  Following this, a 7.5-French Swan-Ganz catheter was advanced into the right atrium where the right atrial pressure was 10/7 mmHg.  The catheter was then manipulated into the right ventricle where the right ventricular pressure was 37/10/4 mmHg.  The catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmHg.  The pulmonary arterial pressures were noted to be 31/14/21 mmHg.  Following this, the catheter was removed, the sheath was flushed and a 6-French JL4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views.  Following this, the catheter was exchanged over the guidewire for 6-French JR4 diagnostic catheter.  We were unable to cannulate the right coronary artery.  Therefore, we exchanged for a Williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views.  Following this, this catheter was exchanged over a guidewire for a 6-French Langston pigtail catheter and the left ventricle was entered and left ventriculography was performed.  Following this, the catheters were removed.  Sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6-French Angio-Seal device.  The patient tolerated the procedure well.  There were no complications.,DESCRIPTION OF FINDINGS: , The left main coronary artery is a large vessel, which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions.  The left circumflex artery is a short vessel, which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions.  The left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches.  There is a 70% ostial lesion in the first diagonal branch and the second diagonal branch has mild-to-moderate luminal irregularities.  The right coronary artery is a very large dominant vessel with a 60% to 70% lesion in its descending mid-portion.  The remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions.  The left ventricle appears to be normal sized.  The aortic valve is heavily calcified.  The estimated ejection fraction is approximately 60%.  There was 4+ mitral regurgitation noted.  The mean gradient across the aortic valve was noted to be 33 mmHg yielding an aortic valve area of 0.89 cm2.,CONCLUSION:,1.  Moderate-to-severe coronary artery disease with a high-grade lesion seen at the ostium of the first diagonal artery as well as a 60% to 70% lesion seen at the mid portion of the right coronary artery.,2.  Moderate-to-severe aortic stenosis with an aortic valve area of 0.89 cm2.,3.  4+ mitral regurgitation.,PLAN: , The patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to Dr Kenneth Fang for possible aortic valve replacement as well as mitral valve repair/replacement and possible surgical revascularization.", Cardiovascular / Pulmonary,3
"IDENTIFYING DATA: , The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.,CHIEF COMPLAINT: , ""I am not sure."" The patient has poor insight into hospitalization and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of schizophrenia and chronic paranoid, for which she has received treatment in Houston, Texas.  According to mental health professionals, the patient had been noncompliant with medications for approximately two weeks.  The patient had taken an airplane from Houston to Seattle, but became agitated, paranoid, expressing paranoid delusions that the stewardess and pilots were trying to reject him and was deplaned in Seattle.  The patient was taken to the local shelter where he remained labile, breaking a window, and was taken to jail.  The patient has now been discharged from jail but involuntarily detained for persistent paranoia and disorganization (no jail hold).,PAST PSYCHIATRIC HISTORY: , History of schizophrenia, chronic paranoid.  The patient as noted has been treated in Houston but has not had recent treatment or medications.,PAST MEDICAL HISTORY:  ,No acute medical problems noted.,CURRENT MEDICATIONS: , None.  The patient was most recently treated with Invega and Abilify according to his records.,FAMILY SOCIAL HISTORY: , The patient resides with his father in Houston.  The patient has no known history of substances abuse.  The patient as noted was in jail prior to admission after breaking a window at the local shelter but has no current jail hold.,FAMILY PSYCHIATRIC HISTORY:,  Need to increase database.,MENTAL STATUS EXAMINATION:,Attitude:  Calm and cooperative.,Appearance:  Shows poor hygiene and grooming.,Psychomotor:  Behavior is within normal limits without agitation or retardation.  No EPS or TDS noted.,Affect:  Is suspicious.,Mood:  Anxious but cooperative.,Speech:  Shows normal rate and rhythm.,Thoughts:  Disorganized,Thought Content:  Remarkable for paranoia ""they want to hurt me."",Psychosis:  The patient endorses paranoid delusions as above.  The patient denies auditory hallucinations.,Suicidal/Homicidal Ideation:  The patient denies on admission.,Cognitive Assessment:  Grossly intact.  The patient is alert and oriented x 3.,Judgment:  Poor, shown by noncompliance with treatment.,Assets:  Include stable physical status.,Limitations:  Include recurrent psychosis.,FORMULATION:  ,The patient with a history of schizophrenia was admitted for increasing mood lability and psychosis due to noncompliance with treatment.,INITIAL IMPRESSION:,AXIS I:  Schizophrenia, chronic paranoid.,AXIS II:  None.,AXIS III:  None.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN:  ,The patient will be restarted on Invega and Abilify for psychosis.  The patient will also be continued on Cogentin for EPS.  Increased database will be obtained.", Psychiatry / Psychology,32
"DIAGNOSIS: , Low back pain and degenerative lumbar disk.,HISTORY:,  The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease.  The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms.  The patient states that this occurred in October 2008 as well as November 2008.  The patient has a history of low back pain, secondary to a fall that originally occurred in 2006.  The patient states that she slipped on a newly waxed floor and fell on her tailbone and low back region.  The patient then had her second fall in March 2006.  The patient states that she was qualifying on the range with a handgun and lost her footing and states that she fell more due to weakness in her lower extremities rather than loss of balance.,PAST MEDICAL HISTORY:,  Past medical history is significant for allergies and thyroid problems.,PAST SURGICAL HISTORY: , The patient has a past surgical history of appendectomy and hysterectomy.,MEDICATIONS:,1.  TriCor.,2.  Vytorin.,3.  Estradiol.,4.  Levothyroxine.,5.  The patient is also taking ibuprofen 800 mg occasionally as needed for pain management.  The patient states she rarely takes this and does not like to take pain medication if at all possible.  The patient states that she has had uncomplicated pregnancies in the past.,SOCIAL HISTORY:,  The patient states she lives in a single-level home with her husband, who is in good health and is able to assist with any tasks or activities the patient is having difficulty with.  The patient rates her general health as excellent and denies any smoking and reports very occasional alcohol consumption.  The patient does state that she has completed exercises on a daily basis of one to one and a half hours a day.  However, has not been able to complete these exercise routine since approximately June 2008, secondary to back pain.  The patient is working full-time as a project manager, and is required to do extensive walking at various periods during a workday.,MEDICAL IMAGING:,  The patient states that she has had an MRI recently performed; however, the results are not available at the time of the evaluation.  The patient states she is able to bring the report in upon next visit.,SUBJECTIVE:  ,The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse.  The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region.  Aggravating factors include stairs and prolonged driving, as well as general limitations with home tasks and projects.  The patient states she is a very active individual and is noticing extreme limitations with ability to complete home tasks and projects she used to be able to complete.,NEUROLOGICAL SYMPTOMS:,  The patient reports having occasional shooting pains into the lower extremities.  However, these are occurring less frequently and is now occurring more frequently in the right versus the left lower extremity when they do occur.,FUNCTIONAL ACTIVITIES AND HOBBIES: , Include exercising and general activities.,PATIENT'S GOAL: , The patient would like to improve her overall body movements and return to daily exercise routine as able and well maintaining safety.,OBJECTIVE: , Upon observation, the patient ambulates independently without the use of assistive device.  However, does present with mild limp and favoring the left lower extremity after extensive standing and walking activity.  The patient does have mild difficulty transferring from the seated position to standing.  However, once is upright, the patient denies any increased pain or symptoms.,ACTIVE RANGE OF MOTION OF LUMBAR SPINE:  ,Forward flexion is 26 cm, fingertip to floor, lateral side bend, fingertip to floor is 52.5 cm bilaterally.,STRENGTH: , Strength is grossly 4/5.  The patient denies any significant tenderness to palpation.  However, does have mild increase in tenderness on the right versus left.  A six-minute walk test revealed painful symptoms and achiness occurring after approximately 400 feet of walking.  The patient was able to continue; however, stopped after 700 feet.  There were two minutes remaining in the six-minute walk test.  The patient does have tight hamstrings as well as a negative slump test.,ASSESSMENT: , The patient would benefit from skilled physical therapy intervention in order to address the following problem list.,PROBLEM LIST:,1.  Increased pain.,2.  Decreased ability to complete tasks and hobbies.,3", Physical Medicine - Rehab,30
"PROCEDURE PERFORMED: , Bassini inguinal herniorrhaphy.,ANESTHESIA: , Local with MAC anesthesia.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  The patient was sedated and an adequate local anesthetic was administered using 1% lidocaine without epinephrine.  The patient was prepped and draped in the usual sterile manner.,A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.  The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated.  The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors.  Care was taken not to injure the ilioinguinal nerve.  Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was then used to retract the cord structures as needed.  Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures.  The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery.,Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature.  The sac was excised and sent to Pathology.  The stump was examined and no bleeding was noted.  The ends of the suture were then cut, and the stump retracted back into the abdomen.,The floor of the inguinal canal was then strengthened by suturing the shelving edge of Poupart's ligament to the conjoined tendon using a 2-0 Prolene, starting at the pubic tubercle and running towards the internal ring.  In this manner, an internal ring was created that admitted just the tip of my smallest finger.,The Penrose drain was removed.  The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring.  Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior and superior iliac spine and around the wound for postanesthetic pain control.  The skin incision was approximated with skin staples.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  Bilateral hydroceles.,POSTOPERATIVE DIAGNOSIS:,  Bilateral hydroceles.,PROCEDURE: , Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,FLUIDS RECEIVED: , 800 mL.,TUBES AND DRAINS: , A 0.25-inch Penrose drains x4.,INDICATIONS FOR OPERATION:  ,The patient is a 17-year-old boy, who has had fairly large hydroceles noted for some time.  Finally, he has decided to have them get repaired.  Plan is for surgical repair.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then shaved, prepped, and then sterilely prepped and draped.  IV antibiotics were given.  Ancef 1 g given.  A scrotal incision was then made in the right hemiscrotum with a 15-blade knife and further extended with electrocautery.  Electrocautery was used for hemostasis.  Once we got to the hydrocele sac itself, we then opened and delivered the testis, drained clear fluid.  There was moderate amount of scarring on the testis itself from the tunica vaginalis.  It was then wrapped around the back and sutured in place with a running suture of 4-0 chromic in a Lord maneuver.  Once this was done, a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation.  A similar procedure was performed on the left, which has also had a hydrocele of the cord, which were both addressed and closed with Lord maneuver similarly.  This testis also was normal but had moderate amount of scarring on the tunic vaginalis from this.  A similar drain was placed.  The testes were then placed back into the scrotum in a proper orientation, and the local wound instillation and wound block was then placed using 30 mL of 0.5% Marcaine without epinephrine.  IV Toradol was given at the end of the procedure.  The skin was then sutured with a running interlocking suture of 3-0 Vicryl and the drains were sutured to place with 3-0 Vicryl.  Bacitracin dressing, ABD dressing, and jock strap were placed.  The patient was in stable condition upon transfer to the recovery room.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Refractory dyspepsia.,POSTOPERATIVE DIAGNOSIS:,1.  Hiatal hernia.,2.  Reflux esophagitis.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with pseudo and esophageal biopsy.,ANESTHESIA:,  Conscious sedation with Demerol and Versed.,SPECIMEN: , Esophageal biopsy.,COMPLICATIONS: , None.,HISTORY:,  The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.  She has been on multiple medical regimens and continues with dyspeptic symptoms.,PROCEDURE: , After proper informed consent was obtained, the patient was brought to the endoscopy suite.  She was placed in the left lateral position and was given IV Demerol and Versed for sedation.  When adequate level of sedation achieved, the gastroscope was inserted into the hypopharynx and the esophagus was easily intubated.  At the GE junction, a hiatal hernia was present.  There were mild inflammatory changes consistent with reflux esophagitis.  The scope was then passed into the stomach.  It was insufflated and the scope was coursed along the greater curvature to the antrum.  The pylorus was patent.  There was evidence of bile reflux in the antrum.  The duodenal bulb and sweep were examined and were without evidence of mass, ulceration, or inflammation.  The scope was then brought back into the antrum.,A retroflexion was attempted multiple times, however, the patient was having difficulty holding the air and adequate retroflexion view was not visualized.  The gastroscope was then slowly withdrawn.  There were no other abnormalities noted in the fundus or body.  Once again at the GE junction, esophageal biopsy was taken.  The scope was then completely withdrawn.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.  She will return to the General Medical Floor.  We will continue b.i.d proton-pump inhibitor therapy as well as dietary restrictions.  She should also attempt significant weight loss.", Gastroenterology,14
"HISTORY: , A 34-year-old male presents today self-referred at the recommendation of Emergency Room physicians and his nephrologist to pursue further allergy evaluation and treatment.  Please refer to chart for history and physical, as well as the medical records regarding his allergic reaction treatment at ABC Medical Center for further details and studies.  In summary, the patient had an acute event of perioral swelling, etiology uncertain, occurring on 05/03/2008 requiring transfer from ABC Medical Center to XYZ Medical Center due to a history of renal failure requiring dialysis and he was admitted and treated and felt that his allergy reaction was to Keflex, which was being used to treat a skin cellulitis dialysis shunt infection.  In summary, the patient states he has some problems with tolerating grass allergies, environmental and inhalant allergies occasionally, but has never had anaphylactic or angioedema reactions.  He currently is not taking any medication for allergies.  He is taking atenolol for blood pressure control.  No further problems have been noted upon his discharge and treatment, which included corticosteroid therapy and antihistamine therapy and monitoring.,PAST MEDICAL HISTORY:,  History of urticaria, history of renal failure with hypertension possible source of renal failure, history of dialysis times 2 years and a history of hypertension.,PAST SURGICAL HISTORY:,  PermCath insertion times 3 and peritoneal dialysis.,FAMILY HISTORY: , Strong for heart disease, carcinoma, and a history of food allergies, and there is also a history of hypertension.,CURRENT MEDICATIONS: , Atenolol, sodium bicarbonate, Lovaza, and Dialyvite.,ALLERGIES: , Heparin causing thrombocytopenia.,SOCIAL HISTORY: , Denies tobacco or alcohol use.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Age 34, blood pressure 128/78, pulse 70, temperature is 97.8, weight is 207 pounds, and height is 5 feet 7 inches.,GENERAL:  The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,HEAD:  Normocephalic.  No masses or lesions noted.,FACE:  No facial tenderness or asymmetry noted.,EYES:  Pupils are equal, round and reactive to light and accommodation bilaterally.  Extraocular movements are intact bilaterally.,EARS:  The tympanic membranes are intact bilaterally with a good light reflex.  The external auditory canals are clear with no lesions or masses noted.  Weber and Rinne tests are within normal limits.,NOSE:  The nasal cavities are patent bilaterally.  The nasal septum is midline.  There are no nasal discharges.  No masses or lesions noted.,THROAT:  The oral mucosa appears healthy.  Dental hygiene is maintained well.  No oropharyngeal masses or lesions noted.  No postnasal drip noted.,NECK:  The neck is supple with no adenopathy or masses palpated.  The trachea is midline.  The thyroid gland is of normal size with no nodules.,NEUROLOGIC:  Facial nerve is intact bilaterally.  The remaining cranial nerves are intact without focal deficit.,LUNGS:  Clear to auscultation bilaterally.  No wheeze noted.,HEART:  Regular rate and rhythm.  No murmur noted.,IMPRESSION:  ,1.  Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.,2.  Renal failure requiring dialysis.,3.  Hypertension.,RECOMMENDATIONS:  ,RAST allergy testing for both food and environmental allergies was performed, and we will get the results back to the patient with further recommendations to follow.  If there is any specific food or inhalant allergen that is found to be quite high on the sensitivity scale, we would probably recommend the patient to avoid the offending agent to hold off on any further reactions.  At this point, I would recommend the patient stopping any further use of cephalosporin antibiotics, which may be the cause of his allergic reaction, and I would consider this an allergy.  Being on atenolol, the patient has a more difficult time treating acute anaphylaxis, but I do think this is medically necessary at this time and hopefully we can find specific causes for his allergic reactions.  An EpiPen was also prescribed in the event of acute angioedema or allergic reaction or sensation of impending allergic reaction and he is aware he needs to proceed directly to the emergency room for further evaluation and treatment recommendations after administration of an EpiPen.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS:,  Stress urinary incontinence, intrinsic sphincter deficiency.,POSTOPERATIVE DIAGNOSES: , Stress urinary incontinence, intrinsic sphincter deficiency.,OPERATIONS: , Cystoscopy, cystocele repair, BioArc midurethral sling.,ANESTHESIA:,  Spinal.,EBL: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY:  ,The patient is a 69-year-old female with a history of hysterectomy, complained of urgency, frequency, and stress urinary incontinence.  The patient had urodynamics done and a cystoscopy, which revealed intrinsic sphincter deficiency.  Options such as watchful waiting, Kegel exercises, broad-based sling to help with ISD versus Coaptite bulking agents were discussed.  Risks and benefits of all the procedures were discussed.  The patient understood and wanted to proceed with BioArc.  Risk of failure of the procedure, recurrence of incontinence due to urgency, mesh erosion, exposure, etc., were discussed.  Risk of MI, DVT, PE, and bleeding etc., were discussed.  The patient understood the risk of infection and wanted to proceed with the procedure.  The patient was told that due to the intrinsic sphincter deficiency, we will try to make the sling little bit tighter to allow better urethral closure, which may put her a high risk of retention versus if we make it too loose, then she may leak afterwards.,The patient understood and wanted to proceed with the procedure.,DETAILS OF THE OPERATION: , The patient was brought to the OR and anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A Foley catheter was placed.  Bladder was emptied.  Two Allis clamps were placed on the anterior vaginal mucosa.  Lidocaine 1% with epinephrine was applied, and hydrodissection was done.  Incision was made.  A bladder was lifted off of the vaginal mucosa.  The bladder cystocele was reduced.  Two stab incisions were placed on the lateral thigh over the medial aspect of the obturator canal.  Using BioArc needle, the needles were passed through under direct palpation through the vaginal incision from the lateral thigh to the vaginal incision.  The mesh arms were attached and arms were pulled back the outer plastic sheath and the excess mesh was removed.  The mesh was right at the bladder neck to the mid-urethra, completely covering over the entire urethra.,The sling was kept little tight, even though the right angle was easily placed between the urethra and the BioArc material.  The urethra was coapted very nicely.  At the end of the procedure, cystoscopy was done and there was no injury to the bladder.  There was good efflux of urine with indigo carmine coming through from both the ureteral openings.  The urethra was normal, seemed to have closed up very nicely with the repair.  The vaginal mucosa was closed using 0 Vicryl in interrupted fashion.  The lateral thigh incisions were closed using Dermabond.  Please note that the irrigation with antibiotic solution was done prior to the BioArc mesh placement.  The mesh was placed in antibiotic solution prior to the placement in the body.  The patient tolerated the procedure well.  After closure, Premarin cream was applied.  The patient was told to use Premarin cream postop.  The patient was brought to Recovery in stable condition.,The patient was told not to do any heavy lifting, pushing, pulling, and no tub bath, etc., for at least 2 months.  The patient understood.  The patient was to follow up as an outpatient.", Surgery,38
"EXAM: , CT abdomen without contrast and pelvis without contrast, reconstruction.,REASON FOR EXAM: , Right lower quadrant pain, rule out appendicitis.,TECHNIQUE:  ,Noncontrast CT abdomen and pelvis.  An intravenous line could not be obtained for the use of intravenous contrast material.,FINDINGS: , The appendix is normal.  There is a moderate amount of stool throughout the colon.  There is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process.  Examination of the extreme lung bases appear clear, no pleural effusions.  The visualized portions of the liver, spleen, adrenal glands, and pancreas appear normal given the lack of contrast.  There is a small hiatal hernia.  There is no intrarenal stone or evidence of obstruction bilaterally.  There is a questionable vague region of low density in the left anterior mid pole region, this may indicate a tiny cyst, but it is not well seen given the lack of contrast.  This can be correlated with a followup ultrasound if necessary.  The gallbladder has been resected.  There is no abdominal free fluid or pathologic adenopathy.  There is abdominal atherosclerosis without evidence of an aneurysm.,Dedicated scans of the pelvis disclosed phleboliths, but no free fluid or adenopathy.  There are surgical clips present.  There is a tiny airdrop within the bladder.  If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.,IMPRESSION:,1.Normal appendix.,2.Moderate stool throughout the colon.,3.No intrarenal stones.,4.Tiny airdrop within the bladder.  If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.  The report was faxed upon dictation.", Gastroenterology,14
"PREOPERATIVE DIAGNOSIS:,  Chest wall mass, left.,POSTOPERATIVE DIAGNOSIS: , Chest wall mass, left.,PROCEDURE:,  Removal of chest wall mass.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was brought to the operating room where he underwent a general endotracheal anesthetic.  The time-out process was followed and preoperative antibiotics were given.  The patient was in the supine position and was prepped and draped in the usual fashion.,The area of the mass, which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected.  An incision was made directly on the mass and carried down to the ribs.  This is where the several chondral cartilages of the lower ribs meet.  So I believe they were isolated in 9th rib anteriorly and I was able to encircle it.  The medial area was __________.  There was no way to perform same procedure there, so what I did, I took an electric saw and proceeded to divide the calcified cartilages of the sternum and also the attachments to the lower ribs.  There was also a separate sharp growth of the mass growing superiorly.  Apparently, I was able to excise the mass and actually it was much larger than it was palpated externally.  This may be due to an extension towards the inside of his chest.  Hemostasis was revised.  The internal mammary was intact and there was no obvious penetration of the pleural cavity.  The specimen was sent to Pathology and then we proceeded to close the defect.  Obviously, the space between the ribs cannot be approximated.  So what we did was approximate the pectoralis major operative defect and then the soft tissues and the skin with subcuticular suture of Monocryl.,The patient tolerated the procedure well.  Estimated blood loss was minimal and he was sent to the recovery room in satisfactory condition.", Surgery,38
"DIAGNOSIS: , Left knee osteoarthritis.,HISTORY: , The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis.  The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area.  The patient was transferred from the hospital to a nursing home and lived there for 1 year.  Prior to this incident, the patient was ambulating independently with a pickup walker throughout her home.  Since that time, the patient has only been performing transverse and has been unable to ambulate.  The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.,PAST MEDICAL HISTORY: , High blood pressure, obesity, right patellar fracture with pin in 1990, and history of blood clots.,MEDICATIONS:  ,Naproxen, Plavix, and stool softener.,MEDICAL DIAGNOSTICS: , The patient states that she had an x-ray of the knee in 2007 and was diagnosed with osteoarthritis.,SUBJECTIVE:,  The patient reports that when seated and at rest, her knee pain is 0/10.  The patient states that with active motion of the left knee, the pain in the anterior portion increases to 5/10.,PATIENT'S GOAL: , To transfer better and walk 5 feet from her bed to the couch.,INSPECTION: , The right knee has a large 8-inch long and very wide tight scar with adhesions to the underlying connective tissue due to her patellar fracture and surgery following an MVA in 1990, bilateral knees are very large due to obesity.  There are no scars, bruising or increased temperature noted in the left knee.,RANGE OF MOTION: , Active and passive range of motion of the right knee is 0 to 90 degrees and the left knee, 0 to 85 degrees.  Pain is elicited during active range of motion of the left knee.,PALPATION: , Palpation to the left knee elicits pain around the patellar tendon and to each side of this area.,FUNCTIONAL MOBILITY:  ,The patient reports that she transfers with standby to contact-guard assist in the home from her bed to her wheelchair and return.  The patient is able to stand modified independent from wheelchair level and tolerates at least 15 seconds of standing prior to needing to sit down due to the left knee pain.,ASSESSMENT:  ,The patient is a 58-year-old female with left knee osteoarthritis.  Examination indicates deficits in pain, muscle endurance, and functional mobility.  The patient would benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN:  ,The patient will be seen two times per week for an initial 4 weeks with re-assessment at that time for an additional 4 weeks if needed.,INTERVENTIONS INCLUDE:,1.  Modalities including electrical stimulation, ultrasound, heat, and ice.,2.  Therapeutic exercise.,3.  Functional mobility training.,4.  Gait training.,LONG-TERM GOALS TO BE ACHIEVED IN 4 WEEKS:,1.  The patient is to have increased endurance in bilateral lower extremities as demonstrated by being able to perform 20 repetitions of all lower extremity exercises in seated and supine positions with minimum 2-pound weight.,2.  The patient is to perform standby assist transfer using a pickup walker.,3.  The patient is to demonstrate 4 steps of ambulation using forward and backward using a pickup walker or front-wheeled walker.,4.  The patient is to report maximum 3/10 pain with weightbearing of 2 minutes in the left knee.,LONG-TERM GOALS TO BE ACHIEVED IN 8 WEEKS:,1.  The patient is to be independent with the home exercise program.,2.  The patient is to tolerate 20 reps of standing exercises with pain maximum of 3/10.,3.  The patient is to ambulate 20 feet with the most appropriate assistive device.,PROGNOSIS TO THE ABOVE-STATED GOALS:,  Fair to good.,The above treatment plan has been discussed with the patient.  She is in agreement.", Physical Medicine - Rehab,30
"CHIEF COMPLAINT:  ,This 18 year old male presents today with shoulder pain right.  Location:  He indicates the problem location is the right shoulder diffusely.  Quality:  Quality of the pain is described by the patient as aching, throbbing and tolerable.  Patient relates pain on a scale from 0 to 10 as 5/10.  Severity:  The severity has worsened over the past 3 months.  Timing (onset/frequency):  Onset was gradual and after pitching a baseball game.  Modifying Factors:  Patient's condition is aggravated by throwing.  He participates with difficulty in basketball.  Past conservative treatments include NSAID and muscle relaxant medications.,ALLERGIES: , No known medical allergies.,MEDICATION HISTORY:,  None.,PAST MEDICAL HISTORY:  ,Childhood Illnesses: (+) strep throat (+) mumps (+) chickenpox,PAST SURGICAL HISTORY:,  No previous surgeries.,FAMILY HISTORY:,  Patient admits a family history of arthritis associated with mother.,SOCIAL HISTORY: , Patient denies smoking, alcohol abuse, illicit drug use and STDs.,REVIEW OF SYSTEMS:,Musculoskeletal: (+) joint or musculoskeletal symptoms (+) stiffness in AM.,Psychiatric: (-) psychiatric or emotional difficulties.,Eyes: (-) visual disturbance or change.,Neurological: (-) neurological symptoms or problems Endocrine: (-) endocrine-related symptoms.,Allergic / Immunologic: (-) allergic or immunologic symptoms.,Ears, Nose, Mouth, Throat: (-) symptoms involving ear, nose, mouth, or throat.,Gastrointestinal: (-) GI symptoms.,Genitourinary: (-) GU symptoms.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Respiratory: (-)breathing difficulties, respiratory symptoms.,Physical Exam:  BP Standing:  116/68 Resp:  16 HR:  68 Temp:  98.1 Height:  5 ft.  11 in.  Weight:  165 lbs.  Patient is a 18 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus.  Oriented to person, place and time.  Right shoulder shows evidence of swelling and tenderness.  Radial pulses are 2 /4, bilateral.  Brachial pulses are 2 /4, bilateral.,Appearance:  Normal.,Tenderness:  Anterior - moderate, Biceps - none, Posterior - moderate and Subacromial - moderate right.,Range of Motion:  Right shoulder ROM shows decreased flexion, decreased extension, decreased adduction, decreased abduction, decreased internal rotation, decreased external rotation.  L shoulder normal.,Strength:  External rotation - fair.  Internal rotation - poor right.,AC Joint:  Pain with ABD and cross-chest - mild right.,Rotator Cuff:  Impingement - moderate.  Painful arc - moderate right.,Instability:  None.,TEST & X-RAY RESULTS:,  X-rays of the shoulder were performed.  X-ray of right shoulder reveals cuff arthropathy present.,IMPRESSION: , Rotator cuff syndrome, right.,PLAN: , Diagnosis of a rotator cuff tendinitis and shoulder impingement were discussed.  I noted that this is a very common condition resulting in significant difficulties with use of the arm.  Several treatment options and their potential benefits were described.  Nonsteroidal anti-inflammatories can be helpful but typically are slow acting.  Cortisone shots can be very effective and are quite safe.  Often more than one injection may be required.  Physical therapy can also be helpful, particularly if there is any loss of shoulder mobility or strength.  If these treatments fail to resolve symptoms, an MRI or shoulder arthrogram may be required to rule out a rotator cuff tear.  Injected shoulder joint and with Celestone Soluspan 1.0 cc .  Ordered x-rays of shoulder right.,PRESCRIPTIONS:,  Vioxx Dosage:  25 mg tablet Sig:  TID Dispense:  60 Refills:  0 Allow Generic:  Yes,PATIENT INSTRUCTIONS:,  Patient was instructed to restrict activity.  Patient was given instructions on RICE therapy.", Orthopedic,27
"DATE OF ADMISSION:,  MM/DD/YYYY.,DATE OF DISCHARGE: , MM/DD/YYYY.,REFERRING PHYSICIAN: , AB CD, M.D.,ATTENDING PHYSICIAN AT DISCHARGE:,  X Y, M.D.,ADMITTING DIAGNOSES:,1.  Ewing sarcoma.,2.  Anemia.,3.  Hypertension.,4.  Hyperkalemia.,PROCEDURES DURING HOSPITALIZATION:  ,Cycle seven Ifosfamide, mesna, and VP-16 chemotherapy.,HISTORY OF PRESENT ILLNESS: , Ms. XXX is a pleasant 37-year-old African-American female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.  She presented initially with a left frontal orbital swelling to Dr. XYZ on MM/DD/YYYY.  A biopsy revealed small round cells and repeat biopsy on MM/DD/YYYY also showed round cells consistent with Ewing sarcoma, genetic analysis indicated a T1122 translocation.  MRI on MM/DD/YYYY showed a 4 cm soft tissue mass without bony destruction.  CT showed similar result.  The patient received her first cycle of chemotherapy on MM/DD/YYYY.  On MM/DD/YYYY, she was admitted to the ED with nausea and vomitting and was admitted to the Hematology and Oncology A Service following her first course of chemotherapy.  She had her last course of chemotherapy on MM/DD/YYYY followed by radiation treatment to the ethmoid sinuses on MM/DD/YYYY.,HOSPITAL COURSE: ,1.  Ewing sarcoma, she presented for cycle seven of VP-16, ifosfamide, and mesna infusions, which she tolerated well throughout the admission.,2.  She was followed for hemorrhagic cystitis with urine dipsticks and only showed trace amounts of blood in the urine throughout the admission.", Discharge Summary,10
"PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Pelvic pain.,3.  Pelvic endometriosis.,PROCEDURE PERFORMED: ,Total abdominal hysterectomy.,ANESTHESIA: , General endotracheal and spinal with Astramorph.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 200 cc.,FLUIDS:  ,2400 cc of crystalloids.,URINE OUTPUT: , 100 cc of clear urine.,INDICATIONS:,  This is a 40-year-old female gravida-0 with a history of longstanding enlarged fibroid uterus.  On ultrasound, the uterus measured 14 cm x 6.5 cm x 7.8 cm.  She had received two dosage of Lupron to help shrink the fibroid.  Her most recent Pap smear was normal.,FINDINGS: , On a manual exam, the uterus is enlarged approximately 14 to 16 weeks size with multiple fibroids palpated.  On laparotomy, the uterus did have multiple pedunculated fibroids, the largest being approximately 7 cm.  The bilateral tubes and ovaries appeared normal.,There was evidence of endometriosis on the posterior wall of the uterus as well as the bilateral infundibulopelvic ligament.  There was some adhesions of the bowel to the left ovary and infundibulopelvic ligament and as well as to the right infundibulopelvic ligament.,PROCEDURE:,  After consent was obtained, the patient was taken to the operating room where spinal anesthetic was first administered and then general anesthetic.  The patient was placed in the dorsal supine position and prepped and draped in normal sterile fashion.  A Pfannenstiel skin incision was made and carried to the underlying Mayo fashion using the second knife.  The fascia was incised in midline and the incision extended laterally using Mayo scissors.  The superior aspect of the fascial incision was grasped with Kocher clamps, tented up, and dissected off the underlying rectus muscle both bluntly and sharply with Mayo scissors.  Attention was then turned to the inferior aspect of the incision, which in a similar fashion was grasped with Kocher clamps, tented up and dissected off the underlying rectus muscles.  The rectus muscles were separated in the midline and the peritoneum was identified, grasped with hemostat, and entered sharply with Metzenbaum scissors.  This incision was extended superiorly and inferiorly with good visualization of the bladder.  The uterus was then brought up out of the incision.  The bowel adhesions were carefully taken down using Metzenbaum scissors.  Good hemostasis was noted at this point.  The self-retaining retractor was then placed.  The bladder blade was placed.  The bowel was gently packed with moist laparotomy sponges and held in place with the blade on the GYN extension.  The uterus was then grasped with a Lahey clamp and brought up out of the incision.  The left round ligament was identified and grasped with Allis clamp and tented up.  A hemostat was passed in the avascular area beneath the round ligament.  A suture #0 Vicryl was used to suture ligate the round ligament.  Two hemostats were placed across the round ligament proximal to the previously placed suture and the Mayo scissors were used to transect the round ligament.  An avascular area of the broad ligament was then identified and entered bluntly.  The suture of #0 Vicryl was then used to suture ligate the left uterovarian ligament.  Two straight Ochsner's were placed across the uterovarian ligament proximal to the previous suture.  The ligament was then transected and suture ligated with #0 Vicryl.  Attention was then turned to the right round ligament, which in a similar fashion was tented up with an Allis clamp.  An avascular area was entered beneath the round ligament using a hemostat and the round ligament was suture ligated and transected.  An avascular area of the broad ligament was then entered bluntly and the right uterovarian ligament was then suture ligated with #0 Vicryl.,Two straight Ochsner's were placed across the ligament proximal to previous suture.  This was then transected and suture ligated again with #0 Vicryl.  The left uterine peritoneum was then identified and grasped with Allis clamps.  The vesicouterine peritoneum was then transected and then entered using Metzenbaum scissors.  This incision was extended across the anterior portion of the uterus and the bladder flap was taken down.  It was sharply advanced with Metzenbaum scissors and then bluntly using a moist Ray-Tec.  The Ray-Tec was left in place at this point to ensure that the bladder was below the level of the cervix.  The bilateral uterine arteries then were skeletonized with Metzenbaum scissors and clamped bilaterally using straight Ochsner's.  Each were then transected and suture ligated with #0 Vicryl.  A curved Ochsner was then placed on either side of the cervix.  The tissue was transected using a long knife and suture ligated with #0 Vicryl.  Incidentally, prior to taking down the round ligaments, a pedunculated fibroid and the right fundal portion of the uterus was injected with Vasopressin and removed using a Bovie.  The cervix was then grasped with a Lahey clamp.  The cervicovaginal fascia was then taken down first using the long-handed knife and then a back handle of the knife to bring the fascia down below the level of the cervix.  A double-pointed scissors were used to enter the vaginal vault below the level of the cervix.  A straight Ochsner was placed on the vaginal vault.  The Jorgenson scissors were used to amputate the cervix and the uterus off of the underlying vaginal tissue.  The vaginal cuff was then reapproximated with #0 Vicryl in a running locked fashion and the pelvis was copiously irrigated.  There was a small area of bleeding noted on the underside of the bladder.  The bladder was tented up using an Allis clamp and a figure-of-eight suture of #3-0 Vicryl was placed with excellent hemostasis noted at this point.  The uterosacral ligaments were then incorporated into the vaginal cuff and the cuff was synched down.  A figure-of-eight suture of #0 Vicryl was placed in the midline of the vaginal cuff in attempt to incorporate the bilateral round ligament.  The round ligament was too short.  It would be a maximal amount of stretch to incorporate, therefore, only the left round ligament was incorporated into the vaginal cuff.  The bilateral adnexal areas were then re-peritonealized with #3-0 Vicryl in a running fashion.  The bladder flap was reapproximated to the vaginal cuff using one interrupted suture.  The pelvis was again irrigated at this point with excellent hemostasis noted.  Approximately 200 cc of saline with methylene blue was placed into the Foley to inflate the bladder.  There was no spillage of blue fluid into the abdomen.  The fluid again was allowed to drain.  All sponges were then removed and the bowel was allowed to return to its anatomical position.  The peritoneum was then reapproximated with #0 Vicryl in a running fashion.  The fascia was reapproximated also with #0 Vicryl in a running fashion.  The skin was then closed with staples.,A previously placed Betadine soaked Ray-Tec was removed from the patient's vagina and sponge stick was used to assess any bleeding in the vaginal vault.  There was no appreciable bleeding.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  The patient was taken to the recovery room in satisfactory condition.  She will be followed immediately postoperatively within the hospital.", Obstetrics / Gynecology,24
"EXAM: , CT scan of the abdomen and pelvis with contrast.,REASON FOR EXAM: , Abdominal pain.,COMPARISON EXAM: , None.,TECHNIQUE: , Multiple axial images of the abdomen and pelvis were obtained.  5-mm slices were acquired after injection of 125 cc of Omnipaque IV.  In addition, oral ReadiCAT was given.  Reformatted sagittal and coronal images were obtained.,DISCUSSION:,  There are numerous subcentimeter nodules seen within the lung bases.  The largest measures up to 6 mm.  No hiatal hernia is identified.  Consider chest CT for further evaluation of the pulmonary nodules.  The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys are within normal limits.  No dilated loops of bowel.  There are punctate foci of air seen within the nondependent portions of the peritoneal cavity as well as the anterior subcutaneous fat.  In addition, there is soft tissue stranding seen of the lower pelvis.  In addition, the uterus is not identified.  Correlate with history of recent surgery.  There is no free fluid or lymphadenopathy seen within the abdomen or pelvis.  The bladder is within normal limits for technique.,No acute bony abnormalities appreciated.  No suspicious osteoblastic or osteolytic lesions.,IMPRESSION:,1.  Postoperative changes seen within the pelvis without appreciable evidence for free fluid.,2.  Numerous subcentimeter nodules seen within the lung bases.  Consider chest CT for further characterization.", Radiology,33
"PREOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,POSTOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,6.  Grade 1+ rectocele.,PROCEDURE PERFORMED:  ,D&C and hysteroscopy.,COMPLICATIONS: , None.,HISTORY: , The patient is a 48-year-old para 2, vaginal delivery.  She has heavy periods lasting 7 to 14 days with spotting in between her periods.  The patient's uterus is 12.2 x 6.2 x 5.3 cm.  Her endometrial thickness is 2 cm.  Her adnexa is within normal limits.  The patient and I had a long discussion.  Consent was reviewed in layman's terms.  The patient understood the foreseeable risks and complications, the alternative treatments and procedure itself and recovery.  Questions were answered.  The patient was taken back to the operative suite.  The patient underwent pelvic examination and then carefully placed in dorsal lithotomy position.  The patient had excellent femoral pulses and there was no excessive extension or hyperflexion of the lower extremities.  The patient's history is that she is at risk for development of condyloma.  The patient's husband was found to have a laryngeal papillomatosis.  She has had a laparotomy, which is an infraumbilical incision appendectomy, a laparoscopy, and bilateral tubal ligation.  Her uterus appears to be mobile by 12-week size.  There is a good descend.  There appears to be no adnexal abnormalities.  Uterus is 12-week sized and has fibroids, it is boggy and probably has a component of adenomyosis.  The patient's cervix was dilated without difficulty utilizing Circon ACMI hysteroscope with a 12-degree lens.  The patient underwent hysteroscopy.  The outflow valve was opened at all times.  The inflow valve was opened just to achieve appropriate distension.  The patient did have no evidence of trauma of the cervix.  No Trendelenburg as we were in room #9.  The patient also had the bag held two fingerbreadths above the level of the heart.  The patient was seen.  There is a 2 x 3 cm focal thickening of the posterior wall of the uterus' endometrial lining, a more of a polypoid nature.  The patient also has one in the fundal area.  The thickened tissue was removed via sharp curettage.  Therefore, we reinserted the hysteroscope.  It appeared that there was an appropriate curettage and that all areas of suspicion were indeed removed.  The patient's procedure was ended with specimen being obtained and sent to Department of Pathology.  We will follow her up in the office.", SOAP / Chart / Progress Notes,35
"ADMITTING DIAGNOSIS: , Cerebrovascular accident (CVA).,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old gentleman with a significant past medical history for nasopharyngeal cancer status post radiation therapy to his pharynx and neck in 1991 who presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness.  This occurred at 2:30 a.m.  His wife said that he had trouble speaking as well, but gradually the symptoms resolved but he was still complaining of a headache and at that point, he was brought to the emergency room.  He arrived at the emergency room here via private ambulance at 6:30 a.m. in the morning.  Upon initial evaluation, he did have some left-sided weakness and was complaining of a headache.  He underwent workup including a CT, which was negative and his symptoms slowly began to resolve.  He was initially admitted, placed on Plavix and aspirin.  However a few hours later, his symptoms returned and he had increasing weakness of his left arm and left leg as well as slurred speech.  Repeat CT scan again done reportedly was negative and he was subsequently heparinized and admitted.  He also underwent an echo, carotid ultrasound, and lab work in the emergency room.  Wife is at the bedside and denies he had any other symptoms previous to this.  He denied any chest pain or palpitations.  She does report that he is on a Z-Pak, got a cortisone shot, and some decongestant from Dr. ABC on Saturday because of congestion and that had gotten better.,ALLERGIES:  ,He has no known drug allergies.,CURRENT MEDICATIONS:,1.  Multivitamin.,2.  Ibuprofen p.r.n.,PAST MEDICAL HISTORY:,1.  Nasopharyngeal cancer.  Occurred in 1991.  Status post XRT of the nasopharyngeal area and his neck because of spread to the lymph nodes.,2.  Lumbar disk disease.,3.  Status post diskectomy.,4.  Chronic neck pain secondary to XRT.,5.  History of thalassemia.,6.  Chronic dizziness since his XRT in 1991.,PAST SURGICAL HISTORY: , Lumbar diskectomy, which is approximately 7 to 8 years ago, otherwise negative.,SOCIAL HISTORY: , He is a nonsmoker.  He occasionally has a beer.  He is married.  He works as a flooring installer.,FAMILY HISTORY:  ,Pertinent for father who died of an inoperable brain tumour.  Mother is obese, but otherwise negative history.,REVIEW OF SYSTEMS:  ,He reports he was in his usual state of health up until he awoke this morning.  He does states that yesterday his son cleaned the walk area with some ether and since then he has not quite been feeling right.  He is a right-handed male and normally wears glasses.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Stable.  His blood pressure was 156/97 in the emergency room, pulse is 73, respiratory rate 20, and saturation is 99%.,GENERAL:  He is alert, pleasant, and in no acute distress at this time.  He answers questions appropriately.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.  Sclerae are clear.  TMs clear.  Oropharynx is clear.,NECK:  Supple with full range of motion.  He does have some increased density to neck, I assume, secondary to XRT.,CARDIOVASCULAR:  Regular rate and rhythm without murmur.,LUNGS:  Clear bilaterally.,ABDOMEN:  Soft, nontender, and nondistended.,EXTREMITIES:  Show no clubbing, cyanosis or edema.,NEUROLOGIC:  He does have a minimally slurred speech at present.  He does have a slight facial droop.  He has significant left upper extremity weakness approximately 3-4/5, left lower extremity weakness is approximately a 2-3/5 on the left.  Handgrip is about 4/5 on the left, right side is 5/5.,LABORATORY DATA:  ,His initial blood work, PT was 11 and PTT 27.  CBC is within normal limits except for hemoglobin of 12.9 and hematocrit of 39.1.  Chem panel is all normal.,EKG showed normal sinus rhythm, normal EKG.  CT of his brain, initially his first CT, which was done this morning at approximately 7 a.m. showed a normal CT.  Repeat CT done at approximately 3:30 p.m. this evening was reportedly also normal.  He underwent an echocardiogram in the emergency room, which was essentially normal.  He had a carotid ultrasound, which revealed total occlusion of the right internal carotid artery, 60% to 80% stenosis of the left internal carotid artery, and 60% stenosis of the left external carotid artery.,MPRESSION AND PLAN:,1.  Cerebrovascular accident, in progress.", Consult - History and Phy.,5
"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,", Urology,39
"PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Normal colon with no evidence of bleeding.,2.  Hiatal hernia.,3.  Fundal gastritis with polyps.,4.  Antral mass.,ANESTHESIA: , Conscious sedation with Demerol and Versed.,SPECIMEN:  ,Antrum and fundal polyps.,HISTORY: , The patient is a 66-year-old African-American female who presented to ABCD Hospital with mental status changes.  She has been anemic as well with no gross evidence of blood loss.  She has had a decreased appetite with weight loss greater than 20 lb over the past few months.  After discussion with the patient and her daughter, she was scheduled for EGD and colonoscopy for evaluation.,PROCEDURE: , After informed consent was obtained, the patient was brought to the endoscopy suite.  She was placed in the left lateral position and was given IV Demerol and Versed for sedation.  When adequate level of sedation was achieved, a digital rectal exam was performed, which demonstrated no masses and no hemorrhoids.  The colonoscope was inserted into the rectum and air was insufflated.  The scope was coursed through the rectum and sigmoid colon, descending colon, transverse colon, ascending colon to the level of the cecum.  There were no polyps, masses, diverticuli, or areas of inflammation.  The scope was then slowly withdrawn carefully examining all walls.  Air was aspirated.  Once in the rectum, the scope was retroflexed.  There was no evidence of perianal disease.  No source of the anemia was identified.,Attention was then taken for performing an EGD.  The gastroscope was inserted into the hypopharynx and was entered into the hypopharynx.  The esophagus was easily intubated and traversed.  There were no abnormalities of the esophagus.  The stomach was entered and was insufflated.  The scope was coursed along the greater curvature towards the antrum.  Adjacent to the pylorus, towards the anterior surface, was a mass like lesion with a central _______.  It was not clear if this represents a healing ulcer or neoplasm.  Several biopsies were taken.  The mass was soft.  The pylorus was then entered.  The duodenal bulb and sweep were examined.  There was no evidence of mass, ulceration, or bleeding.  The scope was then brought back into the antrum and was retroflexed.  In the fundus and body, there was evidence of streaking and inflammation.  There were also several small sessile polyps, which were removed with biopsy forceps.  Biopsy was also taken for CLO.  A hiatal hernia was present as well.  Air was aspirated.  The scope was slowly withdrawn.  The GE junction was unremarkable.  The scope was fully withdrawn.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  She will undergo a CAT scan of her abdomen and pelvis to further assess any possible adenopathy or gastric obstructional changes.  We will await the biopsy reports and further recommendations will follow.", Surgery,38
"EXAM: , Screening full-field digital mammogram.,HISTORY:,  Screening examination of a 58-year-old female who currently denies complaints.  Patient has had diagnosis of right breast cancer in 1984 with subsequent radiation therapy.  The patient's sister was also diagnosed with breast cancer at the age of 59.,TECHNIQUE: , Standard digital mammographic imaging was performed.  The examination was performed with iCAD Second Look Version 7.2.,COMPARISON: , Most recently obtained __________.,FINDINGS: , The right breast is again smaller than the left.  There is a scar marker with underlying skin thickening and retraction along the upper margin of the right breast.  The breasts are again composed of a mixture of adipose tissue and a moderate amount of heterogeneously-dense fibroglandular tissue.  There is again some coarsening of the right breast parenchyma with architectural distortion which is unchanged and most consistent with postsurgical and postradiation changes.  A few benign-appearing microcalcifications are present.,No dominant malignant-appearing mass lesion, developing area of architectural distortion or suspicious-appearing cluster of microcalcifications are identified.  The skin is stable.  No enlarged axillary lymph node is seen.,IMPRESSION:,1.  No significant interval changes are seen.  No mammographic evidence of malignancy is identified.,2.  Annual screening mammography is recommended or sooner if clinical symptoms warrant.,BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.", Radiology,33
"PREOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet arthropathy with scar tissue.,3.  No evidence of instability.,OPERATIVE PROCEDURE PERFORMED,1.  Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty.,2.  Total laminectomy C3, C4, C5, and C6.,3.  Excision of scar tissue.,4.  Repair of dural tear with Prolene 6-0 and Tisseel.,FLUIDS:,  1500 cc of crystalloid.,URINE OUTPUT: , 200 cc.,DRAINS: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA:,  General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:,  Less than 250 cc.,INDICATIONS FOR THE OPERATION:  ,This is the case of a very pleasant 41 year-old Caucasian male well known to me from previous anterior cervical discectomy and posterior decompression.  Last surgery consisted of four-level decompression on 08/28/06.  The patient continued to complain of posterior neck pain radiating to both trapezius.  Review of his MRI revealed the presence of what still appeared to be residual lateral recess stenosis.  It also raised the possibility of instability and based on this I recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial.  Based on this, I did total decompression by removing the lamina of C3 through C6 and doing bilateral medial facetectomy and foraminotomy at C3-C4, C4-C5, C5-C6, and C6-C7 with no spinal instrumentation.  Operation and expected outcome risks and benefits were discussed with him prior to the surgery.  Risks include but not exclusive of bleeding and infection.  Infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection.  There is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord.  This may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma.  There is also the risk of a dural tear with its attendant problems of CSF leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis.  This too may require return to the operating room for evacuation of said pseudomeningocele and repair.  The patient understood the risk of the surgery.  I told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were also placed by Premier Neurodiagnostics for both SSEP and EMG monitoring.  The SSEPs were normal, and the EMGs were silent during the entire case.  After completion of the placement of the monitoring leads, the patient was then positioned prone on a Wilson frame with the head supported on a foam facial support.  Shave was then carried out over the occipital and suboccipital region.  All pressure points were padded.  I proceeded to mark the hypertrophic scar for excision.  This was initially cleaned with alcohol and prepped with DuraPrep.,After sterile drapes were laid out, incision was made using a scalpel blade #10.  Wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar.  Dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of C2 was then identified.  There was absence of the spinous process of C3, C4, C5, and C6, but partial laminectomy was noted; removal of only 15% of the lamina.  With this completed, we proceeded to do a total laminectomy at C3, C4, C5, and C6, which was technically difficult due to the previous surgery.  There was also a dural tear on the right C3-C4 space that was exposed and repaired with Prolene 6-0 and later with Tisseel.  By careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at C3-C4, C4-C5, C5-C6, and C6-C7.  There was significant epidural bleeding, which was carefully coagulated.  At two points, I had to pack this with small pieces of Gelfoam.  After repair of the dural tear, Valsalva maneuver showed no evidence of any CSF leakage.  Area was irrigated with saline and bacitracin and then lined with Tisseel.  The wound was then closed in layers with Vicryl 0 simple interrupted sutures to the fascia; Vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch.  The patient was extubated and transferred to recovery.", Orthopedic,27
"Chief Complaint:, Abdominal pain, nausea, vomiting, fever, altered mental status.,History of Present Illness:, 55 yo WM with reactive airways disease, allergic rhinitis who was in his usual state of health until he underwent a dental extraction with administration of cephalexin 1 week prior to admission. Approximately one day after the dental procedure, he began having nausea, and abdominal pain along with fatigue. The abdominal pain was described as pressure-like and was located in the epigastrium and periumbilical regions. He initially attributed the symptoms to a side effect of the antibiotic he was taking. However, with worsening of his symptoms, he presented to the ER 5 days after dental extraction.,At that time his vitals were T 99.9 ° HR 115 RR 18 BP 182/101. His exam was notable for mild tenderness in the central abdomen. Laboratory evaluation was notable for WBC 15.6, Hgb 13.1, Plt 189, 16% bands, 68% PMNs. Na 127, K4.7, Cl 88, CO2 29, BUN 19, Cr 1.5, Glucose 155, Ca 9.6, alk phos 125, t bili 0.7, ALT 29, nl amylase and lipase. UA with 100 protein, lg blood, 53 RBC, 2 WBC. Plain films done at that time revealed dilation of small bowel loops in mid-abdomen up to 3.5cm in diameter, thought to be most consistent with a paralytic ileus. The patient was discharged home with diagnosis of medication-induced gastroenteritis vs. UTI. He was instructed to stop his current antibiotic but start Levaquin, and he was given Vicodin, and phenergan for symptomatic relief.,Over the next 2 days, the patient began having fevers, non-bloody emesis, diarrhea, and confusion in addition to his persistent nausea, and abdominal pain. On the night of presentation, the patient was found by a cousin in his bathroom lethargic and disoriented. EMS was called and patient was taken to the ER. In the ER, the pt was diaphoretic, unable to answer questions appropriately, hypotensive, and febrile, with some response of bp to multiple IVF boluses (4L). He received acetaminophen, and ceftriaxone 2g IV after blood cultures were obtained and an LP was performed in the ER. He was then admitted to the ICU for further evaluation and management.,Past Medical History:,Asthma,Allergic Rhinitis,Medications:,loratadine,beclomethasone nasal,fluticasone/salmeterol inhaled,Montelukast,cephalexin,hydrocodone,Allergies:, PCN, but has tolerated cephalosporins in the past.,Social History:, No tobacco use, occasional EtOH, no known drug use, works as a real estate agent.,Family History:, HTN, father with SLE, uncle with Addison’s Disease.,Physical Exam:,T 102.9 ° HR 145 RR 22 BP 99/50 98% on room air, (orthostatics were not performed due to patient’s mental status),I/O: minimal urine output after Foley insertion,Gen: lethargic, mild tachypnea,HEENT: no evidence of trauma, sclerae anicteric, pupils are equal round and reactive to light, oropharynx clear, MM dry.,Neck: supple, without increased JVP, lymphadenopathy or bruits. No thyromegaly,Chest: coarse rhonchi bilaterally,CV: tachycardia, regular, no murmurs, gallops, rubs,Abd: hypoactive bowel sounds, soft, slightly distended, mild tenderness throughout. No rebound, no masses or hepatosplenomegaly.,Ext: no cyanosis, clubbing, or edema. 2+ pulses bilateral distal extremities, no petechiae or splinter hemorrhages.,Neuro: lethargic, but arousable, oriented to person, but not to place, or time. He was not able to answer questions appropriately. Moved all extremities equally but was uncooperative with exam. 2+ DTRs bilaterally, no Babinski reflex.,Skin: no rash, ecchymosis, or petechiae,STUDIES:,EKG: sinus tachycardia, normal axis, isolated Q in III, no TWI or ST elevations or depressions,CXR: Heart normal in size, pulmonary vasculature unremarkable, subsegmental atelectasis in the lower lobes. Acromioclavicular osteoarthritis bilaterally. Lucent lesion in the subchondral bone of the R humeral head, likely a degenerative subchondral cyst.,AXR: Minimal dilation of the small bowel loops in the mid abdomen measuring up to 3cm, no mass lesion or free air visible.,MRI brain pre and post gadolinium: No evidence of hemorrhage, abnormal enhancement, mass lesions, mass effect or edema. The ventricles, sulci, and cisterns are age appropriate in size and configuration. There is no evidence for restricted diffusion. There is mucosal thickening lining the walls of the left maxillary sinus, also containing an air fluid level with two different levels within it, most likely from proteinaceous differences. There is mucosal thickening along the posterior wall of the right maxillary sinus. Mucosal thickening is identified along the walls of the sphenoid sinus, ethmoid sinuses and frontal sinus. Sinusitis with chronic and acute features.,Echo: EF 50%, mild LV concentric hypertrophy, otherwise normal chamber sizes and function,TEE: Normal valves, no thrombi, PFO with R to L shunt, trivial MR, trivial TR,RLE Ultrasound with Dopplers – total deep venous obstruction in distal external iliac, common femoral, profunda femoral, and femoral vein, partial DVT in popliteal and posterior tibial veins, and total DVT greater saphenous vein. No venous obstruction on the L LE. R calf 34cm, R thigh 42 cm, L calf 31cm, L thigh 39cm.,CT Abdomen (initial ER visit): Trace bilateral pleural fluid, findings in liver compatible with diffuse fatty infiltration, 3.5cm non calcified R adrenal mass was noted, along with an edematous L adrenal with no discrete mass. There was retroperitoneal edema around the lower abdominal aorta with perinephric stranding, no stone or obstruction. Moderate fullness of small bowel loops was noted, most consistent with a paralytic ileus.,Hospital Course:, The patient developed right lower extremity swelling and was diagnosed with deep venous thrombosis. Diagnostic studies were performed.", General Medicine,15
"PREOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,POSTOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,PROCEDURES:,1.  Rigid bronchoscopy with removal of foreign body, prolonged procedure taking two hours to remove the stent piecemeal in a very difficult and trying situation.,2.  Excision of granulation tissue tumor.,3.  Bronchial dilation with a balloon bronchoplasty, right main bronchus.,4.  Argon plasma coagulation to control bleeding in the trachea.,5.  Placement of a tracheal and bilateral bronchial stents with a silicon wire stent.,ENDOSCOPIC FINDINGS:,1.  Normal true vocal cords.,2.  Proximal trachea with high-grade occlusion blocking approximately 90% of the trachea due to granulation tissue tumor and break down of metallic stent.,3.  Multiple stent fractures in the mid portion of the trachea with granulation tissue.,4.  High-grade obstruction of the right main bronchus by stent and granulation tissue.,5.  Left main bronchus was covered by the distal portion of the stent and was only being ventilated through the struts of the stent.,6.  All in all a high-grade terrible airway obstruction with involvement of the carina, left and right main stem bronchus, mid, distal, and proximal trachea.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient, he was brought into the operating field.  A rapid sequence induction was done.  He was intubated with a rigid scope.  Jet ventilation technique was carried out using a rigid and flexible scope.  A thorough airway inspection was carried out with findings as described above.,Dr. D was present in the operating room and we conferred on operative strategy and agreed that the best of strategy would be to first dilate the right main bronchus, cauterize it to control bleeding and then piecemeal removed the stent from distal to proximal.  This is the technique that was carried out in a painstaking fashion removing bits of the stent piecemeal with finally getting all of the visible stent out of the airway.  It should be noted that Dr. Donovan and I felt that two of the metallic stents were probably in place but we cannot be sure because of the terrible anatomy and the fact that the stent pieces were coming out twisted metal in fragments.  Nevertheless, all the visible stent was removed, and the airway was much better after with the dilation of balloon and the rigid scope.  We took measurements and decided to place stents in the trachea, left and right main bronchus using a Dumon Y-stent.  It was measured 18 mm in tracheal diameter and 14 mm in bronchial diameter.  The right main stem stent was 2.25 cm in length, the left main stem stent was 3 cm in length and the tracheal portion was 9 cm in length.  After it was placed, excellent placement was achieved with the proximal end of the stent 3 cm below the true vocal cords.  The patient tolerated the procedure well and was brought to the recovery room extubated.", Cardiovascular / Pulmonary,3
"PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES: , Rectal bleeding and perirectal abscess.,POSTOPERATIVE DIAGNOSIS: , Perianal abscess.,MEDICATIONS:,  MAC.,DESCRIPTION OF PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  The preparation was excellent and all surfaces were well seen.  The mucosa throughout the colon and in the terminal ileum was normal, with no evidence of colitis.  Special attention was paid to the rectum, including retroflexed views of the distal rectum and the anorectal junction.  There was no evidence of either inflammation or a fistulous opening.  The scope was withdrawn.  A careful exam of the anal canal and perianal area demonstrated a jagged 8-mm opening at the anorectal junction posteriorly (12 o'clock position).  Some purulent material could be expressed through the opening.  There was no suggestion of significant perianal reservoir of inflamed tissue or undrained material.  Specifically, the posterior wall of the distal rectum and anal canal were soft and unremarkable.  In addition, scars were noted in the perianal area.  The first was a small dimpled scar, 1 cm from the anal verge in the 11 o'clock position.  The second was a dimpled scar about 5 cm from the anal verge on the left buttock's cheek.  There were no other abnormalities noted.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Normal colonoscopy to the terminal ileum.,2.  Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.,RECOMMENDATIONS:,1.  Continue antibiotics.,2.  Followup with Dr. X.,3.  If drainage persists, consider surgical drainage.", Gastroenterology,14
"PREOPERATIVE DIAGNOSES:  ,1.  Congenital chylous ascites and chylothorax.,2.  Rule out infradiaphragmatic lymphatic leak.,POSTOPERATIVE DIAGNOSES: , Diffuse intestinal and mesenteric lymphangiectasia.,ANESTHESIA: , General.,INDICATION:  ,The patient is an unfortunate 6-month-old baby boy, who has been hospitalized most of his life with recurrent chylothoraces and chylous ascites.  The patient has been treated somewhat successfully with TPN and voluntary restriction of enteral nutrition, but he had repeated chylothoraces.  Last week, Dr. X took the patient to the operating room in hopes that with thoracotomy, a thoracic duct leak could be found, which would be successfully closed surgically.  However at the time of his thoracotomy exploration what was discovered was a large amount of transdiaphragmatic transition of chylous ascites coming from the abdomen.  Dr. X opened the diaphragm and could literally see a fountain of chylous fluid exiting through the diaphragmatic hole.  This was closed, and we decided that perhaps an abdominal exploration as a last stage effort would allow us to find an area of lymphatic leak that could potentially help the patient from this dismal prognostic disease.  We met with his parents and talked to them about this, and he is here today for that attempt.,OPERATIVE FINDINGS:  ,The patient's abdomen was relatively soft, minimally distended.  Exploration through supraumbilical transverse incision immediately revealed a large amount of chylous ascites upon entering into the peritoneal cavity.  What we found which explains the chronic chylous ascites and chylothorax was a diffuse lymphangiectatic picture involving the small bowel mesentery approximately two thirds to three quarters of the distal small bowel including all of the ileum, the cecum, and the portion of the ascending colon.  It appeared that any attempt to resect this area would have been met with failure because of the extensive lymphatic dilatation all the way down towards the root of the supramesenteric artery.  There was about one quarter to one third of the jejunum that did not appear to be grossly involved, but I did not think that resection of three quarters of the patient's small bowel would be viable surgical option.  Instead, we opted to close his abdomen and refer for potential small intestine transplantation procedure in the future if he is a candidate for that.,The lymphatic abnormality was extensive.  They were linear dilated lymphatic channels on the serosal surface of the bowel in the mesentery.  They were small aneurysm-like pockets of chyle all along the course of the mesenteric structures and in the mesentery medially adjacent to the bowel as well.  No other major retroperitoneal structure or correctable structure was identified.  Both indirect inguinal hernias were wide open and could be palpated from an internal aspect as well.,DESCRIPTION OF OPERATION:  ,The patient was brought from the Pediatric Intensive Care Unit to the operating room within an endotracheal tube im place and with enteral feeds established at full flow to provide maximum fat content and maximum lymphatic flow.  We conducted a surgical time-out and reiterated all of the patient's important identifying information and confirmed the operative plan as described above.  Preparation and draping of his abdomen was done with chlorhexidine based prep solution and then we opened his peritoneal cavity through a transverse supraumbilical incision dividing both rectus muscles and all layers of the abdominal wall fascia.  As the peritoneal cavity was entered, we divided the umbilical vein ligamentum teres remnant between Vicryl ties, and we were able to readily identify a large amount of chylous ascites that had been previously described.  The bowel was eviscerated, and then with careful inspection, we were able to identify this extensive area of intestinal and mesenteric lymphangiectasia that was a source of the patient's chylous ascites.  The small bowel from the ligament of Treitz to the proximal to mid jejunum was largely unaffected, but did not appear that resection of 75% of the small intestine and colon would be a satisfactory tradeoff for The patient, but would likely render him with significant short bowel and nutritional and metabolic problems.  Furthermore, it might burn bridges necessary for consideration of intestinal transplantation in the future if that becomes an option.  We suctioned free all of the chylous accumulations, replaced the intestines to their peritoneal cavity, and then closed the patient's abdominal incision with 4-0 PDS on the posterior sheath and 3-0 PDS on the anterior rectus sheath.  Subcuticular 5-0 Monocryl and Steri-Strips were used for skin closure.,The patient tolerated the procedure well.  He lost minimal blood, but did lose approximately 100 mL of chylous fluid from the abdomen that was suctioned free as part of the chylous ascitic leak.  The patient was returned to the Pediatric Intensive Care Unit with his endotracheal tube in place and to consider the next stage of management, which might be an attempted additional type of feeding or referral to an Intestinal Transplantation Center to see if that is an option for the patient because he has no universally satisfactory medical or surgical treatment for this at this time.", Gastroenterology,14
"PREOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Laryngeal edema.,POSTOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Laryngeal edema.,PROCEDURE PERFORMED: , Tracheostomy change.  A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.,INDICATIONS: , The patient is a 60-year-old Caucasian female who presented to ABCD General Hospital with exacerbation of COPD and CHF.  The patient had subsequently been taken to the operating room by Department of Otolaryngology and a direct laryngoscope was performed.  The patient was noted at that time to have transglottic edema.  Biopsies were taken.  At the time of surgery, it was decided that the patient required a tracheostomy for maintenance of continued ventilation and airway protection.  The patient is currently postop day #6 and appears to be unable to be weaned from ventilator at this time and may require prolonged ventricular support.  A decision was made to perform tracheostomy change.,DESCRIPTION OF PROCEDURE: , The patient was seen in the Intensive Care Unit.  The patient was placed in a supine position.  The neck was then extended.  The sutures that were previously in place in the #6 Shiley with proximal extension were removed.  The patient was preoxygenated to 100%.  After several minutes, the patient was noted to have a pulse oximetry of 100%.  The IV tubing that was supporting the patient's trache was then cut.  The tracheostomy tube was then suctioned.,The inner cannula was then removed from the tracheostomy and a nasogastric tube was placed down the lumen of the tracheostomy tube as a guidewire.  The tracheostomy tube was then removed over the nasogastric tube and the operative field was suctioned.  With the guidewire in place and with adequate visualization, a new #6 Shiley with proximal extension was then passed over the nasogastric tube guidewire and carefully inserted into the trachea.  The guidewire was then removed and the inner cannula was then placed into the tracheostomy.  The patient was then reconnected to the ventilator and was noted to have normal tidal volumes.  The patient had a tidal volume of 500 and was returning 500 cc to 510 cc.  The patient continued to saturate well with saturations 99%.  The patient appeared comfortable and her vital signs were stable.  A soft trache collar was then connected to the trachesotomy.  A drain sponge was then inserted underneath the new trache site.  The patient was observed for several minutes and was found to be in no distress and continued to maintain adequate saturations and continued to return normal tidal volumes.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well.  0.25% acetic acid soaks were ordered to the drain sponge every shift.", Cardiovascular / Pulmonary,3
"EXAM: , Transvaginal ultrasound.,HISTORY: , Pelvic pain.,FINDINGS: , The right ovary measures 1.6 x 3.4 x 2.0 cm.  There are several simple-appearing probable follicular cysts. There is no abnormal flow to suggest torsion on the right.  Left ovary is enlarged, demonstrating a 6.0 x 3.5 x 3.7 cm complex cystic mass of uncertain etiology.  This could represent a large hemorrhagic cyst versus abscess.  There is no evidence for left ovarian torsion.  There is a small amount of fluid in the cul-de-sac likely physiologic.,The uterus measures 7.7 x 5.0 cm.  The endometrial echo is normal at 6 mm.,IMPRESSION:,1.  No evidence for torsion.,2.  Large, complex cystic left ovarian mass as described.  This could represent a large hemorrhagic cyst; however, an abscess/neoplasm cannot be excluded.  Recommend either short interval followup versus laparoscopic evaluation given the large size and complex nature.", Radiology,33
"HISTORY OF PRESENT ILLNESS:,  This is a 41-year-old registered nurse (R.N.).  She was admitted following an overdose of citalopram and warfarin.  The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage.  She notes starting in January, her husband of five years seemed to be quite withdrawn.  It turned out, he was having an affair with one of her best friends and he subsequently moved in with this woman.  The patient is distressed, as over the five years of their marriage, she has gotten herself into considerable debt supporting him and trying to find a career that would work for him.  They had moved to ABCD where he had recently been employed as a restaurant manager.  She also moved her mother and son out there and is feeling understandably upset that he was being dishonest and deceitful with her.  She has history of seasonal affective disorder, winter depressions, characterized by increased sleep, increased irritability, impatience, and fatigue.  Some suggestion on her part that her father may have had some mild bipolar disorder and including the patient has a cyclical and recurrent mood disorder.  In January, she went on citalopram.  She reports since that time, she has lost 40 pounds of weight, has trouble sleeping at night, thinks perhaps her mood got worse on the citalopram, which is possible, though it is also possible that the progressive nature of getting divorce than financial problems has contributed to her worsening mood.,PAST AND DEVELOPMENTAL HISTORY: , She was born in XYZ.  She describes the family as being somewhat dysfunctional.  Father was a truckdriver.  She is an only child.  She reports that she had a history of anorexia and bulimia as a teenager.  In her 20s, she served six years in Naval Reserve.  She was previously married for four years.  She described that as an abusive relationship.  She had a history of being in counseling with ABC, but does not think this therapist, who is now by her estimate 80 years old, is still in practice.,PHYSICAL EXAMINATION:  ,GENERAL:  This is an alert and cooperative woman.,VITAL SIGNS:  Temperature 98.1, pulse 60, respirations 18, blood pressure 95/54, oxygen saturation 95%, and weight is 132.,PSYCHIATRIC:  She makes good eye contact.  Speech is normal in rate, volume, grammar, and vocabulary.  There is no thought disorder.  She denies being suicidal.  Her affect is appropriate for material being discussed.  She has a sense of future, wants to get back to work, has plans to return to counseling.  She appeared to have normal orientation, concentration, memory, and judgment.,Medical history is notable for factor V Leiden deficiency, history of pulmonary embolus, restless legs syndrome.  She has been off her Mirapex.  I did encourage her to go back on the Mirapex, which would likely lead to some improvement in mood by facilitating better sleep.,The patient at this time can contract for safety.  She has made plans for outpatient counseling this Saturday and we will get a referral to a psychiatrist for which she is agreeable to following up with.,LABORATORY DATA: , INR, which is still 8.8.  In 1998, she had a normal MRI.  Electrolytes, BUN, creatinine, and CBC were all normal.,DIAGNOSES:  ,1.  Seasonal depressive disorder.,2.  Restless legs syndrome.,3.  Overdose of citalopram and warfarin.,RECOMMENDATIONS: , The patient reports she has been feeling better since discontinuing antidepressants.  I, therefore, recommend she stay off antidepressants at present.  If needed, she can take Prozac, which has been effective for her in the past and she plans to see a psychiatrist for consultation.  She does give a fairly good history of seasonal depression and given that her mood has improved in the past with Prozac, this will be an appropriate agent to try as needed in the future, but given the situational nature of the depression, she primarily appears to need counseling.,Please feel free to contact me at digital pager if there is additional information I can provide.", Consult - History and Phy.,5
"DIAGNOSES:,1.  Bronchiolitis, respiratory syncytial virus positive; improved and stable.,2.  Innocent heart murmur, stable.,HOSPITAL COURSE: , The patient was admitted for an acute onset of congestion.  She was checked for RSV, which was positive and admitted to the hospital for acute bronchiolitis.  She has always been stable on room air; however, because of her age and her early diagnosis, she was admitted for observation as RSV bronchiolitis typically worsens the third and fourth day of illness.  She was treated per pathway orders.  However, on the second day of admission, the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission.  There was a heart murmur that was heard that sounded innocent, but yet there was no chest x-ray that was obtained.  We did obtain a chest x-ray, which did show a slight perihilar infiltrate in the right upper lobe.  However, the rest of the lungs were normal and the heart was also normal.  There were no complications during her hospitalization and she continued to be stable and eating better.  On day 2 of the admission, it was decided she was okay to go home.  Mother was advised regarding signs and symptoms of increased respiratory distress, which includes tachypnea, increased retractions, grunting, nasal flaring etc. and she was very comfortable looking for this.  During her hospitalization, albuterol MDI was given to the patient and more for mom to learn outpatient care.  The patient did receive a couple of doses, but she did not have any significant respiratory distress and she was discharged in improved condition.,DISCHARGE PHYSICAL EXAMINATION:,VITAL SIGNS:  She is afebrile.  Vital signs were stable within normal limits on room air.,GENERAL:  She is sleeping and in no acute distress.,HEENT:  Her anterior fontanelle was soft and flat.  She does have some upper airway congestion.,CARDIOVASCULAR:  Regular rate and rhythm with a 2-3/6 systolic murmur that radiates to bilateral axilla and the back.,EXTREMITIES:  Her femoral pulses were 2+ and her extremities were warm and well perfused with good capillary refill.,LUNGS:  Her lungs did show some slight coarseness, but good air movement with equal breath sounds.  She does not have any wheezes at this time, but she does have a few scattered crackles at bilateral bases.  She did not have any respiratory distress while she was asleep.,ABDOMEN:  Normal bowel sounds.  Soft and nondistended.,GENITOURINARY:  She is Tanner I female.,DISCHARGE WEIGHT:,  Her weight at discharge 3.346 kg, which is up 6 grams from admission.,DISCHARGE INSTRUCTIONS: , ,ACTIVITY:  No one should smoke near The patient.  She should also avoid all other exposures to smoke such as from fireplaces and barbecues.  She is to avoid contact with other infants since she is sick and they are to limit travel.  There should be frequent hand washings.,DIET:  Regular diet.  Continue breast-feeding as much as possible and encourage oral intake.,MEDICATIONS:  She will be sent home on albuterol MDI to be used as needed for cough, wheezes or dyspnea.,ADDITIONAL INSTRUCTIONS:,  Mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing, if she stops breathing or she decides that she does not want to eat.,", Discharge Summary,10
"PREOPERATIVE DIAGNOSIS:,  Bilateral upper lobe cavitary lung masses.,POSTOPERATIVE DIAGNOSES:,1.  Bilateral upper lobe cavitary lung masses.,2.  Final pending pathology.,3.  Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left.  There are also changes of inflammation throughout.,PROCEDURE PERFORMED: , Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.,ANESTHESIA: , Conscious sedation was with Demerol 150 mg and Versed 4 mg IV.,OPERATIVE REPORT: , The patient is residing in the endoscopy suite.  After appropriate anesthesia and sedation, the bronchoscope was advanced transorally due to the patient's recent history of epistaxis.  Topical lidocaine was utilized for anesthesia.  Epiglottis and vocal cords demonstrated some mild asymmetry of the true cords with right true and false vocal cord appearing slightly more prominent.  This may be normal anatomic variant.  The scope was advanced into the trachea.  The main carina was sharp in appearance.  Right upper, middle, and lower segmental bronchi as well as left upper lobe and lower lobe segmental bronchi were serially visualized.  Immediately noted were some abnormalities including circumferential narrowing and probable edema involving the posterior and apical segmental bronchi on the right and to a lesser degree the anterior segmental bronchus on the left.  No specific intrinsic masses were noted.  Under direct visualization, the scope was utilized to lavage the posterior segmental bronchus in the right upper lobe.  Also cytologic brushings and protected bacteriologic brushing specimens were obtained.  Three biopsies were attempted within the cavitary lesion in the posterior segment of the right upper lobe.  During lavage, some caseous appearing debris appeared intermittently.  The specimens were collected and sent to the lab.  Procedure was terminated with hemostasis having been verified.  The patient tolerated the procedure well.,Throughout the procedure, the patient's vital signs and oximetry were monitored and remained within satisfactory limits.,The patient will be returned to her room with orders as per usual.", Surgery,38
"DOBUTAMINE STRESS ECHOCARDIOGRAM,REASON FOR EXAM: , Chest discomfort, evaluation for coronary artery disease.,PROCEDURE IN DETAIL: , The patient was brought to the cardiac center.  Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute.  The patient maximized at 30 mcg/kg per minute.  Images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145.  Maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.,Wall motion assessed at all levels as well as at recovery.,The patient got nauseated, had some mild shortness of breath.  No angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.,The resting heart rate was 78 with the resting blood pressure 186/98.  Heart rate reduced by the vasodilator effects of dobutamine to 130/80.  Maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.,The EKG at rest showed sinus rhythm with no ST-T wave depression suggestive of ischemia or injury.  Incomplete right bundle-branch block was seen.  The maximal stress test EKG showed sinus tachycardia.  There was subtle upsloping ST depression in III and aVF, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no ST elevation seen.,No ventricular tachycardia or ventricular ectopy seen during the test.  The heart rate recovered in a normal fashion after using metoprolol 5 mg.,The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.,The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose.  All walls mentioned were augmented in a normal fashion.  At maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation.  EF improved to about 70%.,The wall motion score was unchanged.,IMPRESSION:,1.  Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.,2.  Negative EKG criteria for ischemia.,3.  Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view.  This is considered the negative dobutamine stress echocardiogram test, medical management.", Radiology,33
"HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.  The patient also has a positive history of smoking in the past.  At the present time, he is admitted for continued,management of respiratory depression with other medical complications.  The patient was treated for multiple problems at Jefferson Hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter.  In addition, he also developed cardiac complications including atrial fibrillation.  The patient was evaluated by the cardiologist as well as the pulmonary service and Urology.  He had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008.  He subsequently underwent cardiac arrest and he was resuscitated at that time.  He was intubated and placed on mechanical ventilatory support.  Subsequent weaning was unsuccessful.  He then had a tracheostomy placed.,CURRENT MEDICATIONS:,1.  Albuterol.,2.  Pacerone.,3.  Theophylline,4.  Lovenox.,5.  Atrovent.,6.  Insulin.,7.  Lantus.,8.  Zestril.,9.  Magnesium oxide.,10.  Lopressor.,11.  Zegerid.,12.  Tylenol as needed.,ALLERGIES:,  PENICILLIN.,PAST MEDICAL HISTORY:,1.  History of coal miner's disease.,2.  History of COPD.,3.  History of atrial fibrillation.,4.  History of coronary artery disease.,5.  History of coronary artery stent placement.,6.  History of gastric obstruction.,7.  History of prostate cancer.,8.  History of chronic diarrhea.,9.  History of pernicious anemia.,10.  History of radiation proctitis.,11.  History of anxiety.,12.  History of ureteral stone.,13.  History of hydronephrosis.,SOCIAL HISTORY: , The patient had been previously a smoker.  No other could be obtained because of tracheostomy presently.,FAMILY HISTORY: , Noncontributory to the present condition and review of his previous charts.,SYSTEMS REVIEW: , The patient currently is agitated.  Rapidly moving his upper extremities.  No other history regarding his systems could be elicited from the patient.,PHYSICAL EXAM:,General:  The patient is currently agitated with some level of distress.  He has rapid respiratory rate.  He is responsive to verbal commands by looking at the eyes.,Vital Signs:  As per the monitors are stable.,Extremities:  Inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage II especially over the dorsum of the hands and forearm areas.  There is also edema of the forearm extending up to the mid upper arm area.  Palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect.  There is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,IMPRESSION:,1.  Ulceration of bilateral upper extremities.,2.  Cellulitis of upper extremities.,3.  Lymphedema of upper extremities.,4.  Other noninfectious disorders of lymphatic channels.,5.  Ventilatory-dependent respiratory failure.", Cardiovascular / Pulmonary,3
"PROCEDURE PERFORMED,1.  Placement of a subclavian single-lumen tunneled Hickman central venous catheter.,2.  Surgeon-interpreted fluoroscopy.,OPERATION 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 anesthesia was administered.  Next, a #18-gauge needle was used to locate the subclavian vein.  After aspiration of venous blood, a J wire was inserted through the needle using Seldinger technique.  The needle was withdrawn.  The distal tip location of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next, a separate stab incision was made approximately 3 fingerbreadths below the wire exit site.  A subcutaneous tunnel was created, and the distal tip of the Hickman catheter was pulled through the tunnel to the level of the cuff.  The catheter was cut to the appropriate length.  A dilator and sheath were passed over the J wire.  The dilator and J wire were removed, and the distal tip of the Hickman catheter was threaded through the sheath, which was simultaneously withdrawn.  The catheter was flushed and aspirated without difficulty.  The distal tip was confirmed to be in good location with surgeon-interpreted fluoroscopy.  A 2-0 nylon was used to secure the cuff down to the catheter at the skin level.  The skin stab site was closed with a 4-0 Monocryl.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,TITLE OF PROCEDURE:,  Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 2 mL.,COMPLICATIONS:,  None.,FINDINGS: , Approximately 5 mL of serosanguineous drainage.,PROCEDURE: , The patient underwent an incision and drainage procedure with stay suture placement on 05/28/2008 by me and also by Dr. X on 05/23/2008 for a large near 100% auricular hematoma.  She presents for suture removal; however, there is still fluid noted now at the antihelix fold above the concha bullosa below previous sutures placed by Dr. X.  It was recommended that this area be drained through the previous incision and drainage incision which has healed and wound care by the patient appears to be very poor if any at all being performed which may be complicating matters.  Consent was obtained.  The patient is aware that the complications with this ear area severe and auricular deformity is inevitable; however, quick prompt aggressive drainage addressing fluid collections offers a best chance for improvement from an already very difficult situation.,The area was prepped in the usual manner, localized and the previous incision was reopened with a curved hemostat and about 5 mL of serosanguineous drainage was noted.  A through-and-through Keith needle bolster dressing was applied with cottonoid pledget on both sides of the ear to help compression.  She tolerated this procedure very well.", ENT - Otolaryngology,11
"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:", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS:,  Dental caries.,POSTOPERATIVE DIAGNOSIS: , Dental caries.,PROCEDURE: , Dental restorations and extractions.,CLINICAL HISTORY: , This 23-year-old male is a client of the ABC Center because of his disability, the nature of which is unclear to me at this time; however, he reportedly has several issues that qualify him as disabled.  He has had multiple severe carious lesions that warrant multiple extractions at this time.  It is also unclear to me as to how his prior or existing restorations were accomplished.  In any case, he has been cleared for the procedure today.  He has his history and physical in the chart.,PROCEDURE: , The patient was brought to the operating room at 11 o'clock and placed in the supine position.  Dr. X administered the general anesthetic, after which a throat pack was placed.  Available full mouth x-rays were reviewed.  These x-rays were taken at another location.  Teeth 2, 4, 10, 12, 13, 15, 18, 20, 27, and 31 were all in varying degrees of severe decay from complete destruction of the crowns to pulp exposures with periapical radiolucencies.  All of these aforementioned teeth were extracted using combinations of forceps and elevators.  Hemostasis in all of these sites was accomplished with direct pressure using gauze packs.  ,Tooth 5 had caries in the distal surface extending to the occlusal as well as another carious lesion in the buccal.  These carious lesions and his tooth were excavated, and the tooth was restored with amalgam involving these surfaces.  ,Tooth 6 had caries on the facial surface, which was excavated, and the tooth was restored with composite.  ,Tooth 7 had caries involving the distal surface.  ,Tooth 8 likewise had caries involving the distal surface, and both of these distal lesions extended into incisal area.  These carious lesions were excavated, and both of these teeth were restored with composite.  ,Tooth 9 had caries in a mesial surface and a buccal surface, which was excavated, and this tooth was restored with composite.  ,Tooth 28 caries in the mesial surface extending to the occlusal, which was excavated, and the tooth was restored with amalgam, and tooth 30 had carries in the buccal surface, which was excavated, and the tooth was restored with amalgam.  ,A prophylaxis was done, primarily using a rotating rubber cup and some minor scaling, and the mouth was irrigated and suctioned thoroughly.  The throat pack was removed, and the patient was awakened and brought to the recovery room in good condition at 1330 hours.  There was negligible blood loss.", Dentistry,7
"HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.  The patient also has a positive history of smoking in the past.  At the present time, he is admitted for continued,management of respiratory depression with other medical complications.  The patient was treated for multiple problems at Jefferson Hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter.  In addition, he also developed cardiac complications including atrial fibrillation.  The patient was evaluated by the cardiologist as well as the pulmonary service and Urology.  He had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008.  He subsequently underwent cardiac arrest and he was resuscitated at that time.  He was intubated and placed on mechanical ventilatory support.  Subsequent weaning was unsuccessful.  He then had a tracheostomy placed.,CURRENT MEDICATIONS:,1.  Albuterol.,2.  Pacerone.,3.  Theophylline,4.  Lovenox.,5.  Atrovent.,6.  Insulin.,7.  Lantus.,8.  Zestril.,9.  Magnesium oxide.,10.  Lopressor.,11.  Zegerid.,12.  Tylenol as needed.,ALLERGIES:,  PENICILLIN.,PAST MEDICAL HISTORY:,1.  History of coal miner's disease.,2.  History of COPD.,3.  History of atrial fibrillation.,4.  History of coronary artery disease.,5.  History of coronary artery stent placement.,6.  History of gastric obstruction.,7.  History of prostate cancer.,8.  History of chronic diarrhea.,9.  History of pernicious anemia.,10.  History of radiation proctitis.,11.  History of anxiety.,12.  History of ureteral stone.,13.  History of hydronephrosis.,SOCIAL HISTORY: , The patient had been previously a smoker.  No other could be obtained because of tracheostomy presently.,FAMILY HISTORY: , Noncontributory to the present condition and review of his previous charts.,SYSTEMS REVIEW: , The patient currently is agitated.  Rapidly moving his upper extremities.  No other history regarding his systems could be elicited from the patient.,PHYSICAL EXAM:,General:  The patient is currently agitated with some level of distress.  He has rapid respiratory rate.  He is responsive to verbal commands by looking at the eyes.,Vital Signs:  As per the monitors are stable.,Extremities:  Inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage II especially over the dorsum of the hands and forearm areas.  There is also edema of the forearm extending up to the mid upper arm area.  Palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect.  There is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,IMPRESSION:,1.  Ulceration of bilateral upper extremities.,2.  Cellulitis of upper extremities.,3.  Lymphedema of upper extremities.,4.  Other noninfectious disorders of lymphatic channels.,5.  Ventilatory-dependent respiratory failure.", Consult - History and Phy.,5
"SUBJECTIVE:,  Patient presents with Mom and Dad for her 5-year 3-month well-child check.  Family has not concerns stating patient has been doing well overall since last visit.  Taking in a well-balanced diet consisting of milk and dairy products, fruits, vegetables, proteins and grains with minimal junk food and snack food.  No behavioral concerns.  Gets along well with peers as well as adults.  Is excited to start kindergarten this upcoming school year.  Does attend daycare.  Normal voiding and stooling pattern.  No concerns with hearing or vision.  Sees the dentist regularly.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development.  See Denver II form in the chart.,ALLERGIES:,  None.,MEDICATIONS: , None.,FAMILY SOCIAL HISTORY:,  Unchanged since last checkup.  Lives at home with mother, father and sibling.  No smoking in the home.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs:  Weight 43 pounds.  Height 42-1/4 inches.  Temperature 97.7.  Blood pressure 90/64.,General:  Well-developed, well-nourished, cooperative, alert and interactive 5-year -3month-old white female in no acute distress.,HEENT:  Atraumatic, normocephalic.  Pupils equal, round and reactive.  Sclerae clear.  Red reflex present bilaterally.  Extraocular muscles intact.  TMs clear bilaterally.  Oropharynx:  Mucous membranes moist and pink.  Good dentition.,Neck:  Supple, no lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze or crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No masses or organomegaly.,GU:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.,Back:  Straight.  No scoliosis.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.  Cranial nerves II-XII grossly intact.  DTRs 2+/4+ bilaterally.,ASSESSMENT/PLAN:,1. Well 5-year 3-month-old white female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations.  Will receive MMR, DTaP and IPV today.  Discussed risks and benefits as well as possible side effects and symptomatic treatment.  Gave 5-year well-child check handout to mom.  Completed school pre-participation physical.  Copy in the chart.  Completed vision and hearing screening.  Reviewed results with family.,3. Follow up in one year for next well-child check or as needed for acute care.", Pediatrics - Neonatal,29
"PREOPERATIVE DIAGNOSIS:,  Herniated nucleus pulposus of L5-S1 on the left.,POSTOPERATIVE DIAGNOSIS: ,Herniated nucleus pulposus of L5-S1 on the left.,PROCEDURE PERFORMED:, Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMENS: , Disc that was not sent to the lab.,DRAINS: , None.,COMPLICATIONS: , None.,SURGICAL PROGNOSIS: , Remains guarded due to her ongoing pain condition and Tarlov cyst at the L5 nerve root distally.,SURGICAL INDICATIONS: , The patient is a 51-year-old female who has had unrelenting low back pain that radiated down her left leg for the past several months.  The symptoms were unrelieved by conservative modalities.  The symptoms were interfering with all aspects of daily living and inability to perform any significant work endeavors.  She is understanding the risks, benefits, potential complications, as well as all treatment alternatives.  She wished to proceed with the aforementioned surgery due to her persistent symptoms.  Informed consent was obtained.,OPERATIVE TECHNIQUE: , The patient was taken to OR room #5 where she was given general anesthetic by the Department of Anesthesia.  She was subsequently placed on the Jackson spinal table with the Wilson attachment in the prone position.  Palpation did reveal the iliac crest and suspected L5-S1 interspace.  Thereafter the lumbar spine was serially prepped and draped.  A midline incision was carried over the spinal process of L5 to S1.  Skin and subcutaneous tissue were divided sharply.  Electrocautery provided hemostasis.  Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia.  Lumbar fascia was identified and the decussation of fibers was identified at the L5-S1 interspace.  On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery.  This revealed the interspace of suspect level of L5-S1 on the left.  A Kocher clamp was placed between the spinous processes of the suspect level of L5-S1.  X-ray did confirm the L5-S1 interval.  Angled curet was utilized to detach the ligamentum flavum from its bony attachments at the superior edge of S1 lamina and the inferior edge of the L5 lamina.  Meticulous dissection was undertaken and the ligamentum flavum was removed.  Laminotomy was created with Kerrison rongeur, both proximally and distally.  The microscope was positioned and the dura was inspected.  A blunt Penfield elevator was then utilized to dissect and identify the L5-S1 nerve root on the left.  It was noted to be tented over a disc extrusion.  The nerve root was protected and medialized.  It was retracted with a nerve root retractor.  This did reveal a subligamentous disc herniation at approximately the L5-S1 disc space and neuroforaminal area.  A #15 Bard-Parker blade was utilized to create an annulotomy.  Medially, disc material was extruding through this annulotomy.  Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace.  Additional disc material was then removed, both to the right and left of the annulotomy.  Up and downbiting pituitary rongeurs were utilized to remove any other loose disc pieces.  Once this was completed, the wound was copiously irrigated with antibiotic solution and suctioned dry.  The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray did confirm this level.  Nerve root was again expected exhibiting the foramina.  A foraminotomy was created with a Kerrison rongeur.  Once this was created, the nerve root was again inspected and deemed free of tension.  It was mobile within the neural foramina.  The wound was again copiously irrigated with antibiotic solution and suctioned dry.  A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura.  Lumbar fascia was then approximated with #1 Vicryl interrupted fashion, subcutaneous tissue with #2-0 Vicryl interrupted fashion, and #4-0 undyed Vicryl was utilized to approximate the skin.  Compression dressing was applied.  The patient was turned, awoken, and noted to be moving all four extremities without apparent deficits.  She was taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded due to her ongoing pain syndrome that has been requiring significant narcotic medications.", Orthopedic,27
"There is normal and symmetrical filling of the caliceal system.  Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally.  The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects. The postvoid films demonstrate normal emptying of the collecting system, including the urinary bladder.,IMPRESSION:,  Negative intravenous urogram.,", Nephrology,21
"PREOPERATIVE DIAGNOSIS:,  Positive peptic ulcer disease.,POSTOPERATIVE DIAGNOSIS:,  Gastritis.,PROCEDURE PERFORMED: , Esophagogastroduodenoscopy with photography and biopsy.,GROSS FINDINGS:,  The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.,Upon endoscopy, gastroesophageal junction was at 40 cm, no esophageal tumor, varices, strictures, masses, or no reflux esophagitis was noted.  Examination of the stomach reveals mild inflammation of the antrum of the stomach, no ulcers, erosions, tumors, or masses.  The profundus and the cardia of the stomach were unremarkable.  The pylorus was concentric.  The duodenal bulb and sweep with no inflammation, tumors, or masses.,OPERATIVE PROCEDURE: , The patient taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position.  She was given IV sedation using Demerol and Versed.  Olympus videoscope was inserted in the hypopharynx, upon deglutition passed into the esophagus.  Using air insufflation, the scope was advanced down through the esophagus into the stomach along the greater curvature of the stomach to the pylorus to the duodenal bulb and sweep.  The above gross findings noted.  The panendoscope was withdrawn back from the stomach, deflected upon itself.  The lesser curve fundus and cardiac were well visualized.  Upon examination of these areas, panendoscope was returned to midline.  Photographs and biopsies were obtained of the antrum of the stomach.  Air was aspirated from the stomach and panendoscope was slowly withdrawn carefully examining the lumen of the bowel.,Photographs and biopsies were obtained as appropriate.  The patient is sent to recovery room in stable condition.", Surgery,38
"REASON FOR FOLLOWUP:,  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 patient with code last night with CPR and advanced cardiac life support.,HISTORY OF PRESENT ILLNESS: , This is a 65-year-old patient originally admitted by me several weeks ago with profound hyponatremia and mental status changes.  Her history is also significant for likely recurrent aspiration pneumonia and intubation earlier on this admission as well.  Previously while treating this patient I had met with the family and discussed how aggressive the patient would wish her level of care to be given that there was evidence of possible ovarian malignancy with elevated CA-125 and a complex mass located in the ovary.  As the patient was showing signs of improvement with some speech and ability to follow commands, decision was made to continue to pursue an aggressive level of care, treat her dysphagia, hypertension, debilitation and this was being done.  However, last night the patient had apparently catastrophic event around 2:40 in the morning.  Rapid response was called and the patient was intubated, started on pressure support, and given CPR.  This morning I was called to the bedside by nursing stating the family had wished at this point not to continue this aggressive level of care.  The patient was seen and examined, she was intubated and sedated.  Limbs were cool.  Cardiovascular exam revealed tachycardia.  Lungs had coarse breath sounds.  Abdomen was soft.  Extremities were cool to the touch.  Pupils were 6 to 2 mm, doll's eyes were not intact.  They were not responsive to light.  Based on discussion with all family members involved including both sons, daughter and daughter-in-law, a decision was made to proceed with terminal wean and comfort care measures.  All pressure support was discontinued.  The patient was started on intravenous morphine and respiratory was requested to remove the ET tube.  Monitors were turned off and the patient was made as comfortable as possible.  Family is at the bedside at this time.  The patient appears comfortable and the family is in agreement that this would be her wishes per my understanding of the family and the patient dynamics over the past month, this is a very reasonable and appropriate approach given the patient's failure to turn around after over a month of aggressive treatment with likely terminal illness from ovarian cancer and associated comorbidities.,Total time spent at the bedside today in critical care services, medical decision making and explaining options to the family and proceeding with terminal weaning was excess of 37 minutes.", SOAP / Chart / Progress Notes,35
"HISTORY:,  The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle.  Symptoms are worsened by any activity and relieved by rest.  He also feels that when the pain is very severe, he has some subtle right leg weakness.  No left leg symptoms.  No bowel or bladder changes.,On brief examination, full strength in both lower extremities.  No sensory abnormalities.  Deep tendon reflexes are 2+ and symmetric at the patellas and absent at both ankles.  Positive straight leg raising on the right.,MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5-S1 encroaching upon the right exiting S1 nerve root.,NERVE CONDUCTION STUDIES:,  Motor and sensory distal latencies, evoked response amplitudes, and conduction velocities are normal in the lower extremities.  The right common peroneal F-wave is minimally prolonged.  The right tibial H reflex is absent.,NEEDLE EMG:,  Needle EMG was performed on the right leg, left gastrocnemius medialis muscle, and right lumbosacral paraspinal muscles using a disposable concentric needle.  It revealed spontaneous activity in the right gastrocnemius medialis, gluteus maximus, and lower lumbosacral paraspinal muscles.  There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals an acute right S1 radiculopathy.  There is no evidence for peripheral neuropathy or left or right L5 radiculopathy.,Results were discussed with the patient and he is scheduled to follow up with Dr. X in the near future.", Physical Medicine - Rehab,30
"PREOPERATIVE DIAGNOSIS: , Cataract, left eye.,POSTOPERATIVE DIAGNOSIS:  ,Cataract, left eye.,PROCEDURE PERFORMED:  ,Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE: , After the induction of topical anesthesia with 4% Xylocaine drops, the left eye was prepped and draped in the usual fashion.  A speculum was inserted, and the microscope was moved into position.,A 3.2-mm incision was made in clear cornea at the limbus with a diamond keratome at the 3 o'clock position, and 0.1 cc of 1% Xylocaine without preservative was instilled into the anterior chamber.  It was then filled with viscoelastic.  A stab incision was made into the anterior chamber at the limbus at 5 o'clock position with a microblade.,A cystitome was used to make a capsulotomy, and the capsulorrhexis forceps were used to complete a circular capsulorrhexis.  The nucleus was hydrodelineated and hydrodissected with balanced salt solution on a 26-gauge cannula, and the phacoemulsifier was used to phacoemulsify the nucleus using a bimanual technique with the nucleus rotator inserted through the keratotomy incision.  The irrigation-aspiration handpiece was used to systematically aspirate cortex 360 degrees.  The posterior capsule was vacuumed; it was clear and intact.,The capsular bag and the anterior chamber were filled with viscoelastic.  A model MA30AC lens, power 21.5 diopters, serial number 864414.095, was folded, grasped with the lens insertion forceps and inserted into the capsular bag.  The trailing loop was placed inside the bag.  The viscoelastic was removed with the irrigation-aspiration handpiece.  The lens centered well.  A single 10-0 nylon suture was placed to close the wound.  It was checked and ascertained to be watertight.  Decadron 0.25 cc, 0.25 cc of antibiotic and 0.25 cc of Xylocaine were injected subconjunctivally.  Dexacidin ointment was placed in the eye, and the procedure was terminated.,The procedure was well tolerated by the patient who was returned to the recovery room in good condition.", Ophthalmology,26
"PREOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,PROCEDURE:, Redo L4-5 diskectomy left.,COMPLICATIONS:, None.,ANTIBIOTIC (S),: Vancomycin given preoperatively.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, 10 mL.,BLOOD REPLACED:, None.,CRYSTALLOID GIVEN:, 800 mL.,DRAIN (S):, None.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room in supine position. General endotracheal anesthesia was administered. He was turned into the prone position on the operating table and positioned in the modified knee-chest position with Andrews frame being used. Care was taken to protect pressure points. The back was shaved, scrubbed with Betadine scrub, rinsed with alcohol, and prepped with DuraPrep, and draped in the usual sterile fashion with Ioban drape being used. A midline skin incision was made, excising scar from previous surgery. Dissection was carried down through the subcutaneous tissue with electrocautery technique. The lumbosacral fascia was split to the left of the spinous process, and subperiosteal dissection of the spinous process and lamina, area of previous laminotomy was identified. Cross-table lateral was also made to confirm position. The scar was then loosened from the inferior portion of 4, superior of L5 lamina, and a portion of the lamina was removed. I did identify normal dura. The scar was then lysed from the medial wall. Dura and nerve root were identified and protected with nerve root retractor. The bulging disk fragment was still contained under the longitudinal ligament. A rent was made with the Penfield and a moderately large fragment was removed. The disk space was then entered with a cruciate cut in the annulus, with additional nuclear material being received. When no other fragments could be removed from the disk space, no other fragments were felt in the central canal under the longitudinal ligament, and a Murphy ball could be passed through the foramen without evidence of compression, the decompression was complete. Check was made for CSF leakage, and no evidence of significant epidural bleeding was present. The wound was irrigated with antibiotic solution. Twenty milligrams of Depo-Medrol was placed over the dura and nerve root. A free fat graft from the subcutaneous tissue was then placed over the dura. Closure was obtained with the lumbosacral fascia being reapproximated with #1, running, Vicryl suture. Subcutaneous closure was obtained in layers with 2-0, running, Vicryl suture. Skin closure was obtained with 3-0 Vicryl subcuticular suture. Proxi-Strips and sterile dressing was applied. The skin had been infiltrated with 8 mL of 0.5% Marcaine with epinephrine.,After a sterile dressing was applied, the patient was turned into the supine position on the waiting recovery room stretcher, brought from under the effects of anesthesia, and taken to the recovery room.", Orthopedic,27
"Chief Complaint:, Back and hip pain.,History of Present Illness:, The patient is a 73 year old Caucasian male with a history of hypertension, end-stage renal disease secondary to reflux nephropathy / restriction of bladder neck requiring hemodialysis and eventual cadaveric renal transplant now on chronic immunosuppression, peripheral vascular disease with non-healing ulcer of right great toe, and peripheral neuropathy who initially presented to his primary care physician in May 2001 with complaints of low back pain and bilateral hip pain. The pain was described as a constant pain in the middle to lower back and hips. The pain was exacerbated by climbing stairs and in the morning after sleeping. He reported occasional radiation of pain from back into buttocks (greatest on the right side). He has history of chronic feet and leg numbness and paraesthesias related to his neuropathy, but he denied any recent changes in these symptoms in relation to the back pain. He denied any history of trauma. He was treated symptomatically with Acetaminophen with only some relief. He continued to complain intermittently of pain in his back and hips, and occasionally even in his elbows during the next 8 months. In January 2002, plain pelvic films showed no fracture or dislocation of the hips. Elbow films also showed no acute injury, but there were some erosions along the posterior aspect of the olecranon. An MRI was performed of his lumbar spine which showed degenerative disk disease, spondylosis, and annular bulging/herniation at L4-L5 with resultant encroachment on the neural foramen. He was evaluated by neurosurgery, who felt he should not have surgery at this time. His pain continued and progressively worsened, becoming unresponsive to medical therapy including narcotics,In May 2002, as part of a vascular work-up for the patient’s non-healing right toe, an MRA showed extensive vascular disease in the vessels of both legs below the knees and evidence of bilateral trochanteric bursitis. It also revealed an abnormal enhancing lesion in the left proximal femur, the left iliac bone, the right iliac bone, and possibly the right tibia.,Past Medical History:,End stade renal disease secondary to reflux nephropathy,a. numerous related urinary tract infections,b. hemodialysis (1983-1988),c. s/p cadaveric renal transplant (1988),d. baseline creatinine about 2.3.,Hypertension,Peripheral vascular disease,a. history of right foot infected toenail and non-healing ulcer since 2000; receiving hyperbaric oxygen therapy; recent surgery on infected toe in March, 2002,Peripheral Neuropathy,Chronic anemia (on Epogen injections),History of several partial small bowel obstructions - six times during the last 10 years,Past Surgical History:,1. Tonsillectomy and adenoidectomy (1943),2. Left ureter re-implantation (1960),3. Repair of splenic artery aneurysm (1968),4. Left arm AV fistula graft placement and numerous procedures for dialysis access (1983-1988),5. Cadaveric renal transplant (1988),6. Cataract surgery in bilateral eyes,Medications:,1. Imuran 100mg po QD,2. Prednisone 7.5mg po QD,3. Aspirin 81mg po QD,4. Trental 400mg po TID,5. Norvasc 5mg po BID,6. Prinivil 20mg po BID,7. Hydralazine 50mg po Q6H,8. Clonidine TTS III on Thursdays,9. Terasozin 5mg po BID,10. Elavil 30mg po QHS,11. Vicodin 1-2tabs po Q6H prn,12. Epoetin SR 10,000Units SQ QM and F,13. Sodium bicarbonate 648mg po QD,14. Calcium carbonate 2gm po QID,15. Docusate sodium 100mg po QD,16. Chocolate Ensure one can po QID,17. Multivitamin,18. Vitamin E,Social History:, The patient is married with five children and lives with his wife. He is a retired engineer and real estate broker. He denies tobacco use. He drinks alcohol occasionally with up to three drinks a week. No history of drug abuse.,Allergies:, No known drug allergies.,Family History:", Orthopedic,27
"EXAM: , MRI of the brain without contrast.,HISTORY: , Daily headaches for 6 months in a 57-year-old.,TECHNIQUE:  ,Noncontrast axial and sagittal images were acquired through the brain in varying degrees of fat and water weighting.,FINDINGS: , The brain is normal in signal intensity and morphology for age.  There are no extraaxial fluid collections.  There is no hydrocephalus/midline shift.  Posterior fossa, 7th and 8th nerve complexes and intraorbital contents are within normal limits.  The normal vascular flow volumes are maintained.  The paranasal sinuses are clear.,Diffusion images demonstrate no area of abnormally restricted diffusion that suggests acute infarct.,IMPRESSION: , Normal MRI brain.  Specifically, no findings to explain the patient's headaches are identified.", Radiology,33
"ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay.  He had left hip fracture identified on x-rays at that time.  Pain and inability to ambulate brought him in.  He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia.  His medical issues are under good control.  The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03.  The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension.  Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy.  He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions.,PAST MEDICAL HISTORY: , Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation.  Remote history of subdural hematoma precluding the use of Coumadin.  History of depression, panic attacks on Doxepin.  Perioperative anemia.  Swallowing difficulties.,ALLERGIES:,  Zyloprim, penicillin, Vioxx, NSAIDs.,CURRENT MEDICATIONS,1.  Heparin.,2.  Albuterol inhaler.,3.  Combivent.,4.  Aldactone.,5.  Doxepin.,6.  Xanax.,7.  Aspirin.,8.  Amiodarone.,9.  Tegretol.,10.  Synthroid.,11.  Colace.,SOCIAL HISTORY: , Lives in a 1-story home with 1 step down; wife is there.  Speech and language pathology following with current swallowing dysfunction.  He is minimum assist for activities of daily living, bed mobility.,REVIEW OF SYSTEMS:,  Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain.,PHYSICAL EXAMINATION,HEENT:  Oropharynx clear.,CV:  Regular rate and rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended.  Bowel sounds positive.,EXTREMITIES:  Without clubbing, cyanosis, or edema.,NEUROLOGIC:  There are no focal motor or sensory losses to the lower extremities.  Bulk and tone normal in the lower extremities.  Wound site has healed well with staples out.,IMPRESSION ,1.  Status post left hip fracture and hemiarthroplasty.,2.  History of panic attack, anxiety, depression.,3.  Myocardial infarction with stent placement.,4.  Hypertension.,5.  Hypothyroidism.,6.  Subdural hematoma.,7.  Seizures.,8.  History of chronic obstructive pulmonary disease.  Recent respiratory insufficiency.,9.  Renal insufficiency.,10.  Recent pneumonia.,11.  O2 requiring.,12.  Perioperative anemia.,PLAN: , Rehab transfer as soon as medically cleared.", Physical Medicine - Rehab,30
"PREOPERATIVE DIAGNOSIS:,  Torn rotator cuff, right shoulder.,POSTOPERATIVE DIAGNOSES:,1.  Torn rotator cuff, right shoulder.,2.  Subacromial spur with impingement syndrome, right shoulder.,PROCEDURE PERFORMED:,1.  Diagnostic arthroscopy with subacromial decompression.,2.  Open repair of rotator cuff using three Panalok suture anchors.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Approximately 200 cc.,INTRAOPERATIVE FINDINGS: , There was noted to be a full thickness tear to the supraspinatus tendon at the insertion of the greater tuberosity.  There is moderate amount of synovitis noted throughout the glenohumeral joint.  There is a small subacromial spur noted on the very anterolateral border of the acromion.,HISTORY: , This is a 62-year-old female who previously underwent a repair of rotator cuff.  She continued to have pain within the shoulder.  She had a repeat MRI performed, which confirmed the clinical diagnosis of re-tear of the rotator cuff.  She wished to proceed with a repair.  All risks and benefits of the surgery were discussed with her at length.  She was in agreement with the above treatment plan.,PROCEDURE: , On 08/21/03, she was taken to the Operative Room at ABCD General Hospital.  She was placed supine on the operating table.  General anesthesia was applied by the Anesthesiology Department.  She was placed in the modified beachchair position.  Her upper extremity was sterilely prepped and draped in usual fashion.  A stab incision was made in the posterior aspect of the glenohumeral joint.  A camera was placed in the joint and was insufflated with saline solution.  Intraoperative pictures were obtained and the above findings were noted.  A second port site was initiated anteriorly.  Through this a probe was placed and the intraarticular structures were palpated and found to be intact.  A tear of the inner surface of the rotator cuff was identified.  The camera was then taken to the subacromial space.  A straight lateral portal was also used and a shaver was placed into the subacromial space.  Further debridement of the anterolateral border of the acromion was performed to remove evidence of the subacromial spur, which had reformed.  The edges of the rotator cuff were then debrided.  The camera was then removed and the shoulder was suction and dried.  A lateral incision was made over the anterolateral border of the acromion.  Subcuticular tissues were carefully dissected.  Hemostasis was controlled with electrocautery.  The deltoid musculature was then incised and aligned with its fibers exposing the rotator cuff tear and the edges were further debrided using a rongeur.  A trough was then made in the greater tuberosity using the rongeur.  Two Panalok anchors were then placed within the trough and weaved through the suture and third Panalok anchor was placed medial to the trough and weaved through the rotator cuff.  The ends of the suture were tied down from the fixating the rotator cuff within the trough.  The rotator cuff was then further oversewed using the Panalok suture.  The wound was then copiously irrigated and it was then suction dried.  The deltoid muscle was reapproximated using #1 Vicryl.  A continuous infusion pump catheter was placed into the subacromial space to help with postoperative pain control.  The subcutaneous tissues were reapproximated with #2-0 Vicryl.  The skin was closed with #4-0 PDS running subcuticular stitch.  Sterile dressing was applied to the upper extremity.  She was then placed in a shoulder immobilizer.  She was transferred to the recovery room in apparent stable and satisfactory condition.  Prognosis for this patient was guarded.  She will begin pendulum exercises postoperative day #3.  She will follow back in the office in 10 to 14 days for reevaluation.  Physical therapy initiated approximately six weeks postoperatively.", Surgery,38
"REASON FOR CONSULT:,  Altered mental status.,HPI:,  The patient is 77-year-old Caucasian man with benign prostatic hypertrophy, status post cardiac transplant 10 years ago who was admitted to the Physical Medicine and Rehab Service for inpatient rehab after suffering a right cerebellar infarct last month.  Last night, he became confused and he eloped from the unit.  When he was found, he became combative.  This a.m., he continued to be aggressive and required administration of four-point soft restraints in addition to Haldol 1 mg intramuscularly.  There was also documentation of him having paranoid thoughts that his wife was going out spending his money instead of being with him in the hospital.  Given this presentation, Psychiatry was consulted to evaluate and offer management recommendations.,The patient states that he does remember leaving the unit looking for his wife, but does not recall becoming combative, needing restrains and emergency medications.  He reports feeling fine currently, denying any complaints.  The patient's wife notes that her husband might be confused and disoriented due to being in the hospital environment.  She admits that he has some difficulty with memory for sometime and becomes irritable when she is not around.  However, he has never become as combative as he has this particular episode.,He negates any symptoms of depression or anxiety.  He also denies any hallucinations or delusions.  He endorses problems with insomnia.  At home, he takes temazepam.  His wife and son note that the temazepam makes him groggy and disoriented at times when he is at home.,PAST PSYCHIATRIC HISTORY:,  He denies any prior psychiatric treatment or intervention.  However, he was placed on Zoloft 10 years ago after his heart transplant, in addition to temazepam for insomnia.  During this hospital course, he was started on Seroquel 20 mg p.o. q.h.s. in addition to Aricept 5 mg daily.  He denies any history of suicidal or homicidal ideations or attempts.,PAST MEDICAL HISTORY:,1.  Heart transplant in 1997.,2.  History of abdominal aortic aneurysm repair.,3.  Diverticulitis.,4.  Cholecystectomy.,5.  Benign prostatic hypertrophy.,ALLERGIES:,  MORPHINE AND DEMEROL.,MEDICATIONS:,1.  Seroquel 50 mg p.o. q.h.s., 25 mg p.o. q.a.m.,2.  Imodium 2 mg p.o. p.r.n., loose stool.,3.  Calcium carbonate with vitamin D 500 mg b.i.d.,4.  Prednisone 5 mg p.o. daily.,5.  Bactrim DS Monday, Wednesday, and Friday.,6.  Flomax 0.4 mg p.o. daily.,7.  Robitussin 5 mL every 6 hours as needed for cough.,8.  Rapamune 2 mg p.o. daily.,9.  Zoloft 50 mg p.o. daily.,10.  B vitamin complex daily.,11.  Colace 100 mg b.i.d.,12.  Lipitor 20 mg p.o. q.h.s.,13.  Plavix 75 mg p.o. daily.,14.  Aricept 5 mg p.o. daily.,15.  Pepcid 20 mg p.o. daily.,16.  Norvasc 5 mg p.o. daily.,17.  Aspirin 325 mg p.o. daily.,SOCIAL HISTORY:,  The patient is a retired paster and missionary to Mexico.  He is still actively involved in his church.  He denies any history of alcohol or substance abuse.,MENTAL STATUS EXAMINATION:,  He is an average-sized white male, casually dressed, with wife and son at bedside.  He is pleasant and cooperative with good eye contact.  He presents with paucity of speech content; however, with regular rate and rhythm.  He is tremulous which is worse with posturing also some increased motor tone noted.  There is no evidence of psychomotor agitation or retardation.  His mood is euthymic and supple and reactive, appropriate to content with reactive affect appropriate to content.  His thoughts are circumstantial but logical.  He defers most of his responses to his wife.  There is no evidence of suicidal or homicidal ideations.  No presence of paranoid or bizarre delusions.  He denies any perceptual abnormalities and does not appear to be responding to internal stimuli.  His attention is fair and his concentration impaired.  He is oriented x3 and his insight is fair.  On mini-mental status examination, he has scored 22 out of 30.  He lost 1 for time, lost 1 for immediate recall, lost 2 for delayed recall, lost 4 for reverse spelling and could not do serial 7s.  On category fluency, he was able to name 17 animals in one minute.  He was unable to draw clock showing 2 minutes after 10.  His judgment seems limited.,LABORATORY DATA:,  Calcium 8.5, magnesium 1.8, phosphorous 3, pre-albumin 27, PTT 24.8, PT 14.1, INR 1, white blood cell count 8.01, hemoglobin 11.5, hematocrit 35.2, and platelet count 255,000.  Urinalysis on January 21, 2007, showed trace protein, trace glucose, trace blood, and small leukocyte esterase.,DIAGNOSTIC DATA:,  MRI of brain with and without contrast done on January 21, 2007, showed hemorrhagic lesion in right cerebellar hemisphere with diffuse volume loss and chronic ischemic changes.,ASSESSMENT:,AXIS I:,1.  Delirium resulting due to general medical condition versus benzodiazepine ,intoxication/withdrawal.,2.  Cognitive disorder, not otherwise specified, would rule out vascular dementia.,3.  Depressive disorder, not otherwise specified.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,POSTOPERATIVE DIAGNOSIS:,  Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,PROCEDURE PERFORMED:,1.  Injection for myelogram.,2.  Microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left on 08/28/03.,BLOOD LOSS: , Approximately 25 cc.,ANESTHESIA: , General.,POSITION:,  Prone on the Jackson table.,INTRAOPERATIVE FINDINGS:,  Extruded nucleus pulposus at the level of L5-S1.,HISTORY: , This is a 34-year-old male with history of back pain with radiation into the left leg in the S1 nerve root distribution.  The patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity.  He denied any previous history of back pain or back surgeries.  Because of his intractable pain as well as severe weakness in the S1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on.  After an informed consent was obtained, all risks as well as complications were discussed with the patient.  ,PROCEDURE DETAIL:  ,He was wheeled back to Operating Room #5 at ABCD General Hospital on 08/28/03.  After a general anesthetic was administered, a Foley catheter was inserted.,The patient was then turned prone on the Jackson table.  All of his bony prominences were well-padded.  At this time, a myelogram was then performed.  After the lumbar spine was prepped, a #20 gauge needle was then used to perform a myelogram.  The needle was localized to the level of L3-L4 region.  Once inserted into the thecal sac, we immediately got cerebrospinal fluid through the spinal needle.  At this time, approximately 10 cc of Conray injected into the thecal sac.  The patient was then placed in the reversed Trendelenburg position in order to assist with distal migration of the contrast.  The myelogram did reveal that there was some space occupying lesion, most likely disc at the level of L5-S1 on the left.  There was a lack of space filling defect on the left evident on both the AP and the lateral projections using C-arm fluoroscopy.  At this point, the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy.  A long spinal needle was then inserted into region of surgery on the right.  The surgery was going to be on the left.  Once the spinal needle was inserted, a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the L5-S1 nerve root region.  At this time, an approximately 2 cm skin incision was made over the lumbar region, dissected down to the deep lumbar fascia.  At this time, a Weitlaner was inserted.  Bovie cautery was used to obtain hemostasis.  We further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina.  A Cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left-hand side.  At this time, a Taylor retractor was then inserted and held there for retraction.  Suction as well as Bovie cautery was used to obtain hemostasis.  At this time, a small Kerrison Rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression.  Once the laminotomy was performed, a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots.  Once the ligamentum flavum was removed, we immediately identified a piece of disc material floating around outside of the disc space over the S1 nerve root, which was compressive.  We removed the extruded disc with further freeing up of the S1 nerve root.  A nerve root retractor was then placed.  Identification of disc space was then performed.  A #15 blade was then inserted and small a key hole into the disc space was then performed with a #15 blade.  A small pituitary was then inserted within the disc space and more disc material was freed and removed.  The part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc.  Once this was performed, we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free.,At this time, copious irrigation was used to irrigate the wound.  We then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur.  At this time, a small piece of Gelfoam was then used to cover the exposed nerve root.  We did not have any dural leaks during this case.  #1-0 Vicryl was then used to approximate the deep lumbar fascia, #2-0 Vicryl was used to approximate the superficial lumbar fascia, and #4-0 running Vicryl for the subcutaneous skin.  Sterile dressings were then applied.  The patient was then carefully slipped over into the supine position, extubated and transferred to Recovery in stable condition.  At this time, we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level.", Neurosurgery,23
"PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Perforated Meckel's diverticulum.,PROCEDURES PERFORMED:,1.  Diagnostic laparotomy.,2.  Exploratory laparotomy.,3.  Meckel's diverticulectomy.,4.  Open incidental appendectomy.,5.  Peritoneal toilet.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:  ,300 ml.,URINE OUTPUT: , 200 ml.,TOTAL FLUID:,  1600 mL.,DRAIN:,  JP x1 right lower quadrant and anterior to the rectum.,TUBES:,  Include an NG and a Foley catheter.,SPECIMENS: , Include Meckel's diverticulum and appendix.,COMPLICATIONS: , Ventilator-dependent respiratory failure with hypoxemia following closure.,BRIEF HISTORY: , This is a 45-year-old Caucasian gentleman presented to ABCD General Hospital with acute onset of right lower quadrant pain that began 24 hours prior to this evaluation.,The pain was very vague and progressed in intensity.  The patient has had anorexia with decrease in appetite.  His physical examination revealed the patient to be febrile with the temperature of 102.4.  He had right lower quadrant and suprapubic tenderness with palpation with Rovsing sign and rebound consistent with acute surgical abdomen.  The patient was presumed acute appendicitis and was placed on IV antibiotics and recommended that he undergo diagnostic laparoscopy with possible open exploratory laparotomy.  He was explained the risks, benefits, and complications of the procedure and gave informed consent to proceed.,OPERATIVE FINDINGS: , Diagnostic laparoscopy revealed purulent drainage within the region of the right lower quadrant adjacent to the cecum and terminal ileum.  There was large amounts of purulent drainage.  The appendix was visualized, however, it was difficult to be visualized secondary to the acute inflammatory process, purulent drainage, and edema.  It was decided given the signs of perforation and purulent drainage within the abdomen that we would convert to an open exploratory laparotomy.  Upon exploration of the ileum, there was noted to be a ruptured Meckel's diverticulum, this was resected.  Additionally, the appendix appeared normal without evidence of perforation and/or edema and a decision to proceed with incidental appendectomy was performed.  The patient was irrigated with copious amounts of warmth normal saline approximately 2 to 3 liters.  The patient was closed and did develop some hypoxemia after closure.  He remained ventilated and was placed on a large amount of ________.  His hypoxia did resolve and he remained intubated and proceed to the Critical Care Complex or postop surgical care.,OPERATIVE PROCEDURE:,  The patient was brought to the operative suite and placed in the supine position.  He did receive preoperative IV antibiotics, sequential compression devices, NG tube placement with Foley catheter, and heparin subcutaneously.  The patient was intubated by the Anesthesia Department.  After adequate anesthesia was obtained, the abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  Utilizing a #10 blade scalpel, an infraumbilical incision was created.  The Veress needle was inserted into the abdomen.  The abdomen was insufflated to approximately 15 mmHg.  A #10 mm ablated trocar was inserted into the abdomen and a video laparoscope was inserted and the abdomen was explored and the above findings were noted.  A right upper quadrant 5 mm port was inserted to help with manipulation of bowel and to visualize the appendix.  Decision was then made to convert to exploratory laparotomy given the signs of acute perforation.  The instruments were then removed.  The abdomen was then deflated.  Utilizing ________ #10 blade scalpel, a midline incision was created from the xiphoid down to level of the pubic symphysis.,The incision was carried down with a #10 blade scalpel and the bleeding was controlled along the way with electrocautery.  The posterior layer of the rectus fascia and peritoneum was opened carefully with the scissors as the peritoneum had already been penetrated during laparoscopy.  Incision was carried down to the midline within the linea alba.  Once the abdomen was opened, there was noted to be gross purulent drainage.  The ileum was explored and there was noted to be a perforated Meckel's diverticulum.  Decision to resect the diverticulum was performed.,The blood supply to the Meckel's diverticulum was carefully dissected free and a #3-0 Vicryl was used to tie off the blood supply to the Meckel's diverticulum.  Clamps were placed to the proximal supply to the Meckel's diverticulum was tied off with #3-0 Vicryl sutures.  The Meckel's diverticulum was noted to be completely free and was grasped anteriorly and utilizing a GIA stapling device, the diverticulum was transected.  There was noted to be a hemostatic region within the transection and staple line looked intact without evidence of perforation and/or leakage.  Next, decision was decided to go ahead and perform an appendectomy.  Mesoappendix was doubly clamped with hemostats and cut with Metzenbaum scissors.  The appendiceal artery was identified and was clamped between two hemostats and transected as well.  Once the appendix was completely freed of the surrounding inflammation and adhesion.  A plain gut was placed at the base of the appendix and tied down.  The appendix was milked distally with a straight stat and clamped approximately halfway.  A second piece of plain gut suture was used to ligate above and then was transected with a #10 blade scalpel.  The appendiceal stump was then inverted with a pursestring suture of #2-0 Vicryl suture.  Once the ________ was completed, decision to place a JP drain within the right lower quadrant was performed.  The drain was positioned within the right lower quadrant and anterior to the rectum and brought out through a separate site in the anterior abdominal wall.  It was sewn in place with a #3-0 nylon suture.  The abdomen was then irrigated with copious amounts of warmed normal saline.  The remainder of the abdomen was unremarkable for pathology.  The omentum was replaced over the bowel contents and utilizing #1-0 PDS suture, the abdominal wall, anterior and posterior rectus fascias were closed with a running suture.  Once the abdomen was completely closed, the subcutaneous tissue was irrigated with copious amounts of saline and the incision was closed with staples.  The previous laparoscopic sites were also closed with staples.  Sterile dressings were placed over the wound with Adaptic and 4x4s and covered with ABDs.  JPs replaced with bulb suction.  NG tube and Foley catheter were left in place.  The patient tolerated this procedure well with exception of hypoxemia which resolved by the conclusion of the case.,The patient will proceed to the Critical Care Complex where he will be closely evaluated and followed in his postoperative course.  To remain on IV antibiotics and we will manage ventilatory-dependency of the patient.", Gastroenterology,14
"INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant.  His mother had premature rupture of membranes on 12/20/08.  She then presented to the Labor and Delivery with symptoms of flu.  The baby was then induced and delivered.  The mother had a history of premature babies in the past.  This baby was doing well, and then, we had a significant increasing oxygen requirement from room air up to 85%.  He is now on 60% FiO2.,PHYSICAL FINDINGS,GENERAL:  He appears to be pink, well perfused, and slightly jaundiced.,VITAL SIGNS:  Pulse 156, 56 respiratory rate, 92% sat, and 59/28 mmHg blood pressure.,SKIN:  He was pink.,He was on the high-frequency ventilator with good wiggle.,His echocardiogram showed normal structural anatomy.  He has evidence for significant pulmonary hypertension.  A large ductus arteriosus was seen with bidirectional shunt.  A foramen ovale shunt was also noted with bidirectional shunt.  The shunting for both the ductus and the foramen ovale was equal left to right and right to left.,IMPRESSION: , My impression is that baby boy, XYZ, has significant pulmonary hypertension.  The best therapy for this is to continue oxygen.  If clinically worsens, he may require nitric oxide.  Certainly, Indocin should not be used at this time.  He needs to have lower pulmonary artery pressures for that to be considered.,Thank you very much for allowing me to be involved in baby XYZ's care.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS:  ,Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:,  Right trigger thumb.,OPERATIONS PERFORMED:,  Trigger thumb release.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia applied by surgeon with local.,COMPLICATIONS:,", Surgery,38
"TITLE OF OPERATION:,  Mediastinal exploration and delayed primary chest closure.,INDICATION FOR SURGERY:,  The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification.  The patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass.  The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago.  She did not meet the criteria for delayed primary chest closure.,PREOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,POSTOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS:,  None.,FINDINGS: , No evidence of intramediastinal purulence or hematoma.  At completion of the procedure no major changes in hemodynamic performance.,DETAILS OF THE PROCEDURE: , After obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position.  Following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed.  The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed.  The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned.  Through a separate incision and another 15-French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV-PA connection as well as inferior most aspect of the ventriculotomy.  The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires.  The subcutaneous tissue and skin were closed in layers.  There was no evidence of significant increase in central venous pressure or desaturation.  The patient tolerated the procedure well.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition.,I was the surgical attending present in the operating room in charge of the surgical  procedure throughout the entire length of the case.", Cardiovascular / Pulmonary,3
"MYOVIEW NUCLEAR STRESS STUDY,REASON FOR THE TEST:,  Angina, coronary artery disease.,FINDINGS: , The patient exercised according to the Lexiscan nuclear stress study, received a total of 0.4 mg of Lexiscan.  At peak hyperemic effect, 25.8 mCi of Myoview injected for the stress imaging and earlier 8.1 mCi of Myoview injected for the resting and the usual SPECT and gated SPECT protocol was followed in the rest-stress sequence.,The data analyzed using Cedars-Sinai software.,The resting heart rate was 49 with the resting blood pressure of 149/86.  Maximum heart rate achieved was 69 with a maximum blood pressure achieved of 172/76.,EKG at rest showed to be abnormal with sinus rhythm, left atrial enlargement, and inverted T-wave in 1, 2, and aVL as well as from V4 to V6 with LVH.  Maximal stress test EKG showed no change from baseline.,IMPRESSION:  ,Maximal Lexiscan stress test with abnormal EKG at baseline maximal stress test, please refer to the Myoview interpretation.,MYOVIEW INTERPRETATIONS,FINDINGS: , The left ventricle appears to be dilated on both stress and rest with no significant change between stress and rest with left ventricular end-diastolic volume of 227, end-systolic volume of 154 with moderately to severely reduced LV function with akinesis of the inferior and inferoseptal wall.  EF was calculated at 32%, estimated 35% to 40%.,Cardiac perfusion reviewed, showed a large area of moderate-to-severe intensity in the inferior wall and small-to-medium area of severe intensity at the apex and inferoapical wall.  Both defects showed no change on the resting indicative of a fixed defect in the inferior and inferoapical wall consistent with old inferior inferoapical MI.  No reversible defects indicative of myocardium at risk.  The lateral walls as well as the septum and most of the anterior wall showed no reversibility and near-normal perfusion.,IMPRESSION:,1.  Large fixed defect, inferior and apical wall, related to old myocardial infarction.,2.  No reversible ischemia identified.,3.  Moderately reduced left ventricular function with ejection fraction of about 35% consistent with ischemic cardiomyopathy.", Radiology,33
"PREOPERATIVE DIAGNOSIS:,1.  Anal cancer.,2.  Need for IV access.,POSTOPERATIVE DIAGNOSIS:,1.  Anal cancer.,2.  Need for IV access.,OPERATIVE PROCEDURE:,1.  Placement of a Port-A-Cath.,2.  Fluoroscopic guidance.,ANESTHESIA:,  General LMA.,ESTIMATED BLOOD LOSS:,  Minimum.,IV FLUIDS: , Per anesthesia.,RECURRENT COMPLICATIONS: , None.,FINDINGS: , Good port placement on C-arm.,INDICATIONS AND PROCEDURE IN DETAIL: , This is a 55-year-old female who presents with anal cancer, who is beginning chemoradiation and needs IV access for chemotherapy.  Risks and benefits of the procedure explained, the patient appeared to understand, and agreed to proceed.  The patient was taken to the operating room, placed in supine position.  General LMA anesthesia was administered.  She is prepped and draped in the usual sterile fashion.  She was placed in the Trendelenburg position and the left subclavian vein was cannulated and a guide wire placed through the wire.  Fluoroscopy was used to confirm appropriate guide wire location in the subclavian vein to the superior vena cava.  The incision was then made around the guide wire, taken to the subcutaneous tissues with electric Bovie cautery.  A pocket was made in the subcutaneous tissue of adequate size for the port which was cut at 16 cm for appropriate locationing which was cut at 16 cm based on superficial measurements.  The 2-0 Vicryl sutures were used to secure the port in place and the sheath introducer was placed over the guide wire and the guide wire removed with a Port catheter being placed into the sheath introducer.  Fluoroscopy was used to confirm appropriate positioning of the catheter and the skin was closed using interrupted 3-0 Vicryl followed by running 4-0 Vicryl subcuticular stitch.  Heparin flush was used to flush the port.  Steri-Strips were applied and the patient was awakened and extubated in the OR taken to the PACU in good condition.  All counts were reported as correct and I was present for the entire procedure.", Surgery,38
"CHIEF COMPLAINT: , MGUS.,HISTORY OF PRESENT ILLNESS:,  This is an extremely pleasant 86-year-old gentleman, who I follow for his MGUS.  I initially saw him for thrombocytopenia when his ANC was 1300.  A bone marrow biopsy was obtained.  Interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.0 and his white blood cell count was 6.5 with a platelet count of 484,000.  His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia.  All his tests came back as consistent with an MGUS.,Overall, he is doing well.  Since I last saw him, he tells me that he has had onset of atrial fibrillation.  He has now started going to the gym two times per week, and has lost over 10 pounds.  He has a good energy level and his ECOG performance status is 0.  He denies any fever, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Multivitamin q.d., aspirin one tablet q.d., Lupron q. three months, Flomax  0.4 mg q.d., and Warfarin 2.5 mg q.d.,ALLERGIES:  ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post left inguinal hernia repair.,2.  Prostate cancer diagnosed in December 2004, which was a Gleason 3+4.  He is now receiving Lupron.,SOCIAL HISTORY: , He has a very remote history of tobacco use.  He has one to two alcoholic drinks per day.  He is married.,FAMILY HISTORY: , His brother had prostate cancer.,PHYSICAL EXAM:,VIT:", SOAP / Chart / Progress Notes,35
"PREOPERATIVE DIAGNOSES:,1.  Left superficial femoral artery subtotal stenosis.,2.  Arterial insufficiency, left lower extremity.,POSTOPERATIVE DIAGNOSES:,1.  Left superficial femoral artery subtotal stenosis.,2.  Arterial insufficiency, left lower extremity.,OPERATIONS PERFORMED:,1.  Left lower extremity angiogram.,2.  Left superficial femoral artery laser atherectomy.,3.  Left superficial femoral artery percutaneous transluminal balloon angioplasty.  ,4.  Left external iliac artery angioplasty.,5.  Left external iliac artery stent placement.,6.  Completion angiogram.,FINDINGS:  ,This patient was brought to the OR with a non-severe stenosis of the proximal left superficial femoral artery in the upper one-third of his thigh.  He is also known to have severe calcific disease involving the entire left external iliac system as well as the common femoral and deep femoral arteries.,Our initial plan today was to perform an atherectomy with angioplasty and stenting of the left superficial femoral artery as necessary.  However, whenever we started the procedure, it became clear that there was a severe stenosis of the left superficial femoral artery at its takeoff from the left common femoral artery.  The area was severely calcified including the external iliac artery extending up underneath the left inguinal ligament.  Indeed, this ultimately was dissected due to manipulation of sheath catheters and sheath through the area.  Ultimately, this wound up being a much more complex case than initially anticipated.,Because of the above, we ultimately performed a laser atherectomy of the left superficial femoral artery, which then had to be angioplastied to obtain a satisfactory result.  The completion angiogram showed that there was a dissection of the left external iliac artery, which precluded flow down into the left lower extremity.  We then had to come up and perform angioplasty and stenting of the left external iliac artery as well as aggressively dilating the takeoff of the less superficial femoral artery from the common femoral artery.,The left superficial femoral artery was dilated with a 6-mm balloon.,The left external iliac artery and common femoral arteries were dilated with an 8-mm balloon.,A 2.5-mm ClearPath laser probe was used to initially arthrectomize and debulk the superficial femoral artery starting at its takeoff from the common femoral artery and extending down to the tight stenotic area in the upper one-third of the thigh.  After the laser atherectomy was performed, the area still did not look good and so an angioplasty was then done, which looked good; however, as noted above, after we had dealt with the superficial femoral artery, we then had proximal inflow problems, which had to be dealt by angioplasty and stenting.,The patient had good dorsalis pedis pulses bilaterally upon completion.,The right common femoral artery was used for access in an up-and-over technique.,PROCEDURE: , With the patient in the supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in the sterile fashion.,The right common femoral artery was punctured percutaneously, and a #5-French sheath was initially placed.  We used a pigtail catheter to go up and over the aortic bifurcation and placed a stiff Amplatz guidewire down into the left common femoral artery.  We then heparinized the patient and placed a #7-French Raby sheath over the Amplatz wire.  A selective left lower extremity angiogram was then done with the above-noted findings.,We then used a ClearPath 2.5-mm laser probe to laser the proximal superficial femoral artery.  Because of the findings as noted above, this became more involved than initially hoped for.  Once the laser atherectomy had been completed, the vessel still did not look good, so we used a 6-mm balloon to thoroughly dilate the area.  Once that had been done, it looked good and we performed what we felt would be a completion angiogram only to find out that we had a more proximal problem precluding flow down into the left femoral artery.,Once that was discovered, we then had to proceed with angioplasty and stenting of the left external iliac artery right down to the acetabular level.,Once we had dealt with our run-on problems, we then did another completion angiogram, which showed a good flow through the entire area and down into the left lower extremity.,Following completion of the above, all wires, sheaths, and catheters were removed from the right common femoral artery.  Firm pressure was held over the puncture site for 20 minutes followed by application of a sterile Coverlet dressing and a firm pressure dressing.,The patient tolerated the procedure well throughout.  He had good palpable dorsalis pedis pulses bilaterally on completion.  He was taken to the recovery room in satisfactory condition.  Protamine was given to partially reverse the heparin.", Surgery,38
"PREOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1.  Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS:  ,Approximately 1000 cc.,CELL SAVER RETURNED:  ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain.  He had previous lumbar laminectomy at L4-L5.  He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable.  He is suffering from neurogenic claudication.  He was unresponsive to extensive conservative treatment.  He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia.  He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded.  His lumbar spine was then sterilely prepped and draped in the usual fashion.  A previous midline incision was extended from approximate level of L3 to S1.  This was in the midline.  Skin and subcutaneous tissue were debrided sharply.  Electrocautery provided hemostasis.  ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia.  The lumbar fascia was identified and split in the midline.  Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1.  Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4.  Once this was completed, a self-retaining retractor was then placed.  With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable.  These were readily mobile with digital palpation.  A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1.  This bone was morcellized and placed on the back table for utilization for bone grafting.  The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1.  Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained.  Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1.  The microscope was utilized during this portion of procedure for visualization.  There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure.  Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5.  Once this was identified, foraminotomies were created to allow additional mobility.  The wound was then copiously irrigated with antibiotic solution and suctioned dry.  Working type screws, provisional titanium screws were then placed at L4-l5.  This was to allow distraction and reduction of the spondylolisthesis.  These were placed in the pedicles of L4 and L5 under direct intensification.  The position of the screws were visualized, both AP and lateral images.  They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5.  This allowed for additional decompression of the L5 and L4 nerve roots.  Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed.  Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval.  This was taken in sequence up to a 13 mm space.  This was then reduced to a 11 mm as it was much more anatomic in nature.  Once this was completed, the spacers were then placed on the left side and distraction obtained.  Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally.  Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried.  A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft.  There were impacted at the interspace of L4-L5 under direct image intensification.  Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried.  The provisional screws and plates were removed.  This allowed for additional compression along L4-L5 with the cage instrumentation.  Permanent screws were then placed at L4, L5, and S1 bilaterally.  This was performed under direct image intensification.  The position was verified in both AP and lateral images.  Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally.  A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1.  Appropriate cross connecters were applied and the construct was placed over the pedicle screws.  They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra.  Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory.  All connections were tightened and retightened in Torque 2 specifications.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The dura was inspected and noted to be free of tension.  At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors.  An 8-inch Hemovac drain was placed exiting the wound.  The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin.  The remainder of the Hemovac was assembled.  Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape.  He was turned and taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded.", Orthopedic,27
"SUBJECTIVE:  ,The patient seen and examined feels better today.  Still having diarrhea, decreased appetite.  Good urine output 600 mL since 7 o'clock in the morning.  Afebrile.,PHYSICAL EXAMINATION,GENERAL:  Nonacute distress, awake, alert, and oriented x3.,VITAL SIGNS:  Blood pressure 102/64, heart rate of 89, respiratory rate of 12, temperature 96.8, and O2 saturation 94% on room air.,HEENT:  PERRLA, EOMI.,NECK:  Supple.,CARDIOVASCULAR:  Regular rate and rhythm.,RESPIRATORY:  Clear to auscultation bilaterally.,ABDOMEN:  Bowel sounds are positive, soft, and nontender. EXTREMITIES:  No edema.  Pulses present bilaterally.,LABORATORY DATA:  ,CBC, WBC count today down 10.9 from 17.3 yesterday 26.9 on admission, hemoglobin 10.2, hematocrit 31.3, and platelet count 370,000.  BMP, BUN of 28.3 from 32.2, creatinine 1.8 from 1.89 from 2.7.  Calcium of 8.2.  Sodium 139, potassium 3.9, chloride 108, and CO2 of 22.  Liver function test is unremarkable.,Stool positive for Clostridium difficile.  Blood culture was 131.  O2 saturation result is pending.,ASSESSMENT AND PLAN:,1.  Most likely secondary to Clostridium difficile colitis and urinary tract infection improving.  The patient hemodynamically stable, leukocytosis improved and today he is afebrile.,2.  Acute renal failure secondary to dehydration, BUN and creatinine improving.,3.  Clostridium difficile colitis, Continue Flagyl, evaluation Dr. X in a.m.,4.  Urinary tract infection, continue Levaquin for last during culture.,5.  Leucocytosis, improving.,6.  Minimal elevated cardiac enzyme on admission.  Followup with Cardiology recommendations.,7.  Possible pneumonia, continue vancomycin and Levaquin.,8.  The patient may be transferred to telemetry.", Gastroenterology,14
"REASON FOR VISIT:,  Lap band adjustment.,HISTORY OF PRESENT ILLNESS:,  Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment.  Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress.  She was in a car accident a couple of weeks ago and she has problems, she does not feel full.  She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.,PHYSICAL EXAMINATION: , On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit.  She was alert and oriented in no apparent distress.  ,PROCEDURE:  ,I was able to access her port.  She does have an AP standard low profile.  I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her band, she did tolerate water postprocedure.,ASSESSMENT:,  The patient is status post lap band adjustments, doing well, has a total of 7 mL within her band, tolerated water postprocedure.  She will come back in two weeks for another adjustment as needed.,", Bariatrics,2
"CC:, Falls.,HX: ,This 51y/o RHF fell four times on 1/3/93, because her ""legs suddenly gave out."" She subsequently noticed weakness involving the right leg, and often required the assistance of her arms to move it. During some of these episodes she appeared mildly pale and felt generally weak; her husband would give her 3 teaspoons of sugar and she would appear to improve, thought not completely. During one episode she held her RUE in an ""odd fisted posture."" She denied any other focal weakness, sensory change, dysarthria, diplopia, dysphagia or alteration of consciousness. She did not seek medical attention despite her weakness. Then, last night, 1/4/93, she fell again ,and because her weakness did not subsequently improve she came to UIHC for evaluation on 1/5/93.,MEDS: ,Micronase 5mg qd, HCTZ, quit ASA 6 months ago (tired of taking it).,PMH:, 1)DM type 2, dx 6 months ago. 2)HTN. 3)DJD. 4)s/p Vitrectomy and retinal traction OU for retinal detachment 7/92. 5) s/p Cholecystemomy,1968. 6) Cataract implant, OU,1992. 7) s/p C-section.,FHX: ,Grand Aunt (stroke), MG (CAD), Mother (CAD, died MI age 63), Father (with unknown CA), Sisters (HTN), No DM in relatives.,SHX: ,Married, lives with husband, 4 children alive and well. Denied tobacco/ETOH/illicit drug use.,ROS:, intermittent diarrhea for 20 years.,EXAM: ,BP164/82 HR64 RR18 36.0C,MS: A & O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, reading.,CN: Pupils 4.5 (irregular)/4.0 (irregular) and virtually fixed. Optic disks flat. EOM intact. VFFTC. Right lower facial weakness. The rest of the CN exam was unremarkable.,Motor: 5/5 BUE with some question of breakaway. LE: HF and HE 4+/5, KF5/5, AF and AE 5/5. Normal muscle bulk and tone.,Sensory: intact PP/VIB/PROP/LT/T/graphesthesia.,Coord: slowed FNF and HKS (worse on right).,Station: no pronator drift or Romberg sign.,Gait: Unsteady wide-based gait. Unable to heel walk on right.,Reflexes: 2/2+ throughout (Slightly more brisk on right). Plantar responses were downgoing bilaterally.,HEENT: N0 Carotid or cranial bruits.,Gen Exam: unremarkable.,COURSE:, CBC, GS (including glucose), PT/PTT, EKG, CXR on admission, 1/5/93, were unremarkable. HCT, 1/5/93, revealed a hypodensity in the left caudate consistent with ischemic change. Carotid Duplex: 0-15%RICA, 16-49%LICA; antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram showed borderline LV hypertrophy and normal LV function. No valvular abnormalities or thrombus were seen.,The patient's history and exam findings of right facial and RLE weakness with sparing of the RUE would invoke a RACA territory stroke with recurrent artery of Heubner involvement causing the facial weakness.", Radiology,33
"HISTORY: , The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis.  The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised.  Parents; however, did note the patient to be quite dusky since the time of her birth; however, were reassured by the pediatrician that this was normal.  The patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness, some irritability, and rapid heart rate.  Parents do state that she does appear to breathe rapidly, tires somewhat with the feeding with increased respiratory effort and diaphoresis.  The patient is exclusively breast fed and feeding approximately 2 hours.  Upon arrival at Children's Hospital, the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine.  The electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement, northwest axis, and poor R-wave progression, possible right ventricular hypertrophy.,FAMILY HISTORY:,  Family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed.,REVIEW OF SYSTEMS: , A complete review of systems including neurologic, respiratory, gastrointestinal, genitourinary are otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  Physical examination that showed a sedated, acyanotic infant who is in no acute distress.,VITAL SIGNS:  Heart rate of 170, respiratory rate of 65, saturation, it is nasal cannula oxygen of 74% with a prostaglandin infusion at 0.5 mcg/kg/minute.,HEENT:  Normocephalic with no bruit detected.  She had symmetric shallow breath sounds clear to auscultation.  She had full symmetrical pulses.,HEART:  There is normoactive precordium without a thrill.  There is normal S1, single loud S2, and a 2/6 continuous shunt type of murmur could be appreciated at the left upper sternal border.,ABDOMEN:  Soft.  Liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected.,X-RAYS:,  Review of the chest x-ray demonstrated a normal situs, normal heart size, and adequate pulmonary vascular markings.  There is a prominent thymus.  An echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs, a left superior vena cava draining into the left atrium, a criss-cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left-sided morphologic left ventricle.  The left atrium drained through the tricuspid valve into a right-sided morphologic right ventricle.  There is a large inlet ventricular septal defect as pulmonary atresia.  The aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch.  There was a small vertical ductus as a sole source of pulmonary artery blood flow.  The central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter.  Biventricular function is well maintained.,FINAL IMPRESSION: , The patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal-dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function.  The saturations are now also adequate on prostaglandin E1.,RECOMMENDATION: , My recommendation is that the patient be continued on prostaglandin E1.  The patient's case was presented to the cardiothoracic surgical consultant, Dr. X.  The patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence.  A consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention.  The patient will require some form of systemic to pulmonary shunt, modified pelvic shunt or central shunt as a durable source of pulmonary blood flow.  Further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible Rastelli procedure.  The current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional Glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age.  These findings and recommendations were reviewed with the parents via a Spanish interpreter.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS:,  Left distal radius fracture displaced.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture displaced.,SURGERY:  ,Closed reduction and placement of long-arm cast, CPT code 25605.,ANESTHESIA:  ,General LMA.,FINDINGS:  ,The patient was found to have a displaced fracture.  She was found to be in perfect alignment after closed reduction and placement of cast.  The radial deviation was well corrected.,INDICATIONS: , The patient is 5 years old.  She was seen in our office today 1 week after being placed into a cast for a displaced fracture.  She was noted to have significant loss of alignment especially on the lateral view.  She was indicated for closed reduction and placed of the long-arm cast.  Risks and benefits were discussed at length with the family.  They wished to proceed.,PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in supine position.  General anesthesia was induced without incident.  Previous cast was previously removed.  An arm was approached and a closed reduction was performed.  This was checked under AP and lateral projection and was found to be in adequate alignment.  There was very mild residual dorsiflexion deformity noted.,A long-arm cast was then placed with plaster and molding.  Repeat x-rays demonstrated adequate alignment on both views.,The cast was then reinforced with fiberglass.  The patient was awakened from anesthesia and taken to recovery room in good condition.  There were no complications.  All instruments, sponge, and needle counts were correct at the end of case.,PLAN:  ,The patient will be discharged home.  She will return in 3 weeks for cast removal and clinical examination.  She would likely be placed into a wrist-guard at that time.  She has a prescription for Tylenol with codeine elixir.,", Surgery,38
"CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY,PROCEDURE: , Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time.  Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV.  Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.,Retrospective ECG gating was performed.  The patient received 0.4 milligrams of sublingual nitroglycerin prior to the to the scan.  The average heart rate was 62 beats/min.,The patient had no adverse reaction to the contrast.  Multiphase retrospective reconstructions were performed.  Small field of view cardiac and coronary images were analyzed on a 3D work station.  Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease.,CORONARY CTA:,1.  The technical quality of the scan is adequate.,2.  The coronary ostia are in their normal position.  The coronary anatomy is right dominant.,3.  LEFT MAIN:  The left main coronary artery is patent without angiographic stenosis.,4.  LEFT ANTERIOR DESCENDING ARTERY:  The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30% in stenosis severity.  Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities.,5.  The ramus intermedius is a small vessel with minor irregularities.,6.  LEFT CIRCUMFLEX:  The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis.,7.  RIGHT CORONARY ARTERY:  The right coronary artery is a large and dominant vessel.  It demonstrates within its mid-segment calcified atherosclerosis, less than 50% stenosis severity.  Left ventricular ejection fraction is calculated to be 69%.  There are no wall motion abnormalities.,8.  Coronary calcium score was calculated to be 79, indicating at least mild atherosclerosis within the coronary vessels.,ANCILLARY FINDINGS: , None.,FINAL IMPRESSION:,1.  Mild coronary artery disease with a preserved left ventricular ejection fraction of 69%.,2.  Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy.,Thank you for referring this patient to us.", Radiology,33
"CHIEF COMPLAINT:, Diarrhea, vomiting, and abdominal pain.,HISTORY OF PRESENT ILLNESS:, The patient is an 85-year-old female who presents with a chief complaint as described above. The patient is a very poor historian and is extremely hard of hearing, and therefore, very little history is available. She was found by EMS sitting on the toilet having diarrhea, and apparently had also just vomited. Upon my questioning of the patient, she can confirm that she has been sick to her stomach and has vomited. She cannot tell me how many times. She is also unable to describe the vomitus. She also tells me that her belly has been hurting. I am unable to get any further history from the patient because, again, she is an extremely poor historian and very hard of hearing.,PAST MEDICAL HISTORY:, Per the ER documentation is hypertension, diverticulosis, blindness, and sciatica.,MEDICATIONS:, Lorazepam 0.5 mg, dosing interval is not noted; Tylenol PM; Klor-Con 10 mEq; Lexapro; calcium with vitamin D.,ALLERGIES:, SHE IS ALLERGIC TO PENICILLIN.,FAMILY HISTORY:, Unknown.,SOCIAL HISTORY:, Also unknown.,REVIEW OF SYSTEMS:, Unobtainable secondary to the patient's condition.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 80. Respiratory rate 18. Blood pressure 130/80. Temperature 97.6.,GENERAL: Elderly black female who is initially sleeping upon my evaluation, but is easily arousable.,NECK: No JVD. No thyromegaly.,EARS, NOSE, AND THROAT: Her oropharynx is dry. Her hearing is very diminished.,CARDIOVASCULAR: Regular rhythm. No lower extremity edema.,GI: Mild epigastric tenderness to palpation without guarding or rebound. Bowel sounds are normoactive.,RESPIRATORY: Clear to auscultation bilaterally with a normal effort.,SKIN: Warm, dry, no erythema.,NEUROLOGICAL: The patient attempts to answer questions when asked, but is very hard of hearing. She is seen to move all extremities spontaneously.,DIAGNOSTIC DATA:, White count 9.6, hemoglobin 15.9, hematocrit 48.2, platelet count 345, PTT 24, PT 13.3, INR 0.99, sodium 135, potassium 3.3, chloride 95, bicarb 20, BUN 54, creatinine 2.2, glucose 165, calcium 10.3, magnesium 2.5, total protein 8.2, albumin 3.8, AST 33, ALT 26, alkaline phosphatase 92. Cardiac isoenzymes negative x1. EKG shows sinus rhythm with a rate of 96 and a prolonged QT interval.,ASSESSMENT AND PLAN:,1. Pancreatitis. Will treat symptomatically with morphine and Zofran, and also IV fluids. Will keep NPO.,2. Diarrhea. Will check stool studies.,3. Volume depletion. IV fluids.,4. Hyperglycemia. It is unknown whether the patient is diabetic. I will treat her with sliding scale insulin.,5. Hypertension. If the patient takes blood pressure medications, it is not listed on the only medication listing that is available. I will prescribe clonidine as needed.,6. Renal failure. Her baseline is unknown. This is at least partly prerenal. Will replace volume with IV fluids and monitor her renal function.,7. Hypokalemia. Will replace per protocol.,8. Hypercalcemia. This is actually rather severe when adjusted for the patient's low albumin. Her true calcium level comes out to somewhere around 12. For now, I will just treat her with IV fluids and Lasix, and monitor her calcium level.,9. Protein gap. This, in combination with the calcium, may be suggestive of multiple myeloma. It is my understanding that the family is seeking hospice placement for the patient right now. I would have to discuss with the family before undertaking any workup for multiple myeloma or other malignancy.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS,1.  Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS,1.  Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,TITLE OF PROCEDURE,1.  Carpal tunnel release.,2. de Quervain's release.,ANESTHESIA: , MAC,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:  ,After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.  The subcutaneous fat was dissected radially from 2-3 mm and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with scissors.,After irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 Vicryl.  Care was taken to avoid entrapping the motor branch of the median nerve in the suture.  A hemostat was placed under the repair to ensure that the median nerve was not compressed.  The skin was repaired with 5-0 nylon interrupted stitches.,The first dorsal compartment was addressed through a transverse incision at the level of the radial styloid tip.  Dissection was carried down with care taken to avoid and protect the superficial radial nerve branches.  I released the compartment in a separate subsheath for the EPB on the dorsal side.  Both ends of the sheath were released to lengthen them, and then these were repaired with 4-0 Vicryl.  It was checked to make sure that there was significant room remaining for the tendons.  This was done to prevent postoperative subluxation.,I then irrigated and closed the wounds in layers.  Marcaine with epinephrine was placed into all wounds, and dressings and splint were placed.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.", Surgery,38
"EXAM:  ,Ultrasound left lower extremity, duplex venous,REASON FOR EXAM: , Swelling and rule out DVT.,FINDINGS: , Duplex and color Doppler interrogation of the left lower extremity deep venous system was performed. Compressibility, augmentation, and color flow as well as Doppler flow was demonstrated within the common femoral vein, superficial femoral vein, and popliteal vein. The posterior tibial vein also demonstrated flow along its proximal visualized extent.,IMPRESSION: , No evidence of left lower extremity deep venous thrombosis.", Radiology,33
"PREOPERATIVE DIAGNOSIS: , Morbid obesity. ,POSTOPERATIVE DIAGNOSIS: , Morbid obesity. ,PROCEDURE:,  Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. ,ANESTHESIA: , General with endotracheal intubation. ,INDICATIONS FOR PROCEDURE: , This is a 50-year-old male who has been overweight for many years and has tried multiple different weight loss diets and programs.  The patient has now begun to have comorbidities related to the obesity.  The patient has attended our bariatric seminar and met with our dietician and psychologist.  The patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form.,PROCEDURE IN DETAIL: , The risks and benefits were explained to the patient.  Consent was obtained.  The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation.  A Foley catheter was placed for bladder decompression.  All pressure points were carefully padded, and sequential compression devices were placed on the legs.  The abdomen was prepped and draped in standard, sterile, surgical fashion.  Marcaine was injected into the umbilicus.", Gastroenterology,14
"PREOPERATIVE DIAGNOSIS:,  Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip - donor site, abdomen.,INDICATION:  ,This is a 62-year-old female for the above-planned procedure.  She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied.  Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,PROCEDURE: , The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table.  Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen.  This included the neck accordingly.,Two platysmal sling application and operating headlight were utilized.  Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.,The first procedure was performed was that of a quadrilateral blepharoplasty.  Markers were applied to both upper lids in symmetrical fashion.  The skin was excised from the right upper lid first followed by appropriate muscle resection.  Minimal fat removed from the medial upper portion of the eyelid.  Hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture.  Attention was then turned to the lower lid.  A classic skin muscle flap was created accordingly.  Fat was resected from the middle, medial, and lateral quadrant.  The fat was allowed to open drain the arcus marginalis for appropriate contour.  Hemostasis was controlled with the pinpoint cautery accordingly.  Skin was redraped with a conservative amount resected.  Running closure with 7-0 nylon was accomplished without difficulty.  The exact same procedure was repeated on the left upper and lower lid.,After completion of this portion of the procedure, the lag lid was again placed in the eyes.  Eye mass was likewise clamped.  Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure.  The right face was first operated.  It was injected with a 0.25% Marcaine 1:200,000 adrenaline.  A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula.  She had minimal subcutaneous extra fat as noted.  Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline.  The flap was elevated without difficulty with various facelift scissors.  Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.,The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision.  Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery.  The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.,Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication.  The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene.  The skin was draped appropriately and appropriate tissue was resected.  A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface.  Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon.  The hairline temporal incision was closed with running 5-0 nylon.  The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.,The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.,The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described.  Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly.  Approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly.  Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure.  The incision site was closed with 7-0 nylon.,The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.,The patient will be admitted for overnight short stay through the cosmetic package procedure.  She will be discharged in the morning.,Estimated blood loss was less than 75 cc.  No complications noted, and the patient tolerated the procedure well.", Surgery,38
"DIAGNOSIS: , Multiparous female, desires permanent sterilization.,NAME OF OPERATION: , Laparoscopic bilateral tubal ligation with Falope rings.,ANESTHESIA: , General, ET tube.,COMPLICATIONS:,  None.,FINDINGS:  ,Normal female anatomy except for mild clitoromegaly and a posterior uterine fibroid.,PROCEDURE: , The patient was taken to the operating room and placed on the table in the supine position.  After adequate general anesthesia was obtained, she was placed in the lithotomy position and examined.  She was found to have an anteverted uterus and no adnexal mass.  She was prepped and draped in the usual fashion.  The Foley catheter was placed.  A Hulka cannula was inserted into the cervix and attached to the anterior lip of the cervix.,An infraumbilical incision was made with the knife.  A Veress needle was inserted into the abdomen.  Intraperitoneal location was verified with approximately 10 cc of sterile solution.  A pneumoperitoneum was created.  The Veress needle was then removed, and a trocar was inserted directly without difficulty.  Intraperitoneal location was verified visually with the laparoscope.  There was no evidence of any intra-abdominal trauma.,Each fallopian tube was elevated with a Falope ring applicator, and a Falope ring was placed on each tube with a 1-cm to 1.5-cm portion of the tube above the Falope ring.,The pneumoperitoneum was evacuated, and the trocar was removed under direct visualization.  An attempt was made to close the fascia with a figure-of-eight suture.  However, this was felt to be more subcutaneous.  The skin was closed in a subcuticular fashion, and the patient was taken to the recovery room awake with vital signs stable.", Obstetrics / Gynecology,24
"PREOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,POSTOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,OPERATION,Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.,ANESTHESIA,General endotracheal anesthesia.,PROCEDURE,The patient was placed in the supine position.  Under effects of general endotracheal anesthesia, markings were made preoperatively for the mastopexy.  An eccentric circle was drawn around the nipple and a wedge drawn from the inferior border of the areola to the inframammary fold.  A stab incision was made bilaterally and tumescent infiltration of anesthesia, lactated ringers with 1 cc of epinephrine to 1000 cc of lactated ringers was infused with a tumescent blunt needle.  200 cc was infiltrated on each side.  This was followed by power-assisted liposuction and manual liposuction with removal of 350 cc of supernatant fat from both sides utilizing a radial tunneling technique with a 4-mm cannula.  This was followed by the epithelialization of skin between the inner circle corresponding to the diameter of the areola 4 cm diameter and the outer eccentric circle with a tangent at the 6 o'clock position.  This would result in an elevation of the nipple-areolar complex with transposition.  The epithelialization of the wedge inferiorly equalized the circumference distance between the inner circle and the outer circle.  Hemostasis was achieved with electrocautery.  After the epithelialization was performed on both sides, nipple-areolar complex was transposed to new nipple position and the wedge was closed with transposition of the nipple-areolar complex beneath the transposed nipple.  Closure was performed with interrupted 3-0 PDS suture on deep subcutaneous tissue and dermal skin closure with running subcuticular 4-0 Monocryl suture.  Dermabond was applied followed by Adaptic and Kerlix in the suturing spaces supportive mildly compressive dressing.  The patient tolerated the procedure well.  The patient was returned to recovery room in satisfactory condition.", Surgery,38
"PROCEDURE:  ,Trigger thumb release.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual sterile fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A transverse incision was made over the MPJ crease of the thumb.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The flexor sheath was opened under direct vision with a scalpel, and then a scissor was used to release the A1 pulley under direct vision on the radial side, from its proximal extent to its distal extent at the junction of the proximal and middle thirds of the proximal phalanx.  Meticulous hemostasis was maintained with bipolar electrocautery.,The flexor pollicis longus tendon was identified and atraumatically pulled to ensure that no triggering remained.  The patient then actively moved the thumb and no triggering was noted.,After irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,The wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.", Surgery,38
"DISCHARGE DATE:  MM/DD/YYYY,HISTORY OF PRESENT ILLNESS:  Mr. ABC is a 60-year-old white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital.  He underwent a resection there.  He was to be admitted to the Day Hospital for cystectomy.  He was seen in Urology Clinic and Radiology Clinic on MM/DD/YYYY.,HOSPITAL COURSE:  Mr. ABC presented to the Day Hospital in anticipation for Urology surgery.  On evaluation, EKG, echocardiogram was abnormal, a Cardiology consult was obtained.  A cardiac adenosine stress MRI was then proceeded, same was positive for inducible ischemia, mild-to-moderate inferolateral subendocardial infarction with peri-infarct ischemia.  In addition, inducible ischemia seen in the inferior lateral septum.  Mr. ABC underwent a left heart catheterization, which revealed two vessel coronary artery disease.  The RCA, proximal was 95% stenosed and the distal 80% stenosed.  The mid LAD was 85% stenosed and the distal LAD was 85% stenosed.  There was four Multi-Link Vision bare metal stents placed to decrease all four lesions to 0%.  Following intervention, Mr. ABC was admitted to 7 Ardmore Tower under Cardiology Service under the direction of Dr. XYZ.  Mr. ABC had a noncomplicated post-intervention hospital course.  He was stable for discharge home on MM/DD/YYYY with instructions to take Plavix daily for one month and Urology is aware of the same.,DISCHARGE EXAM:,VITAL SIGNS:  Temperature 97.4, heart rate 68, respirations 18, blood pressure 133/70.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  Obese, soft, nontender.  Lower abdomen tender when touched due to bladder cancer.,RIGHT GROIN:  Dry and intact, no bruit, no ecchymosis, no hematoma.  Distal pulses are intact.,DISCHARGE LABS:  CBC:  White count 5.4, hemoglobin 10.3, hematocrit 30, platelet count 132, hemoglobin A1c 9.1.  BMP:  Sodium 142, potassium 4.4, BUN 13, creatinine 1.1, glucose 211.  Lipid profile:  Cholesterol 157, triglycerides 146, HDL 22, LDL 106.,PROCEDURES:,1.  On MM/DD/YYYY, cardiac MRI adenosine stress.,2.  On MM/DD/YYYY, left heart catheterization, coronary angiogram, left ventriculogram, coronary angioplasty with four Multi-Link Vision bare metal stents, two placed to the LAD in two placed to the RCA.,DISCHARGE INSTRUCTIONS:  Mr. ABC is discharged home.  He should follow a low-fat, low-salt, low-cholesterol, and heart healthy diabetic diet.  He should follow post-coronary artery intervention restrictions.  He should not lift greater than 10 pounds for seven days.  He should not drive for two days.  He should not immerse in water for two weeks.  Groin site care reviewed with patient prior to being discharged home.  He should check groin for bleeding, edema, and signs of infection.  Mr. ABC is to see his primary care physician within one to two weeks, return to Dr. XYZ's clinic in four to six weeks, appointment card to be mailed him.  He is to follow up with Urology in their clinic on MM/DD/YYYY at 10 o'clock and then to scheduled CT scan at that time.,DISCHARGE DIAGNOSES:,1.  Coronary artery disease status post percutaneous coronary artery intervention to the right coronary artery and to the LAD.,2.  Bladder cancer.,3.  Diabetes.,4.  Dyslipidemia.,5.  Hypertension.,6.  Carotid artery stenosis, status post right carotid endarterectomy in 2004.,7.  Multiple resections of the bladder tumor.,8.  Distant history of appendectomy.,9.  Distant history of ankle surgery.", General Medicine,15
"HISTORY OF PRESENT ILLNESS: , This is a 70-year-old female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot.  The patient says that the right hand was very swollen, very painful, could not move the fingers, and also, the left foot was very swollen and very painful, and again could not move the toes, came to emergency room, diagnosed with gout and gouty attacks.  I was asked to see the patient regarding chronic kidney disease.,PAST MEDICAL HISTORY:,1.  Diabetes mellitus type 2.,2.  Diabetic nephropathy.,3.  Chronic kidney disease, stage 4.,4.  Hypertension.,5.  Hypercholesterolemia and hyperlipidemia.,6.  Peripheral vascular disease, status post recent, last week PTA of right lower extremity.,SOCIAL HISTORY:,  Negative for smoking and drinking.,CURRENT HOME MEDICATIONS:,  NovoLog 20 units with each meal, Lantus 30 units at bedtime, Crestor 10 mg daily, Micardis 80 mg daily, Imdur 30 mg daily, Amlodipine 10 mg daily, Coreg 12.5 mg b.i.d., Lasix 20 mg daily, Ecotrin 325 mg daily, and calcitriol 0.5 mcg daily.,REVIEW OF SYSTEMS: , The patient denies any complaints, states that the right hand and left foot was very swollen and very painful, and came to emergency room.  Also, she could not urinate and states as soon as they put Foley in, 500 mL of urine came out.  Also they started her on steroids and colchicine, and the pain is improving and the swelling is getting better.  Denies any fever and chills.  Denies any dysuria, frequency or hematuria.  States that the urine output was decreased considerably, and she could not urinate.  Denies any cough, hemoptysis or sputum production.  Denies any chest pain, orthopnea or paroxysmal nocturnal dyspnea.,PHYSICAL EXAMINATION:,General:  The patient is alert and oriented, in no acute distress.,Vital Signs:  Blood pressure 126/67, temperature 97.9, pulse 71, and respirations 20.  The patient's weight is 105.6 kg.,Head:  Normocephalic.,Neck:  Supple.  No JVD.  No adenopathy.,Chest:  Symmetric.  No retractions.,Lungs:  Clear.,Heart:  RRR with no murmur.,Abdomen:  Obese, soft, and nontender.  No rebound.  No guarding.,Extremity:  She has 2+ pretibial edema bilaterally at the lower extremity, but also the left foot, in dorsum of left foot and also right hand is swollen and very tender to move the toes and also fingers in those extremities.,LAB TESTS: , Showed that urine culture is negative up to date.  The patient's white cell is 12.7, hematocrit 26.1.  The patient has 90% segs and 0% bands.  Serum sodium 133, potassium 5.9, chloride 100, bicarb 21, glucose 348, BUN 57, creatinine is 2.39, calcium 8.9, and uric acid yesterday was 10.9.  Sed rate was 121.  BNP was 851.  Urinalysis showed 15 to 20 white cells, 3+ protein, 3+ blood with 25 to 30 red blood cells also.,IMPRESSION:,1.  Urinary tract infection.,2.  Acute gouty attack.,3.  Diabetes mellitus with diabetic nephropathy.,4.  Hypertension.,5.  Hypercholesterolemia.,6.  Peripheral vascular disease, status post recent PTA in the right side.,7.  Chronic kidney disease, stage 4.,PLAN: , At this time is I agree with treatment.  We will add allopurinol 50 mg daily.  This is secondary to the patient is already on colchicine, and also we will discontinue Micardis, we will increase Lasix to 40 b.i.d., and we will follow with the lab results.", General Medicine,15
"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.", Emergency Room Reports,12
"PREOPERATIVE DIAGNOSIS:,  Critical left carotid stenosis.,POSTOPERATIVE DIAGNOSIS: , Critical left carotid stenosis.,PROCEDURE PERFORMED:,  Left carotid endarterectomy with endovascular patch angioplasty.,ANESTHESIA:,  Cervical block.,GROSS FINDINGS:  ,The patient is a 57-year-old black female with chronic renal failure.  She does have known critical carotid artery stenosis.  She wishes to undergo bilateral carotid endarterectomy, however, it was felt necessary by Dr. X to perform cardiac catheterization.  She was admitted to the hospital yesterday with chest pain.  She has been considered for coronary artery bypass grafting.  I have been asked to address the carotid stenosis, left being more severe, this was addressed first.  Intraoperatively, an atherosclerotic plaque was noted in the common carotid artery extending into the internal carotid artery.  The internal carotid artery is quite torturous.  The external carotid artery was occluded at its origin.  When the endarterectomy was performed, the external carotid artery back-bled nicely.  The internal carotid artery had good backflow bleeding noted.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite and placed in the supine position.  Then neck, shoulder, and chest wall were prepped and draped in appropriate manner.  Longitudinal incision was created along the anterior border of the left sternocleidal mastoid muscle and this was taken through the subcutaneous tissue and platysmal muscle utilizing electrocautery.,Utilizing both blunt and sharp dissections, the common carotid artery, the internal carotid artery beyond the atherosclerotic back, the external carotid artery, and the superior thyroid artery were isolated and encircled with a umbilical tape.  During the dissection, facial veins were ligated with #4-0 silk ligature prior to dividing them.  Also during the dissection, ansa cervicalis, hypoglossal, and vagus nerve identified and preserved.  There was some inflammation above the carotid bulb, but this was not problematic.,The patient had been administered 5000 units of aqueous heparin after allowing adequate circulating time.  The internal carotid artery is controlled with Heifitz clip followed by the external carotid artery and the superior thyroid artery being controlled with Heifitz clips.  The common carotid artery was controlled with profunda clamp.  The patient remained neurologically intact.  A longitudinal arteriotomy was created along the posterior lateral border of the common carotid artery.  This was extended across the lobe on to the internal carotid artery.  An endarterectomy was then performed.  The ________ intima was cleared of all debris and the ________ was flushed with copious amounts of heparinized saline.  As mentioned before, the internal carotid artery is quite torturous.  This was shortened by imbricating the internal carotid artery with horizontal mattress stitches of #7-0 Prolene suture.,The wound was copiously irrigated, rather an endovascular patch was then brought on to the field.  This was cut to shape and length.  This was sutured in place with continuous running #6-0 Prolene suture.  The suture line began at both sites.  The suture was tied in the center along the anterior and posterior walls.  Prior to completing the closure, the common carotid artery was flushed.  The internal carotid artery permitted to back bleed.  The clamp was placed after completing the closure.  The clamp was placed at the origin of the internal carotid artery.  Flow was first directed into the external carotid artery then into the internal carotid artery.  The patient remained neurologically intact.  Topical ________ Gelfoam was utilized.  Of note, during the endarterectomy, the patient did receive an additional 7000 units of aqueous heparin.  The wound was copiously irrigated with antibiotic solution.  Sponge, needle, and all counts were correct.  All surgical sites were inspected.  Good hemostasis noted.  The incision was closed in layers with absorbable suture.  Stainless steel staples approximated skin.  Sterile dressings were applied.  The patient tolerated the procedure well, grossly neurologically intact.", Surgery,38
"HISTORY:,  The patient is a 25-year-old gentleman who was seen in the emergency room at Children's Hospital today.  He brought his 3-month-old daughter in for evaluation but also wanted to be evaluated himself because he has had ""rib cage pain"" for the last few days.  He denies any history of trauma.  He does have increased pain with laughing.  Per the patient, he also claims to have an elevated temperature yesterday of 101.  Apparently, the patient did go to the emergency room at ABCD yesterday, but due to the long wait, he left without actually being evaluated and then thought that he might be seen today when he came to Children's.,PAST MEDICAL HISTORY: , The patient has a medical history significant for ""Staphylococcus infection"" that was being treated with antibiotics for 10 days.,CURRENT MEDICATIONS: , He states that he is currently taking no medications.,ALLERGIES:  ,He is not allergic to any medication.,PAST SURGICAL HISTORY: , He denies any past surgical history.,SOCIAL HISTORY: , The patient apparently has a history of methamphetamine use and cocaine use approximately 1 year ago.  He also has a history of marijuana used approximately 1 year ago.  He currently states that he is in a rehab program.,FAMILY HISTORY:,  Unknown by the patient.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 99.9, blood pressure is 108/65, pulse of 84, respirations are 16.,GENERAL:  He is alert and appeared to be in no acute distress.  He had normal hydration.,HEENT:  His pupils were equal, round, reactive.  Extraocular muscles intact.  He had no erythema or exudate noted in his posterior oropharynx.,NECK:  Supple with full range of motion.  No lymphadenopathy noted.,RESPIRATORY:  He had equal breath sounds bilaterally with no wheezes, rales, or rhonchi and no labored breathing; however, he did occasionally have pain with deep inspiration at the right side of his chest.,CARDIOVASCULAR:  Regular rate and rhythm.  Positive S1, S2.  No murmurs, rubs, or gallops noted.,GI:  Nontender, nondistended with normoactive bowel sounds.  No masses noted.,SKIN:  Appeared normal except on the left anterior tibial area where the patient had a healing skin lesion.  There were no vesicles, erythema or induration noted.,MUSCULOSKELETAL:  Nontender with normal range of motion.,NEURO/PSYCHE:  The patient was alert and oriented x3 with nonfocal neurological exam.,ASSESSMENT: , This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology.,PLAN: , Due to the fact that this patient is an adult male, we will transfer him to XYZ Medical Center for further evaluation.  I have spoken with XYZ Medical Center Dr. X who has accepted the patient for transfer.  He was advised that the patient will be coming in a private vehicle due to fact that he is completely stable and appears to be in no acute distress.  Dr. X was happy to accept the transfer and indicated that the patient should come to the emergency room area with the transport paperwork.  The plan was explained in detail to the patient who stated that he understood and would comply.  The appropriate paperwork was created and one copy was given to the patient.,CONDITION ON DISCHARGE: , At the time of discharge, he was stable, vital signs stable, in no acute distress.", Emergency Room Reports,12
"PROCEDURE: , Right L5-S1 intralaminar epidural steroid injection with 120 mg of Depo-Medrol under fluoroscopic guidance.,INDICATION: , The patient is a 51-year-old female with back pain referring into the right leg.,RISKS VERSUS BENEFITS: , The risks and benefits were discussed with the patient prior to the procedure.  She agrees to accept the risks and signs a written consent to proceed with the procedure.,DESCRIPTION OF PROCEDURE: , The patient was placed prone on the table.  The skin was thoroughly cleansed with Betadine swabs x3 and wiped off with a sterile gauze.  The subcutaneous intramuscular and interligamentous region was anesthetized with 4% lidocaine.,A 3-1/2-inch 20-gauge Tuohy catheter was directed under intermittent fluoroscopic guidance at the lamina.  Once the lamina was detected, the catheter was directed cephalad and medially and loss of resistance technique was used to determine the epidural space.,EPIDUROGRAM: , Omnipaque 300 1.5 mL was placed just to the right of the midline.  This was viewed on the AP and lateral projections.  It showed typical epidural spread pattern with good cephalad and caudad flow, and the flow was unrestricted.,Depo-Medrol 120 mg along with an additional bacteriostatic normal saline for a total of 60 mL injected solution was placed just to the right of the midline at L5-S1.,The patient tolerated the procedure well without procedural complications.  She will follow up with me in the office in the next few weeks to monitor her response to the injection.", Pain Management,28
"PROBLEM:,  Probable Coumadin hypersensitivity.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old Caucasian female admitted to the Hospital for elective total left knee arthroplasty.  At the time of admission, the patient has a normal prothrombin time and INR of 13.4 seconds and 1.09 respectively and postoperatively, she was placed on Coumadin which is the usual orthopedic surgery procedure for reducing the risk of postoperative thromboembolic activity.  However, the patient's prothrombin time and INR rapidly rose to supratherapeutic levels.  Even though Coumadin was discontinued on 01/21/09, the patient's prothrombin time and INR has continued to rise.  Her prothrombin time is now 83.3 seconds with an INR of 6.52.  Hematology/Oncology consult was requested for recommendation regarding further evaluation and management.,SOCIAL HISTORY: , The patient is originally from Maine.  She has lived in Arizona for 4 years.  She has had 2 children; however, only one is living.  She had one child died from complications of ulcerative colitis.  She has been predominantly a homemaker during her life, but has done some domestic cleaning work in the past.,CHILDHOOD HISTORY: , Negative for rheumatic fever.  The patient has usual childhood illnesses.,ALLERGIES:  ,No known drug allergies.,FAMILY HISTORY: , The patient's mother died from gastric cancer.  She had a brother who died from mesothelioma.  He did have a positive asbestos exposure working in the shipyards.  The patient's father died from motor vehicle accident.  She had a sister who succumbed to pneumonia as a complication to Alzheimer disease.,HABITS: , No use of ethanol, tobacco, illicit, or recreational substances.,ADULT MEDICAL PROBLEMS: , The patient has a history of diabetes mellitus, hypertension, and hypercholesterolemia, which is all consistent with the metabolic syndrome X.  In addition, the patient's husband, who is present, knows that she has early dementia and has problems with memory and difficulty in processing new information.,SURGERIES: , The patient's only surgery is the aforementioned left knee arthroplasty and bilateral cataract surgery, otherwise negative.,MEDICATIONS: , The patient's medications on admission include:,1.  Fosamax.,2.  TriCor.,3.  Gabapentin.,4.  Hydrochlorothiazide.,5.  Labetalol.,6.  Benicar.,7.  Crestor.,8.  Detrol.,REVIEW OF SYSTEMS: , Unable to obtain review of systems as the patient was given a dose of morphine for postoperative pain and she is a bit obtunded at this time.  She is arousable, but not particularly conversant.,OBSERVATIONS:,GENERAL:  The patient is a drowsy, but arousable, nonconversant, elderly Caucasian female.,HEENT:  Pupils were equal, round, and reactive to light and accommodation.  Extraocular muscles are grossly intact.  Oropharynx benign.,NECK:  Supple.  Full range of motion without bruits or thyromegaly.,LUNGS:  Clear to auscultation and percussion.,BACK:  Without spine or CVA tenderness.,HEART:  Regular rate and rhythm without murmurs, rubs, thrills, or heaves.,ABDOMEN:  Soft and nontender.  Positive bowel sounds without mass or visceromegaly.,LYMPHATIC:  No appreciable adenopathy.,EXTREMITIES:  The patient has some postoperative fullness involving her left knee.  She has a dressing over the left knee.,SKIN:  Without lesions.,NEURO:  Unable to assess in light of post morphine obtunded state.,ASSESSMENT: , Hypersensitivity to Coumadin.,PLAN: , Gave the patient vitamin K at this time.  Literature suggested oral vitamin K is actually more efficacious than parenteral.  However, in light of the fact that the patient is obtunded and is not taking anything right now in the way of oral food or fluids, we will give this to her in an IM fashion.  Repeat prothrombin time and INR in a.m.  Once she has come down to a more therapeutic range, I would initiate low-molecular weight heparin in the form of Fragmin one time a day or Lovenox on a b.i.d. schedule for 4 to 6 weeks postoperatively.", Consult - History and Phy.,5
"HISTORY OF PRESENT ILLNESS:,  Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.  Mom called to the poison control center and the recommendation was to take the patient to the emergency room and be evaluated.  The patient was alert and did not vomit during the transport to the emergency room.  Mom left the patient and his little one-year-old brother in the room by themselves and she went outside of the house for a couple of minutes, and when came back, she saw the patient having the Celesta foils in his hands and half of tablet was moist and on the floor.  The patient said that the pills ""didn't taste good,"" so it is presumed that the patient actually ingested at least two-and-a-half tablets of Celesta, 40 mg per tablet.,PAST MEDICAL HISTORY:,  Baby was born premature and he required hospitalization, but was not on mechanical ventilation.  He doesn't have any hospitalizations after the new born.  No surgeries.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , NOT KNOWN DRUG ALLERGIES.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature 36.2 Celsius, pulse 112, respirations 24, blood pressure 104/67, weight 15 kilograms.,GENERAL:  Alert, in no acute distress.,SKIN:  No rashes.,HEENT:  Head:  Normocephalic, atraumatic.  Eyes:  EOMI, PERRL.  Nasal mucosa clear.  Throat and tonsils, normal.  No erythema, no exudates.,NECK:  Supple, no lymphadenopathy, no masses.,LUNGS:  Clear to auscultation bilateral.,HEART:  Regular rhythm and rate without murmur.  Normal S1, S2.,ABDOMEN:  Soft, nondistended, nontender, present bowel sounds, no hepatosplenomegaly, no masses.,EXTREMITIES:  Warm.  Capillary refill brisk.  Deep tendon reflexes present bilaterally.,NEUROLOGICAL:  Alert.  Cranial nerves II through XII intact.  No focal exam.  Normal gait.,RADIOGRAPHIC DATA: , Patient has had an EKG done at the admission and it was within normal limits for the age.,EMERGENCY ROOM COURSE: , Patient was under observation for 6 hours in the emergency room.  He had two more EKGs during observation in the emergency room and they were all normal.  His vital signs were monitored every hour and were within normal limits.  There was no vomiting, no diarrhea during observation.  Patient did not receive any medication or has had any other lab work besides the EKG.,ASSESSMENT AND PLAN: , Three years old male with accidental ingestion of Celesta.  Discharged home with parents, with a followup in the morning with his primary care physician.", General Medicine,15
"CHIEF REASON FOR CONSULTATION:,  Evaluate recurrent episodes of uncomfortable feeling in the left upper arm at rest, as well as during exertion for the last one month.,HISTORY OF PRESENT ILLNESS:,  This 57-year-old black female complains of having pain and discomfort in the left upper arm, especially when she walks and after heavy meals.  This lasts anywhere from a few hours and is not associated with shortness of breath, palpitations, dizziness, or syncope.  Patient does not get any chest pain or choking in the neck or pain in the back.  Patient denies history of hypertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive of previous myocardial infarction, or acute rheumatic polyarthritis during childhood.  Her exercise tolerance is one to two blocks for shortness of breath and easy fatigability.,MEDICATIONS:,  Patient does not take any specific medications.,PAST HISTORY:,  The patient underwent hysterectomy in 1986.,FAMILY HISTORY:,  The patient is married, has four children who are doing fine.  Family history is positive for hypertension, congestive heart failure, obesity, cancer, and cerebrovascular accident.,SOCIAL HISTORY:, The patient smokes one pack of cigarettes per day and takes drinks on social occasions.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS: , Morbid obesity.,POSTOPERATIVE DIAGNOSIS:  ,Morbid obesity.,PROCEDURE: , Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.,ANESTHESIA: , General with endotracheal intubation.,INDICATION FOR PROCEDURE: , This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful.  She has been to our Bariatric Surgery Seminar, received some handouts, and signed the consent.  The risks and benefits of the procedure have been explained to the patient.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  All pressure points were carefully padded.  She was given general anesthesia with endotracheal intubation.  SCD stockings were placed on both legs.  Foley catheter was placed for bladder decompression.  The abdomen was then prepped and draped in standard sterile surgical fashion.  Marcaine was then injected through umbilicus.  A small incision was made.  A Veress needle was introduced into the abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg.  A 12-mm VersaStep port was placed through the umbilicus.  I then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side.  I placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, I placed a 12-mm VersaStep port.  On the left side, just anterior to the midaxillary line and just subcostal, I placed a 5-mm port.  A few centimeters below and medial to that, I placed a 15-mm port.  I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz.  I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler.  I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device.  I then ran the distal bowel down, approximately 100 cm, and at 100 cm, I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and I passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis.  I reapproximated the edges of the defect.  I lifted it up and stapled across it with another white load stapler.  I then closed the mesenteric defect with interrupted Surgidac sutures.  I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic.  I then put the patient in reverse Trendelenburg.  I placed a liver retractor, identified, and dissected the angle of His.  I then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space.  I fired transversely across the stomach with a 45 blue load stapler.  I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His, thereby creating my gastric pouch.  I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil.  I pulled the anvil into place, and I then opened up my 15-mm port site and passed my EEA stapler.  I passed that in the end of my Roux limb and had the spike come out antimesenteric.  I joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my Roux limb with a white load GI stapler, and removed it with an Endocatch bag.  I put some additional 2-0 Vicryl sutures in the anastomosis for further security.  I then placed a bowel clamp across the bowel.  I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch.  I distended gastric pouch with air.  There was no air leak seen.  I could pass the scope easily through the anastomosis.  There was no bleeding seen through the scope.  We closed the 15-mm port site with interrupted 0 Vicryl suture utilizing Carter-Thomason.  I copiously irrigated out that incision with about 2 L of saline.  I then closed the skin of all incisions with running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.", Gastroenterology,14
"PREOPERATIVE DIAGNOSIS: , Large left adnexal mass, 8 cm in diameter.,POSTOPERATIVE DIAGNOSIS: , Pelvic adhesions, 6 cm ovarian cyst.,PROCEDURES PERFORMED:  ,1.  Pelvic laparotomy.,2.  Lysis of pelvic adhesions.,3.  Left salpingooophorectomy with insertion of Pain-Buster Pain Management System by Dr. X.,GROSS FINDINGS:  ,There was a transabdominal mass palpable in the lower left quadrant.  An ultrasound suggestive with a mass of 8 cm, did not respond to suppression with norethindrone acetate and on repeat ultrasound following the medical treatment, the ovarian neoplasm persisted and did not decreased in size.,PROCEDURE:  ,Under general anesthesia, the patient was placed in lithotomy position, prepped and draped.  A low transverse incision was made down to and through to the rectus sheath.  The rectus sheath was put laterally.  The inferior epigastric arteries were identified bilaterally, doubly clamped and tied with #0 Vicryl sutures.  The rectus muscle was then split transversally and the peritoneum was split transversally as well.  The left adnexal mass was identified and large bowel was attached to the mass and Dr. Zuba from General Surgery dissected the large bowel adhesions and separated them from the adnexal mass.  The ureter was then traced and found to be free of the mass and free of the infundibulopelvic ligament.  The infundibulopelvic ligament was isolated, entered via blunt dissection.  A #0 Vicryl suture was put into place, doubly clamped with curved Heaney clamps, cut with curved Mayo scissors and #0 Vicryl fixation suture put into place.  Curved Heaney clamps were then used to remove the remaining portion of the ovary from its attachment to the uterus and then #0 Vicryl suture was put into place.  Pathology was called to evaluate the mass for potential malignancy and the pathology's verbal report at the time of surgery was that this was a benign lesion.  Irrigation was used.  Minimal blood loss at the time of surgery was noted.  Sigmoid colon was inspected in place in physiologic position of the cul-de-sac as well as small bowel omentum.  Instrument, needle, and sponge counts were called for and found to be correct.  The peritoneum was closed with #0 Vicryl continuous running locking suture.  The rectus sheath was closed with #0 Vicryl continuous running locking suture.  A DonJoy Pain-Buster Pain Management System was placed through the skin into the subcutaneous space and the skin was closed with staples.  Final instrument needle counts were called for and found to be correct.  The patient tolerated the procedure well with minimal blood loss and transferred to recovery area in satisfactory condition.", Obstetrics / Gynecology,24
"SUBJECTIVE:,  The patient is an 89-year-old lady.  She actually turns 90 later this month, seen today for a short-term followup.  Actually, the main reasons we are seeing her back so soon which are elevated blood pressure and her right arm symptoms are basically resolved.  Blood pressure is better even though she is not currently on the higher dose Mavik likely recommended.  She apparently did not feel well with the higher dose, so she just went back to her previous dose of 1 mg daily.  She thinks, she also has an element of office hypertension.  Also, since she is on Mavik plus verapamil, she could switch over to the combined drug Tarka.  However, when we gave her samples of that she thought they were too big for her to swallow.  Basically, she is just back on her previous blood pressure regimen.  However, her blood pressure seems to be better today.  Her daughter says that they do check it periodically and it is similar to today’s reading.  Her right arm symptoms are basically resolved and she attributed that to her muscle problem back in the right shoulder blade.  We did do a C-spine and right shoulder x-ray and those just mainly showed some degenerative changes and possibly some rotator cuff injury with the humeral head quite high up in the glenoid in the right shoulder, but this does not seem to cause her any problems.  She has some vague “stomach problems”, although apparently it is improved when she stopped Aleve and she does not have any more aches or pains off Aleve.  She takes Tylenol p.r.n., which seems to be enough for her.  She does not think she has any acid reflux symptoms or heartburn.  She does take Tums t.i.d. and also Mylanta at night.  She has had dentures for many, many years and just recently I guess in the last few months, although she was somewhat vague on this, she has had some sores in her mouth.  They do heal up, but then she will get another one.  She also thinks since she has been on the Lexapro, she has somewhat of a tremor of her basically whole body at least upper body including the torso and arms and had all of the daughters who I not noticed to speak of and it is certainly difficult to tell her today that she has much tremor.  They do think the Lexapro has helped to some extent.,ALLERGIES: , None.,MEDICATION: , Verapamil 240 mg a day, Mavik 1 mg a day, Lipitor 10 mg one and half daily, vitamins daily, Ocuvite daily, Tums t.i.d., Tylenol 2-3 daily p.r.n., and Mylanta at night.,REVIEW OF SYSTEMS:,  Mostly otherwise as above.,OBJECTIVE:,General:  She is a pleasant elderly lady.  She is in no acute distress, accompanied by daughter.,Vital signs:  Blood pressure:  128/82.  Pulse:  68.  Weight:  143 pounds.,HEENT:  No acute changes.  Atraumatic, normocephalic.  On mouth exam, she does have dentures.  She removed her upper denture.  I really do not see any sores at all.  Her mouth exam was unremarkable.,Neck:  No adenopathy, tenderness, JVD, bruits, or mass.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Extremities:  No significant edema.  Reasonable pulses.  No clubbing or cyanosis, may be just a minimal tremor in head and hands, but it is very subtle and hardly noticeable.  No other focal or neurological deficits grossly.,IMPRESSION:,1.  Hypertension, better reading today.,2.  Right arm symptoms, resolved.,3.  Depression probably somewhat improved with Lexapro and she will just continue that.  She only got up to the full dose 10 mg pill about a week ago and apparently some days does not need to take it.,4.  Perhaps a very subtle tremor.  I will just watch that.,5.  Osteoporosis.,6.  Osteoarthritis.,PLAN:,  I think I will just watch everything for now.  I would continue the Lexapro, we gave her more samples plus a prescription for the 20 mg that she can cut in half.  I offered to see her for again short-term followup.  However, they both preferred just to wait until the annual check up already set up for next April and they know they can call sooner.  She might get a flu shot here in the next few weeks.  Daughter mentioned here today that she thinks her mom is doing pretty well, especially given that she is turning 90 here later this month and I would tend to agree with that.", SOAP / Chart / Progress Notes,35
"CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with ""pins & needles"" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.", Radiology,33
"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.,5
"REASON FOR EVALUATION: , The patient is a 37-year-old white single male admitted to the hospital through the emergency room.  I had seen him the day before in my office and recommended him to go into the hospital.  He had just come from a trip to Taho in Nevada and he became homicidal while there.  He started having thoughts about killing his mother.  He became quite frightened by that thought and called me during the weekend we were able to see him on that Tuesday after talking to him.,HISTORY OF PRESENT ILLNESS: , This is a patient that has been suffering from a chronic psychotic condition now for a number of years.  He began to have symptoms when he was approximately 18 or 19 with auditory and visual hallucinations and paranoid delusions.  He was using drugs and smoking marijuana at that time has experimenting with LXV and another drugs too.  The patient has not used any drugs since age 25.  However, he has continued having intense and frequent psychotic bouts.  I have seen him now for approximately one year.  He has been quite refractory to treatment.  We tried different types of combination of medications, which have included Clozaril, Risperdal, lithium, and Depakote with partial response and usually temporary.  The patient has had starting with probably has had some temporary relief of the symptoms and they usually do not last more than a few days.  The dosages that we have used have been very high.  He has been on Clozaril 1200 mg combined with Risperdal up to 9 mg and lithium at a therapeutic level.  However, he has not responded.,He has delusions of antichrist.  He strongly believes that the dogs have a home in the neighborhood are communicating with him and criticizing him and he believes that all the people can communicate to him with telepathy including the animals.  He has paranoid delusions.  He also gets homicidal like prior to this admission.,PAST PSYCHIATRIC HISTORY:,  As mentioned before, this patient has been psychotic off and on for about 20 years now.  He has had years in which he did better on Clozaril and also his other medications.,With typical anti-psychotics, he has done well at times, but he eventually gets another psychotic bout.,PAST MEDICAL HISTORY: , He has a history of obesity and also of diabetes mellitus.  However, most recently, he has not been treated for diabetes since his last regular weight since he stopped taking Zyprexa.  The patient has chronic bronchitis.  He smokes cigarettes constantly up to 60 a day.,DRUG HISTORY:,  He stopped using drugs when he was 25.  He has got a lapse, but he was more than 10 years and he has been clean ever since then.  As mentioned before, he smokes cigarettes quite heavily and which has been a problem for his health since he also has chronic bronchitis.,PSYCHOSOCIAL STATUS: , The patient lives with his mother and has been staying with her for a few years now.  We have talked to her.  She is very supportive.  His only sister is also very supportive of him.  He has lived in the ABCD houses in the past.  He has done poorly in some of them.,MENTAL STATUS EXAMINATION:,  The patient appeared alert, oriented to time, place, and person.  His affect is flat.  He talked about auditory hallucinations, which are equivocal in nature.  He is not homicidal in the hospital as he was when he was at home.  His voice and speech are normal.  He believes in telepathy.  His memory appears intact and his intelligence is calculated as average.,INITIAL DIAGNOSES:,AXIS I:  Schizophrenia.,AXIS II:  Deferred.,AXIS III:  History of diabetes mellitus, obesity, and chronic bronchitis.,AXIS IV:  Moderate.,AXIS V:  GAF of 35 on admission.,INITIAL TREATMENT AND PLAN:,  Since, the patient has been on high dosages of medications, we will give him a holiday and a structured environment.  We will put him on benzodiazepines and make a decision anti-psychotic later.  We will make sure that he is safe and that he addresses his medical needs well.", Consult - History and Phy.,5
"REASON FOR EXAM: , Aortic valve replacement.  Assessment of stenotic valve.  Evaluation for thrombus on the valve.,PREOPERATIVE DIAGNOSIS:  ,Atrial valve replacement.,POSTOPERATIVE DIAGNOSES:,  Moderate stenosis of aortic valve replacement.  Mild mitral regurgitation.  Normal left ventricular function.,PROCEDURES IN DETAIL: , The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient received a total of 3 mg of Versed and 50 mcg of fentanyl for conscious sedation and pain control.  The oropharynx anesthetized with benzocaine spray and lidocaine solution.,Esophageal intubation was done with no difficulty with the second attempt.  In a semi-Fowler position, the probe was passed to transthoracic views at about 40 to 42 cm.  Multiple pictures obtained.  Assessment of the peak velocity was done later.,The probe was pulled to the mid esophageal level.  Different pictures including short-axis views of the aortic valve was done.  Extubation done with no problems and no blood on the probe.  The patient tolerated the procedure well with no immediate postprocedure complications.,INTERPRETATION: , The left atrium was mildly dilated.  No masses or thrombi were seen.  The left atrial appendage was free of thrombus.  Pulse wave interrogation showed peak velocities of 60 cm per second.,The left ventricle was normal in size and contractility with mild LVH.  EF is normal and preserved.,The right atrium and right ventricle were both normal in size.,Mitral valve showed no vegetations or prolapse.  There was mild-to-moderate regurgitation on color flow interrogation.  Aortic valve was well-seated mechanical valve, bileaflet with acoustic shadowing beyond the valve noticed.  No perivalvular leak was noticed.  There was increased velocity across the valve with peak velocity of 3.2 m/sec with calculated aortic valve area by continuity equation at 1.2 cm2 indicative of moderate aortic valve stenosis based on criteria for native heart valves.,No AIC.,Pulmonic valve was somewhat difficult to see because of acoustic shadowing from the aortic valve.  Overall showed no abnormalities.  The tricuspid valve was structurally normal.,Interatrial septum appeared to be intact, confirmed by color flow interrogation as well as agitated saline contrast study.,The aorta and aortic arch were unremarkable.  No dissection.,IMPRESSION:,1.  Mildly dilated left atrium.,2.  Mild-to-moderate regurgitation.,3.  Well-seated mechanical aortic valve with peak velocity of 3.2 m/sec and calculated valve area of 1.2 cm2 consistent with moderate aortic stenosis.  Reevaluation in two to three years with transthoracic echocardiogram will be recommended.", Cardiovascular / Pulmonary,3
"TITLE OF OPERATION:  ,1.  Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.,2.  A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,INDICATION FOR SURGERY:  ,The patient is a 62-year-old white male who underwent cataract surgery in 09/06.  This was complicated by posterior capsule rupture.  An intraocular lens implant was not attempted.  He developed corneal edema and a preretinal hemorrhage.  He is aware of the risks, benefits, and alternatives of the surgery and now wishes to proceed with secondary scleral suture fixated posterior chamber intraocular lens implant in the left eye, vitrectomy, endolaser, and penetrating keratoplasty.,PREOP DIAGNOSIS:  ,1.  Preretinal hemorrhage.,2.  Diabetic retinopathy.,3.  Aphakia.,4.  Corneal edema.,POSTOP DIAGNOSIS:  ,1.  Preretinal hemorrhage.,2.  Diabetic retinopathy.,3.  Aphakia.,4.  Corneal edema.,ANESTHESIA: , General.,SPECIMEN:  ,1.  Donor corneal swab sent to Microbiology.,2.  Donor corneal scar rim sent to Eye Pathology.,3.  The patient's cornea sent to Eye Pathology.,PROS DEV IMPLANT:  ,ABC Laboratories 16.0 diopter posterior chamber intraocular lens, serial number 123456.,NARRATIVE: , Informed consent was obtained, and all questions were answered.  The patient was brought to the preoperative holding area, where the operative left eye was marked.  He was brought to the operating room and placed in the supine position.  EKG leads were placed.  General anesthesia was induced.  The left ocular surface and periorbital skin were disinfected and draped in the standard fashion for eye surgery after a shield and tape were placed over the unoperated right eye.  A lid speculum was placed.  The posterior segment infusion was placed by the vitreoretinal service.  Peritomy was performed at the 3 and 9 o'clock limbal positions.  A large Flieringa ring was then sutured to the conjunctival surface using 8-0 silk sutures tied in an interrupted fashion.  The cornea was then measured and was found to accommodate a 7.5-mm trephine.  The center of the cornea was marked.  The keratoprosthesis was identified.,A 7.5-mm trephine blade was then used to incise the anterior corneal surface.  This was done after a paracentesis was placed at the 1 o'clock position and viscoelastic was used to dissect peripheral anterior synechiae.  Once the synechiae were freed, the above-mentioned trephination of the anterior cornea was performed.  Corneoscleral scissors were then used to excise completely the central cornea.  The keratoprosthesis was placed in position and was sutured with six interrupted 8-0 silk sutures.  This was done without difficulty.  At this point, the case was turned over to the vitreoretinal team, which will dictate under a separate note.  At the conclusion of the vitreoretinal procedure, the patient was brought under the care of the cornea service.  The 9-0 Prolene sutures double armed were then placed on each lens haptic loop.  The keratoprosthesis was removed.  Prior to this removal, scleral flaps were made, partial thickness at the 3 o'clock and 9 o'clock positions underneath the peritomies.  Wet-field cautery also was performed to achieve hemostasis.  The leading hepatic sutures were then passed through the bed of the scleral flap.  These were drawn out of the eye and then used to draw the trailing hepatic into the posterior segment of the eye followed by the optic.  The trailing hepatic was then placed into the posterior segment of the eye as well.  The trailing haptic sutures were then placed through the opposite scleral flap bed and were withdrawn.  These were tied securely into position with the IOL nicely centered.  At this point, the donor cornea punched at 8.25 mm was then brought into the field.  This was secured with four cardinal sutures.  The corneal button was then sutured in place using a 16-bite 10-0 nylon running suture.  The knot was secured and buried after adequate tension was adjusted.  The corneal graft was watertight.  Attention was then turned back to the IOL sutures, which were locked into position.  The ends were trimmed.  The flaps were secured with single 10-0 nylon sutures to the apex, and the knots were buried.  At this point, the case was then turned back over to the vitreoretinal service for further completion of the retinal procedure.  The patient tolerated the corneal portions of the surgery well and was turned over to the retina service in good condition, having tolerated the procedure well.  No complications were noted.  The attending surgeon, Dr. X, performed the entire procedure.  No complications of the procedure were noted.  The intraocular lens was selected from preoperative calculations.  No qualified resident was available to assist.", Ophthalmology,26
"REASON FOR CONSULT:, Renal insufficiency.,HISTORY OF PRESENT ILLNESS:, A 48-year-old African-American male with a history of coronary artery disease, COPD, congestive heart failure with EF of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. The patient denies any chest pain, palpitations, syncope, or fever. Denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. Nephrology is consulted regarding renal insufficiency.,REVIEW OF SYSTEMS:, Reviewed entirely and negative except for HPI.,PAST MEDICAL HISTORY:, Hypertension, congestive heart failure with ejection fraction of 20%-25% in December 2005, COPD, mild diffuse coronary artery disease, and renal insufficiency.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, Lipitor 20 at bedtime, Toprol XL 100 daily.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY:, The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 180/110. Temperature 98.1. Pulse rate 60. Respiratory rate 23. O2 sat 95% on room air.,GENERAL: A 48-year-old African-American male in no acute distress.,HEENT: Pupils equal, round, and reactive to light and accommodation. No pallor or icterus.,NECK: No JVD, bruit, or lymphadenopathy.,HEART: S1 and S2, regular rate and rhythm, no murmurs, rubs, or gallops.,LUNGS: Clear. No wheezes or crackles.,ABDOMEN: Soft, nontender, nondistended, no organomegaly, bowel sounds present.,EXTREMITIES: No cyanosis, clubbing, or edema.,CNS: Exam is nonfocal.,LABS:, WBC 7, H and H 13 and 40, platelets 330, PT 12, PTT 26, CO2 20, BUN 27, creatinine 3.1, cholesterol 174, BNP 973, troponin 0.18. Previous creatinine levels were 2.7 in December. Urine drug screen positive for cocaine.,ASSESSMENT:, A 48-year-old African-American male with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency with:,1. Hypertensive emergency.,2. Acute on chronic renal failure.,3. Urine drug screen positive.,4. Question CHF versus COPD exacerbation.,PLAN:,1. Most likely, renal insufficiency is a chronic problem. Hypertensive etiology worsened by the patient's chronic cocaine abuse.,2. Control blood pressure with medications as indicated. Hypertensive emergency most likely related to cocaine drug abuse.,Thank you for this consult. We will continue to follow the patient with you.", General Medicine,15
"FINAL DIAGNOSIS/REASON FOR ADMISSION:,1.  Acute right lobar pneumonia.,2.  Hypoxemia and hypotension secondary to acute right lobar pneumonia.,3.  Electrolyte abnormality with hyponatremia and hypokalemia - corrected.,4.  Elevated liver function tests, etiology undetermined.,5.  The patient has a history of moderate-to-severe dementia, Alzheimer's type.,6.  Anemia secondary to current illness and possible iron deficiency.,7.  Darkened mole on the scalp, status post skin biopsy, pending pathology report.,OPERATION AND PROCEDURE: , The patient underwent a scalp skin biopsy with pathology specimen obtained on 6/11/2009.  Dr. X performed the procedure, thoracentesis on 6/12/2009 both diagnostic and therapeutic.  Dr. Y's results pending.,DISPOSITION: , The patient discharged to long-term acute facility under the care of Dr. Z.,CONDITION ON DISCHARGE: , Clinically improved, however, requiring acute care.,CURRENT MEDICATIONS:  ,Include those on admission combined with IV Flagyl 500 mg every 8 hours and Levaquin 500 mg daily.,HOSPITAL SUMMARY: , This is one of several admissions for this 68-year-old female who over the initial 48 hours preceding admission had a complaint of low-grade fever, confusion, dizziness, and a nonproductive cough.  Her symptoms progressed and she presented to the emergency room at Brighton Gardens where a chest x-ray revealed evolving right lobar infiltrate.  She was started on antibiotics.  Infectious Disease was consulted.  She was initially begun on vancomycin.  Blood, sputum, and urine cultures were obtained; the results of which were negative for infection.  She was switched to IV Levaquin and received IV Flagyl for possible C. diff colitis as well as possible cholecystitis.  During her hospital stay, she initially was extremely relatively hypotensive with mild symptoms and she became dizzy with upright positioning.  Her systolic blood pressure was 60-70 mmHg despite rather aggressive IV fluid management up to 250 mL an hour.  She was seen in consultation by Dr. Y who monitored her fluid and pulmonary treatment.  Due to some elevated liver function tests, she was seen in consultation by Dr. X.  An ultrasound was negative; however, she did undergo CT scan of the chest and abdomen and there was a suspicion of fluid circling the gallbladder.  A HIDA scan was performed and revealed no evidence of gallbladder dysfunction.  Liver functions were monitored throughout her stay and while elevated, did reduce to approximately 1.5 times normal value.  She also was seen in consultation by Infectious Disease who followed her for several days and agreed with current management of antibiotics.  Over her week-stay, the patient was moderately hypoxemic with room air pulse oximetry of 90%.  She was placed on incentive spirometry and over the succeeding days, she did have improved pulmonary function.,LABORATORY TESTS: , Initially revealed a white count of 13,000, however, approximately 24 hours following admission her white count stabilized and in fact remained normal throughout her stay.  Blood cultures were negative at 5 days.  Sputum culture was negative.  Urine culture was negative and thoracentesis culture negative at 24 hours.  The patient did receive 2 units of packed red cells with the hemoglobin drop to 9 for cardiovascular support, as no evidence of GI bleeding was obtained.  Her most recent blood work on 6/14/2009 revealed a white count of 7000 and hemoglobin of 12.1 with a hematocrit of 36.8.  Her PT and PTT were normal.  Occult blood studies were negative for occult blood.  Hepatitis B antigen was negative.  Hepatitis A antibody IgM was negative.  Hepatitis B core IgM negative, and hepatitis C core antibody was negative.  At the time of discharge on 6/14/2009, sodium was 135, potassium was 3.7, calcium was 8.0, her ALT was 109, AST was 70, direct bilirubin was 0.2, LDH was 219, serum iron was 7, total iron unbound 183, and ferritin level was 267.,At the time of discharge, the patient had improved.  She complained of some back discomfort and lumbosacral back x-ray did reveal some evidence of mild degenerative disk disease with no obvious compression fracture acute noted and she will be followed by Dr. Z.", General Medicine,15
"CHIEF COMPLAINT:,  Right shoulder pain.,HISTORY OF PRESENT PROBLEM:", Pain Management,28
"CHIEF COMPLAINT:,  Jaw pain this morning.,BRIEF HISTORY OF PRESENT ILLNESS:,  This is a very nice 53-year-old white male with no previous history of heart disease, was admitted to rule out MI and coronary artery disease.  The patient has history of hypercholesterolemia, presently on Lipitor 20 mg a day and hyperthyroidism, on Synthroid 0.088 mg per day.  Also, history of chronic diverticulitis with recent bouts.  The patient has been doing well, seen in my office at the end of December for complete physical examination.  I had ordered a stress test for him, then delayed due to a family illness.  However, denies any chest pain or chest tightness with exertion.  The patient was doing well.  He was watching television yesterday afternoon or p.m. and fell asleep holding his head in his left hand.  He awoke and noticed pain in the jaw and neck area, on both sides, but no shortness of breath, diaphoresis, nausea, or chest pain.  He is able to go to sleep, woke up this morning with same discomfort, decided to call our office, talked to our triage nurse, who instructed to come to the emergency room for possibility of just having a cardiac event.  The patient's pain resolved.  He was given nitroglycerin in the emergency room drawing his blood pressure 67/32.  Blood pressure quickly came back to normal with the patient's reverse Trendelenburg.,FAMILY HISTORY: , Strongly positive for heart disease in his father.  He had a bypass at age 60.  Both parents are alive.  Both have dementia.  His father has history of coronary artery disease and multiple vascular strokes.  He is in his 80s.  His mother is 80, also with dementia.  The patient does not smoke or drink.,PAST MEDICAL HISTORY:,  Remarkable for tonsillectomies.,MEDICATIONS:,  Synthroid and Lipitor.,ALLERGIES:,  PENICILLIN AND BIAXIN.,REVIEW OF SYSTEMS:,  Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient's blood pressure is 113/74, pulse rate is 72, respiratory rate is 18.  He is afebrile.,GENERAL:  He is well-developed, well-nourished white male, in no acute distress.,HEENT:  Pupils equal, round, and reactive to light and accommodation.  Extraocular movements were intact.  Throat was clear.,NECK:  Supple.  There is no organomegaly or thyromegaly.  Carotids are +2 without bruits.,CHEST:  Lungs are clear to auscultation and percussion.,CV:  Without any murmurs or gallops.,ABDOMEN:  Soft.  There is no hepatosplenomegaly.  Bowel sounds are active.  No tenderness.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Peripheral pulses 2+.,NEUROLOGICAL:  Intact.  Motor exam is 5/5.,LABORATORY STUDIES:,  EKG is within normal limits, good sinus rhythm.  His axis is somewhat leftward.  CBC and BMP were normal and cardiac enzymes were negative x1.,IMPRESSION:,1.  Jaw pain, sounds musculoskeletal.  We will rule out angina equivalent.,2.  Hypercholesterolemia.,3.  Hypothyroidism.,PLAN: , Lipitor and thyroid have been ordered.  His chest pain unit protocol for the stress thallium that will be done in the morning.  If test is negative, we will discharge home.  If positive, we will consult Cardiology.  The patient requests Dr. ABC.", General Medicine,15
"PREOPERATIVE DIAGNOSIS: , Right lower quadrant abdominal pain, rule out acute appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Acute suppurative appendicitis.,PROCEDURE PERFORMED:,1.  Diagnostic laparoscopy.,2.  Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and injectable 1% lidocaine and 0.25% Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Appendix.,COMPLICATIONS: , None.,BRIEF HISTORY: , This is a 37-year-old Caucasian female presented to ABCD General Hospital with progressively worsening suprapubic and right lower quadrant abdominal pain, which progressed throughout its course starting approximately 12 hours prior to presentation.  She admits to some nausea associated with it.  There have been no fevers, chills, and/or genitourinary symptoms.  The patient had right lower quadrant tenderness with rebound and percussion tenderness in the right lower quadrant.  She had a leukocytosis of 12.8.  She did undergo a CT of the abdomen and pelvis, which was non diagnostic for an acute appendicitis.  Given the severity of her abdominal examination and her persistence of her symptoms, we recommend the patient undergo diagnostic laparoscopy with probable need for laparoscopic appendectomy and possible open appendectomy.  The risks, benefits, complications of the procedure, she gave us informed consent to proceed.,OPERATIVE FINDINGS:  ,Exploration of the abdomen via laparoscopy revealed an appendix with suppurative fluid surrounding it, it was slightly enlarged.  The left ovary revealed some follicular cysts.  There was no evidence of adnexal masses and/or torsion of the fallopian tubes.  The uterus revealed no evidence of mass and/or fibroid tumors.  The remainder of the abdomen was unremarkable.,OPERATIVE PROCEDURE: , The patient was brought to the operative suite, placed in the supine position.  The abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  The patient underwent general endotracheal anesthesia.  The patient also received a preoperative dose of Ancef 1 gram IV.  After adequate sedation was achieved, a #10 blade scalpel was used to make an infraumbilical transverse incision utilizing a Veress needle.  Veress needle was inserted into the abdomen and the abdomen was insufflated approximately 15 mmHg.  Once the abdomen was sufficiently insufflated, a 10 mm bladed trocar was inserted into the abdomen without difficulty.  A video laparoscope was inserted into the infraumbilical trocar site and the abdomen was explored.  Next, a 5 mm port was inserted in the midclavicular line of the right upper quadrant region.  This was inserted under direct visualization.  Finally, a suprapubic 12 mm portal was created.  This was performed with #10 blade scalpel to create a transverse incision.  A bladed trocar was inserted into the suprapubic region.  This was done again under direct visualization.  Maryland dissector was inserted into the suprapubic region and a window was created between the appendix and mesoappendix at the base of the cecum.  This was done while the 5 mm trocar was used to grasp the middle portion of the appendix and retracted anteriorly.  Utilizing a endovascular stapling device, the appendix was transected and doubly stapled with this device.  Next, the mesoappendix was doubly stapled and transected with the endovascular stapling device.  The staple line was visualized and there was no evidence of bleeding.  The abdomen was fully irrigated with copious amounts of normal saline.  The abdomen was then aspirated.  There was no evidence of bleeding.  All ports were removed under direct visualization.  No evidence of bleeding from the port sites.  The infraumbilical and suprapubic ports were then closed.  The fascias were then closed with #0-Vicryl suture on a UR6 needle.  Once the fascias were closed, all incisions were closed with #4-0 undyed Vicryl.  The areas were cleaned, Steri-Strips were placed across the wound.  Sterile dressing was applied.,The patient tolerated the procedure well.  She was extubated following the procedure, returned to Postanesthesia Care Unit in stable condition.  She will be admitted to General Medical Floor and she will be followed closely in the early postoperative course.", Surgery,38
"REASON FOR EXAM: , Vegetation and bacteremia.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION: , The procedure and its complications were explained to the patient in detail and formal consent was obtained.  The patient was brought to special procedure unit.  His throat was anesthetized with lidocaine spray.  Subsequently, 2 mg of IV Versed was given for sedation.  The patient was positioned.  Probe was introduced without any difficulty.  The patient tolerated the procedure very well.  Probe was taken out.  No complications were noted.  Findings are as mentioned below.,FINDINGS:,1.  Left ventricle has normal size and dimensions with normal function.  Ejection fraction of 60%.,2.  Left atrium and right-sided chambers were of normal size and dimensions.,3.  Left atrial appendage is clean without any clot or smoke effect.,4.  Atrial septum is intact.  Bubble study was negative.,5.  Mitral valve is structurally normal.,6.  Aortic valve reveals echodensity suggestive of vegetation.,7.  Tricuspid valve was structurally normal.,8.  Doppler reveals moderate mitral regurgitation and moderate-to-severe aortic regurgitation.,9.  Aorta is benign.,IMPRESSION:,1.  Normal left ventricular size and function.,2.  Echodensity involving the aortic valve suggestive of endocarditis and vegetation.,3.  Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.", Cardiovascular / Pulmonary,3
"PROCEDURE PERFORMED: , Colonoscopy and biopsy.,INDICATIONS:,  The patient is a 50-year-old female who has had a history of a nonspecific colitis, who was admitted 3 months ago at Hospital because of severe right-sided abdominal pains, was found to have multiple ulcers within the right colon, and was then readmitted approximately 2 weeks later because of a cecal volvulus, and had a right hemicolectomy.  Since then, she has had persistent right abdominal pains, as well as diarrhea, with up to 2-4 bowel movements per day.  She has had problems with recurrent seizures and has been seen by Dr. XYZ, who started her recently on methadone.,MEDICATIONS: , Fentanyl 200 mcg, Versed 10 mg, Phenergan 25 mg intravenously given throughout the procedure.,INSTRUMENT: , PCF-160L.,PROCEDURE REPORT: , Informed consent was obtained from the patient, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications, as well as the possibility of missing polyps within the colon.,A colonoscope was then passed through the rectum, all the way toward the ileal colonic anastomosis, seen within the proximal transverse colon.  The distal ileum was examined, which was normal in appearance.  Random biopsies were obtained from the ileum and placed in jar #1.  Random biopsies were obtained from the normal-appearing colon and placed in jar #2.  Small internal hemorrhoids were noted within the rectum on retroflexion.,COMPLICATIONS: , None.,ASSESSMENT:,1.  Small internal hemorrhoids.,2.  Ileal colonic anastomosis seen in the proximal transverse colon.,3.  Otherwise normal colonoscopy and ileum examination.,PLAN:, Followup results of biopsies.  If the biopsies are unremarkable, the patient may benefit from a trial of tricyclic antidepressants, if it's okay with Dr. XYZ, for treatment of her chronic abdominal pains.", Gastroenterology,14
"CHIEF COMPLAINT:,", Consult - History and Phy.,5
"CHIEF COMPLAINT:  ,", Orthopedic,27
"TITLE OF OPERATION:,1.  Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.,2.  Weil osteotomy with internal screw fixation, first right metatarsal.,3.  Arthroplasty, second right PIP joint.,PREOPERATIVE DIAGNOSES:,1.  Bunion deformity, right foot.,2.  Dislocated second right metatarsophalangeal joint.,3.  Hammertoe deformity, second right digit.,POSTOPERATIVE DIAGNOSES:,1.  Bunion deformity, right foot.,2.  Dislocated second right metatarsophalangeal joint.,3.  Hammertoe deformity, second right digit.,ANESTHESIA:,  Monitored anesthesia care with 20 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:,  60 minutes, a right ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,PREOPERATIVE INJECTABLES:  ,1 g Ancef IV 30 minutes preoperatively.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as two 16-mm partially treaded cannulated screws of the OsteoMed system, one 18-mm partially treaded cannulated screw of the OsteoMed system of the 3.0 size.  One 10-mm 2.0 partially threaded cannulated screw of the OsteoMed system.,DESCRIPTION OF THE PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in the supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical sites.  The right ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set up at 250 mmHg.  The right foot was then prepped, scrubbed, and draped in a normal sterile technique.  The right ankle tourniquet was then inflated.  Attention was then directed on the dorsomedial aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed parallel and medial to the course of the extensor hallucis longus tendon to the right great toe.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal and capsular tissues were mobilized from the head and neck of the first right metatarsal and the base of the proximal phalanx of the right great toe.  The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx and resected transversely.,A lateral capsulotomy was also performed at the level of the first right metatarsophalangeal joint.  Using sharp and dull dissection, the dorsomedial prominence of the first right metatarsal head was adequately exposed and resected with the use of a sagittal saw.  The same saw was used to perform the Austin osteotomy on the capital aspect of the first right metatarsal with its apex distal and its base proximal.  The dorsal arm of the osteotomy was longer than the plantar arm and noted to accommodate for the future internal fixation.  The capital fragment of the first right metatarsal was then transposed laterally and impacted on the shaft of the first right metatarsal.  Two wires of the OsteoMed system were also used as provisional fixation wires and also as guidewires for the insertion of the future screws.  The wires were inserted dorsal distal to plantar proximal through the dorsal arm of the osteotomy.  The two screws from the 3.0 OsteoMed system were inserted over the wires using AO technique.  One screw measured 16 mm, second screw measured 18 mm in length.  Both 3.0 screws were then evaluated for the fixation of the osteotomy after the wires were removed.  Fixation of the osteotomy was found to be excellent.  The dorsomedial prominence of the first right metatarsal shaft was then resected with the sagittal saw.  To improve the correction of the hallux abductus angle, an Akin osteotomy was also performed on the base of the proximal phalanx of the right great toe with its base medially and its apex laterally.  Upon removal of the base wedge from the base of the proximal phalanx, the osteotomy was reduced with the OsteoMed smooth wire, which was also used as a guidewire for the insertion of a 16-mm partially threaded cannulated screw from the OsteoMed 3.0 system.  Upon insertion of the screw, using AO technique, the wire was removed.  The screw was inserted proximal medial to distal lateral through the osteotomy of the base of the proximal phalanx of the right great toe.  Fixation of the osteotomy was found to be excellent.  Reduction of the bunion deformity was also found to be excellent and position of the first right metatarsophalangeal joint was found to be anatomical.  Range of motion of that joint was uninhibited.  The area was flushed copiously with saline.  Then, 3-0 suture material was used to approximate the periosteum and capsular tissues, 4-0 was used to approximate the subcutaneous tissues, and Steri-Strips were used to reinforce the incision.  Attention was directed over the neck of the second right metatarsal head where a 3-cm linear incision was placed directly over the surgical neck of the second right metatarsal.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped and cauterized.  The incision was deepened through the level of the periosteum over the surgical neck of the second right metatarsal.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the surgical neck of the second right metatarsal was adequately exposed and then Weil-type osteotomy was performed from dorsal distal to plantar proximal through the surgical neck of the second right metatarsal.  The capital fragment was then transposed proximally and impacted on the shaft of the second right metatarsal.,The 2.0 Osteo-Med system was also used to fixate this osteotomy wire from that system was inserted dorsal proximal to plantar distal through the second right metatarsal osteotomy and the wire was used as a guidewire for the insertion of the 10-mm partially threaded 2.0 cannulated screw.  Upon insertion of the screw, using AO technique, the wire was then removed.  Fixation of the osteotomy with 2.0 screw was found to be excellent.  The second right metatarsophalangeal joint was then relocated and the dislocation of that joint was completely reduced.  Range of motion of the second right metatarsophalangeal joint was found to be excellent.  Then, 3-0 Vicryl suture material was used to approximate the periosteal tissues.  Then, 4-0 Vicryl was used to approximate the skin incision.  Attention was then directed at the level of the PIP joint of the second right toe where two semi-elliptical incisions were placed directly over the bony prominence at the level of the second right PIP joint.  The island of skin between the two semi-elliptical incisions was resected in toto.  The dissection was carried down to the level of extensor digitorum longus of the second right toe, which was resected transversely at the level of the PIP joint.  A capsulotomy and a medial and lateral collateral ligament release of the PIP joint of the second right toe was also performed and head of the proximal phalanx of the second right digit was adequately exposed.  Using the double-action bone cutter, the head of the proximal phalanx of the second right toe was then resected.  The area was copiously flushed with saline.  The capsular and periosteal tissues were approximated with 2-0 Vicryl and 3-0 Vicryl suture material was also used to approximate the extensor digitorum longus to the second right toe.  A 5-0 Prolene was used to approximate the skin edges of the two semi-elliptical incisions.  Correction of the hammertoe deformity and relocation of the second right metatarsophalangeal joint were evaluated with the foot loaded and were found to be excellent and anatomical.  At this time, the patient's three incisions were covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's right ankle tourniquet was deflated, time was 60 minutes.  Immediate hyperemia was noted on the entire right lower extremity upon deflation of the cuffs.,The patient's right foot was placed in a surgical shoe and the patient was transferred to the recovery room under the care of anesthesia team with the vital signs stable and the vascular status at appropriate levels.  The patient was given instructions and education on how to continue caring for her right foot surgery.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.", Surgery,38
"CC:, Found down.,HX:, 54y/o RHF went to bed at 10 PM at her boyfriend's home on 1/16/96. She was found lethargic by her son the next morning. Three other individuals in the house were lethargic and complained of HA that same morning. Her last memory was talking to her granddaughter at 5:00PM on 1/16/96. She next remembered riding in the ambulance from a Hospital. Initial Carboxyhemoglobin level was 24% (normal < 1.5%) and ABG 7.41/30/370 with O2Sat 75% on 100%FiO2.,MEDS:, unknown anxiolytic, estrogen.,PMH:, PUD, ?stroke and memory difficulty in the past 1-2 years.,FHX:, unknown.,SHX:, divorced. unknown history of tobacco/ETOH/illicit drug use.,EXAM: ,BP126/91, HR86, RR 30, 37.1C.,MS:, Oriented to name only. Speech without dysarthria. 2/3 recall at 5minutes.,CN:, unremarkable.,MOTOR: ,full strength throughout with normal muscle tone and bulk.,SENSORY: ,unremarkable.,COORD/STATION:, unremarkable.,GAIT:, not tested on admission.,GEN EXAM:, notable for erythema of the face and chest.,COURSE:, She underwent a total of four dives under Hyperbaric Oxygen ( 2 dives on 1/17 and 2 dives on 1/18). Neuropsychologic assessment on 1/18/96 revealed marked cognitive impairments with defects in anterograde memory, praxis, associative fluency, attention, and speed of information processing. She was discharged home on 1/19/96 and returned on 2/11/96 after neurologic deterioration. She progressively developed more illogical behavior, anhedonia, anorexia and changes in sleep pattern. She became completely dependent and could not undergo repeat neuropsychologic assessment in 2/96. She was later transferred to another care facility against medical advice. The etiology for these changes became complicated by a newly discovered history of possible ETOH abuse and usual ""anxiety"" disorder.,MRI brain, 2/14/96, revealed increased T2 signal within the periventricular white matter, bilaterally. EEG showed diffuse slowing without epileptiform activity.", Radiology,33
"PREOPERATIVE DIAGNOSIS:  ,Prostate cancer.,POSTOPERATIVE DIAGNOSIS:,  Prostate cancer.,OPERATION PERFORMED:,  Radical retropubic nerve-sparing prostatectomy without lymph node dissection.,ESTIMATED BLOOD LOSS: , 450 mL.,REPLACEMENT:,  250 mL of Cell Saver and crystalloid.,COMPLICATIONS: , None.,INDICATIONS OF SURGERY: , This is a 67-year-old man with needle biopsy proven to be Gleason 6 adenocarcinoma in one solitary place on the right side of the prostate.  Due to him being healthy with no comorbid conditions, he has elected to undergo surgical treatment with radical retropubic prostatectomy.  Potential complications include, but are not limited to:,1.  Infection.,2.  Bleeding.,3.  Incontinence.,4.  Impotence.,5.  Injury to the adjacent viscera.,6.  Deep venous thrombosis.,PROCEDURE IN DETAIL: , Prophylactic antibiotic was given in the preoperative holding area, after which the patient was transferred to the operating room.  Epidural anesthesia and general endotracheal anesthesia were administered by Dr. A without any difficulty.  The patient was shaved, prepped, and draped using the usual sterile technique.  A sterile 16-French Foley catheter was then placed with clear urine drained.  A midline infraumbilical incision was performed by using a #10 scalpel blade.  The rectus fascia and the subcutaneous space were opened by using the Bovie.  Transversalis fascia was opened in the midline and the retropubic space and the paravesical space were developed bluntly.  A Bookwalter retractor was then placed.  The area of the obturator lymph nodes were carefully inspected and no suspicious adenopathy was detected.  Given this patient's low Gleason score and low PSA with a solitary core biopsy positive, the decision was made to not perform bilateral lymphadenectomy.  The endopelvic fascia was opened bilaterally by using the Metzenbaum scissors.  Opening was enlarged by using sharp dissection.  Small perforating veins from the prostate into the lateral pelvic wall were controlled by using bipolar coagulation device.  The dorsal aspect of the prostate was bunched up by using 2-0 silk sutures.  The deep dorsal vein complex was bunched up by using Allis also and ligated by using 0 Vicryl suture in a figure-of-eight fashion.  With the prostate retracted cephalad, the deep dorsal vein complex was transected superficially using the Bovie.  Deeper near the urethra, the dorsal vein complex was transected by using Metzenbaum scissors.  The urethra could then be easily identified.  Nearly two-third of the urethra from anteriorly to posteriorly was opened by using Metzenbaum scissors.  This exposed the blue Foley catheter.  Anastomotic sutures were then placed on to the urethral stump using 2-0 Monocryl suture.  Six of these were placed evenly spaced out anteriorly to posteriorly.  The Foley catheter was then removed.  This allowed for better traction of the prostate laterally.  Lateral pelvic fascia was opened bilaterally.  This effectively released the neurovascular bundle from the apex to the base of the prostate.  Continued dissection from the lateral pelvic fascia deeply opened up the plane into the perirectal fat.  The prostate was then dissected from laterally to medially from this opening in the perirectal fat.  The floor of the urethra posteriorly and the rectourethralis muscle was then transected just distal to the prostate.  Maximal length of ureteral stump was preserved.  The prostate was carefully lifted cephalad by using gentle traction with fine forceps.  The prostate was easily dissected off the perirectal fat using sharp dissection only.  Absolutely, no traction to the neurovascular bundle was evident at any point in time.  The dissection was carried out easily until the seminal vesicles could be visualized.  The prostate pedicles were controlled easily by using multiple medium clips in 4 to 5 separate small bundles on each side.  The bladder neck was then dissected out by using a bladder neck dissection method.  Unfortunately, most of the bladder neck fiber could not be preserved due to the patient's anatomy.  Once the prostate had been separated from the bladder in the area with the bladder neck, dissection was carried out posteriorly to develop a plane between the bladder and the seminal vesicles.  This was developed without any difficulty.  Both vas deferens were identified, hemoclipped and transected.  The seminal vesicles on both sides were quite large and a decision was made to not completely dissect the tip off, as it extended quite deeply into the pelvis.  About two-thirds of the seminal vesicles were able to be removed.  The tip was left behind.  Using the bipolar Gyrus coagulation device, the seminal vesicles were clamped at the tip sealed by cautery and then transected.  This was performed on the left side and then the right side.  This completely freed the prostate.  The prostate was sent for permanent section.  The opening in the bladder neck was reduced by using two separate 2-0 Vicryl sutures.  The mucosa of the bladder neck was everted by using 4-0 chromic sutures.  Small amount of bleeding around the area of the posterior bladder wall was controlled by using suture ligature.  The ureteral orifice could be seen easily from the bladder neck opening and was completely away from the everting sutures.  The previously placed anastomotic suture on the urethral stump was then placed on the corresponding position on the bladder neck.  This was performed by using a French ***** needle.  A 20-French Foley catheter was then inserted and the sutures were sequentially tied down.  A 15 mL of sterile water was inflated to balloon.  The bladder anastomosis to the urethra was performed without any difficulty.  A 19-French Blake Drain was placed in the left pelvis exiting the right inguinal region.  All instrument counts, lap counts, and latex were verified twice prior to the closure.  The rectus fascia was closed in running fashion using #1 PDS.  Subcutaneous space was closed by using 2-0 Vicryl sutures.  The skin was reapproximated by using metallic clips.  The patient tolerated the procedure well and was transferred to the recovery room in stable condition.", Urology,39
"TESTICULAR ULTRASOUND,REASON FOR EXAM:  ,Left testicular swelling for one day.,FINDINGS:  ,The left testicle is normal in size and attenuation, it measures 3.2 x 1.7 x 2.3 cm.  The right epididymis measures up to 9 mm.  There is a hydrocele on the right side.  Normal flow is seen within the testicle and epididymis on the right.,The left testicle is normal in size and attenuation, it measures 3.9 x 2.1 x 2.6 cm.  The left testicle shows normal blood flow.  The left epididymis measures up to 9 mm and shows a markedly increased vascular flow.  There is mild scrotal wall thickening.  A hydrocele is seen on the left side.,IMPRESSION:,1.  Hypervascularity of the left epididymis compatible with left epididymitis.,2.  Bilateral hydroceles.", Radiology,33
"PREOPERATIVE DIAGNOSIS:,  Subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: , Subglottic stenosis.,OPERATIVE PROCEDURES: , Direct laryngoscopy and bronchoscopy.,ANESTHESIA:,  General inhalation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operative table.  General inhalational anesthesia was administered through the patient's tracheotomy tube.  The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway.  There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds.  The stoma showed some suprastomal fibroma.  The remaining tracheobronchial passages were clear.  The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties.  Bleeding was negligible.  There were no untoward complications.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.", Surgery,38
"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.", Nephrology,21
"PREOPERATIVE DIAGNOSES: ,1.  Chronic eustachian tube dysfunction.,2.  Retained right pressure equalization tube.,3.  Retracted left tympanic membrane.,4.  Dizziness.,POSTOPERATIVE DIAGNOSES:,1.  Chronic eustachian tube dysfunction.,2.  Retained right pressure equalization tube.,3.  Retracted left tympanic membrane.,4.  Dizziness.,PROCEDURE:,1.  Removal of the old right pressure equalizing tube with placement of a tube.  Tube used was Santa Barbara.,2.  Myringotomy with placement of a left pressure equalizing tube.  The tube used was Santa Barbara.,ANESTHESIA:,  General.,INDICATION: , This is a 98-year-old female whom I have known for several years.  She has a marginal hearing.  With the additional conductive loss secondary to the retraction of the tympanic membrane, her hearing aid and function deteriorated significantly.  So, we have kept sets of tubes in her ears at all times.  The major problem is that she has got small ear canals and a very sensitive external auditory canal; therefore it cannot tolerate even the wax cleaning in the clinic awake.,The patient was seen in the OR and tubes were placed.  There were no significant findings.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, she was brought to the neurosensory OR, placed under general anesthesia.  Mask airway was used.  IV had already been started.,On the right side, we removed the old tube and then cleaned the cerumen and found that it was larger than the side of the tube in perfection or perforation in tympanic membrane in the anterior inferior quadrant.  In the same area, a small Santa Barbara tube was placed.  This T-tube was cut to 80% of its original length for comfort and then positioned to point straight out and treated.  Three drops of ciprofloxacin eyedrops was placed in the ear canal.,On the left side, the tympanic membrane adhered and it was retracted and has some myringosclerosis.  Anterior, inferior incision was made.  Tympanic membrane bounced back to neutral position.  A Santa Barbara tube was cut to the 80% of the original length and placed in the hole.  Ciprofloxacin drops were placed in the ear.  Procedure completed.,ESTIMATED BLOOD LOSS: , None.,COMPLICATION: , None.,SPECIMEN:,  None.,DISPOSITION:,  To PACU in a stable condition.", Surgery,38
"CHIEF COMPLAINT:,  Status post motor vehicle accident.,HISTORY OF PRESENT ILLNESS: , The patient is a 17-year-old white male who is status post a high-speed motor vehicle accident in which he was ejected from the vehicle.  He denies loss of consciousness, although the EMT people report that he did have loss of consciousness.  The patient was stable en route.  Upon arrival, he complained of headache.,PAST MEDICAL HISTORY:,  Medical:  None.  Surgical:  None.,REVIEW OF SYSTEMS: , CARDIAC:  No history.  PULMONARY:  Some morning cough.  (Patient is a smoker.),MEDICATIONS:,  None.,ALLERGIES:,  ALLERGIC TO PENICILLIN, CAUSES SKIN RASH.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 120/80, pulse 82, respirations 20, temperature 36.8°.,HEENT:  Contusion over right occipital area.  Tympanic membranes benign.,NECK:  Nontender.,CHEST:  Atraumatic, nontender.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Flat, soft, and nontender.,BACK:  Atraumatic, nontender.,PELVIS:  Stable,EXTREMITIES:  Contusion over right forearm.  No bone deformity or crepitus.,RECTAL:  Normal sphincter tone; guaiac negative.,NEUROLOGIC:  Glasgow coma scale 15.  Pupils equal, round, reactive to light.  Patient moves all 4 extremities without focal deficit.,LABORATORY DATA: , Serial hematocrits 42.4, and 40.4.  White blood count 6.3.  Ethanol:  None.  Amylase 66.  Urinalysis normal.  PT 12.6, PTT 29.  Chem-7 panel within normal limits.,X-rays of cervical spine and lumbosacral spine within normal limits.  X-rays of pelvis and chest within normal limits.,ASSESSMENT:,1.  Closed head injury.,2.  Rule out intra-abdominal injury.,PLAN:,  The patient will be admitted to the trauma surgery service for continued evaluation and treatment for closed head injury as well as possible intra-abdominal injury.", Emergency Room Reports,12
"PREOPERATIVE DIAGNOSES:,1.  Neuromuscular dysphagia.,2.  Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSES:,1.  Neuromuscular dysphagia.,2.  Protein-calorie malnutrition.,PROCEDURES PERFORMED:,1.  Esophagogastroduodenoscopy with photo.,2.  Insertion of a percutaneous endoscopic gastrostomy tube.,ANESTHESIA:,  IV sedation and local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well without difficulty.,BRIEF HISTORY:  ,The patient is a 50-year-old African-American male who presented to ABCD General Hospital on 08/18/2003 secondary to right hemiparesis from a CVA.  The patient deteriorated with several CVAs and had became encephalopathic requiring a ventilator-dependency with respiratory failure.  The patient also had neuromuscular dysfunction.  After extended period of time, per the patient's family request and requested by the ICU staff, decision to place a feeding tube was decided and scheduled for today.,INTRAOPERATIVE FINDINGS: , The patient was found to have esophagitis as well as gastritis via EGD and was placed on Prevacid granules.,PROCEDURE: , After informed written consent, the risks and benefits of the procedure were explained to the patient and the patient's family.  First, the EGD was to be performed.,The Olympus endoscope was inserted through the mouth, oropharynx and into the esophagus.  Esophagitis was noted.  The scope was then passed through the esophagus into the stomach.  The cardia, fundus, body, and antrum of the stomach were visualized.  There was evidence of gastritis.  The scope was passed into the duodenal bulb and sweep via the pylorus and then removed from the duodenum retroflexing on itself in the stomach looking at the hiatus.  Next, attention was made to transilluminating the anterior abdominal wall for the PEG placement.  The skin was then anesthetized with 1% lidocaine.  The finder needle was then inserted under direct visualization.  The catheter was then grasped via the endoscope and the wire was pulled back up through the patient's mouth.  The Ponsky PEG tube was attached to the wire.  A skin nick was made with a #11 blade scalpel.  The wire was pulled back up through the abdominal wall point and Ponsky PEG back up through the abdominal wall and inserted into position.  The endoscope was then replaced confirming position.  Photograph was taken.  The Ponsky PEG tube was trimmed and the desired attachments were placed and the patient did tolerate the procedure well.  We will begin tube feeds later this afternoon.", Surgery,38
"PREOPERATIVE DIAGNOSIS:  ,Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,PROCEDURE: , Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation.  ME 30, AC 25.0 diopter lens was used.,COMPLICATIONS:  ,None.,ANESTHESIA: , Local 2%, peribulbar lidocaine.,PROCEDURE NOTE:  ,Right eye was prepped and draped in the normal sterile fashion.  Lid speculum placed in his right eye.  Paracentesis made supratemporally.  Viscoat injected into the anterior chamber.  A 2.8 mm metal keratome blade was then used to fashion a clear corneal beveled incision temporally.  This was followed by circular capsulorrhexis and hydrodissection of the nucleus would be assessed.  Nuclear material removed via phacoemulsification.  Residual cortex removed via irrigation and aspiration.  The posterior capsule was clear and intact.  Capsular bag was then filled with Provisc solution.  The wound was enlarged to 3.5 mm with the keratoma.  The lens was folded in place into the capsular bag.  Residual Provisc was irrigated from the eye.  The wound was secured with one 10-0 nylon suture.  The lid speculum was removed.  One drop of 5% povidone-iodine prep was placed into the eye as well as a drop of Vigamox and TobraDex ointment.  He had a patch placed on it.  The patient was transported to the recovery room in stable condition.", Surgery,38
"PRINCIPAL DIAGNOSIS: , Mullerian adenosarcoma.  ,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old presenting with a large mass aborted through the cervix.,PHYSICAL EXAM:,CHEST:  Clear.  There is no heart murmur.,ABDOMEN:  Nontender.,PELVIC:  There is a large mass in the vagina.  ,HOSPITAL COURSE: , The patient went to surgery on the day of admission.  The postoperative course was marked by fever and ileus.  The patient regained bowel function.  She was discharged on the morning of the seventh postoperative day.,OPERATIONS: , July 25, 2006:  Total abdominal hysterectomy, bilateral salpingo-oophorectomy.,DISCHARGE CONDITION: , Stable.,  ,PLAN: , The patient will remain at rest initially with progressive ambulation thereafter.  She will avoid lifting, driving, stairs, or intercourse.  She will call me for fevers, drainage, bleeding, or pain.  Family history, social history, and psychosocial needs per the social worker.  The patient will follow up in my office in one week.,PATHOLOGY:,  Mullerian adenosarcoma.,MEDICATIONS:,  Percocet 5, #40, one q.3 h. p.r.n. pain.", Hematology - Oncology,16
"PREOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,POSTOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,PROCEDURES,1.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, right leg.,2.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, left leg.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was taken to the operating room where she underwent a general endotracheal anesthesia.  A time-out process was followed and antibiotics were given.,Then, both legs were prepped and draped in the usual fashion with the patient was in the supine position.  An incision was made in the right groin and the greater saphenous vein at its junction with the femoral vein was dissected out and all branches were ligated and divided.  Then, an incision was made just below the knee where the greater saphenous vein was also found and connection to varices from the calf were seen.  A third incision was made in the distal third of the right thigh in the area where there was a communication with large branch varicosities.  Then, a vein stripper was passed from the right calf up to the groin and the greater saphenous vein, which was divided, was stripped without any difficultly.  Several minutes of compression was used for hemostasis.  Then, the exposed branch varicosities both in the lower third of the thigh and in the calf were dissected out and then many stabs were performed to do stab phlebectomies at the level of the thigh and the level of the calf as much as the position would allow us to do.,Then in the left thigh, a groin incision was made and the greater saphenous vein was dissected out in the same way as was on the other side.  Also, an incision was made in the level of the knee and the saphenous vein was isolated there.  The saphenous vein was stripped and a several minutes of local compression was performed for hemostasis.  Then, a number of stabs to perform phlebectomy were performed at the level of the calf to excise branch varicosities to the extent that the patient's position would allow us.  Then, all incisions were closed in layers with Vicryl and staples.,Then, the patient was placed in the prone position and the stab phlebectomies of the right thigh and calf and left thigh and calf were performed using 10 to 20 stabs in each leg.  The stab phlebectomies were performed with a hook and they were very satisfactory.  Hemostasis achieved with compression and then staples were applied to the skin.,Then, the patient was rolled onto a stretcher where both legs were wrapped with the Kerlix, fluffs, and Ace bandages.,Estimated blood loss probably was about 150 mL.  The patient tolerated the procedure well and was sent to recovery room in satisfactory condition.  The patient is to be observed, so a decision will be made whether she needs to stay overnight or be able to go home.", Surgery,38
"FINDINGS:,There are posttraumatic cysts along the volar midline and volar lateral aspects of the lunate which are likely posttraumatic. There is no acute marrow edema (series #12 images #5-7). Marrow signal is otherwise normal in the distal radius and ulna, throughout the carpals and throughout the proximal metacarpals.,There is a partial tear of the volar component of the scapholunate ligament in the region of the posttraumatic lunate cyst with retraction and thickening towards the scaphoid (series #6 image #5, series #8 images #22-36). There is tearing of the membranous portion of the ligament. The dorsal component is intact.,The lunatotriquetral ligament is thickened and lax, but intact (series #8 image #32).,There is no tearing of the radial or ulnar attachment of the triangular fibrocartilage (series #6 image #7). There is a mildly positive ulnar variance. Normal ulnar collateral ligament.,The patient was positioned in dorsiflexion. Carpal alignment is normal and there are no tears of the dorsal or ventral intercarpal ligaments (series #14 image #9).,There is a longitudinal split tear of the ECU tendon which is enlarged both at the level of and distal to the ulnar styloid with severe synovitis (series #4 images #8-16, series #3 images #9-16).,There is thickening of the extensor tendon sheaths within the fourth dorsal compartment with intrinsically normal tendons (series #4 image #12).,There is extensor carpi radialis longus and brevis synovitis in the second dorsal compartment (series #4 image #13).,Normal flexor tendons within the carpal tunnel. There is mild thickening of the tendon sheaths and the median nerve demonstrates increased signal without compression or enlargement (series #3 image #7, series #4 image #7).,There are no pathological cysts or soft tissue masses.,IMPRESSION:,Partial tear of the volar and membranous components of the scapholunate ligament with an associated posttraumatic cyst in the lunate. There is thickening and laxity of the lunatotriquetral ligament.,Longitudinal split tear of the ECU tendon with tendinosis and severe synovitis.,Synovitis of the second dorsal compartment and tendon sheath thickening in the fourth dorsal compartment.,Tendon sheath thickening within the carpal tunnel with increased signal within the median nerve.", Radiology,33
"PREOPERATIVE DIAGNOSES:,1.  Feeding disorder.,2.  Down syndrome.,3.  Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1.  Feeding disorder.,2.  Down syndrome.,3.  Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS:  ,This 6-week-old female infant had been transferred to Children's Hospital because of Down syndrome and congenital heart disease.  She has not been able to feed well and in fact has to now be NG tube fed.  Her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy.,OPERATIVE PROCEDURE:  ,After the induction of general anesthetic, the abdomen was prepped and draped in usual manner.  Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection.  The muscle was divided and the peritoneal cavity entered.  The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field.  The site for gastrostomy was selected and a pursestring suture of #4-0 Nurolon placed in the gastric wall.  A 14-French 0.8 cm Mic-Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube.  Following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 Nurolon affixing the stomach to the posterior fascia.  The anterior fascia was then closed with #3-0 Vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular Monocryl.  The balloon was inflated to the full 5 mL.  A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition.,", Pediatrics - Neonatal,29
"PREOPERATIVE DIAGNOSIS:,  Left little finger extensor tendon laceration.,POSTOPERATIVE DIAGNOSIS: , Left little finger extensor tendon laceration.,PROCEDURE PERFORMED:  ,Repair of left little extensor tendon.,COMPLICATIONS:,  None.,BLOOD LOSS: , Minimal.,ANESTHESIA: , Bier block.,INDICATIONS: , The patient is a 14-year-old right-hand dominant male who cut the back of his left little finger and had a small cut to his extensor tendon.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operative room, laid supine, administered intervenous sedation with Bier block and prepped and draped in a sterile fashion.  The old laceration was opened and the extensor tendon was identified and there was a small longitudinal laceration in the tendon, which is essentially in line with the tendon fibers.  This was just proximal to the PIP joint and on complete flexion of the PIP joint, I did separate just a little bit that was not thought to be significantly dynamically unstable.  It was sutured with a single 4-0 Prolene interrupted figure-of-eight suture and on dynamic motion it did not separate at all.  The wound was irrigated and closed with 5-0 nylon interrupted sutures.  The patient tolerated the procedure well and was taken to the PCU in good condition.", Surgery,38
"HISTORY:,  This is an initial visit for this 95-year-old gentleman with a Hospice diagnosis of CHF.  He was referred to us by Dr. ABC, who reveals a long history of cardiomyopathy and a recent decrease in his ejection fraction to approximately 20-25%.  The patient was seen in the office approximately three days ago with a clinical diagnosis of bronchitis.  The FES, as well as the daughter report that he has had significant clinical and functional decline over the last two to three weeks.  He is no longer ambulatory.  His appetite is significantly decreased and he had significant unmeasured weight loss.  He is notably more weak.  He is unable to perform any of the activities of daily living and he is increasingly somnolent with poor sleep at night.  The patient says that he is ready to die, that he is after all 95 years old and is aware that his clinical and functional status has been declining.  He worked as a chef for almost seven decades and retired approximately two years ago.  He denies pain.  He admits to some cough, but he believes the cough is improved on the current antibiotic.  He does note that he sleeps poorly and unable to indicate a cause for that difficulty in sleeping.  He reports that he recently made a trip to California where he said goodbye to his children that live there.  The patient reports that his goals of care are to stay at home.  He has never been hospitalized with the exception of some surgery on his back in Houston, Texas decades ago that he has no interest in going to a hospital and that he would be happy to sign a DNR form and that he would like no heroics performed in the event that his heart or breathing stops.  He denies anxiety or depression and feels that his life has been quite full and quite successful and that when time comes, he is ready to go.,MEDICATIONS:,  His medications include Avelox 400 mg.  He is on day four of a seven-day dose.  He is on Coreg 3.125 mg a day, lisinopril 5 mg a day, Coumadin 2.5 mg a day, digoxin 0.125 mg every other day, Lasix 80 mg twice daily, Inspra twice daily, and he is on a transdermal nitro patch 12 hours on and 12 hours off.  He takes Tylenol extra strength every four to six hours for bilateral shoulder pain typically one to two doses a day.,PHYSICAL EXAMINATION: , Exam reveals a cachectic somnolent gentleman, who appears to be comfortable.  His blood pressure is 90/60.  His heart rate is 80 and irregular.  His respiratory rate is 14.  Head reveals marked temporal wasting.  He is anicteric.  The pupils are equal and round.  There is jugular venous distention noted approximately 2-3 cm above the notch.  Chest shows good air entry bilaterally with scattered rhonchi.  No audible wheezing.  His heart sounds are irregular and there is a musical systolic ejection murmur radiating to the axilla.  The abdomen is soft with a large midline well-healed surgical scar.  The bowel sounds are normoactive.  There is no tenderness or palpable organomegaly.  He has 2+ edema of his lower extremities with some weeping of the right lower extremity and no evidence of infection.  Neurologically, while somnolent easily aroused and speech is quite clear.  He identities the date as October of 2008, but is otherwise oriented.  His short-term memory is quite poor.  His insight is also poor.  He appears to be somewhat sad.  There are mild regular tremors, right hand worse than left, but there is otherwise no focal neurological deficit.,A phone conversation with his daughter, Xyz, his health care proxy, ensued.  His daughter is very concerned with his clinical decline and is raising the question of whether he would benefit from hospitalization.  She reports that her mother died after a many-year course with heart failure and had upwards of three dozen hospitalizations.  At each hospitalization, she seem to derive benefit and wondered if her dad would drive equal benefit from hospitalizations.  She is aware that he is unwilling to be hospitalized and I believe hopefully that the Hospice team might persuade him.  She also reports that he has been talking about dying for nearly five years.,ASSESSMENT:,  A 95-year-old gentleman with endstage CHF with recent significant clinical and functional decline.  The patient appears to have relatively little in the way of symptoms, although perhaps some sleep hygiene might be of help.  While today the patient appears to be very calm and sedated, the history is one of significant emotional lability.  Family is having great difficulty accepting the terminality of the patient's circumstances.,PLAN:,  A DNR was placed in the house after the above-noted conversation was had.  I believe the patient might benefit from low-dose hypnotic and 7.5 mg of Restoril was ordered.  Reassessment of the patient's condition is warranted.  A family meeting will be offered to review the circumstances of the patient's condition in hopes that family might better accept his wishes and to develop a plan of care for this gentleman.", Hospice - Palliative Care,17
"SUBJECTIVE:,  The patient returns today for a followup.  She was recently in the hospital and was found to be septic from nephrolithiasis.  This was all treated.  She did require a stent in the left ureter.  Dr. XYZ took care of this.  She had a stone, which was treated with lithotripsy.  She is now back here for followup.  I had written out all of her medications with their dose and schedule on a progress sheet.  I had given her instructions regarding follow up here and follow with Dr. F.  Unfortunately, that piece of paper was lost.  Somehow between the hospital and home she lost it and has not been able to find it.  She has no followup appointment with Dr. F.  The day after she was dismissed, her nephew called me stating that the prescriptions were lost, instructions were lost, etc.  Later she apparently found the prescriptions and they were filled.  She tells me she is taking the antibiotic, which I believe was Levaquin and she has one more to take.  She had no clue as to seeing Dr. XYZ again.  She says she is still not feeling very well and feels somewhat sick like.  She has no clue as to still having a ureteral stent.  I explained this to she and her husband again today.,ALLERGIES: , Sulfa.,CURRENT MEDICATIONS:,  As I have given are Levaquin, Prinivil 20 mg a day, Bumex 0.5 mg a day, Levsinex 0.375 mg a day, cimetidine 400 mg a day, potassium chloride 8 mEq a day, and atenolol 25 mg a day.,REVIEW OF SYSTEMS:,  She says she is voiding okay.  She denies fever, chills, or sweats.,OBJECTIVE:,General:  She was able to get up on the table by herself although she is quite unstable.,Vital Signs:  Blood pressure was okay at about 120/70 by me.,Neck:  Supple.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Abdomen:  Soft.,Extremities:  There is no edema.,IMPRESSION:,1.  Hypertension controlled.,2.  Nephrolithiasis status post lithotripsy and stent placed in the left ureter by Dr. F.,3.  Urinary incontinence.,4.  Recent sepsis.,PLAN:,1.  I discussed at length with she and her husband again the need to get into at least an assisted living apartment.,2.  I gave her instructions, in writing, to stop by Dr. F’s office on the way out today to get an appointment for followup regarding her stent.,3.  See me back here in two months.,4.  I made no changes in her medications.", Nephrology,21
"REASON FOR VISIT:,  Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.,HISTORY OF PRESENT ILLNESS:,  Ms. ABC returns today for followup status post L4-L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion on 06/08/07.,Preoperatively, her symptoms, those of left lower extremity are radicular pain.,She had not improved immediately postoperatively.  She had a medial breech of a right L4 pedicle screw.  We took her back to the operating room same night and reinserted the screw.  Postoperatively, her pain had improved.,I had last seen her on 06/28/07 at which time she was doing well.  She had symptoms of what she thought was ""restless leg syndrome"" at that time.  She has been put on ReQuip for this.,She returned.  I had spoken to her 2 days ago and she had stated that her right lower extremity pain was markedly improved.  I had previously evaluated this for a pain possibly relating to deep venous thrombosis and ultrasound was negative.  She states that she had recurrent left lower extremity pain, which was similar to the pain she had preoperatively but in a different distribution, further down the leg.  Thus, I referred her for a lumbar spine radiograph and lumbar spine MRI and she presents today for evaluation.,She states that overall, she is improved compared to preoperatively.  She is ambulating better than she was preoperatively.  The pain is not as severe as it was preoperatively.  The right leg pain is improved.  The left lower extremity pain is in a left L4 and L5 distribution radiating to the great toe and first web space on the left side.,She denies any significant low back pain.  No right lower extremity symptoms.,No infectious symptoms whatsoever.  No fever, chills, chest pain, shortness of breath.  No drainage from the wound.  No difficulties with the incision.,FINDINGS:  ,On examination, Ms. ABC is a pleasant, well-developed, well-nourished female in no apparent distress.  Alert and oriented x 3.  Normocephalic, atraumatic.  Respirations are normal and nonlabored.  Afebrile to touch.,Left tibialis anterior strength is 3 out of 5, extensor hallucis strength is 2 out of 5.  Gastroc-soleus strength is 3 to 4 out of 5.  This has all been changed compared to preoperatively.  Motor strength is otherwise 4 plus out of 5.  Light touch sensation decreased along the medial aspect of the left foot.  Straight leg raise test normal bilaterally.,The incision is well healed.  There is no fluctuance or fullness with the incision whatsoever.  No drainage.,Radiographs obtained today demonstrate pedicle screw placement at L4 and L5 bilaterally without evidence of malposition or change in orientation of the screws.,Lumbar spine MRI performed on 07/03/07 is also reviewed.,It demonstrates evidence of adequate decompression at L4 and L5.  There is a moderate size subcutaneous fluid collection seen, which does not appear compressive and may be compatible with normal postoperative fluid collection, especially given the fact that she had a revision surgery performed.,ASSESSMENT AND PLAN:  ,Ms. ABC is doing relatively well status post L4 and L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion with instrumentation on 07/08/07.  The case is significant for merely misdirected right L4 pedicle screw, which was reoriented with subsequent resolution of symptoms.,I am uncertain with regard to the etiology of the symptoms.  However, it does appear that the radiographs demonstrate appropriate positioning of the instrumentation, no hardware shift, and the MRI demonstrates only a postoperative suprafascial fluid collection.  I do not see any indication for another surgery at this time.,I would also like to hold off on an interventional pain management given the presence of the fluid collection to decrease the risk of infection.,My recommendation at this time is that the patient is to continue with mobilization.  I have reassured her that her spine appears stable at this time.  She is happy with this.,I would like her to continue ambulating as much as possible.  She can go ahead and continue with ReQuip for the restless leg syndrome as her primary care physician has suggested.  I have also her referred to Mrs. Khan at Physical Medicine and Rehabilitation for continued aggressive management.,I will see her back in followup in 3 to 4 weeks to make sure that she continues to improve.  She knows that if she has any difficulties, she may follow up with me sooner.", SOAP / Chart / Progress Notes,35
"SUBJECTIVE:,  The patient is a 78-year-old female who returns for recheck.  She has hypertension.  She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY / SURGERY / HOSPITALIZATIONS:,  Reviewed and unchanged from the dictation on 12/03/2003.,MEDICATIONS:  ,Atenolol 50 mg daily, Premarin 0.625 mg daily, calcium with vitamin D two to three pills daily, multivitamin daily, aspirin as needed, and TriViFlor 25 mg two pills daily.  She also has Elocon cream 0.1% and Synalar cream 0.01% that she uses as needed for rash.,ALLERGIES:  ,Benadryl, phenobarbitone, morphine, Lasix, and latex.,FAMILY HISTORY / PERSONAL HISTORY: , Reviewed.  Mother died from congestive heart failure.  Father died from myocardial infarction at the age of 56.  Family history is positive for ischemic cardiac disease.  Brother died from lymphoma.  She has one brother living who has had angioplasties x 2.  She has one brother with asthma.,PERSONAL HISTORY:,  Negative for use of alcohol or tobacco.,REVIEW OF SYSTEMS:,Bones and Joints:  She has had continued difficulty with lower back pain particularly with standing which usually radiates down her right leg.  She had been followed by Dr. Mills, but decided to see Dr. XYZ who referred to her Dr Isaac.  She underwent several tests.  She did have magnetic resonance angiography of the lower extremities and the aorta which were normal.  She had nerve conduction study that showed several peripheral polyneuropathy.  She reports that she has myelogram last week but has not got results of this.  She reports that the rest of her tests have been normal, but it seems that vertebrae shift when she stands and then pinches the nerve.  She is now seeing Dr. XYZ who comes to Hutchison from KU Medical Center, and she thinks that she probably will have surgery in the near future.,Genitourinary:  She has occasional nocturia.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  227.2 pounds.  Blood pressure:  144/72.  Pulse:  80.  Temperature:  97.5 degrees.,General Appearance:  She is an elderly female patient who is not in acute distress.,Mouth:  Posterior pharynx is clear.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1 and S2 without gallops or rubs.,Abdomen:  Without masses or tenderness to palpation.,Extremities:  Without edema.,IMPRESSION/PLAN:,1.  Hypertension.  She is advised to continue with the same medication.,2.  Syncope.  She previously had an episode of syncope around Thanksgiving.  She has not had a recurrence of this and her prior cardiac studies did not show arrhythmias.,3.  Spinal stenosis.  She still is being evaluated for this and possibly will have surgery in the near future.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2.  Cervical spondylosis with herniated nucleus pulposus, C5-C6.,POSTOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2.  Cervical spondylosis with herniated nucleus pulposus, C5-C6.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C5-C6.,2.  Arthrodesis with anterior interbody fusion, C5-C6.,3.  Spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS:  ,1200 cc of crystalloids.,URINE OUTPUT: , No Foley catheter.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,INDICATIONS FOR THE OPERATION:,  This is a case of a very pleasant 38-year-old Caucasian female who has been complaining over the last eight years of neck pain and shoulder pain radiating down across the top of her left shoulder and also across her shoulder blades to the right side, but predominantly down the left upper extremity into the wrist.  The patient has been diagnosed with fibromyalgia and subsequently, has been treated with pain medications, anti-inflammatories and muscle relaxants.  The patient's symptoms continued to persist and subsequently, an MRI of the C-spine was done, which showed disc desiccation, spondylosis and herniated disk at C5-C6, an EMG and CV revealed a presence of mild-to-moderate carpal tunnel syndrome.  The patient is now being recommended to undergo decompression and spinal instrumentation and fusion at C5-C6.  The patient understood the risks and benefits of the surgery.  Risks include but not exclusive of bleeding and infection.  Bleeding can be in the form of soft tissue bleeding, which may compromise airway for which she can be brought emergently back to the operating room for emergent evacuation of the hematoma as this may cause weakness of all four extremities, numbness of all four extremities, as well as impairment of bowel and bladder function.  This could also result in dural tear with its attendant symptoms of headache, nausea, vomiting, photophobia, and posterior neck pain as well as the development of pseudomeningocele.  Should the symptoms be severe or the pseudomeningocele be large, she can be brought back to the operating room for repair of the CSF leak and evacuation of the pseudomeningocele.  There is also the risk of pseudoarthrosis and nonfusion, for which she may require redo surgery at this level.  There is also the possibility of nonimprovement of her symptoms in about 10% of cases.  The patient understands this risk on top of the potential injury to the esophagus and trachea as well as the carotid artery.  There is also the risk of stroke, should an undiagnosed plaque be propelled into the right cerebral circulation.  The patient also understands that there could be hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  She understood these risks on top of the risks of anesthesia and gave her consent for the procedure.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, the patient was positioned supine on the operating table with the neck placed on hyperextension and the head supported on a foam doughnut.  A marker was placed.  This verified the level to be at the C5-C6 level and incision was then marked in a transverse fashion starting from the midline extending about 5 mm beyond the anterior border of the sternocleidomastoid muscle.  The area was then prepped with DuraPrep after the head was turned 45 degrees to the left.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were carefully controlled with bipolar coagulation and the platysma was cut using a hot knife in a transverse fashion.  Dissection was then carried underneath the platysma superiorly inferiorly.  The anterior border of the sternocleidomastoid was identified and dissection was carried out lateral to the esophagus to trachea as well as medial to the carotid sheath in the sternocleidomastoid muscle.  The prevertebral fascia was noted to be taken her case with a lot of fat deposition.  Bipolar coagulation of bleeders was done; however, branch of the superior thyroid artery was ligated with Hemoclips x4.  After this was completed, a localizing x-ray verified the marker to be at the C6-C7 level.  We proceeded to strip the longus colli muscles off the vertebral body of the C5 and C6.  Self-retaining retractor was then laid down.  An anterior osteophyte was carefully drilled using a Midas 5-mm bur and the disk together with the inferior endplate of C5 and the superior endplate of C6 was also drilled down with the Midas 5-mm bur.  This was later followed with a 3-mm bur and the disk together with posterior longitudinal ligament was removed using Kerrison's ranging from 1 to 4 mm.  The herniation was noted on the right.  However, there was significant neuroforaminal stenosis on the left.  Decompression on both sides was done and after this was completed, a Valsalva maneuver showed no evidence of any CSF leakage.  The area was then irrigated with saline with bacitracin solution.  A 7 mm implant with its inferior packed with Vitoss was then laid down and secured in place with four 14 x 4.0 mm screws and plate 18 mm, all of which were titanium.  X-ray after this placement showed excellent position of all these implants and screws and _____ and the patient's area was also irrigated with saline with bacitracin solution.  A round French 10 JP drain was then laid down and exteriorized through a separate stab incision on the patient's right inferiorly.  The catheter was then anchored to the skin with a nylon 3-0 stitch and connected to a sterile draining system.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl subcuticular 4-0 Stitch for the dermis, and the wound was reinforced with Dermabond.  Dressing was placed only at the exit site of the catheter.  C-collar was placed.  The patient was extubated and transferred to recovery.", Neurosurgery,23
"GENERAL: , Vital signs and temperature as documented in nursing notes.  The patient appears stated age and is adequately developed.,EYES:,  Pupils are equal, round, reactive to light and accommodation.  Lids and conjunctivae reveal no gross abnormality.,ENT:  ,Hearing appears adequate.  No obvious asymmetry or deformity of the ears and nose.,NECK: , Trachea midline.  Symmetric with no obvious deformity or mass; no thyromegaly evident.,RESPIRATORY:,  The patient has normal and symmetric respiratory effort.  Lungs are clear to auscultation.,CARDIOVASCULAR: , S1, S2 without significant murmur.,ABDOMEN: , Abdomen is flat, soft, nontender.  Bowel sounds are active.  No masses or pulsations present.,EXTREMITIES: , Extremities reveal no remarkable dependent edema or varicosities.,MUSCULOSKELETAL:  ,The patient is ambulatory with normal and symmetric gait.  There is adequate range of motion without significant pain or deformity.,SKIN: , Essentially clear with no significant rash or lesions.  Adequate skin turgor.,NEUROLOGICAL: , No acute focal neurologic changes.,PSYCHIATRIC:,  Mental status, judgment and affect are grossly intact and normal for age.", General Medicine,15
"PREOPERATIVE DIAGNOSIS: , Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:,  Acute cholecystitis.,PROCEDURE PERFORMED:,  Laparoscopic cholecystectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Zero.,COMPLICATIONS: , None.,PROCEDURE:  ,The patient was taken to the operating room, and after obtaining adequate general anesthesia, the patient was placed in the supine position.  The abdominal area was prepped and draped in the usual sterile fashion.  A small skin incision was made below the umbilicus.  It was carried down in the transverse direction on the side of her old incision.  It was carried down to the fascia.  An open pneumoperitoneum was created with Hasson technique.  Three additional ports were placed in the usual fashion.  The gallbladder was found to be acutely inflamed, distended, and with some necrotic areas.  It was carefully retracted from the isthmus, and the cystic structure was then carefully identified, dissected, and divided between double clips.  The gallbladder was then taken down from the gallbladder fossa with electrocautery.  There was some bleeding from the gallbladder fossa that was meticulously controlled with a Bovie.  The gallbladder was then finally removed via the umbilical port with some difficulty because of the size of the gallbladder and size of the stones.  The fascia had to be opened.  The gallbladder had to be opened, and the stones had to be extracted carefully.  When it was completed, I went back to the abdomen and achieved complete hemostasis.  The ports were then removed under direct vision with the scope.  The fascia of the umbilical wound was closed with a figure-of-eight 0 Vicryl.  All the incisions were injected with 0.25% Marcaine, closed with 4-0 Monocryl, Steri-Strips, and sterile dressing.,The patient tolerated the procedure satisfactorily and was transferred to the recovery room in stable condition.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Prostate cancer.,POSTOPERATIVE DIAGNOSIS: , Prostate cancer.,OPERATION: , Cystoscopy and removal of foreign objects from the urethra.,BRACHYTHERAPY:,  Iodine 125.,ANESTHESIA: , General endotracheal.  The patient was given Levaquin 500 mg IV preoperatively.,Total seeds were 59.  Activity of 0.439, 30 seeds in the periphery with 10 needles and total of 8 seeds at the anterior of the fold, 4 needles.  Please note that the total needles placed on the top were actually 38 seeds and 22 seeds were returned back.,BRIEF HISTORY: , This is a 72-year-old male who presented to us with elevated PSA and prostate biopsy with Gleason 6 cancer on the right apex.  Options such as watchful waiting, brachytherapy, radical prostatectomy, cryotherapy, and external beam radiation were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, incontinence, erectile dysfunction, urethral stricture, dysuria, burning pain, hematuria, future procedures, and failure of the procedure were all discussed.  The patient understood all the risks, benefits, and options and wanted to proceed with the procedure.  The patient wanted to wait until he came back from his summer vacations, so a one dose of Zoladex was given.  Prostate size measured about 15 g in the OR and about 22 g about two months ago.  Consent was obtained.,DETAILS OF THE OPERATION:  ,The patient was brought to the OR and anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient had a Foley catheter placed sterilely.  The scrotum was taped up using Ioban.  Transrectal ultrasound was done.  The prostate was measured 15 g.  Multiple images were taken.  A volume study was done.  This was given to the physicist, Dr. X was present who is radiation oncologist who helped with implanting of the seeds.  Total of 38 seeds were placed in the patient with 10 peripheral needles and then 4 internal needles.  Total of 30 seeds were placed in the periphery and total of 8 seeds were placed in the inside.  They were done directly under transrectal ultrasound vision.  The seeds were placed directly under ultrasound guidance.  There was a nice distribution of the seeds.  A couple of more seeds were placed on the right side due to the location of the prostate cancer.  Subsequently at the end of the procedure, fluoroscopy was done.  Couple of images were obtained.  Cystoscopy was done at the end of the procedure where a seed was visualized right in the urethra, which was grasped and pulled out using grasper, which was difficult to get the seed off of the spacers, which was actually pulled out.  There were no further seeds visualized in the bladder.  The bladder appeared normal.  At the end of the procedure, a Foley catheter was kept in place of 18 French and the patient was brought to recovery in stable condition.", Surgery,38
"CHIEF COMPLAINT:,  Right-sided facial droop and right-sided weakness.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old lady, a resident of a skilled nursing facility, with past medical history of a stroke and dementia with expressive aphasia, was found today with a right-sided facial droop, and was transferred to the emergency room for further evaluation.  While in the emergency room, she was found to having the right-sided upper extremity weakness and right-sided facial droop.  The CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident, will be admitted to monitor bed for observation and treatment and also she was recently diagnosed with urinary tract infection, which was resistant to all oral medications.,ALLERGIES: , SHE IS ALLERGIC TO PENICILLIN.,SOCIAL HISTORY: , She is a nondrinker and nonsmoker and currently lives at the skilled nursing facility.,FAMILY HISTORY: , Noncontributory.,PAST MEDICAL HISTORY:,1.  Cerebrovascular accident with expressive aphasia and lower extremity weakness.,2.  Abnormality of gait and wheelchair bound secondary to #1.,3.  Hypertension.,4.  Chronic obstructive pulmonary disease, on nasal oxygen.,5.  Anxiety disorder.,6.  Dementia.,PAST SURGICAL HISTORY: , Status post left mastectomy secondary to breast cancer and status post right knee replacement secondary to osteoarthritis.,REVIEW OF SYSTEMS: , Because of the patient's inability to communicate, is not obtainable, but apparently, she has urine incontinence and also stool incontinence, and is wheelchair bound.,PHYSICAL EXAMINATION:,GENERAL:  She is an 83-year-old patient, awake, and non-communicable lady, currently in bed, follows commands by closing and opening her eyes.,VITAL SIGNS:  Temperature is 99.6, pulse is 101, respirations 18, and blood pressure is in the 218/97.,HEENT:  Pupils are equal, round, and reactive to light.  External ocular muscles are intact.  Conjunctivae anicteric.  There is a slight right-sided facial droop.  Oropharynx is clear with the missing teeth on the upper and the lower part.  Tympanic membranes are clear.,NECK:  Supple.  There is no carotid bruit.  No cervical adenopathy.,CARDIAC:  Regular rate and rhythm with 2/6 systolic murmur, more at the apex.,LUNGS:  Clear to auscultation.,ABDOMEN:  Soft and no tenderness.  Bowel sound is present.,EXTREMITIES:  There is no pedal edema.  Both knees are passively extendable with about 10-15 degrees of fixed flexion deformity on both sides.,NEUROLOGIC:  There is right-sided slight facial droop.  She moves both upper extremities equally.  She has withdrawal of both lower extremities by touching her sole of the feet.,SKIN:  There is about 2 cm first turning to second-degree pressure ulcer on the right buttocks.,LABORATORY DATA: , The CT scan of the head shows brain atrophy with no acute events.  Sodium is 137, potassium 3.7, chloride 102, bicarbonate 24, BUN of 22, creatinine 0.5, and glucose of 92.  Total white blood cell count is 8.9000, hemoglobin 14.4, hematocrit 42.7, and the platelet count of 184,000.  The urinalysis was more than 100 white blood cells and 10-25 red blood cells.  Recent culture showed more than 100,000 colonies of E. coli, resistant to most of the tested medications except amikacin, nitrofurantoin, imipenem, and meropenem.,ASSESSMENT:,1.  Recent cerebrovascular accident with right-sided weakness.,2.  Hypertension.,3.  Dementia.,4.  Anxiety.,5.  Urinary tract infection.,6.  Abnormality of gait secondary to lower extremity weakness.,PLAN: , We will keep the patient NPO until a swallowing evaluation was done.  We will start her on IV Vasotec every 4 hours p.r.n. systolic blood pressure more than 170.  Neuro check every 4 hours for 24 hours.  We will start her on amikacin IV per pharmacy.  We will start her on Lovenox subcutaneously 40 mg every day and we will continue with the Ecotrin as swallowing evaluation was done.  Resume home medications, which basically include Aricept 10 mg p.o. daily, Diovan 160 mg p.o. daily, multivitamin, calcium with vitamin D, Ecotrin, and Tylenol p.r.n.  I will continue with the IV fluids at 75 mL an hour with a D5 normal saline at the range of 75 mL an hour and adding potassium 10 mEq per 1000 mL and I would follow the patient on daily basis.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSES,1.  Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.,2.  Documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery, last procedure in 2005.,3.  Primary malignant ventricular arrhythmia and necessitated ventricular fibrillation.  He is intubated and ventilated.,POSTOPERATIVE DIAGNOSES:,  Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.  Primary ventricular arrhythmia.  Occluded left anterior descending artery, successfully re-canalized with angioplasty and implantation of the drug-eluting stent.  Previously stented circumflex with mild stenosis and previously documented occlusion of the right coronary artery, well collateralized.,PROCEDURES:,  Left heart catheterization, selective bilateral coronary angiography and left ventriculography.  Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent.  Right heart catheterization and Swan-Ganz catheter placement for monitoring.,DESCRIPTION OF PROCEDURE:  ,The patient arrived from the emergency room intubated and ventilated.  He is hemodynamically stable on heparin and Integrilin bolus and infusion was initiated.  The right femoral area was prepped and draped in usual sterile fashion.  Lidocaine 2 mL was then filled locally.  The right femoral artery was cannulated with an 18-guage needle followed by a 6-French vascular sheath.  A guiding catheter XB 3.5 was advanced in manipulated to cannulate the left coronary artery and angiography was obtained.  A confirmed occlusion of the left anterior descending artery with minimal collaterals and also occlusion of the right coronary artery, which is well collateralized.  An angioplasty wire with present wire was advanced into the left anterior descending artery, and could cross the area of occlusion within the stent.  An angioplasty balloon measuring 2.0 x 15 was advanced and three inflations were obtained.  It successfully re-canalized the artery.  There is evidence of residual stenosis within the distal aspect of the previous stents.  A drug-eluting stent Xience 2.75 x 15 was advanced and positioned within the area of stenosis with its distal marker adjacent to bifurcation with a diagonal branch and was deployed at 12 and 18 atmospheres.  The intermittent result was improved.  An additional inflation was obtained more proximally.  His blood pressure fluctuated and dropped in the 70s, correlating with additional sedation.  There is patency of the left anterior descending artery and good antegrade flow.  The guiding catheter was replaced with a 5-French Judkins right catheter manipulated to cannulate the right coronary artery and selective angiography was obtained.  The catheter was then advanced into the left ventricle and pressure measurement was obtained including pullback across the aortic valve.  The right femoral vein was cannulated with an 18-guage needle followed by an 8-French vascular sheath.  A 8-French Swan-Ganz catheter was then advanced under fluoroscopic and hemodynamic control and pressure stenting was obtained from the right ventricle, pulmonary artery, and pulmonary capillary wedge position.  Cardiac catheter was determined by thermal dilution.  The procedure was then concluded, well tolerated and without complications.  The vascular sheath was in secured in place and the patient return to the coronary care unit for further monitoring.  Fluoroscopy time was 8.2 minutes.  Total amount of contrast was 113 mL.,HEMODYNAMICS:,  The patient remained in sinus rhythm with intermittent ventricular bigeminy post revascularization.  His initial blood pressure was 96/70 with a mean of 83 and the left ventricular pressure was 17 mmHg.  There was no gradient across the aortic valve.  Closing pressure was 97/68 with a mean of 82.,Right heart catheterization with right atrial pressure at 13, right ventricle 31/9, pulmonary artery 33/19 with a mean of 25, and capillary wedge pressure of 19.  Cardiac output was 5.87 by thermal dilution.,CORONARIES:,  On fluoroscopy, there was evidence of previous coronary stent in the left anterior descending artery and circumflex distribution.,A.  Left main coronary:  The left main coronary artery is of good caliber and has no evidence of obstructive lesions.,B.  Left anterior descending artery:  The left anterior descending artery was initially occluded within the previously stented proximal-to-mid segment.  There is minimal collateral flow.,C.  Circumflex:  Circumflex is a nondominant circulation.  It supplies a first obtuse marginal branch on good caliber.  There is an outline of the stent in the midportion, which has mild 30% stenosis.  The rest of the vessel has no significant obstructive lesions.  It also supplies significant collaterals supplying the occluded right coronary artery.,D.  Right coronary artery:  The right coronary artery is a weekly dominant circulation.  The vessel is occluded in intermittent portion and has a minimal collateral flow distally.,ANGIOPLASTY: , The left anterior descending artery was the site of re-canalization by angioplasty and implantation of a drug-eluting stent (Xience 15 mm length deployed at 2.9 mm) final result is good with patency of the left anterior descending artery, good antegrade flow and no evidence of dissection.  The stent was deployed proximal to the bifurcation with a second diagonal branch, which has remained patent.  There is a septal branch overlapped by the stent, which is also patent, although presenting a proximal stenosis.  The distal left anterior descending artery trifurcates with two diagonal branches and apical left anterior descending artery.  There is good antegrade flow and no evidence of distal embolization.,CONCLUSION: , Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution, complicated with primary ventricular malignant arrhythmia and required defibrillation along intubation and ventilatory support.,Previously documented coronary artery disease with remote angioplasty and stents in the left anterior descending artery and circumflex artery.,Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution related to in-stent thrombosis of the left anterior descending artery, successfully re-canalized with angioplasty and a drug-eluting stent.  There is mild-to-moderate disease of the previously stented circumflex and clinic occlusion of the right coronary artery, well collateralized.,Right femoral arterial and venous vascular access.,RECOMMENDATION:,  Integrilin infusion is maintained until tomorrow.  He received aspirin and Plavix per nasogastric tube.  Titrated doses of beta-blockers and ACE inhibitors are initiated.  Additional revascularization therapy will be adjusted according to the clinical evaluation.", Cardiovascular / Pulmonary,3
"CHIEF COMPLAINT:,  Fever.,HISTORY OF PRESENT ILLNESS:,  This is an 18-month-old white male here with his mother for complaint of intermittent fever for the past five days.  Mother states he just completed Amoxil several days ago for a sinus infection.  Patient does have a past history compatible with allergic rhinitis and he has been taking Zyrtec serum.  Mother states that his temperature usually elevates at night.  Two days his temperature was 102.6.  Mother has not taken it since, and in fact she states today he seems much better.  He is cutting an eye tooth that causes him to be drooling and sometimes fussy.  He has had no vomiting or diarrhea.  There has been no coughing.  Nose secretions are usually discolored in the morning, but clear throughout the rest of the day.  Appetite is fine.,PHYSICAL EXAMINATION:,General:  He is alert in no distress.,Vital Signs:  Afebrile.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  TMs are clear bilaterally.  Nares patent.  Clear secretions present.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular, no murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,Skin:  Normal turgor.,ASSESSMENT:,1.  Allergic rhinitis.,2.  Fever history.,3.  Sinusitis resolved.,4.  Teething.,PLAN:,  Mother has been advised to continue Zyrtec as directed daily.  Supportive care as needed.  Reassurance given and he is to return to the office as scheduled.", Consult - History and Phy.,5
"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.", Urology,39
"CHIEF COMPLAINT:, Left foot pain.,HISTORY:, XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to continue playing He was examined by John Houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. He has been in a walking boot. He has been taped firmly. Pain with weightbearing activities. He is limping a bit. No significant foot injuries in the past. Most of his pain is located around the dorsal aspect of the hindfoot and midfoot. ,PHYSICAL EXAM:, He does have some swelling from the hindfoot out toward the midfoot. His arch is maintained. His motion at the ankle and subtalar joints is preserved. Forefoot motion is intact. He has pain with adduction and abduction across the hindfoot. Most of this discomfort is laterally. His motor strength is grossly intact. His sensation is intact, and his pulses are palpable and strong. His ankle is not tender. He has minimal to no tenderness over the ATFL. He has no medial tenderness along the deltoid or the medial malleolus. His anterior drawer is solid. His external rotation stress is not painful at the ankle. His tarsometatarsal joints, specifically 1, 2 and 3, are nontender. His maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. Some tenderness over the dorsolateral side of the talonavicular joint as well. The medial talonavicular joint is not tender.,RADIOGRAPHS:, Those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic. I don't see a definite fracture. The tarsometarsal joints are anatomically aligned. Radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified. Review of an MR scan of the ankle dated 12/01/05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area. Also some changes along the dorsal talonavicular joint. I don't see any significant marrow edema or definitive fracture line. ,IMPRESSION:,  Left Chopart joint sprain.,PLAN:,  I have spoken to XYZ about this. Continue with ice and boot for weightbearing activities. We will start him on a functional rehab program and progress him back to activities when his symptoms allow. He is clear on the prolonged duration of recovery for these hindfoot type injuries.", Consult - History and Phy.,5
"SUBJECTIVE:,  This is an 11-year-old female who comes in for two different things.  1.  She was seen by the allergist.  No allergies present, so she stopped her Allegra, but she is still real congested and does a lot of snorting.  They do not notice a lot of snoring at night though, but she seems to be always like that.  2.  On her right great toe, she has got some redness and erythema.  Her skin is kind of peeling a little bit, but it has been like that for about a week and a half now.,PAST MEDICAL HISTORY:,  Otherwise reviewed and noted.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home.,REVIEW OF SYSTEMS:,  She has been having the redness of her right great toe, but also just a chronic nasal congestion and fullness.  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,General:  Well-developed female, in no acute distress, afebrile.,HEENT:  Sclerae and conjunctivae clear.  Extraocular muscles intact.  TMs clear.  Nares patent.  A little bit of swelling of the turbinates on the left.  Oropharynx is essentially clear.  Mucous membranes are moist.,Neck:  No lymphadenopathy.,Chest:  Clear.,Abdomen:  Positive bowel sounds and soft.,Dermatologic:  She has got redness along the lateral portion of her right great toe, but no bleeding or oozing.  Some dryness of her skin.  Her toenails themselves are very short and even on her left foot and her left great toe the toenails are very short.,ASSESSMENT:,1.  History of congestion, possibly enlarged adenoids, or just her anatomy.,2.  Ingrown toenail, but slowly resolving on its own.,PLAN:,1.  For the congestion, we will have ENT evaluate.  Appointment has been made with Dr. XYZ for in a couple of days.,2.  I told her just Neosporin for her toe, letting the toenail grow out longer.  Call if there are problems.", General Medicine,15
"PREOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,POSTOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,4.  Postoperative coagulopathy.,OPERATIVE PROCEDURE:,1.  Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass.,2.  Open sternotomy covered with Ioban.,3.  Insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.,ANESTHESIA: , General endotracheal.,OPERATIVE PROCEDURE: , With the patient in the supine position, he was prepped from shin to knees and draped in a sterile field.  A right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass.  A sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm, freeing up the right atrium and the ascending aorta and anterior right ventricle.  The patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava.  A percutaneous catheter for arterial return was placed using Seldinger technique through exposed right femoral artery and then two 3-mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava.  After satisfactory heparinization has been obtained, the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium.  After the heart was brought to the operating room and triggered, the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place.  A cardiectomy was then performed by starting in the right atrium.  The wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the Swan-Ganz catheter was brought out into the operative field.  Cardiectomy was then performed, first resecting the anterior portion of the right atrium and then transecting the aorta, the pulmonary artery, the septum between the right and left atriums, and then the heart was removed.  The right and left atrium, aorta, and pulmonary artery were prepared for the transplant.  First, we did a side-to-side anastomosis, continued to the left atrium and this was performed using 3-0 Prolene suture and a right atrial anastomosis side-to-side was performed using 3-0 Prolene suture.  The pulmonary artery was then anastomosed using 5-0 Prolene and the aorta was anastomosed with 4-0 Prolene.  The arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood.  Air was evacuated and the sutures were tied down.  The clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass.  The patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass.  Blood factors and factor VII were given to try and correct the coagulopathy.  Because of excessive transfusions that were required, a Mahurkar catheter was inserted through the left common femoral vein, first placing a needle into the vein and then guidewire removed, and the needle dilators were then placed and then the Mahurkar catheter was then placed with 2-0 nylon suture.  Hemofiltration was started in the operating room at this time.  After he had satisfactory hemostasis, we decided to do the chest open and cover it with Ioban, which we did, and one chest tube was inserted into the mediastinum through a separate stab wound.  The patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively.  This was left in place and the pulse generation, the pacemaker was in a right infraclavicular position, which was left in place because of the coagulopathy.  The patient received 11 units of packed red blood cells, 7 platelets, 23 fresh-frozen plasma, 20 cryoprecipitates, and factor VII.  Urine output for the procedure was 520 mL.  The preservation time of the heart is in the anesthesia sheet.  The estimated blood loss was at least 6 L.  The patient was taken to the intensive care unit in guarded condition.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS: , Extremely large basal cell carcinoma, right lower lid.,POSTOPERATIVE DIAGNOSIS:,  Extremely large basal cell carcinoma, right lower lid.,TITLE OF OPERATION: , Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.,PROCEDURE: , The patient was brought into the operating room and prepped and draped in usual fashion.  Xylocaine 2% with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid.  A frontal nerve block was also given on the right upper lid.  The anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect.  The area was marked with a marking pen with margins of 3 to 4 mm, and a #15 Bard-Parker blade was used to make an incision at the nasal and temporal margins of the lesion.,The incision was carried inferiorly, and using a Steven scissors the normal skin, muscle, and conjunctiva was excised inferiorly.  The specimen was then marked and sent to pathology for frozen section.  Bleeding was controlled with a wet-field cautery, and the right upper lid was everted, and an incision was made 3 mm above the lid margin with the Bard-Parker blade in the entire length of the upper lid.  The incision reached the orbicularis, and Steven scissors were used to separate the tarsus from the underlying orbicularis.  Vertical cuts were made nasally and temporally, and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly.  It was placed into the defect in the lower lid and sutured with multiple interrupted 6-0 Vicryl sutures nasally, temporally, and inferiorly.,The defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region.  The defect was closed with interrupted 5-0 Prolene sutures, and the preauricular graft was sutured in place with multiple interrupted 6-0 silk sutures.  The upper border of the graft was attached to the upper lid after incision was made in the gray line with a Superblade, and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision.,Cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins, and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied.  The patient tolerated the procedure well and was sent to recovery room in good condition.", Ophthalmology,26
"CHIEF COMPLAINT:,  This 1-year-old female presents today for a health maintenance exam.  Patient was accompanied by mother.,The child eats 3 meals a day plus 2 snacks and is off the bottle.  She sleeps through the night.  She takes morning and afternoon naps.  Mother is concerned about child's red, matted eye and not walking completely alone yet.  Immunizations need to be updated at today's visit.,DEVELOPMENTAL MILESTONES:,  1 year developmental milestones reached:  bangs blocks together, drinks from cup, eating finger foods, feeds self, gives toys on request, imitates vocalizations, looks for dropped or hidden objects, points to desired objects, pulls to stand and cruises, releases cube into cup after demonstration, says ""mama"" and ""dada"" with meaning, says one or two other words, tries to build tower of 2 cubes and waves bye.,ALLERGIES:,  No known medical allergies.,MEDICATIONS:,  None.,PMH: , Past medical history is unremarkable.,PSH: , No previous surgeries.,FAMILY HISTORY:,  Patient admits a family history of cancer associated with maternal aunt, hypertension associated with paternal grandfather.,SOCIAL HISTORY:,  She lives at home with parents.  Patient admits being in daycare.,REVIEW OF SYSTEMS:,  No change since last visit,PHYSICAL EXAM:,  Temp:  97.6 Height:  0 ft.  31 in.  Weight:  28 lbs.  BMI:  20,Growth Chart Entry:  Weight:  28 lbs 0 ozs Height:  0 ft 31 in Head Circumference:  18.50 in Patient is a 1 year-old female who appears in no apparent distress, well developed and well nourished.,Inspection of head and face shows anterior fontanel normal, posterior fontanel normal and head is normocephalic and atraumatic.,Eyes:  Fundoscopic exam reveals red reflex is present bilaterally.,Alignment is normal.,Sclera is white bilaterally.,Left inferior palpebral conjunctiva reveals conjunctivitis.,Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.,ENT:  Pinna:  normal.,Otoscopic examination reveals no abnormalities of external auditory canals and tympanic membranes.,Inspection of nose reveals no abnormalities and nares that are normal.,Nasal mucosa moist, pink, and without mass or exudate with no abnormalities of the septum and turbinates noted.,Inspection of lips, gums, and palate reveals no abnormalities.,Examination of oropharynx reveals no abnormalities and tissues pink and moist.,Neck:  Neck exam reveals no masses.,Respiratory:  Assessment of respiratory effort reveals even and nonlabored respirations.  Auscultation of lungs reveal clear lung fields and no rubs noted.,Cardiovascular:  Heart auscultation reveals rate is regular, rhythm is regular and no murmurs, gallop, rubs or clicks.  Femoral pulses are 2 /4, bilateral.,Abdomen:  Abdomen soft, nontender, bowel sounds present x 4 without palpable masses.  Palpation of liver reveals no abnormalities.  Palpation of spleen reveals no abnormalities.,Genitourinary:  Examination of anus and perineum shows no abnormalities.,Musculoskeletal:  Inspection and palpation of bones, joints and muscles is unremarkable.,Muscle tone is normal.,Skin:  Skin is not pale, jaundice, or cyanotic.  Skin turgor, hydration, and texture is good.  Palpation of skin shows no abnormalities.,Neurologic/Psychiatric:  Moves all extremities.,TEST & X-RAY RESULTS:,  Hb:  12 g/dl.,IMPRESSION:,  Routine well child care.  Acute conjunctivitis.,PLAN:", Pediatrics - Neonatal,29
"PREOPERATIVE DIAGNOSIS: , Recurrent bladder tumors.,POSTOPERATIVE DIAGNOSIS:,  Recurrent bladder tumors.,OPERATION: , Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors.,ANESTHESIA:,  General.,INDICATIONS: , A 79-year-old woman with recurrent bladder tumors of the bladder neck.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, prepped and draped in lithotomy position under satisfactory general anesthesia.  A #21-French cystourethroscope was inserted into the bladder.  Examination of the bladder showed approximately a 3-cm area of erythema and recurrent papillomatosis just above and lateral to the left ureteral orifice.  No other lesions were noted.  Using a cold punch biopsy forceps, a random biopsy was obtained.  The entire area was electrofulgurated using the Bugbee electrode.  The patient tolerated the procedure well and left the operating room in satisfactory condition.", Urology,39
"The effects of eye dilation drops will gradually decrease. It typically takes TWO to SIX HOURS for the effects to wear off. During this time, reading may be more difficult and sensitivity to light may increase. For a short time, wearing sunglasses may help.", Office Notes,25
"MALE PHYSICAL EXAMINATION,HEENT:  Pupils equal, round and reactive to light and accommodation.  Extraocular movements are intact.  Sclerae are anicteric.  TMs are clear bilaterally.  Oropharynx is clear without erythema or exudate.,NECK:  Supple without lymphadenopathy or thyromegaly.  Carotids are silent.  There is no jugular venous distention.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm without S3, S4.  No murmurs or rubs are appreciated.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No masses, hepatomegaly or splenomegaly are appreciated.,GU:  Normal **circumcised male.  No discharge or hernias.  No testicular masses.,RECTAL EXAM:  Normal rectal tone.  Prostate is smooth and not enlarged.  Stool is Hemoccult negative.,EXTREMITIES:  Reveal no clubbing, cyanosis, or edema.  Peripheral pulses are +2 and equal bilaterally in all four extremities.,JOINT EXAM:  Reveals no tenosynovitis.,NEUROLOGIC:  Cranial nerves II through XII are grossly intact.  Motor strength is 5/5 and equal in all four extremities.  Deep tendon reflexes are +2/4 and equal bilaterally.  Patient is alert and oriented times 3.,PSYCHIATRIC:  Grossly normal.,DERMATOLOGIC:  No lesions or rashes.", General Medicine,15
"PREOPERATIVE DIAGNOSIS: , Severe tricompartmental osteoarthritis, left knee with varus deformity.,POSTOPERATIVE DIAGNOSIS:,  Severe tricompartmental osteoarthritis, left knee with varus deformity.,PROCEDURE PERFORMED:  ,Left total knee cemented arthroplasty.,ANESTHESIA: , Spinal with Duramorph.,ESTIMATED BLOOD LOSS:  ,50 mL.,NEEDLE AND SPONGE COUNT:,  Correct.,SPECIMENS: , None.,TOURNIQUET TIME:  ,Approximately 77 minutes.,IMPLANTS USED:,1.  Zimmer NexGen posterior stabilized LPS-Flex GSF femoral component size D, left.,2.  All-poly patella, size 32/8.5 mm thickness.,3.  Prolong highly cross-linked polyethylene 12 mm.,4.  Stemmed tibial component, size 2.,5.  Palacos cement with antibiotics x2 batches.,INDICATION: , The patient is an 84-year-old female with significant endstage osteoarthritis of the left knee, who has had rapid progression with pain and disability.  Surgery was indicated to relieve her pain and improve her functional ability.  Goal objectives and the procedure were discussed with the patient.  Risks and benefits were explained.  No guarantees have been made or implied.  Informed consent was obtained.,DESCRIPTION OF THE PROCEDURE:  ,The patient was taken to the operating room and once an adequate spinal anesthesia with Duramorph was achieved, her left lower extremity was prepped and draped in a standard sterile fashion.  A nonsterile tourniquet was placed proximally in the thigh.  Antibiotics were infused prior to Foley catheter insertion.  Time-out procedure was called.,A straight longitudinal anterior midline incision was made.  Dissection was carried down sharply down the skin, subcutaneous tissue and the fascia.  Deep fascia was exposed.  The tourniquet was inflated at 300 mmHg prior to the skin incision.  A standard medial parapatellar approach was made.  The quadriceps tendon was incised approximately 1 cm from the vastus medialis insertion.  Incision was then carried down distally and distal arthrotomy was completed.  Patellar tendon was well protected.  Retinaculum and capsule was incised approximately 5 mm from the medial border of the patella for later repair.  The knee was exposed very well.  Significant tricompartmental osteoarthritis was noted.  The osteophytes were removed with a rongeur.  Anterior and posterior cruciate ligaments were excised.  Medial and lateral meniscectomies were performed.  Medial dissection was performed subperiosteally along the medial aspect of the proximal tibia to address the varus deformity.  The medial compartment was more affected than lateral.  Medial ligaments were tied.  Retropatellar fat pad was excised.  Osteophytes were removed.  Using a Cobb elevator, the medial soft tissue periosteum envelope was well reflected.,Attention was placed for the preparation of the femur.  The trochlear notch was ossified.  A rongeur was utilized to identify the notch and then using an intramedullary drill guide, a starting hole was created slightly anterior to the PCL attachment.  The anterior portal was 1 cm anterior to the PCL attachment.  The anterior femoral sizer was positioned keeping 3 degrees of external rotation.  Rotation was also verified using the transepicondylar axis and Whiteside line.  The pins were positioned in the appropriate holes.  Anterior femoral cut was performed after placing the cutting guide.  Now, the distal cutting guide was attached to the alignment and 5 degrees of valgus cut was planned.  A distal femoral cut was made which was satisfactory.  A sizer was positioned which was noted to be D.  The 5-in-1 cutting block size D was secured with spring pins over the resected bone.  Using an oscillating saw, cuts were made in a sequential manner such as anterior condyle, posterior condyle, anterior chamfer, and posterior chamfer.  Then using a reciprocating saw, intercondylar base notch cut and side cuts were made.  Following this, the cutting block for High-Flex knee was positioned taking 2 mm of additional posterior condyle.  Using a reciprocating saw, the side cuts were made and bony intercondylar notch cut was completed.  The bone with its attached soft tissue was removed.  Once the femoral preparation was completed, attention was placed for the preparation of the tibia.  The medial and the lateral collateral ligaments were well protected with a retractor.  The PCL retractor was positioned and the tibia was translated anteriorly.  Osteophytes were removed.  The extramedullary tibial alignment guide was affixed to the tibia and appropriate amount of external rotation was considered reference to the medial 1/3rd of the tibial tubercle.  Similarly, horseshoe alignment guide was positioned and the alignment guide was well aligned to the distal 1/3rd of the crest of the tibia as well as the 2nd toe.  Once the alignment was verified in a coronal plane, the tibial EM guide was well secured and then posterior slope was also aligned keeping the alignment rod parallel to the tibial crest.  A built-in 7-degree posterior slope was considered with instrumentation.  Now, the 2 mm stylus arm was positioned over the cutting block medially, which was the most affected site.  Tibial osteotomy was completed 90 degrees to the mechanical axis in the coronal plane.  The resected thickness of the bone was satisfactory taken 2 mm from the most affected site.  The resected surface shows some sclerotic bone medially.  Now, attention was placed for the removal of the posterior osteophytes from the femoral condyle.  Using curved osteotome, angle curette, and a rongeur, the posterior osteophytes were removed.  Now, attention was placed for confirming the flexion-extension gap balance using a 10 mm spacer block in extension and 12 mm in flexion.  Rectangular gap was achieved with appropriate soft tissue balance in both flexion and extension.  The 12 mm spacer block was satisfactory with good stability in flexion and extension.,Attention was now placed for completion of the tibia.  Size 2 tibial trial plate was positioned.  Appropriate external rotation was maintained with the help of the horseshoe alignment rod.  Reference to the tibial crest distally and 2nd toe was considered as before.  The midpoint of the trial tray was collinear with the medial 1/3rd of the tibial tubercle.  The rotation of tibial plate was satisfactory as required and the preparation of the tibia was completed with intramedullary drill followed by broach impactor.  At this point, trial femoral and tibial components were reduced using a 12 mm trial liner.  The range of motion and stability in both flexion and extension was satisfactory.  No further soft tissue release was indicated.  I was able to achieve 0 degrees of extension and complete flexion of the knee.,Attention was now placed for the preparation of the patella.  Using a patellar caliper, the thickness was measured to be 21.5 mm.  This gives an ideal resection of 8.5 mm keeping 13 mm of bone intact.  Reaming was initiated with a patellar reamer reaming up to 13 mm with the reaming alignment guide.  Using a caliper, the resected patella was measured, which was noted to be 13 mm.  A 32 sizer was noted to accommodate the resected surface very well.  Drilling was completed and trial 32 button was inserted without any difficulty.  The tracking was satisfactory.  There was no evidence of any subluxation or dislocation of the patella.  The trial components position was satisfactory.  The alignment and the rotation of all 3 components were satisfactory.  All the trial components were removed and the wound was thoroughly irrigated with Pulsavac lavage irrigation mechanical system.  The resected surfaces were dried with a sponge.  Two batches of Palacos cement were mixed.  The cementing was initiated starting with tibia followed by femur and patella.  Excess peripheral cement were removed with the curette and knife.  The knee was positioned in extension with a 12 mm trial liner.  Patellar clamp was placed after cementing the all-poly patella.  Once the cement was set hard and cured, tourniquet was deflated.  Hemostasis was achieved.  The trial 12 mm liner was replaced with definitive Prolong highly cross-linked polyethylene liner.  Range of motion and stability was verified at 0 degrees and flexion of 120 degrees.  Anterior-posterior drawer test was satisfactory.  Medial and lateral stability was satisfactory.  Patellar tracking was satisfactory.  The wound was thoroughly irrigated.  Hemostasis was achieved.  A local cocktail was injected, which included the mixture of 0.25% plain Marcaine, 30 mg of Toradol, and 4 mg of morphine.  The quadriceps mechanism and distal arthrotomy was repaired with #1 Vicryl in figure-of-8 fashion.  The subcutaneous closure was performed in layers using 2-0 Vicryl and 0 Vicryl followed by 2-0 Vicryl proximally.  The skin was approximated with staples.  Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias.  The patient was then transferred to the recovery room in a stable condition.  There were no intraoperative complications noted.  She tolerated the procedure very well.", Orthopedic,27
"PREOPERATIVE DIAGNOSIS: , Wrist ganglion.,POSTOPERATIVE DIAGNOSIS: , Wrist ganglion.,TITLE OF PROCEDURE: , Excision of dorsal wrist ganglion.,PROCEDURE: , After administering appropriate antibiotics and general anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with an Esmarch and tourniquet inflated to 250 mmHg.  I made a transverse incision directly over the ganglion.  Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.  I then excised the ganglion and its stalk.  In addition, approximately a square centimeter of the dorsal capsule was removed at the origin of stalk, leaving enough of a defect to prevent formation of a one-way valve.  We then identified the scapholunate ligament, which was uninjured.  I irrigated and closed in layers and injected Marcaine with epinephrine.  I dressed and splinted the wound.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.", Surgery,38
"CC: ,Episodic confusion.,HX: ,This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The ""stroke"" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week.,PMH:, Bilateral Hearing Loss of unknown etiology, S/P bilateral ear surgery many years ago.,MEDS:, DPH and ASA,SHX/FHX:, 2-4 Beers/day. 1-2 packs of cigarettes per day.,EXAM:, BP 111/68, P 68BPM, 36.8C. Alert and Oriented to person, place and time, 30/30 on mini-mental status test, Speech fluent and without dysarthria. CN: Left superior quandranopia only. Motor: 5/5 strength throughout. Sensory: unremarkable except for mild decreased vibration sense in feet. Coordination: unremarkable. Gait and station testing were unremarkable. He was able to tandem walk without difficulty. Reflexes: 2+ and symmetric throughout. Flexor plantar responses bilaterally.,LAB:, Gen Screen, CBC, PT, PTT all WNL. DPH 4.6mcg/ml.,Review of outside MRI Brain done 1/17/92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus. The area did not enhance with gadolinium contrast.,CXR:, 8/31/92: 5 x 6 mm spiculated opacity in apex right lung.,EEG:, 8/24/92: normal awake and asleep,MRI Brain with/without contrast: 8/31/92: Decreased T1 and increased T2 signal in the right temporal lobe. The lesion increased in size and enhances more greatly when compared to the 1/17/92 MRI exam. There is also edema surrounding the affected area and associated mass effect.,NEUROPSYCHOLOGICAL TESTING:, Low-average digit symbol substitution, mildly impaired verbal learning, and severely defective delayed recall. There was relative preservation of other cognitive functions. The findings were consistent with left mesiotemporal dysfunction.,COURSE: ,Patient underwent right temporal lobectomy on 9/16/92 following initial treatment with Decadron. Pathologic analysis was consistent with a Grade 2 astrocytoma. GFAP staining positive. Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed.", Neurology,22
"PREOPERATIVE DIAGNOSES,1.  Surgical absence of left nipple areola with personal history of breast cancer.,2.  Breast asymmetry.,POSTOPERATIVE DIAGNOSES,1.  Surgical absence of left nipple areola with personal history of breast cancer.,2.  Breast asymmetry.,PROCEDURE,1.  Left nipple areolar reconstruction utilizing a full-thickness skin graft from the left groin.,2.  Redo right mastopexy.,ANESTHESIA,General endotracheal.,COMPLICATIONS,None.,DESCRIPTION OF PROCEDURE IN DETAIL,The patient was brought to the operating room and placed on the table in the supine position and after suitable induction of general endotracheal anesthesia, the patient was placed in a frog-leg position and prepped and draped in usual fashion for the above-noted procedure.  The initial portion of the procedure was harvesting a full-thickness skin graft from the left groin region.  This was accomplished by ellipsing out a 42-mm diameter circle of skin just below the thigh, peroneal crease.  The defect was then closed with 3-0 Vicryl followed by 3-0 chromic suture in a running locked fashion.  The area was dressed with antibiotic ointment and then a Peri-Pad.  The patient's legs were brought out frog-leg back to the midline and sterile towels were placed over the opening in the drapes.  Surgical team's gloves were changed and then attention was turned to the planning of the left nipple flap.,A maltese cross pattern was employed with a 1-cm diameter nipple and a 42-mm diameter nipple areolar complex.  Once the maltese cross had been designed on the breast at the point where the nipple was to be placed, the areas of the portion of flap were de-epithelialized.  Then, when this had been completed, the dermis about the maltese cross was incised full thickness to allow mobilization of the flap to form the neonipple.  At this point, a Bovie electrocautery was used to control bleeding points and then 4-0 chromic suture was used to suture the arms of the flap together creating the nipple.  When this had been completed, the skin graft, which had been harvested from the left groin was brought onto the field where it was prepared by removing all subcutaneous tissue from the posterior aspect of the graft and carefully removing the hair follicles encountered within the graft.  At this point, the graft was sutured into position in the defect using 3-0 chromic in an interrupted fashion and then trimming the ellipse to an appropriate circle to fill the areola.  At this point, 4-0 chromic was used to run around the perimeter of the full-thickness skin graft and then at this point the nipple was delivered through a cruciate incision in the middle of the skin graft and then inset appropriately with 4-0 chromic.  The areolar skin graft was pie crusted.  Then, at this point, the area of areola was dressed with silicone gel sheeting.  A silo was placed over the neonipple with 3-0 nylon through the apex of the neonipple to support the nipple in an erect position.  Mastisol and Steri-Strips were then applied.,At this point, attention was turned to the right breast where a 2-cm wide ellipse transversely oriented and with its inferior most aspect just inferior to the transverse mastopexy incision line was made.  The skin was removed from the area and then a layered closure of 3-0 Vicryl followed by 3-0 PDS in a running subcuticular fashion was carried out.  When this had been completed, the Mastisol and Steri-Strips were applied to the transverse right breast incision.  Fluff dressings were applied to the right breast as well as the area around the silo on the left breast around the reconstructed nipple areola.  The patient was then placed in Surgi-Bra and then was taken from the operating room to the recovery room in good condition.", Surgery,38
"PREOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet arthropathy with scar tissue.,3.  No evidence of instability.,OPERATIVE PROCEDURE PERFORMED,1.  Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty.,2.  Total laminectomy C3, C4, C5, and C6.,3.  Excision of scar tissue.,4.  Repair of dural tear with Prolene 6-0 and Tisseel.,FLUIDS:,  1500 cc of crystalloid.,URINE OUTPUT: , 200 cc.,DRAINS: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA:,  General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:,  Less than 250 cc.,INDICATIONS FOR THE OPERATION:  ,This is the case of a very pleasant 41 year-old Caucasian male well known to me from previous anterior cervical discectomy and posterior decompression.  Last surgery consisted of four-level decompression on 08/28/06.  The patient continued to complain of posterior neck pain radiating to both trapezius.  Review of his MRI revealed the presence of what still appeared to be residual lateral recess stenosis.  It also raised the possibility of instability and based on this I recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial.  Based on this, I did total decompression by removing the lamina of C3 through C6 and doing bilateral medial facetectomy and foraminotomy at C3-C4, C4-C5, C5-C6, and C6-C7 with no spinal instrumentation.  Operation and expected outcome risks and benefits were discussed with him prior to the surgery.  Risks include but not exclusive of bleeding and infection.  Infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection.  There is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord.  This may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma.  There is also the risk of a dural tear with its attendant problems of CSF leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis.  This too may require return to the operating room for evacuation of said pseudomeningocele and repair.  The patient understood the risk of the surgery.  I told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were also placed by Premier Neurodiagnostics for both SSEP and EMG monitoring.  The SSEPs were normal, and the EMGs were silent during the entire case.  After completion of the placement of the monitoring leads, the patient was then positioned prone on a Wilson frame with the head supported on a foam facial support.  Shave was then carried out over the occipital and suboccipital region.  All pressure points were padded.  I proceeded to mark the hypertrophic scar for excision.  This was initially cleaned with alcohol and prepped with DuraPrep.,After sterile drapes were laid out, incision was made using a scalpel blade #10.  Wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar.  Dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of C2 was then identified.  There was absence of the spinous process of C3, C4, C5, and C6, but partial laminectomy was noted; removal of only 15% of the lamina.  With this completed, we proceeded to do a total laminectomy at C3, C4, C5, and C6, which was technically difficult due to the previous surgery.  There was also a dural tear on the right C3-C4 space that was exposed and repaired with Prolene 6-0 and later with Tisseel.  By careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at C3-C4, C4-C5, C5-C6, and C6-C7.  There was significant epidural bleeding, which was carefully coagulated.  At two points, I had to pack this with small pieces of Gelfoam.  After repair of the dural tear, Valsalva maneuver showed no evidence of any CSF leakage.  Area was irrigated with saline and bacitracin and then lined with Tisseel.  The wound was then closed in layers with Vicryl 0 simple interrupted sutures to the fascia; Vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch.  The patient was extubated and transferred to recovery.", Surgery,38
"OPERATION PERFORMED:  ,Dental prophylaxis under general anesthesia.,PREOPERATIVE DIAGNOSES:,1.  Impacted wisdom teeth.,2.  Moderate gingivitis.,POSTOPERATIVE DIAGNOSES:,1.  Impacted wisdom teeth.,2.  Moderate gingivitis.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,Minimal.,DURATION OF SURGERY:  ,One hour 17 minutes.,BRIEF HISTORY:  ,The patient was referred to me by Dr. X.  He contacted myself and stated that Angelica was going to have her wisdom teeth extracted in the setting of a hospital operating room at Hospital and he inquired if we could pair on the procedure and I could do her full mouth dental rehabilitation before the wisdom teeth were removed by him.  I agreed.  I saw her in my office and she was cooperative for full mouth set of radiographs in my office and a clinical examination.  This clinical and radiographic examination revealed no dental caries; however, she was in need of a good dental cleaning.,OPERATIVE PREPARATION:  ,The patient was brought to Hospital Day Surgery accompanied by her mother.  I met with them and discussed the needs of the child, types of restoration to be performed, and the risks and benefits of the treatment as well as the options and alternatives of the treatment.  After all their questions and concerns were addressed, they gave their informed consent to proceed with the treatment.  The patient's history and physical examination was reviewed.  Once she was cleared by Anesthesia, she was taken back to the operating room.,OPERATIVE PROCEDURE:  ,The patient was placed on the surgical table in the usual supine position with all extremities protected.  Anesthesia was induced by mask.  The patient was then intubated with a nasal endotracheal tube and the tube was stabilized.  The head was wrapped and the eyes were taped shut for protection.  An Angiocath was previously placed in preop.  The head and neck were draped in sterile towels, and the body was covered with lead apron and sterile sheath.  A moist continuous throat pack was placed beyond tonsillar pillars.  Plastic lip and cheek retractors were then placed.  Preoperative digital intraoral photographs were taken.  No digital radiographs were taken in the operating room, as I stated before I had a full set of digital radiographs taken in my office.  A prophylaxis was then performed using a Prophy cup and fluoridated Prophy paste after scaling and replaning was done.  She presented with moderate calculus on the buccal surfaces of her maxillary, first molars and lower molars.  She did not require any restorative dentistry.,Upon the conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  The original treatment plan was verified with the actual treatment provided.  Postoperative clinical photographs were taken.  The continuous gauze throat pack was removed with continuous suction and visualization.  Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, taken to the recovery room, breathing spontaneously with stable vital signs.,FINDINGS: , This patient presented in her permanent dentition.  Her teeth #1, 16, 17, and 32 were impacted and are going to be removed following my full mouth dental rehabilitation by Dr. Alexander.  Oral hygiene was fair.  There was generalized plaque and calculus throughout.  She did not have any caries, did not require any restorative dentistry.,CONCLUSION:,  Following my dental surgery, the patient continued to intubated and was prepped for oral surgery procedures by Dr. X and his associates.  There were no postop pain requirements.  I did not have any specific requirements for the patient or her mother and that will be handled by Dr. X and their instructions on soft foods, etc., and pain control will be managed by them.", Dentistry,7
"REASON FOR CONSULTATION:,  New diagnosis of non-small cell lung cancer.,HISTORY OF PRESENT ILLNESS: , ABCD is a very nice 47-year-old gentleman without much past medical history who has now been diagnosed with a new non-small cell lung cancer stage IV metastatic disease.  We are consulted at this time to discuss further treatment options.,ABCD and his wife state that his history goes back to approximately 2-2-1/2 weeks ago when he developed some left-sided flank pain.  Initially, he did not think much of this and tried to go about doing work and everything else but the pain gradually worsened.  Eventually this prompted him to present to the emergency room.  A CT scan was done there, and he was found to have a large left adrenal mass worrisome for metastatic disease.  At that point, he was transferred to XYZ Hospital for further evaluation.  On admission on 12/19/08, a CT scan of the chest, abdomen, and pelvis was done for full staging purposes.  The CT scan of the chest showed an abnormal soft tissue mass in the right paratracheal region, extending into the precarinal region, the subcarinal region, and the right hilum.  This was causing some compression on the inferior aspect of the SVC and also some narrowing of the right upper lobe pulmonary artery.  There was an abnormal lymph node noted in the AP window and left hilar region.  There was another spiculated mass within the right upper lobe measuring 2.0 x 1.5 cm.  There was also an 8 mm non-calcified nodule noted in the posterior-inferior aspect of the left upper lobe suspicious for metastatic disease.  There were areas of atelectasis particularly in the right base.  There was also some mild ground glass opacity within the right upper lobe adjacent to the right hilum potentially representing focal area of pulmonary edema versus small infarction related to the right upper lobe pulmonary artery narrowing.  There was a small lucency adjacent to the medial aspect of the left upper lobe compatible with a small pneumothorax.  In the abdomen, there was a mass involved in the left adrenal gland as well as a nodule involving the right adrenal gland both of which appeared necrotic compatible with metastatic tumor.  All other structures appeared normal.  On 12/22/08, a CT-guided biopsy of the left adrenal mass was performed.  Pathology from this returned showing metastatic poorly differentiated non-small cell carcinoma.  At this point, we have been consulted to discuss further treatment options.,On further review, ABCD states that he has may be had a 20 pound weight loss over the last couple of months which he relates to anorexia or decreased appetite.  He has not ever had a chronic smoker's cough and still does not have a cough.  He has no sputum production or hemoptysis.  He and his wife are very anxious about this diagnosis.,PAST MEDICAL HISTORY: , He denies any history of heart disease, lung disease, kidney disease, liver disease, hepatitis major infection, seizure disorders or other problems.,PAST SURGICAL HISTORY: , He denies having any surgeries.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  At home he takes no medication except occasional aspirin or ibuprofen, recently for his flank pain.  He does take a multivitamin on occasion.,SOCIAL HISTORY:  He has about a 30-pack-a-year history of smoking.  He used to drink alcohol heavily and has a history of getting a DUI about a year-and-half ago resulting in him having his truck-driving license revoked.  Since that time he has worked with printing press.  He is married and has two children, both of whom are grown in their 20s, but are now living at home.,FAMILY HISTORY: , His mother died for alcohol-related complications.  He otherwise denies any history of cancers, bleeding disorders, clotting disorders, or other problems.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL:  He has lost about 20 pounds of weight as described above.  He also has a trouble with fatigue.  No lightheadedness or dizziness.  HEENT:  He denies any new or changing headache, change in vision, double vision, or loss of vision, ringing in his ears, loss of hearing in one year.  He does not take care of his teeth very well but currently he has no mouth, jaw, or teeth pain.  RESPIRATORY:  He has had some little bit of dyspnea on exertion but otherwise denies shortness of breath at rest.  No cough, congestion, wheezing, hemoptysis, and sputum production.  CVS:  He denies any chest pains, palpitations, PND, orthopnea, or swelling of his lower extremities.  GI:  He denies any odynophagia, dysphagia, heartburn on a regular basis, abdominal pain, abdominal swelling, diarrhea, blood in his stool, or black tarry stools.  He has been somewhat constipated recently.  GU:  He denies any burning with urination, kidney stones, blood in his urine, dysuria, difficulty getting his urine out or other problems.  MUSCULOSKELETAL:  He denies any new bony aches or pains including back pain, hip pain, and rib pain.  No muscle aches, no joint swelling, and no history of gout.  SKIN:  No rashes, no bruising, petechia, non-healing wounds, or ulcerations.  He has had no nail or hair changes.  HEM:  He denies any bloody nose, bleeding gums, easy bruising, easy bleeding, swollen lymphs or bumps.  ENDOCRINE:  He denies any tremor, shakiness, history of diabetes, thyroid problems, new or enlarging stretch marks, exophthalmos, insomnia, or tremors.  NEURO:  He denies any mental status changes, anxiety, confusion, depression, hallucinations, loss of feeling in her arm or leg, numbness or tingling in hands or feet, loss of balance, syncope, seizures, or loss of coordination.,PHYSICAL EXAMINATION,VITAL SIGNS:  His T-max is 98.8.  His pulse is 85, respirations 18, and blood pressure 126/80 saturating over 90% on room air.,GENERAL:  No acute distress, pleasant gentleman who appears stated age.,HEENT:  NC/AT.  Sclerae anicteric.  Conjunctiva clear.  Oropharynx is clear without erythema, exudate, or discharge.,NECK:  Supple.  Nontender.  No elevated JVP.  No carotid bruits.  No thyromegaly.  No thyroid nodules.  Carotids are 2+ and symmetric.,BACK:  Spine is straight.  No spinal tenderness.  No CVA tenderness.  No presacral edema.,CHEST:  Clear to auscultation and percussion bilaterally.  No wheezes, rales, or rhonchi.  Normal symmetric chest wall expansion with inspiration.,CVS:  Regular rate and rhythm.  No murmurs, gallops, or rubs.,ABDOMEN:  Soft, nontender, nondistended.  No hepatosplenomegaly.  No guarding or rebound.  No masses.  Normoactive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  No joint swelling.  Full range of motion.,SKIN:  No rashes, wounds, ulcerations, bruises, or petechia.,NEUROLOGIC:  Cranial nerves II through XII are intact.  He has intact sensation to light touch throughout.  He has 2+ deep tendon reflexes bilaterally in the biceps, triceps, brachioradialis, patellar and ankle reflexes.  He is alert and oriented x3.,LABORATORY DATA: , His white blood cell count is 9.4, hemoglobin 13.0, hematocrit 38%, and platelets 365,000.  The differential shows 73% neutrophils, 17% lymphocytes, 7.6% monocytes, 1.9% eosinophils, and 0.7% basophils.  Chemistry shows sodium 138, potassium 3.8, chloride 104, CO2 of 31, BUN 9, creatinine 1.0, glucose 104, calcium 12.3, alkaline phosphatase 104, AST 16, ALT 12, total protein 7.6, albumin 3.5, total bilirubin 0.5, ionized calcium 1.7.  His INR is 1.0 with the PT of 11.4 and a PTT of 31.3.,IMAGINING DATA:,  MRI of the brain on 12/23/08 - this shows some mild white matter disease, question of minimal pontine ischemic gliosis as well as a small incidental venous angioma in the left posterior frontal deep white matter.  There is no evidence of cerebral metastasis, hemorrhage, or acute infarction.,ASSESSMENT/PLAN: , ABCD is a very nice 47-year-old gentleman without much past medical history, who now presents with metastatic non-small cell lung cancer.  At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable.  His wife particularly had a very hard time with this prognosis.  They preferred not to know the exact average as to how long someone lives with this disease.  I did offer chemotherapy as a way to treat this disease.  Chemotherapy has been associated both with palliation of symptoms as well as prolong survival.  At this point, he has an excellent functional status and I think he would tolerate chemotherapy quite well.,In terms of chemotherapy, I talked briefly about the side affects including but not limited to GI upset, diarrhea, nausea, vomiting, mucositis, fatigue, loss of appetite, low blood counts including the possible need for transfusion as well as the risk of infections, which in some rare cases can be fatal.  I would likely use carboplatin and gemcitabine.  This would be both medications given on day 1 with a dose of gemcitabine on day 8.  This cycle will be repeated after 1-week break so that the cycle lasts 21 days.  The goal will be to complete 6 cycles of this as long as he is responding and tolerating the medication.,In terms of staging Mr. ABCD'S had all the appropriate staging.  A PET-CT scan could be done, but at this point would not provide much mean full information beyond the CT scans that we have.,At this point, his biggest issue is pain and he is getting a pain consult to help control his pain.  He will be ready to be discharged from the hospital once his pain is under better control.  As this is the holiday weekend, I do not have a way of scheduling a followup appointment with them, but I did give he and his wife my card and instructed them to call on Monday.  At that point, we will get him in and I will also begin working on making arrangements for his chemotherapy.,Thank you very much for this interesting consult.", Hematology - Oncology,16
"DATE OF EXAMINATION: , Start:  12/29/2008 at 1859 hours.  End:  12/30/2008 at 0728 hours.,TOTAL RECORDING TIME:,  12 hours, 29 minutes.,PATIENT HISTORY:,  This is a 46-year-old female with a history of events concerning for seizures.  The patient has a history of epilepsy and has also had non-epileptic events in the past.  Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,VIDEO EEG DIAGNOSES,1.  Awake:  Normal.,2.  Sleep:  Activation of a single left temporal spike seen maximally at T3.,3.  Clinical events:  None.,DESCRIPTION:  ,Approximately 12 hours of continuous 21-channel digital video EEG monitoring was performed.  During the waking state, there is a 9-Hz dominant posterior rhythm.  The background of the record consists primarily of alpha frequency activity.  At times, during the waking portion of the record, there appears to be excessive faster frequency activity.  No activation procedures were performed.,Approximately four hours of intermittent sleep was obtained.  A single left temporal, T3, spike is seen in sleep.  Vertex waves and sleep spindles were present and symmetric.,The patient had no clinical events during the recording.,CLINICAL INTERPRETATION:  ,This is abnormal video EEG monitoring for a patient of this age due to the presence of a single left temporal spike seen during sleep.  The patient had no clinical events during the recording period.  Clinical correlation is required.", Neurology,22
"PREOPERATIVE DIAGNOSES:,1.  Nasopharyngeal mass.,2.  Right upper lid skin lesion.,POSTOPERATIVE DIAGNOSES:,1.  Nasopharyngeal tube mass.,2.  Right upper lid skin lesion.,PROCEDURES PERFORMED:,1.  Functional endoscopic sinus surgery.,2.  Excision of nasopharyngeal mass via endoscopic technique.,3.  Excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 51-year-old Caucasian female with a history of a nasopharyngeal mass discovered with patient's chief complaint of nasal congestion and chronic ear disease.  The patient had a fiberoptic nasopharyngoscopy performed in the office which demonstrated the mass and confirmed also on CT scan.  The patient also has had this right upper lid skin lesion which appears to be a cholesterol granuloma for numerous months.  It appears to be growing in size and is irregularly bordered.  After risks, complications, consequences, and questions were addressed to the patient, a written consent was obtained for the procedure.,PROCEDURE: , The patient was brought to the operating suite by Anesthesia and placed on the operating table in supine position.  After this, the patient was turned to 90 degrees by the Department of Anesthesia.  The right upper eyelid skin lesion was injected with 1% lidocaine with epinephrine 1:100,000 approximately 1 cc total.  After this, the patient's bilateral nasal passages were then packed with cocaine-soaked cottonoids of 10% solution of 4 cc total.  The patient was then prepped and draped in usual sterile fashion and the right upper lid skin was then first cut around the skin lesion utilizing a Superblade.  After this, the skin lesion was then grasped with a ________ in the  superior aspect and the skin lesion was cut and removed in the subcutaneous plane utilizing Westcott scissors.  After this, the ________ was then hemostatically controlled with monopolar cauterization.  The patient's skin was then reapproximated with a running #6-0 Prolene suture.  A Mastisol along with a single Steri-Strip was in place followed Maxitrol ointment.  Attention then was drawn to the nasopharynx.  The cocaine-soaked cottonoids were removed from the nasal passages bilaterally and zero-degree otoscope was placed all the way to the patient's nasopharynx.  The patient had a severely deviated nasal septum more so to the right than the left.  There appeared to be a spur on the left inferior aspect and also on the right posterior aspect.  The nasopharyngeal mass appeared polypoid in nature almost lymphoid tissue looking.  It was then localized with 1% lidocaine with epinephrine 1:100,000 of approximately 3 cc total.  After this, the lesion was then removed on the right side with the XPS blade.  The torus tubarius was noted on the left side with the polypoid lymphoid tissue involving this area completely.  This area was taken down with the XPS blade.  Prior to taking down this lesion with the XPS, multiple biopsies were taken with a straight biter.  After this, a cocaine-soaked cottonoid was placed back in the patient's left nasal passage region and the nasopharynx and the attention was then drawn to the right side.  The zero-degree otoscope was placed in the patient's right nasal passage and all the way to the nasopharynx.  Again, the XPS was then utilized to take down the nasopharyngeal mass in its entirety with some involvement overlying the torus tubarius.  After this, the patient was then hemostatically controlled with suctioned Bovie cauterization.  A FloSeal was then placed followed by bilateral Merocels and bacitracin-coated ointment.  The patient's Meroceles were then tied together to the patient's forehead and the patient was then turned back to the Anesthesia.  The patient was extubated in the operating room and was transferred to the recovery room in stable condition.  The patient tolerated the procedure well and sent home and with instructions to followup approximately in one week.  The patient will be sent home with a prescription for Keflex 500 mg one p.o. b.i.d, and Tylenol #3 one to two p.o. q.4-6h. pain #30.", ENT - Otolaryngology,11
"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.", Podiatry,31
"CHIEF COMPLAINT:, Headache and pain in the neck and lower back.,HISTORY OF PRESENT ILLNESS:, The patient is a 34 year old white man with AIDS (CD4 -67, VL -341K) and Castleman’s Disease who presents to the VA Hospital complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks. He was hospitalized 3 months prior to his current presentation with abdominal pain and diffuse lymphadenopathy. Excisional lymph node biopsy during that admission showed multicentric Castleman’s Disease. He was started on cyclophosphamide and prednisone and his lymphadenopathy dramatically improved. His hospitalization was complicated by the development of acute renal failure from tumor lysis syndrome and he required hemodialysis for only a few sessions. The patient was discharged on HAART and later returned for 2 cycles of modified CHOP chemotherapy.,Approximately five weeks prior to his current presentation, the patient was involved in a motor vehicle accident at 40 mph. He said he was not wearing his seatbelt and had hit his head on the roof of the car. He did not lose consciousness. The patient went to the VA ER but left against medical advice prior to being fully evaluated. Records showed that the patient had complained of some neck soreness but he was able to move his neck without any difficulty.,Two weeks later, the patient started having headaches, neck and lower back pain during a road trip with his family to Mexico . He returned to Houston and approximately one week prior to admission, the patient presented to the VA ER for further evaluation. Spinal films were unremarkable and the patient was sent home on pain medications with a diagnosis of muscle strain. The patient followed up with his primary care physician and was admitted for further workup.,On the day of admission, the patient complains of severe pain that is worse in the lower back than in the neck. The pain is 7-8 out of 10 and does not radiate. He also complains of diffuse headaches and intermittent blurriness of his vision. He complains of having a very stiff neck that hurts when he bends it. He denies any fevers, chills, or night sweats. He denies any numbness or tingling of his extremities and he denies any bowel or bladder incontinence. None of the medications that he takes provides adequate relief of his pain.,Regarding his AIDS and Castleman’s Disease, his lymphadenopathy have completely resolved by physical exam. He no longer has any of the symptoms from his previous hospitalization. He is scheduled to have his next cycle of chemotherapy during the week of his current admission. He has been noncompliant with his HAART and has been off the medications for >3 weeks.,Past Medical History:, HIV diagnosed 11 years ago. No history of opportunistic infections. Recently diagnosed with Castleman’s Disease (9/03) from excisional lymph node biopsy s/p cyclophosphamide/prednisone ( 9/25/03 ) and modified CHOP ( 10/15/03 , 11/10/03 ). Last CD4 count is 67 and viral load is 341K (9/03). Currently is off HAART x 3 weeks because of noncompliance.,PAST SURGICAL HISTORY:, Excisional lymph node biopsy (9/03).,FAMILY HISTORY:, There was no history of hypertension, coronary artery disease, stroke, cancer or diabetes.,SOCIAL HISTORY:, Patient is single and he lives alone. He is heterosexual and has a history of sexual encounter with prostitutes in Japan. He works as a plumber over the last 5 years. He smokes and drinks occasionally and denies any history of IV drug use. No blood transfusion. No history of incarceration. Recently traveled to Mexico .,MEDICATION:, Tylenol #3 q6h prn, ibuprofen 800 mg q8h prn, methocarbamol 750 mg qid.,ALLERGIES:, ,  Sulfa (rash).,REVIEW OF SYSTEMS:, The patient complains of feeling weak and fatigued. He has no appetite over the past week and has lost 8 pounds during this period. No chest pain, palpitations, shortness of breath or coughing. He denies any nausea, vomiting, or abdominal pain. No focal neuro deficits. Otherwise, as stated in HPI.,PHYSICAL EXAM:,VS: T 98 BP 121/89 P 80 R 20 O2 Sat 100% on room air.,Ht: 5'9"" Wt: 159 lbs.,GEN: Well developed man in no apparent distress. Alert and Oriented X 3.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Papilledema present bilaterally. Moist mucous membranes. No oropharyngeal lesions.,NECK: Stiff, difficulty with neck flexion; no lymphadenopathy,LUNGS: Clear to auscultation bilaterally.,CV: Regular rate and rhythm. No murmurs, gallops, rubs.,ABD: Soft with active bowel sounds. Nontender/Nondistended. No rebound or guarding. No hepatosplenomegaly.,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally.,BACK: No point tenderness to spine,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes palpated,SKIN: warm, no rashes, no lesions,STUDIES:,C-spine/lumbosacral spine (11/30):  Within normal limits.,CXR (12/8):  Normal heart size, no infiltrate. Hila and mediastinum are not enlarged.,CT Head with and without contrast (12/8): Ventriculomegaly and potentially minor hydrocephalus. Otherwise normal CT scan of the brain. No evidence of abnormal enhancement of the brain or mass lesions within the brain or dura.,HOSPITAL COURSE:,  The patient was admitted to the medicine floor and a lumbar puncture was performed. The opening pressure was greater than 55. The CSF results are shown in the table. A diagnostic study was sent.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,PROCEDURE:, Right total knee arthroplasty.,DESCRIPTION OF THE OPERATION:, The patient was brought to the Operating Room and after the successful placement of an epidural, as well as general anesthesia, administration 1 gm of Ancef preoperatively, the patient's right thigh, knee and leg were scrubbed, prepped and draped in the usual sterile fashion. The leg was exsanguinated by gravity and pneumatic tourniquet was inflated to 300 mmHg.,A straight anterior incision was carried down through the skin and subcutaneous tissue. Unilateral flaps were developed and a median retinacular parapatellar incision was made. The extensor mechanism was partially divided and the patella was everted. Some of the femoral bone spurs were resected using an osteotome and a rongeur. Ascending drill hole was made in the distal femur and the distal femoral cut, anterior and posterior and chamfer cuts were accomplished for a 67.5 femoral component.,At this point the ACL was resected. Some of the fat pad and synovium were resected, as well as both medial and lateral menisci. A posterior cruciate retractor was utilized, the tibia brought forward and a centering drill hole made in the tibia. The intramedullary guide was used for cutting the tibia. It was set at 8 mm. An additional 2 mm was resected because of a moderate defect medially.,A trial reduction was done with a 71 tibial baseplate. This was pinned and drilled and then trial reduction done with a 10-mm insert.,This gave good stability and a full range of motion.,The patella was measured with the calibers and 9 mm of bone was resected with an oscillating saw. A 34-mm component was drilled for.,A further trial reduction was done and two liters of pulse lavage were used to clean the bony surfaces. A packet of cement was hand mixed, pressurized with a spatula into the proximal tibia. Multiple drill holes were made on the medial side of the tibia where the bone was somewhat sclerotic. The tibia baseplate was secured and the patella was inserted, held with a clamp. The extraneous cement was removed. At this point the tibial baseplate was locked into place and the femoral component also seated solidly.,The knee was extended, held in this position for another 5-6 minutes until the cement was cured. Further extraneous cement was removed. The pneumatic tourniquet was released, hemostasis was obtained with electrocoagulation.,Retinaculum, quadriceps and extensor were repaired with multiple figure-of-eight #1 Vicryl sutures, the subcutaneous tissue with 2-0 and the skin with skin staples. A sterile, bulky compression dressing was placed. The patient was stable on operative release.", Surgery,38
"INDICATION FOR OPERATION:,  Right coronal synostosis with left frontal compensatory bossing causing plagiocephaly.,PREOPERATIVE DIAGNOSIS:,  Syndromic craniosynostosis.,POSTOPERATIVE DIAGNOSIS: , Syndromic craniosynostosis.,TITLE OF OPERATION: , Anterior cranial vault reconstruction with fronto-orbital bar advancement.,SPECIMENS: , None.,DRAINS: , One subgaleal drain exiting from the left posterior aspect of wound.,DESCRIPTION OF PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was started, the patient was placed on the operating table in supine position with the head held on a horseshoe-shaped headrest and the head was prepped and draped down the routine manner.  Here, the proposed scalp incision was infiltrated with 1% Xylocaine and then a zigzag scalp incision was made from one ear to the other ear, posterior to the coronal suture.  Scalp incision was reflected anteriorly and then the periosteum was taken off of the bone and then the temporalis muscles were reflected anterolaterally until the anterior cranial vault was exposed and then the periorbital rim, nasion and orbital part of the zygomatic arch were all dissected out as well as the pterion.  Using a craniotome, several bur holes were made; two on the either side of the midline posteriorly and then two posterolaterally.  The two posterior bur holes were then connected with a punch over the superior sagittal sinus and then the craniotome was used to fashion a flap first on the left and then on the right, going paramedian along the superior sagittal sinus in the midline and then curving over the fronto-orbital bar.  We then dissected superior sagittal sinus off of the inner table of the right bundle flap and then connected the right bundle flap going across the pterion on the right, which was abnormal.  The pterion on the right was then run short down after removing both bone flaps and then the dura was dissected off from the orbital roofs.  On the right, the orbital roof was jagged and abnormal and we had to repair a CSF leak from where the dura was punctured by the orbital roof.  The orbital rim was then dissected out and then using the saw and chisels, we were able to make the releasing cuts to free up the orbital rims, zygomatic arch and then remove the orbital bar going posteriorly and then the distal bar was split in the middle and then reapproximated with a bone graft in the middle to move the orbits out a little bit and the orbital bar was held together using absorbable plate.  It was then replaced and advanced and then relaxing, barrel-staving incisions were made in the bone flaps and the orbital rim and it was held on the right side with an absorbable plate to fix it in the proper position.  The bone flaps were then reapproximated using absorbable plates and screws, as well as #2-0 Vicryl to secure back into place.  Some of the places were also secured in the midline posteriorly, as well as off to the right where the bony defects were in place.  The periosteum was then brought over the skull and fastened in place and the temporalis muscles were tacked up to the periosteum.  The wounds were irrigated out.  A drain was left in posteriorly and then the wounds were closed in a routine manner using Vicryl for the galea and fast-absorbing gut for the skin followed by sterile dressings.  The patient tolerated the procedure well and did receive blood transfusions.", Neurosurgery,23
"PREOPERATIVE DIAGNOSIS: , Screening. ,POSTOPERATIVE DIAGNOSIS:,  Tiny Polyps.,PROCEDURE PERFORMED:  , Colonoscopy.,PROCEDURE:  , The procedure, indications, and risks were explained to the patient, who understood and agreed.  He was sedated with Versed 3 mg, Demerol 25 mg during the examination.  ,A digital rectal exam was performed and the Pentax Video Colonoscope was advanced over the examiner's finger into the rectum.  It was passed to the level of the cecum.  The ileocecal valve was identified, as was the appendiceal orifice.  ,Slowly withdrawal through the colon revealed a small polyp in the transverse colon.  This was approximately 3 mm in size and was completely removed using multiple bites with cold biopsy forceps.  In addition, there was a 2 mm polyp versus lymphoid aggregate in the descending colon.  This was also removed using the cold biopsy forceps.  Further detail failed to reveal any other lesions with the exception of small hemorrhoids.  ,IMPRESSION:  , Tiny polyps.  ,PLAN:  , If adenomatous, repeat exam in five years.  Otherwise, repeat exam in 10 years.,", Gastroenterology,14
"CC:, Left hemibody numbness.,HX:, This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when walking. She denied any recent colds/flu-like illness or history of multiple sclerosis. She denied symptoms of Lhermitte's or Uhthoff's phenomena.,MEDS:, none.,PMH:, 1)Bronchitis twice in past year (last 2 months ago).,FHX:, Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80.,SHX:, Denies Tobacco/ETOH/illicit drug use.,EXAM:, BP112/76 HR52 RR16 36.8C,MS: unremarkable.,CN: unremarkable.,Motor: 5/5 strength throughout except for slowing of right hand fine motor movement. There was mildly increased muscle tone in the RUE and RLE.,Sensory: decreased PP below T2 level on left and some dysesthesias below L1 on the left.,Coord: positive rebound in RUE.,Station/Gait: unremarkable.,Reflexes: 3+/3 throughout all four extremities. Plantar responses were flexor, bilaterally.,Rectal exam not done.,Gen exam reportedly ""normal."",COURSE:, GS, CBC, PT, PTT, ESR, Serum SSA/SSB/dsDNA, B12 were all normal. MRI C-spine, 7/145/93, showed an area of decreased T1 and increased T2 signal at the C4-6 levels within the right lateral spinal cord. The lesion appeared intramedullary and eccentric, and peripherally enhanced with gadolinium. Lumbar puncture, 7/16/93, revealed the following CSF analysis results: RBC 0, WBC 1 (lymphocyte), Protein 28mg/dl, Glucose 62mg/dl, CSF Albumin 16 (normal 14-20), Serum Albumin 4520 (normal 3150-4500), CSF IgG 4.1mg/dl (normal 0-6.2), CSF IgG, % total CSF protein 15% (normal 1-14%), CSF IgG index 1.1 (normal 0-0.7), Oligoclonal bands were present. She was discharged home.,The patient claimed her symptoms resolved within one month. She did not return for a scheduled follow-up MRI C-spine.", Radiology,33
"REASON FOR EXAM: , Followup for fetal growth. , ,INTERPRETATION: , Real-time exam demonstrates a single intrauterine fetus in cephalic presentation with a regular cardiac rate of 147 beats per minute documented. ,FETAL BIOMETRY:  ,BPD = 8.3 cm = 33 weeks, 4 days,HC = 30.2 cm = 33 weeks, 4 days,AC = 27.9 cm = 32 weeks, 0 days,FL =  6.4 cm = 33 weeks, 1 day,The head to abdomen circumference ratio is normal at 1.08, and the femur length to abdomen circumference ratio is normal at 23.0%.  Estimated fetal weight is 2,001 grams.  ,The amniotic fluid volume appears normal, and the calculated index is normal for the age at 13.7 cm.  ,A detailed fetal anatomic exam was not performed at this setting, this being a limited exam for growth.  The placenta is posterofundal and grade 2., ,IMPRESSION: , Single viable intrauterine pregnancy in cephalic presentation with a composite gestational age of 32 weeks, 5 days, plus or minus 17 days, giving and estimated date of confinement of 8/04/05.  There has been normal progression of fetal growth compared to the two prior exams of 2/11/05 and 4/04/05.  The examination of 4/04/05 questioned an echogenic focus within the left ventricle.  The current examination does not demonstrate any significant persistent echogenic focus involving the left ventricle.", Radiology,33
"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.,", Urology,39
"EXAM:,  CT examination of the abdomen and pelvis with intravenous contrast.,INDICATIONS:,  Abdominal pain.,TECHNIQUE:  ,CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration.  Oral contrast was not administered.  There was no comparison of studies.,FINDINGS,CT PELVIS:,Within the pelvis, the uterus demonstrates a thickened-appearing endometrium.  There is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology.  There is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid.  Several smaller fibroids were also suspected.,The ovaries are unremarkable in appearance.  There is no free pelvic fluid or adenopathy.,CT ABDOMEN:,The appendix has normal appearance in the right lower quadrant.  There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis.  The small and large bowels are otherwise unremarkable.  The stomach is grossly unremarkable.  There is no abdominal or retroperitoneal adenopathy.  There are no adrenal masses.  The kidneys, liver, gallbladder, and pancreas are in unremarkable appearance.  The spleen contains several small calcified granulomas, but no evidence of masses.  It is normal in size.  The lung bases are clear bilaterally.  The osseous structures are unremarkable other than mild facet degenerative changes at L4-L5 and L5-S1.,IMPRESSION:,1.  Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm.,2.  Multiple uterine fibroids.,3.  Prominent endometrium.,4.  Followup pelvic ultrasound is recommended.", Radiology,33
"REASON FOR EXAMINATION: , Cardiac arrhythmia.,INTERPRETATION: , No significant pericardial effusion was identified.,The aortic root dimensions are within normal limits.  The four cardiac chambers dimensions are within normal limits.  No discrete regional wall motion abnormalities are identified.  The left ventricular systolic function is preserved with an estimated ejection fraction of 60%.  The left ventricular wall thickness is within normal limits.,The aortic valve is trileaflet with adequate excursion of the leaflets.  The mitral valve and tricuspid valve motion is unremarkable.  The pulmonic valve is not well visualized.,Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg.  Doppler interrogation of the mitral in-flow pattern is within normal limits for age.,IMPRESSION:,1.  Preserved left ventricular systolic function.,2.  Mild mitral regurgitation.,3.  Mild tricuspid regurgitation.", Cardiovascular / Pulmonary,3
"HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old male complaining of abdominal pain.  The patient also has a long-standing history of diabetes which is treated with Micronase daily.,PAST MEDICAL HISTORY: , There is no significant past medical history noted today.,PHYSICAL EXAMINATION:,HEENT:  Patient denies ear abnormalities, nose abnormalities and throat abnormalities.,Cardio:  Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.,Resp:  Patient denies asthma, lung infections and lung lesions.,GI:  Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,GU:  Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.,Endocrine:  Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,Dermatology:  Patient denies allergic reactions, rashes and skin lesions.,MEDS:,  Micronase 2.5 mg Tab PO QAM #30.  Bactrim 400/80 Tab PO BID #30.,SOCIAL HISTORY:,  No known history of drug or alcohol abuse.  Work, diet, and exercise patterns are within normal limits.,FAMILY HISTORY:,  No significant family history.,REVIEW OF SYSTEMS:,  Non-contributory.,Vital Signs:  Height = 72 in.  Weight =184 lbs.  Upright BP = 120/80 mmHg.  Pulse = 80 bpm.  Resp =12 pm.  Patient is afebrile.,Neck:  The neck is supple.  There is no jugular venous distension.  The thyroid is nontender, or normal size and conto.,Lungs:  Lung expansion and excursions are symmetric.  The lungs are clear to auscultation and percussion.,Cardio:  There is a regular rhythm.  SI and S2 are normal.  No abnormal heart sounds are detected.  Blood pressure is equal bilaterally.,Abdomen:  Normal bowel sounds are present.  The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness.  No hernias are noted.,Extremities:  There is no clubbing, cyanosis, or edema.,ASSESSMENT: , Diabetes type II uncontrolled.  Acute cystitis.,PLAN: , Endocrinology Consult, complete CBC.  ,RX: , Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.", General Medicine,15
"CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08.,TECHNIQUE:,  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.,FINDINGS: , The liver is normal in size and attenuation.,The gallbladder is normal.,The spleen is normal in size and attenuation.,The adrenal glands and pancreas are unremarkable.,The kidneys are normal in size and attenuation.,No hydronephrosis is detected.  Free fluid is seen within the right upper quadrant within the lower pelvis.  A markedly thickened loop of distal small bowel is seen.  This segment measures at least 10-cm long.  No definite pneumatosis is appreciated.  No free air is apparent at this time.  Inflammatory changes around this loop of bowel.  Mild distention of adjacent small bowel loops measuring up to 3.5 cm is evident.  No complete obstruction is suspected, as there is contrast material within the colon.  Postsurgical changes compatible with the partial colectomy are noted.  Postsurgical changes of the anterior abdominal wall are seen.  Mild thickening of the urinary bladder wall is seen.,IMPRESSION:,1.  Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis.  An inflammatory process such as infection or ischemia must be considered.  Close interval followup is necessary.,2.  Thickening of the urinary bladder wall is nonspecific and may be due to under distention.  However, evaluation for cystitis is advised.", Radiology,33
"PREOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,POSTOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,PROCEDURE: , Left axillary lymph node excisional biopsy.,ANESTHESIA:,  LMA.,INDICATIONS: , Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only.  Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast.  Patient has been following with Dr. Diener and Dr. Wilmot.  I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both.  She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion.  I recommended that she have this lymph node removed.  The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution, draped in a sterile fashion.  An incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia.  I was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures.  The lymph node was excised in its entirety.  The wound was irrigated.  The lymph node sent to pathology.  The wound was then closed.  Hemostasis was assured and the patient was taken to recovery room in stable condition.", Surgery,38
"PREOPERATIVE DIAGNOSES:,1.  Blepharochalasia.,2.  Lower lid large primary and secondary bagging.,POSTOPERATIVE DIAGNOSES:,1.  Blepharochalasia.,2.  Lower lid large primary and secondary bagging.,PROCEDURE: , Quad blepharoplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,CONDITION: , The patient did well.,PROCEDURE:  ,The patient had marks and measurements prior to surgery.  Additional marks and measurements were made at the time of surgery; these were again checked.  At this point, the area was injected with 0.5% lidocaine with 1:200,000 epinephrine.  Appropriate time waited for the anesthetic and epinephrine effect.,Beginning on the left upper lid, the skin excision was completed.  The muscle was opened, herniated, adipose tissue pad in the middle and medial aspect was brought forward, cross-clamped, excised, cauterized, and allowed to retract.  The eyes were kept irrigated and protected throughout the procedure.  Attention was turned to the opposite side.  Procedure was carried out in the similar manner.,At the completion, the wounds were then closed with a running 6-0 Prolene, skin adhesives, and Steri-Strips.  Attention was turned to the right lower lid.  A lash line incision was made.  A skin flap was elevated and the muscle was opened.  Large herniated adipose tissue pads were present in each of the three compartments.  They were individually elevated, cross-clamped, excised, cauterized, and allowed to retract.,At the completion, a gentle tension was placed on the facial skin and several millimeters of the skin excised.  Attention was turned to he opposite side.  The procedure was carried out as just described.  The contralateral side was reexamined and irrigated.  Hemostasis was good and it was closed with a running 6-0 Prolene.  The opposite side was closed in a similar manner.,Skin adhesives and Steri-Strips were applied.  The eyes were again irrigated and cool Swiss Eye compresses applied.  At the completion of the case, the patient was extubated in the operating room, breathing on her own, doing well, and transferred in good condition from operating room to recovering room.", Ophthalmology,26
"PREOPERATIVE DIAGNOSIS: , Right breast mass with atypical proliferative cells on fine-needle aspiration.,POSTOPERATIVE DIAGNOSIS:,  Benign breast mass.,ANESTHESIA: , General,NAME OF OPERATION:,  Excision of right breast mass.,PROCEDURE:,  With the patient in the supine position, the right breast was prepped and draped in a sterile fashion.  A curvilinear incision was made directly over the mass in the upper-outer quadrant of the right breast.  Dissection was carried out around a firm mass, which was dissected with surrounding margins of breast tissue.  Hemostasis was obtained using electrocautery.  Frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma, but appeared benign.  The breast tissues were approximated using 4-0 Vicryl.  The skin was closed using 5-0 Vicryl running subcuticular stitches.  A sterile bandage was applied.  The patient tolerated the procedure well.,", Hematology - Oncology,16
"PREOPERATIVE DIAGNOSIS: , Complex right lower quadrant mass with possible ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1.  Right ruptured tubal pregnancy.,2.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Laparoscopy with removal of tubal pregnancy and right partial salpingectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS:  ,Less than 100 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 25-year-old African-American female, gravida 7, para-1-0-5-1 with two prior spontaneous abortions with three terminations who presents with pelvic pain.  She does have a slowly increasing beta HCG starting at 500 to 849 and the max to 900.  Ultrasound showed a complex right lower quadrant mass with free fluid in the pelvis.  It was decided to perform a laparoscopy for the possibility of an ectopic pregnancy.,FINDINGS: , On bimanual exam, the uterus was approximately 10 weeks' in size, mobile, and anteverted.  There were no adnexal masses appreciated although there was some fullness in the right lower quadrant.  The cervical os appeared parous.,Laparoscopic findings revealed a right ectopic pregnancy, which was just distal to the right fallopian tube and attached to the fimbria as well as adherent to the right ovary.  There were some pelvic adhesions in the right abdominal wall as well.  The left fallopian tube and ovary and uterus appeared normal.  There was no evidence of endometriosis.  There was a small amount of blood in the posterior cul-de-sac.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped, placed under general anesthesia, and placed in the dorsal lithotomy position.  The bimanual exam was performed, which revealed the above findings.  A weighted speculum was placed in the patient's posterior vaginal vault and the 12 o' clock position of the cervix was grasped with the vulsellum tenaculum.  The cervix was then serially dilated using Hank dilators up to a #10.  A sharp curette was then introduced and curettage was performed obtaining a mild amount of tissue.  The tissue was sent to pathology for evaluation.  The uterine elevator was then placed in the patient's cervix.  Gloves were changed.  The attention was turned to the anterior abdominal wall where a 1 cm infraumbilical skin incision was made.  While tenting up the abdominal wall, the Veress needle was placed without difficulty.  The abdomen was then insufflated with appropriate volume and flow of CO2.  The #11 step trocar was then placed without difficulty in abdominal wall.  The placement was confirmed with a laparoscope.  It was then decided to put a #5 step trocar approximately 2 cm above the pubis symphysis in order to manipulate the pelvic contents.  The above findings were then noted.  Because the tubal pregnancy was adherent to the ovary, an additional port was placed in the right lateral aspect of the patient's abdomen.  A #12 step trocar port was placed under direct visualization.  Using a grasper, Nezhat-Dorsey suction irrigator, the mass was hydro-dissected off of the right ovary and further shelled away with graspers.  This was removed with the gallbladder grasper through the right lateral port site.  There was a small amount of oozing at the distal portion of the fimbria where the mass has been attached.  Partial salpingectomy was therefore performed.  This was done using the LigaSure.  The LigaSure was clamped across the portion of the tube including distal tube and ligated and transected.  Good hemostasis was obtained in all of the right adnexal structures.  The pelvis was then copiously suction irrigated.  The area again was then visualized and again found to be hemostatic.  The instruments were then removed from the patient's abdomen under direct visualization.  The abdomen was then desufflated and the #11 step trocar was removed.  The incisions were then repaired with #4-0 undyed Vicryl and dressed with Steri-Strips.  The uterine elevator was removed from the patient's vagina.,The patient tolerated the procedure well.  The sponge, lap, and needle count were correct x2.  She will follow up postoperatively as an outpatient.", Surgery,38
"HISTORY OF PRESENT ILLNESS:  ,The patient is a 38-year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration.  The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip.  The pain is located laterally as well as anteriorly into the groin.  She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip.  She is here for evaluation for the first time.  She sought no previous medical attention for this.,PAST MEDICAL HISTORY:  ,Significant for depression and reflux disease.,PAST SURGICAL HISTORY: , Cesarean section x 2.,CURRENT MEDICATIONS: , Listed in the chart and reviewed with the patient.,ALLERGIES:  ,The patient has no known drug allergies.,SOCIAL HISTORY:  ,The patient is married.  She is employed as an office manager.  She does smoke cigarettes, one pack per day for the last 20 years.  She consumes alcohol 3 to 5 drinks daily.  She uses no illicit drugs.  She exercises monthly mainly walking and low impact aerobics.  She also likes to play softball.,REVIEW OF SYSTEMS: , Significant for occasional indigestion and nausea as well as anxiety and depression.  The remainder of the systems negative.,PHYSICAL EXAMINATION: , The patient is 5 foot, 2 inches tall, weighs 155 pounds.  The patient ambulates independently without an assist device with normal stance and gait.  Inspection of the hips reveals normal contour and appearance and good symmetry.  The patient is able to do an active straight leg raise against gravity and against resistance bilaterally.  She has no significant trochanteric tenderness.  She does, however, have some tenderness in the groin bilaterally.  There is no crepitus present with passive or active range of motion of the hips.  She is grossly neurologically intact in the bilateral lower extremities.,DIAGNOSTIC DATA:,  X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip.  There are no acute findings.  No fractures or dislocations.  There are minimal degenerative changes noted in the joint.  There is, however, the suggestion of an exostosis on the superior femoral neck, which could be consistent with femoroacetabular impingement.,IMPRESSION: , Bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on x-rays and her clinical picture is also consistent with possible labral tear.,PLAN:,  After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip.  We will get that done as soon as possible.  In the meantime, she is asked to moderate her activities.  She will follow up as soon as the MRIs are performed.", Orthopedic,27
"HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.  He has difficulty recollecting the exact details and chronology of his problem.  To the best of his recollection, he thinks that about six months ago he developed weakness of his right leg.  He describes that he is reaching to get something from a cabinet and he noticed that he was unable to stand on his right toe.  Since that time, he has had difficulty pushing off when he walks.  He has mild tingling and numbness in his toes, but this has been a chronic problem and nothing new since he has developed the weakness.  He has chronic mild back pain, but this has been persistent for many years and has not changed.  He has experienced cramps in both calves for the past year.  This dissipated about two months ago.  He does not think that his left leg is weak.  He does not have any bowel or bladder incontinence.  There is no radicular pain.  He does not think that the problem is progressive, meaning that the weakness that he perceives in his right leg is no different than when it was six months ago.,He first sought medical attention for this problem in October.  He then saw you a couple of months later.  He has undergone an EMG and nerve conduction studies.  Unfortunately, he cannot undergo an MRI of his spine because he has an ear implant.  He has had a CT scan that shows degenerative changes, but nothing obviously abnormal.,In addition, the patient has hyperCKemia.  He tells me that he has had an elevated CK prior to starting taking stat medications, although this is not entirely clear to me.  He thinks that he is not taking Lipitor for about 15 months and thought that his CK was in the 500 or 600s prior to starting it.  Once it was started, it increased to about 800 and then came down to about 500 when it was stopped.  He then had a recent bump again up to the 1000 and since Lipitor has been stopped, his CK apparently has returned to about the 500 or 600s.  I do no have any laboratory data to support these statements by the patient, but he seems to be up to speed on this.  More recently, he has been started taking Zetia.  He does not have any proximal weakness.  He denies any myalgias., ,PAST MEDICAL HISTORY:,  He has coronary artery disease and has received five stents.  He has hypertension and hypercholesterolemia.  He states that he was diagnosed with diabetes based on the results of an abnormal oral glucose tolerance test.  He believes that his glucose shot up to over 300 with this testing.  He does not take any medications for this and his blood glucoses are generally normal when he checks it.  He has had plastic surgery on his face from an orbital injury.  He also had an ear graft when he developed an ear infection during his honeymoon., ,CURRENT MEDICATIONS:, He takes amlodipine, Diovan, Zetia, hydrochlorothiazide, Lovaza (fish oil), Niaspan, aspirin, and Chantix.  , ,ALLERGIES:,  He has no known drug allergies., ,SOCIAL HISTORY:,  He lives with his wife.  He works at Shepherd Pratt doing network engineering.  He smokes a pack of cigarettes a day and is working on quitting.  He drinks four alcoholic beverages per night.  Prior to that, he drank significantly more.  He denies illicit drug use.  He was athletic growing up., ,FAMILY HISTORY:,  His mother died of complications from heart disease.  His father died of heart disease in his 40s.  He has two living brothers.  One of them he does not speak too much with and does not know about his medical history.  The other is apparently healthy.  He has one healthy child.  His maternal uncles apparently had polio.  When I asked him to tell me further details about this, he states that one of them had to wear crutches due to severe leg deformans and then the other had leg deformities in only one leg.  He is fairly certain that they had polio.  He is unaware of any other family members with neurological conditions.,REVIEW OF SYSTEMS: , He has occasional tinnitus.  He has difficulty sleeping.  Otherwise, a complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:, ,Vital Signs:", Neurology,22
"PREOPERATIVE DIAGNOSES,1.  End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2.  Ischemic cardiomyopathy, ejection fraction 20%.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2.  Ischemic cardiomyopathy, ejection fraction 20%.,OPERATION,Left forearm arteriovenous fistula between cephalic vein and radial artery.,INDICATION FOR SURGERY,This is a patient referred by Dr. Michael Campbell.  He is a 44-year-old African-American, who has end-stage renal disease and also ischemic cardiomyopathy.  This morning, he received coronary angiogram by Dr. A, which was reportedly normal, after which, he was brought to the operating room for an AV fistula.  All the advantages, disadvantages, risks, and benefits of the procedure were explained to him for which he had consented.,ANESTHESIA,Monitored anesthesia care.,DESCRIPTION OF PROCEDURE,The patient was identified, brought to the operating room, placed supine, and IV sedation given.  This was done under monitored anesthesia care.  He was prepped and draped in the usual sterile fashion.  He received local infiltration of 0.25% Marcaine with epinephrine in the region of the proposed incision.,Incision was about 2.5 cm long between the cephalic vein and the distal part of the forearm and the radial artery.  Incision was deepened down through the subcutaneous fascia.  The vein was identified, dissected for a good length, and then the artery was identified and dissected.  Heparin 5000 units was given.  The artery clamped proximally and distally, opened up in the middle.  It was found to have Monckeberg's arteriosclerosis of a moderate intensity.  The vein was of good caliber and size.,The vein was clipped distally, fashioned to size and shape, and arteriotomy created in the distal radial artery and end-to-side anastomosis was performed using 7-0 Prolene and bled prior to tying it down.  Thrill was immediately felt and heard.,The incision was closed in two layers and sterile dressing applied.", Surgery,38
"CHIEF COMPLAINT: , Buttock abscess.,HISTORY OF PRESENT ILLNESS: , This patient is a 24-year-old African-American female who presented to the hospital with buttock pain.  She started off with a little pimple on the buttock.  She was soaking it at home without any improvement.  She came to the hospital on the first.  The patient underwent incision and drainage in the emergency department.  She was admitted to the hospitalist service with elevated blood sugars.  She has had positive blood cultures.  Surgery is consulted today for evaluation.,PAST MEDICAL HISTORY:  ,Diabetes type II, poorly controlled, high cholesterol.,PAST SURGICAL HISTORY: , C-section and D&C.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , Insulin, metformin, Glucotrol, and Lipitor.,FAMILY HISTORY: , Diabetes, hypertension, stroke, Parkinson disease, and heart disease.,REVIEW OF SYSTEMS: , Significant for pain in the buttock.  Otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  This is an overweight African-American female not in any distress.,VITAL SIGNS:  She has been afebrile since admission.  Vital signs have been stable.  Blood sugars have been in the 200 range.,HEENT:  Normal to inspection.,NECK:  No bruits or adenopathy.,LUNGS:  Clear to auscultation.,CV:  Regular rate and rhythm.,ABDOMEN:  Protuberant, soft, and nontender.,EXTREMITIES:  No clubbing, cyanosis or edema.,RECTAL EXAM:  The patient has a drained abscess on the buttock cheek.  There is some serosanguineous drainage.  There is no longer any purulent drainage.  The wound appears relatively clean.  I do not see a lot of erythema.,ASSESSMENT AND PLAN: , Left buttock abscess, status post incision and drainage.  I do not believe surgical intervention is warranted.  I have recommended some local wound care.  Please see orders for details.", General Medicine,15
"CHIEF COMPLAINT:,  Weak and shaky.,HISTORY OF PRESENT ILLNESS:,  The patient is a 75-year-old, Caucasian female who comes in today with complaint of feeling weak and shaky.  When questioned further, she described shortness of breath primarily with ambulation.  She denies chest pain.  She denies cough, hemoptysis, dyspnea, and wheeze.  She denies syncope, presyncope, or palpitations.  Her symptoms are fairly longstanding but have been worsening as of late.,PAST MEDICAL HISTORY:,  She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history.  She states that she has underlying history of heart disease but is not able to elaborate to any significant extent.  She also has a history of hypertension and type II diabetes but is not currently taking any medication.  She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections.  Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair.,CURRENT MEDICATIONS:,  She is on two different medications, neither of which she can remember the name and why she is taking it.,ALLERGIES: , She has no known medical allergies.,FAMILY HISTORY:,  Remarkable for coronary artery disease, stroke, and congestive heart failure.,SOCIAL HISTORY:,  She is a widow, lives alone.  Denies any tobacco or alcohol use.,REVIEW OF SYSTEMS:,  Dyspnea on exertion.  No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling.,PHYSICAL EXAMINATION:,General:  She is alert but seems somewhat confused and is not able to provide specific details about her past history.,Vital Signs:  Blood pressure:  146/80.  Pulse:  68.  Weight:  147 pounds.,HEENT:  Unremarkable.,Neck:  Supple without JVD, adenopathy, or bruit.,Chest:  Clear to auscultation.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft.,Extremities:  No edema.,LABORATORY:,  O2 sat 100% at rest and with exertion.  Electrocardiogram was normal sinus rhythm.  Nonspecific S-T segment changes.  Chest x-ray pending.,ASSESSMENT/PLAN:,1.  Dyspnea on exertion, uncertain etiology.  Mother would be concerned about the possibility of coronary artery disease given the patient’s underlying risk factors.  We will have the patient sign a release of records so that we can review her previous history.  Consider setting up for a stress test.,2.  Hypertension, blood pressure is acceptable today.  I am not certain as to what, if the patient’s is on any antihypertensive agents.  We will need to have her call us what the names of her medications, so we can see exactly what she is taking.,3.  History of diabetes.  Again, not certain as to whether the patient is taking anything for this particular problem when she last had a hemoglobin A1C.  I have to obtain some further history and review records before proceeding with treatment recommendations.", General Medicine,15
"PREOPERATIVE DIAGNOSIS:,  Worrisome skin lesion, left hand.,POSTPROCEDURE DIAGNOSIS:,  Worrisome skin lesion, left hand.,PROCEDURE:,  The patient gave informed consent for his procedure.  After informed consent was obtained, attention was turned toward the area of interest, which was prepped and draped in the usual sterile fashion.,Local anesthetic medication was infiltrated around and into the area of interest.  There was an obvious skin lesion there and this gentleman has a history of squamous cell carcinoma.  A punch biopsy of the worrisome skin lesion was obtained with a portion of the normal tissue included.  The predominant portion of the biopsy was of the lesion itself.,Lesion was removed.  Attention was turned toward the area.  Pressure was held and the area was hemostatic.,The skin and the area were closed with 5-0 nylon suture.  All counts were correct.  The procedure was closed.  A sterile dressing was applied.  There were no complications.  The patient had no neurovascular deficits, etc., after this minor punch biopsy procedure.,", Dermatology,8
"PRE AND POSTOPERATIVE DIAGNOSIS:,  Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR.  After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted.  At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position.  The patient's posterior cervical area was then prepped and draped in the usual sterile fashion.  At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine.  A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated.  After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken.  This showed the spinous process to be at the C4 level.  Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified.  After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken.  This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time.  At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina.  The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe.  This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur.  However, progress was limited because of thickness of the bone.  Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area.  After the bone had been thinned out, further bone was removed using the Kerrison rongeur.  At this point the nerve root was visually inspected and observed to be decompressed.  However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade.  Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery.  After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin.  Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches.  The subcutaneous layer was then reapproximated using 000 Dexon.  The skin was reapproximated using a running 000 nylon.  Sterile dressings were applied.  The patient was then extubated in the OR and transferred to the Recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  minimal.", Neurosurgery,23
"OPERATION,1.  Insertion of a left subclavian Tesio hemodialysis catheter.,2.  Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and MAC anesthesia was administered.  Next, the patient's chest and neck were prepped and draped in the standard surgical fashion.  Lidocaine 1% was used to infiltrate the skin in the region of the procedure.  Next a #18-gauge finder needle was used to locate the left subclavian vein.  After aspiration of venous blood, Seldinger technique was used to thread a J wire through the needle.  This process was repeated.  The 2 J wires and their distal tips were confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next, the subcutaneous tunnel was created.  The distal tips of the individual Tesio hemodialysis catheters were pulled through to the level of the cuff.  A dilator and sheath were passed over the individual J wires.  The dilator and wire were removed, and the distal tip of the Tesio hemodialysis catheter was threaded through the sheath, which was simultaneously withdrawn.  The process was repeated.  Both distal tips were noted to be in good position.  The Tesio hemodialysis catheters were flushed and aspirated without difficulty.  The catheters were secured at the cuff level with a 2-0 nylon.  The skin was closed with 4-0 Monocryl.  Sterile dressing was applied.  The patient tolerated the procedure well and was transferred to the PACU in good condition.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS: , Renal failure.,POSTOPERATIVE DIAGNOSIS:,  Renal failure.,OPERATION PERFORMED: , Insertion of peritoneal dialysis catheter.,ANESTHESIA: , General.,INDICATIONS:  ,This 14-year-old young lady is in the renal failure and in need of dialysis.  She had had a previous PD catheter placed, but it became infected and had to be removed.  She, therefore, comes back to the operating room for a new PD catheter.,OPERATIVE PROCEDURE:  ,After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner.  A small transverse right upper quadrant incision was made and carried down through the skin and subcutaneous tissue with sharp dissection.  The fascia was divided and the posterior fascia and peritoneum were identified.  A hole was made in the posterior fascia through the peritoneum and into the peritoneal cavity.  The omentum came up through the hole and so therefore the omentum was actually brought up and a small portion of it removed, which could easily be brought up through the incision.  A PD catheter was then placed into the pelvis over a guidewire.  At this point, the peritoneum and posterior fascia was closed around the catheter.  The anterior fascia was then closed over the top of the cuff leaving the cuff buried in the fascia.  The second incision was then made lateral and the catheter brought out through a second incision and the subcutaneous cuff then positioned at that site.  The catheter was then connected and two runs of a 150 mL of fluid were made with a good inflow and a good clear return.  The skin was closed with 5-0 subcuticular Monocryl.  Sterile dressings were applied and the young lady awakened and taken to the recovery room in satisfactory condition.", Nephrology,21
"PREOPERATIVE DIAGNOSES:,1.  Torn anterior cruciate ligament, right knee.,2.  Patellofemoral instability, right knee.,3.  Possible torn medial meniscus.,POSTOPERATIVE DIAGNOSES:,1.  Complete tear anterior cruciate ligament, right knee.,2.  Complex tear of the posterior horn lateral meniscus.,3.  Tear of posterior horn medial meniscus.,4.  Patellofemoral instability.,5.  Chondromalacia patella.,PROCEDURES PERFORMED:,1.  Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin.,2.  Repair of lateral meniscus using two fast fixed meniscal repair sutures.,3.  Partial medial meniscectomy.,4.  Partial chondroplasty of patella.,5.  Lateral retinacular release.,6.  Open medial plication as well of the right knee.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,TOURNIQUET TIME:,  130 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be a grade-II chondromalacia patellofemoral joint.  The patella was noted to be situated laterally past the lateral femoral condyle.  There was a tear to the posterior horn of the medial meniscus within the white zone.  There was a complex tear involving a horizontal cleavage component to the posterior horn of the lateral meniscus as well in the entire meniscus.  There was a complete tear of the anterior cruciate ligament.  The posterior cruciate ligament appeared intact.  Preoperatively, she had a positive Lachman with a positive pivot shift test as well as increased patellofemoral instability.,HISTORY: , This is a 39-year-old female who has sustained a twisting injury to her knee while on trampoline in late August.  She was diagnosed per MRI.  An MRI confirmed the clinical diagnosis of anterior cruciate ligament tear.  She states she has had multiple episodes of instability to the patellofemoral joint throughout the years with multiple dislocations.  She elected to proceed with surgery to repair the anterior cruciate ligament as well as possibly plicate the medial retinaculum to help prevent further dislocations of the patellofemoral joint.  All risks and benefits of surgery were discussed with her at length.  She was in agreement with the treatment plan.,PROCEDURE:  ,On 09/11/03, she was taken to the operating room at ABCD General Hospital.  She was placed supine on the operating table.  General anesthetic was applied by the Anesthesiology Department.  Tourniquet was placed on the proximal thigh and it was then placed in a knee holder.  She was sterilely prepped and draped in the usual fashion.  An Esmarch was used to exsanguinate the lower extremity.  Tourniquet was inflated to 325 mmHg.  Longitudinal incision was made just medial to the tibial tubercle.  The subcutaneous tissue was carefully dissected.  Hemostasis was controlled with electrocautery.  The tendons of gracilis and semitendinosus were identified and isolated, and then stripped off the musculotendinous junction.  They were taken on the back table.  The soft tissue debris was removed from the tendons.  The ends of the tendons were sewn together using #5 Tycron whip type sutures.  The tendons were measured on back table and found to be 8 mm as the most adequate size, they were then placed under tension on the back table.  Stab incision was made in the inferolateral parapatellar region, through this camera was placed in the knee.  The knee was inflated with saline solution and operative pictures were obtained.  The above findings were noted.  A second port site was initiated in the inferomedial parapatellar region.  Through this, a probe was placed.  Tear in the posterior horn medial meniscus was identified.  It was resected using a meniscal resector.  It was then further contoured using arthroscopic shaver.  Attention was then taken to the lateral compartment.  A partial meniscectomy was performed using the resector and the shaver.  The posterior periphery of the lateral meniscus was also noticed to be unstable.  A repair was then performed using two fasting fixed meniscal repair sutures to help anchor the meniscus around the popliteus tendon.  There was noted to be excellent fixation.  The shaver was then taken into the intrachondral notch.  First a partial chondroplasty was performed on the patella to remove the loose articular debris as well as a partial synovectomy to the medial aspect of the patellar femoral joint.  Next, the remnant of the anterior cruciate ligament was removed using the arthroscopic shaver and arthroplasty was then performed on the medial aspect of the lateral femoral condyle.  Next, a tibial guide was placed through the anterior medial portal.  A ___ pin was then placed up through the anterior incision entering the tibial eminence just anterior to the posterior cruciate ligament.  This tibial tunnel was then drilled using 8 mm cannulated drill.  Next, an over-the-top guide was then placed at approximately the 11:30 position.  A ____ pin was then placed into the femur and 8 mm drill was then used to drill this femoral tunnel approximately 35 mm.  Next the U shape guide was placed through tibial tunnel into the femur.  A pin was then placed through the distal femur from lateral to medial, through the U-shaped guide a puller wire was then passed through the distal femur.  It was then pulled out through the tibial tunnel using the You-shaped guide.  The tendon was then placed around the wire.  The wire was pulled back up through the tibial into the femoral tunnel.  A 40 mm bioabsorbable pin was then placed through the femoral tunnel securing the hamstring tendons.  Attention was then pulled through the tibial tunnel.  The knee was cycled approximately 20 times.  A 9 mm bioabsorbable screw was then placed through the tibial tunnel fixating the distal aspect of the graft.  There was noted definite fixation of the graft.  There was no evidence of impingement either in full flexion or full extension.  The knee was copiously irrigated and it was then suctioned dry.  A longitudinal incision was made just medial to the patellofemoral joint.  Soft tissues were carefully dissected and the medial retinaculum was incised along with the incision.  Following this, a release of lateral retinaculum was performed using a knife to further release the patellofemoral joint and allow further medial plication.  The medial retinaculum was then plicated using #1 Ethibond sutures and then oversewn with #0 Vicryl suture.  The subcuticular tissues were reapproximated with #2-0 Vicryl simple interrupted sutures followed by a #4-0 PDS running subcuticular stitch.  She was placed in a DonJoy knee immobilizer.  The tourniquet was deflated.  It was noted the lower extremity was warm and pink with good capillary refill.  She was transferred to the recovery room in apparent stable and satisfactory condition.  Prognosis for this patient is guarded.  She will be full weightbearing on the lower extremity using the knee immobilizer locked in extension.  She may remove her dressing two to three days, however, follow back in the office in 10 to 14 days for suture removal.  She will require one to two more physical therapy to help regain motion and strength to the lower extremity.", Surgery,38
"CHIEF REASON FOR CONSULTATION:,  Evaluate recurrent episodes of uncomfortable feeling in the left upper arm at rest, as well as during exertion for the last one month.,HISTORY OF PRESENT ILLNESS:,  This 57-year-old black female complains of having pain and discomfort in the left upper arm, especially when she walks and after heavy meals.  This lasts anywhere from a few hours and is not associated with shortness of breath, palpitations, dizziness, or syncope.  Patient does not get any chest pain or choking in the neck or pain in the back.  Patient denies history of hypertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive of previous myocardial infarction, or acute rheumatic polyarthritis during childhood.  Her exercise tolerance is one to two blocks for shortness of breath and easy fatigability.,MEDICATIONS:,  Patient does not take any specific medications.,PAST HISTORY:,  The patient underwent hysterectomy in 1986.,FAMILY HISTORY:,  The patient is married, has four children who are doing fine.  Family history is positive for hypertension, congestive heart failure, obesity, cancer, and cerebrovascular accident.,SOCIAL HISTORY:, The patient smokes one pack of cigarettes per day and takes drinks on social occasions.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS: , Epistaxis and chronic dysphonia.,POSTOPERATIVE DIAGNOSES:,1.  Atrophic dry nasal mucosa.,2.  Epistaxis.,3.  Atrophic laryngeal changes secondary to inhaled steroid use.,PROCEDURE PERFORMED:,1.  Cauterization of epistaxis, left nasal septum.,2.  Fiberoptic nasal laryngoscopy.,ANESTHESIA: , Neo-Synephrine with lidocaine nasal spray.,FINDINGS:,1.  Atrophic dry cracked nasal mucosa.,2.  Atrophic supraglottic and glottic changes likely secondary to inhaled steroids and recent endotracheal tube intubation.,INDICATIONS: , The patient is a 37-year-old African-American female who was admitted to ABCD General Hospital with a left wrist abscess.  The patient was taken to the operating room for incision and drainage.  Postoperatively, the patient was placed on nasal cannula oxygen and developed subsequent epistaxis.  Upon evaluating the patient, the patient complains of epistaxis from the left naris as well as some chronic dysphonia that had become exacerbated after surgery.  The patient does report of having endotracheal tube intubation during anesthesia.  The patient also gives a history of inhaled steroid use for her asthma.,The patient was extubated after surgery without difficulty, but continued to have some difficulty and the Department of Otolaryngology was asked to evaluate the patient regarding epistaxis and dysphonia.,PROCEDURE DETAILS:,  After the procedure was described, the patient was placed in the seated position.  The fiberoptic nasal laryngoscope was then inserted into the patient's left naris.  The nasal mucosal membranes were dry and atrophic throughout.  There was no evidence of any mass lesions.  The nasal laryngoscope was then advanced towards the posterior aspect of the nasal cavity.  There was no evidence of mass, ulceration, lesion, or obstruction.  The nasolaryngoscopy continued to be advanced into the oropharynx and the vallecula and the base of the tongue were evaluated and were without evidence of mass lesion or ulceration.,The fiberoptic scope was further advanced and visualization of the larynx revealed some atrophic, dry, supraglottic, and glottic changes.  There was no evidence of any local mass lesion, nodule, or ulcerations.  There was no evidence of any erythema.  Upon phonation, the vocal cords approximated completely and upon inspiration, the true vocal cords were abducted in a normal fashion and was symmetric.  The airway was stable and patent throughout the entire examination.  The nasal laryngoscope was then slowly withdrawn from the supraglottic region and the scope was further advanced into the oropharynx and nasopharynx.  The eustachian tube was completely visualized and was patent without obstruction.  The scope was then further removed without difficulty.  The patient tolerated the procedure well and remained in stable condition.,RECOMMENDATIONS AND PLAN: , The patient would benefit from Ocean nasal spray as well as bacitracin ointment applied to the anterior naris.  At this time, we were unable to discontinue the patient's inhaled steroids that she is using for her asthma.  If this becomes possible in the future, this may provide her some relief of her chronic dysphonia.  The patient is to follow up with Department of Otolaryngology after discharge from the hospital for further evaluation of these problems.", ENT - Otolaryngology,11
"REASON FOR REFERRAL: , Ms. A is a 60-year-old African-American female with 12 years of education who was referred for neuropsychological evaluation by Dr. X after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in July.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION:,  Historical information was obtained from a review of available medical records and clinical interview with Ms. A.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  Ms. A presented to the ABC Hospital emergency department on 07/26/2009 reporting that after she had woken up that morning she noticed numbness and weakness in her left hand, slurred speech, and left facial droop.  Neurological evaluation with Dr. X confirmed left hemiparesis.  Brain CT showed no evidence of intracranial hemorrhage or mass effect and that she received TPA and had moderate improvement in left-sided weakness.  These symptoms were thought to be due to a right middle cerebral artery stroke.  She was transferred to the ICU for monitoring.  Ultrasound of the carotids showed 20% to 30% stenosis of the right ICA and 0% to 19% stenosis of the left ICA.  On 07/29/2009, she was admitted for acute inpatient rehabilitation for the treatment of residual functional deficits of her acute ischemic right MCA/CVA.  At discharge on 08/06/2009, she was mainly on supervision for all ADLs and walking with a rolling walker, but tolerating increased ambulation with a cane.  She was discharged home with recommendations for outpatient physical therapy.  She returned to the Sinai ER on 08/2009/2009 due to reported left arm pain, numbness, and weakness, which lasted 10 to 15 minutes and she reported that it felt ""just like the stroke.""  Brain CT on 08/2009/2009 was read as showing ""mild chronic microvascular ischemic change of deep white matter,"" but no acute or significant interval change compared to her previous scan.  Neurological examination with Dr. Y was within normal limits, but she was admitted for a more extensive workup.  Due to left arm pain an ultrasound was completed on her left upper extremity, but it did not show deep vein thrombosis.,Followup CT on 08/10/2009 showed no significant interval change.  MRI could not be completed due to the patient's weight.  She was discharged on 08/11/2009 in stable condition after it was determined that this event was not neurological in origin; however, note that Ms. A referred to this as a second stroke.,Ms. A presented for a followup outpatient neurological evaluation with Dr. X on 09/22/2009, at which time a brief neuropsychological screening was also conducted.  She demonstrated significant impairments in confrontation naming, abstract verbal reasoning, and visual and verbal memory and thus a more comprehensive evaluation was suggested due to her intent to return to her full-time work duty.  During the current interview, Ms. A reported that she noticed mild memory problems including some difficultly remembering conversations, events, and at times forgetting to take her medications.  She also reported mild difficulty finding words in conversation, solving novel problems and tasks (e.g. difficulty learning to use her camcorder), but overall denied significant cognitive deficits in attention, concentration, language or other areas of cognitive functioning.  When asked about her return to work, she said that she was still on light duty due to limited physical activity because of residual left leg weakness.  She reported that no one had indicated to her that she appeared less capable of performing her job duties, but said that she was also receiving fewer files to process and enter data into the computer at the Social Security Agency that she works at.  Note also that she had some difficulty explaining exactly what her job involved.  She also reported having problems falling asleep at work and that she is working full-time although on light duty.,OTHER MEDICAL HISTORY:  ,As mentioned, Ms. A continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly.  She was diagnosed with sleep apnea approximately two years ago and was recently counseled by Dr. X on the need to use her CPAP because she indicated she never used it at night.  She reported that since her appointment with Dr. X, she has been using it ""every other night.""  When asked about daytime fatigue, Ms. A initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen.  She reported at times ""snoring"" and forgetting where she is at and said that a supervisor offered to give her coffee at one point.  She receives approximately two to five hours of sleep per night.  Other current untreated risk factors include obesity and hypercholesterolemia.  Her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke).,CURRENT MEDICATIONS: , Aspirin 81 mg daily, Colace 100 mg b.i.d., Lipitor 80 mg daily, and albuterol MDI p.r.n.,SUBSTANCE USE:,  Ms. A denied drinking alcohol or using illicit drugs.  She used to smoke a pack of cigarettes per day, but quit five to six years ago.,FAMILY MEDICAL HISTORY: , Ms. A had difficulty providing information on familial medical history.  She reported that her mother died three to four years ago from lung cancer.  Her father has gout and blood clots.  Siblings have reportedly been treated for asthma and GI tumors.  She was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc.,SOCIAL HISTORY: , Ms. A completed high school degree.  She reported that she primarily obtained B's and C's in school.  She received some tutoring for algebra in middle school, but denied ever having been held back a grade failing any classes or having any problems with attention or hyperactivity.,She currently works for the Social Security Administration in data processing.  As mentioned, she has returned to full-time work, but continues to perform only light duties due to her physical condition.  She is now living on her own.  She has never driven.  She reported that she continues to perform ADLs independently such as cooking and cleaning.  She lost her husband in 2005 and has three adult daughters.  She previously reported some concerns that her children wanted her to move into assisted living, but she did not discuss that during this current evaluation.  She also reported number of other family members who had recently passed away.  She has returned to activities she enjoys such as quire, knitting, and cooking and plans to go on a cruise to the Bahamas at the end of October.,PSYCHIATRIC HISTORY: , Ms. A did not report a history of psychological or psychiatric treatment.  She reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events.  She reported that this only ""comes and goes."",TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II),  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test", Consult - History and Phy.,5
"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,15
"PREOPERATIVE DIAGNOSIS:  ,1.  Right carpal tunnel syndrome.,2.", Surgery,38
"CC:, Confusion.,HX: , A 71 y/o RHM ,with a history of two strokes ( one in 11/90 and one in 11/91), had been in a stable state of health until 12/31/92 when he became confused, and displayed left-sided weakness and difficulty speaking. The symptoms resolved within hours and recurred the following day. He was then evaluated locally and HCT revealed an old right parietal stroke. Carotid duplex scan revealed a ""high grade stenosis"" of the RICA. Cerebral Angiogram revealed 90%RICA and 50%LICA stenosis. He was then transferred to UIHC Vascular Surgery for carotid endarterectomy. His confusion persisted and he was evaluated by Neurology on 1/8/93 and transferred to Neurology on 1/11/93.,PMH:, 1)cholecystectomy. 2)inguinal herniorrhaphies, bilaterally. 3)ETOH abuse: 3-10 beers/day. 4)Right parietal stroke 10/87 with residual left hemiparesis (Leg worse than arm). 5) 2nd stoke in distant past of unspecified type.,MEDS:, None on admission.,FHX:, Alzheimer's disease and stroke on paternal side of family.,SHX:, 50+pack-yr cigarette use.,ROS:, no weight loss. poor appetite/selective eater.,EXAM:, BP137/70 HR81 RR13 O2Sat 95% Afebrile.,MS: Oriented to city and month, but did not know date or hospital. Naming and verbal comprehension were intact. He could tell which direction Iowa City and Des Moines were from Clinton and remembered 2-3 objects in two minutes, but both with assistance only. Incorrectly spelled ""world"" backward, as ""dlow."",CN: unremarkable except neglects left visual field to double simultaneous stimulation.,Motor: Deltoids 4+/4-, biceps 5-/4, triceps 5/4+, grip 4+/4+, HF4+/4-, HE 4+/4+, Hamstrings 5-/5-, AE 5-/5-, AF 5-/5-.,Sensory: intact PP/LT/Vib.,Coord: dysdiadochokinesis on RAM, bilaterally.,Station: dyssynergic RUE on FNF movement.,Gait: ND,Reflexes: 2+/2+ throughout BUE and at patellae. Absent at ankles. Right plantar was flexor; and Left plantar was equivocal.,COURSE:, CBC revealed normal Hgb, Hct, Plt and WBC, but Mean corpuscular volume was large at 103FL (normal 82-98). Urinalysis revealed 20+WBC. GS, TSH, FT4, VDRL, ANA and RF were unremarkable. He was treated for a UTI with amoxacillin. Vitamin B12 level was reduced at 139pg/ml (normal 232-1137). Schillings test was inconclusive dure to inability to complete a 24-hour urine collection. He was placed on empiric Vitamin B12 1000mcg IM qd x 7 days; then qMonth. He was also placed on Thiamine 100mg qd, Folate 1mg qd, and ASA 325mg qd. His ESR and CRP were elevated on admission, but fell as his UTI was treated.,EEG showed diffuse slowing and focal slowing in the theta-delta range in the right temporal area. HCT with contrast on 1/19/93 revealed a gyriform enhancing lesion in the left parietal lobe consistent with a new infarct; and an old right parietal hypodensity (infarct). His confusion was ascribed to the UTI in the face of old and new strokes and Vitamin B12 deficiency. He was lost to follow-up and did not undergo carotid endarterectomy.", Radiology,33
"PREOPERATIVE DIAGNOSES:,1.  Right hyoid mass, rule out carcinomatosis.,2.  Weight loss.,3.  Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1.  Right hyoid mass, rule out carcinomatosis.,2.  Weight loss.,3.  Chronic obstructive pulmonary disease.,4.  Changes consistent with acute and chronic bronchitis.,5.  Severe mucosal irregularity with endobronchial narrowing of the right middle and lower lobes.,6.  Left vocal cord irregularity.,PROCEDURE PERFORMED:  ,Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.,ANESTHESIA: , Demerol 50 mg with Versed 3 mg as well as topical cocaine and lidocaine solution.,LOCATION OF PROCEDURE: , Endoscopy suite #4.,After informed consent was obtained and following the review of the procedure including procedure as well as possible risks and complications were explained and consent was previously obtained, the patient was sedated with the above stated medication and the patient was continuously monitored on pulse oximetry, noninvasive blood pressure, and EKG monitoring.  Prior to starting the procedure, the patient was noted to have a baseline oxygen saturation of 86% on room air.  Subsequently, she was given a bronchodilator treatment with Atrovent and albuterol and subsequent saturation increased to approximately 90% to 91% on room air.,The patient was placed on a supplemental oxygen as the patient was sedated with above-stated medication.  As this occurred, the bronchoscope was inserted into the right naris with good visualization of the nasopharynx and oropharynx.  The cords were noted to oppose bilaterally on phonation.  There was some slight mucosal irregularity noted on the vocal cord on the left side.  Additional topical lidocaine was instilled on the vocal cords, at which point the bronchoscope was introduced into the trachea, which was midline in nature.  The bronchoscope was then advanced to the distal trachea and additional lidocaine was instilled.  At this time, the bronchoscope was further advanced through the main stem and additional lidocaine was instilled.  Bronchoscope was then further advanced into the right upper lobe, which revealed no evidence of any endobronchial lesion.  The mucosa was diffusely friable throughout.  Bronchoscope was then slowly withdrawn into the right main stem and additional lidocaine was instilled.  At this point, the bronchoscope was then advanced to the right bronchus intermedius.  At this time, it was noted that there was severe mucosal irregularities of nodular in appearance significantly narrowing the right lower lobe and right middle lobe opening.  The mucosal area throughout this region was severely friable.  Additional lidocaine was instilled as well as topical epinephrine.  At this time, bronchoscope was maintained in this region and endobronchial biopsies were performed.  At the initial attempt of inserting biopsy forceps, some resistance was noted within the proximal channel at this time making advancement of the biopsy forceps out of the proximal channel impossible.  So the biopsy forceps was withdrawn and the bronchoscope was completely withdrawn and new bronchoscope was then utilized.  At this time, bronchoscope was then reinserted into the right naris and subsequently advanced to the vocal cords into the right bronchus intermedius without difficulty.  At this time, the biopsy forceps were easily passed and visualized in the right bronchus intermedius.  At this time, multiple mucosal biopsies were performed with some mild oozing noted.  Several aliquots of normal saline lavage followed.  After completion of multiple biopsies there was good hemostasis.  Cytology flushing was also performed in this region and subsequently several aliquots of additional normal saline lavage was followed.  Bronchoscope was unable to be passed distally to the base of the segment of the right lower lobe or distal to the further visualized endobronchial anatomy of the right middle lobe subsegments.  The bronchoscope was then withdrawn to the distal trachea.,At this time, bronchoscope was then advanced to the left main stem.  Additional lidocaine was instilled.  The bronchoscope was advanced to the left upper and lower lobe subsegments.  There was no endobronchial lesion visualized.  There is mild diffuse erythema and fibromucosa was noted throughout.  No endobronchial lesion was visualized in the left bronchial system.  The bronchoscope was then subsequently further withdrawn to the distal trachea and readvanced into the right bronchial system.  At this time, bronchoscope was readvanced into the right bronchus intermedius and additional aliquots of normal saline lavage until cleared.  There is no gross bleeding evidenced at this time or diffuse mucosal erythema and edema present throughout.  The bronchoscope was subsequently withdrawn and the patient was sent to recovery room.  During the bronchoscopy, the patient noted ________ have desaturation and required increasing FiO2 with subsequent increased saturation to 93% to 94%.  The patient remained at this level of saturation or greater throughout the remaining of the procedure.,The patient postprocedure relates having some intermittent hemoptysis prior to the procedure as well as moderate exertional dyspnea.  This was confirmed by her daughter and mother who were also present at the bedside postprocedure.  The patient did receive a nebulizer bronchodilator treatment immediately prebronchoscopy and postprocedure as well.  The patient also admitted to continued smoking in spite of all of the above.  The patient was extensively counseled regarding the continued smoking especially with her present symptoms.  She was advised regarding smoking cessation.  The patient was also placed on a prescription of prednisone 2 mg tablets starting at 40 mg a day decreasing every three days to continue to wean off.  The patient was also administered Solu-Medrol 60 mg IV x1 in recovery room.  There was no significant bronchospastic component noted, although because of the severity of the mucosal edema, erythema, and her complaints, short course of steroids will be instituted.  The patient was also advised to refrain from using any aspirin or other nonsteroidal anti-inflammatory medication because of her hemoptysis.  At this time, the patient was also advised that if hemoptysis were to continue or worsen or develop progressive dyspnea, to either contact myself, , or return to ABCD Emergency Room for evaluation of possible admission.  However, the above was reviewed with the patient in great detail as well as with her daughter and mother who were at the bedsite at this time as well.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Thyroid goiter.,POSTOPERATIVE DIAGNOSIS:  ,Thyroid goiter.,PROCEDURE PERFORMED: , Total thyroidectomy.,ANESTHESIA:,1.  General endotracheal anesthesia.,2.  9 cc of 1% lidocaine with 1:100,000 epinephrine.,COMPLICATIONS:,  None.,PATHOLOGY: , Thyroid.,INDICATIONS:  ,The patient is a female with a history of Graves disease.  Suppression was attempted, however, unsuccessful.  She presents today with her thyroid goiter.  A thyroidectomy was indicated at this time secondary to the patient's chronic condition.  Indications, alternatives, risks, consequences, benefits, and details of the procedure including specifically the risk of recurrent laryngeal nerve paresis or paralysis or vocal cord dysfunction and possible trach were discussed with the patient in detail.  She agreed to proceed.  A full informed consent was obtained.,PROCEDURE: , The patient presented to ABCD General Hospital on 09/04/2003 with the history was reviewed and physical examinations was evaluated.  The patient was brought by the Department of Anesthesiology, brought back to surgical suite and given IV access and general endotracheal anesthesia.  A 9 cc of 1% lidocaine with 1:100,000 of epinephrine was infiltrated into the area of pre-demarcated above the suprasternal notch.  Time is allowed for full hemostasis to be achieved.  The patient was then prepped and draped in the normal sterile fashion.  A #10 blade was then utilized to make an incision in the pre-demarcated and anesthetized area.  Unipolar electrocautery was utilized for hemostasis.  Finger dissection was carried out in the superior and inferior planes.  Platysma was identified and dissected and a subplatysmal plane was created in the superior and inferior, medial and lateral directions using hemostat, Metzenbaum, and blunt dissection.  The strap muscles were identified.  The midline raphe was not easily identifiable at this time.  An incision was made through what appeared to be in the midline raphe and dissection was carried down to the thyroid.  Sternohyoid and sternothyroid muscles were identified and separated on the patient's right side and then subsequently on the left side.  It was noted at this time that the thyroid lobule on the right side is a bi-lobule.  Kitner blunt dissection was utilized to bluntly dissect the overlying thyroid fascia as well as strap muscles off the thyroid, force in the lateral direction.  This was carried down to the inferior and superior areas.  The superior pole of the right lobule was then identified.  A hemostat was placed in the cricothyroid groove and a Kitner was placed in this area.  A second Kitner was placed on lateral aspect of the superior pole and the superior pole of the right thyroid was retracted inferiorly.  Careful dissection was then carried out in a very meticulous fashion in the superior lobe and identified the appropriate vessels and cauterized with bipolar or ligated with the suture ligature.  This was carried out until the superior pole was identified.  Careful attention was made to avoid nerve injury in this area.  Dissection was then carried down again bluntly separating the inferior and superior lobes.  The bilobed right thyroid was then retracted medially.  The recurrent laryngeal nerve was then identified and tracked to its insertion.  The overlying vessels of the middle thyroid vein as well as the associated structures were then identified and great attention was made to perform a right careful meticulous dissection to remove the fascial attachments superficial to the recurrent laryngeal nerve off the thyroid.  When it was completed, this lobule was then removed from Berry's ligament.  There was noted to be no isthmus at this time and the entire right lobule was then sent to the Pathology for further evaluation.  Attention was then diverted to the patient's left side.  In a similar fashion, the sternohyoid and sternothyroid muscles were already separated.  Army-Navy as well as femoral retractors were utilized to lateralize the appropriate musculature.  The middle thyroid vein was identified.  Blunt dissection was carried out laterally to superiorly once again.  A hemostat was utilized to make an opening in the cricothyroid groove and a Kitner was then placed in this area.  Another Kitner was placed on the lateral aspect of the superior lobe of the left thyroid and retracted inferiorly.  Once again, a careful meticulous dissection was utilized to identify the appropriate structures in the superior pole of the left thyroid and suture ligature as well as bipolar cautery was utilized for hemostasis.  Once again, a careful attention was made not to injure the nerve in this area.  The superior pole was then freed appropriately and blunt dissection was carried down to lateral and inferior aspects.  The inferior aspect was then identified.  The inferior thyroid artery and vein were then identified and ligated.  The left thyroid was then medialized and the recurrent laryngeal nerve has been identified.  A careful dissection was then carried out to remove the fascial attachments superficial to the recurrent laryngeal nerve on the side as close to the thyroid gland as possible.  The thyroid was then removed from the Berry's ligament and it was then sent to Pathology for further evaluation.  Evaluation of the visceral space did not reveal any bleeding at this time.  This was irrigated and pinpoint areas were bipolored as necessary.  Surgicel was then placed bilaterally.  The strap muscles as well as the appropriate fascial attachments were then approximated with a #3-0 Vicryl suture in the midline.  The platysma was identified and approximated with a #4-0 Vicryl suture and the subdermal plane was approximated with a #4-0 Vicryl suture.  A running suture consisting of #5-0 Prolene suture was then placed and fast absorbing #6-0 was then placed in a running fashion.  Steri-Strips, Tincoban, bacitracin and a pressure gauze was then placed.  The patient was then admitted for further evaluation and supportive care.  The patient tolerated the procedure well.  The patient was transferred to Postanesthesia Care Unit in stable condition.", Surgery,38
"HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above.  He was seen a few weeks ago for routine followup, and he was noted for microhematuria.  Due to his history of kidney stone, renal ultrasound as well as IVP was done.  He presents today for followup.  He denies any dysuria, gross hematuria or flank pain issues.  Last stone episode was over a year ago.  No history of smoking.  Daytime frequency 3 to 4 and nocturia 1 to 2, good stream, empties well with no incontinence.,Creatinine 1.0 on June 25, 2008, UA at that time was noted for 5-9 RBCs, renal ultrasound of 07/24/2008 revealed 6 mm left intrarenal stone, with no hydronephrosis.  IVP same day revealed a calcification over the left kidney, but without bilateral hydronephrosis.  The calcification previously noted on the ureter appears to be outside the course of the ureter.  Otherwise unremarkable.  This is discussed.,IMPRESSION:  ,1.  A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP.  The patient is asymptomatic.  We have discussed surgical intervention versus observation.  He indicates that this stone is not bothersome, prefers observation, need for hydration with a goal of making over 2 liters of urine within 24 hours is discussed.,2.  Microhematuria, we discussed possible etiologies of this, and the patient is agreeable to cystoscopy in the near future.  Urine sent for culture and sensitivity.,PLAN: , As above.  The patient will follow up for cystoscopy, urine sent for cytology, continue hydration.  Call if any concern.  The patient is seen and evaluated by myself.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS:,  Medial meniscal tear of the right knee.,POSTOPERATIVE DIAGNOSES:,1.  Medial meniscal tear, right knee.,2.  Lateral meniscal tear, right knee.,3.  Osteochondral lesion, medial femoral condyle, right knee.,4.  Degenerative joint disease, right knee.,5.  Patella grade-II chondromalacia.,6.  Lateral femoral condyle grade II-III chondromalacia.,PROCEDURE PERFORMED:,1.  Arthroscopy, right knee.,2.  Medial meniscoplasty, right knee.,3.  Lateral meniscoplasty, right knee.,4.  Medial femoral chondroplasty, right knee.,5.  Medical femoral microfracture, right knee.,6.  Patellar chondroplasty.,7.  Lateral femoral chondroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,BRIEF HISTORY AND INDICATION FOR PROCEDURE: , The patient is a 47-year-old female who has knee pain since 03/10/03 after falling on ice.  The patient states she has had inability to bear significant weight and had swelling, popping, and giving away, failing conservative treatment and underwent an operative procedure.,PROCEDURE:,  The patient was taken to the Operative Suite at ABCD General Hospital on 09/08/03, placed on the operative table in supine position.  Department of Anesthesia administered general anesthetic.  Once adequately anesthetized, the right lower extremity was placed in a Johnson knee holder.  Care was ensured that all bony prominences were well padded and she was positioned and secured.  After adequately positioned, the right lower extremity was prepped and draped in the usual sterile fashion.  Attention was then directed to creation of the arthroscopic portals, both medial and lateral portal were made for arthroscope and instrumentation respectively.  The arthroscope was advanced through the inferolateral portal taking in a suprapatellar pouch.  All compartments were then examined in sequential order with photodocumentation of each compartment.  The patella was noted to have grade-II changes of the inferior surface, otherwise appeared to track within the trochlear groove.  There was mild grooving of the trochlear cartilage.  The medial gutter was visualized.  There was no evidence of loose body.  The medial compartment was then entered.  There was noted to be a large defect on the medial femoral condyle grade III-IV chondromalacia changes with exposed bone in evidence of osteochondral displaced fragment.  There was also noted to be a degenerative meniscal tear of the posterior horn of the medial meniscus.  The arthroscopic probe was then introduced and the meniscus and chondral surfaces were probed throughout its entirety and photos were taken.  At this point, a meniscal shaver was then introduced and the chondral surfaces were debrided as well as any loose bodies removed.  This gave a smooth shoulder to the chondral lesion.  After this, the meniscus was debrided until it had been smooth over the frayed edges.  At this point, the shaver was removed.  The meniscal binder was then introduced and the meniscus was further debrided until the tear was adequately contained at this point.  The shaver was reintroduced and all particles were again removed and the meniscus was smoothed over the edge.  The probe was then reintroduced and the shaver removed, the meniscus was probed ___________ and now found to be stable.  At this point, attention was directed to the rest of the knee.  The ACL was examined.  It was intact and stable.  The lateral compartment was then entered.  There was noted to be a grade II-III changes of the lateral femoral condyle.  Again, with the edge of some friability at the shoulder of this cartilage lesion.  There was noted to be some mild degenerative fraying of the posterior horn of the lateral meniscus.  The probe was introduced and the remaining meniscus appeared stable.  This was then removed and the stapler was introduced.  A chondroplasty and meniscoplasty were then performed until adequately debrided and smoothed over.  The lateral gutter was then visualized.  There was no evidence of loose bodies.  Attention was then redirected back to the medial and femoral condyles.,At this point, a 0.62 K-wire was then placed in through the initial portal, medial portal, as well as an additional poke hole, so we can gain access and proper orientation to the medial femoral lesion.  Microfacial technique was then used to introduce the K-wire into the subchondral bone in multiple areas until we had evidence of some bleeding to allow ___________ of this lesion.  After this was performed, the shaver was then reintroduced and the loose bodies and loose fragments were further debrided.  At this point, the shaver was then moved to the suprapatellar pouch and the patellar chondroplasty was then performed until adequately debrided.  Again, all compartments were then re-visualized and there was no further evidence of other pathology or loose bodies.  The knee was then copiously irrigated and suctioned dry.  All instrumentation was removed.  Approximately 20 cc of 0.25% plain Marcaine was injected into the portal site and the remaining portion intraarticular.  Sterile dressings of Adaptic, 4x4s, ABDs, and Webril were then applied.  The patient was then transferred back to the gurney in supine position.,DISPOSITION:  The patient tolerated the procedure well with no complications.  The patient was transferred to PACU in satisfactory condition.", Surgery,38
"PREOPERATIVE DIAGNOSES:,1.  Extruded herniated disc, left L5-S1.,2.  Left S1 radiculopathy (acute).,3.  Morbid obesity.,POSTOPERATIVE DIAGNOSES:,1.  Extruded herniated disc, left L5-S1.,2.  Left S1 radiculopathy (acute).,3.  Morbid obesity.,PROCEDURE PERFORMED: , Microscopic lumbar discectomy, left L5-S1.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,50 cc.,HISTORY: , This is a 40-year-old female with severe intractable left leg pain from a large extruded herniated disc at L5-S1.  She has been dealing with these symptoms for greater than three months.  She comes to my office with severe pain, left my office and reported to the Emergency Room where she was admitted for pain control one day before surgery.  I have discussed the MRI findings with the patient and the potential risks and complications.  She was scheduled to go to surgery through my office, but because of her severe symptoms, she was unable to keep that appointment and reported right to the Emergency Room.  We discussed the diagnosis and the operative procedure in detail.  I have reviewed the potential risks and complications and she had agreed to proceed with the surgery.  Due to the patient's weight which exceeds 340 lb, there was some concern about her operative table being able to support her weight and also my standard microlumbar discectomy incision is not ________ in this situation just because of the enormous size of the patient's back and abdomen and I have discussed this with her.  She is aware that she will have a much larger incision than what is standard and has agreed to accept this.,OPERATIVE PROCEDURE:  ,The patient was taken to OR #5 at ABCD General Hospital.  While in the hospital gurney, Department of Anesthesia administered general anesthetic, endotracheal intubation was followed.  A Jackson table was prepared for the patient and was reinforced replacing struts under table to prevent the table from collapsing.  The table reportedly does have a limit of 500 lb, but the table has never been stressed above 275 lb.  Once the table was reinforced, the patient was carefully rolled in a prone position on the Jackson table with the bony prominences being well padded.  A marker was placed in from the back at this time and an x-ray was obtained for incision localization.  The back is now prepped and draped in the usual sterile fashion.  A midline incision was made over the L5-S1 disc space taking through subcutaneous tissue sharply with a #10 Bard-Parker scalpel.  The lumbar dorsal fascia was then encountered and incised to the left of midline.  In the subperiosteal fashion, the musculature was elevated off the lamina at L5 and S1 after facet joint, but not disturbing the capsule.  A second marker was now placed and an intraoperative x-ray confirms our location at the L5-S1 disc space.  The microscope was brought into the field at this point and the remainder of the procedure done with microscopic visualization and illumination.  A high speed drill was used to perform a laminotomy by removing small portion of the superior edge of the S1 lamina and the inferior edge of the L5 lamina.  Ligaments and fragments were encountered and removed at this time.  The epidural space was now encountered.  The S1 nerve root was now visualized and found to be displaced dorsally as a result of a large disc herniation while the nerve was carefully protected with a Penfield.  A small stab incision was made into the disc fragment and probably a large portion of disc extrudes from the opening.  This disc fragment was removed and the nerve root was much more supple, it was carefully retracted.  The nerve root was now retracted and using a series of downgoing curettes, additional disc material was removed from around the disc space and from behind the body of S1 and L5.  At this point, all disc fragments were removed from the epidural space.  Murphy ball was passed anterior to the thecal sac in the epidural space and there was no additional compression that I can identify.  The disc space was now encountered and loose disc fragments were removed from within the disc space.  The disc space was then irrigated.  The nerve root was then reassessed and found to be quite supple.  At this point, the Murphy ball was passed into the foramen of L5 and this was patent and also into the foramen of S1 by passing ventral and dorsal to the nerve root and there were no obstructions in the passage of the device.  At this point, the wound was irrigated copiously and suctioned dry.  Gelfoam was used to cover the epidural space.  The retractors were removed at this point.  The fascia was reapproximated with #1 Vicryl suture, subcutaneous tissue with #2-0 Vicryl suture and Steri-Strips for curved incision.  The patient was transferred to the hospital gurney in supine position and extubated by Anesthesia, subsequently transferred to Postanesthesia Care Unit in stable condition.", Orthopedic,27
"CHIEF COMPLAINT:,  Followup on diabetes mellitus, status post cerebrovascular accident.,SUBJECTIVE:,  This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side.  We have done EMG studies.  He has noticed it since his stroke about five years ago.  He has been to see a neurologist.  We have tried different medications and it just does not seem to help.  He checks his blood sugars at home two to three times a day.  He kind of adjusts his own insulin himself.  Re-evaluation of symptoms is essentially negative.  He has a past history of heavy tobacco and alcohol usage.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt; 118 lbs, B/P; 108/72, T; 96.5, P; 80 and regular.  ,General:  A 70-year-old male who does not appear to be in acute distress but does look older than his stated age.  He has some missing dentition.,Skin:  Dry and flaky. ,CV:  Heart tones are okay, adequate carotid pulsations.  He has 2+ pedal pulse on the left and 1+ on the right.,Lungs: Diminished but clear.,Abdomen:  Scaphoid.,Rectal:  His prostate check was normal per Dr. Gill.,Neuro:  Sensation with monofilament testing is better on the left than it is on the right.,IMPRESSION:,1.  Diabetes mellitus.,2.  Neuropathy.,3.  Status post cerebrovascular accident.,PLAN:,  Refill his medications x 3 months.  We will check an A1c and BMP.  I have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood.  We will check a PSA.  Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in three months and p.r.n.", SOAP / Chart / Progress Notes,35
"REASON FOR EXAM: , Atrial flutter/cardioversion.,PROCEDURE IN DETAIL: , The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient received sedation prior to the cardioversion with a transesophageal echo as dictated earlier with a total of 50 mcg of fentanyl and 6 mg of Versed.  The pads were applied in the anterior-posterior approach.  The synchronized cardioversion with biphasic energy delivered at 150 J. First attempt was unsuccessful.  Second attempt at 200 J with anterior-posterior approach.  With biphasic synchronized energy delivered was also unsuccessful with degeneration of the atrial flutter into atrial fibrillation.,The patient was decided to be on wave control and amiodarone and reattempted cardioversion after anticoagulation for four to six weeks and because of the reduced LV function, the success of the rate without antiarrhythmic may be low.,IMPRESSION: , Unsuccessful direct current cardioversion with permanent atrial fibrillation.", Cardiovascular / Pulmonary,3
"The right eardrum is intact showing a successful tympanoplasty.  I cleaned a little wax from the external meatus.  The right eardrum might be very slightly red but not obviously infected.  The left eardrum (not the surgical ear) has a definite infection with a reddened bulging drum but no perforation or granulation tissue.  Also some wax at the external meatus I cleaned with a Q-tip with peroxide.  The patient has no medical allergies.  Since he recently had a course of Omnicef we chose to put him on Augmentin (I checked and we did not have samples), so I phoned in a two-week course of Augmentin 400 mg chewable twice daily with food at Walgreens.  I looked at this throat which looks clear.  The nose only has a little clear mucinous secretions.  If there is any ear drainage, please use the Floxin drops.  I asked Mom to have the family doctor (or Dad, or me) check the ears again in about two weeks from now to be sure there is no residual infection.  I plan to see the patient again later this spring.", ENT - Otolaryngology,11
"PREOPERATIVE DIAGNOSES:,1.  Hoarseness.,2.  Bilateral true vocal cord lesions.,3.  Leukoplakia.,POSTOPERATIVE DIAGNOSES:,1.  Hoarseness.,2.  Bilateral true vocal cord lesions.,3.  Leukoplakia.,PROCEDURE PERFORMED:  ,Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS:,  Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:  The patient is a 33-year-old Caucasian male with a history of chronic hoarseness and bilateral true vocal cord lesions, and leukoplakia discovered on a fiberoptic nasal laryngoscopy in the office.  Discussed risks, complications, and consequences of a surgical biopsy of the left true vocal cord and consent was obtained.,PROCEDURE: , The patient was brought to operative suite by anesthesia, placed on the operating table in supine position.  After this, the patient was placed under general endotracheal intubation anesthesia and the operative table was turned 90 degrees by the Department of Anesthesia.  A shoulder roll was then placed followed by the patient being placed in reverse Trendelenburg.,After this, a mouthguard was placed in the upper teeth and a Dedo laryngoscope was placed in the patient's oral cavity and advanced through the oral cavity in the oropharynx down into the hypopharynx.  The patient's larynx was then brought into view with the true vocal cords hidden underneath what appeared to be redundant false vocal cords.  The left true vocal cord was then first addressed and appeared to have an extensive area of leukoplakia extending from the posterior one-third up to the anterior third.  The false vocal cord also appeared to be very full on the left side along with fullness in the subglottic region.  The patient's anterior commissure appeared to be clear.  The false cord on the right side also appeared to be very redundant and overshadowing the true vocal cord.  Once the true vocal cord was retracted laterally, there was revealed a second area of leukoplakia involving the right true vocal cord in the anterior one-third aspect.  The patient's subglottic region was very edematous and with redundant mucosal tissue.  The areas of leukoplakia appeared to be cobblestoned in appearance, irregularly bordered, and very hard to the touch.  The left true vocal cord was then first addressed, was stripped from posteriorly to anteriorly utilizing a #45 laryngeal forceps.  After this, the patient had pressure placed upon this area with tropical adrenaline and a rectal swab to maintain hemostasis.  The specimen was passed off the field and was sent to Pathology for evaluation.  Hemostasis was maintained on the left side.  Prior to taking this biopsy, the Louie arm was attached to the laryngoscope and then suspended on the Mayo stand.  The Zeiss operating microscope was then brought into view to directly visualize the vocal cords.  The biopsies were taken under direct visualization utilizing the Zeiss operating microscope.  After the specimen was taken and the laryngoscope was desuspended from the Mayo stand and Louie arm was removed, the scope was then pulled more cephalad and the piriform sinuses, valecula, and base of the tongue were all directly visualized, which appeared normal except for the left base of tongue appeared to be full.  This area was biopsied multiple times with a straight laryngeal forceps and passed off the field and sent to Pathology as specimen.  The scope was then pulled back into the superior aspect of hypopharynx into the oropharynx and the oral cavity demonstrated no signs of any gross lesions.  A bimanual examination was then performed, which again demonstrated a fullness on the left base of tongue region with no signs of any other gross lesions.  There were no signs of any palpable cervical lymphadenopathy.  The tooth guard was removed and the patient was then turned back to anesthesia.  The patient did receive intraoperatively 10 mg of Decadron.  The patient tolerated the procedure well and was extubated in the operating room.,The patient was transferred to recovery room in stable condition and tolerated the procedure well.  The patient will be sent home with prescriptions for Medrol DOSEPAK, Tylenol with Codeine, Elixir, and amoxicillin 250 mg per 5 cc.", Surgery,38
"HISTORY OF PRESENT ILLNESS: ,The patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom.  At that time, he reports both legs gave away on him and he fell.  He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.  He was able to get up shortly after falling and according to the patient and his son, subsequently returned back to normal.,He was then well until the 3rd of July 2008 when his legs again gave way on him.  This was not preceded by lightheadedness.  He was rushed to the hospital and was found to have pneumonia, and the fall was blamed on the pneumonia.  He started using a walker from that time, prior to that he was able to walk approximately two miles per day.  He again had a fall in August of 2008 after his legs gave way.  Again, there was no lightheadedness associated with this.  He was again found to have pneumonia and again was admitted to hospital after which he went to rehabilitation and was able to use his walker again after this.  He did not, however, return to the pre-July baseline.  In October of 2008, after another fall, he was found to have pneumonia again and shingles.  He is currently in a Chronic Rehabilitation Unit.  He cannot use a walker and uses a wheelchair for everything.  He states that his hands have been numb, involving all the fingers of both hands for the past three weeks.  He is also losing muscle bulk in his hands and has noticed some general weakness of his hands.  He does, however, note that strength in his hands has not been normal since July 2008, but it is clearly getting worse.  He has been aware of some fasciculations in his legs starting in August 2008, these are present both in the lower legs and the thighs.  He does not report any cramps, problems with swallowing or problems with breathing.  He reports that he has had constipation alternating with diarrhea, although there has been no loss of control of either his bowel or bladder.  He has had some problems with blood pressure drops, and does feel presyncopal when he stands.  He also reports that he has no feeling in his feet, and that his feet feel like sponges.  This has been present for about nine months.  He has also lost joint position sense in his feet for approximately nine months.,PAST MEDICAL HISTORY:,1.  Pneumonia.  He has had recurrent episodes of pneumonia, which started at approximately age 20.  These have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year.  He is usually treated with antibiotics and then discharged.  There is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia.,2.  He has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement.  The patient does not have any history of diabetes and does not report any other medical problems.  He has lost approximately 18 pounds in the past month.,3.  He had an appendectomy in the 1940s.,4.  He had an ankle resection in 1975.,SOCIAL HISTORY:  ,The patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars.  He has not smoked for the past 27 years.  He hardly ever uses alcohol.  He is currently retired.,FAMILY HISTORY: , There is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases.  His aunt has a history of type II diabetes.,CURRENT MEDICATIONS: , Fludrocortisone 0.1 mg p.o. q.d., midodrine 5 mg p.o. q.i.d., Cymbalta 30 mg p.o. per day, Prilosec 20 mg p.o. per day, Lortab 10 mg p.o. per day, Amoxil 500 mg p.o. per day, vitamin B12 1000 mcg weekly, vitamin D 1000 units per day, Metamucil p.r.n., enteric-coated aspirin once a day, Colace 200 mg p.o. q.d., Senokot three tablets p.o. p.r.n., Reglan 10 mg p.o. q.6h., Xanax 0.25 mg p.o. q.8h. p.r.n., Ambien 5 mg p.o. q.h.s. p.r.n. and Dilaudid 2 mg tablets p.o. q.3h. p.r.n., Protonix 40 mg per day, and Megace 400 mg per day.,ALLERGIES:,  He has no medication or food allergies.,REVIEW OF SYSTEMS:,  Please see the health questionnaire and clinical notes from today.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS:  BP was 137/60, P was 89, and his weight could not be measured because he was in a wheelchair.  His pain score was 0.,APPEARANCE:  No acute distress.  He is pleasant and well-groomed.,HEENT:  Atraumatic, normocephalic.  No carotid bruits appreciated.,LUNGS:  There were few coarse crackles in both lung bases.,CARDIOVASCULAR:  Revealed a normal first and second heart sound, with no third or fourth heart sound and no murmurs.  The pulse was regular and of normal volume.,ABDOMEN:  Soft with no masses and normal bowel sounds.  There were no carotid bruits.,EXTREMITIES:  No contractures appreciated.,NEUROLOGICAL EXAM:,MSE:  His orientation, language, calculations, 100-7 tests were all normal.  There was atrophy and fasciculations in both the arms and legs.,CRANIAL NERVES:  Cranial nerve examination was normal with the exception that there was some mild atrophy of his tongue and possible fasciculations.  His palatal movement was normal and gag reflex was normal.,MOTOR:  Strength was decreased in all muscle groups as follows:  Deltoid 4/4, biceps 4+/4+, triceps 5/5, wrist extensors 4+/4+, finger extensors 4-/4-, finger flexors 4-/4-, interossei 4-/4-, hip flexors 4+/4+, hip extensors 4+/4+, knee extensors 4/4, and knee flexors 4/4.  Foot dorsiflexion, plantar flexion, eversion, toe extension and toe flexion was all 0 to 1.  There was atrophy in both hands and general atrophy of the lower limb muscles.  The feet were both cold and showed dystrophic features.  Fasciculations were present mainly in the hands.  There was evidence of dysmetria and past pointing in the left hand.,REFLEXES:  Reflexes were 0 in all sites in the arms and legs.  The jaw reflex was 2+.  Vibration was severely decreased at the elbow and wrist and was absent in the fingers.  Vibration was absent in the toes and ankle bilaterally and was severely decreased at the knee.  Joint position sense was absent in the toes and severely decreased in the fingers.  Pin perception was absent in the feet and was decreased to the upper thighs.  Pin was decreased or absent in the fingers and decreased above the elbows.  The same distribution of sensory loss was found with monofilament testing.,COORDINATION:  Coordination was barely normal in the right hand.  Rapid alternating movements were decreased in the left hand greater than the right hand.  The patient was unable to stand and therefore gait, Romberg's test and balance could not be assessed.,DIAGNOSTIC STUDIES: , Previous diagnostic studies and patient reports.  There were extensive patient reports, all of which were reviewed.  A previous x-ray study of the lateral chest performed in October 2008 showed poor inspiration with basilar atelectasis and an infiltrate.  An x-ray of the cervical, thoracic and lumbar spine showed some evidence of lumbar spinal stenosis.  A CTA of the neck with and without contrast performed in November 2008 showed minor stenosis in the left carotid, a mild hard and soft plaque in the right carotid with approximately 55% stenosis.  The posterior circulation showed a slightly dominant right vertebral artery with no stenosis.  There was no significant stenosis, but there was minor extracranial stenosis noted.  An MRI of the brain with and without contrast performed in November 2008 showed no evidence of an acute infarct, major vascular occlusion, and no abnormal enhancement with gadolinium administration.  There was also no significant sinusitis or mastoiditis.  This was an essentially normal brain MRI.  A CBC performed in January 2009 showed an elevated white cell count of 11.3, a low red cell count of 3.43, elevated MCH of 32.4 and the rest of the study was normal.  An electrolyte study performed in January 2009 showed a sodium which was low at 127, a calcium which was low at 8.3, and a low protein of 5.2 and albumin of 3.1.  The glucose was 86.  TSH performed in January 2009 was 1.57, which is within the normal range.  Vitamin B12 was greater than a 1000, which is normal and the folate was 18.2, which was normal.  A myocardial stress study performed in December 2008 showed normal myocardial perfusion with Persantine Cardiolite SPECT.  The ECG was non-diagnostic.  There was normal regional wall motion of the left ventricle.  The left ventricular ejection fraction was 68%, which is within the normal range for males.  A CT of the lumbar spine without contrast performed in December 2008 showed a broad-based disc bulge at L1-L2, L2-L3, L3-L4 and L4-L5.  At L5-S1, in addition to the broad-based disc bulge, there was also an osteophyte complex and evidence of flavum hypertrophy without canal stenosis.  There was severe bilateral neural foraminal stenosis at L5-S1 and moderate neural foraminal stenosis at L1-L4.  An echocardiogram was performed in November 2008 and showed mild left atrial enlargement, normal left ventricular systolic function, mild concentric left ventricular hypertrophy, scleral degenerative changes in the aortic and mitral apparatus, mild mitral regurgitation, mild tricuspid regurgitation and mild to moderate aortic regurgitation.,DIAGNOSTIC IMPRESSION:  ,The patient presents with a severe neuropathy with marked large fiber sensory as well as motor findings.  He is diffusely weak as well as atrophic in all muscle groups both in his upper and lower extremities, although he is disproportionately weak in his lower extremities.  His proprioceptive and vibratory loss is severe in both the distal upper and lower extremities, signifying that he either has a severe sensory neuropathy or has involvement of the dorsal root ganglia.  According to the history, which was carefully checked, the initial onset of these symptoms goes back one and a half years, although there has only been significant progression in his condition since July 2008.  As indicated below, further diagnostic studies including a detailed nerve conduction and EMG test today showed evidence of a severe sensory, motor, and axonal neuropathy and in addition there was evidence of a diffuse polyradiculopathy.  There was no involvement of the tongue on EMG.  The laboratory testing as indicated below failed to show a specific cause for the neuropathy.  We are still, however, waiting for the paraneoplastic antibodies, which were send out lab to the Mayo Clinic.  This type of very severe sensorimotor neuropathy with significant proprioceptive loss may be seen in several conditions including peripheral nerve vasculitis due to a variety of disorders such as SLE, Sjogren's, rheumatoid arthritis, and mixed connective tissue disease.  In addition, it may also be seen with certain toxins, particularly chemotherapeutic agents.  The patient did not receive any of these.  It may also be seen as part of a paraneoplastic syndrome.  Although the patient does not have any specific clinical symptoms of a cancer, it is noted that he has had an 18-pound weight loss in the past month and does have a remote history of smoking.  We have requested that he obtain a CT of his chest, abdomen and pelvis while he is in Acute Rehabilitation.  The verbal reports of these possibly did not show any evidence of a cancer.  We did also request that he obtain a gallium scan to see if there was any evidence of an unsuspected neoplasm.  The patient did undergo a nerve and muscle biopsy, this was a radial nerve and biceps muscle biopsy from the left arm.  This showed evidence of severe axonal loss.  There was no evidence of a vasculitis.  The vessels did show some mild intimal changes that would be consistent with atherosclerosis.  There were a few perivascular changes; however, there was no clear evidence of a necrotizing vasculitis even on multiple sections.  The muscle biopsy showed severe muscle fiber atrophy, with evidence of fiber grouping.  Again, there was no evidence of inflammation or vasculitis.  Evaluation so far has also shown no evidence of an amyloid neuropathy, no evidence of a monoclonal gammopathy, of sarcoidosis, and again there is no past history of a significant toxin or infective cause for the neuropathy.  Specifically, there is no history of HIV exposure.  We would await the results of the gallium scan and of the paraneoplastic antibodies to see if these are helpful in making a diagnosis.  At this point, because of the severity and the axonal nature of the neuropathy, there is no specific therapy that will reverse the course of the illness, unless we find a specific etiology that can be stopped or reversed.  I have discussed these issues at length with the patient and with his son.  We also addressed whether or not there might be a previously undiagnosed inherited neuropathy.  I think this is unlikely given the short history and the rapid progression of the disorder.,There is also no family history that we can detect a neuropathy, and the patient does not have the typical phenotype for a chronic inherited neuropathy such as Charcot-Marie-Tooth disease type 2.  However, since I have only seen the patient on one occasion and do not know what his previous examination showed two years ago, I cannot be certain that there may not have been the presence of a neuropathy preceding this.,PLAN:,1.  Nerve conduction and EMG will be performed today.  The results were indicated above.,2.  The following laboratory studies were requested including electrolytes, CBC, thyroid function tests, B12, ANA, C-reactive protein, complement, cryoglobulins, double-stranded DNA antibodies, folate level, hemoglobin A1c, immunofixation electrophoresis, P-ANCA, C-ANCA, protein electrophoresis, rheumatoid factor, paraneoplastic antibody studies requested from the Mayo Clinic, B12.  These studies showed minor changes, which included a low sodium level of 129 as previously noted, a low creatinine of 0.74, low calcium of 8.6, low total protein of 5.7.  The B12 was greater than 2000.  The immunoelectrophoresis, ANA, double-stranded DNA, ANCA, hemoglobin A1c, folate, cryoglobulins, complement, C-reactive protein were all normal or negative.  The B12 level was greater than 2000.  Liver function tests were normal.  The glucose was 90.  ESR was 10.  Hemoglobin A1c was 5.5.,3.  A left radial sensory and left biceps biopsy were requested and have been performed and interpreted as indicated above.,4.  CT of chest, abdomen and pelvis.,5.  Whole body gallium scan for evidence of an underlying neoplasm.,6.  The patient will go to the Rehabilitation Facility for Acute Rehabilitation and Training.,7.  We have not made any changes to his medication.  He does have some mild orthostatic changes; however, he is adequately controlled with midodrine at a dose of 2.5 mg three times a day as needed up to 5 mg four times a day.  Usually, he uses a lower dose of 2.5 three times a day to 5 mg three times a day.,8.  Followup will be as determined by the family.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,POSTOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,OPERATION PERFORMED: , Left neck dissection.,ANESTHESIA:  ,General endotracheal.,INDICATIONS: , The patient is a very nice gentleman, who has had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.  He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound, which are suspicious for recurrent cancer.  Left neck dissection is indicated.,DESCRIPTION OF OPERATION: , The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, the table was then turned.  A shoulder roll placed under the shoulders and the face was placed in an extended fashion.  The left neck, chest, and face were prepped with Betadine and draped in a sterile fashion.  A hockey stick skin incision was performed, extending a previous incision line superiorly towards the mastoid cortex through skin, subcutaneous tissue and platysma with Bovie electrocautery on cut mode.  Subplatysmal superior and inferior flaps were raised.  The dissection was left lateral neck dissection encompassing zones 1, 2A, 2B, 3, and the superior portion of 4.  The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck.  This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles, stripped from the carotid artery, the X cranial nerve, the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr. X in the paratracheal region.  The submandibular gland was removed as well.  The X, XI, and XII cranial nerves were preserved.  The internal jugular vein and carotid artery were preserved as well.  Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure.  There were two obviously positive nodes in this neck dissection.  One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2.  A #10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2-0 silk ligature.  The wound was closed in layers using a 3-0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples.  A fluff and Kling pressure dressing was then applied.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.", Surgery,38
"PREOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Status post spontaneous vaginal delivery.,POSTOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Status post spontaneous vaginal delivery.,PROCEDURE PERFORMED:,1.  Dilation and curettage (D&C).,2.  Hysteroscopy.,ANESTHESIA: , IV sedation with paracervical block.,ESTIMATED BLOOD LOSS:,  Less than 10 cc.,INDICATIONS:  ,This is a 17-year-old African-American female that presents 7 months status post spontaneous vaginal delivery without complications at that time.  The patient has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.,PROCEDURE:,  The patient was consented and seen in the preoperative suite.  She was taken to the operative suite, placed in a dorsal lithotomy position, and placed under IV sedation.  She was prepped and draped in the normal sterile fashion.  Her bladder was drained with the red Robinson catheter which produced approximately 100 cc of clear yellow urine.  A bimanual exam was done, was performed by Dr. X and Dr. Z.  The uterus was found to be anteverted, mobile, fully involuted to a pre-pregnancy stage.  The cervix and vagina were grossly normal with no obvious masses or deformities.  A weighted speculum was placed in the posterior aspect of the vagina and the anterior lip of the cervix was grasped with the vulsellum tenaculum.,The uterus was sounded to 8 cm.  The cervix was sterilely dilated with Hank dilator and then Hagar dilator.  At the time of blunt dilation, it was noticed that the dilator passed posteriorly with greater ease than it had previously.  The dilation was discontinued at that time because it was complete and the hysteroscope was placed into the uterus.  Under direct visualization, the ostia were within normal limits.  The endometrial lining was hyperplastic, however, there was no evidence of retained products or endometrial polyps.  The hyperplastic tissue did not appear to have calcification or other abnormalities.  There was a small area of the lower uterine segment posteriorly that was suspicious for endometrial perforation, however this area was hemostatic, no evidence of bowel involvement and was approximately 1 x 1 cm in nature.  The hysteroscope was removed and a sharp curette was placed intrauterine very carefully using a anterior wall for guidance.  Endometrial curettings were obtained and the posterior aspect suspicious for perforation was gently probed and seemed to have clamped down since the endometrial curetting.  The endometrial sampling was placed on Telfa pad and sent to Pathology for evaluation.  A rectal exam was performed at the end of the procedure which showed no hematoma formation in the posterior cul-de-sac.  There was a normal consistency of the cervix and the normal step-off.  The uterine curette was removed as well as the vulsellum tenaculum and the weighted speculum.  The cervix was found to be hemostatic.  The patient was taken off the dorsal lithotomy position and recovered from her IV sedation in the recovery room.  The patient will be sent home once stable from anesthesia.  She will be instructed to followup in the office in two weeks for discussion of the pathologic report of the endometrial curettings.  The patient is sent home on Tylenol #3 prescription as she is allergic to Motrin.  The patient is instructed to refrain from intercourse douching or using tampons for the next two weeks.  The patient is also instructed to contact us if she has any problems with further bleeding, fevers, or difficulty with urination.", Surgery,38
, ENT - Otolaryngology,11
"CHIEF COMPLAINT:,  Toothache.,HISTORY OF PRESENT ILLNESS:  ,This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled.  Complains of new tooth pain.  The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days.  The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only.  The patient denies any other problems or complaints.  The patient denies any recent illness or injuries.  The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  No recent weight change.  HEENT:  No headache, no neck pain, the toothache pain for the past three days as previously mentioned.  There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids.  The patient denies any rhinorrhea.  No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No focal weakness or numbness.  Normal speech.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling has been noted.,PAST MEDICAL HISTORY: , Chronic knee pain.,CURRENT MEDICATIONS: , OxyContin and Vicodin.,ALLERGIES:,  PENICILLIN AND CODEINE.,SOCIAL HISTORY: , The patient is still a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient is a little overweight but otherwise appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Eyes are normal with clear conjunctiva and cornea bilaterally.  There is no icterus, injection, or discharge.  Pupils are 3 mm and equally round and reactive to light bilaterally.  There is no absence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Ears are normal bilaterally without any sign of infection.  There is no erythema, swelling of canals.  Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it.  Nose is normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  NECK:  Supple, nontender, and full range of motion.  There is no meningismus.  No cervical lymphadenopathy.  No JVD.  Mouth and oropharynx shows multiple denture and multiple dental caries.  The patient has tenderness to tooth #12 as well as tooth #21.  The patient has normal gums.  There is no erythema or swelling.  There is no purulent or other discharge noted.  There is no fluctuance or suggestion of abscess.  There are no new dental fractures.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion or swelling.  The buccal membranes are normal.  Mucous membranes are moist.  The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally without shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to back, arms and legs.  The patient has normal use of his extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact to the extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No cervical lymphadenopathy is palpated.,EMERGENCY DEPARTMENT COURSE: , The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction.,DIAGNOSES:,1.  ODONTALGIA.,2.  MULTIPLE DENTAL CARIES.,CONDITION UPON DISPOSITION:  ,Stable.,DISPOSITION: , To home.,PLAN: , The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes.  The patient was requested to have reevaluation within two days.  The patient was given a prescription for Percocet and clindamycin.  The patient was given drug precautions for the use of these medicines.  The patient was offered discharge instructions on toothache but states that he already has it.  He declined the instructions.  The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.", Emergency Room Reports,12
"CHIEF COMPLAINT:,  Chronic otitis media.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth.  There is also associated chronic nasal congestion.  There had been no bouts of spontaneous tympanic membrane perforation, but there had been elevations of temperature up to 102 during the acute infection.  He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia.,ALLERGIES:,  None.,MEDICATIONS:,  None.,FAMILY HISTORY:,  Noncontributory.,MEDICAL HISTORY: , Mild reflux.,PREVIOUS SURGERIES:,  None.,SOCIAL HISTORY: , The patient is not in daycare.  There are no pets in the home.  There is no secondhand tobacco exposure.,PHYSICAL EXAMINATION: , Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present.  Left ear is still little bit black.  Nose, moderate inferior turbinate hypertrophy.  No polyps or purulence.  Oral cavity, oropharynx 2+ tonsils.  No exudates.  Neck, no nodes, masses or thyromegaly.  Lungs are clear to A&P.  Cardiac exam, regular rate and rhythm.  No murmurs.  Abdomen is soft and nontender.  Positive bowel sounds.,IMPRESSION: , Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, and wax accumulation.,PLAN:,  The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia.", ENT - Otolaryngology,11
"REFERRAL INDICATIONS,1.  Pacemaker at ERI.,2.  History AV block.,PROCEDURES PLANNED AND PERFORMED:,  Dual chamber generator replacement.,FLUOROSCOPY TIME: , 0 minutes.,MEDICATION AT THE TIME OF STUDY,1.  Ancef 1 g.,2.  Versed 2 mg.,3.  Fentanyl 50 mcg.,CLINICAL HISTORY:  ,The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to generator replacement have been discussed with the patient.  Risks including but not limited to bleeding, infection, vascular injury, and the need for pacemaker upgrade were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF OPERATION: , The patient was transported to the cardiac catheterization laboratory in a fasting state.  The region of the left dorsal pectoral groove was prepped and draped in a usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area of the previous incision.  A transverse incision was made through the skin and subcutaneous tissue.  Hemostasis was achieved with electrocautery.  Using blunt dissection, pacemaker, and leads were removed from the pocket.  Leads were disconnected from the pulse generator and interrogated.  The pocket was washed with antibiotic impregnated saline.  The new pulse generator was obtained and connected securely to the leads and placed back in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using running stitch.  Sponge and needle counts were correct at the end of the procedure.  No acute complications were noted.,DEVICE DATA,1.  Explanted pulse generator Medronic, product # KDR601, serial # ABCD1234.,2.  New pulse generator Medronic, product # ADDR01, serial # ABCD1234.,3.  Right atrial lead, product # 4068, serial # ABCD1234.,4.  Right atrial lead, product # 4068, serial # ABCD1234.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 572 ohms.  P wave measure 3.7 mV, pacing threshold 1.5 volts at 0.5 msec.,2.  Right ventricular lead impedance 365 ohms.  No R waves to measure, pacing threshold 0.9 volts at 0.5 msec.,CONCLUSIONS,1.  Successful dual chamber generator replacement.,2.  No acute complications.,PLAN,1.  She will be monitored for 3 hours and then dismissed home.,2.  Resume all medications.  Ex-home dismissal instructions.,3.  Doxycycline 100 mg one p.o. twice daily for 7 days.,4.  Wound check in 7-10 days.,5.  Continue followup in device clinic.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS:,  Headaches, question of temporal arteritis.,POSTOPERATIVE DIAGNOSIS:,  Headaches, question of temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was brought to the operating room where her right temporal area was prepped and draped in the usual fashion.  Xylocaine 1% was utilized and then an incision was made in front of the right ear and deepened anteriorly.  The temporal artery was found and exposed in an extension of about 2 cm.  The artery was proximally and distally ligated with 6-0 Prolene and also a side branch and a sample was sent for pathology.  Hemostasis achieved with a cautery and the incision was closed with a subcuticular suture of Monocryl.,Then, the patient was turned and her left temporal area was prepped and draped in the usual fashion.  A similar procedure was performed with 1% Xylocaine and exposed her temporal artery, which was excised in an extent to about 2 cm.  This was also proximally and distally ligated with 6-0 Prolene and also side branch.  Hemostasis was achieved with a cautery and the skin was closed with a subcuticular suture of Monocryl.,Dressings were applied to both areas.,The patient tolerated the procedure well.  Estimated blood loss was negligible, and the patient went back to Same Day Surgery for recovery.", Neurology,22
"PREOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,POSTOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,PROCEDURE PERFORMED:,1.  Partial tarsectomy navicula, right foot.,2.  Partial metatarsectomy, right foot.,HISTORY:  ,This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint.  The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin.  She states that she has been diagnosed with hereditary osteochondromas.  She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back.  The patient desires surgical treatment at this time.,PROCEDURE:  ,An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal.  Foot was then prepped and draped in the usual sterile orthopedic fashion.,Foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was then inflated to 250 mmHg.  The foot was lowered as well as the operating table.  The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge.  Attention was then directed to the navicular region on the right foot.  The area was palpated until the bony prominence was noted.  A curvilinear incision was made over the area of bony prominence.  At that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site.  The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  The dissection was carried down to the level of the capsule and periosteum.  A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone.  The periosteum and the capsule were then reflected from the navicular bone at this time.  A bony prominence was noted both medially and plantarly to the navicular bone.  An osteotome and mallet were then used to resect the enlarged portion of the navicular bone.  After resection with an osteotome there was noted to be a large plantar shelf.  The surrounding soft tissues were then freed from this plantar area.  Care was taken to protect the attachments of the posterior tibial tendon as much as possible.  Only minimal resection of its attachment to the fiber was performed in order to expose the bone.  Sagittal saw was then used to resect the remaining plantar medial prominent bone.  The area was then smoothed with reciprocating rasp until no sharp edges were noted.  The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted.  The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl.  The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed.,Attention was then directed to the fifth metatarsal.  There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal.  Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal.  The incision was then deepened with #15 blade.  Care was taken to preserve the extensor tendon.  The incision was then created over the capsule and periosteum of the fifth metatarsal head.  Capsule and periosteum were reflected both dorsally, laterally, and plantarly.  At that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal.  A sagittal saw was used to resect both of these osteal prominences.,All remaining sharp edges were then smoothed with reciprocating rasp.  The area was inspected for the remaining bony prominences and none was noted.  The area was flushed with copious amounts of sterile saline.  The capsule and periosteum were then reapproximated with #3-0 Vicryl.  Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line.  Running #5-0 subcutaneous stitch was then performed.  Steri-Strips were applied to both surgical sites.  Dressings consisted of Adaptic, soaked in Betadine, 4x4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred to the PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated.  The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise.", Surgery,38
"TITLE OF OPERATION:,1.  Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.,2.  Weil osteotomy with internal screw fixation, first right metatarsal.,3.  Arthroplasty, second right PIP joint.,PREOPERATIVE DIAGNOSES:,1.  Bunion deformity, right foot.,2.  Dislocated second right metatarsophalangeal joint.,3.  Hammertoe deformity, second right digit.,POSTOPERATIVE DIAGNOSES:,1.  Bunion deformity, right foot.,2.  Dislocated second right metatarsophalangeal joint.,3.  Hammertoe deformity, second right digit.,ANESTHESIA:,  Monitored anesthesia care with 20 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:,  60 minutes, a right ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,PREOPERATIVE INJECTABLES:  ,1 g Ancef IV 30 minutes preoperatively.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as two 16-mm partially treaded cannulated screws of the OsteoMed system, one 18-mm partially treaded cannulated screw of the OsteoMed system of the 3.0 size.  One 10-mm 2.0 partially threaded cannulated screw of the OsteoMed system.,DESCRIPTION OF THE PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in the supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical sites.  The right ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set up at 250 mmHg.  The right foot was then prepped, scrubbed, and draped in a normal sterile technique.  The right ankle tourniquet was then inflated.  Attention was then directed on the dorsomedial aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed parallel and medial to the course of the extensor hallucis longus tendon to the right great toe.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal and capsular tissues were mobilized from the head and neck of the first right metatarsal and the base of the proximal phalanx of the right great toe.  The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx and resected transversely.,A lateral capsulotomy was also performed at the level of the first right metatarsophalangeal joint.  Using sharp and dull dissection, the dorsomedial prominence of the first right metatarsal head was adequately exposed and resected with the use of a sagittal saw.  The same saw was used to perform the Austin osteotomy on the capital aspect of the first right metatarsal with its apex distal and its base proximal.  The dorsal arm of the osteotomy was longer than the plantar arm and noted to accommodate for the future internal fixation.  The capital fragment of the first right metatarsal was then transposed laterally and impacted on the shaft of the first right metatarsal.  Two wires of the OsteoMed system were also used as provisional fixation wires and also as guidewires for the insertion of the future screws.  The wires were inserted dorsal distal to plantar proximal through the dorsal arm of the osteotomy.  The two screws from the 3.0 OsteoMed system were inserted over the wires using AO technique.  One screw measured 16 mm, second screw measured 18 mm in length.  Both 3.0 screws were then evaluated for the fixation of the osteotomy after the wires were removed.  Fixation of the osteotomy was found to be excellent.  The dorsomedial prominence of the first right metatarsal shaft was then resected with the sagittal saw.  To improve the correction of the hallux abductus angle, an Akin osteotomy was also performed on the base of the proximal phalanx of the right great toe with its base medially and its apex laterally.  Upon removal of the base wedge from the base of the proximal phalanx, the osteotomy was reduced with the OsteoMed smooth wire, which was also used as a guidewire for the insertion of a 16-mm partially threaded cannulated screw from the OsteoMed 3.0 system.  Upon insertion of the screw, using AO technique, the wire was removed.  The screw was inserted proximal medial to distal lateral through the osteotomy of the base of the proximal phalanx of the right great toe.  Fixation of the osteotomy was found to be excellent.  Reduction of the bunion deformity was also found to be excellent and position of the first right metatarsophalangeal joint was found to be anatomical.  Range of motion of that joint was uninhibited.  The area was flushed copiously with saline.  Then, 3-0 suture material was used to approximate the periosteum and capsular tissues, 4-0 was used to approximate the subcutaneous tissues, and Steri-Strips were used to reinforce the incision.  Attention was directed over the neck of the second right metatarsal head where a 3-cm linear incision was placed directly over the surgical neck of the second right metatarsal.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped and cauterized.  The incision was deepened through the level of the periosteum over the surgical neck of the second right metatarsal.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the surgical neck of the second right metatarsal was adequately exposed and then Weil-type osteotomy was performed from dorsal distal to plantar proximal through the surgical neck of the second right metatarsal.  The capital fragment was then transposed proximally and impacted on the shaft of the second right metatarsal.,The 2.0 Osteo-Med system was also used to fixate this osteotomy wire from that system was inserted dorsal proximal to plantar distal through the second right metatarsal osteotomy and the wire was used as a guidewire for the insertion of the 10-mm partially threaded 2.0 cannulated screw.  Upon insertion of the screw, using AO technique, the wire was then removed.  Fixation of the osteotomy with 2.0 screw was found to be excellent.  The second right metatarsophalangeal joint was then relocated and the dislocation of that joint was completely reduced.  Range of motion of the second right metatarsophalangeal joint was found to be excellent.  Then, 3-0 Vicryl suture material was used to approximate the periosteal tissues.  Then, 4-0 Vicryl was used to approximate the skin incision.  Attention was then directed at the level of the PIP joint of the second right toe where two semi-elliptical incisions were placed directly over the bony prominence at the level of the second right PIP joint.  The island of skin between the two semi-elliptical incisions was resected in toto.  The dissection was carried down to the level of extensor digitorum longus of the second right toe, which was resected transversely at the level of the PIP joint.  A capsulotomy and a medial and lateral collateral ligament release of the PIP joint of the second right toe was also performed and head of the proximal phalanx of the second right digit was adequately exposed.  Using the double-action bone cutter, the head of the proximal phalanx of the second right toe was then resected.  The area was copiously flushed with saline.  The capsular and periosteal tissues were approximated with 2-0 Vicryl and 3-0 Vicryl suture material was also used to approximate the extensor digitorum longus to the second right toe.  A 5-0 Prolene was used to approximate the skin edges of the two semi-elliptical incisions.  Correction of the hammertoe deformity and relocation of the second right metatarsophalangeal joint were evaluated with the foot loaded and were found to be excellent and anatomical.  At this time, the patient's three incisions were covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's right ankle tourniquet was deflated, time was 60 minutes.  Immediate hyperemia was noted on the entire right lower extremity upon deflation of the cuffs.,The patient's right foot was placed in a surgical shoe and the patient was transferred to the recovery room under the care of anesthesia team with the vital signs stable and the vascular status at appropriate levels.  The patient was given instructions and education on how to continue caring for her right foot surgery.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.", Orthopedic,27
"CHIEF COMPLAINT:,  Questionable foreign body, right nose.  Belly and back pain.  ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain.  This does not seem to be slowing him down.  They have not noticed any change in his urine or bowels.  They have not noted him to have any fevers or chills or any other illness.  They state he is otherwise acting normally.  He is eating and drinking well.  He has not had any other acute complaints, although they have noted a foul odor coming from his nose.  Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics.  His nose got better and then started to become malodorous again.  Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there.  Otherwise, he has not had any runny nose, earache, no sore throat.  He has not had any cough, congestion.  He has been acting normally.  Eating and drinking okay.  No other significant complaints.  He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper.,PAST MEDICAL HISTORY: , Otherwise negative.,ALLERGIES: , No allergies.,MEDICATIONS: , No medications other than recent amoxicillin.,SOCIAL HISTORY: , Parents do smoke around the house.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.  He is afebrile.,GENERAL:  This is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance.,HEENT:  TMs, canals are normal.  Left naris normal.  Right naris, there is some foul odor as well as questionable purulent drainage.  Examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous.  This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual.  There was some erythema.  No other purulent drainage noted.  There was some bloody drainage.  This was suctioned and all mucous membranes were visualized and are negative.,NECK:  Without lymphadenopathy.  No other findings.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  His abdomen is entirely benign, soft, nontender, nondistended.  Bowel sounds active.  No organomegaly or mass noted.,BACK:  Without any findings.  Diaper area normal.,GU:  No rash or infections.  Skin is intact.,ED COURSE: , He also had a P-Bag placed, but did not have any urine.  Therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine.  There was a little bit of blood from catheterization but otherwise normal urine.  X-ray noted some stool within the vault.  Child is acting normally.  He is jumping up and down on the bed without any significant findings.,ASSESSMENT:,1.  Infected foreign body, right naris.,2.  Mild constipation.,PLAN:,  As far as the abdominal pain is concerned, they are to observe for any changes.  Return if worse, follow up with the primary care physician.  The right nose, I will place the child on amoxicillin 125 per 5 mL, 1 teaspoon t.i.d.  Return as needed and observe for more foreign bodies.  I suspect, the child had placed this cotton ball in his nose again after the first episode.", Emergency Room Reports,12
"CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture. There was minimal associated edema and no mass effect. Following extirpation of the tumor mass, she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions. In 11/91 she received BCNU and Procarbazine chemotherapy protocols. This was followed by four courses of 5FU/Carboplatin (3/92, 6/92, 9/92 ,10/92) chemotherapy.,On 10/12/92 she presented for her 4th course of 5FU/Carboplatin and complained of non-radiating dull low back pain, and proximal lower extremity weakness, but was still able to ambulate. She denied any bowel/bladder difficulty.,PMH: ,s/p oral surgery for wisdom tooth extraction.,FHX/SHX: ,1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.,MEDS: ,Decadron 12mg/day.,EXAM: ,Vitals unremarkable.,MS: Unremarkable.,Motor: 5/5 BUE, LE: 4+/5- prox, 5/5 distal to hips. Normal tone and muscle bulk.,Sensory: No deficits appreciated.,Coord: Unremarkable.,Station: No mention in record of being tested.,Gait: Mild difficulty climbing stairs.,Reflexes: 1+/1+ throughout and symmetric. Plantar responses were down-going bilaterally.,INITIAL IMPRESSION:, Steroid myopathy. Though there was enough of a suspicion of ""drop"" metastasis that an MRI of the L-spine was obtained.,COURSE:, The MRI L-spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris, suggestive of subarachnoid seeding of tumor. No focal mass or cord compression was visualized. CSF examination revealed: 19RBC, 22WBC, 17 Lymphocytes, and 5 histiocytes, Glucose 56, Protein 150. Cytology (negative). The patient was discharged home on 10/17/92, but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months. She was last seen on 3/3/93 and showed signs of worsening weakness (left hemiplegia: R > L) as her tumor grew and spread. She then entered a hospice.", Radiology,33
"PREOPERATIVE DIAGNOSIS:,  Iron deficiency anemia.,POSTOPERATIVE DIAGNOSIS:,  Diverticulosis.,PROCEDURE:,  Colonoscopy.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice.  Preparation was good, although there was some residual material in the cecum that was difficult to clear completely.  The mucosa was normal throughout the colon.  No polyps or other lesions were identified, and no blood was noted.  Some diverticula were seen of the sigmoid colon with no luminal narrowing or evidence of inflammation.  A retroflex view of the anorectal junction showed no hemorrhoids.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Diverticulosis in the sigmoid.,2.  Otherwise normal colonoscopy to the cecum.,RECOMMENDATIONS:,1.  Follow up with Dr. X as needed.,2.  Screening colonoscopy in 2 years.,3.  Additional evaluation for other causes of anemia may be appropriate.", Surgery,38
"CHIEF COMPLAINT: , Recurrent nasal obstruction.,HISTORY OF PRESENT ILLNESS:,  The patient is a 5-year-old male, who was last evaluated by Dr. F approximately one year ago for suspected nasal obstruction, possible sleep apnea.  Dr. F's assessment at that time was the patient not had sleep apnea and did not truly even seem to have allergic rhinitis.  All of his symptoms had resolved when he had seen Dr. F, so no surgical plan was made and no further followup was needed.  However, the patient reports again today with his mother that they are now having continued symptoms of nasal obstruction and questionable sleep changes.  Again, the mother gives a very confusing sleep history but it does not truly sound like the child is having apneic events that are obstructive in nature.  It sounds like he is snoring loudly and does have some nasal obstruction at nighttime.  He also is sniffing a lot through his nose.  He has been tried on some nasal steroids but they only use this on a p.r.n. basis about one or two days every month and we are unsure if that has even helped at all, probably not.  The child is not having any problems with his ears including ear infections or hearing.  He is also not having any problems with strep throat.,PAST MEDICAL HISTORY: , Eczema.,PAST SURGICAL HISTORY: , None.,MEDICATIONS:,  None.,ALLERGIES:,  No known drug allergies.,FAMILY HISTORY: , No family history of bleeding diathesis or anesthesia difficulties.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight 43 pounds, height 37 inches, temperature 97.4, pulse 65, and blood pressure 104/48.,GENERAL:  The patient is a well-nourished male in no acute distress.  Listening to his voice today in the clinic, he does not sound to have a hyponasal voice and has a wide range of consonant pronunciation.,NOSE:  Anterior rhinoscopy does demonstrate boggy turbinates bilaterally with minimal amount of watery rhinorrhea.,EARS:  The patient tympanic membranes are clear and intact bilaterally.  There is no middle ear effusion.,ORAL CAVITY:  The patient has 2+ tonsils bilaterally.  There are clearly nonobstructive.  His uvula is midline.,NECK:  No lymphadenopathy appreciated.,ASSESSMENT AND PLAN: , This is a 5-year-old male, who presents for repeat evaluation of a possible nasal obstruction, questionable sleep apnea.  Again, the mother gives a confusing sleep history but it does not really sound like he is having apneic events.  They deny any actual gasping events.  It sounds like true obstructive events.  He clearly has some symptoms at this point that would suggest possible allergic rhinitis or chronic rhinitis.  I think the most appropriate way to proceed would be to first try this child on a nasal corticosteroid and use it appropriately.  I have given them prescription for Nasacort Aqua one spray to each nostril twice a day.  I instructed them on correct way to use this and the importance to use it on a daily basis.  They may not see any benefit for several weeks.  I would like to evaluate him in six weeks to see how we are progressing.  If he continues to have problems, I think at that point we may consider performing a transnasal exam in the office to examine his adenoid bed and that would really be the only surgical option for this child.  He may also need an allergy evaluation at that point if he continues to have problems.  However, I would like to be fairly conservative in this child.  Should the mother still have concerns regarding his sleeping at our next visit or should his symptoms worsen (I did instruct her call us if it worsens), we may even need to pursue a sleep study just to settle that issue once and for all.  We will see him back in six weeks.", ENT - Otolaryngology,11
"PROCEDURE:, Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,INDICATION FOR THE PROCEDURE:, Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,MEDICATIONS:, General anesthesia.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, aspiration, and post ERCP pancreatitis.,DESCRIPTION OF PROCEDURE:, After informed consent and appropriate sedation, the duodenoscope was inserted into the oropharynx, down the esophagus, and into the stomach. The scope was then advanced through the pylorus to the ampulla. The ampulla had a markedly abnormal appearance, as it was enlarged and very prominent. It extended outward with an almost polypoid shape. It had what appeared to be adenomatous-appearing mucosa on the tip. There also was ulceration noted on the tip of this ampulla. The biliary and pancreatic orifices were identified. This was located not at the tip of the ampulla, but rather more towards the base. Cannulation was performed with a Wilson-Cooke TriTome sphincterotome with easy cannulation of the biliary tree. The common bile duct was mildly dilated, measuring approximately 12 mm. The intrahepatic ducts were minimally dilated. There were no filling defects identified. There was felt to be a possible stricture within the distal common bile duct, but this likely represented an anatomic variant given the abnormal shape of the ampulla. The patient has no evidence of obstruction based on lab work and clinically. Nevertheless, it was decided to proceed with brush cytology of this segment. This was done without any complications. There was adequate drainage of the biliary tree noted throughout the procedure. Multiple efforts were made to access the pancreatic ductal anatomy; however, because of the shape of the ampulla, this was unsuccessful. Efforts were made to proceed in a long scope position, but still were unsuccessful. Next, biopsies were obtained of the ampulla away from the biliary orifice. Four biopsies were taken. There was some minor oozing which had ceased by the end of the procedure. The stomach was then decompressed and the endoscope was withdrawn.,FINDINGS:,1. Abnormal papilla with bulging, polypoid appearance, and looks adenomatous with ulceration on the tip; biopsies taken.,2. Cholangiogram reveals mildly dilated common bile duct measuring 12 mm and possible distal CBD stricture, although I think this is likely an anatomic variant; brush cytology obtained.,3. Unable to access the pancreatic duct.,RECOMMENDATIONS:,1. NPO except ice chips today.,2. Will proceed with MRCP to better delineate pancreatic ductal anatomy.,3. Follow up biopsies and cytology.", Surgery,38
"CLINICAL HISTORY: , This is a 64-year-old male patient, who had a previous stress test, which was abnormal and hence has been referred for a stress test with imaging for further classification of coronary artery disease and ischemia.,PERTINENT MEDICATIONS:,  Include Tylenol, Robitussin, Colace, Fosamax, multivitamins, hydrochlorothiazide, Protonix and flaxseed oil.,With the patient at rest 10.5 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.,PROCEDURE AND INTERPRETATION: , The patient exercised for a total of 4 minutes and 41 seconds on the standard Bruce protocol.  The peak workload was 7 METs.  The resting heart rate was 61 beats per minute and the peak heart rate was 173 beats per minute, which was 85% of the age-predicted maximum heart rate response.  The blood pressure response was normal with the resting blood pressure 126/86, and the peak blood pressure of 134/90.  EKG at rest showed normal sinus rhythm with a right-bundle branch block.  The peak stress EKG was abnormal with 2 mm of ST segment depression in V3 to V6, which remained abnormal till about 6 to 8 minutes into recovery.  There were occasional PVCs, but no sustained arrhythmia.  The patient had an episode of supraventricular tachycardia at peak stress.  The ischemic threshold was at a heart rate of 118 beats per minute and at 4.6 METs.  At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting images.,MYOCARDIAL PERFUSION IMAGING:,1.  The overall quality of the scan was fair in view of increased abdominal uptake, increased bowel uptake seen.,2.  There was a large area of moderate to reduced tracer concentration seen in the inferior wall and the inferior apex.  This appeared to be partially reversible in the resting images.,3.  The left ventricle appeared normal in size.,4.  Gated SPECT images revealed normal wall motion and normal left ventricular systolic function with normal wall thickening.  The calculated ejection fraction was 70% at rest.,CONCLUSIONS:,1.  Average exercise tolerance.,2.  Adequate cardiac stress.,3.  Abnormal EKG response to stress, consistent with ischemia.  No symptoms of chest pain at rest.,4.  Myocardial perfusion imaging was abnormal with a large-sized, moderate intensity partially reversible inferior wall and inferior apical defect, consistent with inferior wall ischemia and inferior apical ischemia.,5.  The patient had run of SVT at peak stress.,6.  Gated SPECT images revealed normal wall motion and normal left ventricular systolic function.", Radiology,33
"CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS:  ,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.  He described the pain as 8/10 in severity and the intensity varied.  The symptoms persisted and he subsequently developed nausea and vomiting at 3 a.m. in the morning of admission.  The patient vomited twice and he states that he did note a temporary decrease in pain following his vomiting.  The patient was brought to the emergency room approximately 4 a.m. and evaluation including the CT scan, which revealed dilated loops of bowel without obvious obstruction.  The patient was subsequently admitted for possible obstruction.  The patient does have a history of previous small bowel obstruction approximately 20 times all but 2 required hospitalization, but all resolved with conservative measures (IV fluid, NG tube decompression, bowel rest.)  He has had previous abdominal surgeries including colon resection for colon CA and cholecystectomy as well as appendectomy.,PAST HISTORY: , Hypertension treated with Cozaar 100 mg daily and Norvasc 10 mg daily.  Esophageal reflux treated with Nexium 40 mg daily.  Allergic rhinitis treated with Allegra 180 mg daily.  Sleep disturbances, depression and anxiety treated with Paxil 25 mg daily, Advair 10 mg nightly and Ativan 1 mg nightly.  Glaucoma treated with Xalatan drops.  History of chronic bronchitis with no smoking history for which he uses p.r.n. Flovent and Serevent.,PREVIOUS SURGERIES:  ,Partial colon resection of colon carcinoma in 1961 with no recurrence, cholecystectomy 10 years ago, appendectomy, and glaucoma surgery.,FAMILY HISTORY: , Father died at age 85 of ""old age,"" mother died at age 89 of ""old age.""  Brother died at age 92 of old age, 2 brothers died in their 70s of Parkinson disease.  Son is at age 58 and has a history of hypertension, hypercholesterolemia, rheumatoid arthritis, and glaucoma.,SOCIAL HISTORY:  ,The patient is widowed and a retired engineer.  He denies cigarettes smoking or alcohol intake.,REVIEW OF SYSTEMS: , Denies fevers or weight loss.  HEENT:  Denies headaches, visual abnormality, decreased hearing, tinnitus, rhinorrhea, epistaxis or sore throat.  Neck:  Denies neck stiffness, no pain or masses in the neck.  Respiratory:  Denies cough, sputum production, hemoptysis, wheezing or shortness of breath.  Cardiovascular:  Denies chest pain, angina pectoris, DOE, PND, orthopnea, edema or palpitation.  Gastrointestinal:  See history of the present illness.  Urinary:  Denies dysuria, frequency, urgency or hematuria.  Neuro:  Denies seizure, syncope, incoordination, hemiparesis or paresthesias.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-developed, well-nourished elderly white male who is currently in no acute distress after receiving analgesics.,HEENT:  Atraumatic, normocephalic.  Eyes, EOMs full, PERRLA.  Fundi benign.  TMs normal.  Nose clear.  Throat benign.,NECK:  Supple with no adenopathy.  Carotid upstrokes normal with no bruits.  Thyroid is not enlarged.,LUNGS:  Clear to percussion and auscultation.,HEART:  Regular rate, normal S1 and S2 with no murmurs or gallops.  PMI is nondisplaced.,ABDOMEN:  Mildly distended with mild diffuse tenderness.  There is no rebound or guarding.  Bowel sounds are hypoactive.,EXTREMITIES:  No cyanosis, clubbing or edema.  Pulses are strong and intact throughout.,GENITALIA:  Atrophic male, no scrotal masses or tenderness.  Testicles are atrophic.  No hernia is noted.,RECTAL:  Unremarkable, prostate was not enlarged and there were no nodules or tenderness.,LAB DATA:,  WBC 12.1, hemoglobin and hematocrit 16.9/52.1, platelets 277,000.  Sodium 137, potassium 3.9, chloride 100, bicarbonate 26, BUN 27, creatinine 1.4, glucose 157, amylase 103, lipase 44.  Alkaline phosphatase, AST and ALT are all normal.  UA is negative.,Abdomen and pelvic CT showed mild stomach distention with multiple fluid-filled loops of bowel, no obvious obstruction noted.,IMPRESSION:,1.  Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction.,2.  Hypertension.,3.  Esophageal reflux.,4.  Allergic rhinitis.,5.  Glaucoma.,PLAN: , The patient is admitted to the medical floor.  He has been kept NPO and will be given IV fluids.  He will also be given antiemetic medications with Zofran and an analgesic as necessary.  General surgery consultation was obtained.  Abdominal series x-ray will be done.", Consult - History and Phy.,5
"CHIEF COMPLAINT: , Blood in urine.,HISTORY OF PRESENT ILLNESS:  ,This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder.  The patient has had problems with hematuria in the past, but the patient noted that this episode began yesterday, and today he has been passing principally blood with very little urine.  The patient states that there is no change in his chronic lower back pain and denies any incontinence of urine or stool.  The patient has not had any fever.  There is no abdominal pain and the patient is still able to pass urine.  The patient has not had any melena or hematochezia.  There is no nausea or vomiting.  The patient has already completed chemotherapy and is beyond treatment for his cancer at this time.  The patient is receiving radiation therapy, but it is targeted to the bones and intended to give symptomatic relief of his skeletal pain and not intended to treat and cure the cancer.  The patient is not enlisted in hospice, but the principle around the patient's current treatment management is focusing on comfort care measures.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  The patient does report generalized fatigue and weakness over the past several days.  HEENT:  No headache, no neck pain, no rhinorrhea, no sore throat.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough, although the patient does get easily winded with exertion over these past few days.  GASTROINTESTINAL:  The patient denies any abdominal pain.  No nausea or vomiting.  No changes in the bowel movement.  No melena or hematochezia.  GENITOURINARY:  A gross hematuria since yesterday as previously described.  The patient is still able to pass urine without difficulty.  The patient denies any groin pain.  The patient denies any other changes to the genital region.  MUSCULOSKELETAL:  The chronic lower back pain which has not changed over these past few days.  The patient does have multiple other joints, which cause him discomfort, but there have been no recent changes in these either.  SKIN:  No rashes or lesions.  No easy bruising.  NEUROLOGIC:  No focal weakness or numbness.  No incontinence of urine or stool.  No saddle paresthesia.  No dizziness, syncope or near-syncope.  ENDOCRINE:  No polyuria or polydipsia.  No heat or cold intolerance.  HEMATOLOGIC/LYMPHATIC:  The patient does not have a history of easy bruising or bleeding, but the patient has had previous episodes of hematuria.,PAST MEDICAL HISTORY: , Prostate cancer with metastatic disease as previously described.,PAST SURGICAL HISTORY: , TURP.,CURRENT MEDICATIONS:,  Morphine, Darvocet, Flomax, Avodart and ibuprofen.,ALLERGIES: , VICODIN.,SOCIAL HISTORY: , The patient is a nonsmoker.  Denies any alcohol or illicit drug use.  The patient does live with his family.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure is 108/65, pulse is 109, respirations 16, oxygen saturation is 97% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed.  The patient appears to be pale, but otherwise looks well.  The patient is calm, comfortable.  The patient is pleasant and cooperative.  HEENT:  Eyes normal with clear conjunctivae and corneas.  Nose is normal without rhinorrhea or audible congestion.  Mouth and oropharynx normal without any sign of infection.  Mucous membranes are moist.  NECK:  Supple.  Full range of motion.  No JVD.  CARDIOVASCULAR:  Heart is mildly tachycardic with regular rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, nondistended.  No rebound or guarding.  No hepatosplenomegaly.  Normal bowel sounds.  No bruit.  No masses or pulsatile masses.  GENITOURINARY:  The patient has normal male genitalia, uncircumcised.  There is no active bleeding from the penis at this time.  There is no swelling of the testicles.  There are no masses palpated to the testicles, scrotum or the penis.  There are no lesions or rashes noted.  There is no inguinal lymphadenopathy.  Normal male exam.  MUSCULOSKELETAL:  Back is normal and nontender.  There are no abnormalities noted to the arms or legs.  The patient has normal use of the extremities.  SKIN:  The patient appears to be pale, but otherwise the skin is normal.  There are no rashes or lesions.  NEUROLOGIC:  Motor and sensory are intact to the extremities.  The patient has normal speech.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  There is no evidence of bruising noted to the body.  No lymphadenitis is palpated.,EMERGENCY DEPARTMENT TESTING:,  CBC was done, which had a hemoglobin of 7.7 and hematocrit of 22.6.  Neutrophils were 81%.  The RDW was 18.5, and the rest of the values were all within normal limits and unremarkable.  Chemistry had a sodium of 134, a glucose of 132, calcium is 8.2, and rest of the values are unremarkable.  Alkaline phosphatase was 770 and albumin was 2.4.  Rest of the values all are within normal limits of the LFTs.  Urinalysis was grossly bloody with a large amount of blood and greater than 50 rbc's.  The patient also had greater than 300 of the protein reading, moderate leukocytes, 30-50 white blood cells, but no bacteria were seen.  Coagulation profile study had a PT of 15.9, PTT of 43 and INR of 1.3.,EMERGENCY DEPARTMENT COURSE: , The patient was given normal saline 2 liters over 1 hour without any adverse effect.  The patient was given multiple doses of morphine to maintain his comfort while here in the emergency room without any adverse effect.  The patient was given Levaquin 500 mg by mouth as well as 2 doses of Phenergan over the course of his stay here in the emergency department.  The patient did not have an adverse reaction to these medicines either.  Phenergan resolved his nausea and morphine did relieve his pain and make him pain free.  I spoke with Dr. X, the patient's urologist, about most appropriate step for the patient, and Dr. X said he would be happy to care for the patient in the hospital and do urologic scopes if necessary and surgery if necessary and blood transfusion.  It was all a matter of what the patient wished to do given the advanced stage of his cancer.  Dr. X was willing to assist in any way the patient wished him to.  I spoke with the patient and his son about what he would like to do and what the options were from doing nothing from keeping him comfortable with pain medicines to admitting him to the hospital with the possibility of scopes and even surgery being done as well as the blood transfusion.  The patient decided to choose a middle ground in which he would be transfused with 2 units of blood here in the emergency room and go home tonight.  The patient's son felt comfortable with his father's choice.  This was done.  The patient was transfused 2 units of packed red blood cells after appropriately typed and match.  The patient did not have any adverse reaction at any point with his transfusion.  There was no fever, no shortness of breath, and at the time of disposition, the patient stated he felt a little better and felt like he had a little more strength.  Over the course of the patient's several-hour stay in the emergency room, the patient did end up developing enough problems with clotted blood in his bladder that he had a urinary obstruction.  Foley catheter was placed, which produced bloody urine and relieved the developing discomfort of a full bladder.  The patient was given a leg bag and the Foley catheter was left in place.,DIAGNOSES,1.  HEMATURIA.,2.  PROSTATE CANCER WITH BONE AND BLADDER METASTATIC DISEASE.,3.  SIGNIFICANT ANEMIA.,4.  URINARY OBSTRUCTION.,CONDITION ON DISPOSITION:  ,Fair, but improved.,DISPOSITION: , To home with his son.,PLAN: , We will have the patient follow up with Dr. X in his office in 2 days for reevaluation.  The patient was given a prescription for Levaquin and Phenergan tablets to take home with him tonight.  The patient was encouraged to drink extra water.  The patient was given discharge instructions on hematuria and asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern.", Consult - History and Phy.,5
"PROCEDURE PERFORMED:,  Right heart catheterization.,INDICATION: , Refractory CHF to maximum medical therapy.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient and the patient's family in detail, informed consent was obtained both verbally and in writing.  The patient was taken to Cardiac Catheterization Suite where the right internal jugular region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein.  Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right internal jugular vein.  A steel guidewire was then inserted through the needle into the vessel without resistance.  Small nick was then made in the skin and the needle was removed.  An #8.5 French venous sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  A Swan-Ganz catheter was inserted to 20 cm and the balloon was inflated.  Under fluoroscopic guidance, the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position.  Hemodynamics were measured along the way.  Pulmonary artery saturation was obtained.  The Swan was then kept in place for the patient to be transferred to the ICU for further medical titration.  The patient tolerated the procedure well.  The patient returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,  Body surface area equals 2.04, hemoglobin equals 9.3, O2 is at 2 liters nasal cannula.  Pulmonary artery saturation equals 37.8.  Pulse oximetry on 2 liters nasal cannula equals 93%.  Right atrial pressure is 8, right ventricular pressure equals 59/9, pulmonary artery pressure equals 61/31 with mean of 43, pulmonary artery wedge pressure equals 21, cardiac output equals 3.3 by the Fick method, cardiac index is 1.6 by the Fick method, systemic vascular resistance equals 1821, and transpulmonic gradient equals 22.,IMPRESSION:  ,Exam and Swan findings consistent with low perfusion given that the mixed venous O2 is only 38% on current medical therapy as well as elevated right-sided filling pressures and a high systemic vascular resistance.,PLAN: , Given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve, the patient will need to be discharged home on Primacor.  The patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia.  At this time, we will transfer the patient to the Intensive Care Unit for titration of the Primacor therapy.  We will also increase his Lasix to 80 mg IV q.d.  We will increase his amiodarone to 400 mg daily.  We will also continue with his Coumadin therapy.  As stated previously, we will discontinue vasodilator therapy starting with the Isordil.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Possible inflammatory bowel disease.,POSTOPERATIVE DIAGNOSIS: , Polyp of the sigmoid colon.,PROCEDURE PERFORMED:  ,Total colonoscopy with photography and polypectomy.,GROSS FINDINGS: , The patient had a history of ischiorectal abscess.  He has been evaluated now for inflammatory bowel disease.  Upon endoscopy, the colon prep was good.  We were able to reach the cecum without difficulty.  There are no diverticluli, inflammatory bowel disease, strictures, or obstructing lesions.  There was a pedunculated polyp approximately 4.5 cm in size located in the sigmoid colon at approximately 35 cm.  This large polyp was removed using the snare technique.,OPERATIVE PROCEDURE:  ,The patient was taken to the endoscopy suite, prepped and draped in left lateral decubitus position.  IV sedation was given by Anesthesia Department.  The Olympus videoscope was inserted into anus.  Using air insufflation, the colonoscope was advanced through the anus to the rectum, sigmoid colon, descending colon, transverse colon, ascending colon and cecum, the above gross findings were noted.  The colonoscope was slowly withdrawn and carefully examined the lumen of the bowel.  When the polyp again was visualized, the snare was passed around the polyp.  It required at least two to three passes of the snare to remove the polyp in its totality.  There was a large stalk on the polyp.  ________ the polyp had been removed down to the junction of the polyp in the stalk, which appeared to be cauterized and no residual adenomatous tissue was present.  No bleeding was identified.  The colonoscope was then removed and patient was sent to recovery room in stable condition.", Surgery,38
"GENERAL APPEARANCE: , This is a well-developed and well-nourished, ??,VITAL SIGNS: , Blood pressure ??, heart rate ?? and regular, respiratory rate ??, temperature is ?? degrees Fahrenheit.  Height is ?? feet ?? inches.  Weight is ?? pounds.  This yields a body mass index of ??.,HEAD, EYES, EARS, NOSE AND THROAT:,  The pupils were equal, round and reactive to light.  Extraocular movements are intact.  Sclera are nonicteric.  Ears, nose, mouth and throat - Externally the ears and nose are normal.  The mucous membranes are moist and midline.,NECK:  ,The neck is supple without masses.  No thyromegaly, no carotid bruits, no adenopathy.,LUNGS:  ,There is a normal respiratory effort.  Bilateral breath sounds are clear.  No wheezes or rales or rhonchi.,CARDIAC: , Normal cardiac impulse location.  S1 and S2 are normal.  No rubs, murmurs or gallops.  A regular rate and rhythm.  There are no abdominal aortic bruits.  The carotid, brachial, radial, femoral, popliteal and dorsalis pedis pulses are 2+ and equal bilaterally.,EXTREMITIES: , The extremities are without clubbing, cyanosis, or edema.,CHEST: , The chest examination is unremarkable.,BREASTS:  ,The breasts show no masses or tenderness.  No axillary adenopathy.,ABDOMEN:,  The abdomen is flat, soft, nontender, no organomegaly, no masses, normal bowel sounds are present.,RECTAL: , Examination was deferred.,LYMPHATIC: , No neck, axillary or groin adenopathy was noted.,SKIN EXAMINATION:,  Unremarkable.,MUSCULOSKELETAL EXAMINATION: , Grossly normal.,NEUROLOGIC: , The cranial nerves two through twelve are grossly intact.  Patellar and biceps reflexes are normal.,PSYCHIATRIC: , The patient is awake, alert and oriented times three.  Judgment and insight are good.  Affect is appropriate.", Office Notes,25
"PROCEDURE IN DETAIL:,  After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table.  After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty.  The patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus.  The 4 rectus muscles were looped and isolated using 2-0 silk suture.  The retinal periphery was then inspected via indirect ophthalmoscopy.,", Ophthalmology,26
"REASON FOR VISIT: , The patient referred by Dr. X for evaluation of her possible tethered cord.,HISTORY OF PRESENT ILLNESS:,  Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.  The last surgery was in 03/95.  She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM.,Denies any new bowel or bladder dysfunction or increased sensory loss.  She had some patchy sensory loss from L4 to S1.,MEDICATIONS: , Singulair for occasional asthma.,FINDINGS: , She is awake, alert, and oriented x 3.  Pupils equal and reactive.  EOMs are full.  Motor is 5 out of 5.  She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus.  There is no evidence of clonus.  There is diminished sensation from L4 to S1, having proprioception.,ASSESSMENT AND PLAN: , Possible tethered cord.  I had a thorough discussion with the patient and her parents.  I have recommended a repeat MRI scan.  The prescription was given today.  MRI of the lumbar spine was just completed.  I would like to see her back in clinic.  We did discuss the possible symptoms of this tethering.", Consult - History and Phy.,5
"TITLE OF OPERATION:,1.  Diagnostic arthroscopy exam under anesthesia, left shoulder.,2.  Debridement of chondral injury, left shoulder.,3.  Debridement, superior glenoid, left shoulder.,4.  Arthrotomy.,5.  Bankart lesion repair.,6.  Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).,INDICATION FOR SURGERY: , The patient was seen multiple times preoperatively and found to have chronic instability of her shoulder.  Risks and benefits of the procedure had been discussed in length including but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, continued instability, recurrent instability, medical complications, surgical complications, and anesthesia complications.  The patient understood and wishes to proceed.,PREOP DIAGNOSIS: , Anterior instability, left shoulder.,POSTOP DIAGNOSES:,1.  Anterior instability, left shoulder.,2.  Grade 4 chondromalacia, 10% humeral head, chondral defect 1 cm squared, left shoulder.,3.  Type 1 superior labrum anterior and posterior lesion, left shoulder.,4.  Anteroinferior glenoid erosions 10% bony surface, left shoulder.,5.  Bankart lesion, left shoulder.,PROCEDURE: , The patient was placed in a supine position and both shoulders examined systematically.  She had full range of motion with no joint adhesions.  She had equal range of motion bilaterally.  She had Hawkins 2 anteriorly and posteriorly in both shoulders with a grade 1 sulcus sign in both shoulders.  This was the same when the arm was in neutral or in external rotation.  The patient was then turned to right lateral decubitus position, axillary roll was placed, and beanbag was inflated.  Peroneal nerve was well protected.  All bony prominences were well protected.,The left upper extremity was then prepped and draped in the usual sterile fashion.  The patient was given antibiotics well before the start of the procedure to decrease the risk of infection.  The arm was placed in a arm holder with 10 pounds of traction.  A posterior portal was created in the usual manner by isolating gently with the spinal needle, it was insufflated with 30 cubic centimeters of saline.  A small incision was made after infiltrating the skin with Marcaine and epinephrine.  The scope was introduced into the shoulder with no difficulty.  It was then examined systematically.  The patient did have diffuse synovitis throughout her shoulder.  Her posterior humeral head showed an enlarged bold spot with some other areas of chondromalacia on the posterior head.  She also had an area 1 cm in diameter, which was on more central portion of the head and more inferiorly which appeared to be more of an impaction-type injury.  This had some portions of fibrillated and loose cartilage, hanging from the edges.  These were later debrided, but the dissection was proximally 10 to 15% of the humeral surface.,The biceps tendon appeared to be normal.  The supraspinatus, infraspinatus tendons were normal.  The inferior pouch was normal with no capsular tearing and no HAGL lesions.  The posteroinferior labrum was normal as well as the posterosuperior labrum.  There was some fraying in the posterosuperior labrum, which was later debrided.  It was found essentially to be a type 1 lesion anteriorly and superiorly.  The anterosuperior labrum appeared to be detached, which appeared to be more consistent with a sublabral hole.  The middle glenohumeral ligament was present as an entire sheath, but attach to the labrum.  The labrum did appeared to be detached from the anterior glenoid from the 11 o'clock position all the way down to the 6 o'clock position.  The biceps anchor itself was later probed and found to be stable and normal.  The subscapularis tendon was normal.  The anterior band of the glenohumeral ligament was present, but it was clearly avulsed off the glenoid.  There was some suggestion of anteroinferior bony erosions, which was later substantiated when the shoulder was opened.  The patient was missing about 10 to 15% of her anteroinferior glenoid rim.  The patient had a positive drive-through sign.,The arm was then moved to lateral and placed through range of motion.  There was contact of the rotator cuff to the superior glenoid in flexion at 115 degrees, maximum flexion was 150 degrees.  The arm abducted and externally rotated.  There was contact to the rotator cuff with posterosuperior labrum.  This occurred with the arm position of 90 degrees with abduction at 55 degrees of external rotation.  It should be noted that the maximum abduction is 150 degrees and with the arm abducted 90 degrees, maximum external rotation was 95 degrees.  The patient did have a positive relocation maneuver.  The posterior labrum did appear to tilt-off, but did not appear to peel off.,The arm was then placed back in the arm holder.  Anterior portal was created with Wissinger rod.  A blue cannula was inserted into the shoulder without difficulty.  Shaver was introduced in the labrum.  Also the area of chondromalacia as mentioned above was debrided.  The labrum was found to be stable with only a type 1 SLAP lesion, and there was no evidence as there was really a type 2 SLAP lesion.  The instruments were then removed along with excess fluid.  The posterior portals were closed with single 4-0 nylon suture.  The anterior portal was left open.  The patient was then placed in a supine position, and the extremity was reprepped and draped in anticipation of performing open capsular shift.,The patient's anterior incision made just lateral to the coracoid in the skin line.  Mediolateral skin flaps were developed, and cephalic vein was identified and protected throughout the case.  The interval was developed down the clavipectoral fascia.  The conjoined tendon was retracted medially and the deltoid laterally.  The patient's subscapularis was intact, and the subscapularis split was then made between the upper one half and lower one half in line with muscle fibers.  The capsule could easily be detached from the muscle, and the interval developed very easily.  A retractor was placed inferiorly to protect the axillary nerve.  Then Gelpi retractor was used to hold the subscapularis split open.,Next, an arthrotomy was made down at the 9 o'clock position.  The labrum was identified and found to be attached all the way down to 6 o'clock position.  The inferior flap was then created in a usual manner and tied with a 0 Vicryl suture.  The patient's glenoid rim did have some erosion as mentioned above with some bone loss and flattening.  This was debrided with the soft tissue.  Three Mitek suture anchors were then placed into the glenoid rim right at the margin of articular cartilage to the scapular neck.  These were absorbable anchors with nonabsorbable sutures.  They had excellent fixation once they had been placed.,Next, the capsular shift and Bankart repair were performed in the usual manner with the number 2 Ti-Cron sutures as an outside in and then inside out technique.  This brought the capsule right up to the edge of the glenoid rim.  With the arm in internal rotation and posterior pressure on the head, the capsule was then secured to the rim with no difficulty under direct visualization.  The capsule did come right up into the joint as expected with this type of repair.  The superior flap was then closed, the inferior flap over the superior anchor.  The interval between two flaps was closed with multiple number 2 Ti-Cron sutures.  Once this has been completed, there was no tension on the repair with the arm to side until 10 degrees of external rotation was reached.  The arm abducted 90 degrees.  There was tension on the repair until 20 degrees of external rotation reached.,The wound was thoroughly irrigated throughout with antibiotic-impregnated irrigation.  The subscapularis split was closed with interrupted 0 Vicryl sutures.  The deep subcutaneous tissues were closed with interrupted 0 Vicryl sutures.  The superficial subcutaneous tissues were closed with number 2-0 Vicryl sutures.  The skin was closed with 4-0 subcuticular Prolene, reinforced with Steri-Strips.  A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer.  The patient was sent to the recovery room in stable and satisfactory condition.", Orthopedic,27
"DISCHARGE DIAGNOSIS:,1.  Epigastric pain.  Questionable gastritis, questionable underlying myocardial ischemia.,2.  Congestive heart failure exacerbation.,3.  Small pericardial effusion with no tamponade.,4.  Hypothyroidism.,5.  Questionable subacute infarct versus neoplasm in the pons.,6.  History of coronary artery disease, status post angioplasty and stent.,7.  Hypokalemia.,CLINICAL RESUME: , This 83 year-old woman who presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months.  She has had extensive work up and had her gallbladder removed on April 22, 2007, and had an endoscopy, which had demonstrative gastric ulcer disease apparently about a year ago.  She has had abdominal CAT scan and gastric emptying studies which was normal.,A CT scan of the abdomen done on her May 9, 2007, which showed bilateral peripelvic renal cysts and a redundant sigmoid colon.  Otherwise unremarkable.  The patient follows with Dr. XYZ as an outpatient.  The patient had some worsening of her symptoms over the last few days and then came to the ER.  She was admitted.  Please refer to Dr. XYZ initial H&P for complete details.,HOSPITAL COURSE:,1.  Epigastric pain, nausea, and vomiting.  The patient was restituted with antiemetics and her symptoms improved.  It was not clear whether her nausea and abdominal pain were due to gastritis, peptic ulcer disease/gastric ischemia, or cardiac origin.  A brain MRI was also done which basically showed a tiny focus of abnormal enhancement in the pons, which could be subacute like infarct.  However, brain neoplasm could not be excluded.  Other workup including a CT angio did not show any evidence of acute pulmonary emboli.  It showed some moderate cardiomegaly with bilateral pleural effusions, and a small pericardial effusion.  The patient underwent Cardiolite stress test but finished only the resting studies, which was inconclusive.  She refused to complete the stress test.  She was seen by Dr. XYZ in consultation who recommended that the patient should have a small bowel follow through and eventually angiogram as an outpatient.,2.  Congestive heart failure exacerbation.  The patient was treated with ACE inhibitors, diuretics, Aldactone, and Lasix, and improved.  An echocardiogram done showed an ejection fraction of about 30% to 35%, mild water decrease in LV systolic function, with multiple segmental wall motion abnormalities, a small anterior pericardial effusion, but no electrocardiographic signs of cardiac tamponade.  There was some pseudo normal pattern of filling, mild MR and global hypokinesis of the LV.,3.  Small pericardial effusion.  The patient did not have any clinical or echocardiographic evidence of tamponade.,4.  Hypothyroidism.  TSH was quite elevated at 19.,5.  Questionable subacute infarct versus neoplasm in the pons on an MRI of the head.,6.  History of coronary artery disease/angioplasty and stents.,7.  Hyperkalemia.,8.  Patient was doing well.  She was back to her baseline and was refusing further workup and the patient was stable and it was felt she could be safely discharged home to have further testing done as an outpatient.,MEDICATIONS AND ADVICE ON DISCHARGE:,1.  She is to continue taking Coreg 12.5 mg p.o. b.i.d.,2.  Cozaar 50 mg p.o. daily.,3.  Aldactone 25 mg p.o. daily.,4.  Synthroid 0.075 mg p.o. daily.,5.  Carafate 1 gram p.o.  4 times a day.,6.  Claritin 10 mg p.o. daily.,7.  Lasix 20 mg p.o. daily.,8.  K-Dur 20 mEq p.o. daily.,9.  Prilosec 40 mg p.o. daily.,10.  Zofran 4 mg p.o. q.4-6 hourly p.r.n.,She is to follow up with her primary care physician, Dr. XYZ in 2 to 3 days' time.  She is to follow up with Dr. XYZ her cardiologist in 1 to 2 days' time.  She is to follow up with Dr. XYZ from GI as scheduled.  The patient was advised that she will need a small bowel follow through with angiogram which can be arranged by her gastroenterologist as an outpatient.  She was also advised that she would need a repeat MRI of her head in 2 to 3 months' time.  She will also need repeat echocardiogram done in one month for a pericardial effusion.  This can be arranged by her primary care physician.  Repeat TSH to be done in 6 weeks' time.,Over 35 minutes were spent in the patient discharged.", General Medicine,15
"HISTORY OF PRESENT ILLNESS:,  This 66-year-old white male was seen in my office on Month DD, YYYY.  Patient was recently discharged from Doctors Hospital at Parkway after he was treated for pneumonia.  Patient continues to have severe orthopnea, paroxysmal nocturnal dyspnea, cough with greenish expectoration.  His exercise tolerance is about two to three yards for shortness of breath.  The patient stopped taking Coumadin for reasons not very clear to him.  He was documented to have recent atrial fibrillation.  Patient has longstanding history of ischemic heart disease, end-stage LV systolic dysfunction, and is status post ICD implantation.  Fasting blood sugar this morning is 130.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Blood pressure is 120/60.  Respirations 18 per minute.  Heart rate 75-85 beats per minute, irregular.  Weight 207 pounds.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good. ,NECK:  Supple.  JVP is flat.  Carotid upstroke is good. ,LUNGS:  Severe inspiratory and expiratory wheezing heard throughout the lung fields.  Fine crepitations heard at the base of the lungs on both sides. ,CARDIOVASCULAR:  PMI felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. First and second heart sounds are normal in character.  There is a II/VI systolic murmur best heard at the apex.,ABDOMEN:  Soft.  There is no hepatosplenomegaly.,EXTREMITIES:  Patient has 1+ pedal edema.,MEDICATIONS: , ,1.  Ambien 10 mg at bedtime p.r.n.,2.  Coumadin 7.5 mg daily.,3.  Diovan 320 mg daily.,4.  Lantus insulin 50 units in the morning.,5.  Lasix 80 mg daily.,6.  Novolin R p.r.n.,7.  Toprol XL 100 mg daily.,8.  Flovent 100 mcg twice a day.,DIAGNOSES:,1.  Atherosclerotic coronary vascular disease with old myocardial infarction.,2.  Moderate to severe LV systolic dysfunction.,3.  Diabetes mellitus.,4.  Diabetic nephropathy and renal failure.,5.  Status post ICD implantation.,6.  New onset of atrial fibrillation.,7.  Chronic Coumadin therapy.,PLAN:,1.  Continue present therapy.,2.  Patient will be seen again in my office in four weeks.", Office Notes,25
"PREOPERATIVE DIAGNOSIS: , Nasal deformity, status post rhinoplasty.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,  Revision rhinoplasty (CPT 30450).  Left conchal cartilage harvest (CPT 21235).,ANESTHESIA: , General.,INDICATIONS FOR THE PROCEDURE: , This patient is an otherwise healthy male who had a previous nasal fracture.  During his healing, perioperatively he did sustain a hockey puck to the nose resulting in a saddle-nose deformity with septal hematoma.  The patient healed status post rhinoplasty as a result but was left with a persistent saddle-nose dorsal defect.  The patient was consented for the above-stated procedure.  The risks, benefits, and alternatives were discussed.,DESCRIPTION OF PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion.  The patient did have approximately 12 mL of Lidocaine with epinephrine 1% with 1:100,000 infiltrated into the nasal soft tissues.  In addition to this, cocaine pledgets were placed to assist with hemostasis.,At this point, attention was turned to the left ear.  Approximately 3 mL of 1% Lidocaine with 1:100,000 epinephrine was infiltrated into the subcutaneous tissues of the conchal bulb.  Betadine was utilized for preparation.  A 15 blade was used to incise along the posterior conchal area and a Freer elevator was utilized to lift the soft tissues off the conchal cartilage in a submucoperichondrial plane.  I then completed this along the posterior aspect of the conchal cartilage, was transected in the concha cavum and concha cymba, both were harvested.  These were placed aside in saline.  Hemostasis was obtained with bipolar electrocauterization.  Bovie electrocauterization was also employed as needed.  The entire length of the wound was then closed with 5-0 plain running locking suture.  The patient then had a Telfa placed both anterior and posterior to the conchal defect and placed in a sandwich dressing utilizing a 2-0 Prolene suture.  Antibiotic ointment was applied generously.,Next, attention was turned to opening and lifting the soft tissues of the nose.  A typical external columella inverted V gull-wing incision was placed on the columella and trailed into a marginal incision.  The soft tissues of the nose were then elevated using curved sharp scissors and Metzenbaums.  Soft tissues were elevated over the lower lateral cartilages, upper lateral cartilages onto the nasal dorsum.  At this point, attention was turned to osteotomies and examination of the external cartilages.,The patient did have very broad lower lateral cartilages leading to a bulbous tip.  The lower lateral cartilages were trimmed in a symmetrical fashion leaving at least 8 mm of lower lateral cartilage bilaterally along the lateral aspect.  Having completed this, the patient had medial and lateral osteotomies performed with a 2-mm osteotome.  These were done transmucosally after elevating the tract using a Cottle elevator.  Direct hemostasis pressure was applied to assist with bruising.,Next, attention was turned to tip mechanisms.  The patient had a series of double-dome sutures placed into the nasal tip.  Then, 5-0 Dexon was employed for intradomal suturing, 5-0 clear Prolene was used for interdomal suturing.  Having completed this, a 5-0 clear Prolene alar spanning suture was employed to narrow the superior tip area.,Next, attention was turned to dorsal augmentation.  A Gore-Tex small implant had been selected, previously incised.  This was taken to the back table and carved under sterile conditions.  The patient then had the implant placed into the super-tip area to assist with support of the nasal dorsum.  It was placed into a precise pocket and remained in the midline.,Next, attention was turned to performing a columella strut.  The cartilage from the concha was shaped into a strut and placed into a precision pocket between the medial footplate of the lower lateral cartilage.  This was fixed into position utilizing a 5-0 Dexon suture.,Having completed placement of all augmentation grafts, the patient was examined for hemostasis.  The external columella inverted gull-wing incision along the nasal tip was closed with a series of interrupted everting 6-0 black nylon sutures.  The entire marginal incisions for cosmetic rhinoplasty were closed utilizing a series of 5-0 plain interrupted sutures.,At the termination of the case, the ear was inspected and the position of the conchal cartilage harvest was hemostatic.  There was no evidence of hematoma, and the patient had a series of brown Steri-Strips and Aquaplast cast placed over the nasal dorsum.  The inner nasal area was then examined at the termination of the case and it seemed to be hemostatic as well.,The patient was transferred to the PACU in stable condition.  He was charged to home on antibiotics to prevent infection both from the left ear conchal cartilage harvest and also the Gore-Tex implant area.  He was asked to follow up in 4 days for removal of the bolster overlying the conchal cartilage harvest.", Surgery,38
"CHIEF COMPLAINT:,  GI bleed.,HISTORY OF PRESENT ILLNESS:,  The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue.  CBC revealed microcytic anemia with hemoglobin of 8.9.  Stool dark brown, strongly OB positive.  The patient denied any shortness of breath.  No chest pain.  No GI complaints.  The patient was admitted to ABCD for further evaluation.,PAST MEDICAL HISTORY:  ,Significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism.,PHYSICAL EXAMINATION:,GENERAL:  The patient is in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Benign.,NECK:  Supple.  No adenopathy.,LUNGS:  Clear with good air movement.,HEART:  Irregularly regular.  No gallops.,ABDOMEN:  Positive bowel sounds, soft, and nontender.  No masses or organomegaly.,EXTREMITIES:  1+ lower extremity edema bilaterally.,HOSPITAL COURSE: , The patient underwent upper endoscopy performed by Dr. A, which revealed erosive gastritis.  Colonoscopy did reveal diverticulosis as well as polyp, which was resected.  The patient tolerated the procedure well.  She was transfused, and prior to discharge hemoglobin was stable at 10.7.  The patient was without further GI complaints.  Coumadin was held during hospital stay and recommendations were given by GI to hold Coumadin for an additional three days after discharge then resume.  The patient was discharged with outpatient PMD, GI, and Cardiology followup.,DISCHARGE DIAGNOSES:,1.  Upper gastrointestinal bleed.,2.  Anemia.,3.  Atrial fibrillation.,4.  Non-insulin-dependent diabetes mellitus.,5.  Hypertension.,6.  Hypothyroidism.,7.  Asthma.,CONDITION UPON DISCHARGE: , Stable.,MEDICATIONS: , Feosol 325 mg daily, multivitamins one daily, Protonix 40 mg b.i.d., KCl 20 mEq daily, Lasix 40 mg b.i.d., atenolol 50 mg daily, Synthroid 80 mcg daily, Actos 30 mg daily, Mevacor 40 mg daily, and lisinopril 20 mg daily.,ALLERGIES:,  None.,DIET: , 1800-calorie ADA.,ACTIVITY: , As tolerated.,FOLLOWUP: , The patient to hold Coumadin through weekend.  Followup CBC and INR were ordered.  Outpatient followup as arranged.", Discharge Summary,10
"PREOPERATIVE DIAGNOSIS: , A 39-week intrauterine pregnancy with complete breech presentation.,POSTOPERATIVE DIAGNOSIS:,  A 39-week intrauterine pregnancy in vertex presentation, status post successful external cephalic version.,PROCEDURE: , External cephalic version.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:  ,The patient was brought to Labor and Delivery where a reactive fetal heart tracing was obtained.  The patient was noted to have irregular contractions.  She was given 1 dose of subcutaneous terbutaline which resolved her contraction.  A bedside ultrasound was performed which revealed single intrauterine pregnancy and complete breech presentation.  There was noted to be adequate fluid.  Using manual pressure, the breech was manipulated in a forward roll fashion until a vertex presentation was obtained.  Fetal heart tones were checked intermittently during the procedure and were noted to be reassuring.  Following successful external cephalic version, the patient was placed on continuous external fetal monitoring.  She was noted to have a reassuring and reactive tracing for 1 hour following the external cephalic version.  She did not have regular contractions and therefore she was felt to be stable for discharge to home.  She was given appropriate labor instructions.", Surgery,38
"CHIEF COMPLAINT: , Marginal zone lymphoma.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 46-year-old woman, who I am asked to see in consultation for a newly diagnosed marginal zone lymphoma (MALT-type lymphoma).  A mass was found in her right breast on physical examination.  On 07/19/10, she had a mammogram and ultrasound, which confirmed the right breast mass.  On 07/30/10, she underwent a biopsy, which showed a marginal zone lymphoma (MALT-type lymphoma).,Overall, she is doing well.  She has a good energy level and her ECOG performance status is 0.  She denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  She has normal bowel and bladder habits.  No melena or hematochezia.,CURRENT MEDICATIONS:  ,Macrobid 100 mg q.d.,ALLERGIES:  ,Sulfa, causes nausea and vomiting.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  She is status post a left partial nephrectomy as a new born.,2.  In 2008 she had a right ankle fracture.,SOCIAL HISTORY: , She has a 20-pack year history of tobacco use.  She has rare alcohol use.  She has no illicit drug use.  She is in the process of getting divorced.  She has a 24-year-old son in the area and 22-year-old daughter.,FAMILY HISTORY:  ,Her mother had uterine cancer.  Her father had liver cancer.,PHYSICAL EXAM:,VIT:", Hematology - Oncology,16
"PREOPERATIVE DIAGNOSIS: , Status post Mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,POSTOPERATIVE DIAGNOSIS: , Status post Mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,PROCEDURES:,1.  Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid.,2.  Repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.,ASSISTANT: , None.,ANESTHESIA: , Attended local by Strickland and Associates.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position.  Dressing was removed from the left eye, which revealed the defect as noted above.  After systemic administration of alfentanil, local anesthetic was infiltrated into the left upper lid, left lateral canthus, and left lower eyelid.  The patient was prepped and draped in the usual ophthalmic fashion.  Protective scleral shell was placed in the left eye.  A 4-0 silk traction sutures placed through the upper eyelid margin.  The medial aspect of the remaining lower eyelid was freshened with straight iris scissors and fibrin was removed from the inferior aspect of the wound.  The eyelid was everted and a tarsoconjunctival pedicle flap was developed by incision of the tarsus approximately 3-1/2-4 mm from the lid margin the full width of the eyelid.  Relaxing incisions were made both medially and laterally and Mueller's muscle was subsequently dissected free from the superior tarsal border.  The tarsoconjunctival pedicle was then anchored to the lateral orbital rim with two interrupted 6-0 Vicryl sutures and one 4-0 Vicryl suture.  The protective scleral shell was removed from the eye.  The medial aspect of the eyelid was advanced temporally.  The tarsoconjunctival pedicle was then cut to size and the tarsus was anchored to the medial aspect of the eyelid with multiple interrupted 6-0 Vicryl sutures.  The conjunctiva and lower lid retractors were attached to the advanced tarsal edge with a running 7-0 Vicryl suture.  The upper eyelid wound was present.  It was advanced to the advanced tarsoconjunctival pedicle temporally.  The conjunctival pedicle was slightly trimmed to make a lateral canthal tendon and the upper eyelid was advanced to the tarsoconjunctival pedicle temporally with an interrupted 6-0 Vicryl suture, it was then secured to the lateral orbital rim with two interrupted 6-0 Vicryl sutures.  Skin muscle flap was then elevated, was draped superiorly and nasally and was anchored to the medial aspect of the eyelid with interrupted 7-0 Vicryl sutures.  Burrows triangle was removed as was necessary to create smooth wound closure, which was closed with interrupted 7-0 Vicryl suture.  Temporally the orbicularis was resuspended from the advanced skin muscle flap with interrupted 6-0 Vicryl suture to the periosteum overlying the lateral orbital rim.  The skin muscle flap was secured to the underlying tarsoconjunctival pedicle with vertical mattress sutures of 7-0 Vicryl followed by wound closure temporally with interrupted 7-0 Vicryl suture with removal of a burrow's triangle as was necessary to create smooth wound closure.  Erythromycin ointment was then applied to the eye and to the wound followed by multiple eye pads with moderate pressure.  The patient tolerated the procedure well and left the operating room in excellent condition.  There were no apparent complications.", Surgery,38
"HISTORY:  ,I had the pleasure of meeting and evaluating the patient today, referred for evaluation of tracheostomy tube placement and treatment recommendations.  As you are well aware, he is a pleasant 64-year-old gentleman who unfortunately is suffering from end-stage COPD, who required tracheostomy tube placement about three months ago when being treated for acute exacerbation of COPD and having difficulty coming off ventilatory support.  He now resides in an extended care facility with a capped tracheostomy tube, and he unfortunately states he has had not had to use the tracheostomy tube since his discharge and admission to the extended care facility.  He requires constant oxygen administration and has been having no problems with shortness of breath, worsening, requiring opening the tracheostomy tube site.  He states there has been some tenderness associated with the tracheostomy tube and difficulty with swallowing and he wishes to have it removed.  Apparently there is no history of any airway issues while sleeping or need for uncapping the tube and essentially the tube has just remained present for months capped in his neck.  No history of any previous tracheostomy tube insertion.,PAST MEDICAL HISTORY: , COPD, history of hypercarbic hypoxemia, history of coronary artery disease, history of previous myocardial infarction, and history of liver cirrhosis secondary to alcohol use.,PAST SURGICAL HISTORY:  ,Tonsillectomy, adenoidectomy, cholecystectomy, appendectomy, hernia repair, and tracheostomy.,FAMILY HISTORY:  ,Strong for heart disease, coronary artery disease, hypertension, diabetes mellitus, and cerebrovascular accident.,CURRENT MEDICATIONS:,  Prevacid, folic acid, aspirin, morphine sulfate, Pulmicort, Risperdal, Colace, clonazepam, Lotrisone, Roxanol, Ambien, Zolpidem tartrate, simethicone, Robitussin, and prednisone.,ALLERGIES: , Nitroglycerin.,SOCIAL HISTORY: , The patient has a 25-year-smoking history, which I believe is quite heavy and he has a significant alcohol use in the past.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Age 64, blood pressure is 110/78, pulse 96, and temperature is 98.6.,GENERAL:  The patient was examined in his wheelchair, resting comfortably, in no acute distress.,HEAD:  Normocephalic.  No masses or lesions noted.,FACE:  No facial tenderness or asymmetry noted.,EYES:  Pupils are equal, round and reactive to light and accommodation bilaterally.  Extraocular movements are intact bilaterally.,EARS:  The tympanic membranes are intact bilaterally with a good light reflex.  The external auditory canals are clear with no lesions or masses noted.  Weber and Rinne tests are within normal limits.,NOSE:  The nasal cavities are patent bilaterally.  The nasal septum is midline.  There are no nasal discharges.  No masses or lesions noted.,THROAT:  The oral mucosa appears healthy.  Dental hygiene is maintained well.  No oropharyngeal masses or lesions noted.  No postnasal drip noted.,NECK:  The patient has a stable-appearing tracheostomy tube site and the stoma appears to be without signs of infection.  The previous incision was vertical in nature and there is no hypertrophic scar formation.  No adenopathy noted.  No stridor noted.,NEUROLOGIC:  Cranial nerve VII intact bilaterally.  No signs of tremor.,LUNGS:  Diminished breath sounds in all four quadrants.  No wheezes noted.,HEART:  Regular rate and rhythm.,PROCEDURE: , Limited bronchoscopy and then fiberoptic laryngoscopy.,IMPRESSION:  ,1.  End-stage chronic obstructive pulmonary disease with a history of respiratory failure requiring mechanical ventilatory support with tracheostomy tube placement.,2.  Difficulty tolerating tracheostomy tubes secondary to swallow discomfort and neck irritation with no further need for tracheostomy tube over the past few months with the patient tolerating capped tracheostomy tube 24 hours a day.,3.  History of coronary artery disease.,4.  History of myocardial infarction.,5.  History of cirrhosis of liver.,RECOMMENDATIONS: , I discussed with the patient in detail after fiberoptic laryngoscopy and limited bronchoscopy was performed in the office whether or not to pull out the tracheostomy tube.  His vocal cords moved well, and I do not see any signs of granuloma or airway obstruction either in the supraglottic or subglottic region, and I felt he would tolerate the tube being removed with close monitoring by nursing at his extended care facility.  I did impress the fact that I believe he probably will have other events requiring airway support, which could include intubation, and if the intubation is prolonged a tracheostomy may be needed.  Creation of a long-term tracheostoma may be beneficial whereas the patient would not need such a long tracheostomy tube, and I informed the patient there are other options other than the tube he has at the present time.  The patient still wished to have the tube removed and he is aware he may need to have it replaced or he may have trouble with the area healing or scarring or he could end up having an emergent airway situation with the tube gone, but wishes to have it removed, and I did remove it today.  Dressing was applied and we will see him back next week to make sure everything is healing properly.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1.  Lumbar discogram L2-3.,2.  Lumbar discogram L3-4.,3.  Lumbar discogram L4-5.,4.  Lumbar discogram L5-S1.,ANESTHESIA:  ,IV sedation.,PROCEDURE IN DETAIL:  ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table.  The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained.  We then proceeded to prepare the low back with a Betadine solution and draped sterile.  Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space.  A metallic marker was then placed laterally and a needle entrance point was determined.  A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections.  A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus.  We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.", Neurology,22
"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,22
"PREOPERATIVE DIAGNOSIS: , Coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.,DESCRIPTION OF PROCEDURE:,LEFT HEART CATHETERIZATION WITH ANGIOGRAPHY AND MID ABDOMINAL AORTOGRAPHY:,Under local anesthesia with 2% lidocaine with premedication, a right groin preparation was done.  Using the percutaneous Seldinger technique via the right femoral artery, a left heart catheterization was performed.  Coronary arteriography was performed with 6-French performed coronary catheters.  We used a 6-French JR4 and JL4 catheters to take multiple cineangiograms of the right and left coronary arteries.  After using the JR4 6-French catheter, nitroglycerin was administered because of the possibility of ostial spasm, and following that, we used a 5-French JR4 catheter for additional cineangiograms of the right coronary artery.  A pigtail catheter was placed in the mid abdominal aorta and abdominal aortic injection was performed to rule out abdominal aortic aneurysm, as there was dense calcification in the mid abdominal aorta.,ANALYSIS OF PRESSURE DATA: , Left ventricular end-diastolic pressure was 5 mmHg.  On continuous tracing from the left ventricle to the ascending aorta, there is no gradient across the aortic valve.  The aortic pressures were normal.  Contours of intracardiac pressure were normal.,ANALYSIS OF ANGIOGRAMS:,  Selective cineangiograms were obtained with injection of contrast to the left ventricle, coronary arteries, and mid abdominal aorta.  A pigtail catheter was introduced into the left ventricle and ventriculogram performed in right anterior oblique position.  The mitral valve is competent and demonstrates normal mobility.  The left ventricular cavity is normal in size with excellent contractility.  Aneurysmal dilatation and/or dyskinesia absent.  The aortic valve is tricuspid and normal mobility.  The ascending aorta appeared normal.,Pigtail catheter was introduced in the mid abdominal aorta and placed just above the renal arteries.  An abdominal aortic injection was performed.  Under fluoroscopy, we see heavy dense calcification of the mid abdominal aorta between the renal artery and the bifurcation.  There was some difficulty initially with maneuvering the wire pass that area and it was felt that might be a tight stenosis.  The abdominal aortogram reveals wide patency of that area with mild intimal irregularity.  There is a normal left renal artery, normal right renal artery.  The celiac seems to be normal, but what I believe is the splenic artery seen initially at its origin is normal.  The common left iliac and common right iliac arteries are essentially normal in this area.,CORONARY ANATOMY:,  One notes ostial coronary calcification of the right coronary artery.  Cineangiogram obtained with 6-French JR4 and 5-French JR4 catheters.  Prior to the introduction of the 5-French JR4 nitroglycerin was administered sublingually.  The 6-French JR4 catheters appeared to a show an ostial lesion of over 50%.  There was backwash of dye into the aorta, although there is a fine funneling of the ostium towards the proximal right coronary artery.  In the proximal portion of the right coronary artery just into the Shepherd turn, there is a 50% smooth tapering of the right coronary artery in the proximal third.  Then the artery seems to have a little bit more normal size and it divides into a large posterior descending artery posterolateral branch vessel.  The distal portion of the vessel is free of disease.  The conus branch is seen arising right at the beginning part of the right coronary artery.  We then removed the 6-French catheter and following nitroglycerin and sublingually we placed a 5-French catheter and again finding a stenosis, may be less than 50%.  At the ostium of the right coronary artery, calcification again is identified.  Backwash of dye noted at the proximal lesion, looked about the same 50% along the proximal turn of the Shepherd turn area.,The left coronary artery is normal, although there is a rim of ostial calcification, but there is no tapering or stenosis.  It forms the left anterior descending artery, the ramus branch, and the circumflex artery.,The left anterior descending artery is a very large vessel, very tortuous in its proximal segment, very tortuous in its mid and distal segment.  There appears to be some mild stenosis of 10% in the proximal segment.  It gives off a large diagonal branch in the proximal portion of the left anterior descending artery and it is free of disease.  The remaining portion of the left anterior descending artery is free of disease.  Upon injection of the left coronary artery, we see what I believe is the dye enters probably directly into the left ventricle, but via fistula excluding the coronary sinus, and we get a ventriculogram performed.  I could not identify an isolated area, but it seems to be from the interventricular septal collaterals that this is taking place.,The ramus branch is normal and free of disease.,The left circumflex artery is a tortuous vessel over the lateral wall and terminating in the inferoposterior wall that is free of disease.,The patient has a predominantly right coronary system.  There is no _______ circulation connecting the right and left coronary systems.,The patient tolerated the procedure well.  The catheter was removed.  Hemostasis was achieved.  The patient was transferred to the recovery room in a stable condition.,IMPRESSION:,1.  Excellent left ventricular contractility with normal left ventricular cavity size.,2.  Calcification of the mid abdominal aorta with wide patency of all vessels.  The left and right renal arteries are normal.  The external iliac arteries are normal.,3.  Essentially normal left coronary artery with some type of interventricular septal to left ventricular fistula.,4.  Ostial stenosis of the right coronary artery that appears to be about 50% or greater.  The proximal right coronary artery has 50% stenosis as well.,5.  Coronary calcification is seen under fluoroscopy at the ostia of the left and right coronary arteries.,RECOMMENDATIONS:  ,The patient has heavy calcification of the coronary arteries and continued risk factor management is needed.  The ostial lesion of the right coronary artery may be severe.  It is at least 50%, but it could be worse.  Therefore, she will be evaluated for the possibility of an IVUS and/or _______ analysis of the proximal right coronary artery.  We will reevaluate her stress nuclear study as well.  Continue aggressive medical therapy.", Surgery,38
"PHYSICAL EXAMINATION:,  Patient is a 46-year-old white male seen for annual physical exam and had an incidental PSA elevation of 4.0.  All other systems were normal.,PROCEDURES:  ,Sextant biopsy of the prostate.,Radical prostatectomy:  Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.,PATHOLOGY:,Prostate biopsy:  Right lobe, negative.  Left lobe, small focus of adenocarcinoma, Gleason's 3 + 3 in approximately 5% of the tissue.,Radical prostatectomy:  Negative lymph nodes.  Prostate gland showing moderately differentiated infiltrating adenocarcinoma, Gleason 3 + 2 extending to the apex involving both lobes of the prostate, mainly right.  Tumor overall involved less than 5% of the tissue.  Surgical margin was reported and involved at the apex.  The capsule and seminal vesicles were free.,DISCHARGE NOTE:,  Patient has made good post-op recovery other than mild urgency incontinence.  His post-op PSA is 0.1 mg/ml.", SOAP / Chart / Progress Notes,35
"PREOPERATIVE DIAGNOSES:,1.  Nasal obstruction secondary to deviated nasal septum.,2.  Bilateral turbinate hypertrophy.,PROCEDURE:,  Cosmetic rhinoplasty.  Request for cosmetic change in the external appearance of the nose.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION:  ,The patient is a 26-year-old white female with longstanding nasal obstruction.  She also has concerns with regard to the external appearance of her nose and is requesting changes in the external appearance of her nose.  From her functional standpoint, she has severe left-sided nasal septal deviation with compensatory inferior turbinate hypertrophy.  From the aesthetic standpoint, the nose is over projected, lacks rotation, and has a large dorsal hump.  First we are going to straighten the nasal septum and reduce the size of the turbinates and then we will also take down the hump, rotate the tip of the nose, and de-project the nasal tip.  I explained to her the risks, benefits, alternatives, and complications for postsurgical procedure.  She had her questions asked and answered and requested that we proceed with surgery as outlined above.,PROCEDURE DETAILS: , The patient was taken to the operating room and placed in supine position.  The appropriate level of general endotracheal anesthesia was induced.  The face, head, and neck were sterilely prepped and draped.  The nose was anesthetized and vasoconstricted in the usual fashion.  Procedure began with a left hemitransfixion incision, which was brought down into the left intercartilaginous incision.  Right intercartilaginous incision was also made and the dorsum of the nose was elevated in the submucoperichondrial and subperiosteal plane.  Intact bilateral septomucoperichondrial flaps were elevated and a severe left-sided nasal septal deviation was corrected by detachment of the caudal nasal septum from the maxillary crest in a swinging door fashion and placing it back into the midline.  Posterior vomerine spur was divided superiorly and inferiorly and a large spur was removed.  Anterior and inferior one-third of each inferior turbinate was clamped, cut, and resected.  The upper lateral cartilages were divided from their attachments to the dorsal nasal septum and the cartilaginous septum was lowered by approximately 2 mm.  The bony hump of the nose was lowered with a straight osteotome by 4 mm.  Fading medial osteotomies were carried out and lateral osteotomies were then created in order to narrow the bony width of the nose.  The tip of the nose was then addressed via a retrograde dissection and removal of cephalic caudal semicircle cartilage medially at the tip.  The caudal septum was shortened by 2 mm in an angle in order to enhance rotation.  Medial crural footplates were reattached to the caudal nasal septum with a projection rotation control suture of #3-0 chromic.  The upper lateral cartilages were rejoined to the dorsal septum with a #4-0 plain gut suture.  No middle valves or bone grafts were necessary.  Intact mucoperichondrial flaps were closed with 4-0 plain gut suture and Doyle nasal splints were placed on either side of the nasal septum.  The middle meatus was filled with Surgicel and Cortisporin otic and external Denver splint was applied with sterile tape and Mastisol.  Excellent aesthetic and functional results were thus obtained and the patient was awakened in the operating room, taken to the recovery room in good condition.", Cosmetic / Plastic Surgery,6
"DIAGNOSIS:,  Possible cerebrovascular accident.,DESCRIPTION: , The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages.  The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically.  A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session.  Transient periods of drowsiness occurred naturally producing irregular 5-7 cycle per second activity mostly over the anterior regions.  Hyperventilation was not performed.  No epileptiform activity or any definite lateralizing findings were seen.,IMPRESSION: , Mildly abnormal study.  The findings are suggestive of a generalized cerebral disorder.  Due to the abundant amount of movement artifacts, any lateralizing findings, if any cannot be well appreciated.  Clinical correlation is recommended.", Radiology,33
"PREOPERATIVE DIAGNOSIS:,  Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,POSTOPERATIVE DIAGNOSIS: , Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,PROCEDURE PERFORMED:,1.  Anterior cervical discectomy, C4-C5 and C5-C6.,2.  Arthrodesis, C4-C5 and C5-C6.,3.  Partial corpectomy, C5.,4.  Machine bone allograft, C4-C5 and C5-C6.,5.  Placement of anterior cervical plate with a Zephyr C4 to C6.,6.  Fluoroscopic guidance.,7.  Microscopic dissection.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , 60 mL.,COMPLICATIONS: , None.,INDICATIONS:,  This is a patient who presents with progressive weakness in the left upper extremity as well as imbalance.  He has also noted to have cord signal at the C4-C5 level secondary to a very large disc herniation that came behind the body at C5 as well and as well as a large disc herniation at C5-C6.  Risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed.  He understood and wished to proceed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in the supine position.  Preoperative antibiotics were given.  The patient was placed in the supine position with all pressure points noted and well padded.  The patient was prepped and draped in standard fashion.  An incision was made approximately above the level of the cricoid.  Blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially.  We then placed needle into the disc spaces and was found to be at C5-C6.  Distracting pins were placed in the body of C4 and in to the body of C6.  The disc was then completely removed at C4-C5.  There was very significant compression of the cord.  This was carefully removed to avoid any type of pressure on the cord.  This was very severe and multiple free fragments were noted.  This was taken down to the level of ligamentum.  Both foramen were then also opened.  Other free fragments were also found behind the body of C5, part of the body of C5 was taken down to assure that all of these were removed.  The exact same procedure was done at C5-C6; however, if there were again free fragments noted, there was less not as severe compression at the C4-C5 area.  Again part of the body at C5 was removed to make sure that there was no additional constriction.  Both nerve roots were then widely decompressed.  Machine bone allograft was placed into the C4-C5 as well as C5-C6 and then a Zephyr plate was placed in the body of C4 and to the body of C6 with a metal pin placed into the body at C5.  Excellent purchase was obtained.  Fluoroscopy showed good placement and meticulous hemostasis was obtained.  Fascia was closed with 3-0 Vicryl, subcuticular 3-0 Dermabond for skin.  The patient tolerated the procedure well and went to recovery in good condition.", Surgery,38
"REASON FOR CONSULTATION: , Renal failure.,HISTORY OF PRESENT ILLNESS:,  Thank you for referring Ms. Abc to ABCD Nephrology.  As you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to XYZ Hospital.  She had been admitted at that time with chest pain and was subsequently transferred to University of A and had a cardiac catheterization, which did not show any coronary artery disease.  She also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin.  Her creatinine both at XYZ Hospital and University of A was elevated at 2.4.  I do not have the results from the prior years.  A repeat creatinine on 08/16/06 was 2.3.  The patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration.  She also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection.  She had bladder studies a long time ago.  She complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria.  She also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones.  She denies any nonsteroidal antiinflammatory drug use.  She denies any other over-the-counter medication use.  She has chronic hypokalemia and has been on potassium supplements recently.  She is unsure of the dose.  ,PAST MEDICAL HISTORY: ,1.  Hypertension on and off for years.  She states she has been treated intermittently but lately has again been off medications.,2.  Gastroesophageal reflux disease.,3.  Gastritis.,4.  Hiatal hernia.,5.  H. pylori infection x3 in the last six months treated.,6.  Chronic hypokalemia secondary to chronic diarrhea.,7.  Recurrent admissions with nausea, vomiting, and dehydration.  ,8.  Renal cysts found on a CAT scan of the abdomen.,9.  No coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease.  ,10.  Stomach bypass surgery 1975 with chronic diarrhea.,11.  History of UTI multiple times recently.,12.  Questionable history of kidney stones.,13.  History of gingival infection secondary to chronic steroid use, which was discontinued in July 2001.,14.  Depression.,15.  Diffuse degenerative disc disease of the spine.,16.  Hypothyroidism.,17.  History of iron deficiency anemia in the past.  ,18.  Hyperuricemia.  ,19.  History of small bowel resection with ulcerative fibroid.  ,20.  Occult severe GI bleed in July 2001.,PAST SURGICAL HISTORY: ,  The patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck April 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor August 4, 2005.  ,CURRENT MEDICATIONS: ,1.  Nexium 40 mg q.d.,2.  Synthroid 1 mg q.d. ,3.  Potassium one q.d., unsure about the dose.  ,4.  No history of nonsteroidal drug use.,ALLERGIES:", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS: , Incompetent glottis.,POSTOPERATIVE DIAGNOSIS:,  Incompetent glottis.,OPERATION PERFORMED:,1.  Fat harvesting from the upper thigh.,2.  Micro-laryngoscopy.,3.  Fat injection thyroplasty.,FINDINGS AND PROCEDURE: , With the patient in the supine position under adequate general endotracheal anesthesia, the operative area was prepped and draped in a routine fashion.  A 1-cm incision was made in the upper thigh, and approximately 5 cc of fat was liposuctioned from the subcutaneous space.  After this had been accomplished, the wound was closed with an interrupted subcuticular suture of 4-0 chromic and a light compression dressing was applied.,Next, the fat was placed in a urine strainer and copiously washed using 100 cc of PhysioSol containing 100 units of regular insulin.  After this had been accomplished, it was placed in a 3-cc BD syringe and, thence, into the Stasney fat injector device.  Next, a Dedo laryngoscope was used to visualize the larynx, and approximately *** cc of fat was injected into the right TA muscle and *** cc of fat into the left TA muscle.,The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition.  Estimated blood loss was negligible.", ENT - Otolaryngology,11
"PREOPERATIVE DIAGNOSES:,1.  Trimalleolar ankle fracture.,2.  Dislocation right ankle.,POSTOPERATIVE DIAGNOSES:,1.  Trimalleolar ankle fracture.,2.  Dislocation right ankle.,PROCEDURE PERFORMED: , Closed open reduction and internal fixation of right ankle.,ANESTHESIA:  ,Spinal with sedation.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,Minimal.,TOTAL TOURNIQUET TIME:  ,75 minutes at 325 mmHg.,COMPONENTS: , Synthes small fragment set was used including a 2.5 mm drill bed.  A six hole one-third tibial plate, one 12 mm 3.5 mm cortical screw fully threaded and two 16 mm 3.5 mm cortical fully-threaded screws.  There were two 20 mm 4.0 cancellous screws and one 18 mm 4.0 cancellous screw placed.  There were two 4.0 cancellous partially-threaded screws placed.,GROSS FINDINGS:  ,Include a comminuted fracture involving the lateral malleolus as well as a medial and posterior malleolus fracture as well.,HISTORY OF PRESENT ILLNESS: , The patient is an 87-year-old Caucasian female who presented to ABCD General Hospital Emergency Room complaining of right ankle pain status post a trip and fall.  The patient noted while walking with a walker, apparently tripped and fell.  The patient had significant comorbidities, seen and evaluated by the Emergency Room Department as well as Department of Orthopedics while in the Emergency Room.  At that time, a closed reduction was performed and she was placed in a Robert-Jones splint.  After complete medical workup and clearance, we elected to take her to the operating room for definitive care.,PROCEDURE:  ,After all potential complications and risks as well as risks and benefits of the above-mentioned procedure was discussed at length with the patient and family, informed consent was obtained.  The upper extremity was then confirmed with the operating surgeon, the patient, the nursing staff and Department of Anesthesia.  The patient was then transferred to preoperative area in the Operative Suite #3 and placed on the operating room table in supine position.  At this time, the Department of Anesthesia administered spinal anesthetic to the patient as well as sedation.  All bony prominences were well padded at this time.  A nonsterile tourniquet was placed on the right upper thigh of the patient.  This was then removed and the right lower extremity was sterilely prepped and draped in the usual sterile fashion.  The right lower extremity was then elevated and exsanguinated using Esmarch and tourniquet was then placed to 325 mmHg and kept up to a total of 75 minutes.  Next, after all bony and soft tissue landmarks were identified, a 6 cm longitudinal incision was made directly over this vestibule on the right ankle.  A sharp dissection was carefully taken down to the level of bone taking care to protect the neurovascular structures.  Once the bone was reached, the fractured site was identified.  The bony ends were then opened and divided of all hematoma as well as excess periosteum within the fracture site.  The wound was copiously irrigated and dried.  Next, the fracture was then reduced in anatomic position.  There was noted to be quite a bit of comminution as well as soft overall status of the bone.  It was held in place with reduction forceps.  A six hole one-third tubular Synthes plate was then selected for instrumentation.  It was contoured using ________ and placed on the lateral aspect of the distal fibula.  Next, the three most proximal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged and then a 3.5 mm fully threaded cortical screw was placed in each.  The most proximal was a 12 mm and the next two were 16 mm in length.  Next, the three most distal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged, and a 4.0 cancellous screw was placed in each hole.  The most distal with a 20 mm and two most proximal were 18 mm in length.  Next the Xi-scan was used to visualize the hardware placement as well as the fracture reduction appeared to be in good anatomic position, all hardware was in good position.  There was no lateralization of the joints.  Attention was then directed towards the medial aspect of the ankle.  Again, after all bony and soft tissue landmarks were identified, a 4 cm longitudinal incision was made directly over the medial malleolus.  Again, the dissection was carefully taken down the level of the fracture site.  The retractors were then placed to protect all neurovascular structures.  Once the fracture site was identified, it was dried of all hematoma as well as excess periosteum.  The fracture site was then displaced and the ankle joint was visualized including the dome of the talus.  There appeared to be some minor degenerative changes of the talus, but no loose bodies.  Next, the wound was copiously irrigated and suctioned dry.  The medial malleolus was placed in reduced position and held in place with a 1.25 mm K-wire.  Next, the 2.5 mm drill bed was then used to sequentially drill holes to full depth and 4.0 cancellous screws were placed in each, each with a 45 mm in length.  These appeared to hold the fracture site securely in an anatomic position.  Again, Xi-scan was brought in to confirm placement of the screws.  They were in good overall position and there was no lateralization of the joint.  At this time, each wound was copiously irrigated and suctioned dry.  The wounds were then closed using #2-0 Vicryl suture in subcutaneous fashion followed by staples on the skin.  A sterile dressing was applied consistent with Adaptic, 4x4s, Kerlix, and Webril.  A Robert-Jones style splint was then placed on the right lower extremity.  This was covered by a 4-inch Depuy dressing.  At this time, the Department of Anesthesia reversed the sedation.  The patient was transferred back to the hospital gurney and to the Postanesthetic Care Unit.  The patient tolerated the procedure well.  There were no complications.", Orthopedic,27
"SUBJECTIVE:,  He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing.  He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by Dr. Blackman; it looked like it was Depo-Medrol 80 mg.  He said that it worked fairly well, although it seemed to still take awhile to get rid of it.  He has been using over-the-counter Benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement, but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest, legs, arms and back.,OBJECTIVE:,Vitals:  Temperature is 99.2.  His weight is 207 pounds.,Skin:  Examination reveals a raised, maculopapular rash in kind of a linear pattern over his arms, legs and chest area which are consistent with a poison ivy or a poison oak.,ASSESSMENT AND ,PLAN:,  Poison ivy.  Plan would be Solu-Medrol 125 mg IM X 1.  Continue over-the-counter Benadryl or Rx allergy medicine that he was given the last time he was here, which is a one-a-day allergy medicine; he can not exactly remember what it is, which would also be fine rather than the over-the-counter Benadryl if he would like to use that instead.", SOAP / Chart / Progress Notes,35
"CC:, Progressive memory and cognitive decline.,HX:, This 73 y/o RHF presented on 1/12/95, with progressive memory and cognitive decline since 11/94.,Her difficulties were first noted by family the week prior to Thanksgiving, when they were taking her to Vail, Colorado to play ""Murder She Wrote"" at family gathering. Unbeknownst to the patient was the fact that she had been chosen to be the ""assassin."" Prior to boarding the airplane her children hid a toy gun in her carry-on luggage. As the patient walked through security the alarm went off and within seconds she was surrounded, searched and interrogated. She and her family eventually made their flight, but she seemed unusually flustered and disoriented by the event. In prior times they would have expected her to have brushed off the incident with a ""chuckle."",While in Colorado her mentation seemed slow and she had difficulty reading the lines to her part while playing ""Murder She Wrote."" She needed assistance to complete the game. The family noted no slurring of speech, difficulty with vision, or focal weakness at the time.,She returned to work at a local florist shop the Monday following Thanksgiving, and by her own report, had difficulty carrying out her usual tasks of flower arranging and operating the cash register. She quit working the next day and never went back.,Her mental status appeared to remain relatively stable throughout the month of November and December and during that time she was evaluated by a local neurologist. Serum VDRL, TFTs, GS, B12, Folate, CBC, CXR, and MRI of the Brain were all reportedly unremarkable. The working diagnosis was ""Dementia of the Alzheimer's Type."",One to two weeks prior to her 1/12/95 presentation, she became repeatedly lost in her own home. In addition, she, and especially her family, noticed increased difficulty with word finding, attention, and calculation. Furthermore, she began expressing emotional lability unusual for her. She also tended to veer toward the right when walking and often did not recognize the location of people talking to her.,MEDS:, None.,PMH:, Unremarkable.,FHX:, Father and mother died in their 80's of ""old age."" There was no history of dementing illness, stroke, HTN, DM, or other neurological disease in her family. She has 5 children who were alive and well.,SHX: ,She attained a High School education and had been widowed for over 30 years. She lived alone for 15 years until to 12/94, when her daughters began sharing the task of caring for her. She had no history of tobacco, alcohol or illicit drug use.,EXAM:, Vitals signs were within normal limits.,MS: A&O to person place and time. At times she seemed in absence. She scored 20/30 on MMSE and had difficulty with concentration, calculation, visuospatial construction. Her penmanship was not normal, and appeared ""child-like"" according to her daughters. She had difficulty writing a sentence and spoke in a halting fashion; she appeared to have difficulty finding words. In addition, while attempting to write, she had difficulty finding the right margin of the page.,CN: Right homonymous inferior quadrantanopsia bordering on a right homonymous hemianopsia. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle tone and bulk.,Sensory: extinguishing of RUE sensation on double simultaneous stimulation, and at times she appeared to show sign of RUE neglect. There were no unusual spontaneous movements noted.,Coord: unremarkable except for difficulty finding the target on FNF exercise when the target was moved into the right side visual field.,Station: No sign of Romberg or pronator drift. There was no truncal ataxia.,Gait: decreased RUE swing and a tendency to veer and circumambulate to the right when asked to walk toward a target.,Reflexes: 2/2 and symmetric throughout all four extremities. Plantar responses were equivocal, bilaterally.,COURSE:,  CBC, GS, PT, PTT, ESR, UA, CRP, TSH, FT4, and EKG were unremarkable. CSF analysis revealed: 38 RBC, 0 WBC, Protein 36, glucose 76. The outside MRI was reviewed and was found to show increased signal on T2 weighted images in the gyri of the left parietal-occipital regions. Repeat MRI, at UIHC, revealed the same plus increased signal on T2 weighted images in the left frontal region as well. CXR, transthoracic echocardiogram and 4 vessel cerebral angiogram were unremarkable. A 1/23/95, left frontal brain biopsy revealed spongiform changes without sign of focal necrosis, vasculitis or inflammatory changes. The working diagnosis became Creutzfeldt-Jakob Disease (Heidenhaim variant). The patient died on 2/15/95. Brain tissue was sent to the University of California at San Francisco. Analysis there revealed diffuse vacuolization throughout most of the cingulate gyrus, frontal cortex, hypothalamus, globus pallidus, putamen, insula, amygdala, hippocampus, cerebellum and medulla. This vacuolization was most severe in the entorhinal cortex and parahippocampal gyrus. Hydrolytic autoclaving technique was used with PrP-specific antibodies to identify the presence of protease resistant PrP (CJD). The patient's brain tissue was strongly positive for PrP (CJD).", Neurology,22
"REASON FOR CONSULTATION:,  Ventricular ectopy and coronary artery disease.,HISTORY OF PRESENT ILLNESS:  ,I am seeing the patient upon the request of Dr. Y.  The patient is a very well known to me.  He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty.  The patient had presented to the hospital after having coughing episodes for about two weeks on and off, and seemed to have also given him some shortness of breath.  The patient was admitted and being treated for pneumonia, according to him.  The patient denies any chest pain, chest pressure, or heaviness.  Denies any palpitations, fluttering, or awareness of heart activity.  However, on monitor, he was noticed to have PVCs random.  He had run off three beats consecutive one time at 12:46 p.m. today.  The patient denied any awareness of that or syncope.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever or chills.,EYES:  No visual disturbances.,ENT:  No difficulty swallowing.,CARDIOVASCULAR:  Prior history of chest discomfort in 08/2009 with negative stress study.,RESPIRATORY:  Cough and shortness of breath.,MUSCULOSKELETAL:  Positive for arthritis and neck pain.,GU:  Unremarkable.,NEUROLOGIC:  Otherwise unremarkable.,ENDOCRINE:  Otherwise unremarkable.,HEMATOLOGIC:  Otherwise unremarkable.,ALLERGIC:  Otherwise unremarkable.,PAST MEDICAL HISTORY:,1.  Positive for coronary artery disease since 2002.,2.  History of peripheral vascular disease for over 10 years.,3.  COPD.,4.  Hypertension.,PAST SURGICAL HISTORY:,  Right fem-popliteal bypass about eight years ago, neck fusion in the remote past, stent-supported angioplasty to unknown vessel in the heart.,MEDICATIONS AT HOME:,1.  Aspirin 81 mg daily.,2.  Clopidogrel 75 mg daily.,3.  Allopurinol 100 mg daily.,4.  Levothyroxine 100 mcg a day.,5.  Lisinopril 10 mg a day.,6.  Metoprolol 25 mg a day.,7.  Atorvastatin 10 mg daily.,ALLERGIES: , THE PATIENT DOES HAVE ALLERGY TO MEDICATION.  HE SAID HE CANNOT TAKE ASPIRIN BECAUSE OF INTOLERANCE FOR HIS STOMACH AND STOMACH UPSET, BUT NO TRUE ALLERGY TO ASPIRIN.,FAMILY HISTORY:,  No history of premature coronary artery disease.  One daughter has early onset diabetes and one child has asthma.,SOCIAL HISTORY: , He is married and retired.  He has nine children, 25 grandchildren.  He smokes one pack per day.  He smoked 50 pack years and had no intention of quitting according to him.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature of 97, heart rate of 90, blood pressure of 187/105.,HEENT:  Normocephalic and atraumatic.  No thyromegaly or lymphadenopathy.,NECK:  Supple.,CARDIOVASCULAR:  Upstroke is normal.  Distal pulse symmetrical.  Heart regular with a normal S1 with normally split S2.  There is an S4 at the apex.,LUNGS:  With decreased air entry.  No wheezes.,ABDOMINAL:  Benign.  No masses.,EXTREMITIES:  No edema, cyanosis, or clubbing.,NEUROLOGIC:  Awake, alert, and oriented x3.  No focal deficits.,IMAGING STUDIES: , Echocardiogram on 08/26/2009, showed mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle, EF of 40%, mild mitral regurgitation, and diastolic dysfunction, grade 2.", Consult - History and Phy.,5
"HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old male complaining of abdominal pain.  The patient also has a long-standing history of diabetes which is treated with Micronase daily.,PAST MEDICAL HISTORY: , There is no significant past medical history noted today.,PHYSICAL EXAMINATION:,HEENT:  Patient denies ear abnormalities, nose abnormalities and throat abnormalities.,Cardio:  Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.,Resp:  Patient denies asthma, lung infections and lung lesions.,GI:  Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,GU:  Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.,Endocrine:  Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,Dermatology:  Patient denies allergic reactions, rashes and skin lesions.,MEDS:,  Micronase 2.5 mg Tab PO QAM #30.  Bactrim 400/80 Tab PO BID #30.,SOCIAL HISTORY:,  No known history of drug or alcohol abuse.  Work, diet, and exercise patterns are within normal limits.,FAMILY HISTORY:,  No significant family history.,REVIEW OF SYSTEMS:,  Non-contributory.,Vital Signs:  Height = 72 in.  Weight =184 lbs.  Upright BP = 120/80 mmHg.  Pulse = 80 bpm.  Resp =12 pm.  Patient is afebrile.,Neck:  The neck is supple.  There is no jugular venous distension.  The thyroid is nontender, or normal size and conto.,Lungs:  Lung expansion and excursions are symmetric.  The lungs are clear to auscultation and percussion.,Cardio:  There is a regular rhythm.  SI and S2 are normal.  No abnormal heart sounds are detected.  Blood pressure is equal bilaterally.,Abdomen:  Normal bowel sounds are present.  The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness.  No hernias are noted.,Extremities:  There is no clubbing, cyanosis, or edema.,ASSESSMENT: , Diabetes type II uncontrolled.  Acute cystitis.,PLAN: , Endocrinology Consult, complete CBC.  ,RX: , Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.", Consult - History and Phy.,5
"CHIEF COMPLAINT: , Bladder cancer.,HISTORY OF PRESENT ILLNESS:,  The patient is a 68-year-old Caucasian male with a history of gross hematuria.  The patient presented to the emergency room near his hometown on 12/24/2007 for evaluation of this gross hematuria.  CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall.  Urology referral was initiated and the patient was sent to be evaluated by Dr. X. He eventually underwent a bladder biopsy on 01/18/08, which demonstrated high-grade transitional cell carcinoma without any muscularis propria in the specimen.  Additionally, the patient underwent workup for a right adrenal lesion, which was noted on the initial CT scan.  This workup involved serum cortisol analysis as well as potassium and aldosterone and ACTH level measurement.  All of this workup was found to be grossly negative.  Secondary to the absence of muscle in the specimen, the patient was taken back to the operating room on 02/27/08 by Dr. X and the tumor was noted to be very large with significant tumor burden as well as possible involvement of the bladder neck.  At that time, the referring urologist determined the tumor to be too large and risky for local resection, and the patient was referred to ABCD Urology for management and diagnosis.  The patient presents today for evaluation by Dr. Y.,PAST MEDICAL HISTORY: , Includes condyloma, hypertension, diabetes mellitus, hyperlipidemia, undiagnosed COPD, peripheral vascular disease, and claudication.  The patient denies coronary artery disease.,PAST SURGICAL HISTORY:,  Includes bladder biopsy on 01/18/08 without muscularis propria in the high-grade TCC specimen and a gun shot wound in 1984 followed by exploratory laparotomy x2.  The patient denies any bowel resection or GU injury at that time; however, he is unsure.,CURRENT MEDICATIONS:,1.  Metoprolol 100 mg b.i.d.,2.  Diltiazem 120 mg daily.,3.  Hydrocodone 10/500 mg p.r.n.,4.  Pravastatin 40 mg daily.,5.  Lisinopril 20 mg daily.,6.  Hydrochlorothiazide 25 mg daily.,FAMILY HISTORY: , Negative for any GU cancer, stones or other complaints.  The patient states he has one uncle who died of lung cancer.  He denies any other family history.,SOCIAL HISTORY: , The patient smokes approximately 2 packs per day times greater than 40 years.  He does drink occasional alcohol approximately 5 to 6 alcoholic drinks per month.  He denies any drug use.  He is a retired liquor store owner.,PHYSICAL EXAMINATION:,GENERAL:  He is a well-developed, well-nourished Caucasian male, who appears slightly older than stated age.  VITAL SIGNS:  Temperature is 96.7, blood pressure is 108/57, pulse is 75, and weight of 193.8 pounds.  HEAD AND NECK:  Normocephalic atraumatic.  LUNGS:  Demonstrate decreased breath sounds globally with small rhonchi in the inferior right lung, which is clear somewhat with cough.  HEART:  Regular rate and rhythm.  ABDOMEN:  Soft and nontender.  The liver and spleen are not palpably enlarged.  There is a large midline defect covered by skin, of which the fascia has numerous holes poking through.  These small hernias are of approximately 2 cm in diameter at the largest and are nontender.  GU:  The penis is circumcised and there are no lesions, plaques, masses or deformities.  There is some tenderness to palpation near the meatus where 20-French Foley catheter is in place.  Testes are bilaterally descended and there are no masses or tenderness.  There is bilateral mild atrophy.  Epididymidis are grossly within normal limits bilaterally.  Spermatic cords are grossly within normal limits.  There are no palpable inguinal hernias.  RECTAL:  The prostate is mildly enlarged with a small focal firm area in the midline near the apex.  There is however no other focal nodules.  The prostate is grossly approximately 35 to 40 g and is globally firm.  Rectal sphincter tone is grossly within normal limits and there is stool in the rectal vault.  EXTREMITIES:  Demonstrate no cyanosis, clubbing or edema.  There is dark red urine in the Foley bag collection.,LABORATORY EXAM:,  Review of laboratory from outside facility demonstrates creatinine of 2.38 with BUN of 42.  Additionally, laboratory exam demonstrates a grossly normal serum cortisol, ACTH, potassium, aldosterone level during lesion workup.  CT scan was reviewed from outside facility, report states there is left kidney atrophy without hydro or stones and there is thickened left bladder wall and posterior margins with a balloon inflated in the prostate at the time of the exam.  There is a 3.1 cm right heterogeneous adrenal nodule and there are no upper tract lesions or stones noted.,IMPRESSION:,  Bladder cancer.,PLAN:  ,The patient will undergo a completion TURBT on 03/20/08 with bilateral retrograde pyelograms at the time of surgery.  Preoperative workup and laboratory as well as paper work were performed in clinic today with Dr. Y. The patient will be scheduled for anesthesia preop.  The patient will have urine culture redrawn from his Foley or penis at the time of preoperative evaluation with anesthesia.  The patient was counseled extensively approximately 45 minutes on the nature of his disease and basic prognostic indicators and need for additional workup and staging.  The patient understands these instructions and also agrees to quit smoking prior to his next visit.  This patient was seen in evaluation with Dr. Y who agrees with the impression and plan.", Urology,39
"PREOPERATIVE DIAGNOSIS: , Malignant mass of the left neck.,POSTOPERATIVE DIAGNOSIS:,  Malignant mass of the left neck, squamous cell carcinoma.,PROCEDURES,1.  Left neck mass biopsy.,2.  Selective surgical neck dissection, left.,DESCRIPTION OF PROCEDURE:,  After obtaining an informed, the patient was taken to the operating room where a time-out process was followed.  Preoperative antibiotic was given and Dr. X proceeded to intubate the patient after a detailed anesthetic preparation that started in the Same Day Surgery and followed in the operating room.  Finally, a 5.5-French endotracheal tube was inserted and the patient was able to tolerate that and did have stable vital signs and a proper oxygenation.,Then, the patient was positioned with the neck slightly distended and turned toward the opposite side of the operation.  The neck was prepped and draped in the usual fashion.  I proceeded to mark the site of the mass and then also to mark the proposed site for the creation of a flap.  Then, I performed an extensive anesthetic block of the area.,Then, an incision was made along the area marked for development of the flap, but in a very limited extent, just to expose the cervical mass.  The cervical mass, which was about 4 cm in diameter and very firm and rubbery, was found lodged between the sternocleidomastoid muscle and the internal jugular vein in the area III of the neck.  A wedge sample was sent to Pathology for frozen section.  At the same time, we waited for the result and the initial report was not clear in the sense that a lot of lymphoepithelial reaction was seen.  Therefore, a larger sample was sent to Pathology and at that particular time, the fresh frozen was reported as having squamous elements.  This was not totally clear in my mind and therefore I proceeded to excise the full mass, which luckily was not attached to any structures except in the very deep surface.  There, there were some attachments to branches of the external carotid artery, which had to be suture ligated.  At any rate, the whole specimen was to the lab and finally the diagnosis was that of a metastatic squamous cell carcinoma.,With that information in hand, we proceeded to continue with a neck dissection and proceeded to make an incision along the previously marked sites of the flap, which basically involved a reverse U shape on the left neck.  This worked out quite nicely.  The external jugular vein was out of the way, so initially we did not deal with it.  We proceeded to tackle the area III and extended into II-A.  When we excised the mass, the upper end was in intimate relationship with the parotid gland, which was relatively large in this patient, but it looked normal otherwise.  Also, I felt that the submaxillary gland was enlarged.  At any rate, we decided to clean up the areas III and IV and a few nodes from II-A that were removed, and then we went into the posterior triangle where we identified the spinal accessory nerve, which we protected, actually did not even dissect close to it.,The same nerve had been already identified anterior to the internal jugular vein, very proximally behind the digastric and the sternocleidomastoid muscle.  At any rate, there were large nodes in the posterior triangle, in areas V-A and V-B, which were excised and sent to Pathology for examination.  Also, there was a remnant of a capsule of the main mass that we proceeded to excise and sent to Pathology as an extra specimen.  Hemostasis was revised and found to be adequate.  The flaps had been protected by folding it to the chest and protected by wet sponges on both sides of the flap.  The flap was replaced in its position.  A soft Jackson-Pratt catheter was left in the area, and then we proceeded to approximate the flap with a number of subcutaneous sutures of Vicryl and then running sutures of subcuticular Monocryl to the skin.  I would like to mention that also the facial vein was excised and the external jugular vein was ligated.  It was in very lateral location and it was on the site of the drain, so we ligated that but did not excise it.  A pressure dressing was applied.,The patient tolerated the procedure well.  Estimated blood loss was no more than 100 mL.  The patient was extubated in the operating room and sent for recovery.", Hematology - Oncology,16
"HISTORY OF PRESENT ILLNESS:,  The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home.  The patient states that she was on the ladder on Saturday and she stepped down after the ladder.  Felt some pain in her left hip.  Subsequently fell injuring her left shoulder.  It's unclear how long she was on the floor.  She was taken by EMS to Hospital where she was noted radiographically to have a left proximal humerus fracture and a nondisplaced left hip fracture.  Orthopedics was consulted.  Given the nature of the injury and the unclear events, an extensive workup was performed including a head CT and CT of the abdomen, which identified no evidence of intracranial injury and renal calculi only.  She presently is complaining of pain to the left shoulder.  She states she also has pain to the hip with motion of the leg.  She denies any numbness or paresthesias.  She states prior to this, she was relatively active within her home.  She does care for her daughter who has a mess.  The patient denies any other injuries.  Denies back pain.,PREVIOUS MEDICAL HISTORY:,  Extensive including coronary artery disease, peripheral vascular disease, status post MI, history of COPD, diverticular disease, irritable bowel syndrome, GERD, PMR, depressive disorder, and hypertension.,PREVIOUS SURGICAL HISTORY:,  Includes a repair of a right intertrochanteric femur fracture.,ALLERGIES,1.  PENICILLIN.,2.  SULFA.,3.  ACE INHIBITOR.,PRESENT MEDICATIONS,1.  Lipitor 20 mg q.d.,2.  Metoprolol 25 mg b.i.d.,3.  Plavix 75 mg once a day.,4.  Aspirin 325 mg.,5.  Combivent Aerosol two puffs twice a day.,6.  Protonix 40 mg q.d.,7.  Fosamax 70 mg weekly.,8.  Multivitamins including calcium and vitamin D.,9.  Hydrocortisone.,10.  Nitroglycerin.,11.  Citalopram 20 mg q.d.,SOCIAL HISTORY:,  She denies alcohol or tobacco use.  She is the caretaker for her daughter, who is widowed and lives at home.,FAMILY HISTORY:,  Not obtainable.,REVIEW OF SYSTEMS: , Patient is hard of hearing.  She also has vision problems.  Denies headache syndrome.  Presently, denies chest pain or shortness of breath.  She denies abdominal pain.  Presently, she has left hip pain and left shoulder pain.  No urinary frequency or dysuria.  No skin lesions.  She does have swelling to both lower extremities for the last several weeks.  She denies endocrinopathies.  Psychiatric issues include chronic depression.,PHYSICAL EXAMINATION,GENERAL:  The patient is alert and responsive.,EXTREMITIES:  The left upper extremity, there is moderate swelling and ecchymosis to the brachial compartment.  She is diffusely tender over the proximal humerus.  She is unable to actively elevate her arm due to pain.  The neurovascular exam to the left upper extremity is otherwise intact with a 1+ radial pulse.  She does have chronic degenerative change to the MP and IP joints of both hands.  The left lower extremity, the thigh compartment is supple.  She has pain with log rolling tenderness over the greater trochanter.  The patient has pain with any attempt at hip flexion passively or actively.  The knee range of motion between 5 and 60 degrees with no point specific tenderness, no joint effusion, and an intact extensive mechanism.  She has 2 to 3+ bilateral pitting edema pretibially and pedally.  The patient has a weak motor response to the left lower extremity.  She has a 1+ dorsalis pedis pulse.  Her sensory examination is intact plantarly and dorsally on the foot.,RADIOGRAPHS:,  Left shoulder series was performed which identifies a three-part valgus-impacted left proximal humerus fracture with displacement of the greater tuberosity fragment approximately 1 cm.  There is no evidence of dislocation.  There was an AP pelvis as well as left hip series, which identify a nondisplaced valgus-impacted type 1 femoral neck fracture.  There is also evidence of severe degenerative disk disease with degenerative scoliosis of the LS spine.  There is evidence of previous surgical repair of the right proximal femur with an intact intramedullary nail.,LABORATORY STUDIES: , Patient's H&H is 13 and 38.7, white blood cell count is 6.9, and there are 198,000 platelets.  Electrolytes, sodium 137, potassium 4.1, chloride 102, CO2 is 27, BUN is 20, and creatinine 0.62.  Urinalysis, the urine is clear yellow, 0 to 2 white cells, and no bacteria.,ASSESSMENT,1.  This is an 88-year-old household ambulator with a walker, status post fall with injuries to left shoulder and left hip.  The left shoulder fracture is a valgus-impacted proximal humerus fracture and the left hip is a nondisplaced type 1 femoral neck fracture.,2.  Extensive medical history including coronary artery disease, peripheral vascular disease, and chronic obstructive pulmonary disease on Plavix.,PLAN:,  I have discussed this case with the emergency room physician as well as the patient.  Patient should be admitted to medical service for medical clearance for surgery of her left hip, which will include a percutaneous screw fixation.  Since the patient is on Plavix, I recommend that the Plavix be discontinued and should be placed on Lovenox 30 mg subcu q.d. which may be stopped 24 hours before the procedure.  She will need cardiology clearance, which would include an echo in advance of the procedure.  I have explained the nature of the injuries to the patient, the recommended surgical procedures, and the postop course and rehabilitation required thereafter.  She presently understands and agrees with the plan.", Emergency Room Reports,12
"PREOPERATIVE DX: , Stress urinary incontinence.,POSTOPERATIVE DX: , Stress urinary incontinence.,OPERATIVE PROCEDURE: , SPARC suburethral sling.,ANESTHESIA: , General.,FINDINGS & INDICATIONS: , Outpatient evaluation was consistent with urethral hypermobility, stress urinary incontinence.  Intraoperatively, the bladder appeared normal with the exception of some minor trabeculations.  The ureteral orifices were normal bilaterally.,DESCRIPTION OF OPERATIVE PROCEDURE:,  This patient was brought to the operating room, a general anesthetic was administered.  She was placed in dorsal lithotomy position.  Her vulva, vagina, and perineum were prepped with Betadine scrubbed in solution.  She was draped in usual sterile fashion.  A Sims retractor was placed into the vagina and Foley catheter was inserted into the bladder.  Two Allis clamps were placed over the mid urethra.  This area was injected with 0.50% lidocaine containing 1:200,000 epinephrine solution.  Two areas suprapubically on either side of midline were injected with the same anesthetic solution.  The stab wound incisions were made in these locations and a sagittal incision was made over the mid urethra.  Metzenbaum scissors were used to dissect bilaterally to the level of the ischial pubic ramus.  The SPARC needles were then placed through the suprapubic incisions and then directed through the vaginal incision bilaterally.  The Foley catheter was removed.  A cystoscopy was performed using a 70-degree cystoscope.  There was noted to be no violation of the bladder.  The SPARC mesh was then snapped onto the needles, which were withdrawn through the stab wound incisions.  The mesh was snugged up against a Mayo scissor held under the mid urethra.  The overlying plastic sheaths were removed.  The mesh was cut below the surface of the skin.  The skin was closed with 4-0 Plain suture.  The vaginal vault was closed with a running 2-0 Vicryl stitch.  The blood loss was minimal.  The patient was awoken and she was brought to recovery in stable condition.", Urology,39
"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.", Neurosurgery,23
"PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA:,  General endotracheal.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia.  The McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,The nasopharynx was inspected with a laryngeal mirror.  The adenoid tissue was fulgurated with the suction Bovie set at 35.  The catheters and the dental gauze roll were then removed.  The anterior tonsillar pillars were infiltrated with 0.5% Marcaine and epinephrine.  Using the radiofrequency wand, the tonsils were ablated bilaterally.  If bleeding occurred, it was treated with the wand on coag mode using a coag mode of 3 and an ablation mode of 9.  The tonsillectomy was completed.,The nasopharynx and nasal passages were suctioned free of debris, and the procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.", ENT - Otolaryngology,11
"CC: ,Gait difficulty.,HX: ,This 59 y/o RHF was admitted with complaint of gait difficulty. The evening prior to admission she noted sudden onset of LUE and LLE weakness. She felt she favored her right leg, but did not fall when walking. She denied any associated dysarthria, facial weakness, chest pain, SOB, visual change, HA, nausea or vomiting.,PMH:, tonsillectomy, adenoidectomy, skull fx 1954, HTN, HA.,MEDS: ,none on day of exam.,SHX: ,editorial assistant at newspaper, 40pk-yr Tobacco, no ETOH/Drugs.,FHX: ,noncontributory,ADMIT EXAM: ,P95 R20, T36.6, BP169/104,MS: A&O to person, place and time. Speech fluent and without dysarthria, Naming-comprehension-reading intact. Euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light, Fundi flat, VFFTC, EOMI, Face symmetric with intact sensation, Gag-shrug-corneal reflexes intact, Tongue ML with full ROM,Motor: Full strength throughout right side. Mildly decreased left grip and left extensor hallucis longus. Biceps/Triceps/Wrist flexors and extensor were full strength on left. However she demonstrated mild LUE pronator drift and had difficulty standing on her LLE despite full strength on bench testing of the LLE.,Sensory: No deficit to PP/T/Vib/Prop/ LT,Coord: decreased speed and magnitude of FNF, Finger tapping and HKS, on left side only.,Station: mild LUE upward drift.,Gait: tendency to drift toward the left. Difficulty standing on LLE.,Reflexes were symmetric, plantar responses were flexor bilaterally.,Gen exam unremarkable.,COURSE: ,Admit Labs: ESR, PT/PTT, GS, UA, EKG, and HCT were unremarkable. Hgb 13.9, Hct 41%, Plt 280k, WBC 5.5.,The patient was diagnosed with a probable lacunar stroke and entered into the TOAST study (Trial of ORG10172[a low molecular weight heparin] in Acute Stroke Treatment).,Carotid Duplex: 16-49%RICA and 0-15%LICA stenosis with anterograde vertebral artery flow, bilaterally. Transthoracic echocardiogram showed mild mitral regurgitation, mild tricuspid regurgitation and a left to right shunt. There was no evidence of blood clot.,Hospital course: 5 days after admission the patient began to complain of proximal LLE and left flank pain. On exam, she had weakness of the quadriceps and hip flexors of the LLE. Her pain increased with left hip flexion. In addition, she complained of paresthesias about the lateral aspect of the medial anterior left thigh; and upon on sensory testing, she had decreased PP/TEMP sensation in a left femoral nerve distribution. She denied any back/neck pain and the rest of her neurologic exam remained unchanged from admission.,Abdominal CT Scan, 2/4/96, revealed a large left retroperitoneal iliopsoas hematoma.,Hgb 8.9g/dl. She was transfused with 4 units of pRBCs. She underwent surgical decompression and evacuation of the hematoma via a posterior flank approach on 2/6/96. Her postoperative course was uncomplicated. She was discharged home on ASA.,At follow-up, on 2/23/96, she complained of left sided paresthesias (worse in the LLE than in the LUE) and feeling of ""swollen left foot."" These symptoms had developed approximately 1 month after her stroke. Her foot looked normal and her UE strength was 5/4+ proximally and distally, and LE strength 5/4+ proximally and 5/5- distally. She was ambulatory. There was no evidence of LUE upward drift. A somatosensory evoked potential study revealed an absent N20 and normal P14 potentials. This was suggestive of a lesion involving the right thalamus which might explain her paresthesia/dysesthesia as part of a Dejerine-Roussy syndrome.", Consult - History and Phy.,5
"CC:, Right shoulder pain.,HX: ,This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck (Lhermitte's phenomena). She denied any history of neck/back/head trauma.,She had been taking Naprosyn with little relief.,PMH: ,1) Catamenial Headaches. 2) Allergy to Macrodantin.,SHX/FHX:, Smokes 2ppd cigarettes.,EXAM: ,Vital signs were unremarkable.,CN: unremarkable.,Motor: full strength throughout. Normal tone and muscle bulk.,Sensory: No deficits on LT/PP/VIB/TEMP/PROP testing.,Coord/Gait/Station: Unremarkable.,Reflexes: 2/2 in BUE except 2+ at left biceps. 1+/1+BLE except an absent right ankle reflex.,Plantar responses were flexor bilaterally. Rectal exam: normal tone.,IMPRESSION:, C-spine lesion.,COURSE: ,MRI C-spine revealed a central C5-6 disk herniation with compression of the spinal cord at that level. EMG/NCV showed normal NCV, but 1+ sharps and fibrillations in the right biceps (C5-6), brachioradialis (C5-6), triceps (C7-8) and teres major; and 2+ sharps and fibrillations in the right pronator terres. There was increased insertional activity in all muscles tested on the right side. The findings were consistent with a C6-7 radiculopathy.,The patient subsequently underwent C5-6 laminectomy and her symptoms resolved.", Neurology,22
"PREOPERATIVE DIAGNOSES:,1.  Left facial cellulitis.,2.  Possible odontogenic abscess of the #18, #19, and #20.,POSTOPERATIVE DIAGNOSES:,1.  Left facial cellulitis.,2.  Possible odontogenic abscess of the #18, #19, and #20.,PROCEDURE PERFORMED: , Attempted incision and drainage (I&D) of odontogenic abscess.,ANESTHESIA:  ,1% lidocaine plain approximately 5 cc total.,COMPLICATIONS: , The patient is very noncompliant with attempted procedure refusing further exam and treatment after localization and attempted FNA.  The attempted FNA was without any purulent aspirate although limited in the area of attempted examination.,INDICATIONS FOR THE PROCEDURE: , The patient is a 39-year-old Caucasian female who was admitted to ABCD General Hospital on 08/21/03 secondary to acute left facial cellulitis suspected to be secondary to odontogenic etiology.  The patient states that this was started approximately 24 hours ago.  The patient subsequently presented to ABCD General Hospital Emergency Room secondary to worsening of left face swelling and increasing in pain.  The patient admits to poor dental hygiene.  Denies any recent or dental abscesses in the past.  The patient is a substance abuser, does admit to smoking cocaine approximately three days ago.  The patient did have a CT scan of the face obtained with contrast demonstrated no signs of any acute abscess although a profuse amount of cellulitis was noted.  After risks, complications, consequences, and questions were discussed with the patient, a written consent was obtained for an I&D of a possible odontogenic abscess ________ on the CT scan.,PROCEDURE:  ,The patient was brought in upright and supine position.  Approximately 5 cc of 1% lidocaine without epinephrine was injected in the localized area along the buccogingival sulcus of the left side.  This was done at the base of #18, #19, and #20 teeth.  After this, the patient did have approximately 2 more mg of morphine given through the IV for pain control.  After this, the #18 gauge needle on a ________ syringe was then utilized to attempt a FNA at the base of #18 tooth and #19 with one stick placed.  There were no signs of any purulent drainage, although at this time the patient became very irate and noncompliant and refusing further examination.  The patient understood consequences of her actions.  Does state that she does not care at this time and just wants to be left alone.  At this time, the bed was actually placed back in its normal position and the patient will be continued on clindamycin 900 mg IV q.6h. along with pain control utilizing Toradol, morphine, and Vicodin.  The patient will also be started on Peridex oral rinse of 10 cc p.o. swish and spit t.i.d. and a K-pad to the left face.", Dentistry,7
"PREOPERATIVE DIAGNOSIS:,  Ovarian cyst, persistent.,POSTOPERATIVE DIAGNOSIS: , Ovarian cyst.,ANESTHESIA:,  General,NAME OF OPERATION:,  Diagnostic laparoscopy and drainage of cyst.,PROCEDURE:,  The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced.  An infraumbilical incision was made, and Veress needle placed without difficulty.  Gas was entered into the abdomen at two liters.  The laparoscope was entered, and the abdomen was visualized.  The second puncture site was made, and the second trocar placed without difficulty.  The cyst was noted on the left, a 3-cm, ovarian cyst.  This was needled, and a hole cut in it with the scissors.  Hemostasis was intact.  Instruments were removed.  The patient was awakened and taken to the recovery room in good condition.", Radiology,33
"PREOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,PROCEDURES PERFORMED: , ,1.  Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies.,2.  Bone grafts.,3.  Bilateral forehead reconstruction with autologous graft.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:,  None.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE: , Stable, transferred to recovery room.,ESTIMATED BLOOD LOSS: , 300 mL.,CRYSTALLOIDS: , Packed red blood cells 440 mL, FFP 100 mL.,URINARY OUTPUT: , 160 mL.,INDICATIONS FOR PROCEDURE: , The patient is a 9-month-old baby with a history of trigonocephaly and metopic synostosis.  We have discussed locations, the nature of trigonocephaly's repair, metopic synostosis repair with bilateral fronto-orbital advancement, forehead reconstruction, and bone graft.  We have discussed risks and benefits.  Risks included, but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgeries, minimal possibility of death, the alternatives, devastating bleeding, anesthesia, death, dehiscence, infection.  The parents understand, decide to proceed with surgery.  Informed consent was obtained and we proceed with surgery.,DESCRIPTION OF PROCEDURE: , The patient was taken into the operating room, placed in the supine position.  General anesthetic was administered.  Prophylactic dose of antibiotic was given.  Lines were placed by Anesthesia and then the head of the bed was turned to 100 degrees.  The patient was once more positioned and padded in the usual manner.  The incision was marked with the help of a marking pen and local anesthetic was infiltrated after prepping the area one time, then the definitive prep and draping of the area was done.,The procedure began with an incision through the full-thickness of the skin into the subcutaneous tissue down to the subgaleal plane.  The subgaleal plane was developed and reflected anteriorly and slightly posteriorly.  Hemostasis achieved with electrocautery.  Raney clips were applied to both flaps to prevent significant bleeding.  Then, we proceed with craniotomy part and Dr. Y proceeded with this part of the procedure.  I assisted her and this will be described in a different operative report.  Then, the area corresponding to the C-shaped osteotomy was marked and then we proceed in conjunction with Dr. Y to develop these osteotomies with the help of the Midas by retracting the contents of the skull at the level of the anterior fossa as well as the orbital contents with the help of a ribbon retractor.  The osteotomies were done with the Midas and some irrigation.  There was an osteotomy done at the level of the frontozygomatic suture just posterior to the frontozygomatic suture and then these osteotomies continued down intraorbitally and lateral through the zygoma to the level of the intraorbital rim.  This was done on both sides.  Hemostasis achieved with bone wax and electrocautery.  Once the osteotomies were completed, __________ of the osteotomy sites allowed advancements.  On the left side, there was a minor fracture to the superior orbital rim that was plated.  The bone grafts were customized placing these at the level of the sphenoid bone in the posterior aspect of the orbital rim.  The temporalis muscle was advanced and attached to the orbital rim with holes that have been drilled with Midas and a 3-0 Vicryl interrupted stitches.  The forehead flaps were attached with the help of absorbable mesh.  The forehead portions were applied to the fronto-orbital advancement of fronto-orbital piece with the help of Synthes mesh and 3-mm screws.  Hemostasis was checked.  The flaps were retracted back into position.,The wound was closed with 3-0 Vicryl interrupted sutures, 4-0 Vicryl interrupted stitches, and 5-0 running fast absorbing gut.  Dressing was applied with Xeroform, bacitracin, and ABDs and a burn net.  The patient tolerated the procedure well without complications and was transferred to the recovery room in stable condition.  I was present and participated in all aspects of the procedure.  Sponge, needle, and instrument counts were completed at the end of the procedure.", Surgery,38
"REASON FOR ADMISSION: , A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.,PAST MEDICAL HISTORY:,1.  Diabetes type II.,2.  High blood pressure.,3.  High cholesterol.,4.  Acid reflux disease.,5.  Chronic back pain.,PAST SURGICAL HISTORY:,1.  Lap-Band done today.,2.  Right foot surgery.,MEDICATIONS:,1.  Percocet on a p.r.n. basis.,2.  Keflex 500 mg p.o. t.i.d.,3.  Clonidine 0.2 mg p.o. b.i.d.,4.  Prempro, dose is unknown.,5.  Diclofenac 75 mg p.o. daily.,6.  Enalapril 10 mg p.o. b.i.d.,7.  Amaryl 2 mg p.o. daily.,8.  Hydrochlorothiazide 25 mg p.o. daily.,9.  Glucophage 100 mg p.o. b.i.d.,10.  Nifedipine extended release 60 mg p.o. b.i.d.,11.  Omeprazole 20 mg p.o. daily.,12.  Zocor 20 mg p.o. at bedtime.,ALLERGIES: , No known allergies.,HISTORY OF PRESENT COMPLAINT: , This 54-year-old patient had had Lap-Band at Tempe St Luke this morning.  She woke up at home this evening with massive swelling of the left side of the tongue.  The patient therefore came to the emergency room for evaluation.  The patient was almost intubated on clinical grounds.  Anesthesia was called to see the patient and they decided to give a trial of conservative management of Decadron and racemic epinephrine.,REVIEW OF SYSTEMS:,GENERAL:  The patient denies any itching of the skin or urticaria.  She has not noticed any new rashes.  She denies fever, chill, or malaise.,HEENT:  The patient denies vision difficulty.,RESPIRATORY:  No cough or wheezing.,CARDIOVASCULAR:  No palpitations or syncopal episodes.,GASTROINTESTINAL:  The patient denies swallowing difficulty.,Rest of the review of systems not remarkable.,SOCIAL HISTORY:  ,The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  Obese 54-year-old lady, not in acute distress at this time.,VITAL SIGNS:  On arrival in the emergency room, blood pressure was 194/122, pulse was 94, respiratory rate of 20, and temperature was 96.6.  O2 saturation was 95% on room air.,HEAD AND NECK:  Face is symmetrical.  Tongue is still swollen, especially on the left side.  The floor of the mouth is also indurated.  There is no cervical lymphadenopathy.  There is no stridor.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  There is no swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.", Consult - History and Phy.,5
"GENERAL: , Vital signs and temperature as documented in nursing notes.  The patient appears stated age and is adequately developed.,EYES:,  Pupils are equal, round, reactive to light and accommodation.  Lids and conjunctivae reveal no gross abnormality.,ENT:  ,Hearing appears adequate.  No obvious asymmetry or deformity of the ears and nose.,NECK: , Trachea midline.  Symmetric with no obvious deformity or mass; no thyromegaly evident.,RESPIRATORY:,  The patient has normal and symmetric respiratory effort.  Lungs are clear to auscultation.,CARDIOVASCULAR: , S1, S2 without significant murmur.,ABDOMEN: , Abdomen is flat, soft, nontender.  Bowel sounds are active.  No masses or pulsations present.,EXTREMITIES: , Extremities reveal no remarkable dependent edema or varicosities.,MUSCULOSKELETAL:  ,The patient is ambulatory with normal and symmetric gait.  There is adequate range of motion without significant pain or deformity.,SKIN: , Essentially clear with no significant rash or lesions.  Adequate skin turgor.,NEUROLOGICAL: , No acute focal neurologic changes.,PSYCHIATRIC:,  Mental status, judgment and affect are grossly intact and normal for age.", Consult - History and Phy.,5
"CHIEF COMPLAINT: , Right shoulder pain.,HISTORY: , The patient is a pleasant, 31-year-old, right-handed, white female who injured her shoulder while transferring a patient back on 01/01/02.  She formerly worked for Veteran's Home as a CNA.  She has had a long drawn out course of treatment for this shoulder.  She tried physical therapy without benefit and ultimately came to a subacromion decompression in November 2002.  She had ongoing pain and was evaluated by Dr. X who felt that she had a possible brachial plexopathy.  He also felt she had a right superficial radial neuritis and blocked this with resolution of her symptoms.  He then referred her to ABCD who did EMG testing, demonstrating a right suprascapular neuropathy although a C5 radiculopathy could not be ruled out.  MRI testing on the cervical spine was then done which was negative for disk herniation and she underwent suprascapular nerve decompression of the scapular notch on 12/18/03.  She finally went to an anterior axillary nerve block because of ongoing pain in the anterior shoulder again by Dr. X.  She comes to me for impairment rating.  She has no chronic health problems otherwise, fevers, chills, or general malaise.  She is not working.  She is right-hand dominant.  She denies any prior history of injury to her shoulder.,PAST MEDICAL HISTORY:,  Negative aside from above.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,Please see above.,REVIEW OF SYSTEMS:,  Negative aside from above.,PHYSICAL EXAMINATION:  ,A pleasant, age appropriate woman, moderately overweight, in no apparent distress.  Normal gait and station, normal posture, normal strength, tone, sensation and deep tendon reflexes with the exception of 4+/5 strength in the supraspinatus musculature on the right.  She has decreased motion in the right shoulder as follows.  She has 160 degrees of flexion, 155 degrees of abduction, 35 degrees of extension, 25 degrees of adduction, 45 degrees of internal rotation and 90 degrees of external rotation.  She has a positive impingement sign on the right.,ASSESSMENT:,  Right shoulder impingement syndrome, right suprascapular neuropathy.,DISCUSSION: , With a reasonable degree of medical certainty, she is at maximum medical improvement and she does have an impairment based on AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition.  The reason for this impairment is the incident of 01/01/02.  For her suprascapular neuropathy, she is rated as a grade IV motor deficit which I rate as a 13% motor deficit.  This is multiplied by a maximum upper extremity impairment for involvement of the suprascapular nerve of 16% which produces a 2% impairment of the upper extremity when the two values are multiplied together, 2% impairment of the upper extremity.  For her lack of motion in the shoulder she also has additional impairment on the right.  She has a 1% impairment of the upper extremity due to lack of shoulder flexion.  She has a 1% impairment of the upper extremity due to lack of shoulder abduction.  She has a 1% impairment of the upper extremity due to lack of shoulder adduction.  She has a 1% impairment of the upper extremity due to lack of shoulder extension.  There is no impairment for findings in shoulder external rotation.  She has a 3% impairment of the upper extremity due to lack of shoulder internal rotation.  Thus the impairment due to lack of motion in her shoulder is a 6% impairment of the upper extremity.  This combines with the 2% impairment of the upper extremity due to weakness in the suprascapular nerve root distribution to produce an 8% impairment of the upper extremity which in turn is a 5% impairment of the whole person based on the AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition, stated with a reasonable degree of medical certainty.", IME-QME-Work Comp etc.,18
"PREOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,POSTOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,PROCEDURES:,1. Repair of XXX upper lid laceration.,2. Repair of XXX upper lid canalicular laceration.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with XXX eye upper eyelid laceration involving the canaliculus.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient was brought to the operating room and placed in the supine position, where (s)he was prepped and draped in the routine fashion for general ophthalmic plastic reconstructive surgery, once the appropriate cardiac and respiratory monitoring was placed on him/her, and once general endotracheal anesthetic had been administered. The patient then had the wound freshened up with Westcott scissors and cotton-tip applications. Hemostasis was achieved with a high-temp disposable cautery. Once this had been done, the proximal end of the XXX upper lid canalicular system was intubated with a Monoka tube on a Prolene. The proximal end was then found and this was intubated with the same tubing system. Then, two 6-0 Vicryl sutures were used to reapproximate the medial canthal tendon. Once this had been done, the skin was reapproximated with interrupted 6-0 Vicryl sutures and interrupted 6-0 plain gut sutures. To ensure that the punctum was in the correct position and in the Monoka tube was seated with a seater, and the tube was cut short. The patient's nose was suctioned of blood, and (s)he was awakened from general endotracheal anesthesia and did well. (S)he left the operating room in good condition.", Ophthalmology,26
"POSTOPERATIVE DIAGNOSIS: , Type 4 thoracoabdominal aneurysm.,OPERATION/PROCEDURE: , A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.,DESCRIPTION OF PROCEDURE IN DETAIL: , Patient was brought to the operating room and put in supine position, and general endotracheal anesthesia was induced through a double-lumen endotracheal tube.  Patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30-degree angle.  The left groin, abdominal and chest were prepped and draped in a sterile fashion.  A thoracoabdominal incision was made.  The 8th interspace was entered.  The costal margin was divided.  The retroperitoneal space was entered and bluntly dissected free to the psoas, bringing all the peritoneal contents to the midline, exposing the aorta.  The inferior pulmonary ligament was then taken down so the aorta could be dissected free at the T10 level just above the diaphragm.  It was dissected free circumferentially.  The aortic bifurcation was dissected free, dissecting free both iliac arteries.  The left inferior pulmonary vein was then dissected free, and a pursestring of 4-0 Prolene was placed on this.  The patient was heparinized.  Through a stab wound in the center of this, a right-angle venous cannula was then placed at the left atrium and secured to a Rumel tourniquet.  This was hooked to a venous inflow of left heart bypass machine.  A pursestring of 4-0 Prolene was placed on the aneurysm and through a stab wound in the center of this, an arterial cannula was placed and hooked to outflow.  Bypass was instituted.  The aneurysm was cross clamped just above T10 and also, cross clamped just below the diaphragm.  The area was divided at this point.  A 26-mm graft was then sutured in place with running 3-0 Prolene suture.  The graft was brought into the diaphragm.  Clamps were then placed on the iliacs, and the pump was shut off.  The aorta was opened longitudinally, going posterior between the left and right renal arteries, and it was completely transected at its bifurcation.  The SMA, celiac and right renal artery were then dissected free as a complete island, and the left renal was dissected free as a complete Carrell patch.  The island was laid in the graft for the visceral liner, and it was sutured in place with running 4-0 Prolene suture with pledgetted 4-0 Prolene sutures around the circumference.  The clamp was then moved below the visceral vessels, and the clamp on the chest was removed, re-establishing flow to the visceral vessels.  The graft was cut to fit the bifurcation and sutured in place with running 3-0 Prolene suture.  All clamps were removed, and flow was re-established.  An 8-mm graft was sutured end-to-end to the Carrell patch and to the left renal.  A partial-occlusion clamp was placed.  An area of graft was removed.  The end of the graft was cut to fit this and sutured in place with running Prolene suture.  The partial-occlusion clamp was removed.  Protamine was given.  Good hemostasis was noted.  The arterial cannula, of course, had been removed when that part of the aneurysm was removed.  The venous cannula was removed and oversewn with a 4-0 Prolene suture.  Good hemostasis was noted.  A 36 French posterior and a 32 French anterior chest tube were placed.  The ribs were closed with figure-of-eight #2 Vicryl.  The fascial layer was closed with running #1 Prolene, subcu with running 2-0 Dexon and the skin with running 4-0 Dexon subcuticular stitch.  Patient tolerated the procedure well.", Surgery,38
"CLINICAL HISTORY:  ,Probable right upper lobe lung adenocarcinoma.,SPECIMEN: , Lung, right upper lobe resection.,GROSS DESCRIPTION:,  Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".  It consists of one lobectomy specimen measuring 16.1 x 10.6 x,4.5.cm.  The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable.  Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass.  This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum.  There is no necrosis or hemorrhage evident.  The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.,FINAL DIAGNOSIS:,  Right lung, upper lobe, lobectomy:  Bronchioloalveolar carcinoma, mucinous type,COMMENT:,  Right upper lobe, lobectomy.,Tumor type:  Bronchioloalveolar carcinoma, mucinous type.,Histologic grade:  Well differentiated.,Tumor size (greatest diameter):  3.6 cm.,Blood/lymphatic vessel invasion:  Absent.,Perineural invasion:  Absent.,Bronchial margin:  Negative.,Vascular margin:  Negative.,Inked surgical margin:  Negative.,Visceral pleura:  Not involved.,In situ carcinoma:  Absent.,Non-neoplastic lung:  Emphysema.,Hilar lymph nodes:  Number of positive lymph nodes:  0; Total number of lymph nodes:  1.,P53 immunohistochemical stain is negative in the tumor.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS: , Right chronic subdural hematoma.,POSTOPERATIVE DIAGNOSIS: ,Right chronic subdural hematoma.,TYPE OF OPERATION: , Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 100 cc.,OPERATIVE PROCEDURE:,  In preoperative identification, the patient was taken to the operating room and placed in supine position.  Following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  Table was turned.  The right shoulder roll was placed.  The head was turned to the left and rested on a doughnut.  The scalp was shaved, and then prepped and draped in usual sterile fashion.  Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss.  The parietal boss incision was opened.  It was about an inch and a half in length.  It was carried down to the skull.  Self-retaining retractor was placed.  A bur hole was now fashioned with the perforator.  This was widened with a 2-mm Kerrison punch.  The dura was now coagulated with bipolar electrocautery.  It was opened in a cruciate-type fashion.  The dural edges were coagulated back to the bony edges.  There was egress of a large amount of liquid.  Under pressure, we irrigated for quite sometime until irrigation was returning mostly clear.  A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision.  It was secured with a 3-0 nylon suture.  The area was closed with interrupted inverted 2-0 Vicryl sutures.  The skin was closed with staples.  Sterile dressing was applied.  The patient was subsequently returned back to anesthesia.  He was extubated in the operating room, and transported to PACU in satisfactory condition.", Neurosurgery,23
"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,10
"CC:, Confusion and slurred speech.,HX , (primarily obtained from boyfriend): This 31 y/o RHF experienced a ""flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found ""passed out"" in bed, and when awoken appeared confused, and lethargic. She apparently recovered within 24 hours. For two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). She left a stove on.,She began slurring her speech 2 days prior to admission. On the day of presentation she developed right facial weakness and began stumbling to the right. She denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. There was no history of illicit drug/ETOH use or head trauma.,PMH:, Migraine Headache.,FHX: , Unremarkable.,SHX: ,Divorced. Lives with boyfriend. 3 children alive and well. Denied tobacco/illicit drug use. Rarely consumes ETOH.,ROS:, Irregular menses.,EXAM: ,BP118/66.  HR83. RR 20. T36.8C.,MS: Alert and oriented to name only. Perseverative thought processes. Utilized only one or two word answers/phrases. Non-fluent. Rarely followed commands. Impaired writing of name.,CN: Flattened right nasolabial fold only.,Motor: Mild weakness in RUE manifested by pronator drift. Other extremities were full strength.,Sensory: withdrew to noxious stimulation in all 4 extremities.,Coordination: difficult to assess.,Station: Right pronator drift.,Gait: unremarkable.,Reflexes: 2/2BUE, 3/3BLE, Plantars were flexor bilaterally.,General Exam: unremarkable.,INITIAL STUDIES:, CBC, GS, UA, PT, PTT, ESR, CRP, EKG were all unremarkable. Outside HCT showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified).,COURSE: ,MRI Brian Scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left MCA distribution suggesting slow flow. The latter suggested a vasculopathy such as Moya Moya, or fibromuscular dysplasia. HIV, ANA, Anti-cardiolipin Antibody titer, Cardiac enzymes, TFTs, B12, and cholesterol studies were unremarkable.,She underwent a cerebral angiogram on 2/12/92. This revealed an occlusion of the left MCA just distal to its origin. The distal distribution of the left MCA filled on later films through collaterals from the left ACA. There was also an occlusion of the right MCA just distal to the temporal branch. Distal branches of the right MCA filled through collaterals from the right ACA. No other vascular abnormalities were noted. These findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as Moya Moya disease. She was subsequently given this diagnosis. Neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. She had long latencies responding and understood only simple questions. Affect was blunted and there was distinct lack of concern regarding her condition. She was subsequently discharged home on no medications.,In 9/92 she was admitted for sudden onset right hemiparesis and mental status change. Exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. OB/GYN exam including cervical biopsy, and abdominal/pelvic CT scanning revealed stage IV squamous cell cancer of the cervix. She died 9/24/92 of cervical cancer.", Radiology,33
"PREOPERATIVE DIAGNOSES:  ,1.  Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2.  Cervical spondylosis.,3.  Cervical stenosis, C5-C6 secondary to above (723.0).,POSTOPERATIVE DIAGNOSES:  ,1.  Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2.  Cervical spondylosis.,3.  Cervical stenosis, C5-C6 secondary to above (723.0), with surgical findings confirmed.,PROCEDURES: , ,1.  Anterior cervical discectomy at C5-C6 with spinal cord and spinal canal decompression (63075).,2.  Anterior interbody fusion at C5-C6, (22554) utilizing Bengal cage (22851).,3.  Anterior instrumentation for stabilization by Uniplate construction, C5-C6, (22845); with intraoperative x-ray times two.,ANESTHESIA: , General.,SERVICE: , Neurosurgery.,OPERATION:  ,The patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected only in a subplatysmal manner bluntly, and with only blunt dissection at the prevertebral space where a localizing intraoperative x-ray was obtained, once self-retaining retractors were placed along the mesial edge of a cauterized longus colli muscle, to protect surrounding tissues throughout the remainder of the case.  A prominent anterior osteophyte at C5-C6 was then localized, compared to preoperative studies in the usual fashion intraoperatively, and the osteophyte was excised with a rongeur and bony fragments saved.  This allowed for an annulotomy, which was carried out with a #11 blade and discectomy, removed with straight disc forceps portions of the disc, which were sent to Pathology for a permanent section.  Residual osteophytes and disc fragments were removed with 1 and 2-mm micro Kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well.  A hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace, a sign of a decompressed status.  At no time during the case was evidence of CSF leakage, and hemostasis was readily achieved with pledgets of Gelfoam subsequently removed with copious amounts of antibiotic irrigation.  Once the decompression was inspected with a double ball dissector and all found to be completely decompressed, and the dura bulged at the interspace, and pulsated, then a Bengal cage was filled with the patient's own bone elements and fusion putty and countersunk into position, and was quite tightly applied.  Further stability was added nonetheless with an appropriate size Uniplate, which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner.  The wound was inspected, and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was Steri-Stripped for reinforcement, and a sterile dressing was applied, incorporating a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner.  Once the sterile dressing was applied, the patient was taken from the operating room to the recovery area having left in stable condition.,At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.", Surgery,38
"ADENOIDECTOMY,PROCEDURE:,  The patient was brought into the operating room suite, anesthesia administered via endotracheal tube.  Following this the patient was draped in standard fashion.  The Crowe-Davis mouth gag was inserted in the oral cavity.  The palate and tonsils were inspected, the palate was suspended with a red rubber catheter passed through the right nostril.  Following this, the mirror was used to visualize the adenoid pad and an adenoid curet was seated against the vomer.  The adenoid pad was removed without difficulty.  The nasopharynx was packed.  Following this, the nasopharynx was unpacked, several discrete bleeding sites were gently coagulated with electrocautery and the nasopharynx and oral cavity were irrigated.  The Crowe-Davis was released.,The patient tolerated the procedure without difficulty and was in stable condition on transfer to recovery.", Surgery,38
"REASON FOR CONSULT: , For evaluation of left-sided chest pain, 5 days post abdominal surgery.,PAST MEDICAL HISTORY:, None.,HISTORY OF PRESENT COMPLAINT: , This 87-year-old patient has been admitted in this hospital on 12/03/08.  The patient underwent laparoscopic appendicectomy by Dr. X.  The patient had postoperative paralytic ileus, which has resolved.  The patient had developed left-sided chest pain yesterday.  In the postoperative period, the patient has had fluid retention, had gain about 25 pounds, and he had swelling of the lower extremities.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS:  No recent fever.,ENT:  Unremarkable.,RESPIRATORY:  He denies cough but develop this left-sided chest pain, which does not increase with inspiration, pain is located on the left posterior axillary line and over the fourth and fifth rib.,CARDIOVASCULAR:  No known heart problems.,GASTROINTESTINAL:  The patient denies nausea or vomiting.  He is status post laparoscopic appendicectomy, and he is tolerating oral diet.,GENITOURINARY:  No dysuria, no hematuria.,ENDOCRINE:  Negative for diabetes or thyroid problems.,NEUROLOGIC:  No history of CVA or TIA.,Rest of review of systems unremarkable.,SOCIAL HISTORY:  ,The patient is a nonsmoker.  He denies use of alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  An 87-year-old gentleman, not toxic looking.,HEAD AND NECK:  Oral mucosa is moist.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.  There is reproducible tenderness over the left posterior-lateral axis.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Slightly distended.  Bowel sounds are positive.,EXTREMITIES:  He has 2+ to 3+ pedal swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.,LABORATORY DATA: , White count is 12,500, hemoglobin is 13, hematocrit is 39, and platelets 398,000.  Glucose is 123, total protein is 6, and albumin is 2.9.,ASSESSMENT AND PLAN:,1.  Ruptured appendicitis.  The patient is 6 days post surgery.  He is tolerating oral fluids and moving bowels.,2.  Left-sided chest pain, need to rule out PE by distance of pretty low probability.  The patient, however, has low-oxygen saturation.  We will do ultrasound of the lower extremity and if this is positive we would proceed with the CT angiogram.,3.  Fluid retention, manage as per surgeon.,4.  Paralytic ileus, resolving.,5.  Leukocytosis, we will monitor.", General Medicine,15
"PREOPERATIVE DIAGNOSES:,1.  Hallux valgus, right foot.,2.  Hallux interphalangeus, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux valgus, right foot.,2.  Hallux interphalangeus, right foot.,PROCEDURES PERFORMED:,1.  Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2.  Akin bunionectomy, right toe with internal wire fixation.,ANESTHESIA: , TIVA/local.,HISTORY:  ,This 51-year-old female presents to ABCD preoperative holding area after keeping herself NPO since mid night for a surgery on her painful bunion through her right foot.  The patient has a history of gradual onset of a painful bunion over the past several years.  She has tried conservative methods such as wide shoes, accommodative padding on an outpatient basis with Dr. X all of which have provided inadequate relief.  At this time, she desires attempted surgical correction.  The risks versus benefits of the procedure have been discussed with the patient in detail 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 and placed on the operative table in supine position and a safety strap was placed across her waist for her protection.  Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was placed over the Webril.,After adequate IV sedation was administered by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 0.5% Marcaine plain and 1% Lidocaine plain was injected into the foot in a standard Mayo block fashion.  The foot was elevated off the table.  Esmarch bandages were used to exsanguinate the right foot.  The pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered in the operative field and the sterile stockinet was reflected.  A sterile Betadine was wiped away with a wet and dry sponge and one toothpick was used to test anesthesia, which was found to be adequate.  Attention was directed to the first metatarsophalangeal joint, which was found to be contracted, laterally deviated, and had decreased range of motion.  A #10 blade was used to make a 4 cm dorsolinear incision.  A #15 blade was used to deepen the incision through the subcutaneous layer.  All superficial subcutaneous vessels were ligated with electrocautery.  Next, a linear capsular incision was made down the bone with a #15 blade.  The capsule was elevated medially and laterally off the metatarsal head and the metatarsal head was delivered into the wound.  A hypertrophic medial eminence was resected with a sagittal saw taking care not to strike the head.  The medial plantar aspect of the metatarsal head had some erosive changes and eburnation.  Next, a 0.45 inch Kirschner wire was placed with some access guide slightly plantar flexing the metatarsal taking care not to shorten it.  A sagittal saw was used to make a long-arm Austin osteotomy in the usual fashion.  Standard lateral release was also performed as well as a lateral capsulotomy freeing the fibular sesamoid complex.,The capital head was shifted laterally and impacted on the residual metatarsal head.  Nice correction was achieved and excellent bone to bone contact was achieved.  The bone stock was slightly decreased, but adequate.  Next, a 0.45 inch Kirschner wire was used to temporarily fixate the metatarsal capital fragment.  A 2.7 x 18 mm Synthes cortical screw was thrown using standard AO technique.  Excellent rigid fixation was achieved.  A second 2.0 x 80 mm Synthes fully threaded cortical screw was also thrown using standard AO technique at the proximal aspect of the metatarsal head.  Again, an excellent rigid fixation was obtained and the screws were tight.  The temporary fixation was removed.  A medial overhanging bone was resected with a sagittal saw.  The foot was loaded and the hallux was found to have an interphalangeus deformity present.,A sagittal saw was used to make a proximal cut in approximately 1 cm dorsal to the base of the proximal phalanx, leaving a lateral intact cortical hinge.  A distal cut parallel with the nail base was performed and a standard proximal Akin osteotomy was done.,After the wedge bone was removed, the saw blade was reinserted and used to tether the osteotomy with counter-pressure used to close down the osteotomy.  A #15 drill blade was used to drill two converging holes on the medial aspect of the bone.  A #28 gauge monofilament wire was inserted loop to loop and pulled through the bone.  The monofilament wire was twisted down and tapped into the distal drill hole.  The foot was loaded again and the toe had an excellent cosmetic straight appearance and the range of motion of the first metatarsophalangeal joint was then improved.  Next, reciprocating rasps were used to smooth all bony surfaces.  Copious amounts of sterile saline was used to flush the joint.  Next, a #3-0 Vicryl was used to reapproximate the capsular periosteal tissue layer.  Next, #4-0 Vicryl was used to close the subcutaneous layer.  #5-0 Vicryl was used to the close the subcuticular layer in a running fashion.  Next, 1 cc of dexamethasone phosphate was then instilled in the joint.  The Steri-Strips were applied followed by standard postoperative dressing consisting of Owen silk, 4 x 4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.  The patient tolerated the above anesthesia and procedure 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 is to be partial weightbearing with crutches.  She is to follow with Dr. X.  She was given emergency contact numbers and instructions to call if problems arise.  She was given prescription for Vicodin ES #25 one p.o. q.4-6h. p.r.n. pain and Naprosyn one p.o. b.i.d.  500 mg.  She was discharged in stable condition.", Orthopedic,27
"SUBJECTIVE:,  The patient is a 76-year-old white female who presents to the clinic today originally for hypertension and a med check.  She has a history of hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.  Since her last visit she has been followed by Dr. Kumar.  Those issues are stable.  She has had no fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure.,PAST MEDICAL HISTORY:,  She has an intolerance to Prevacid.,CURRENT MEDICATIONS:,  Evista 60 daily, Levothroid 0.05 mg daily, Claritin 10 daily, Celebrex 200 daily, HCTZ 25 daily and amitriptyline p.r.n.,PAST SURGICAL HISTORY:,  Bilateral mastectomies, tonsillectomy, EGD, flex sig in 2001 and a heart cath.,FAMILY HISTORY: , Father passed away at 81; mother of multiple myeloma at 83.,SOCIAL HISTORY:,  She is married.  A 76-year-old who used to smoke a pack a day and quit in 1985.  She is retired.,REVIEW OF SYSTEMS:,  Essentially negative in HEENT, chest, cardiovascular, GI, GU, musculoskeletal, or neurologic.,OBJECTIVE:,  Temperature is 97.5 degrees.  Blood pressure is 168/70.  Pulse is 88.  Weight is 129 pounds.,GENERAL:  She is an elderly 76-year-old in no acute distress.,HEENT:  Atraumatic.  Extraocular muscles were intact.  Pupils equal, round and reactive to light and accommodation.  Tympanic membranes are clear, dry and intact.  Sinuses and throat are clear.  Neck is soft, supple.  No meningeal signs are present.  No thyromegaly is present.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, nontender.  Bowel sounds are positive.  No organomegaly or peritoneal signs are present.,EXTREMITIES:  Moving all extremities.  Peripheral pulses are normal.  No edema is present.,NEUROLOGIC:  Alert and oriented.  Cranial nerves II-XII grossly intact.  Strength 5+/5 globally.  Reflexes 2+/IV globally.  Romberg is negative.  There is no numbness, tingling, weakness or other neurologic deficit present.,BREASTS:  Surgically absent but there are no lumps, lesions, masses, discharge or adenopathy present.,BACK:  Straight.,SKIN:  Clear.,GENITALIA:  Deferred as she has been followed by Dr. XYZ many times this year.  She does have a history of some elevated cholesterol.,ASSESSMENT:,1.  Hypertension, suboptimal control.,2.  Hypothyroidism.,3.  Arthritis.,4.  Allergic rhinitis.,5.  History of kidney stones.,6.  Osteoporosis.,PLAN:,1.  CBC, complete metabolic profile, UA for hypertension.,2.  Chest x-ray for history of breast cancer.,3.  DEXA scan, full body for osteoporosis.,4.  Flex is up to date.,5.  Pneumovax has been given in the last five years.,6.  Lipid profile for elevated cholesterol.,7.  Refill meds.,8.  Follow up every three to six months for blood pressure check or sooner p.r.n. problems.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS:,  Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury.,POSTOPERATIVE DIAGNOSES:,1.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis.,2.  25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.,PROCEDURE PERFORMED:,1.  Repair of nerve and tendon, right ring finger.,2.  Exploration of digital laceration.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,TOTAL TOURNIQUET TIME:  ,57 minutes.,COMPLICATIONS: , None.,DISPOSITION:  ,To PACU in stable condition.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger.,GROSS OPERATIVE FINDINGS: , After wound exploration, it was found there was a 100% laceration to the ulnar digital neurovascular bundle.  The FDS had a partial ulnar slip laceration and the FDP had a 25% transverse laceration as well.  The radial neurovascular bundle was found to be completely intact.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room and placed in the supine position.  All bony prominences were adequately padded.  Tourniquet was placed on the right upper extremity after being packed with Webril, but not inflated at this time.  The right upper extremity was prepped and draped in the usual sterile fashion.  The hand was inspected.  Palmar surface revealed approximally 0.5 cm laceration at the base of the right ring finger at the base of proximal phalanx, which was approximated with nylon suture.  The sutures were removed and the wound was explored.  It was found that the ulnar digital neurovascular bundle was 100% transected.  The radial neurovascular bundle on the right ring finger was found to be completely intact.  We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25% laceration in a transverse fashion to the FDP.  We copiously irrigated the wound.  Repair was undertaken of the FDS with #3-0 undyed Ethibond suture.  The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact.  Attention during our repair at the flexor tendon, the A1 pulley was incised for better visualization as well as better tendon excursion after repair.  Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury.  The digital nerve was dissected proximally and distally to likely visualize the nerve.  The nerve was then approximated using microvascular technique with #8-0 nylon suture.  The hands were well approximated.  The nerve was not under undue tension.  The wound was then copiously irrigated and the skin was closed with #4-0 nylon interrupted horizontal mattress alternating with simple suture.  Sterile dressing was placed and a dorsal extension Box splint was placed.  The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition.  Overall prognosis is good.", Neurosurgery,23
"PREOPERATIVE DIAGNOSIS: , Coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.,DESCRIPTION OF PROCEDURE:,LEFT HEART CATHETERIZATION WITH ANGIOGRAPHY AND MID ABDOMINAL AORTOGRAPHY:,Under local anesthesia with 2% lidocaine with premedication, a right groin preparation was done.  Using the percutaneous Seldinger technique via the right femoral artery, a left heart catheterization was performed.  Coronary arteriography was performed with 6-French performed coronary catheters.  We used a 6-French JR4 and JL4 catheters to take multiple cineangiograms of the right and left coronary arteries.  After using the JR4 6-French catheter, nitroglycerin was administered because of the possibility of ostial spasm, and following that, we used a 5-French JR4 catheter for additional cineangiograms of the right coronary artery.  A pigtail catheter was placed in the mid abdominal aorta and abdominal aortic injection was performed to rule out abdominal aortic aneurysm, as there was dense calcification in the mid abdominal aorta.,ANALYSIS OF PRESSURE DATA: , Left ventricular end-diastolic pressure was 5 mmHg.  On continuous tracing from the left ventricle to the ascending aorta, there is no gradient across the aortic valve.  The aortic pressures were normal.  Contours of intracardiac pressure were normal.,ANALYSIS OF ANGIOGRAMS:,  Selective cineangiograms were obtained with injection of contrast to the left ventricle, coronary arteries, and mid abdominal aorta.  A pigtail catheter was introduced into the left ventricle and ventriculogram performed in right anterior oblique position.  The mitral valve is competent and demonstrates normal mobility.  The left ventricular cavity is normal in size with excellent contractility.  Aneurysmal dilatation and/or dyskinesia absent.  The aortic valve is tricuspid and normal mobility.  The ascending aorta appeared normal.,Pigtail catheter was introduced in the mid abdominal aorta and placed just above the renal arteries.  An abdominal aortic injection was performed.  Under fluoroscopy, we see heavy dense calcification of the mid abdominal aorta between the renal artery and the bifurcation.  There was some difficulty initially with maneuvering the wire pass that area and it was felt that might be a tight stenosis.  The abdominal aortogram reveals wide patency of that area with mild intimal irregularity.  There is a normal left renal artery, normal right renal artery.  The celiac seems to be normal, but what I believe is the splenic artery seen initially at its origin is normal.  The common left iliac and common right iliac arteries are essentially normal in this area.,CORONARY ANATOMY:,  One notes ostial coronary calcification of the right coronary artery.  Cineangiogram obtained with 6-French JR4 and 5-French JR4 catheters.  Prior to the introduction of the 5-French JR4 nitroglycerin was administered sublingually.  The 6-French JR4 catheters appeared to a show an ostial lesion of over 50%.  There was backwash of dye into the aorta, although there is a fine funneling of the ostium towards the proximal right coronary artery.  In the proximal portion of the right coronary artery just into the Shepherd turn, there is a 50% smooth tapering of the right coronary artery in the proximal third.  Then the artery seems to have a little bit more normal size and it divides into a large posterior descending artery posterolateral branch vessel.  The distal portion of the vessel is free of disease.  The conus branch is seen arising right at the beginning part of the right coronary artery.  We then removed the 6-French catheter and following nitroglycerin and sublingually we placed a 5-French catheter and again finding a stenosis, may be less than 50%.  At the ostium of the right coronary artery, calcification again is identified.  Backwash of dye noted at the proximal lesion, looked about the same 50% along the proximal turn of the Shepherd turn area.,The left coronary artery is normal, although there is a rim of ostial calcification, but there is no tapering or stenosis.  It forms the left anterior descending artery, the ramus branch, and the circumflex artery.,The left anterior descending artery is a very large vessel, very tortuous in its proximal segment, very tortuous in its mid and distal segment.  There appears to be some mild stenosis of 10% in the proximal segment.  It gives off a large diagonal branch in the proximal portion of the left anterior descending artery and it is free of disease.  The remaining portion of the left anterior descending artery is free of disease.  Upon injection of the left coronary artery, we see what I believe is the dye enters probably directly into the left ventricle, but via fistula excluding the coronary sinus, and we get a ventriculogram performed.  I could not identify an isolated area, but it seems to be from the interventricular septal collaterals that this is taking place.,The ramus branch is normal and free of disease.,The left circumflex artery is a tortuous vessel over the lateral wall and terminating in the inferoposterior wall that is free of disease.,The patient has a predominantly right coronary system.  There is no _______ circulation connecting the right and left coronary systems.,The patient tolerated the procedure well.  The catheter was removed.  Hemostasis was achieved.  The patient was transferred to the recovery room in a stable condition.,IMPRESSION:,1.  Excellent left ventricular contractility with normal left ventricular cavity size.,2.  Calcification of the mid abdominal aorta with wide patency of all vessels.  The left and right renal arteries are normal.  The external iliac arteries are normal.,3.  Essentially normal left coronary artery with some type of interventricular septal to left ventricular fistula.,4.  Ostial stenosis of the right coronary artery that appears to be about 50% or greater.  The proximal right coronary artery has 50% stenosis as well.,5.  Coronary calcification is seen under fluoroscopy at the ostia of the left and right coronary arteries.,RECOMMENDATIONS:  ,The patient has heavy calcification of the coronary arteries and continued risk factor management is needed.  The ostial lesion of the right coronary artery may be severe.  It is at least 50%, but it could be worse.  Therefore, she will be evaluated for the possibility of an IVUS and/or _______ analysis of the proximal right coronary artery.  We will reevaluate her stress nuclear study as well.  Continue aggressive medical therapy.", Cardiovascular / Pulmonary,3
"CHIEF COMPLAINT:,  Followup on diabetes mellitus, status post cerebrovascular accident.,SUBJECTIVE:,  This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side.  We have done EMG studies.  He has noticed it since his stroke about five years ago.  He has been to see a neurologist.  We have tried different medications and it just does not seem to help.  He checks his blood sugars at home two to three times a day.  He kind of adjusts his own insulin himself.  Re-evaluation of symptoms is essentially negative.  He has a past history of heavy tobacco and alcohol usage.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt; 118 lbs, B/P; 108/72, T; 96.5, P; 80 and regular.  ,General:  A 70-year-old male who does not appear to be in acute distress but does look older than his stated age.  He has some missing dentition.,Skin:  Dry and flaky. ,CV:  Heart tones are okay, adequate carotid pulsations.  He has 2+ pedal pulse on the left and 1+ on the right.,Lungs: Diminished but clear.,Abdomen:  Scaphoid.,Rectal:  His prostate check was normal per Dr. Gill.,Neuro:  Sensation with monofilament testing is better on the left than it is on the right.,IMPRESSION:,1.  Diabetes mellitus.,2.  Neuropathy.,3.  Status post cerebrovascular accident.,PLAN:,  Refill his medications x 3 months.  We will check an A1c and BMP.  I have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood.  We will check a PSA.  Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in three months and p.r.n.", General Medicine,15
"PROCEDURE:,  Colonoscopy.,PREOPERATIVE DIAGNOSES: , Change in bowel habits and rectal prolapse.,POSTOPERATIVE DIAGNOSIS: , Normal colonoscopy.,PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice.  The preparation was poor, but mucosa was visible after lavage and suction.  Small lesions might have been missed in certain places, but no large lesions are likely to have been missed.  The mucosa was normal, was visualized.  In particular, there was no mucosal abnormality in the rectum and distal sigmoid, which is reported to be prolapsing.  Biopsies were taken from the rectal wall to look for microscopic changes.  The anal sphincter was considerably relaxed, with no tone and a gaping opening.  The patient tolerated the procedure well and was sent to recovery room.,FINAL DIAGNOSIS: , Normal colonic mucosa to the cecum.  No contraindications to consideration of a repair of the prolapse.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Left patellar chondromalacia.,POSTOPERATIVE DIAGNOSIS:,  Left patellar chondromalacia with tight lateral structures.,PROCEDURE:,  Left knee arthroscopy with lateral capsular release.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME:  ,47 minutes.,MEDICATION:  ,The patient received 0.5% Marcaine local anesthetic 32 mL.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,HISTORY AND PHYSICAL:  ,The patient is a 14-year-old girl who started having left knee pain in the fall of 2007.  She was not seen in Orthopedic Clinic until November 2007.  The patient had an outside MRI performed that demonstrated left patellar chondromalacia only.  The patient was referred to physical therapy for patellar tracking exercises.  She was also given a brace.  The patient reported increasing pain with physical therapy and mother strongly desired other treatment.  It was explained to the mother in detail that this is a difficult problem to treat although majority of the patients get better with physical therapy.  Her failure with nonoperative treatment is below the standard 6-month trial; however, given her symptoms and severe pain, lateral capsular release was offered.  Risk and benefits of surgery were discussed.  Risks of surgery including risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling.  All questions were answered, and mother and daughter agreed to the above plans.,PROCEDURE NOTE: , The patient was taken to the operating room and placed on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A nonsterile tourniquet was placed on the upper aspect of left thigh.  The extremity was then prepped and draped in the standard surgical fashion.  A medial suprapatellar portal was marked on the skin as well as anteromedial and anterolateral joint line.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  Esmarch was then removed.  Incisions were then made.  Camera was initially inserted into the lateral joint line.  Visualization of patellofemoral joint revealed type 2 chondromalacia with slight lateral subluxation.  The patient did have congruent articulation about 30 degrees of knee flexion.  Visualization of the medial joint line revealed no loose bodies.  There was a small plica.  Visualization of the medial joint line revealed no significant chondromalacia.  Menisci was probed and tested with no signs of tears and instability.  ACL was noted to be intact.  The intercondylar notch and lateral joint line also revealed no significant chondromalacia or meniscal pathology.  Lateral gutter also demonstrated no loose bodies or plica.  The camera was then removed and inserted into the anteromedial portal using two 18-gauge needles.  The extent of lateral capsular release was marked using a monopolar coblator, lateral capsular release was performed.  The patient had significant improvement in anteromedial translation from 25% to 50%.  At the end of the case, all instruments were removed.  The knee was injected with 32 mL of 0.5% Marcaine with additional epinephrine.  Please note, the patient received 30 mL of 1:500,000 dilution epinephrine at the beginning of the case.  The portals were then closed using 4-0 Monocryl.  The wound was clean and dry, and dressed with Steri-Strips, Xeroform, and 4 x 4s.  The kneecap was translated medially under pressure and a bias placed.  The tourniquet was released at 47 minutes.  The patient was then placed in the knee immobilizer.  The patient tolerated the procedure well and was subsequently extubated and taken to the recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will weightbear as tolerated in the knee immobilizer.  She will start physical therapy within 1 to 2 weeks to work on patella mobilization as well as reconditioning and strengthening.  Intraoperative findings were relayed to the mother.  All questions were answered.", Orthopedic,27
"HISTORY:  ,The patient is a 76-year-old male, with previous history of dysphagia, status post stroke.  The patient stated that he was at Hospital, secondary to his stroke, where he had his initial modified barium swallow study.  The patient stated that the results of that modified revealed aspiration with thin liquids only.  He is currently eating and drinking without difficulty and he feels that he can return to a regular diet with thin liquids.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,STUDY: , Modified barium swallow study was performed in the radiology suite in cooperation with Dr. X. The patient was seated upright and in a video-imaging chair throughout this assessment.,To evaluate the patient's swallowing function and safety, he was administered graduated amounts of liquid and food mixed with barium in the form of thin liquids (teaspoon x3, cup sip x3); nectar-thick liquid (teaspoon x2, cup sip x3); pureed consistency (teaspoon x3); solid consistency (1/4 cracker x1).,FINDINGS,ORAL STAGE: , The patient had no spillage out lips.  Oral residual after swallow with increased viscosity requiring multiple swallows to clear oral cavity.,The patient has reduced lingual retraction contributing to vallecula pooling after the swallow.  Trace premature spillage was noted with thin liquids during this assessment.,PHARYNGEAL STAGE: , Aspiration noted on cup sips of thin liquid.  Trace-to-mild penetration with teaspoon amounts of thin liquid during and after the swallow.  The penetration after the swallow occurred secondary to spillage on the piriform sinuses into the laryngeal vestibule.  The patient has incomplete laryngeal closure, which allowed the aspiration and penetration with thin liquids.  The patient had no aspiration or penetration occur with nectar-thick liquid, puree, and solid food.  The patient has a mildly reduced hyolaryngeal elevation and anterior movement that leads to incomplete epiglottic inversion that contributes to vallecula pooling.  Mild-to-moderate pooling in the vallecula after the swallow with liquids and puree, this residual did decrease with the solid feed presentation.  The patient has mild residual of pooling in the piriform sinuses after a swallow that did clear with sequential swallows.,CERVICAL ESOPHAGEAL STAGE: , The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION: , Mild aspiration with cup sips of thin liquid, penetration during and after the swallow with teaspoon amounts of thin liquid.  No aspiration or penetration occurred with thick liquid, pureed, or solid food during this assessment.,PROGNOSTIC IMPRESSION: , With a modified diet, the patient's potential for swallowing safety is good.,PLAN:,Based on this evaluation, the following is recommended:,1.  The patient should be on a regular diet with nectar-thick liquids to help prevent aspiration and penetration.,2.  The patient should have unthickened water in between meals to help decrease his risk of dehydration.,3.  The patient should complete good oral care two times a day to decrease bacterial growth in mouth.,4.  The patient should be seated at a 90-degree angle when eating and drinking, as well as take small bites and small sips to help decrease risk of aspiration and penetration and reflux.,Thank you for the opportunity to evaluate the patient.  I look forward to working with him in the outpatient setting to improve his swallowing function and safety.  Outpatient skilled speech therapy is recommended for a trial of neuromuscular electrical stimulation therapy for muscle re-education, as well as to train patient to use swallowing techniques and maneuvers that should improve his swallowing function and safety.", Consult - History and Phy.,5
"ADMITTING DIAGNOSIS: , Encephalopathy related to normal-pressure hydrocephalus.,CHIEF COMPLAINT:,  Diminished function secondary to above.,HISTORY:  ,This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was diagnosed.  He had a shunt placed and was stabilized medically.  He has gotten a return of function to the legs and was started on some early therapy.  Significant functional limitations have been identified and ongoing by the rehab admission team.  Significant functional limitations have been ongoing.  He will need to be near-independent at home for periods of time, and he is brought in now for rehabilitation to further address functional issues, maximize skills and safety and allow a safe disposition home.,PAST MEDICAL HISTORY: , Positive for prostate cancer, intermittent urinary incontinence and left hip replacement.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS,1.  Tylenol as needed.  ,2.  Peri-Colace b.i.d.,SOCIAL HISTORY:,  He is a nonsmoker and nondrinker.  Prior boxer.  He lives in a home where he would need to be independent during the day.  Family  relatives intermittently available.  Goal is to return home to an independent fashion to that home setting.,FUNCTIONAL HISTORY: , Prior to admission was independent with activities of daily living and ambulatory skills.  Presently, he has resumed therapies and noted to have supervision levels for most activities of daily living.  Memory at minimal assist.  Walking at supervision., REVIEW OF SYSTEMS:  ,Negative for headaches, nausea, vomiting, fevers, chills, shortness of breath or chest pain currently.  He has had some dyscoordination recently and headaches on a daily basis, most days, although the Tylenol does seem to control that pain.,PHYSICAL EXAMINATION,VITAL SIGNS:  The patient is afebrile with vital signs stable.,HEENT:  Oropharynx clear, extraocular muscles are intact.,CARDIOVASCULAR:  Regular rate and rhythm, without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended,  positive bowel sounds.,EXTREMITIES:  Without clubbing, cyanosis, or edema.  The calves are soft and nontender bilaterally.,NEUROLOGIC:  No focal, motor or sensory losses through the lower extremities.  He moves upper and lower extremities well.  Bulk and tone normal in the upper and lower extremities.  Cognitively showing intact with appropriate receptive and expressive skills.,IMPRESSION ,", Neurology,22
"EXAM: , Ultrasound examination of the scrotum.,REASON FOR EXAM: , Scrotal pain.,FINDINGS:  ,Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed.  The left testicle measures 5.1 x 2.8 x 3.0 cm.  There is no evidence of intratesticular masses.  There is normal Doppler blood flow.  The left epididymis has an unremarkable appearance.  There is a trace hydrocele.,The right testicle measures 5.3 x 2.4 x 3.2 cm.  The epididymis has normal appearance.  There is a trace hydrocele.  No intratesticular masses or torsion is identified.  There is no significant scrotal wall thickening.,IMPRESSION:  ,Trace bilateral hydroceles, which are nonspecific, otherwise unremarkable examination.", Radiology,33
"SUBJECTIVE:  ,This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum.  He says he does not feel short of breath.  He denies any fever or chills.,REVIEW OF SYSTEMS:,HEENT:  Denies any severe headache or sore throat.,CHEST:  No true pain.,GI:  No nausea, vomiting, or diarrhea.,PAST HISTORY:,  He states that he is on Coumadin because he had a cardioversion done two months ago for atrial fibrillation.  He also lists some other medications.  I do have his medications list.  He is on Pacerone, Zaroxolyn, albuterol inhaler, Neurontin, Lasix, and several other medicines.  Those are the predominant medicines.  He is not a diabetic.  The past history otherwise, he has had smoking history, but he quit several years ago and denies any COPD or emphysema.  No one else in the family is sick.,PHYSICAL EXAMINATION:,GENERAL:  The patient appears comfortable.  He did not appear to be in any respiratory distress.  He was alert.  I heard him cough once during the entire encounter.  He did not bring up any sputum at that time.,VITAL SIGNS:  His temperature is 98, pulse 71, respiratory rate 18, blood pressure 122/57, and pulse ox is 95% on room air.,HEENT:  Throat was normal.,RESPIRATORY:  He was breathing normally.  There was clear and equal breath sounds.  He was speaking in full sentences.  There was no accessory muscle use.,HEART:  Sounded regular.,SKIN:  Normal color, warm and dry.,NEUROLOGIC:  Neurologically he was alert.,IMPRESSION: , Viral syndrome, which we have been seeing in many cases throughout the week.  The patient asked me about antibiotics and I did not see a need to do this since he did not appear to have an infection other than viral given his normal temperature, normal pulse, normal respiratory rate, and near normal oxygen.  The patient being on Coumadin I explained to him that unless there was a solid reason to put him on antibiotics, he would be advised not to do so because antibiotics can alter the gut floor causing the INR to increase while on Coumadin which may cause serious bleeding.  The patient understands this.  I then asked him if the cough was annoying him, he said it was.  I offered him a cough syrup, which he agreed to take.  The patient was then discharged with Tussionex Pennkinetic a hydrocodone time-release cough syrup.  I told to check in three days, if the symptoms were not getting better.  The patient appeared to be content with this treatment and was discharged in approximately 30 to 45 minutes later.  His wife calls me very angry that I did not give him antibiotics.  I explained her exactly what I explained to him that they were not indicative at this time, and she became very upset saying that they came there specifically for antibiotics and I explained again that antibiotics are not indicated for viral infection and that I did not think he had a bacterial infection.,DIAGNOSIS: , Viral respiratory illness.", General Medicine,15
"REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.", Neurology,22
"COMPARISON STUDIES:, None.,MEDICATION: ,  Lopressor 5 mg IV.,HEART RATE AFTER MEDICATION:, 64bpm,EXAM:,TECHNIQUE: Tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc’s of Isovue 370 was injected in the right arm.,TECHNICAL QUALITY:,Examination is limited secondary to extensive artifact from defibrillator wires.,There is good demonstration of the coronary arteries and there is good bolus timing.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,The left main coronary artery is a moderate-sized vessel with a normal ostium. There is no calcific or non-calcific plaque. The vessel bifurcates into a left anterior descending artery and a left circumflex artery.,LEFT ANTERIOR DESCENDING ARTERY:,The left anterior descending artery is a moderate-sized vessel, with a small first diagonal branch and a large second diagonal branch. The vessel continues as a small vessel, tapering at the apex of the left ventricle. There is calcific plaque within the mid vessel, with dense calcific plaque at the bifurcation of the second diagonal branch. This limits evaluation of the vessel lumen, and although a flow-limiting lesion cannot be excluded, there is no evidence of a high-grade stenosis. There is ostial calcification within the second diagonal branch as well. The LAD distal to the second diagonal branch is small relative to the more proximal vessel, and this is worrisome for a proximal flow-limiting lesion.,In addition, there is marked tapering of the D2 branch distal to the proximal and ostial calcific plaque. This is worrisome for either occlusion or a high-grade stenosis. There is only minimal contrast that is identified in the distal vessel.,LEFT CIRCUMFLEX ARTERY:,The left circumflex artery is a moderate-sized vessel with a patent ostium. There is calcific plaque within the proximal vessel. There is dense calcific plaque at the bifurcation of the OM1, and the AV groove branch. The AV groove branch tapers as a small vessel at the base of the heart. The dense calcific plaque within the bifurcation of the OM1 and the AV groove branch limits evaluation of the vessel lumen. There is no demonstrated high-grade stenosis, but a flow-limiting lesion cannot be excluded here.,RIGHT CORONARY ARTERY:,The right coronary artery is a moderate-sized vessel with a patent ostium. There is proximal mixed calcific and non-calcific plaque, but there is no flow-limiting lesion. The vessel continues as a moderate-sized vessel to the crux of the heart, supplying a small posterior descending artery and moderate to large posterolateral ventricular branches.,There is scattered calcific plaque within the mid vessel and there is also calcific plaque within the distal vessel at the origin of the posterior descending artery. There is no flow-limited lesion demonstrated.,The right coronary artery is dominant.,NONCORONARY CARDIAC STRUCTURE:,CARDIAC CHAMBERS:, There is diffuse myocardial thinning within the left ventricle, particularly within the apex where there is subendocardial calcification, consistent with chronic infarction. There is ventricular enlargement. There is no demonstrated aneurysm or pseudoaneurysm.,CARDIAC VALVES: ,There is calcification within the left aortic valve cusp. The aortic valve is tri-leaflet. Normal mitral valve.,PERICARDIUM:, Normal.,GREAT VESSELS: ,There are atherosclerotic changes within the aorta.,VISUALIZED LUNG PARENCHYMA, MEDIASTINUM AND CHEST WALL: ,Normal.,IMPRESSION:,Limited examination secondary to extensive artifact from the pacemaker wires.,There is extensive calcific plaque within the left anterior descending artery as well as within the proximal second diagonal branch. There is marked tapering of the LAD distal to the bifurcation of the D1 and this is worrisome for a flow-limiting lesion, but there is no evidence of occlusion.,There is marked tapering of the D1 branch distal to the calcific plaque and occlusion cannot be excluded.,There is dense calcific plaque within the left circumflex artery, and although a flow-limiting lesion cannot be excluded here, there is no evidence of an occlusion or high-grade stenosis.,There is mixed soft and calcific plaque within the proximal RCA, but there is no flow limiting lesion demonstrated.,There is diffuse thinning of the left ventricular wall, most focal at the apex where there is also dense calcification, consistent with chronic infarction. There is no demonstrated aneurysm or pseudoaneurysm.", Radiology,33
"DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - ""This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant."",When and how did subject of donation arise - ""My mom and I talked about it together as a family."",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer:  ""I would rather not go there.  Well, since we were talking, ""I will tell you that my mother really does not understand.  She is very worried.  She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor.  I don't think my mom really understands, and I know that she really needs a kidney.  I think she is coming around to accepting."",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - ""Well, my children are fine and my husband is very supportive."",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - ""My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate."",How would your family and friends react if you decided not to be a donor - ""I don't think that is going to happen."",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - ""I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother.  I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup."",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - ""That is my mother."",How your relationship with the recipient change if you donate your kidney - ""I am not sure that it will change at all.  I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others."",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact.  I am away from my children and my husband a lot because of I travel with my job.  So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - ""Yes, I have a very good understanding of the transplant process.  I work as a contract nursing all over the country.  I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process."",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - ""Yes, I do understand all the risks.  I have had a long conversation with the coordinator and we have talked about these things."",Have you thought about how you might feel if the kidney is rejected - ""I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine.  It is a part of the way I am managing my stress about this."",Do you have any doubts or concerns about donating - ""No, I don't have any doubts or any concerns right now.  I just wish this headache would go away.,Do you understand that there will be pain after the transplant - ""Of course, I do."",What are your expectations about your recuperation - ""I am planning on staying with my mom for three months in the Houston area after the transplant.  We live outside of Tampa, Florida; so this will be an adventure for both of us."",Do you need to speak further to any of the transplant team members - ""No, I have had a long talk with ABC.  I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - ""I had a one cesarian section, and I also suffered from asthma as a child.  I am in otherwise good health."",Are you currently on any medication - ""Yes, I am on Folic acid."",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - ""No, I have not.  I have a good supportive system and a lot of people that I can talk to when I need to."",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - ""No."",Any typical drinks you prefer - ""I am a nondrinker."",What kinds of recreational drugs have you tried?  Have you used any recently - ""None."",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS:  LENGTH OF TIME MARRIED:  ""I live with my family, my husband, and my two children with good relationship.  We have been married for 29 years."",NAME OF SPOUSE/PARTNER:  ""His name is Xyz."",AGE AND HEALTH OF SPOUSE/PARTNER:  He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter.  Our elder child has just finished college."",CHILDREN:  I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - ""I will stay with a friend.  He lives in the Houston area.  I am staying with that friend right now, while I am here for my workup."",CURRENT OCCUPATION:,What is your current occupation - ""I currently work on a contract basis as a nurse.  I go on assignments all over the country, and I work until the contract is over.  This allowed me to be flexible and the best candidate for donation to mom."",Do you have the support of your employer - ""Absolutely."",PAID OFF TIME:,Paid leave - ""None."",Disability coverage:  ""None."",SUPPORTIVE ENVIRONMENT:,  ""Yes.""", Nephrology,21
"EXAM:,  Bilateral carotid ultrasound.,REASON FOR EXAM: , Headache.,TECHNIQUE:  ,Color grayscale and Doppler analysis is employed.,FINDINGS:,  On the grayscale images, the right common carotid artery demonstrates patency with mild intimal thickening only.  At the level of the carotid bifurcation, there is heterogeneous hard plaque present, but without grayscale evidence of greater than 50% stenosis.  Right common carotid waveform is normal with a peak systolic velocity of 0.474 m/second and an end-diastolic velocity of 0.131 m/second.  The right ECA is patent as well with the velocity measurement 0.910 m/second.,The right internal carotid artery at the bifurcation demonstrates plaque formation, but no evidence of greater than 50% stenosis.  Proximal peak systolic velocity in the internal carotid artery is 0.463 m/second with proximal end-diastolic velocity of 0.170.  The mid internal carotid peak systolic velocity is 0.564 m/second, and mid ICA end-diastolic velocity is 0.199 m/second.  Right ICA distal PSV 0.580 m/second, right ICA distal EDV 0.204 m/second.  Vertebral flow is antegrade on the right at 0.469 m/second.,On the left, the common carotid artery demonstrates intimal thickening, but is otherwise patent.  At the level of the bifurcation, however, there is more pronounced plaque formation with approximately 50% stenosis by the grayscale analysis.  See the velocity measurements below:,Left carotid ECA measurement 0.938 m/second.  Left common carotid PSV 0.686 m/second, and left common carotid end-diastolic velocity 0.137 m/second.,Left internal carotid artery again demonstrates prominent focus of hard plaque with up to at least 50% stenosis.  This should be further assessed with CTA for more precise measurement.  The left proximal ICA/PSV 0.955 m/second, left proximal ICA/EDV 0.287 m/second.  There is spectral broadening in the proximal aspect of the carotid waveform.  The left carotid ICA mid PSV 0.895, left carotid ICA mid EDV 0.278 with also spectral broadening present.,The left distal ICA/PSV 0.561, left distal ICA/EDV 0.206, again the spectral broadening present.  Vertebral flow is antegrade at 0.468 m/second.,IMPRESSION: , The study demonstrates bilateral hard plaque at the bifurcation, left greater than right.  There is at least 50% stenosis of the left internal carotid artery at its bifurcation and a followup CTA is recommended for further assessment.", Neurology,22
"PREOPERATIVE DIAGNOSES:,1.  Chondromalacia patella.,2.  Patellofemoral malalignment syndrome.,POSTOPERATIVE DIAGNOSES:,1.  Grade-IV chondromalacia patella.,2.  Patellofemoral malalignment syndrome.,PROCEDURE PERFORMED:,1.  Diagnostic arthroscopy with partial chondroplasty of patella.,2.  Lateral retinacular release.,3.  Open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws.,ANESTHESIA:,  General.,COMPLICATIONS: , None.,TOURNIQUET TIME: , Approximately 70 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , Grade-IV chondromalacia noted to the central and lateral facet of the patella.  There was a grade II to III chondral changes to the patellar groove.  The patella was noted to be displaced laterally riding on the edge of the lateral femoral condyle.  The medial lateral meniscus showed small amounts of degeneration, but no frank tears were seen.  The articular surfaces and the remainder of the knee appeared intact.  Cruciate ligaments also appeared intact to direct stress testing.,HISTORY:  ,This is a 36-year-old Caucasian female with a long-standing history of right knee pain.  She has been diagnosed in the past with chondromalacia patella.  She has failed conservative therapy.  It was discussed with her the possibility of a arthroscopy lateral release and a tubercle transfer (anterior medialization of the tibial tubercle) to release stress from her femoral patellofemoral joint.  She elected to proceed with the surgical intervention.  All risks and benefits of the surgery were discussed with her.  She was in agreement with the treatment plan.,PROCEDURE: , On 09/04/03, she was taken to Operating Room at ABCD General Hospital.  She was placed supine on the operating table with the general anesthesia administered by the Anesthesia Department.  Her leg was placed in a Johnson knee holder and sterilely prepped and draped in the usual fashion.  A stab incision was made in inferolateral and parapatellar regions.  Through this the cannula was placed and the knee was inflated with saline solution.  Intraoperative pictures were obtained.  The above findings were noted.  Second portal site was initiated in the inferomedial parapatellar region.  Through this, a arthroscopic shaver was placed and the chondroplasty in the patella was performed and removed the loose articular debris.  Next, the camera was placed through the inferomedial portal.  An arthroscopic Bovie was placed through the inferolateral portal.  A release of lateral retinaculum was then performed using the Bovie.  Hemostasis was controlled with electrocautery.  Next, the knee was suctioned dry.  An Esmarch was used to exsanguinate the lower extremity.  Tourniquet was inflated to 325 mmHg.  An oblique incision was made along the medial parapatellar region of the knee.  The subcuticular tissues were carefully dissected and the hemostasis was again controlled with electrocautery.  The retinaculum was then incised in line with the incision.  The patellar tendon was identified.  The lateral and medial border of the tibial tubercle were cleared of all soft tissue debris.  Next, an osteotome was then used to cut the tibial tubercle to 45 degree angle leaving the base of the bone incision intact.  The tubercle was then pushed anteriorly and medially decreasing her Q-angle and anteriorizing the tibial tubercle.  It was then held in place with a Steinmann pin.  Following this, a two 4.5 mm cannulated screws, partially threaded, were drilled in place using standard technique to help fixate the tibial tubercle.  There was excellent fixation noted.  The Q-angle was noted to be decreased to approximately 15 degrees.  She was transferred approximately 1 cm in length.  The wound was copiously irrigated and suctioned dry.  The medial retinaculum was then plicated causing further medialization of the patella.  The retinaculum was reapproximated using #0 Vicryl.  Subcuticular tissue were reapproximated with #2-0 Vicryl.  Skin was closed with #4-0 Vicryl running PDS suture.  Sterile dressing was applied to the lower extremities.  She was placed in a Donjoy knee immobilizer locked in extension.  It was noted that the lower extremity was warm and pink with good capillary refill following deflation of the tourniquet.  She was transferred to recovery room in apparent stable and satisfactory condition.,Prognosis of this patient is poor secondary to the advanced degenerative changes to the patellofemoral joint.  She will remain in the immobilizer approximately six weeks allowing the tubercle to reapproximate itself to the proximal tibia.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,POSTOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,PROCEDURES:,1.  Open septorhinoplasty with placement of bilateral spreader grafts.,2.  Placement of a radiated rib tip graft.,3.  Placement of a morcellized autogenous cartilage dorsal onlay graft.,4.  Placement of endogen, radiated collagen dorsal onlay graft.,5.  Placement of autogenous cartilage columellar strut graft.,6.  Bilateral lateral osteotomies.,7.  Takedown of the dorsal hump with repair of the bony and cartilaginous open roof deformities.,8.  Fracture of right upper lateral cartilage.,ANESTHESIA:  ,General endotracheal tube anesthesia.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,100 mL.,URINE OUTPUT:,  Not recorded.,SPECIMENS:,  None.,DRAINS: , None.,FINDINGS:  ,1.  The patient had a marked dorsal hump, which was both bony and cartilaginous in nature.,2.  The patient had marked hypertrophy of his nasalis muscle bilaterally contributing to the soft tissue dorsal hump.,3.  The patient had a C-shaped deformity to the left before he had tip ptosis.,INDICATIONS FOR PROCEDURE: , The patient is a 22-year-old Hispanic male who is status post blunt trauma to the nose approximately 9 months with the second episode 2 weeks following and suffered a marked dorsal deformity.  The patient was evaluated, but did not complain of nasal obstruction, and his main complaint was his cosmetic deformity.  He was found to have a C-shaped deformity to the left as well as some tip ptosis.  The patient was recommended to undergo an open septorhinoplasty to repair of this cosmetic defect.,OPERATION IN DETAIL: , After obtaining a full consent from the patient, identified the patient, prepped with Betadine, brought to the operating room and placed in the supine position on the operating table.  The appropriate Esmarch was placed; and after adequate sedation, the patient was subsequently intubated without difficulty.  The endotracheal tube was then secured, and the table was then turned clockwise to 90 degrees.  Three Afrin-soaked cottonoids were then placed in nasal cavity bilaterally.  The septum was then injected with 3 mL of 1% lidocaine with 1:100,000 epinephrine in the subperichondrial plane bilaterally.  Then, 50 additional mL of 1% lidocaine with 1:100,000 epinephrine was then injected into the nose in preparation for an open rhinoplasty.,Procedure was begun by first marking a columellar incision.  This incision was made using a #15 blade.  A lateral transfixion incision was then made bilaterally using a #15 blade, and then, the columellar incision was completed using iris scissors with care not to injure the medial crura.  However, there was a dissection injury to the left medial crura.  Dissection was then taken in the subperichondrial plane over the lower lateral cartilages and then on to the upper lateral cartilage.  Once we reached the nasal bone, a Freer was used to elevate the tissue overlying the nasal bone in a subperiosteal fashion.  Once we had completed exposure of the bony cartilaginous structures, we appreciated a very large dorsal hump, which was made up of both a cartilaginous and bony portions.  There was also an obvious fracture of the right upper lateral cartilage.  There was also marked hypertrophy what appeared to be in the nasalis muscle in the area of the dorsal hump.  The skin was contributing to the patient's cosmetic deformity.  In addition, we noted what appeared to be a small mucocele coming from the area of the fractured cartilage on the right upper lateral cartilage.  This mucocele was attempted to be dissected free, most of which was removed via dissection.  We then proceeded to remove takedown of the dorsal hump using a Rubin osteotome.  The dorsal hump was taken down and passed off the table.  Examination of the specimen revealed the marking amount of scar tissue at the junction of the bone and cartilage.  This was passed off to use later for possible onlay grafts.  There was now a marked open roof deformity of the cartilage and bony sprue.  A septoplasty was then performed throughout and a Kelly incision on the right side.  Subperichondrial planes were elevated on the right side, and then, a cartilage was incised using a caudal and subperichondrial plane elevated on the left side.  A 2 x 3-cm piece of the cardinal cartilage was then removed with care to leave at least 1 cm dorsal and caudal septal strut.  This cartilage was passed down the table and then 2 columellar strut grafts measuring approximately 15 mm in length were then used and placed to close the bony and cartilaginous open roof deformities.  The spreader grafts were sewn in place using three interrupted 5-0 PDS sutures placed in the horizontal fashion bilaterally.  Once these were placed, we then proceeded to work on the bony open roof.  Lateral osteotomies were made with 2-mm osteotomes bilaterally.  The nasal bones were then fashioned medially to close the open roof deformity, and this reduced the width of the bony nasal dorsum.  We then proceeded to the tip.  A cartilaginous strut was then fashioned from the cartilaginous septum.  It was approximately 15 mm long.  This was placed, and a pocket was just formed between the medial crura.  This pocket was taken down to the nasal spine, and then, the strut graft was placed.  The intradermal sutures were then placed using interrupted 5-0 PDS suture to help to provide more tip projection and definition.  The intradermal sutures were then placed to help to align the nasal tip.  The cartilage strut was then sutured in place to the medial crura after elevating the vestibular skin off the medial crura in the area of the plane suturing.  Prior to the intradermal suturing, the vestibular skin was also taken off in the area of the dome.,The columellar strut was then sutured in place using interrupted 5-0 PDS suture placed in a horizontal mattress fashion with care to help repair the left medial crural foot.  The patient had good tip support after this maneuver.  We then proceeded to repair the septal deformity created by taking down the dorsal hump with the Rubin osteotome.  This was done by crushing the remaining cartilage in the morcellizer and then wrapping this crushed cartilage in endogen, which is a radiated collagen.  The autogenous cartilage was wrapped in endogen in a sandwich fashion, and then, a 4-0 chromic suture was placed through this to help with placement of the dorsal onlay graft.,The dorsal onlay was then sewn into position, and then, the 4-0 chromic suture was brought out through this externally to help the superior placement of the dorsal onlay graft.  Once we were happy with the position of the dorsal onlay graft, the graft was then sutured in place using two interrupted 4-0 fast-absorbing sutures inferiorly just above the superior edge of the lower lateral cartilages.  Once we were happy with the placement of this, we did need to take down some of the bony dorsal hump laterally, and this was done using a #6 and then followed with a #3 push grafts.  This wrapping was performed prior to placement of the dorsal onlay graft.,I went through content with the dorsal onlay graft and the closure of the roof deformities as well as placement of the columellar strut, we then felt the patient could use a bit more tip projection; and therefore, we fashioned a radiated rib into a small octagon; and this was sutured in place over the tip using two interrupted 5-0 PDS sutures.,At this point, we were happy with the test results, although the patient did have significant amount of fullness in the dorsal hump area due to soft tissue thick and fullness.  There do not appear to be any other pathology causing the patient dorsal hump and therefore, we felt we have achieved the best cosmetic result at this point.  The septum was reapproximated using a fast-absorbing 4-0 suture and a Keith needle placed in the mattress fashion.  The Kelly incision was closed using two interrupted 4-0 fast-absorbing gut suture.  Doyle splints were then placed within the nasal cavity and secured to the inferior septum using a 3-0 monofilament suture.  The columellar skin was reapproximated using interrupted 6-0 nylon sutures, and the marginal incision of the vestibular skin was closed using interrupted 4-0 chromic sutures.,At the end of the procedure, all sponge, needle, and instrument counts were correct.  A Denver external splint was then applied.  The patient was awakened, extubated, and transported to Anesthesia Care Unit in good condition.", Surgery,38
"PREOPERATIVE DIAGNOSES:,  ,1.  Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2.  Neck pain with left radiculopathy, progressive (723.1/723.4).,3.  Headaches, progressive (784.0).,POSTOPERATIVE DIAGNOSES:,  ,1.  Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2.  Neck pain with left radiculopathy, progressive (723.1/723.4).,3.  Headaches, progressive (784.0).,PROCEDURES:,  ,1.  Anterior cervical discectomy at C5-C6 for neural decompression (63075).,2.  Anterior interbody fusion C5-C6 (22554) utilizing Bengal cage (22851).,3.  Anterior cervical instrumentation at C5-C6 for stabilization by Uniplate construction at C5-C6 (22845); with intraoperative x-ray x2.,SERVICE:  ,  Neurosurgery,ANESTHESIA:,", Neurosurgery,23
"The right eardrum is intact showing a successful tympanoplasty.  I cleaned a little wax from the external meatus.  The right eardrum might be very slightly red but not obviously infected.  The left eardrum (not the surgical ear) has a definite infection with a reddened bulging drum but no perforation or granulation tissue.  Also some wax at the external meatus I cleaned with a Q-tip with peroxide.  The patient has no medical allergies.  Since he recently had a course of Omnicef we chose to put him on Augmentin (I checked and we did not have samples), so I phoned in a two-week course of Augmentin 400 mg chewable twice daily with food at Walgreens.  I looked at this throat which looks clear.  The nose only has a little clear mucinous secretions.  If there is any ear drainage, please use the Floxin drops.  I asked Mom to have the family doctor (or Dad, or me) check the ears again in about two weeks from now to be sure there is no residual infection.  I plan to see the patient again later this spring.", Office Notes,25
"PREOPERATIVE DIAGNOSIS:,  Right breast mass with abnormal mammogram.,POSTOPERATIVE DIAGNOSIS:,  Right breast mass with abnormal mammogram.,PROCEDURE PERFORMED:,  Right breast excisional biopsy with needle-localization.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,SPECIMEN: , Right breast mass and confirmation by Radiology that the specimen was received with the mass was in the specimen.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,BRIEF HISTORY:  ,The patient is a 41-year-old female who presented to Dr. X's office with abnormal mammogram with a strong family history of breast cancer requesting needle-localized breast biopsy for nonpalpable breast mass.,PROCEDURE: , After informed consent, the risks and benefits of the procedure were explained to the patient.  The patient was brought into the operating suite.  After IV sedation was given, the patient was prepped and draped in normal sterile fashion.  A radial incision was made in the right lateral breast with a #10 blade scalpel.  The needle was brought into the field.  An Allis was used to grasp the breast mass and breast tissue using the #10 scalpel.  The mass was completely excised and sent out for specimen after confirmation by Radiology that the mass was in the specimen.,Hemostasis was then obtained with electrobovie cautery.  The skin was then closed with #4-0 Monocryl in a running subcuticular fashion.  Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure well and was transferred to Recovery in stable condition.", Surgery,38
"PROCEDURE:,  Diagnostic fiberoptic bronchoscopy.,ANESTHESIA:  ,  Plain lidocaine 2% was given intrabronchially for local anesthesia.,PREOPERATIVE MEDICATIONS:,  ,1.  Lortab (10 mg) plus Phenergan (25 mg), p.o.  1 hour before the procedure.,2.  Versed a total of 5 mg given IV push during the procedure.,INDICATIONS: ,", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS: , Endometrial cancer.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:,  Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.,ANESTHESIA:,  General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology, uterus with attached tubes and ovaries, right and left pelvic lymph nodes, para-aortic nodes.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding and was found to have a Grade II endometrial carcinoma on biopsy.  She was counseled to undergo staging laparotomy.,FINDINGS:,  Examination under anesthesia revealed a small uterus with no nodularity.  During the laparotomy, the uterus was small, mobile, and did not show any evidence of extrauterine spread of disease.  Other abdominal viscera, including the diaphragm, liver, spleen, omentum, small and large bowel, and peritoneal surfaces, were palpably normal.  There was no evidence of residual neoplasm after removal of the uterus.  The uterus itself showed no serosal abnormalities and the tubes and ovaries were unremarkable in appearance.,PROCEDURE: , The patient was brought to the Operating Room with an IV in place.  Anesthesia was induced, after which she was examined, prepped and draped.,A vertical midline incision was made and fascia was divided.  The peritoneum was entered without difficulty and washings were obtained.  The abdomen was explored with findings as noted.  A Bookwalter retractor was placed and bowel was packed.  Clamps were placed on the broad ligament for traction.  The retroperitoneal spaces were opened by incising lateral and parallel to the infundibulopelvic ligament.  The round ligaments were isolated, divided, and ligated.  The peritoneum overlying the vesicouterine fold was incised to mobilize the bladder.,Retroperitoneal spaces were then opened, allowing exposure of pelvic vessels and ureters.  The infundibulopelvic ligaments were isolated, divided, and doubly ligated.  The uterine artery pedicles were skeletonized, clamped, divided, and suture ligated.  Additional pedicles were developed on each side of the cervix, after which tissue was divided and suture ligated.  When the base of the cervix was reached, the vagina was cross-clamped and divided, allowing removal of the uterus with attached tubes and ovaries.  Angle stitches of o-Vicryl were placed, incorporating the uterosacral ligaments and the vaginal vault was closed with interrupted figure-of-eight stitches.  The pelvis was irrigated and excellent hemostasis was noted.,Retractors were repositioned to allow exposure for lymphadenectomy.  Metzenbaum scissors were used to incise lymphatic tissues.  Borders of the pelvic node dissection included the common iliac bifurcation superiorly, the psoas muscle laterally, the cross-over of the deep circumflex iliac vein over the external iliac artery inferiorly, and the anterior division of the hypogastric artery medially.  The posterior border of dissection was the obturator nerve, which was carefully identified and preserved bilaterally.  Ligaclips were applied where necessary.  After the lymphadenectomy was performed bilaterally, excellent hemostasis was noted.,Retractors were again repositioned to allow exposure of para-aortic nodes.  Lymph node tissue was mobilized, Ligaclips were applied, and the tissue was excised.  The pelvis was again irrigated and excellent hemostasis was noted.  The bowel was run and no evidence of disease was seen.,All packs and retractors were removed and the abdominal wall was closed using a running Smead-Jones closure with #1 permanent monofilament suture.  Subcutaneous tissues were irrigated and a Jackson-Pratt drain was placed.  Scarpa's fascia was closed with a running stitch and skin was closed with a running subcuticular stitch.  The final sponge, needle and instrument counts were correct at the completion of the procedure. ,The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.", Surgery,38
"PREOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1.  Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS:  ,Approximately 1000 cc.,CELL SAVER RETURNED:  ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain.  He had previous lumbar laminectomy at L4-L5.  He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable.  He is suffering from neurogenic claudication.  He was unresponsive to extensive conservative treatment.  He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia.  He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded.  His lumbar spine was then sterilely prepped and draped in the usual fashion.  A previous midline incision was extended from approximate level of L3 to S1.  This was in the midline.  Skin and subcutaneous tissue were debrided sharply.  Electrocautery provided hemostasis.  ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia.  The lumbar fascia was identified and split in the midline.  Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1.  Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4.  Once this was completed, a self-retaining retractor was then placed.  With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable.  These were readily mobile with digital palpation.  A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1.  This bone was morcellized and placed on the back table for utilization for bone grafting.  The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1.  Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained.  Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1.  The microscope was utilized during this portion of procedure for visualization.  There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure.  Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5.  Once this was identified, foraminotomies were created to allow additional mobility.  The wound was then copiously irrigated with antibiotic solution and suctioned dry.  Working type screws, provisional titanium screws were then placed at L4-l5.  This was to allow distraction and reduction of the spondylolisthesis.  These were placed in the pedicles of L4 and L5 under direct intensification.  The position of the screws were visualized, both AP and lateral images.  They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5.  This allowed for additional decompression of the L5 and L4 nerve roots.  Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed.  Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval.  This was taken in sequence up to a 13 mm space.  This was then reduced to a 11 mm as it was much more anatomic in nature.  Once this was completed, the spacers were then placed on the left side and distraction obtained.  Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally.  Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried.  A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft.  There were impacted at the interspace of L4-L5 under direct image intensification.  Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried.  The provisional screws and plates were removed.  This allowed for additional compression along L4-L5 with the cage instrumentation.  Permanent screws were then placed at L4, L5, and S1 bilaterally.  This was performed under direct image intensification.  The position was verified in both AP and lateral images.  Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally.  A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1.  Appropriate cross connecters were applied and the construct was placed over the pedicle screws.  They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra.  Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory.  All connections were tightened and retightened in Torque 2 specifications.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The dura was inspected and noted to be free of tension.  At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors.  An 8-inch Hemovac drain was placed exiting the wound.  The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin.  The remainder of the Hemovac was assembled.  Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape.  He was turned and taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded.", Neurosurgery,23
"EXAM: , CT chest with contrast.,HISTORY: , Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,TECHNIQUE:  ,Post contrast-enhanced spiral images were obtained through the chest.,FINDINGS:  ,There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates.  The remainder of the lung parenchyma is clear.  There is no pneumothorax or effusion.  The heart size and pulmonary vessels appear unremarkable.  There was no axillary, hilar or mediastinal lymphadenopathy.,Images of the upper abdomen are unremarkable.,Osseous windows are without acute pathology.,IMPRESSION: , Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia.", Radiology,33
"PROCEDURES:,1.  Placement of SynchroMed infusion pump.,2.  Tunneling of SynchroMed infusion pump catheter,3.  Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,DESCRIPTION OF PROCEDURE: , Under general endotracheal anesthesia, the patient was placed in a lateral decubitus position.  The patient was prepped and draped in a sterile manner.  The intrathecal catheter was placed via a percutaneous approach by the pain management specialist at which point an incision was made adjacent to the needle containing the intrathecal catheter.  This incision was carried down through the skin and subcutaneous tissue to the paraspinous muscle fascia which was cleared around the entry point of the intrathecal catheter needle.  A pursestring suture of 3-0 Prolene was placed around the needle in the paraspinous muscle.  The needle was withdrawn.  The pursestring suture was tied to snug the tissues around the catheter and prevent cerebrospinal fluid leak.  The catheter demonstrated free flow of cerebrospinal fluid,throughout the RV procedure.  The catheter was anchored to the paraspinous muscle with an anchoring device using interrupted sutures of 3-0 Prolene.  Antibiotic irrigation and antibiotic soak sponge were placed into the wound, and the catheter was clamped to prevent persistent leakage of cerebrospinal fluid while the SynchroMed-pump pocket was created.  Then, I turned my attention to the anterior abdominal wall where an oblique incision was made and carried down through the skin and subcutaneous tissue to the external oblique fascia, which was freed from attachments to the overlying subcutaneous tissue utilizing blunt and sharp dissection with electrocautery.  A pocket was created that would encompass the SynchroMed fusion pump.  A tunneling device was then passed through the subcutaneous tissue from the back incision to the abdominal incision, and a SynchroMed pump catheter was placed to the tunneling device.  The tunneling device was then removed leaving the SynchroMed pump catheter extending from the anterior abdominal wall incision to the posterior back incision.  The intrathecal catheter was trimmed.  A clear plastic boot was placed over the intrathecal catheter, and the connecting device was advanced from the SynchroMed pump catheter into the intrathecal catheter connecting the 2 catheters together.  The clear plastic boot was then placed over the connection, and it was anchored in place with 0-silk ties.  Good CSF was then demonstrated flowing through the SynchroMed pump catheter.  The SynchroMed pump catheter was connected to the SynchroMed pump and anchored in place with a 0-silk tie.  Excess catheter was coiled and placed behind the pump.  The pump was placed into the subcutaneous pocket created for it on the anterior abdominal wall.  The pump was anchored to the anterior abdominal wall fascia with interrupted sutures of 2-0 Prolene; 4 of the sutures were placed.  The subcutaneous tissues were irrigated with normal saline.  The subcutaneous tissue of both wounds was closed with running suture of 3-0 Vicryl.  The skin of both wounds was closed with staples.  Antibiotic ointment and a sterile dressing were applied.  The patient was awake and taken to the recovery room.  The patient tolerated the procedure well and was stable at the completion of the procedure.  All sponge and lap, needle and instrument counts were correct at the completion of the procedure.", Surgery,38
"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,24
"PROCEDURE: , Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,INDICATIONS FOR PROCEDURE: , A 17-year-old with history of 40-pound weight loss, abdominal pain, status post appendectomy with recurrent abscess formation and drainage.  Currently, he has a fistula from his anterior abdominal wall out.  It does not appear to connect to the gastrointestinal tract, but merely connect from the ventral surface of the rectus muscles out the abdominal wall.  CT scans show thickened terminal ileum, which suggest that we are dealing with Crohn's disease.  Endoscopy is being done to evaluate for Crohn's disease.,MEDICATIONS:  ,General anesthesia.,INSTRUMENT:,  Olympus GIF-160 and PCF-160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FINDINGS: , With the patient in the supine position, intubated under general anesthesia.  The endoscope was inserted without difficulty into the hypopharynx.  The scope was advanced down the esophagus, which had normal mucosal coloration and vascular pattern.  Lower esophageal sphincter was located at 40 cm from the central incisors.  It appeared normal and appeared to function normally.  The endoscope was advanced into the stomach, which was distended with excess air.  Rugal folds were flattened completely.  There were multiple superficial erosions scattered throughout the fundus, body, and antral portions consistent with Crohn's involvement of the stomach.  The endoscope was advanced through normal-appearing pyloric valve into the first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  Biopsies were obtained x2 in the second portion of the duodenum, antrum, body, and distal esophagus at 37 cm from the central incisors for histology.  Two additional biopsies were obtained in the antrum for CLO testing.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated that part of the procedure well.,The patient was turned and scope was changed for colonoscopy.  Prior to colonoscopy, it was noted that there was a perianal fistula at 7 o'clock.  The colonoscope was then inserted into the anal verge.  The colonic clean out was excellent.  The scope was advanced without difficulty to the cecum.  The cecal area had multiple ulcers with exudate.  The ileocecal valve was markedly distorted.  Biopsies were obtained x2 in the cecal area and then the scope was withdrawn through the ascending, transverse, descending, sigmoid, and rectum.  The colonic mucosa in these areas was well seen and there were a few scattered aphthous ulcers in the ascending and descending colon.  Biopsies were obtained in the cecum at 65 cm, transverse colon 50 cm, rectosigmoid 20 cm, and rectum at 5 cm.  No fistulas were noted in the colon.  Excess air was evacuated from the colon.  The scope was removed.  The patient tolerated the procedure well and was taken to recovery in satisfactory condition.,IMPRESSION: , Normal esophagus and duodenum.  There were multiple superficial erosions or aphthous ulcers in the stomach along with a very few scattered aphthous ulcers in the colon with marked cecal involvement with large ulcers and a very irregular ileocecal valve.  All these findings are consistent with Crohn's disease.,PLAN:  ,Begin prednisone 30 mg p.o. daily.  Await PPD results and chest x-ray results, as well as cocci serology results.  If these are normal, then we would recommend Remicade 5 mg/kg IV infusion.  We would start Modulon 50 mL/h for 20 hours to reverse the malnutrition state of this boy.  Check CMP and phosphate every Monday, Wednesday, and Friday for receding syndrome noted by following potassium and phosphate.  We will discuss with Dr. X possibly repeating the CT fistulogram if the findings on the previous ones are inconclusive as far as the noting whether we can rule in or out an enterocutaneous fistula.  He will need an upper GI to rule out small intestinal strictures and involvement of the small intestine that cannot be seen with upper and lower endoscopy.  If he has no stricture formation in the small bowel, we would then recommend a video endoscopy capsule to further evaluate any mucosal lesions consistent with Crohn's in the small intestine that we cannot visualize with endoscopy.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  Stage IV necrotic sacral decubitus.,POSTOPERATIVE DIAGNOSIS:,  Stage IV necrotic sacral decubitus.,PROCEDURE PERFORMED:,  Debridement of stage IV necrotic sacral decubitus.,GROSS FINDINGS: , This is a 92-year-old African-American female who was brought into the office 48 hours earlier with a chief complaint of necrotic foul-smelling wound in the sacral region and upon examination was found to have absolutely necrosis of the fat and subcutaneous tissue in the sacral region approximately 15 cm x 15 cm.  A long discussion with the family ensued that it needs to be debrided and then cleaned and then if she cannot keep the stool out of the wound that she will probably need a diverting colostomy.,OPERATIVE PROCEDURE:  ,The patient was properly prepped and draped under local sedation.  A 0.25% Marcaine was injected circumferentially around the necrotic decubitus.  A wide excision and debridement of the necrotic decubitus taken down to the presacral fascia and all necrotic tissue was electrocauterized and removed.  All bleeding was cauterized with electrocautery and then a Kerlix stack was then placed and a pressure dressing applied.  The patient was sent to recovery in satisfactory condition.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Left distal radius fracture, metaphyseal extraarticular.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture, metaphyseal extraarticular.,PROCEDURE: , Open reduction and internal fixation of left distal radius.,IMPLANTS:  ,Wright Medical Micronail size 2.,ANESTHESIA: , LMA.,TOURNIQUET TIME: , 49 minutes.,BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,PATHOLOGY: , None.,TIME OUT: , Time out was performed before the procedure started.,INDICATIONS:,  The patient was a 42-year-old female who fell and sustained a displaced left metaphyseal distal radius fracture indicated for osteosynthesis.  The patient was in early stage of gestation.  Benefits and risks including radiation exposure were discussed with the patient and consulted her primary care doctor.,DESCRIPTION OF PROCEDURE: , Supine position, LMA anesthesia, well-padded arm, tourniquet, Hibiclens, alcohol prep, and sterile drape.,Exsanguination achieved, tourniquet inflated to 250 mmHg.  First, under fluoroscopy the fracture was reduced.  A 0.045 K-wire was inserted from dorsal ulnar corner of the distal radius and crossing fracture line to maintain the reduction.  A 2-cm radial incision, superficial radial nerve was exposed and protected.  Dissecting between the first and second dorsal extensor retinaculum, the second dorsal extensor compartment was elevated off from the distal radius.  The guidewire was inserted under fluoroscopy.  A cannulated drill was used to drill antral hole.  Antral awl was inserted.  Then we reamed the canal to size 2.  Size 2 Micronail was inserted to the medullary canal.  Using distal locking guide, three locking screws were inserted distally.  The second dorsal incision was made.  The deep radial dorsal surface was exposed.  Using locking guide, two proximal shaft screws were inserted and locked the nail to the radius.  Fluoroscopic imaging was taken and showing restoration of the height, tilt, and inclination of the radius.  At this point, tourniquet was deflated, hemostasis achieved, wounds irrigated and closed in layers.  Sterile dressing applied.  The patient then was extubated and transferred to the recovery room under stable condition.,Postoperatively, the patient will see a therapist within five days.  We will immobilize wrist for two weeks and then starting flexion-extension and prosupination exercises.", Orthopedic,27
"PREOPERATIVE DIAGNOSIS:,  Dorsal ganglion, right wrist.,POSTOPERATIVE DIAGNOSIS:,  Dorsal ganglion, right wrist.,OPERATIONS PERFORMED:,  Excision dorsal ganglion, right wrist.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME:,  minutes.,DESCRIPTION OF PROCEDURE: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated and the tourniquet was elevated to 290 mm/Hg.  A transverse incision was made over the dorsal ganglion.  Using blunt dissection the dorsal ulnar sensory nerve branches and radial sensory nerve branches were dissected and retracted out of the operative field.  The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field.  The ganglion was then further dissected to its origin from the dorsal distal scapholunate interosseus ligament and excised in toto.  Care was taken to protect ligament integrity.  Reactive synovium was then removed using soft tissue rongeur technique.  The wound was then infiltrated with 0.25% Marcaine.  The tendons were allowed to resume their normal anatomical position.  The skin was closed with 3-0 Prolene subcuticular stitch.  Sterile dressings were applied.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.", Orthopedic,27
"ADMISSION DIAGNOSES,1.  Neck pain with right upper extremity radiculopathy.,2.  Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,DISCHARGE DIAGNOSES,1.  Neck pain with right upper extremity radiculopathy.,2.  Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression C4-C5, C5-C6, and C6-C7.,2.  Arthrodesis with anterior interbody fusion C4-C5, C5-C6, and C6-C7.,3.  Spinal instrumentation C4 through C7.,4.  Implant.,5.  Allograft.,COMPLICATIONS:,  None.,COURSE ON ADMISSION: , This is the case of a very pleasant 41-year-old Caucasian female who was seen in clinic as an initial consultation on 09/13/07 complaining of intense neck pain radiating to the right shoulder blade to top of the right shoulder in to the right upper extremity to the patient's hand.  The patient's symptoms have been persistent and had gotten worse with subjective weakness of the right upper extremity since its onset for several weeks now.  The patient has been treated with medications, which has been unrelenting.  The patient had imaging studies that showed evidence of cervical spondylosis with herniated disk and stenosis at C4-C5, C5-C6 and C6-C7.  The patient underwent liver surgery and postoperatively her main issue was that of some degree of on and off right shoulder pain and some operative site soreness, which was treated well with IV morphine.  The patient has resolution of the pain down the arm, but she does have some tingling of the right thumb and right index finger.  The patient apparently is doing well with slight dysphagia, we treated her with Decadron and we will send her home with Medrol.  The patient will have continued pain medication coverage with Darvocet and Flexeril.  The patient will follow up with me as scheduled.  Instructions have been given.", Orthopedic,27
"PREOPERATIVE DIAGNOSIS: , Right tympanic membrane perforation.,POSTOPERATIVE DIAGNOSIS: , Right tympanic membrane perforation along with chronic otitis media.,PROCEDURE: , Right ear examination under anesthesia.,INDICATIONS: , The patient is a 15-year-old child with history of a right tympanic membrane perforation following tube placement as well as right conductive hearing loss.  Exam in the office revealed a posterior superior right marginal tympanic perforation.  Risks and benefits of surgery including risk of bleeding, general anesthesia, hearing loss as well as recurrent perforation were discussed with the mother.  The mother wished to proceed with surgery.,FINDINGS:,  The patient was brought to the room, placed in supine position, given general endotracheal anesthesia.  The postauricular crease was then injected with 1% Xylocaine with 1:200,000 epinephrine along with external meatus.  An area of the scalp was shaved above the ear and then also 1% Xylocaine with 1:200,000 epinephrine injected, a total of 4 mL local anesthetic was used.  The ear was then prepped and draped in the usual sterile fashion.  The microscope was then brought into view and examining the marginal perforation, the patient was noted to have large granuloma under the tympanic membrane at the anterior border of the drum.  The granulation tissue was debrided as much as possible.  Decision was made to cancel the tympanoplasty after debriding the middle ear space as much as possible.  The middle ear space was filled with Floxin drops.  The patient woke up anesthesia, extubated, and brought to recovery room in stable condition.  There were no intraoperative complications.  Needle and sponge was correct.  Estimated blood loss minimal.", ENT - Otolaryngology,11
"ADMISSION DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Symptomatic fibroid uterus.,DISCHARGE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Symptomatic fibroid uterus.,4.  Extensive adenomyosis by pathological report.,OPERATION PERFORMED: , On 6/10/2009 total abdominal hysterectomy (TAH).,COMPLICATIONS:,  None.,BLOOD TRANSFUSIONS: , None.,INFECTIONS: , None.,SIGNIFICANT LAB AND X-RAY: , On admission hemoglobin and hematocrit was 10.5 and 32.8 respectively.  On discharge, hemoglobin and hematocrit 7.9 and 25.2.,HOSPITAL COURSE AND TREATMENT:  ,The patient was admitted to the surgical suite and taken to the operating room on 6/10/2009 where a total abdominal hysterectomy (TAH) with low intraoperative complication was performed.  The patient tolerated all procedures well.  On the 1st postoperative day, the patient was afebrile and all vital signs were stable.  On the 3rd postoperative day, the patient was ambulating with difficulty and tolerating clear liquid diet.  On the 4th postoperative day, the patient was complaining of pain in her back and abdomen as well as incisional wound tenderness.  On the 5th postoperative day, the patient was afebrile.  Vital signs were stable.  The patient was tolerating a diet and ambulating without difficulty.  The patient was desirous of going home.  The patient denied any abdominal pain or flank pain.  The patient had minimal incisional wound tenderness.  The patient was desirous of going home and was discharged home.,DISCHARGE CONDITION: , Stable.,DISCHARGE INSTRUCTIONS:,  Regular diet, bedrest x1 week with slow return to normal activity over the ensuing 4 to 6 weeks, pelvic rest for 6 weeks.  Motrin 600 mg tablets 1 tablet p.o. q.8h. p.r.n. pain, Colace 100 mg tablets 1 tablet p.o. daily p.r.n. constipation and ferrous sulfate 60 mg tablets 1 tablet p.o. daily, and multiple vitamin 1 tablet p.o. daily.  The patient is to return on Wednesday 6/17/2009 for removal of staples.  The patient was given a full explanation of her clinical condition.  The patient was given full and complete postoperative and discharge instructions.  All her questions were answered.", Obstetrics / Gynecology,24
"EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day.  Fever.  Right upper quadrant pain for one day.  ,COMPARISON: , None. ,TECHNIQUE:,  CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement.  ,CT ABDOMEN: , Lung bases are clear.  The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable.  The aorta is normal in caliber.  There is no retroperitoneal lymphadenopathy.  ,CT PELVIS: , The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change.  Per CT, the colon and small bowel are unremarkable.  The bladder is distended.  No free fluid/air.  Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1.  Unremarkable exam; specifically no evidence for acute appendicitis. ,2.  No acute nephro-/ureterolithiasis. ,3.  No secondary evidence for acute cholecystitis.,Results were communicated to the ER at the time of dictation.", Radiology,33
"HISTORY OF PRESENT ILLNESS:,  The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room.  She was intubated and fishbone.,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract.,ALLERGIES:  ,No known drug allergies.,CURRENT MEDICATIONS: , Prevacid, Humulin, Diprivan, Proventil, Unasyn, and Solu-Medrol.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , Negative for illicit drugs, alcohol, and tobacco.,PHYSICAL EXAMINATION:  ,Please see the hospital chart.,LABORATORY DATA: , Please see the hospital chart.,HOSPITAL COURSE: , The patient was taken to the operating room by Dr. X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed.  The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated.  If not she would require tracheostomy.  The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated.  She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home.  So, the patient is being prepared for discharge at this point.  We will have Dr. X evaluate her before she leaves to make sure I do not have any problem with her going home.  Dr. Y feels she could be discharged today and will have her return to see him in a week.", General Medicine,15
"REASON FOR CONSULTATION: , Management of blood pressure.,HISTORY OF PRESENT ILLNESS: , The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.  She is on multiple medications, unable to control the blood pressure.  From cardiac standpoint, the patient denies any symptoms of chest pain, or shortness of breath.  She complains of fatigue and tiredness.  The child had some congenital anomaly, was transferred to Hospital, where the child has had surgery.  The patient is in intensive care unit.,CORONARY RISK FACTORS:,  History of hypertension, history of gestational diabetes mellitus, nonsmoker, and cholesterol is normal.  No history of established coronary artery disease and family history noncontributory for coronary disease.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY:  ,No major surgery except for C-section.,MEDICATIONS:,  Presently on Cardizem and metoprolol were discontinued.  Started on hydralazine 50 mg t.i.d., and labetalol 200 mg b.i.d., hydrochlorothiazide, and insulin supplementation.,ALLERGIES: , None.,PERSONAL HISTORY: , Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,  Hypertension, gestational diabetes mellitus, pre-eclampsia, this is her third child with one miscarriage.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR:  No congestive heart.  No arrhythmia.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis, or melena.,UROLOGIC:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGICAL:  No TIA.  No CVA.  No seizure disorder.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 86, blood pressure 175/86, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.,LUNGS:  Clear.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.,LABORATORY DATA: , EKG shows sinus tachycardia with nonspecific ST-T changes.  Labs were noted.  BUN and creatinine within normal limits.,IMPRESSION:,1.  Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.,2.  No prior history of cardiac disease except for borderline gestational diabetes mellitus.,RECOMMENDATIONS:,1.  We will get an echocardiogram for assessment left ventricular function.,2.  The patient will start on labetalol and hydralazine to see how see fairs.,3.  Based on response to medication, we will make further adjustments.  Discussed with the patient regarding plan of care, fully understands and consents for the same.  All the questions answered in detail.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS: , Abdominal wall abscess.,POSTOPERATIVE DIAGNOSIS: , Abdominal wall abscess.,PROCEDURE: , Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.,ANESTHESIA: , LMA.,INDICATIONS: , Patient is a pleasant 60-year-old gentleman, who initially had a sigmoid colectomy for diverticular abscess, subsequently had a dehiscence with evisceration.  Came in approximately 36 hours ago with pain across his lower abdomen.  CT scan demonstrated presence of an abscess beneath the incision.  I recommended to the patient he undergo the above-named procedure.  Procedure, purpose, risks, expected benefits, potential complications, alternatives forms of therapy were discussed with him, and he was agreeable to surgery.,FINDINGS:,  The patient was found to have an abscess that went down to the level of the fascia.  The anterior layer of the fascia was fibrinous and some portions necrotic.  This was excisionally debrided using the Bovie cautery, and there were multiple pieces of suture within the wound and these were removed as well.,TECHNIQUE:  ,Patient was identified, then taken into the operating room, where after induction of appropriate anesthesia, his abdomen was prepped with Betadine solution and draped in a sterile fashion.  The wound opening where it was draining was explored using a curette.  The extent of the wound marked with a marking pen and using the Bovie cautery, the abscess was opened and drained.  I then noted that there was a significant amount of undermining.  These margins were marked with a marking pen, excised with Bovie cautery; the curette was used to remove the necrotic fascia.  The wound was irrigated; cultures sent prior to irrigation and after achievement of excellent hemostasis, the wound was packed with antibiotic-soaked gauze.  A dressing was applied.  The finished wound size was 9.0 x 5.3 x 5.2 cm in size.  Patient tolerated the procedure well.  Dressing was applied, and he was taken to recovery room in stable condition.", Gastroenterology,14
"DIAGNOSES ON ADMISSION,1.  Cerebrovascular accident (CVA) with right arm weakness.,2.  Bronchitis.,3.  Atherosclerotic cardiovascular disease.,4.  Hyperlipidemia.,5.  Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1.  Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2.  Old coronary infarct, anterior aspect of the right external capsule.,3.  Acute bronchitis with reactive airway disease.,4.  Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5.  Atherosclerotic cardiovascular disease.,6.  Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room.  Plavix was started  in addition to baby aspirin.  He was kept on oral Zithromax for his cough.  He was given Xopenex treatment, because of his respiratory distress.  Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid.  Dr. X saw him in consultation and recommended CT angiogram.  This showed no significant obstructive lesion other than what was known on the ultrasound.  Head MRI was done and revealed the above findings.  The patient was begun on PT and improved.  By discharge, he had much improved strength in his right arm.  He had no further progressions.  His cough improved with oral Zithromax and nebulizer treatments.  His platelets also improved as well.  By discharge, his platelets was up to 107,000.  His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential.  Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate.  Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1.  PT/INR on admission was 1.03, PTT 34.7.  At the time of discharge, the patient's cough was much improved.  His right arm weakness has much improved.  His lung examination has just occasional rhonchi.  He was changed to a metered dose inhaler with albuterol.  He is being discharged home.  An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation.  He will follow up in my office in 1 week.  He is to start PT and OT as an outpatient.  He is to avoid driving his car.  He is to notify, if further symptoms.  He has 2 more doses of Zithromax at home, he will complete.  His prognosis is good.", Neurology,22
"PREOPERATIVE DIAGNOSIS:  ,Bladder cancer.,POSTOPERATIVE DIAGNOSIS: , Bladder cancer.,OPERATION:  ,Transurethral resection of the bladder tumor (TURBT), large.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , The patient is an 82-year-old male who presented to the hospital with renal insufficiency, syncopal episodes.  The patient was stabilized from cardiac standpoint on a renal ultrasound.  The patient was found to have a bladder mass.  The patient does have a history of bladder cancer.  Options were watchful waiting, resection of the bladder tumor were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE were discussed.  The patient understood all the risks, benefits, and options and wanted to proceed with the procedure.,DETAILS OF THE OR:  ,The patient was brought to the OR, anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in the usual sterile fashion.  A 23-French scope was inserted inside the urethra into the bladder.  The entire bladder was visualized, which appeared to have a large tumor, lateral to the right ureteral opening.,There was a significant papillary superficial fluffiness around the left ________.  There was a periureteral diverticulum, lateral to the left ureteral opening.  There were moderate trabeculations throughout the bladder.  There were no stones.  Using a French cone tip catheter, bilateral pyelograms were obtained, which appeared normal.  Subsequently, using 24-French cutting loop resectoscope a resection of the bladder tumor was performed all the way up to the base.  Deep biopsies were sent separately.  Coagulation was performed around the periphery and at the base of the tumor.  All the tumors were removed and sent for path analysis.  There was an excellent hemostasis.  The rest of the bladder appeared normal.  There was no further evidence of tumor.  At the end of the procedure, a 22 three-way catheter was placed, and the patient was brought to the recovery in a stable condition.", Surgery,38
"REASON FOR CONSULTATION:, Regarding weakness and a history of polymyositis.,HISTORY OF PRESENT ILLNESS:, The patient is an 87-year-old white female who gives a history of polymyositis diagnosed in 1993. The patient did have biopsy of the quadriceps muscle performed at that time which, per her account, did show an abnormality. She was previously followed by Dr. C, neurology, over several years but was last followed up in the last three to four years. She is also seeing Dr. R at rheumatology in the past. Initially, she was treated with steroids but apparently was intolerant of that. She was given other therapy but she is unclear of the details of that. She has had persistent weakness of the bilateral lower extremities and has ambulated with the assistance of a walker for many years. She has also had a history of spine disease though the process there is not known to me at this time.,She presented on February 1, 2006 with productive cough, fevers and chills, left flank rash and pain there as well as profound weakness. Since admission, she has been diagnosed with a left lower lobe pneumonic process as well as shingles and is on therapy for both. She reports that strength in the proximal upper extremities has remained good. However, she has no grip strength. Apparently, this has been progressive over the last several years as well. She also presently has virtually no strength in the lower extremities and that is worse within the last few days. Prior to admission, she has had cough with mild shortness of breath. Phlegm has been dark in color. She has had reflux and occasional dysphagia. She has also had constipation but no other GI issues. She has no history of seizure or stroke like symptoms. She occasionally has headaches. No vision changes. Other than the left flank skin changes, she has had no other skin issues. She does have a history of DVT but this was 30 to 40 years ago. No history of dry eyes or dry mouth. She denies chest pain at present.,PAST MEDICAL AND SURGICAL HISTORY:, Hysterectomy, cholecystectomy, congestive heart failure, hypertension, history of DVT, previous colonoscopy that was normal, renal artery stenosis.,MEDICATIONS:, Medications prior to admission: Os-Cal, Zyrtec, potassium, Plavix, Bumex, Diovan.,CURRENT MEDICATIONS:, Acyclovir, azithromycin, ceftriaxone, Diovan, albuterol, Robitussin, hydralazine, Atrovent.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, She is a widow. She has 8 children that are healthy with the exception of one who has coronary artery disease and has had bypass. She also has a son with lumbar spine disease. No tobacco, alcohol or IV drug abuse.,FAMILY HISTORY:, No history of neurologic or rheumatologic issues.,REVIEW OF SYSTEMS:, As above.,PHYSICAL EXAMINATION:,VITAL SIGNS: She is afebrile. Current temperature 98. Respirations 16, heart rate 80 to 90. Blood pressure 114/55.,GENERAL APPEARANCE: She is alert and oriented and in no acute distress. She is pleasant. She is reclining in the bed.,HEENT: Pupils are reactive. Sclera are clear. Oropharynx is clear.,NECK: No thyromegaly. No lymphadenopathy.,CARDIOVASCULAR: Heart is regular rate and rhythm.,RESPIRATORY: Lungs have a few rales only.,ABDOMEN: Positive bowel sounds. Soft, nontender, nondistended. No hepatosplenomegaly.,EXTREMITIES: No edema.,SKIN: Left flank dermatome with vesicular rash that is red and raised consistent with zoster.,JOINTS: No synovitis anywhere. Strength is 5/5 in the proximal upper extremities. Proximal lower extremities are 0 out of 5. She has no grip strength at present.,NEUROLOGICAL: Cranial nerves II through XII grossly intact. Reflexes 2/4 at the biceps, brachial radialis, triceps. Nil out of four at the patella and Achilles bilaterally. Sensation seems normal. Chest x-ray shows COPD, left basilar infiltrate, cardiomegaly, atherosclerotic changes.,LABORATORY DATA:, White blood cell count 6.1, hemoglobin 11.9, platelets 314,000. Sed rate 29 and 30. Electrolytes: Sodium 134, potassium 4.9, creatinine 1.2, normal liver enzymes. TSH is slightly elevated at 5.38. CPK 36, BNP 645. Troponin less than 0.04.,IMPRESSION:,1. The patient has a history of polymyositis, apparently biopsy proven with a long standing history of bilateral lower extremity weakness. She has experienced dramatic worsening in the last 24 hours of the lower extremity weakness. This in the setting of an acute illness, presumably a pneumonic process.,2. She also gives a history of spine disease though the details of that process are not available either.,The question raised at this time is of recurrence in inflammatory myopathy which would need to include not only polymyositis but also inclusion body myositis versus progressive spine disease versus weakness secondary to acute illness versus neuropathic process versus other.,3. Zoster of the left flank.,4. Left lower lobe pneumonic process.,5. Elevation of the thyroid stimulating hormone.,RECOMMENDATIONS:,1. I have asked Dr. C to see the patient and he has done so tonight. He is planning for EMG nerve conduction study in the morning.,2. I would consider further spine evaluation pending review of the EMG nerve conduction study.,3. Agree with supportive care being administered thus far and will follow along with you.", Rheumatology,34
"PROCEDURE: , Phacoemulsification with posterior chamber intraocular lens insertion.,INTRAOCULAR LENS: , Allergan Medical Optics model S140MB XXX diopter chamber lens.,PHACO TIME:,  Not known.,ANESTHESIA: , Retrobulbar block with local minimal anesthesia care.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:,  None.,DESCRIPTION OF PROCEDURE: , While the patient was in the holding area, the operative eye was dilated with four sets of drops.  The drops consisted of Cyclogyl 1%, Acular, and Neo-Synephrine 2.5 %.  Additionally, a peripheral IV was established by the anesthesia team.  Once the eye was dilated, the patient was wheeled to the operating suite.,Inside the operating suite, central monitoring lines were established.  Through the peripheral IV, the patient received intravenous sedation consisting of Propofol and once somnolent from this, retrobulbar block was administered consisting of 2 cc's of 2% Xylocaine  plain with 150 units of Wydase.  The block was administered in a retrobulbar fashion using an Atkinson needle and a good block was obtained.  Digital pressure was applied for approximately five minutes.,The patient was then prepped and draped in the usual sterile fashion for ophthalmological surgery.  A Betadine prep was carried out of the face, lids, and eye.  During the draping process, care was taken to isolate the lashes.  A wire lid speculum was inserted to maintain patency of the lids.  With benefit of the operating microscope, a diamond blade was used to place a groove temporally.  A paracentesis wound was also placed temporally using the same blade.  Viscoelastic was then instilled into the anterior chamber through the paracentesis site and a 2.8 mm. diamond keratome was used to enter the anterior chamber through the previously placed groove.  The cystotome was then inserted into the eye and circular capsulorhexis was performed without difficulty.  The capsular remnant was withdrawn from the eye using long angled McPherson forceps.  Balanced salt solution with a blunt cannula was then inserted into the eye and hydrodissection was performed.  The lens was noted to rotate freely within the capsular bag.  The phaco instrument was then inserted into the eye using the Kelman tip.  The lens nucleus was grooved and broken into two halves.  One of the halves was in turn broken into quarters.  Each of the quarters was removed from the eye using the memory 2 settings and phacoemulsification.  Attention was then turned toward the remaining half of the nucleus and this, in turn, was removed as well, with the splitting maneuver.  Once the nucleus had been removed from the eye, the irrigating and aspirating tip was inserted and the cortical material was stripped out in sections.  Once the cortical material had been completely removed, a diamond dusted cannula was inserted into the eye and the posterior capsule was polished.  Viscoelastic was again instilled into the capsular bag as well as the anterior chamber.  The wound was enlarged slightly using the diamond keratome.  The above described intraocular lens was folded outside the eye using a mustache fold and inserted using folding forceps.  Once inside the eye, the lens was unfolded into the capsular bag in a single maneuver.  It was noted to be centered nicely.  The viscoelastic was then withdrawn from the eye using the irrigating and aspirating tip of the phaco machine.,Next, Miostat was instilled into the operative eye and the wound was checked for water tightness.  It was found to be such.  After removing the drapes and speculum, TobraDex drops were instilled into the operative eye and a gauze patch and Fox protective shield were placed over the eye.,The patient tolerated the procedure extremely well and was taken to the recovery area in good condition.  The patient is scheduled to be seen in follow-up in the office tomorrow, but should any complications arise this evening, the patient is to contact me immediately.", Surgery,38
"TITLE OF PROCEDURE:  ,Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring devices were placed.  The chest, abdomen and legs were prepped and draped in the sterile fashion.  The right greater saphenous vein was harvested and prepared by ligating all branches with 4-0 Surgilon and flushed with heparinized blood.  Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.  Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The pericardium was opened.  The pericardial cradle was created.  The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted.  A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet.  An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene.  The ascending aorta was crossclamped.  Cold blood potassium cardioplegia was given to the ascending aorta followed by sumping through the ascending aorta followed by cold retrograde potassium cardioplegia.  The obtuse marginal coronary artery was identified and opened and end-to-side anastomosis was performed to the reversed autogenous saphenous vein with running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde cardioplegia were given and the posterior descending branch of the right coronary artery was identified and opened.  End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde potassium cardioplegia were given.  The mammary artery was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified and opened.  End-to-side anastomosis was performed through the left internal mammary artery with running 8-0 Prolene suture.  The mammary pedicle was sutured to the heart with interrupted 5-0 Prolene suture.  A warm antegrade and retrograde cardioplegia were given.  The aortic crossclamp was removed.  The partial occlusion clamp was placed.  Aortotomies were made.  The veins were cut to fit these and sutured in place with running 5-0 Prolene suture.  A partial occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Ventricular and atrial pacing wires were placed.  The patient was fully warmed and weaned from cardiopulmonary bypass.  The patient was decannulated in the routine fashion and Protamine was given.  Good hemostasis was noted.  A single mediastinal and left pleural chest tube were placed.  The sternum was closed with interrupted wire, linea alba with running 0 Prolene, the sternal fascia was closed with running 0 Prolene, the subcutaneous tissue with running 2-0 Dexon and the skin with running 3-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.", Surgery,38
"PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic inflammatory disease.,2.  Pelvic adhesions.,3.  Pelvic pain.,4.  Fibroid uterus.,5.  Enterocele.,POSTOPERATIVE DIAGNOSES:,1.  Chronic pelvic inflammatory disease.,2.  Pelvic adhesions.,3.  Pelvic pain.,4.  Fibroid uterus.,5.  Enterocele.,PROCEDURE PERFORMED:,1.  Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy.,2.  McCall's culdoplasty.,3.  Cystoscopy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 350 cc.,INDICATIONS:  ,The patient is a 45-year-old Caucasian female with complaints of long standing pelvic pain throughout the menstrual cycle and worse with menstruation, uncontrolled with Anaprox DS also with complaints of dyspareunia.  On laparoscopy in May of 2003, PID, adenomyosis, and uterine fibroids were demonstrated.  The patient desires definitive treatment.,FINDINGS AT THE TIME OF SURGERY:  ,Uterus was retroverted and somewhat boggy on bimanual examination without any palpable adnexal abnormalities.  On laparoscopic examination, the uterus was quite soft and boggy consistent with the uterine adenomyosis.  There was also evidence of fibroid change in the right fundal aspect of the uterus.  There was a white exudative material covering the uterus as well as bilateral ovaries and fallopian tubes.  There were filmy adhesions to the right pelvic side wall, as well as left pelvic side wall.,PROCEDURE: , The patient taken to the operative suite where anesthesia was found to be adequate.  She was then prepared and draped in the normal sterile fashion.  A Foley catheter was initially placed and was noted to be draining clear to yellow urine.  A weighted speculum was placed in the patient's vagina.  The bladder was elevated and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterus sounded to 7 cm and the cervix was then progressively dilated.  A #20 Hank dilator, which was left within the cervix used in conjunction with the vulsellum tenaculum as a uterine manipulator.  At this time, after the gloves were changed, attention was then turned to the patient's abdomen.  A small approximately 1 cm infraumbilical incision was made with the scalpel.  A Veress needle was then inserted through this incision and a pneumoperitoneum was created with CO2 gas with appropriate volumes and pressures.  A #10 mm step trocar was then inserted through this site and intraabdominal placing was confirmed with the laparoscope.  On entrance into the patient's abdomen and pelvis, survey of the abdomen and pelvis revealed the operative area to be relatively free of adhesions except for the right pelvic saddle in which there were filmy adhesions.  There was also white exudate noted covering the surface of the uterus and adnexa and the uterus had a quite boggy appearance.  At this time, under transillumination in the left anterior axillary line, a second incision was made with a scalpel and through this site a #12 mm step trocar was inserted under direct visualization by the laparoscope.  A third incision was made in the right anterior axillary line under transillumination and through this site a second #12 mm step trocar was placed under direct visualization by the laparoscope.  Then 2 cm above the pubic symphysis in the midline and fourth incision was made and a #5 mm step trocar was inserted through this site.  The uterus was elevated and deviated to the patient's right and infundibulopelvic ligament on the left was placed on tension with the aid of a grasper.  The Endo-GIA was placed through the left sided port and was fired was to cross the infundibulopelvic ligament and down passed to the level of the round ligament, transecting and stapling at the same time.  Attention was then turned to the right adnexa.,The uterus was brought over to the patient's left and the right infundibulopelvic ligament was placed on tension with the aid of a grasper.  An Endo-GIA was used to transect and staple this vasculature and down passed to the level of round ligament.  At this time, there was noted to be a small remnant of the round ligament on the right and a Harmonic scalpel was used to complete the transection and was found to be hemostatic.  In addition, on the left the same procedure was performed to completely transect the round ligament on the left and a good hemostasis was noted.  At this time, the uterus was dropped and the vesicouterine peritoneum was grasped with graspers.  The bladder was then dissected off of the lower uterine segment with the aid of a Harmonic scalpel and hemostasis was appreciated.  The anterior cervix of the uterus was scored in the midline up to the level of the fundus with the aid of a Harmonic scalpel and then out to the adnexa bilaterally to aid in orientation during the vaginal portion of the procedure.  At this time, copious suction irrigation was performed and the operative sites were found to be hemostatic.  The pneumoperitoneum was the evacuated and the attention was then turned to the vaginal portion of the procedure.  The weighted speculum was placed into the patient's vagina.  At this time, the Foley catheter was noted to have ________ and there was noted to be a small puncture site noted into the Foley bulb.  The Foley catheter was replaced and the bladder was to be filled at a later time with methylene blue to rule out any bladder injury during the laparoscopic part of the procedure.  The cervix was then grasped from right to left with a Lahey clamps and the anterior vaginal mucosa was placed on stretch with aid of Allis clamps.  The vaginal mucosa anteriorly was then incised with aid of a scalpel from the 9 o'clock position to 3 o'clock position.  The anterior vaginal mucosa and bladder were suctioned and were then dissected away from the lower uterine segment with the aid of Mayo scissors and blunt dissection until anteriorly the peritoneal cavity was entered at which time the peritoneal incision was extended bluntly.  Next, using Lahey clamps serially following the ________ placed by the Harmonic scalpel from above were followed up to the pubic uterine fundus until the uterus was delivered into the vagina anteriorly.  At this time, two curved Heaney clamps were placed across the uterine artery on the right.  This was then transected and suture ligated with #0 Vicryl suture.  The second clamp was advanced to incorporate the cardinal ligament complex and this was then transected and suture ligated with #0 Vicryl suture.  Attention was then turned to the left uterine artery which was again doubly clamped with curved Heaney clamps, transected and suture ligated with #0 Vicryl suture.  This second clamp was then advanced to capture the vasculature and the cardinal ligament complex.  This was again transected and suture ligated with #0 Vicryl suture.,Next, the uterosacral were clamped off with the curved Heaney clamps and this clamp was met in the midline by another clamp just underneath the cervix and clamping off of the vaginal cuff.  Next the uterus, ovaries and cervix were transected away from the vaginal cuff with the aid of double pointed scissors and this specimen was handed off to pathology.  At this time, the bladder was instilled with approximately 800 cc of methylene blue and there was no evidence of any leak of blue dye as could be seen from the prospective of the vaginal portion of the procedure.  Next, the posterior vaginal cuff and posterior peritoneum were incorporated in a running lock stitch of #0 Chromic beginning at the 9'o clock position over to the 3'o clock position.  Next, the anterior vaginal mucosa was grasped with the Allis clamp and the peritoneum was identified anteriorly.  The angles of the vaginal cuff were then closed with #0 Chromic suture figure-of-eight stitch with care taken to incorporate the anterior vaginal mucosa, the anterior peritoneum, and the previously closed posterior vaginal mucosa and the posterior peritoneum.  Two additional sutures medially were placed and these were tagged and not tied in place.  A #0 Vicryl suture on a UR6 needle was used to perform the McCall's culdoplasty type approximation with the vaginal cuff to open and the uterosacral ligament visualized.  This was then tied in place and the remainder of the vaginal cuff was closed with #0 Chromic suture with figure-of-eight stitches.  At this time, the gloves were changed and attention was returned to the laparoscopic portion of the procedure at which time the abdomen was re-insufflated and the patient was placed in Trendelenburg.  The bowel was moved out of the way and copious suction irrigation was performed and all operative areas were noted to be hemostatic.  The bladder was again filled with approximately 400 cc methylene blue and from the laparoscopic ________ point there was no evidence of leakage of blue dye at this time.  The pneumoperitoneum was then evacuated and a cystoscopy was performed filling the bladder with approximately 400 cc of normal saline and there was noted to be a pinpoint perforation right on bladder dome which was found to be hemostatic and was not found to have any leakage at this time.  The bladder was then drained and the Foley catheter was replaced and after gloves changed, attention was turned to the abdomen with the laparoscopic instruments removed from the patient's abdomen.  The skin incisions were closed with #4-0 undyed Vicryl in a subcuticular fashion.  Approximately 10 cc of 0.25% Marcaine in total were injected at incision site for additional analgesia.  The Steri-Strips were placed.  The patient tolerated the procedure well and taken to recovery in stable condition.  Sponge, lap, and needle counts were correct x2.  The specimens include the uterus, cervix, bilateral ovaries, and fallopian tubes.  The patient will have her Foley catheter maintained for approximately 7 to 10 days.", Surgery,38
"SUBJECTIVE:,  This is a 54-year-old female who comes for dietary consultation for weight reduction secondary to diabetes.  She did attend diabetes education classes at Abc Clinic.  She comes however, wanting to really work at weight reduction.  She indicates that she has been on the Atkins' diet for about two years and lost about ten pounds.  She is now following a veggie diet which she learned about in Poland originally.  She has been on it for three weeks and intends to follow it for another three weeks.  This does not allow any fruits or grains or starchy vegetables or meats.  She does eat nuts for protein.  She is wanting to know if she is at risk of having a severe low blood sugar reaction in this form of diet.  She also wants to know that if she gets skinny enough, if the diabetes will go away.  Her problem time, blood sugar wise, is in the morning.  She states that if she eats too much in the evening that her blood sugars are always higher the next morning.,OBJECTIVE:,  Weight:  189 pounds.  Reported height:  5 feet 5 inches.  BMI is approximately 31-1/2.  Diabetes medications include metformin 500 mg daily.  Lab from 5/12/04:  Hemoglobin A1C was 6.4%.,A diet history was obtained.  I instructed the patient on dietary guidelines for weight reduction.  A 1200-calorie meal plan was recommended.,ASSESSMENT:,  Patient's diet history reflects that she is highly restricting carbohydrates in her food intake.  She does not have blood sugar records with her for me to review, but we discussed strategies for improving blood sugar control in the morning.  This primarily included a recommendation of including some solid protein with her bedtime snack which could be done in the form of nuts.  She is doing some physical activity two to three times a week.  This includes aerobic walking with weights on her arms and her ankles.  She is likely going to need to increase frequency in this area to help support weight reduction.  Her basal metabolic rate was estimated at 1415 calories a day.  Her total calorie requirements for weight maintenance are estimated at 1881 calories a day.  A 1200-calorie meal plan should support a weight loss of at least one pound a week.,PLAN:,  Recommend patient increase the frequency of her walking to five days a week.  Encouraged a 30-minute duration.  Also recommend patient include some solid protein with her bedtime snack to help address fasting blood sugar elevations.  And lastly, I encouraged caloric intake of just under 1200 calories daily.  Recommend keeping food records and tracking caloric intake.  It is unlikely that her blood sugars would drop significantly low on the current dose of Glucophage.  However, I encouraged her to be careful not to reduce calories below 1000 calories daily.  She may want to consider a multivitamin as well.  This was a one-hour consultation.", Consult - History and Phy.,5
"REASON FOR CONSULTATION: , Syncope.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 69-year-old gentleman, a good historian, who relates that he 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.  No palpitation.  Presently, he is comfortable, lying in the bed.  As per the patient, no prior cardiac history.,CORONARY RISK FACTORS: , History of hypertension.  No history of diabetes mellitus.  Nonsmoker.  Cholesterol status is borderline elevated.  No history of established coronary artery disease.  Family history noncontributory.,PAST MEDICAL HISTORY:  ,Hypertension, hyperlipidemia, recently diagnosed with Parkinson's, as a Parkinson's tremor, admitted for syncopal evaluation.,PAST SURGICAL HISTORY: ,Back surgery, shoulder surgery, and appendicectomy.,FAMILY HISTORY: , Nonsignificant.,MEDICATIONS:,1.  Pain medications.,2.  Thyroid supplementation.,3.  Lovastatin 20 mg daily.,4.  Propranolol 20 b.i.d.,5.  Protonix.,6.  Flomax.,ALLERGIES:,  None.,PERSONAL HISTORY:,  He is married.  Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  No weakness, fatigue, or tiredness.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  No congestive heart failure.  No arrhythmias.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No nausea, vomiting, hematemesis, or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Arthritis and muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGIC:  No TIA or CVA.  No seizure disorder.,ENDOCRINE/HEMATOLOGIC:  Nonsignificant.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 93, blood pressure of 158/93, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.  No significant carotid bruits.,LUNGS:  Air entry is bilaterally decreased.,HEART:  PMI is displaced.  S1 and S2 are regular.,ABDOMEN:  Soft and nontender.  Bowel sounds are present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.  The patient is moving all extremities; however, the patient has tremors.,RADIOLOGICAL DATA: , EKG reveals normal sinus rhythm with underlying nonspecific ST-T changes secondary to tremors.,LABORATORY DATA: , H&H stable.  White count of 14.  BUN and creatinine are within normal limits.  Cardiac enzyme profile is negative.  Ammonia level is elevated at 69.  CT angiogram of the chest, no evidence of pulmonary embolism.  Chest x-ray is negative for acute changes.  CT of the head, unremarkable, chronic skin changes.  Liver enzymes are within normal limits.,IMPRESSION:,1.  The patient is a 69-year-old gentleman, admitted with syncopal episode and possible seizure disorder.", General Medicine,15
"PROCEDURE: , Left heart catheterization, coronary angiography, left ventriculography.,COMPLICATIONS: , None.,PROCEDURE DETAIL: , The right femoral area was draped and prepped in the usual fashion after Xylocaine infiltration.  A 6-French arterial sheath was placed in the usual fashion.  Left and right coronary angiograms were then performed in various projections after heparin was given 2000 units intraaortic.  The right coronary artery was difficult to cannulate because of its high anterior takeoff.  This was nondominant.  Several catheters were used.  Ultimately, an AL1 diagnostic catheter was used.  A pigtail catheter was advanced across the aortic valve.  Left ventriculogram was then done in the RAO view using 30 mL of contrast.  Pullback gradient was obtained across the aortic valve.  Femoral angiogram was performed through the sheath which was above the bifurcation, was removed with a Perclose device with good results.  There were no complications.  He tolerated this procedure well and returned to his room in good condition.,FINDINGS,1.  Right coronary artery:  This has an unusual high anterior takeoff.  The vessel is nondominant, has diffuse mild-to-moderate disease.,2.  Left main trunk:  A 30% to 40% distal narrowing is present.,3.  Left anterior descending:  Just at the ostium of the vessel and up to and including the bifurcation of the first large diagonal branch, there is 80 to 90% narrowing.  The diagonal is a large vessel about 3 mm in size.,4.  Circumflex:  Dominant vessel, 50% narrowing at the origin of the obtuse marginal.  After this, there is 40% narrowing in the AV trunk.  The small posterior lateral branch has diffuse mild disease and then the vessel gives rise to a fairly large posterior ventricular branch, which has 70% ostial narrowing, and then after this the posterior descending has 80% narrowing at its origin.,5.  Left ventriculogram:  Normal volume in diastole and systole.  Normal systolic function is present.  There is no mitral insufficiency or left ventricular outflow obstruction.,DIAGNOSES,1.  Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.  Dominant circumflex system.  Severe disease of the posterior descending.  Mild left main trunk disease.,2.  Normal left ventricular systolic function.,Given the complex anatomy of the predominant problem which is the left anterior descending; given its ostial stenosis and involvement of the bifurcation of the diagonal, would recommend coronary bypass surgery.  The patient also has severe disease of the circumflex which is dominant.  This anatomy is not appropriate for percutaneous intervention.  The case will be reviewed with a cardiac surgeon.", Cardiovascular / Pulmonary,3
, Cardiovascular / Pulmonary,3
"CHIEF COMPLAINT: , Worsening seizures.,HISTORY OF PRESENT ILLNESS:  ,A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.  The patient stated she was in her normal state of well being when she was experiencing having frequent seizures.  She lives in assisted living.  She has been falling more frequently.  The patient was driving a scooter and apparently was hitting into the wall with unresponsiveness in association with this.  There was no head trauma, but apparently she was doing that many times and there was no responsiveness.  The patient has no memory of the event.  She is now back to her baseline.  She states her seizures are worse in the setting of stress, but it is not clear to her why this has occurred.  She is on Carbatrol 300 mg b.i.d. and she has been very compliant and without any problems.  The patient is admitted for EMU monitoring for the characterization of these episodes and for the possibility of complex partial epilepsy syndrome or better characterization of this current syndrome.,PAST MEDICAL HISTORY:  ,Include dyslipidemia and hypertension.,FAMILY HISTORY:  ,Positive for stroke and sleep apnea.,SOCIAL HISTORY: , No smoking or drinking.  No drugs.,MEDICATIONS AT HOME: , Include, Avapro, lisinopril, and dyslipidemia medication, she does not remember.,REVIEW OF SYSTEMS:,  The patient does complain of gasping for air, witnessed apneas, and dry mouth in the morning.  The patient also has excessive daytime sleepiness with EDS of 16.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Last blood pressure 130/85, respirations 20, and pulse 70.,GENERAL:  Normal.,NEUROLOGICAL:  As follows.  Right-handed female, normal orientation, normal recollection to 3 objects.  The patient has underlying MR. Speech, no aphasia, no dysarthria.  Cranial nerves, funduscopic intact without papilledema.  Pupils are equal, round, and reactive to light.  Extraocular movements intact.  No nystagmus.  Her mood is intact.  Symmetric face sensation.  Symmetric smile and forehead.  Intact hearing.  Symmetric palate elevation.  Symmetric shoulder shrug and tongue midline.  Motor 5/5 proximal and distal.  The patient does have limp on the right lower extremity.  Her Babinski is hyperactive on the left lower extremity, upgoing toes on the left.  Sensory, the patient does have sharp, soft touch, vibration intact and symmetric.  The patient has trouble with ambulation.  She does have ataxia and uses a walker to ambulate.  There is no bradykinesia.  Romberg is positive to the left.  Cerebellar, finger-nose-finger is intact.  Rapid alternating movements are intact.  Upper airway examination, the patient has a Friedman tongue position with 4 oropharyngeal crowding.  Neck more than 16 to 17 inches, BMI elevated above 33.  Head and neck circumference very high.,IMPRESSION:,1.  Cerebral palsy, worsening seizures.,2.  Hypertension.,3.  Dyslipidemia.,4.  Obstructive sleep apnea.,5.  Obesity.,RECOMMENDATIONS:,1.  Admission to the EMU, drop her Carbatrol 200 b.i.d., monitor for any epileptiform activity.  Initial time of admission is 3 nights and 3 days.,2.  Outpatient polysomnogram to evaluate for obstructive sleep apnea followed by depression if clinically indicated.  Continue her other medications.,3.  Consult Dr. X for hypertension, internal medicine management.,4.  I will follow this patient per EMU protocol.", Consult - History and Phy.,5
"IMPRESSION:  ,EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.", Neurology,22
"PREOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.,POSTOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.  Significant coronary artery disease, very severe PAD.,PROCEDURES PERFORMED:,1.  Right common femoral artery cannulation.,2.  Conscious sedation using IV Versed and IV fentanyl.,3.  Retrograde bilateral coronary angiography.,4.  Abdominal aortogram with pelvic runoff.,5.  Left external iliac angiogram with runoff to the patient's left foot.,6.  Left external iliac angiogram with runoff to the patient's right leg.,7.  Right common femoral artery angiogram runoff to the patient's right leg.,PROCEDURE IN DETAIL:,  The patient was taken to the cardiac catheterization laboratory after having a valid consent.  He was prepped and draped in the usual sterile fashion.,After local infiltration with 2% Xylocaine, the right common femoral artery was entered percutaneously and a 4-French sheath was placed over the artery.  The arterial sheath was flushed throughout the procedure.,Conscious sedation was obtained using IV Versed and IV fentanyl.,With the help of a Wholey wire, a 4-French 4-curve Judkins right coronary artery catheter was advanced into the ascending aorta.  The wire was removed, the catheter was flushed.  The catheter was engaged in the left main.  Injections were performed at the left main in different views.  The catheter was then exchanged for an RCA catheter, 4-French 4-curve which was advanced into the ascending aorta with the help of a J-wire.  The wire was removed, the catheter was flushed.  The catheter was engaged in the RCA.  Injections were performed at the RCA in different views.,The catheter was then exchanged for a 5-French Omniflush catheter, which was advanced into the abdominal aorta with the help of a regular J-wire.  The wire was removed.  The catheter was flushed.  Abdominal aortogram was then performed with runoff to the patient's pelvis.,The Omniflush catheter was then retracted into the aortic bifurcation.  Through the Omniflush catheter, a Glidewire was then advanced distally into the left SFA.  The Omniflush was then removed.  Through the wire, a Royal Flush catheter was then advanced into the left external iliac.  The wire was removed.  Left external iliac angiogram was performed with runoff to the patient's left foot _______ was then performed.  The catheter was then retracted into the left common iliac.  Angiograms were performed of the left common iliac with runoff to the patient's left groin.  The catheter was then positioned at the level of the right common iliac.  Angiogram of the right common iliac with runoff to the patient's right leg was then performed.  The catheter was then removed with the help of a J-wire.  The J-wire was left in the abdominal aorta.  Hand injection was performed of the right common femoral artery in 2 locations with runoff to the patient's right leg.,The wire was then removed.  The arterial sheath was then removed after being flushed.  Hemostasis was obtained using hand compression.,The patient tolerated the procedure well and had no complications.  At the end of the procedure, palpable right common femoral pulses were noted as well as 1+ right PT pulse.,Hemodynamic Findings:,  Aortic pressure 140/70.,ANGIOGRAPHIC FINDINGS: , Left main with calcification 25% to 40% lesion.,The left main is very short.,LAD with calcification 25% to 40% proximal lesion.,D1 has 25% lesion.  No in-stent restenosis was noted in D1.,D2 and D3 are very small with luminal irregularities.,Circumflex artery was diseased throughout the vessel.  The circumflex artery has an ostium of 60% to 75% lesion distally and the circumflex has a 75% lesion.,OM1 has 25% to 40% lesion.  These OMs are small with luminal irregularities.,RCA has 25% to 50% lesion, distally, the RCA has luminal irregularities.,Left ventriculography was not done.,ABDOMINAL AORTOGRAM:,  Right renal artery with luminal irregularities.  Left renal artery with luminal irregularities.  The abdominal aorta has 25% lesion.,Right common iliac has a 25% to 50% lesion as well as a distal 75% lesion.,The right external iliac has a proximal 75% lesion.,The distal part of the right external iliac as well as the right common femoral appears to be occlusive by the 5-French sheath.,The right SFA was visualized, although not very well.,Left common iliac with 25% to 50% lesion.  Left external iliac with 25% to 40% lesion.  Left common femoral with 25% to 40% lesion.  Left SFA with 25% lesion.  Left popliteal with wall luminal irregularities.,Three-vessel runoff is noted at the level of the left knee and at the level of the left ankle.,Conclusions:  Severe coronary artery disease.  Very severe peripheral arterial disease.,PLAN: , Because of the anatomic distribution of the coronary artery disease, for now we will continue medical treatment for CAD.  We will proceed with revascularization of the right external iliac as well as right common femoral.  Discontinue tobacco.", Surgery,38
"HISTORY OF PRESENT ILLNESS:,  The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.  He also has a history of obesity, hypertension, sleep apnea, chronic low back pain, cataracts, and past history of CA of the lung.  This consultation was made for better control of his blood sugars.  On questioning, the patient says that he does not have diabetes.  He says that he has never been told about diabetes except during his last admission at Jefferson Hospital.  Apparently, he was started on glipizide at that time.  His blood sugars since then have been good and he says when he went back to Jefferson three weeks later, he was told that he does not have a sugar problem.  He is not sure.  He is not following any specific diet.  He says ""my doctor wants me to lose 30-40 pounds in weight"" and he would not mind going on a diet.  He has a long history of numbness of his toes.  He denies any visual problems.,PAST MEDICAL HISTORY: , As above that includes CA of the lung, COPD, bilateral cataracts.  He has had chronic back pain.  There is also a history of bilateral hip surgeries, penile implant and removal, umbilical hernia repair, and back pain with two surgeries with details of which are unknown.,SOCIAL HISTORY: , The patient has been a smoker since the age of 10.  So, he was smoking 2-3 packs per day.  Since being started on Chantix, he says he has cut it down to half a pack per day.  He does not abuse alcohol.,MEDICATIONS: ,1.  Glipizide 5 mg p.o. daily.,2.  Theophylline.,3.  Z-Pak.,4.  Chantix.,5.  Januvia 100 mg daily.,6.  K-Lor.,7.  OxyContin.,8.  Flomax.,9.  Lasix.,10.  Advair.,11.  Avapro.,12.  Albuterol sulfate.,13.  Vitamin B tablet.,14.  OxyContin and oxycodone for pain.,FAMILY HISTORY: , Positive for diabetes mellitus in the maternal grandmother.,REVIEW OF SYSTEMS: , As above.  He says he has had numbness of toes for a long time.  He denies any visual problems.  His legs have been swelling up from time to time for a long time.  He also has history of COPD and gets short of breath with minimal activity.  He is also not able to walk due to his weight.  He has had ulcers on his legs, which he gets discharge from.  He has chronic back pain and takes OxyContin.  He denies any constipation, diarrhea, abdominal pain, nausea or vomiting.  There is no chest pain.  He does get short of breath on walking.,PHYSICAL EXAMINATION:,The patient is a well-built, obese, white male in no acute distress.,Vital signs:  Pulse rate of 89 per minute and regular.  Blood pressure of 113/69, temperature is 98.4 degrees Fahrenheit, and respirations are 18.,HEENT:  Head is normocephalic and atraumatic.  Eyes, PERRLA.  EOMs intact.  Fundi were not examined.,Neck:  Supple.  JVP is low.  Trachea central.  Thyroid small in size.  No carotid bruits.,Heart:  Shows normal sinus rhythm with S1 and S2.,Lungs:  Show bilateral wheezes with decreased breath sounds at the bases.,Abdomen:  Soft and obese.  No masses.  Bowel sounds are present.,Extremities:  Show bilateral edema with changes of chronic venostasis.  He does have some open weeping sores.  Pulses could not be palpated due to leg swelling.,IMPRESSION/PLAN:,1.  Diabetes mellitus, type 2, new onset.  At this time, the patient is on Januvia as well as glipizide.  His blood sugar right after eating his supper was 101.  So, I am going to discontinue glipizide, continue on Januvia, and add no-concentrated sweets to the diet.  We will continue to follow his blood sugars closely and make adjustments as needed.,2.  Neuropathy, peripheral, query etiology.  We will check TSH and B12 levels.,3.  Lymphedema.,4.  Recurrent cellulitis.,5.  Obesity, morbid.,6.  Tobacco abuse.  He was encouraged to cut his cigarettes down to 5 cigarettes a day.  He says he feels like smoking after meals.  So, we will let him have it after meals first thing in the morning and last thing at night.,7.  Chronic venostasis.,8.  Lymphedema.  We would check his lipid profile also.,9.  Hypertension.,10.  Backbone pain, status post back surgery.,11.  Status post hernia repair.,12.  Status post penile implant and removal.,13.  Umbilical hernia repair.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:,  This 77-year-old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux.  The patient has a history of chronic osteomyelitis and non-healing ulceration to the left hallux of almost 10 years' duration.  He has failed outpatient antibiotic therapy and conservative methods.  At this time, he desires to attempt surgical correction.  The patient is not interested in a hallux amputation at this time; however, he is consenting to removal of infected bone.  He was counseled preoperatively about the strong probability of the hallux being a ""floppy tail"" after the surgery and accepts the fact.  The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL:  ,The patient's wound was debrided with a #15 blade and down to good healthy tissue preoperatively.  The wound was on the planar medial, distal and dorsal medial.  The wound's bases were fibrous.  They did not break the bone at this point.  They were each approximately 0.5 cm in diameter.  After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection.,Due to the patient's history of diabetes and marked calcifications on x-ray, a pneumatic ankle tourniquet was not applied.  Next, a total of 3 cc of a 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was used to infiltrate the left hallux and perform a digital block.  Next, the foot was prepped and draped in the usual aseptic fashion.  It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected.  Next, a #10 blade was used to make a linear incision approximately 3.5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium.  Next, the incision was deepened through the subcutaneous tissue.  A heavy amount of bleeding was encountered.  Therefore, a Penrose drain was applied at the tourniquet, which failed.  Next, an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis.  Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery.  Next, the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon.  The long extensor tendon was thickened and overall exhibited signs of hypertrophy.  The transverse incision through the long extensor tendon was made with a #15 blade.  Immediately upon entering the joint, yellow discolored fluid was drained from the interphalangeal joint.  Next, the extensor tendon was peeled dorsally and distally off the bone.  Immediately the head of the proximal phalanx was found to be lytic, disease, friable, crumbly, and there were free fragments of the medial aspect of the bone, the head of the proximal phalanx.  This bone was removed with a sharp dissection.  Next, after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx, a sagittal saw was used to resect the approximately one-half of the proximal phalanx.  This was passed off as the infected bone specimen for microbiology and pathology.  Next, the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx.  Next, there was diseased soft tissue envelope around the bone, which was also resected to good healthy tissue margins.  The pulse lavage was used to flush the wound with 1000 cc of gentamicin-impregnated saline.  Next, cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin.  This bone was found to be hard and healthy appearing.  The wound after irrigation was free of all debris and infected tissue.  Therefore anaerobic and aerobic cultures were taken and sent to microbiology.  Next, OsteoSet beads, tobramycin-impregnated, were placed.  Six beads were placed in the wound.  Next, the extensor tendon was re-approximated with #3-0 Vicryl.  The subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  Next, the skin was closed with #4-0 nylon in a horizontal mattress technique.,The Esmarch bandage was released and immediate hyperemic flush was noted at the digits.  A standard postoperative dressing was applied consisting of 4 x 4s, Betadine-soaked #0-1 silk, Kerlix, Kling, and a loosely applied Ace wrap.  The patient tolerated the above anesthesia and procedure without complications.  He was transported via a cart to the Postanesthesia Care Unit.  His vitals signs were stable and vascular status was intact.  He was given a medium postop shoe that was well-formed and fitting.  He is to elevate his foot, but not apply ice.  He is to follow up with Dr. X.  He was given emergency contact numbers.  He is to continue the Vicodin p.r.n. pain that he was taking previously for his shoulder pain and has enough of the medicine at home.  The patient was discharged in stable condition.", Orthopedic,27
"PAST MEDICAL HISTORY:,  Unremarkable, except for diabetes and atherosclerotic vascular disease.,ALLERGIES:,  PENICILLIN.,CURRENT MEDICATIONS:,  Include Glucovance, Seroquel, Flomax, and Nexium.,PAST SURGICAL HISTORY: , Appendectomy and exploratory laparotomy.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,The patient is a non-smoker.  No alcohol abuse.  The patient is married with no children.,REVIEW OF SYSTEMS:,  Significant for an old CVA.,PHYSICAL EXAMINATION:,  The patient is an elderly male alert and cooperative.  Blood pressure 96/60 mmHg.  Respirations were 20.  Pulse 94.  Afebrile.  O2 was 94% on room air.  HEENT:  Normocephalic and atraumatic.  Pupils are reactive.  Oral mucosa is grossly normal.  Neck is supple.  Lungs:  Decreased breath sounds.  Disturbed breath sounds with poor exchange.  Heart:  Regular rhythm.  Abdomen:  Soft and nontender.  No organomegaly or masses.  Extremities:  No cyanosis, clubbing, or edema.,LABORATORY DATA: , Oropharyngeal evaluation done on 11/02/2006 revealed mild oropharyngeal dysphagia with no evidence of laryngeal penetration or aspiration with food or liquid.  Slight reduction in tongue retraction resulting in mild residual remaining in the palatal sinuses, which clear with liquid swallow and double-saliva swallow.,ASSESSMENT:,1.  Cough probably multifactorial combination of gastroesophageal reflux and recurrent aspiration.,2.  Old CVA with left hemiparesis.,3.  Oropharyngeal dysphagia.,4.  Diabetes.,PLAN:,  At the present time, the patient is recommended to continue on a regular diet, continue speech pathology evaluation as well as perform double-swallow during meals with bolus sensation.  He may use Italian lemon ice during meals to help clear sinuses as well.  The patient will follow up with you.  If you need any further assistance, do not hesitate to call me.", Consult - History and Phy.,5
"DIAGNOSIS:,  Polycythemia vera with secondary myelofibrosis.,REASON FOR VISIT:, Followup of the above condition.,CHIEF COMPLAINT: , Left shin pain.,HISTORY OF PRESENT ILLNESS: , A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis.  Diagnosis was made some time in 2005/2006.  Initially, he underwent phlebotomy.  He subsequently transferred his care here.  In the past, he has been on hydroxyurea and interferon but did not tolerate both of them.  He is JAK-2 positive.  He does not have any siblings for a match-related transplant.  He was seen for consideration of a MUD transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health.,At our institution, the patient received a trial of lenalidomide and prednisone for a short period.  He did well with the combination.  Subsequently, he developed intolerance to lenalidomide.  He complained of severe fatigue and diarrhea.  This was subsequently stopped.,The patient reports some injury to his left leg last week.  His left leg apparently was swollen.  He took steroids for about 3 days and stopped.  Left leg swelling has disappeared.  The patient denies any other complaints at this point in time.  He admits to smoking marijuana.  He says this gives him a great appetite and he has actually gained some weight.  Performance status in the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS:  He is afebrile.  Blood pressure 144/85, pulse 86, weight 61.8 kg, and respiratory rate 18 per minute.  GENERAL:  He is in no acute distress.  HEENT:  There is no pallor, icterus or cervical adenopathy that is noted.  Oral cavity is normal to exam.  CHEST:  Clear to auscultation.  CARDIOVASCULAR:  S1 and S2 normal with regular rate and rhythm.  ABDOMEN:  Soft and nontender with no hepatomegaly.  Spleen is palpable 4 fingerbreadths below the left costal margin.  There is no guarding, tenderness, rebound or rigidity noted.  Bowel sounds are present.  EXTREMITIES:  Reveal no edema.  Palpation of the left tibia revealed some mild tenderness.  However, I do not palpate any bony abnormalities.  There is no history of deep venous thrombosis.,LABORATORY DATA: , CBC from today is significant for a white count of 41,900 with an absolute neutrophil count of 34,400, hemoglobin 14.8 with an MCV of 56.7, and platelet count 235,000.,ASSESSMENT AND PLAN:,1.  JAK-2 positive myeloproliferative disorder.  The patient has failed pretty much all available options.  He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.  I have e-mailed Dr. X to see whether he will be a candidate for the LBH trial.  Hopefully, we can get a JAK-2 inhibitor trial quickly on board.,2.  I am concerned about the risk of thrombosis with his elevated white count.  He is on aspirin prophylaxis.  The patient has been told to call me with any complaints.,3.  Left shin pain.  I have ordered x-rays of the left tibia and knee today.  The patient will return to the clinic in 3 weeks.  He is to call me in the interim for any problems.", SOAP / Chart / Progress Notes,35
"PREOPERATIVE DIAGNOSIS: , Intrauterine pregnancy at term with previous cesarean section.,SECONDARY DIAGNOSES,1.  Desires permanent sterilization.,2.  Macrosomia.,POSTOPERATIVE DIAGNOSES,1.  Desires permanent sterilization.,2.  Macrosomia.,3.  Status post repeat low transverse cesarean and bilateral tubal ligation.,PROCEDURES,1.  Repeat low transverse cesarean section.,2.  Bilateral tubal ligation (BTL).,ANESTHESIA: , Spinal.,FINDINGS:,  A viable female infant weighing 7 pounds 10 ounces, assigned Apgars of 9 and 9.  There was normal pelvic anatomy, normal tubes.  The placenta was normal in appearance with a three-vessel cord.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room with an IV running and a Foley catheter in place, satisfactory spinal anesthesia was administered following which a wedge was placed under the right hip.  The abdomen was prepped and draped in a sterile fashion.  A Pfannenstiel incision was made and carried sharply down to the level of fascia.  The fascia was incised transversely.  The fascia was dissected away from the underlying rectus muscles.  With sharp and blunt dissection, rectus muscles were divided in midline.  The perineum was entered bluntly.  The incision was carried vertically with scissors.  Transverse incision was made across the bladder peritoneum.  The bladder was dissected away from the underlying lower uterine segment.  Bladder retractor was placed to protect the bladder.  The lower uterine segment was entered sharply with a scalpel.  Incision was carried transversely with bandage scissors.  Clear amniotic fluids were encountered.  The infant was out of the pelvis and was in oblique vertex presentation.  The head was brought down into the incision and delivered easily as were the shoulders and body.  The mouth and oropharynx were suctioned vigorously.  The cord was clamped and cut.  The infant was passed off to the waiting pediatrician in satisfactory condition.  Cord bloods were taken.,Placenta was delivered spontaneously and found to be intact.  Uterus was explored and found to be empty.  Uterus was delivered through the abdominal incision and massaged vigorously.  Intravenous Pitocin was administered.  T clamps were placed about the margins of the uterine incision, which was closed primarily with a running locking stitch of 0 Vicryl with adequate hemostasis.  Secondary running locking stitch was placed for extra strength to the wound.  At this point, attention was diverted to the patient's tubes, a Babcock clamp grasped the isthmic portion of each tube and approximately 1-cm knuckle on either side was tied off with two lengths of 0 plain catgut.  Intervening knuckle was excised and passed off the field.  The proximal end of the tubal mucosa was cauterized.  Cul-de-sac and gutters were suctioned vigorously.  The uterus was returned to its proper anatomic position in the abdomen.  The fascia was closed with a simple running stitch of 0 PDS.,The skin was closed with running subcuticular of 4-0 Monocryl.  Uterus was expressed of its contents.  Patient was brought to the recovery room in satisfactory condition.  There were no complications.  There was 600 cc of blood loss.  All sponge, needle, and instrument counts were reported to be correct.,SPECIMEN: , Tubal segments.,DRAIN: , Foley catheter draining clear yellow urine.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Voluntary sterility.,POSTOPERATIVE DIAGNOSIS: , Voluntary sterility.,OPERATIVE PROCEDURE:,  Bilateral vasectomy.,ANESTHESIA:,  Local.,INDICATIONS FOR PROCEDURE:  ,A gentleman who is here today requesting voluntary sterility.  Options were discussed for voluntary sterility and he has elected to proceed with a bilateral vasectomy.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, and after appropriately identifying the patient, the patient was prepped and draped in the standard surgical fashion and placed in a supine position on the OR table.  Then, 0.25% Marcaine without epinephrine was used to anesthetize the scrotal skin.  A small incision was made in the right hemiscrotum.  The vas deferens was grasped with a vas clamp.  Next, the vas deferens was skeletonized.  It was clipped proximally and distally twice.  The cut edges were fulgurated.  Meticulous hemostasis was maintained.  Then, 4-0 chromic was used to close the scrotal skin on the right hemiscrotum.  Next, the attention was turned to the left hemiscrotum, and after the left hemiscrotum was anesthetized appropriately, a small incision was made in the left hemiscrotum.  The vas deferens was isolated.  It was skeletonized.  It was clipped proximally and distally twice.  The cut edges were fulgurated.  Meticulous hemostasis was maintained.  Then, 4-0 chromic was used to close the scrotal skin.  A jockstrap and sterile dressing were applied at the end of the case.  Sponge, needle, and instruments counts were correct.", Surgery,38
"PREOPERATIVE DIAGNOSES:,1.  Maxillary atrophy.,2.  Severe mandibular atrophy.,3.  Acquired facial deformity.,4.  Masticatory dysfunction.,POSTOPERATIVE DIAGNOSES:,1.  Maxillary atrophy.,2.  Severe mandibular atrophy.,3.  Acquired facial deformity.,4.  Masticatory dysfunction.,PROCEDURE PERFORMED: , Autologous iliac crest bone graft to maxilla and mandible under general anesthetic.,Dr. X and company accompanied the patient to OR #6 at 7:30 a.m.  Nasal trachea intubation was performed per routine.  The bilateral iliac crest harvest was first performed by Dr. X and company under separate OR report.  Once the bone was harvested, surgical templets were used to recontour initially the maxillary graft and the mandibular graft.  Then, CAT scan models were used to find tune and adjust the bony contact regions for the maxillary tricortical block graft and the mandibular tricortical block graft.  Subsequent to the harvest of the bilateral ilium, the intraoral region was scrubbed per routine.  Surgical team scrubbed and gowned in usual fashion and the patient was draped.  Xylocaine 1%, 1:100,000 epinephrine 7 ml was infiltrated into the labial and palatal mucosa.  A primary incision was made in the maxilla starting on the patient's left tuberosity region along the crest of the residual ridge to the contralateral side in similar fashion.  Release incisions were made in the posterior region of the maxilla.,A full-thickness periosteal reflexion first exposed the palatal region.  The contents of the neurovascular canal from the greater palatine foramina were identified.  The hard palate was directly observed.  The facial tissues were then reflected exposing the lateral aspect of the maxilla, the zygomatic arch, the infraorbital nerve, artery and vein, the lateral piriform rim, the inferior piriform rim, and the remaining issue of the nasal spine.  Similar features were reflected on the contralateral side.  The area was re-contoured with rongeurs.  The block of bone, which was formed and harvested from the left ilium was then placed and found to be stable.  A surgical mallet then compressed this bone further into the region.  A series of five 2 mm diameter titanium screws measuring 14 mm to 16 mm long were then used to fixate the block of bone into the residual maxilla.  Particulate bone was then placed around the remaining block of bone.  A piece of AlloDerm mixed with Croften and patient's platelet-rich plasma, which was centrifuged from drawing 20 cc of blood was then mixed together and placed over the lateral aspect of the block.  The tissues were expanded then with a tissue Metzenbaum scissors and once the labial tissue was expanded, the tissues were approximated for primary closure without tension using interrupted and continuous sutures #3-0 Gore-Tex.  Attention was brought then to the mandible.  1% Xylocaine, 1:100,000 epinephrine was infiltrated in the labial mucosa 5 cc were given.  A primary incision was made between the mental foramina and the residual crest of the ridge and reflected first to the lingual area observing the superior genial tubercle in the facial area degloving the mentalis muscle and exposing the anterior body.  The anterior body was found to be approximately 3 mm in height.  A posterior tunnel was done first on the left side along the mylohyoid ridge and then under retromolar pad to the external oblique and the ridge was then degloved.  A tunnel was formed in the posterior region separating the mental nerve artery and vein from the flap and exposing that aspect of the body of the mandible.  A similar procedure was done on the contralateral side.  The tissues were stretched with tissue scissors and then a high speed instrumentation was used to decorticate the anterior mandible using a 1.6 mm twist drill and a pear shaped bur was used in the posterior region to begin original exploratory phenomenon of repair.  A block of bone was inserted between the mental foramina and fixative with three 16 cm screws first with a twist drill then followed with self-tapping 2 mm diameter titanium screws.  The block of bone was further re-contoured in situ.  Particulate bone was then injected into the posterior tunnels bilaterally.  A piece of AlloDerm was placed over those particulate segments.  The tissues were approximated for primary closure using #3-0 Gore-Tex suture both interrupted and horizontal mattress in form.  The tissues were compressed for about four minutes to allow platelet clots to form and to help adhere the flap.,The estimated blood loss in the harvest of the hip was 100 cc.  The estimated blood loss in the intraoral procedure was 220 cc.  Total blood loss for the procedure 320 cc.  The fluid administered 300 cc.  The urine out 180.  All sponges were counted encountered for as were sutures.  The patient was taken to Recovery at approximately 12 o'clock noon.", Dentistry,7
"ADMISSION DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, and hypertension.,DISCHARGE DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.,PROCEDURE: , Laparoscopic cholecystectomy.,SERVICE: , Surgery.,HISTORY OF PRESENT ILLNESS:,  Ms. ABC is a 57-year-old woman.  She suffers from morbid obesity.  She also has diabetes and obstructive sleep apnea.  She was evaluated in the Bariatric Surgical Center for placement of a band.  During her workup, she was noted to have evidence of cholelithiasis.  It was felt that the patient would benefit from removal of her gallbladder prior to having band placement secondary to her diabetes and the risk of infection of the band.  The patient was scheduled to undergo her procedure on 12/31/09; however, at blood glucose check, the patient was noted to be hyperglycemic, her sugar was 438.  She was admitted to the hospital for treatment of her hyperglycemia.,HOSPITAL COURSE: , Ms. ABC was admitted to the hospital.  She was seen by Dr. A.  He put her on an insulin drip.  Her sugars slowly did come down to normal down to between 115 and 134.  On the next day, she was then taken to the operating room, where she underwent her laparoscopic cholecystectomy.  She was noted to be a difficult intubation for the procedure.  There were some indications of chronic cholecystitis, a little bit of edema, mild edema and adhesions of omentum around the gallbladder.  She underwent the procedure.  She tolerated without difficulty.  She was recovered in the Postoperative Care Unit and then returned to the floor.  Her blood sugar postprocedure was noted to be 233.  She was started back on a sliding scale insulin.  She continued to do well and was felt to be stable for discharge following the procedure.,DISCHARGE INSTRUCTIONS:  ,To return to the Medifast diet.  To continue with her blood glucose.  She needs to follow up with Dr. B, and she will see me next week on Friday.  We will determine if we will proceed with her lap band at that time.  She may shower.  She needs to keep her wounds clean and dry.  No heavy lifting.  No driving on narcotic pain medicines.  She needs to continue with her CPAP machine and continue to monitor her sugars.", General Medicine,15
"PROBLEMS LIST:,1.  Nonischemic cardiomyopathy.,2.  Branch vessel coronary artery disease.,3.  Congestive heart failure, NYHA Class III.,4.  History of nonsustained ventricular tachycardia.,5.  Hypertension.,6.  Hepatitis C.,INTERVAL HISTORY: , The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications.  However, he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest.  He has history of orthopnea and PND.  He has gained a few pounds of weight but denied to have any palpitation, presyncope, or syncope.,REVIEW OF SYSTEMS: , Positive for right upper quadrant pain.  He has occasional nausea, but no vomiting.  His appetite has decreased.  No joint pain, TIA, seizure or syncope.  Other review of systems is unremarkable.,I reviewed his past medical history, past surgical history, and family history.,SOCIAL HISTORY: , He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.,ALLERGIES: , He has no known drug allergies.,MEDICATIONS:,  I reviewed his medication list in the chart.  He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 91 per minute and regular, blood pressure 151/102 in the right arm and 152/104 in the left arm, weight 172 pounds, which is about 6 pounds more than last visit in 11/07.  HEENT:  Atraumatic and normocephalic.  No pallor, icterus or cyanosis.  NECK:  Supple.  Jugular venous distention 5 cm above the clavicle present.  No thyromegaly.  LUNGS:  Clear to auscultation.  No rales or rhonchi.  Pulse ox was 98% on room air.  CVS:  S1 and S2 present.  S3 and S4 present.  ABDOMEN:  Soft and nontender.  Liver is palpable 5 cm below the right subcostal margin.  EXTREMITIES:  No clubbing or cyanosis.  A 1+ edema present.,ASSESSMENT AND PLAN:,  The patient has hypertension, nonischemic cardiomyopathy, and branch vessel coronary artery disease.  Clinically, he is in NYHA Class III.  He has some volume overload and was not unfortunately taking Lasix as prescribed.  I have advised him to take Lasix 40 mg p.o. b.i.d.  I also increased the dose of hydralazine from 75 mg t.i.d. to 100 mg t.i.d.  I advised him to continue to take Toprol and lisinopril.  I have also added Aldactone 25 mg p.o. daily for survival advantage.  I reinforced the idea of not using cocaine.  He states that it was a mistake, may be somebody mixed in his drink, but he has not intentionally taken any cocaine.  I encouraged him to find a primary care provider.  He will come for a BMP check in one week.  I asked him to check his blood pressure and weight.  I discussed medication changes and gave him an updated list.  I have asked him to see a gastroenterologist for hepatitis C.  At this point, his Medicaid is pending.  He has no insurance and finds hard to find a primary care provider.  I will see him in one month.  He will have his fasting lipid profile, AST, and ALT checked in one week.", Consult - History and Phy.,5
"HISTORY OF PRESENT ILLNESS: , The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain.  He attributes this to an incident in which he was injured in 1994.  I do not have any paperwork authenticating his claim that there is an open claim.  Most recently he was working at Taco Bell, when he had a recurrence of back pain, and he was seen in our clinic on 04/12/05.  He rated pain of approximately 8/10 in severity., ,He took a Medrol Dosepak and states that his pain level has decreased to approximately 4-5/10.  He still localizes it to a band between L4 and the sacrum.  He initially had some right leg pain but states that this is minimal and intermittent at the present time.  His back history is significant for two laminectomies and a discectomy performed from 1990 to 1994.  The area of concern was L4-L5., ,The patient's MRI dated 10/18/04 showed multi-level degenerative changes, with facet involvement at L2-L3, L3-L4 and L5-S1.  There was no neural impingement.  He also had an MR myelogram, which showed severe stenosis at L3-L4, however it was qualified in that it may have been artifact, rather than a genuine finding., ,REVIEW OF SYSTEMS:,  Focal lower paralumbar pain, affecting both right and left sides, as well as intermittent right leg pain which appears to have improved significantly with the Medrol Dosepak.  He denies any recent illness.  He has no constitutional complaints such as fevers, chills or sweats.  HEENT: The patient denies any cephalgia, ocular, nasopharyngeal symptoms.  He has no dysphagia.  Cardiovascular: He denies any palpitations, chest pain, syncope or near-syncope.  Pulmonary: He denies any dyspnea or respiratory difficulties.  GI: The patient has no abdominal pain, nausea or vomiting.  GU: The patient denies any urinary frequency or dysuria. There is no gross hematuria.  Dermatologic: The patient notes no new onset of rash or other dermatological abnormalities.  Musculoskeletal: Denies any recent falls or near-falls.  He denies any abnormalities of endocrine, immunologic, hematologic, organ systems.  , ,MEDICATIONS: , Atenolol, Zestril, Vicodin., ,ALLERGIES:,  None., ,SOCIOECONOMIC STATUS:,  Lifting limitations of 5 pounds and limited stooping, bending and twisting., ,PHYSICAL EXAMINATION: , Vital signs:  Blood pressure 158/86, respiration 14, pulse 60, temperature 100.2.  He is sitting upright, alert and oriented and in no acute distress.  Skin is warm and dry.  Gross neurologic examination is normal.  ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes.  Neck: Full range of motion with no adenopathy or thyromegaly.  Cardiovascular: Regular rate and rhythm.  Lungs: Clear.  , ,On examination of the lumbar spine, he is minimally tender to palpation.  There is no overt muscular spasm.  His range of motion is estimated at 40 degrees of flexion and 15 degrees of extension.  Straight leg raises do not elicit any leg complaints on today's visit.  Lower extremity reflexes are symmetric., ,DIAGNOSIS: , Low back pain with a history of right leg pain.  The leg pain is no longer present.  His pain level has improved., ,PLAN:  ,1.  The patient will take another Medrol Dosepak.,2.  He can continue with physical therapy.,3.  He also continues with the same lifting restrictions.,4.  Follow up is within one week.", Orthopedic,27
"FINDINGS:,There is a lobulated mass lesion of the epiglottis measuring approximately 22 x 16 x 30 mm (mediolateral x AP x craniocaudal) in size. There is slightly greater involvement on the right side however there is bilateral involvement of the aryepiglottic folds. There is marked enlargement of the bilateral aryepiglottic folds (left greater than right). There is thickening of the glossoepiglottic fold. There is an infiltrative mass like lesion extending into the pre-epiglottic space.,There is no demonstrated effacement of the piriform sinuses. The mass obliterates the right vallecula. The paraglottic spaces are normal. The true and false cords appear normal. Normal thyroid, cricoid and arytenoid cartilages.,There is lobulated thickening of the right side of the tongue base, for which invasion of the tongue cannot be excluded. A MRI examination would be of benefit for further evaluation of this finding.,There is a 14 x 5 x 12 mm node involving the left submental region (Level I).,There is borderline enlargement of the bilateral jugulodigastric nodes (Level II). The left jugulodigastric node,measures 14 x 11 x 8 mm while the right jugulodigastric node measures 15 x 12 x 8 mm.,There is an enlarged second left high deep cervical node measuring 19 x 14 x 15 mm also consistent with a left Level II node, with a probable necrotic center.,There is an enlarged second right high deep cervical node measuring 12 x 10 x 10 mm but no demonstrated central necrosis.,There is an enlarged left mid level deep cervical node measuring 9 x 16 x 6 mm, located inferior to the hyoid bone but cephalad to the cricoid consistent with a Level III node.,There are two enlarged matted nodes involving the right mid level deep cervical chain consistent with a right Level III nodal disease, producing a conglomerate nodal mass measuring approximately 26 x 12 x 10 mm.,There is a left low level deep cervical node lying along the inferior edge of the cricoid cartilage measuring approximately 18 x 11 x 14 mm consistent with left Level IV nodal disease.,There is no demonstrated pretracheal, prelaryngeal or superior mediastinal nodes. There is no demonstrated retropharyngeal adenopathy.,There is thickening of the adenoidal pad without a mass lesion of the nasopharynx. The torus tubarius and fossa of Rosenmuller appear normal.,IMPRESSION:,Epiglottic mass lesion with probable invasion of the glossoepiglottic fold and pre-epiglottic space with invasion of the bilateral aryepiglottic folds.,Lobulated tongue base for which tongue invasion cannot be excluded. An MRI may be of benefit for further assessment of this finding.,Borderline enlargement of a submental node suggesting Level I adenopathy.,Bilateral deep cervical nodal disease involving bilateral Level II, Level III and left Level IV.", Radiology,33
"DISCHARGE DIAGNOSES:,1.  End-stage renal disease, on hemodialysis.,2.  History of T9 vertebral fracture.,3.  Diskitis.,4.  Thrombocytopenia.,5.  Congestive heart failure with ejection fraction of approximately 30%.,6.  Diabetes, type 2.,7.  Protein malnourishment.,8.  History of anemia.,HISTORY AND HOSPITAL COURSE: , The patient is a 77-year-old white male who presented to Hospital of Bossier on April 14, 2008.  The patient was found to have lumbar diskitis and was going to require extensive antibiotic therapy, which was the cause of need for continued hospitalization.  He also needed to continue with dialysis and he needed to improve his rehabilitation.  The patient tolerated his medication well and he was going through rehab fairly well without any significant troubles.  He did have some bouts of issues with constipation on and off throughout his hospitalization, but this seemed to come under control with more aggressive management.  The patient had remained afebrile.  He did also have a bout with some episodic confusion problems, which appeared to be more of a sundowner-type of a problem, but this too cleared with his stay here at Promise.  On the day of discharge, on May 9, 2008, the patient was in good spirits, was very clear and lucid.  He denied any complaints of pain.  He did have some trouble with sleep at night at times, but I think this was mainly tied into the fact that he sleeps a lot during the day.  The patient has increased his appetite some and has been eating some.  His vital signs remain stable.  His blood pressure on discharge was 126/63, heart rate is 80, respiratory rate of 20 and temperature was 98.3.  PPD was negative.  An SMS form was filled out in plan for his discharge and he was sent with medications that he had been receiving while here at Promise.,The patient and his family understood our plan and agreed with it.  He thanked us for the care that he received at Promise and thought that they did a fantastic job taking care of him.  He did not have any acute questions as to where he was going and what the next step of his care would be, but we did discuss this at length prior to date of discharge.,", Discharge Summary,10
"Dear Sample Doctor:,Thank you for referring Mr. Sample Patient for cardiac evaluation.  This is a 67-year-old, obese male who has a history of therapy-controlled hypertension, borderline diabetes, and obesity.  He has a family history of coronary heart disease but denies any symptoms of angina pectoris or effort intolerance.  Specifically, no chest discomfort of any kind, no dyspnea on exertion unless extreme exertion is performed, no orthopnea or PND.  He is known to have a mother with coronary heart disease.  He has never been a smoker.  He has never had a syncopal episode, MI, or CVA.  He had his gallbladder removed.  No bleeding tendencies.  No history of DVT or pulmonary embolism.  The patient is retired, rarely consumes alcohol and consumes coffee moderately.  He apparently has a sleep disorder, according to his wife (not in the office), the patient snores and stops breathing during sleep.  He is allergic to codeine and aspirin (angioedema).,Physical exam revealed a middle-aged man weighing 283 pounds for a height of 5 feet 11 inches.  His heart rate was 98 beats per minute and regular.  His blood pressure was 140/80 mmHg in the right arm in a sitting position and 150/80 mmHg in a standing position.  He is in no distress.  Venous pressure is normal.  Carotid pulsations are normal without bruits.  The lungs are clear.  Cardiac exam was normal.  The abdomen was obese and organomegaly was not palpated.  There were no pulsatile masses or bruits.  The femoral pulses were 3+ in character with a symmetrical distribution and dorsalis pedis and posterior tibiales were 3+ in character.  There was no peripheral edema.  ,He had a chemistry profile, which suggests diabetes mellitus with a fasting blood sugar of 136 mg/dl.  Renal function was normal.  His lipid profile showed a slight increase in triglycerides with normal total cholesterol and HDL and an acceptable range of LDL.  His sodium was a little bit increased.  His A1c hemoglobin was increased.  He had a spirometry, which was reported as normal.  ,He had a resting electrocardiogram on December 20, 2002, which was also normal.  He had a treadmill Cardiolite, which was performed only to stage 2 and was terminated by the supervising physician when the patient achieved 90% of the predicted maximum heart rate.  There were no symptoms or ischemia by EKG.  There was some suggestion of inferior wall ischemia with normal wall motion by Cardiolite imaging.,In summary, we have a 67-year-old gentleman with risk factors for coronary heart disease.  I am concerned with possible diabetes and a likely metabolic syndrome of this gentleman with truncal obesity, hypertension, possible insulin resistance, and some degree of fasting hyperglycemia, as well as slight triglyceride elevation.  He denies any symptoms of coronary heart disease, but he probably has some degree of coronary atherosclerosis, possibly affecting the inferior wall by functional testings.  ,In view of the absence of symptoms, medical therapy is indicated at the present time, with very aggressive risk factor modification.  I explained and discussed extensively with the patient, the benefits of regular exercise and a walking program was given to the patient.  He also should start aggressively losing weight.  I have requested additional testing today, which will include an apolipoprotein B, LPa lipoprotein, as well as homocystine, and cardio CRP to further assess his risk of atherosclerosis.  ,In terms of medication, I have changed his verapamil for a long acting beta-blocker, he should continue on an ACE inhibitor and his Plavix.  The patient is allergic to aspirin.  I also will probably start him on a statin, if any of the studies that I have recommended come back abnormal and furthermore, if he is confirmed to have diabetes.  Along this line, perhaps, we should consider obtaining the advice of an endocrinologist to decide whether this gentleman needs treatment for diabetes, which I believe he should.  This, however, I will leave entirely up to you to decide.  If indeed, he is considered to be a diabetic, a much more aggressive program should be entertained for reducing the risks of atherosclerosis in general, and coronary artery disease in particular.,I do not find an indication at this point in time to proceed with any further testing, such as coronary angiography, in the absence of symptoms.,If you have any further questions, please do not hesitate to let me know.,Thank you once again for this kind referral.,Sincerely,,Sample Doctor, M.D.", Cardiovascular / Pulmonary,3
"GENERAL:,  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: , Negative rash, negative jaundice.,HEMATOPOIETIC: , Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: , Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:,  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS: , Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  ,Negative postnasal drip, negative sore throat.,CARDIOVASCULAR: , Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:,  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL: , Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY: , Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.,MUSCULOSKELETAL:,  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC: , See psychiatric evaluation.,ENDOCRINE: , No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.", Office Notes,25
"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,27
"HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer.  CyberKnife treatment was completed one month ago.  She is now being seen for her first post-CyberKnife treatment visit.,Since undergoing CyberKnife treatment, she has had low-level nausea without vomiting.  She continues to have pain with deep inspiration and resolving dysphagia.  She has no heartburn, cough, hemoptysis, rash, or palpable rib pain.,MEDICATIONS: , Dilantin 100 mg four times a day, phenobarbital 30 mg three times per day, levothyroxine 0.025 mg p.o. q. day, Tylenol with Codeine b.i.d., prednisone 5 mg p.r.n., citalopram 10 mg p.o. q. day, Spiriva q. day, Combivent inhaler p.r.n., omeprazole 20 mg p.o. q. day, Lidoderm patch every 12 hours, Naprosyn 375 mg p.o. b.i.d., oxaprozin 600 mg p.o. b.i.d., Megace 40 mg p.o. b.i.d., and Asacol p.r.n.,PHYSICAL EXAMINATION: , BP:  122/86.  Temp:  96.8.  HR:  79.  RR:  26.  RAS:  100%.,HEENT:  Normocephalic.  Pupils are equal and reactive to light and accommodation.  EOMs intact.,NECK:  Supple without masses or lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally,CARDIAC:  Regular rate and rhythm without rubs, murmurs, or gallops.,EXTREMITIES:  No cyanosis, clubbing or edema.,ASSESSMENT: , The patient has done well with CyberKnife treatment of a stage IA non-small cell lung cancer, right upper lobe, one month ago.,PLAN: , She is to return to clinic in three months with a PET CT.", SOAP / Chart / Progress Notes,35
"Chief Complaint:, Dark urine and generalized weakness.,History of Present Illness:,40 year old Hispanic male presented to the emergency room complaining of generalized weakness, fatigue and dark urine for one week. In addition, he stated that his family had noticed yellowing of his skin and eyes, though he himself had not noticed.,He did complain of subjective fever and chills along with occasional night sweats during the prior week or so and he noted anorexia for 3-4 weeks leading to 26 pound weight loss (213 lbs. to 187 lbs.). He was nauseated but denied vomiting. He did admit to intermittent abdominal discomfort which he could not localize. In addition, he denied any history of liver disease, but had undergone cholecystectomy many years previous.,Past Medical History:, DM II-HbA1c unknown,Past Surgical History:, Cholecystectomy without complication,Family History:, Mother with diabetes and hypertension. Father with diabetes. Brother with cirrhosis (etiology not documented).,Social History:, He was unemployed and denied any alcohol or drug use. He was a prior “mild” smoker, but quit 10 years previous.,Medications:, Insulin (unknown dosage),Allergies:, No known drug allergies.,Physical Exam:,Temperature: 98.2,Blood pressure:118/80,Heart rate: 95,Respiratory rate: 18,GEN: Middle age Latin-American Male, jaundice, alert and oriented to person/place/time.,HEENT: Normocephalic, atraumatic. Icteric sclerae, pupils equal, round and reactive to light. Clear oropharynx.,NECK: Supple, without jugular venous distension, lymphadenopathy, thyromegaly or carotid bruits.,CV: Regular rate and rhythm, normal S1 and S2. No murmurs, gallops or rubs,PULM: Clear to auscultation bilaterally without rhonchi, rales or wheezes,ABD: Soft with mild RUQ tenderness to deep palpation, Murphy’s sign absent. Bowel sounds present. Hepatomegaly with liver edge 3 cm below costal margin. Splenic tip palpable.,RECTAL: Guaiac negative,EXT: Shotty inguinal lymphadenopathy bilaterally, largest node 2cm,NEURO: Strength 5/5 throughout, sensation intact, reflexes symmetric. No focal abnormality identified. No asterixis,SKIN: Jaundice, no rash. No petechiae, gynecomastia or spider angiomata.,Hospital Course:,The patient was admitted to the hospital to begin workup of liver failure. Initial labs were considered to be consistent with an obstructive pattern, so further imaging was obtained. A CT scan of the abdomen and pelvis revealed lymphadenopathy and a markedly enlarged liver. His abdominal pain was controlled with mild narcotics and he was noted to have decreasing jaundice by hospital day 4. An US guided liver biopsy revealed only acute granulomatous inflammation and fibrosis. The overall architecture of the liver was noted to be well preserved.,Gastroenterology was consulted for EGD and ERCP. The EGD was normal and the ERCP showed normal biliary anatomy without evidence of obstruction. In addition, they performed an endoscopic ultrasound-guided fine needle aspiration of two lymph-nodes, one in the subcarinal region and one near the celiac plexus. Again, pathologic results were insufficient to make a tissue diagnosis.,By the second week of hospitalization, the patient was having intermittent low-grade fevers and again experiencing night-sweats. He remained jaundice. Given the previous negative biopsies, surgery was consulted to perform an excisional biopsy of the right groin lymph node, which revealed no evidence of carcinoma, negative AFB and GMS stains and a single noncaseating granuloma.,By his fourth week of hospitalization, he remained ill with evidence of ongoing liver failure. Surgery performed an open liver biopsy and lymph node resection.,STUDIES (HISTORICAL):,CT abdomen: Multiple enlarged lymph nodes near the porta hepatis and peri-pancreatic regions. The largest node measures 3.5 x 3.0 cm. The liver is markedly enlarged (23cm) with a heterogenous pattern of enhancement. The spleen size is at the upper limit of normal. Pancreas, adrenal glands and kidneys are within normal limits. Visualized portions of the lung parenchyma are grossly normal.,CT neck: No abnormalities noted,CT head: No intracranial abnormalities,RUQ US (for biopsy): Heterogenous liver with lymphadenopathy.,ERCP: No filling defect noted; normal pancreatic duct visualized. Normal visualization of the biliary tree, no strictures. Normal exam.", General Medicine,15
"PREOPERATIVE DIAGNOSIS:,  Right renal mass.,POSTOP DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED:,  Laparoscopic right radical nephrectomy.,ESTIMATED BLOOD LOSS:,  100 mL.,X-RAYS: , None.,SPECIMENS: , Right radical nephrectomy specimen.,COMPLICATIONS: , None.,ANESTHESIA:  ,General endotracheal.,DRAINS:,  16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 71-year-old woman recently diagnosed with 6.5 cm right upper pole renal mass.  This is an enhancing lesion suspicious for renal cell carcinoma versus oncocytoma.  I discussed a variety of options with her, and she opted to proceed with a laparoscopic right radical nephrectomy.  All questions were answered, and she wished to proceed with surgery as planned.,PROCEDURE IN DETAIL:,  After acquisition of appropriate written and informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table.  Note that, sequential compression devices were placed on both lower extremities and were activated per induction of anesthesia.  After institution of adequate general anesthetic via the endotracheal route, she was placed into the right anterior flank position with the right side elevated in a roll and the right arm across her chest.  All pressure points were carefully padded, and she was securely taped to the table to prevent shifting during the procedure.  Her abdomen was then prepped and draped in the standard surgical fashion after placing a 16-French Foley catheter per urethra to gravity drainage.  The abdomen was insufflated in the right outer quadrant.  Note that, the patient had had previous surgery which complicated accesses somewhat and that she had a previous hysterectomy.  The abdomen was insufflated into the right lateral abdomen with Veress needle to 50 mm of pressure without incident.  We then placed a 10/12 Visiport trocar approximately 7 cm lateral to the umbilicus.  Once this had entered into the peritoneal cavity without incident, the remaining trocars were all placed.  Under direct laparoscopic visualization, we placed three additional trocars; an 11-mm screw-type trocar in the umbilicus, a 6-mm screw-type trocar in the upper midline approximately 7 cm above the umbilicus, and 10/12 trocar in the lower midline about 7 cm below the umbilicus within and over the old hysterectomy scar.  There were some adhesions of omentum to the underside of that scar, and these were taken down sharply using laparoscopic scissors.,We began nephrectomy procedure by reflecting the right colon, by incising the white line of Toldt.  This exposed the retroperitoneum on the right side.  The duodenum was identified and reflected medially in a Kocher maneuver using sharp dissection only.  We then identified the ureter and gonadal vein in the retroperitoneum.  The gonadal vein was left down along the vena cava, and the plane underneath the ureter was elevated and this plane was carried up towards the renal hilum.  Sequential packets of tissue were taken using primarily the LigaSure Atlas device.  Once we got to the renal hilum, it became apparent that this patient had two sets of renal arteries and veins.  We proceeded then and skeletonized the structures into four individual packets.  We then proceeded to perform the upper pole dissection and developing the plane above the kidney and between the kidney and adrenal gland.  The adrenal was spared during this procedure.  There was no contiguous connection between the renal mass and a right adrenal gland.  This plane of dissection was taken down primarily using the LigaSure device.  We then sequentially took the four vessels going to the kidney initially taking two renal arteries with the endo GI stapler and then to renal veins again with endo GI stapler sequential flaring.  Once this was completed, the kidney was free except for its attachment to the ureter and lateral attachments.  The lateral attachments of the kidney were taken down using the LigaSure Atlas device, and then the ureter was doubly clipped and transected.  The kidney was then freed within the retroperitoneum.  A 50-mm EndoCatch bag was introduced through the lower most trocar site, and the kidney was placed into this bag for subsequent extraction.  We extended the lower most trocar site approximately 6 cm to facilitate extraction.  The kidney was removed and passed off the table as a specimen for pathology.  This was bivalved by pathology, and we reviewed the specimen.", Surgery,38
"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.", Consult - History and Phy.,5
"FLEXIBLE BRONCHOSCOPY,The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit.  I explained to the parents that the possible risks include:  irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax.  A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back.  The sample will then be sent for testing.  The flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.,The parents seem to understand, had the opportunity to ask questions and were satisfied with the information.  A booklet containing the description of the procedure and other information was provided.", Pediatrics - Neonatal,29
"PREOPERATIVE DIAGNOSIS: , Morton's neuroma, third interspace, left foot.,POSTOPERATIVE DIAGNOSIS:,  Morton's neuroma, third interspace, left foot.,OPERATION PERFORMED: , Excision of neuroma, third interspace, left foot.,ANESTHESIA: , General (local was confirmed by surgeon).,HEMOSTASIS: , Ankle pneumatic tourniquet 225 mmHg.,TOURNIQUET TIME: , 18 minutes.  Electrocautery was necessary.,INJECTABLES: , 50:50 mixture of 0.5% Marcaine and 1% Xylocaine, both plain.  Also, 0.5 mL dexamethasone phosphate (4 mg/mL).,INDICATIONS: , Please see dictated H&P for specifics.,PROCEDURE:  ,After proper identification was made, the patient was brought to the operating room and placed on the table in supine position.  The patient was then placed under general anesthesia.  A local block was then injected into the third ray of the left foot.  The left foot was then prepped with chlorhexidine gluconate and then draped in the usual sterile technique.  The left foot was then exsanguinated with an Esmarch bandage and elevated and an ankle pneumatic tourniquet was then inflated.  Attention was then directed to the third interspace where a longitudinal incision was placed just proximal to the webspace.  The incision was deepened via sharp and blunt dissection with care taken to protect all vital structures.  Identification of the neuroma was made following plantar flexion of the digits.  It was grasped with a hemostat and it was dissected in toto and removed.  It was then sent to pathology.  The area was then flushed with copious amounts of sterile saline.  Closure was with 4-0 Vicryl in the subcutaneous tissue and then running subcuticular 4-0 nylon suture in the skin.  Steri-Strips were then placed over that area.  A sterile compressive dressing consisting of saline-soaked gauze, ABD, Kling, Coban was placed over the foot.  The tourniquet was then released.  Good flow was noted to return to all digits.  The patient did tolerate the procedure well.  He left the operating room with all vital signs stable and neurovascular status intact.  The patient went to the recovery.  The patient previously had been given both oral and written preoperative as well as postoperative instructions and a prescription for pain.  The patient will follow up with me in approximately 4 days for dressing change.", Podiatry,31
"PRE-OP DIAGNOSIS:,  Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,POST-OP DIAGNOSIS:,  Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,PROCEDURE:,1.  KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels.,2.  Bone biopsy (medically necessary).,ANESTHESIA:, General,COMPLICATIONS:, None,BLOOD LOSS:, Minimal,INDICATIONS:,  Mrs. Smith is a 75-year-old female who has had severe back pain that began approximately three months ago and is debilitating.  She has been unresponsive to nonoperative treatment modalities including bed rest and analgesics.  She presents with and is on medication therapy for COPD, diabetes and hypertension (other co-morbidities may be present upon admission and should be documented in the operative note).,Radiographic imaging including MRI confirms multiple compression fractures of the thoracolumbar spine including T12, L1 and L2.  In addition to the fractures, she presents with kyphotic posture.  Films on 1/04 demonstrated L1 and L2 osteoporotic fractures.  Films on 2/04 demonstrated increased loss of height at L1.  Films on 3/04 demonstrated a new compression fracture at T12 and further collapse of L1.  The L2 fracture is documented on radiographic studies as being chronic and a year or more old.  The T12 fracture has the most significant kyphotic deformity.  Based on these findings, we have decided to perform KYPHON Balloon Kyphoplasty on the L1 and T12 fractures.,PROCEDURE:,  The patient was brought to the operating room/radiology suite and general anesthesia/local sedation with endotracheal intubation was performed.  The patient was positioned prone on the Jackson table.  The back was prepped and draped.  The image intensifier (C-arm) was brought into position and the T12 pedicles were identified and marked with a skin marker.  In view of the collapse of T12, a transpedicular approach to the vertebral body was appropriate.  An 11-gauge needle was advanced through the T12 pedicle to the junction of the pedicle and vertebral body on the right side.  Positioning was confirmed on the AP and lateral plane.  Following satisfactory placement of the needle, the stylet was removed.  A guide pin was inserted through the 11g to a point 3mm from the anterior cortex.  AP and lateral images were taken to verify position and trajectory.  Alongside of the guide pin a 1-cm paramedian incision was made.  The needle was then removed leaving the guide pin in place.  The osteointroducer was placed over the guide pin and advanced through the pedicle.  Once I was at the junction of the pedicle and the vertebral body, a lateral image was taken to insure that the cannula was positioned approximately 1cm past the vertebral body wall.  Through the cannula, a drill was advanced into the vertebral body under fluoroscopic guidance toward the anterior cortex, creating a channel.  The anterior cortex was probed with the guide pin to ensure no perforations in the anterior cortex.  After completing the entry into the vertebral body, a 15 mm inflatable bone tamp was inserted through the cannula and advanced under fluoroscopic guidance into the vertebral body near the anterior cortex.  The radiopaque marker bands on the bone tamp were identified using AP and lateral images.  The above sequence of instrument placement was then repeated on the left side of the T12 vertebral body.  Once both bone tamps were in position, they were inflated to 0.5 cc and 50 psi.  Expansion of the bone tamps was done sequentially in increments of 0.25 to 0.5 cc of contrast, with careful attention being paid to the inflation pressures and balloon position.  The inflation was monitored with AP and lateral imaging.  The final balloon volume was 3.5 cc on the right side and 3 cc on the left.  There was no breach of the lateral wall or anterior cortex of the vertebral body.  Direct reduction of the fracture was achieved, end plate movement was noted and approximately 5 mm of height restoration was achieved.  Under fluoroscopic imaging, and the use of the bone void fillers, internal fixation was achieved through a low-pressure injection of KYPHON HV-R bone cement.  The cavity was filled with a total volume of 3.5 cc on the right side and 3 cc on the left side.  Once the bone cement had hardened, the cannulas were then removed.,At this time, we proceeded to perform a balloon kyphoplasty at L1 using the same sequence of steps as on T12.  An entry needle was placed bilaterally through the pedicle into the vertebral body, a cortical window was created, inflation of the bone tamps directly reduced the fracture, the bone tamps were removed, and internal fixation by bone void filler insertion was achieved.  Throughout the procedure, AP and lateral imaging monitored positioning.,Post-procedure, all incisions were closed with sutures.  The patient was kept in the prone position for approximately 10 minutes post cement injection.  She was then turned supine, monitored briefly and returned to the floor.  She was moving both her lower extremities at this time.,Throughout the procedure, there were no intraoperative complications.  Estimated blood loss was minimal.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  Ovarian cyst, persistent.,POSTOPERATIVE DIAGNOSIS: , Ovarian cyst.,ANESTHESIA:,  General,NAME OF OPERATION:,  Diagnostic laparoscopy and drainage of cyst.,PROCEDURE:,  The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced.  An infraumbilical incision was made, and Veress needle placed without difficulty.  Gas was entered into the abdomen at two liters.  The laparoscope was entered, and the abdomen was visualized.  The second puncture site was made, and the second trocar placed without difficulty.  The cyst was noted on the left, a 3-cm, ovarian cyst.  This was needled, and a hole cut in it with the scissors.  Hemostasis was intact.  Instruments were removed.  The patient was awakened and taken to the recovery room in good condition.", Obstetrics / Gynecology,24
"A 1 cm infraumbilical skin incision was made.  Through this a Veress needle was inserted into the abdominal cavity.  The abdomen was filled with approximately 2 liters of CO2 gas.  The Veress needle was withdrawn.  A trocar sleeve was placed through the incision into the abdominal cavity.  The trocar was withdrawn and replaced with the laparoscope.  A 1 cm suprapubic skin incision was made.  Through this a second trocar sleeve was placed into the abdominal cavity using direct observation with the laparoscope.  The trocar was withdrawn and replaced with a probe.,The patient was placed in Trendelenburg position, and the bowel was pushed out of the pelvis.  Upon visualization of the pelvis organs, the uterus, fallopian tubes and ovaries were all normal.  The probe was withdrawn and replaced with the bipolar cautery instrument.  The right fallopian tube was grasped approximately 1 cm distal to the cornual region of the uterus.  Electrical current was applied to the tube at this point and fulgurated.  The tube was then regrasped just distal to this and refulgurated.  It was then regrasped just distal to the lateral point and refulgurated again.  The same procedure was then carried out on the opposite tube.  The bipolar cautery instrument was withdrawn and replaced with the probe.  The fallopian tubes were again traced to their fimbriated ends to confirm the burn points on the tubes.  The upper abdomen was visualized, and the liver surface was normal.  The gas was allowed to escape from the abdomen, and the instruments were removed.  The skin incisions were repaired.  The instruments were removed from the vagina.,There were no complications to the procedure.  Blood loss was minimal.  The patient went to the postanesthesia recovery room in stable condition.", Obstetrics / Gynecology,24
"EXAM: , Cardiac catheterization and coronary intervention report.,PROCEDURES:,1.  Left heart catheterization, coronary angiography, left ventriculography.,2.  PTCA/Endeavor stent, proximal LAD.,INDICATIONS: , Acute anterior ST-elevation MI.,ACCESS: , Right femoral artery 6-French.,MEDICATIONS:,1.  IV Valium.,2.  IV Benadryl.,3.  Subcutaneous lidocaine.,4.  IV heparin.,5.  IV ReoPro.,6.  Intracoronary nitroglycerin.,ESTIMATED BLOOD LOSS: , 10 mL.,CONTRAST:  ,185 mL.,COMPLICATIONS: , None.,PROCEDURE: , The patient was brought to the cardiac catheterization laboratory with acute ST-elevation MI and EKG.  She was prepped and draped in the usual sterile fashion.  The right femoral region was infiltrated with subcutaneous lidocaine, adequate anesthesia was obtained.  The right femoral artery was entered with _______ modified Seldinger technique and a J wire was passed.  The needle was exchanged for 6 French sheath.  The wire was removed.  The sheath was washed with sterile saline.  Following this, the left coronary was attempted to be cannulated with an XP catheter, however, the catheter folded on itself and could not reach the left main, this was removed.  A second 6-French JL4 guiding catheter was then used to cannulate the left main and initial guiding shots demonstrated occlusion of the proximal LAD.  The patient had an ACT check, received additional IV heparin and IV ReoPro.  The lesion was crossed with 0.014 BMW wire and redilated with a 2.5 x 20-mm balloon at nominal pressures.  The balloon was deflated and angiography demonstrated establishment of flow.  Following this, the lesion was stented with a 2.5 x 18-mm Endeavor stent at 10 atmospheres.  The balloon was deflated, reinflated at 12 atmospheres, deflated and removed.  Final angiography demonstrated excellent clinical result.  Additional angiography was performed with a wire out.  Following this, the wire and the catheter was removed.  Following this, the right coronary was selectively cannulated with diagnostic catheter and angiographic views were obtained in multiple views.  This catheter was removed.  The pigtail catheter was placed in the left ventricle and left ventriculography was performed with pullback pressures across the aortic valve.  At the end of procedure, wires and catheter were removed.  Right femoral angiography was performed and a right femoral Angio-Seal kit was deployed at the right femoral arteriotomy site.  There was no hematoma.  Peripheral pulses _______ procedure.  The patient tolerated the procedure well.  Symptoms of chest pain resolved at the end of the procedure with no complications.,RESULTS:,1.  Coronary angiography.,A.  Left main free of obstruction.,B.  LAD, subtotal proximal stenosis.,C.  Circumflex large vessel with three large obtuse marginal branches.  No high-grade obstruction, evidence of minimal plaquing.,D.  Right coronary 70% mid vessel stenosis and 50% mid to distal stenosis before giving rise to a right dominant posterior lateral and posterior descending artery.,2.  Left ventriculogram.  Left ventricular ejection fraction estimated at 45% to 50%.  There was an akinetic apical wall.,3.  Hemodynamics.  Aortic pressure 145/109, left ventricular pressure 147/13, left ventricular end-diastolic pressure 34 mmHg.,IMPRESSION:,1.  Acute ST-elevation myocardial infarction, culprit lesion, left anterior descending occlusion.,2.  Two-vessel coronary disease.,3.  Mild-to-moderate impaired LV systolic function.,4.  Successful stent left anterior descending, 100% occlusion, 0% residual stenosis.,PLAN:  ,Overnight observation in ICU.  Start aspirin, Plavix, beta-blocker and ACE inhibitor.  Check serial cardiac enzymes.  Further recommendations to follow.  Check fasting lipid panel, in addition add a statin.  Further recommendations to follow.", Cardiovascular / Pulmonary,3
"EXAMINATION: , Cardiac catheterization.,PROCEDURE PERFORMED: , Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.,INDICATION: , Syncope with severe aortic stenosis.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained from the patient, the patient was brought to the cardiac catheterization laboratory in a post observed state.  The right groin was prepped and draped in the usual sterile fashion.  After adequate conscious sedation and local anesthesia was obtained, a 6-French sheath was placed in the right common femoral artery and a 8-French sheath was placed in the right common femoral vein.  Following this, a 7.5-French Swan-Ganz catheter was advanced into the right atrium where the right atrial pressure was 10/7 mmHg.  The catheter was then manipulated into the right ventricle where the right ventricular pressure was 37/10/4 mmHg.  The catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmHg.  The pulmonary arterial pressures were noted to be 31/14/21 mmHg.  Following this, the catheter was removed, the sheath was flushed and a 6-French JL4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views.  Following this, the catheter was exchanged over the guidewire for 6-French JR4 diagnostic catheter.  We were unable to cannulate the right coronary artery.  Therefore, we exchanged for a Williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views.  Following this, this catheter was exchanged over a guidewire for a 6-French Langston pigtail catheter and the left ventricle was entered and left ventriculography was performed.  Following this, the catheters were removed.  Sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6-French Angio-Seal device.  The patient tolerated the procedure well.  There were no complications.,DESCRIPTION OF FINDINGS: , The left main coronary artery is a large vessel, which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions.  The left circumflex artery is a short vessel, which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions.  The left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches.  There is a 70% ostial lesion in the first diagonal branch and the second diagonal branch has mild-to-moderate luminal irregularities.  The right coronary artery is a very large dominant vessel with a 60% to 70% lesion in its descending mid-portion.  The remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions.  The left ventricle appears to be normal sized.  The aortic valve is heavily calcified.  The estimated ejection fraction is approximately 60%.  There was 4+ mitral regurgitation noted.  The mean gradient across the aortic valve was noted to be 33 mmHg yielding an aortic valve area of 0.89 cm2.,CONCLUSION:,1.  Moderate-to-severe coronary artery disease with a high-grade lesion seen at the ostium of the first diagonal artery as well as a 60% to 70% lesion seen at the mid portion of the right coronary artery.,2.  Moderate-to-severe aortic stenosis with an aortic valve area of 0.89 cm2.,3.  4+ mitral regurgitation.,PLAN: , The patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to Dr Kenneth Fang for possible aortic valve replacement as well as mitral valve repair/replacement and possible surgical revascularization.", Surgery,38
"REASON FOR REFERRAL:,  Chest pain, possible syncopal spells.,She is a very pleasant 31-year-old mother of two children with ADD.,She was doing okay until January of 2009 when she had a partial hysterectomy.  Since then she just says ""things have changed"".  She just does not want to go out anymore and just does not feel the same.  Also, at the same time, she is having a lot of household stressors with both of her children having ADD and ODD and she feels she does not get enough support from her husband.  Her 11-year-old is having a lot of trouble at school and she often has to go there to take care of problems.,In this setting, she has been having multiple cardiovascular complaints including chest pains, which feel ""like cramps"" and sometimes like a dull ache, which will last all day long.  She is also tender in the left breast area and gets numbness in her left hand.  She has also had three spells of ""falling"", she is not really clear on whether these are syncopal, but they sound like they could be as she sees spots before her eyes.  Twice it happened, when getting up quickly at night and another time in the grocery store.  She suffered no trauma.  She has no remote history of syncope.  Her weight has not changed in the past year.,MEDICATIONS: , Naprosyn, which she takes up to six a day.,ALLERGIES:,  Sulfa.,SOCIAL HISTORY: , She does not smoke or drink.  She is married with two children.,REVIEW OF SYSTEMS:,  Otherwise unremarkable.,PEX:,  BP:  130/70 without orthostatic changes.  PR:  72.  WT:  206 pounds.  She is a healthy young woman.  No JVD.  No carotid bruit.  No thyromegaly.  Cardiac:  Regular rate and rhythm.  There is no significant murmur, gallop, or rub.  Chest:  Mildly tender in the upper pectoral areas bilaterally (breast exam was not performed).  Lungs:  Clear.  Abdomen:  Soft.  Moderately overweight.  Extremities:  No edema and good distal pulses.,EKG: , Normal sinus rhythm, normal EKG.,ECHOCARDIOGRAM (FOR SYNCOPE): , Essentially normal study.,IMPRESSION:,1.  Syncopal spells - These do sound, in fact, to be syncopal.  I suspect it is simple orthostasis/vasovagal, as her EKG and echocardiogram looks good.  I have asked her to drink plenty of fluids and to not to get up suddenly at night.  I think this should take care of the problem.  I would not recommend further workup unless these spells continue, at which time I would recommend a tilt-table study.,2.  Chest pains - Atypical for cardiac etiology, undoubtedly due to musculoskeletal factors from her emotional stressors.  The Naprosyn is not helping that much, I gave her a prescription for Flexeril and instructed her in its use (not to drive after taking it).,RECOMMENDATIONS:,1.  Reassurance that her cardiac checkup looks excellent, which it does.,2.  Drink plenty of fluids and arise slowly from bed.,3.  Flexeril 10 mg q 6 p.r.n.,4.  I have asked her to return should the syncopal spells continue.", Consult - History and Phy.,5
"PROCEDURE PERFORMED:,  Cervical epidural steroid injection, C5-6.,ASSISTANT:,  None.,ANESTHESIA:,  Local.,DETAILS OF PROCEDURE: , The patient was brought to the operating theater and placed prone onto the radiolucent table.  Subsequent monitored anesthesia care was administered.  The C-arm was brought into the operative field and an AP view of the lumbar spine was obtained with particular attention to the C5-6 level.  The neck area was then prepped with Betadine solution and draped sterile.  A metallic marker was placed over the C5-6 lamina and a skin wheal was raised in the skin.  A #20-gauge Tuohy needle was then advanced into the spinal canal using 1% Xylocaine anesthetic and the depth of penetration to the C5 lamina was determined.  The needle was redirected into the interlaminar space and advanced to the previously determined level.  A 10 cc syringe was then placed onto the end of the needle and, using an air-negative technique, the needle was advanced into the epidural space.  When a free flow of air was produced, a solution of 80 mg Depo-Medrol, 2 cc of 1% Xylocaine injectable, and 5 cc of normal saline was then injected into the epidural space.  The Tuohy needle was removed.  Betadine was cleansed from the skin.  A bandage was placed over the needle entrance point.  The patient was turned supine onto a regular hospital bed and subsequently allowed to be awakened from anesthesia.  The patient was taken to the recovery room in stable condition.", Pain Management,28
"CHIEF COMPLAINT: , Motor vehicle accident.,HISTORY OF PRESENT ILLNESS: , This is a 32-year-old Hispanic female who presents to the emergency department today via ambulance.  The patient was brought by ambulance following a motor vehicle collision approximately 45 minutes ago.  The patient states that she was driving her vehicle at approximately 40 miles per hour.  The patient was driving a minivan.  The patient states that the car in front of her stopped too quickly and she rear-ended the vehicle ahead of her.  The patient states that she was wearing her seatbelt.  She was driving.  There were no other passengers in the van.  The patient states that she was restrained by the seatbelt and that her airbag deployed.  The patient denies hitting her head.  She states that she does have some mild pain on the left aspect of her neck.  The patient states that she believes she may have passed out shortly after the accident.  The patient states that she also has some pain low in her abdomen that she believes is likely due to the steering wheel or deployment on the airbag.  The patient denies any pain in her knees, ankles, or feet.  She denies any pain in her shoulders, elbows, and wrists.  The patient does state that she is somewhat painful throughout the bones of her pelvis as well.  The patient did not walk after this accident.  She was removed from her car and placed on a backboard and immobilized.  The patient denies any chest pain or difficulty breathing.  She denies any open lacerations or abrasions.  The patient has not had any headache, nausea or vomiting.  She has not felt feverish or chilled.  The patient does states that there is significant deformity to the front of the vehicle that she was driving, which again was a minivan.  There were no oblique vectors or force placed on this accident.  The patient had straight rear-ending of the vehicle in front of her.  The pain in her abdomen is most significant pain currently and she ranks it at 5 out of 10.  The patient states that her last menstrual cycle was at the end of May.  She does not believe that she could be pregnant.  She is taking oral birth control medications and also has an intrauterine device to prevent pregnancy as the patient is on Accutane.,PAST MEDICAL HISTORY:,  No significant medical history other than acne.,PAST SURGICAL HISTORY:,  None.,SOCIAL HABITS: ,  The patient denies tobacco, alcohol or illicit drug usage.,MEDICATIONS:,  Accutane.,ALLERGIES: , No known medical allergies.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  This is a Hispanic female who appears her stated age of 32 years.  She is well-nourished, well-developed, in no acute distress.  The patient is pleasant.  She is immobilized on a backboard and also her cervical spine is immobilized as well on a collar.  The patient is without capsular retractions, labored respirations or accessory muscle usage.  She responds well and spontaneously.,VITAL SIGNS:  Temperature 98.2 degrees Fahrenheit, blood pressure 129/84, pulse 75, respiratory rate 16, and pulse oximetry 97% on room air.,HEENT:  Head is normocephalic.  There is no crepitus.  No bony step-offs.  There are no lacerations on the scalp.  Sclerae are anicteric and noninjected.  Fundoscopic exam appears normal without papilledema.  External ocular movements are intact bilaterally without nystagmus or entrapment.  Nares are patent and free of mucoid discharge.  Mucous membranes are moist and free of exudate or lesions.,NECK:  Supple.  No thyromegaly.  No JVD.  No carotid bruits.  Trachea is midline.  There is no stridor.,HEART:  Regular rate and rhythm.  Clear S1 and S2.  No murmur, rub or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales, or rhonchi.,ABDOMEN:  Soft, nontender with the exception of mild-to-moderate tenderness in the bilateral lower pelvic quadrants.  There is no organomegaly here.  Positive bowel sounds are auscultated throughout.  There is no rigidity or guarding.  Negative CVA tenderness bilaterally.,EXTREMITIES:  No edema.  There are no bony abnormalities or deformities.,PERIPHERAL VASCULAR:  Capillary refill is less than two seconds in all extremities.  The patient does have intact dorsalis pedis and radial pulses bilaterally.,PSYCHIATRIC:  Alert and oriented to person, place, and time.  The patient recalls all events regarding the accident today.,NEUROLOGIC:  Cranial nerves II through XII are intact bilaterally.  No focal deficits are appreciated.  The patient has equal and strong distal and proximal muscle group strength in all four extremities.  The patient has negative Romberg and negative pronator drift.,LYMPHATICS:  No appreciable adenopathy.,MUSCULOSKELETAL:  The patient does have pain free range of motion at the bilateral ankles, bilateral knees, bilateral hips, bilateral shoulders, bilateral elbows, and bilateral wrists.  There are no bony abnormalities identified.  The patient does have some mild tenderness over palpation of the bilateral iliac crests.,SKIN:  Warm, dry, and intact.  No lacerations.  There are no abrasions other than a small abrasion on the patient's abdomen just inferior to the umbilicus.  No lacerations and no sites of trauma or bleeding are identified.,DIAGNOSTIC STUDIES: , The patient does have multiple x-rays done.  There is an x-ray of the pelvis, which shows normal pelvis and right hip.  There is also a CT scan of the cervical spine that shows no evidence of acute traumatic bony injury of the cervical spine.  There is some prevertibral soft tissue swelling from C5 through C7.  This is nonspecific and could be due to prominence of upper esophageal sphincter.  The CT scan of the brain without contrast shows no evidence of acute intracranial injury.  There is some mucus in the left sphenoid sinus.  The patient also has emergent CT scan without contrast of the abdomen.  The initial studies show some dependent atelectasis in both lungs.  There is also some low density in the liver, which could be from artifact or overlying ribs; however, a CT scan with contrast is indicated.  A CT scan with contrast is obtained and this is found to be normal without bleeding or intraabdominal or pelvic abnormalities.  The patient has laboratory studies done as well.  CBC is within normal limits without anemia, thrombocytopenia or leukocytosis.  The patient has a urine pregnancy test, which is negative and urinalysis shows no blood and is normal.,EMERGENCY DEPARTMENT COURSE: , The patient was removed from the backboard within the first half hour of her emergency department stay.  The patient has no significant bony deformities or abnormalities.  The patient is given a dose of Tylenol here in the emergency department for treatment of her pain.  Her pain is controlled with medication and she is feeling more comfortable and removed from the backboard.  The patient's CT scans of the abdomen appeared normal.  She has no signs of bleeding.  I believe, she has just a contusion and abrasion to her abdomen from the seatbelt and likely from the airbag as well.  The patient is able to stand and walk through the emergency department without difficulty.  She has no abrasions or lacerations.,ASSESSMENT AND PLAN:,  Multiple contusions and abdominal pain, status post motor vehicle collision.  Plan is the patient does not appear to have any intraabdominal or pelvic abnormities following her CT scans.  She has normal scans of the brain and her C-spine as well.  The patient is in stable condition.  She will be discharged with instructions to return to the emergency department if her pain increases or if she has increasing abdominal pain, nausea or vomiting.  The patient is given a prescription for Vicodin and Flexeril to use it at home for her muscular pain.", Emergency Room Reports,12
"FINDINGS:,There are posttraumatic cysts along the volar midline and volar lateral aspects of the lunate which are likely posttraumatic. There is no acute marrow edema (series #12 images #5-7). Marrow signal is otherwise normal in the distal radius and ulna, throughout the carpals and throughout the proximal metacarpals.,There is a partial tear of the volar component of the scapholunate ligament in the region of the posttraumatic lunate cyst with retraction and thickening towards the scaphoid (series #6 image #5, series #8 images #22-36). There is tearing of the membranous portion of the ligament. The dorsal component is intact.,The lunatotriquetral ligament is thickened and lax, but intact (series #8 image #32).,There is no tearing of the radial or ulnar attachment of the triangular fibrocartilage (series #6 image #7). There is a mildly positive ulnar variance. Normal ulnar collateral ligament.,The patient was positioned in dorsiflexion. Carpal alignment is normal and there are no tears of the dorsal or ventral intercarpal ligaments (series #14 image #9).,There is a longitudinal split tear of the ECU tendon which is enlarged both at the level of and distal to the ulnar styloid with severe synovitis (series #4 images #8-16, series #3 images #9-16).,There is thickening of the extensor tendon sheaths within the fourth dorsal compartment with intrinsically normal tendons (series #4 image #12).,There is extensor carpi radialis longus and brevis synovitis in the second dorsal compartment (series #4 image #13).,Normal flexor tendons within the carpal tunnel. There is mild thickening of the tendon sheaths and the median nerve demonstrates increased signal without compression or enlargement (series #3 image #7, series #4 image #7).,There are no pathological cysts or soft tissue masses.,IMPRESSION:,Partial tear of the volar and membranous components of the scapholunate ligament with an associated posttraumatic cyst in the lunate. There is thickening and laxity of the lunatotriquetral ligament.,Longitudinal split tear of the ECU tendon with tendinosis and severe synovitis.,Synovitis of the second dorsal compartment and tendon sheath thickening in the fourth dorsal compartment.,Tendon sheath thickening within the carpal tunnel with increased signal within the median nerve.", Orthopedic,27
"HISTORY:,  A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis.  The patient was status post coronary artery bypass surgery aortic valve repair at Shadyside Hospital.  The patient subsequently developed CVA.  She also developed thrombosis of the right arm, which ultimately required right hand amputation.  She was stabilized and eventually transferred to HealthSouth for further management.,PHYSICAL EXAMINATION:,Vital Signs:  Pulse of 90 and blood pressure 150/70.,Heart:  Sounds were heard, grade 2/6 systolic murmur at the precordium.,Chest:  Clinically clear.,Abdomen:  Some suprapubic tenderness.  Evidence of right lower arm amputation.,The patient was started on Prevacid 30 mg daily, levothyroxine 75 mcg a day, Toprol 25 mg twice a day, Zofran 4 mg q.6 h, Coumadin dose at 5 mg and was adjusted.  She was given a pain control using Vicodin and Percocet, amiodarone 200 mg a day, Lexapro 20 mg a day, Plavix 75 mg a day, fenofibrate 145 mg, Lasix 20 mg IV twice a day, Lantus 50 units at bedtime and Humalog 10 units a.c. and sliding scale insulin coverage.  Wound care to the right heel was supervised by Dr. X.  The patient initially was fed through NG tube, which was eventually discontinued.  Physical therapy was ordered.  The patient continued to do well.  She was progressively ambulated.  Her meds were continuously adjusted.  The patient's insulin was eventually changed from Lantus to Levemir 25 units twice a day.  Dr. Y also followed the patient closely for left heel ulcer.,LABORATORY DATA: , The latest cultures from left heel are pending.  Her electrolytes revealed sodium of 135 and potassium of 3.2.  Her potassium was switched to K-Dur 40 mEq twice a day.  Her blood chemistries are otherwise closely monitored.  INRs were obtained and were therapeutic.  Throughout her hospitalization, multiple cultures were also obtained.  Urine cultures grew Klebsiella.  She was treated with appropriate antibiotics.  Her detailed blood work is as in the chart.  Detailed radiological studies are as in the chart.  The patient made a steady progress and eventually plans were made to transfer the patient to ABC furthermore aggressive rehabilitation.,FINAL DIAGNOSES:,1.  Atherosclerotic heart disease, status post coronary artery bypass graft.,2.  Valvular heart disease, status post aortic valve replacement.,3.  Right arm arterial thrombosis, status post amputation right lower arm.,4.  Hypothyroidism.,5.  Uncontrolled diabetes mellitus, type 2.,6.  Urinary tract infection.,7.  Hypokalemia.,8.  Heparin-induced thrombocytopenia.,9.  Peripheral vascular occlusive disease.,10.  Paroxysmal atrial fibrillation.,11.  Hyperlipidemia.,12.  Depression.,13.  Carotid stenosis.", General Medicine,15
"CHIEF COMPLAINT:,  ""I took Ecstasy."",HISTORY OF PRESENT ILLNESS: , This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.  The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis.  Mother called the EMS service when the patient vomited.  On arrival here, the patient states that she no longer has any nausea and that she feels just fine.  The patient states she feels wired but has no other problems or complaints.  The patient denies any pain.  The patient does not have any auditory of visual hallucinations.  The patient denies any depression or suicidal ideation.  The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself.  The patient denies any homicidal ideation.  The patient denies any recent illness or recent injuries.  The mother states that the daughter appears to be back to her usual self now.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No recent illness.  No fever or chills.  HEENT:  No headache.  No neck pain.  No vision change or hearing change.  No eye or ear pain.  No rhinorrhea.  No sore throat.  CARDIOVASCULAR:  No chest pain.  No palpitations or racing heart.  RESPIRATIONS:  No shortness of breath.  No cough.  GASTROINTESTINAL: One episode of nonbloody, nonbilious emesis this morning without any nausea since then.  The patient denies any abdominal pain.  No change in bowel movements.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No dizziness, syncope, or near syncope.  PSYCHIATRIC:  The patient denies any depression, suicidal ideation, homicidal ideation, auditory hallucinations or visual hallucinations.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  None.,PAST SURGICAL HISTORY: , Appendectomy when she was 9 years old.,CURRENT MEDICATIONS: , Birth control pills.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies smoking cigarettes.  The patient does drink alcohol and also uses illicit drugs.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure 140/86, pulse is 79, respirations 16, oxygen saturation 100% on room air and is interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, and well developed, appears to be healthy.  The patient is calm and comfortable, in no acute distress and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctiva bilaterally.  The patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally.  No evidence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Ears are normal without any sign of infection.  Mouth and oropharynx are normal without any signs of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +3 and bounding.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, normal and benign.  MUSCULOSKELETAL:  No abnormalities noted in back, arms, or legs.  The patient is normal use of her extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact in all extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  The patient does not have any smell of alcohol and does not exhibit any clinical intoxication.  The patient is quite pleasant, fully cooperative.  HEMATOLOGIC/LYMPHATIC: NO lymphadenitis is noted.  No bruising is noted.,DIAGNOSES:,1.  ECSTASY INGESTION.,2.  ALCOHOL INGESTION.,3.  VOMITING SECONDARY TO STIMULANT ABUSE.,CONDITION UPON DISPOSITION: , Stable disposition to home with her mother.,PLAN:,  I will have the patient followup with her physician at the ABC Clinic in two days for reevaluation.  The patient was advised to stop drinking alcohol, and taking Ecstasy as this is not only in the interest of her health, but was also illegal.  The patient is asked to return to the emergency room should she have any worsening of her condition, develop any other problems or symptoms of concern.", General Medicine,15
"PREOPERATIVE DIAGNOSIS: , Tonsillitis.,POSTOPERATIVE DIAGNOSIS:  ,Tonsillitis.,PROCEDURE PERFORMED:  ,Tonsillectomy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room and prepped and draped in the usual fashion.  After induction of general endotracheal anesthesia, the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll on the upper lip to provide soft palate retraction.  The nasopharynx was inspected with the laryngeal mirror.,Attention was then directed to the right tonsil.  The anterior tonsillar pillar was infiltrated with 1.5 cc of 1% Xylocaine with 1:100,000 epinephrine, as was the left tonsillar pillar.  The right tonsil was grasped with the tenaculum and retracted out of its fossa.  The anterior tonsillar pillar was incised with the #12 knife blade.  The plica semilunaris was incised with the Metzenbaum scissors.  Using the Metzenbaum scissors and the Fisher knife, the tonsil was dissected free of its fossa onto an inferior pedicle around which the tonsillar snare was placed and applied.  The tonsil was removed from the fossa and the fossa packed with a cherry gauze sponge as previously described.  By a similar procedure, the opposite tonsillectomy was performed and the fossa was packed.,Attention was re-directed to the right tonsil.  The pack was removed and bleeding was controlled with the suction Bovie unit.  Bleeding was then similarly controlled in the left tonsillar fossa and the nasopharynx after removal of the packs.  The catheters were then removed.  The nasal passages and oropharynx were suctioned free of debris.  The procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.", ENT - Otolaryngology,11
"PROCEDURES:,1.  Right and left heart catheterization.,2.  Coronary angiography.,3.  Left ventriculography.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cardiac catheterization laboratory.  Patient was prepped and draped in sterile fashion.  Via modified Seldinger technique, the right femoral vein was punctured and a 6-French sheath was placed over a guide wire.  Via modified Seldinger technique, right femoral artery was punctured and a 6-French sheath was placed over a guide wire.  The diagnostic procedure was performed using the JL-4, JR-4, and a 6-French pigtail catheter along with a Swan-Ganz catheter.  The patient tolerated the procedure well and there were immediate complications were noted.  Angio-Seal was used at the end of the procedure to obtain hemostasis.,CORONARY ARTERIES:,LEFT MAIN CORONARY ARTERY:  The left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery.  No significant stenotic lesions were identified in the left main coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:  The left descending artery is a moderate sized vessel, which gives rise to multiple diagonals and perforating branches.  No significant stenotic lesions were identified in the left anterior descending coronary artery system.,CIRCUMFLEX ARTERY:  The circumflex artery is a moderate sized vessel.  The vessel is a stenotic lesion.  After the right coronary artery, the RCA is a moderate size vessel with no focal stenotic lesions.,HEMODYNAMIC DATA: , Capital wedge pressure was 22.  The aortic pressure was 52/24.  Right ventricular pressure was 58/14.  RA pressure was 14.  The aortic pressure was 127/73.  Left ventricular pressure was 127/15.  Cardiac output of 9.2.,LEFT VENTRICULOGRAM: , The left ventriculogram was performed in the RAO projection only.  In the RAO projection, the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50%.  Severe mitral regurgitation was also noted.,IMPRESSION:,1.  Left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50%.,2.  Severe mitral regurgitation.,3.  No significant coronary artery disease identified in the left main coronary artery, left anterior descending coronary artery, circumflex coronary artery or the right coronary artery.,", Surgery,38
"SUBJECTIVE: , The patient is a 55-year-old African-American male that was last seen in clinic on 07/29/2008 with diagnosis of new onset seizures and an MRI scan, which demonstrated right contrast-enhancing temporal mass.  Given the characteristics of this mass and his new onset seizures, it is significantly concerning for a high-grade glioma.  ,OBJECTIVE: , The patient is alert and oriented times three, GCS of 15.  Cranial nerves II to XII are grossly intact.  Motor exam demonstrates 5/5 strength in all four extremities.  Sensation is intact to light touch, pain, temperature, and proprioception.  Cerebellar exam is intact.  Gait is normal and tandem on heels and toes.  Speech is appropriate.  Judgment is intact.  Pupils are equal and reactive to light.,ASSESSMENT AND PLAN: , The patient is a 55-year-old African-American male with a new diagnosis of rim-enhancing right temporal mass.  Given the characteristics of the MRI scan, it is highly likely that he demonstrates high-grade glioma and concerning for glioblastoma multiforme.  We have discussed in length the possible benefits of biopsy, surgical resection, medical management, as well as chemotherapy, radiation treatments, and doing nothing.  Given the high probability that the mass represents a high-grade glioma, the patient, after weighing the risks and the benefits of surgery, has agreed to undergo a surgical biopsy and resection of the mass as well as concomitant chemotherapy and radiation as the diagnosis demonstrates a high-grade glioma.  The patient has signed consent for his right temporal craniotomy for biopsy and likely resection of right temporal brain tumor.  He agrees that he will be n.p.o. after mid night on Wednesday night.  He is sent for preoperative assessment with the Anesthesiology tomorrow morning.  He has undergone vocational rehab assessment.", Neurology,22
"TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the skull base without contrast.,FINDINGS: , There is mild generalized atrophy.  Scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes.  The brain parenchyma is otherwise normal in attenuation with no evidence of mass, hemorrhage, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  The visualized paranasal sinuses and mastoid air cells are clear.  The bony calvarium and skull base are within normal limits.  ,IMPRESSION: , No acute abnormalities.", Neurology,22
"PREOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth.,POSTOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32.,PROCEDURE: , Extraction of remaining teeth numbers 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, and 32.,ANESTHESIA:,  General, oral endotracheal.,COMPLICATIONS: , None.,CONDITION:,  Stable to PACU.,PROCEDURE:  Patient was brought to the operating room, placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia, the patient was prepped and draped in the usual fashion for an intraoral procedure.  Gauze throat pack was placed and local anesthetic was administered in the upper and lower left quadrants and extraction of teeth was begun on the upper left quadrant teeth numbers 9, 10, 11, 12, 13, 14, 15, and 16 were removed with elevators and forceps extraction.  Moving to the lower quadrant on the left side, tooth numbers 17, 18, 19, 20, 21, 22, 23, and 24 were removed with elevators and routine forceps extraction.  The flaps were then closed with 3-0 gut sutures and upon completion of the two quadrants on the left side, the endotracheal tube was then relocated from the right side to the left side for access to the quadrants on the right.  Teeth numbers 2, 3, 4, 5, 7, and 8 were then removed with elevators and routine forceps extraction.  It was noted that tooth #6 was missing, could not be seen whether tooth #6 was palately impacted, but the tooth was not encountered.  On the lower right quadrant, teeth numbers 25, 26, 27, 28, 29, 30, and 31 were removed with elevators and routine forceps extraction.  Tooth #32 was partially bony impacted, but exposed, so it was removed by removing bone on buccal aspect with high-speed drill with a round bur.  Tooth was then luxated from the socket.  The flaps were then closed on both quadrants with 3-0 gut sutures.  The area was irrigated thoroughly with normal saline solution and a total of 8.5 mL of lidocaine 2% with 1:100, 000 epinephrine and 3.6 mL of bupivacaine 0.5% with epinephrine 1:200, 000.  Upon completion of the procedure, the throat pack was removed.  The pharynx was suctioned.  An oral gastric tube was passed and small amount of stomach contents were suctioned.  The patient was then extubated and taken to PACU in stable condition.", Dentistry,7
"CHIEF COMPLAINT:,  Abdominal pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.  She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was ""normal.""  She was given oral antibiotics of Cipro and Flagyl.  She has had no nausea and vomiting, but has had persistent associated anorexia.  She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago.  She denies any bright red blood per rectum and no history of recent melena.  Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice.  The patient denies any significant recent weight loss.,PAST MEDICAL HISTORY:  ,Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.,PAST SURGICAL HISTORY: , Significant for cholecystectomy, appendectomy, and hysterectomy.  She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.,ALLERGIES: , SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.,SOCIAL HISTORY: , She does not drink or smoke.,REVIEW OF SYSTEMS: , Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an elderly thin white female, very pleasant, in no acute distress.,VITAL SIGNS:  Her temperature is 98.8 and vital signs are all stable, within normal limits.,HEENT:  Head is grossly atraumatic and normocephalic.  Sclerae are anicteric.  The conjunctivae are non-injected.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,ABDOMEN:  Generally nondistended and soft.  She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness.  There is no CVA or flank tenderness, although some very minimal left flank tenderness.,PELVIC:  Currently deferred, but has history of grade 4 urinary bladder prolapse.,EXTREMITIES:  Grossly and neurovascularly intact.,LABORATORY VALUES:  ,White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal.  Alkaline phosphatase elevated at 184.  Liver function tests otherwise normal.  Electrolytes normal.  Glucose 134, BUN 4, and creatinine 0.7.,DIAGNOSTIC STUDIES:,  EKG shows normal sinus rhythm.,IMPRESSION AND PLAN: , A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant.  Currently is a nonacute abdomen.  The working diagnosis would be sigmoid diverticulitis.  She does have a history in the distant past of sigmoid diverticulitis.  I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth.  The patient was seen 5 years ago by Dr. Y in Colorectal Surgery.  We will consult her also for evaluation.  The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically.  The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.", Gastroenterology,14
"EXAM: , CT of abdomen with and without contrast.  CT-guided needle placement biopsy.,HISTORY: , Left renal mass.,TECHNIQUE: , Pre and postcontrast enhanced images were acquired through the kidneys.,FINDINGS: , Comparison made to the prior MRI.  There is re-demonstration of multiple bilateral cystic renal lesions.  Several of these demonstrate high attenuation in the precontrast phase of the exam suggesting that they are hemorrhagic cysts.  There was however one cyst seen in the lower pole of the left kidney, which demonstrated apparent enhancement from 30 to 70 Hounsfield units post contrast administration.  This measured approximately 1.4 x 1.3 cm to the exophytic half of the lower pole.  No other enhancing renal masses were seen.  The visualized liver, spleen, pancreas, and adrenal glands were unremarkable.  There are changes of cholecystectomy.  Mild prominence of the common bile duct is likely secondary to cholecystectomy.  There is no abdominal lymphadenopathy, masses, fluid collection, or ascites.,Lung bases are clear.  No acute bony pathology was noted.,IMPRESSION: , Solitary apparently enhancing left renal mass in the lower pole as described.  Renal cell carcinoma cannot be excluded.,CT-GUIDED NEEDLE BIOPSY, LEFT KIDNEY MASS: , Following discussion of risks, benefits, and alternatives, the patient wished to proceed with CT-guided biopsy of left renal lesion.  The patient was placed in the decubitus position.  The region overlying the left renal mass of note was marked.  Area was prepped and draped in usual sterile fashion.  Local anesthesia was achieved with approximately 8 mL of 1% lidocaine with bicarbonate.  The Versed and fentanyl were given to achieve conscious sedation.  Utilizing an 18 x 15 gauge coaxial system, 3 core biopsies were obtained through the mass in question, and sent to pathology for analysis.  Following procedure, scans through the region demonstrate a small subcutaneous hematoma in the region of the superficial anesthesia.  No perinephric fluid/hematoma was identified.  The patient tolerated the procedure without immediate complications.,IMPRESSION: , Three core biopsies through the region of the left renal tumor as described.", Radiology,33
"PREOPERATIVE DIAGNOSIS: ,Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Ahmed valve model S2 implant with pericardial reinforcement XXX eye,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage, hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox and Ocular. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion. A speculum was placed on the eyelids and microscope was brought into position. A #7-0 Vicryl suture was passed through the superotemporal limbus and traction suture was placed at the superotemporal limbus and the eye was rotated infranasally so as to expose the superotemporal conjunctiva. At this point, smooth forceps and Westcott scissors were used to create a 100-degree superotemporal conjunctival peritomy, approximately 2 mm posterior to the superotemporal limbus. This was then dissected anteriorly to the limbus edge and then posteriorly. Steven scissors were then dissected in a superotemporal quadrant between the superior and lateral rectus muscles to provide good exposure. At this point, we primed the Ahmed valve with a #27 gauge cannula using BSS and it was noted to be patent. We then placed Ahmed valve in the superotemporal subconjunctival recess underneath the subtenon space and this was pushed posteriorly. We then measured with calipers so that it was positioned 9 mm posterior to the limbus. The Ahmed valve was then tacked down with #8-0 nylon suture through both fenestrations. We then applied light cautery to the superotemporal episcleral bed. We placed a paracentesis at the temporal position and inflated the anterior chamber with a small amount of Healon. We then used a #23 gauge needle and entered the superotemporal sclera, approximately 1 mm posterior to the limbus into the anterior chamber away from iris and away from cornea. We then trimmed the tube, beveled up in a 30 degree fashion with Vannas scissors, and introduced the tube through the #23 gauge tract into the anterior chamber so that approximately 2-3 mm of tube was extending into the anterior chamber. We burped some of the Healon out of the anterior chamber and filled it with BSS and we felt that the tube was in good position away from the lens, away from the cornea, and away from the iris. We then tacked down the tubes to the sclera with #8-0 Vicryl suture in a figure-of- eight fashion. The pericardium was soaked in gentamicin. We then folded the pericardium 1x1 cm piece onto itself and then placed it over the tube and this was tacked down in all four quadrants to the sclera with #8-0 nylon suture. At this point, we then re-approximated the conjunctiva to its original position and we closed it with an #8-0 Vicryl suture on a TG needle in a running fashion with interrupted locking bites. We then removed the traction suture. At the end of the case, the pupil was round, the chamber was deep, the tube appeared to be well positioned. The remaining portion of the Healon was burped out of the anterior chamber with BSS and the pressure was felt to be adequate. The speculum was removed. Ocuflox and Maxitrol ointment were placed over the eye. Then, an eye patch and shield were placed over the eye. The patient was awakened and taken to the recovery room in stable condition.", Ophthalmology,26
"PROCEDURE:,  Subcutaneous ulnar nerve transposition.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve.  Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected.,Osborne's fascia was released, an ulnar neurolysis performed, and the ulnar nerve was mobilized.  Six cm of the medial intermuscular septum was excised, and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly.,The subcutaneous plane just superficial to the flexor-pronator mass was developed.  Meticulous hemostasis was maintained with bipolar electrocautery.  The nerve was transposed anteriorly, superficial to the flexor-pronator mass.  Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve.,A semicircular medially based flap of flexor-pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating.  The subcutaneous tissue and skin were closed with simple interrupted sutures.  Marcaine with epinephrine was injected into the wound.  The elbow was dressed and splinted.  The patient was awakened and sent to the recovery room in good condition, having tolerated the procedure well.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,POSTOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,PROCEDURE: , Ultrasound-guided right pleurocentesis.,ANESTHESIA: , Local with lidocaine.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient and his mother, the chest was scanned with portable ultrasound.  Findings revealed a normal right hemidiaphragm, a moderate right pleural effusion without septation or debris, and no gliding sign of the lung on the right.  Using sterile technique and with ultrasound as a guide, a pleural catheter was inserted and serosanguinous fluid was withdrawn, a total of 1 L.  The patient tolerated the procedure well.  Portable x-ray is pending.", Cardiovascular / Pulmonary,3
"Chief Complaint:, Abdominal pain, nausea and vomiting.,History of Present Illness:, A 50-year-old Asian female comes to The Methodist Hospital on January 2, 2001, complaining of a 3-day history of abdominal pain. The pain is described as crampy in the central part of her abdomen, and is associated with nausea and vomiting during the previous 24 hours. The patient denied passing any stool or gas per rectum for the previous 24 hours. She had been admitted recently to the hospital from December 19 to December 23, 2000, with a three-week history of fevers to 101.8, diaphoresis, anorexia, malaise and skin ""lumps"". She described a total of three ""lumps"". The first one started as a pin-sized lesion that grew up and then disappeared, the other two didn't resolve. They were described as ""erythematous nodular lesions on the extensor surface of the left arm."" A punch biopsy was obtained from these skin lesions, showing deep dermis and subcutaneous adipose tissue that contained ""multiple granulomas composed of histiocytes and multinucleated giant cells without caseating necrosis"". However, one granuloma in the deep dermis, showed a hint of central necrosis. Special stains for acid - fast bacilli and fungi were reported as negative. No atypia or malignancy was noted. A CT scan of the chest was obtained on December 19, 2000 and showed numerous masses with spiculated borders bilaterally, predominately in the upper lobes and superior segments of the lower lobes. No cavitary lesions, mediastinal masses or definite hilar adenopathy were reported. The patient underwent bronchoscopy and transbronchial biopsy which showed fragments of bronchial mucosa and wall with underlying lung parenchyma. Minimal to mild interstitial lymphocytes with a few microfoci of neutrophils were seen. They were also able to appreciate intra-alveolar fibrinous exudates. One of the blood cultures drawn on December 19, 2000 grew Streptococcus mitis.,The patient was discharged on ethambutol 1200 mg po qd, clarithromycin 500 mg po bid, ampicillin 500 mg po q 6h and fluconazole 200 mg po qd.,Past Medical History:,1. Post-streptococcal glomerulonephritis at age 10.,2. End stage renal disease diagnosed in 1994, on peritoneal dialysis until 1996.,3. Cadaveric transplant in October 1996,4. Steroid induced diabetes mellitus,5. Hypertension,Past Surgical History:,1. Total abdominal hysterectomy in January 1996,2. Cesarean section X2 in 1996 and 1997,3. Appendectomy in 1971,4. Insertion of peritoneal dialysis catheter in 1994,5. Cadaveric transplant in October 1996,Social History:,The patient denies a history of smoking, drinking or intravenous drug use. She came to the United States in 1973. She works as a nurse in a newborn nursery. Her hobby is gardening. She traveled to Las Vegas on May 2000 and stayed for 6 months. She denied ill contacts or pets.,Allergies:, Ciprofloxacin and Enteric coated aspirin,Medications:, prednisone 20 mg po qd, enalapril 2.5 mg po qd, clonidine patch TTS 3 1/week, Prograf 5 mg po bid, ranitidine 150 mg po bid, furosemide 40 mg po bid, atorvastatin 10 mg po qd, multivitamins 1 tab po qd, estrogen patch, fluconazole 200 mg po qd, metformin 500 mg po bid, glyburide 10 mg po qd, clarithromycin 500 mg po bid, ethambutol 1200 mg po qd, ampicillin 500 mg po q 6h.,Family History:, She described a family history of hypertension. Her mother died after a myocardial infarction at age 59. Her father was diagnosed with congestive heart failure and had a pacemaker placed.,Review of systems:, Non-contributory. The patient denied fever, chills, ulcers, liver disease or history of gallstones.,Vaccines: The patient was vaccinated with BCG before starting elementary school in the Philippines.,Physical Examination:, At the time of the examination the patient was alert and oriented times three and in no acute distress. She was well nourished.,BP 106/60 lying down; HR 86; RR 12; T 96.1° F; Hgt. =5' 2""; Wgt. =121 lbs.,SKIN: There was no rash or skin lesions.,HEENT: She had no oral lesions and moist mucous membranes. No icterus was noted.,NECK: Her neck was supple without lymphadenopathy or thyromegaly.,LUNGS: Crackles at the right lower base with normal respiratory excursion and no dullness to percussion.,HEART: IV/VI crescendo - decrescendo systolic murmur was heard at the second intercostal space with radiation to the neck.,ABDOMEN: The abdomen was distended. Bowel sounds were normal. No hepatosplenomegaly, tenderness or rebound tenderness could be detected during the examination.,EXTREMITIES: No cyanosis, clubbing or edema was noted.,RECTAL: Normal rectal exam. Guaiac negative.,NEUROLOGIC: Normal and non-focal.,Hospital Course:,  The patient was admitted and a nasogastric tube was placed. IV fluids were started. A KUB was obtained showing an abnormal bowel gas pattern. Multiple loops of distended bowel were noted in the mid abdomen. Air and feces were noted within the colon in the right side. An Abdominal CT scan was obtained. There was a small amount of perihepatic fluid noted. The liver and spleen were normal. The kidneys were atrophic. The gallbladder was moderately distended. There was marked dilatation of the small bowel proximally and distally. There was gas and contrast material in the colon. A diagnostic procedure was performed.", Consult - History and Phy.,5
"PREOPERATIVE DIAGNOSIS:,  Bilateral inguinal hernia. ,POSTOPERATIVE DIAGNOSIS: , Bilateral inguinal hernia. ,PROCEDURE: , Bilateral direct inguinal hernia repair utilizing PHS system and placement of On-Q pain pump. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation and the abdomen and groins were prepped and draped in standard, sterile surgical fashion.  I did an ilioinguinal nerve block on both sides, injecting Marcaine 1 fingerbreadth anterior and 1 fingerbreadth superior to the anterior superior iliac spine on both sides.", Surgery,38
"ADMITTING DIAGNOSIS:,  Posttraumatic AV in right femoral head.,DISCHARGE DIAGNOSIS:,  Posttraumatic AV in right femoral head.,SECONDARY DIAGNOSES PRIOR TO HOSPITALIZATION:,1.  Opioid use.,2.  Right hip surgery.,3.  Appendectomy.,4.  Gastroesophageal reflux disease.,5.  Hepatitis diagnosed by liver biopsy.,6.  Blood transfusion.,6.  Smoker.,7.  Trauma with multiple orthopedic procedures.,8.  Hip arthroscopy.,POSTOP COMORBIDITIES: , Postop acute blood loss anemia requiring transfusion and postop pain.,PROCEDURES DURING THIS HOSPITALIZATION:,  Right total hip arthroplasty and removal of hardware.,CONSULTS:,  Acute pain team consult.,DISPOSITION: , Home.,HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE:,  For details, please refer to clinic notes and OP notes.  In brief, the patient is a 47-year-old female with a posttraumatic AV in the right femoral head.  She came in consult with Dr. X who after reviewing the clinical and radiological findings recommended she undergo a right total hip arthroplasty and removal of old hardware.  After being explained the risks, benefits, alternative options, and possible outcomes of surgery, she was agreeable and consented to proceed and therefore on the day of her admission, she was sent to the operating room where she underwent a right total hip arthroplasty and removal of hardware without any complications.  She was then transferred to PACU for recovery and postop orthopedic floor for convalescence, physical therapy, and discharge planning.  DVT prophylaxis was initiated with Lovenox.  Postop pain was adequately managed with the aid of Acute Pain team.  Postop acute blood loss anemia was treated with blood transfusions to an adequate level of hemoglobin.  Physical therapy and occupational therapy were initiated and continued to work with her towards discharge clearance on the day of her discharge.,DISPOSITION:,  Home.  On the day of her discharge, she was afebrile, vital signs were stable.  She was in no acute distress.  Her right hip incision was clean, dry, and intact.  Extremity was warm and well perfused.  Compartments were soft.  Capillary refill less than two seconds.  Distal pulses were present.,PREDISCHARGE LABORATORY FINDINGS: , White count of 10.9, hemoglobin of 9.5, and BMP is pending.,DISCHARGE INSTRUCTIONS: , Continue diet as before.,ACTIVITY: , Weightbearing as tolerated in the right lower extremity as instructed.  Do not lift, drive, move furniture, do strenuous activity for six weeks.  Call Dr. X if there is increased temperature greater than 101.5, increased redness, swelling, drainage, increased pain that is not relieved by current pain regimen as per postop orthopedic discharge instruction sheet.,FOLLOW-UP APPOINTMENT:  Follow up with Dr. X in two weeks.", Orthopedic,27
"SUBJECTIVE:,  This is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy.  Patient reports that she had gestational diabetes with her first pregnancy.  She did use insulin at that time as well.  She does not fully understand what ketones are.  She walks her daughter to school and back home each day which takes 20 minutes each way.  She is not a big milk drinker, but she does try to drink some.,OBJECTIVE:,  Weight is 238.3 pounds.  Weight from last week’s visit was 238.9 pounds.  Prepregnancy weight is reported at 235 pounds.  Height is 62-3/4 inches.  Prepregnancy BMI is approximately 42-1/2.  Insulin schedule is NovoLog 70/30, 20 units in the morning and 13 units at supper time.  Blood sugar records for the last week reveal the following:  Fasting blood sugars ranging from 92 to 104 with an average of 97, two-hour postprandial breakfast readings ranging from 172 to 196 with an average of 181, two-hour postprandial lunch readings ranging from 149 to 189 with an average of 168 and two-hour postprandial dinner readings ranging from 109 to 121 with an average of 116.  Overall average is 140.  A diet history was obtained.  Expected date of confinement is May 1, 2005.  Instructed the patient on dietary guidelines for gestational diabetes.  A 2300 meal plan was provided and reviewed.  The Lily Guide for Meal Planning was provided and reviewed.,ASSESSMENT:,  Patient’s basal energy expenditure adjusted for obesity is estimated at 1566 calories a day.  Her total calorie requirements, including physical activity factors as well as additional calories for pregnancy, totals 2367 calories a day.  Her diet history reveals that she is eating three meals a day and three snacks.  The snacks were just added last week following presence of ketones in her urine.  We identified carbohydrate sources in the food supply, recognizing that they are the foods that raise blood sugar the most.  We identified 15 gram equivalents of carbohydrate and established a carbohydrate budget.  We also discussed the goal of balancing food intake with blood sugar control and adequate caloric intake to sustain appropriate weight gain for the pregnancy of 1/2 a pound a week through the duration of the pregnancy.  We discussed the physiology of ketone production from inadequate calories or inadequate insulin and elevated blood sugars.  While a sample meal plan was provided reflecting the patient’s carbohydrate budget I emphasized the need for her to eat according to her appetite, but to work at consistency in the volume of carbohydrates consumed at a given meal or a given snack from day to day.  Patient was assured that we can titrate the insulin to match whatever eating pattern is suitable for her as long as she can do it on a consistent basis.  At the same time she was encouraged to continue to eliminate the more concentrated forms of refined carbohydrates.,PLAN:,  Recommend the patient work with the following meal plan with a carbohydrate budget representing approximately 45% of the calories from carbohydrate.  Breakfast:  Three carbohydrate servings.  Morning snack:  One carbohydrate serving.  Lunch:  Four carbohydrate servings.  Afternoon snack:  One carbohydrate serving.  Supper:  Four carbohydrate servings.  Bedtime snack:  One carbohydrate serving.  Encouraged patient to include some solid protein with each of her meals as well as with the bedtime snack.  Encouraged three servings of dairy products per day to meet nutritional needs for calcium during pregnancy.  Recommend patient include a fruit or a vegetable with most of her meals.  Also recommend including solid protein with each meal as well as with the bedtime snack.  Charlie Athene reviewed blood sugars at this consultation as well, and made the following insulin adjustment:  Morning 70/30, will increase from 20 units up to 24 units and evening 70/30, we will increase from 13 units up to 16 units.  Patient was encouraged to call in blood sugars at the end of the week if they are outside of the range of over 90 fasting and over 120 two-hour postprandial.  Provided my name and number should there be additional dietary questions.", SOAP / Chart / Progress Notes,35
"PREOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:,  Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:,  Local/IV sedation.,COMPLICATIONS:,  None.,SUMMARY:  ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details).  Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle.  After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle.  These needles were removed and the patient was discharged in stable condition.", Orthopedic,27
"REVIEW OF SYSTEMS,GENERAL:  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY:  Negative rash, negative jaundice.,HEMATOPOIETIC:  Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC:  Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS:  Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  Negative postnasal drip, negative sore throat.,CARDIOVASCULAR:  Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL:  Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY:  Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.  **No history of OB/GYN problems.,MUSCULOSKELETAL:  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC:  See psychiatric evaluation.,ENDOCRINE:  No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.", Consult - History and Phy.,5
"RE:  Sample Patient,Dear Dr. Sample:,Sample Patient was seen at the Vision Rehabilitation Institute on Month DD, YYYY.  She is an 87-year-old woman with a history of macular degeneration, who admits to having PDT therapy within the last year.  She would like to get started with some vision therapy so that she may be able to perform her everyday household chores, as well as reading small print.  At this time, she uses a small handheld magnifier, which is providing her with only limited help.,A complete refractive work-up was performed today, in which we found a mild change in her distance correction, which allowed her the ability to see 20/70 in the right eye and 20/200 in the left eye.  With a pair of +4 reading glasses, she was able to read 0.5M print quite nicely.  I have loaned her a pair of +4 reading glasses at this time and we have started her with fine-detailed reading.  She will return to our office in a matter of two weeks and we will make a better determination on what near reading glasses to prescribe for her.  I think that she is an excellent candidate for low vision help.  I am sure that we can be of great help to her in the near future.,Thank you for allowing us to share in the care of your patient.,With best regards,,Sample Doctor, O.D.", Ophthalmology,26
"FINDINGS:,1.  The patient's supine blood pressure was 153/88 with heart rate of 54 beats per minute.,2.  There was no significant change in heart rate or blood pressure on 80-degree tilt.,3.  No symptoms reported during the tilt study.,CONCLUSION: , Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome.", Cardiovascular / Pulmonary,3
"PREOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,PROCEDURE: , Endoscopic release of left transverse carpal ligament.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia provided by surgeon.  ,TOURNIQUET TIME: , 12 minutes.,OPERATIVE PROCEDURE IN DETAIL: , With the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mmHg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the palm between FCR and FCU, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,Hamate sounds were then used to palpate the Hood of Hamate.  The Agee Inside Job was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.  The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the Agee Inside Job was withdrawn, dividing transverse carpal ligament under direct vision.  After complete division of transverse carpal ligament, the Agee Inside Job was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished.  One cc of Celestone was then introduced into the carpal tunnel and irrigated free.  ,The wound was then closed with a running 3-0 Prolene subcuticular stitch.  Steri-strips were applied and a sterile dressing was applied over the Steri-strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.", Orthopedic,27
"HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old woman whom I have been following, who has had angina.  In any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when I spoke to her.  I advised her to call 911, which she did.  While waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain.  By the time she presented here, she is currently pain-free and is feeling well.,PAST CARDIAC HISTORY: , The patient has been having arm pain for several months.  She underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia.  I had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker.  However, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room.  On 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80%  mid LAD lesion, circumflex normal, and RCA totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area.  The decision was made to transfer  her as she may be having collateral insufficiency from the LAD stenosis to the RCA vessel.  She underwent that with drug-eluting stents on 08/16/08, with I believe three or four total placed, and was discharged on 08/17/08.  She had some left arm discomfort on 08/18/08, but this was mild.  Yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin.  This is her usual angina.  She is being admitted with unstable angina post stent.,PAST MEDICAL HISTORY: , Longstanding hypertension, CAD as above, hyperlipidemia, and overactive bladder.,MEDICATIONS:,1.  Detrol LA 2 mg once a day.,2.  Prilosec for GERD 20 mg once a day.,3.  Glucosamine 500/400 mg once a day for arthritis.,4.  Multivitamin p.o. daily.,5.  Nitroglycerin sublingual as available to her.,6.  Toprol-XL 25 mg once a day which I started although she had been bradycardic, but she seems to be tolerating.,7.  Aspirin 325 mg once a day.,8.  Plavix 75 mg once a day.,9.  Diovan 160 mg once a day.,10.  Claritin 10 mg once a day for allergic rhinitis.,11.  Norvasc 5 mg once a day.,12.  Lipitor 5 mg once a day.,13.  Evista 60 mg once a day.,ALLERGIES: , ALLERGIES TO MEDICATIONS ARE NONE.  SHE DENIES ANY SHRIMP OR SEA FOOD ALLERGY.,FAMILY HISTORY: , Her father died of an MI in his 50s and a brother had his first MI and bypass surgery at 54.,SOCIAL HISTORY:  ,She does not smoke cigarettes, abuse alcohol, no use of illicit drugs.  She is divorced and lives alone and is a retired laboratory technician from Cornell Diagnostic Laboratory.,REVIEW OF SYSTEMS:,  She denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08.  No morning headaches or fatigue.  No psychiatric diagnosis.  No psoriasis, no lupus.  Remainder of the review of systems is negative x14 systems except as described above.,PHYSICAL EXAMINATION:,GENERAL:  She is a pleasant elderly woman, currently in no acute distress.,VITAL SIGNS:  Height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 47,  respiratory rate 16, and O2 saturation 100%,HEENT:  Cranium is normocephalic and atraumatic.  She has moist mucosal membranes.,NECK:  Veins are not distended.  There are no carotid bruits.,LUNGS:  Clear to auscultation and percussion without wheezes.,HEART:  S1 and S2, regular rate.  No significant murmurs, rubs or gallops.  PMI nondisplaced.,ABDOMEN:  Soft and nondistended.  Bowel sounds present.,EXTREMITIES:  Without significant clubbing, cyanosis or edema.  Pulses grossly intact.  Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI and there is no evidence of hematoma or bruit and intact distal pulses.,LABORATORY DATA: , EKG reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,Sodium 136, potassium 3.8, chloride 105, and bicarbonate 27.  BUN 16 and creatinine 0.9.  Glucose 110.  Magnesium 2.5.  ALT 107 and AST 65 and these were normal on 08/15/08.  INR is 0.89, PTT 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,IMPRESSION AND PLAN:  ,The patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery.  In any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, I am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy.  We will continue her beta-blocker and I cannot increase the dose because she is bradycardic already.  Aspirin, Plavix, valsartan, Lipitor, and Norvasc.  I am going to add Imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out MI, although there is a little suspicion.  I suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect.  My concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal LV function.  She will continue the glucosamine for her arthritis, Claritin for allergies, and Detrol LA for urinary incontinence.,Total patient care time in the emergency department 75 minutes.  All this was discussed in detail with the patient and her daughter who expressed understanding and agreement.  The patient desires full resuscitation status.", Consult - History and Phy.,5
"PROCEDURE: , Elective male sterilization via bilateral vasectomy.,PREOPERATIVE DIAGNOSIS:  ,Fertile male with completed family.,POSTOPERATIVE DIAGNOSIS:,  Fertile male with completed family.,MEDICATIONS:  ,Anesthesia is local with conscious sedation.,COMPLICATIONS: , None.,BLOOD LOSS: , Minimal.,INDICATIONS:  ,This 34-year-old gentleman has come to the office requesting sterilization via bilateral vasectomy.  I discussed the indications and the need for procedure with the patient in detail, and he has given consent to proceed.  He has been given prophylactic antibiotics.,PROCEDURE NOTE: , Once satisfactory sedation have been obtained, the patient was placed in the supine position on the operating table.  Genitalia was shaved and then prepped with Betadine scrub and paint solution and were draped sterilely.  The procedure itself was started by grasping the right vas deferens in the scrotum, and bringing it up to the level of the skin.  The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath.  The vas was brought out of the incision carefully.  A 2-inch segment was isolated, and 1-inch segment was removed.  The free ends were cauterized and were tied with 2-0 silk sutures in such a fashion that the ends double back on themselves.  After securing hemostasis with a cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Attention was now turned to the left side.  The vas was grasped and brought up to the level of the skin.  The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath.  The vas was brought out of the incision carefully.  A 2-inch segment was isolated, and 1-inch segment was removed.  The free ends were cauterized and tied with 2-0 silk sutures in such a fashion that the ends double back on themselves.  After securing hemostasis with the cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Bacitracin ointment was applied as well as dry sterile dressing.  The patient was awakened and was returned to Recovery in satisfactory condition.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,POSTOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,OPERATION: , Left chest tube placement.,IV SEDATION: , 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.,PROCEDURE: , With the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion.  A 1% lidocaine was liberally infiltrated into the skin, subcutaneous tissue, deep fascia and the anterior axillary line just below the level of the nipple.  The incision was made and deepened through the different layers to reach the intercostal space.  The pleura was entered on top of the underlying rib and finger digital palpation was performed.  Multiple loculations were encountered.  Break up of loculations was performed posteriorly and a chest tube was directed posteriorly.  Only a small amount of fluid was noted to come out initially.  This was sent for various studies.  Soft adhesions were encountered.  The plan was to obtain a chest x-ray and start Activase installation.", Surgery,38
"PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION,This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation.  The original consultation and treatment planning will be separately performed.  At the time of the implantation, special coordination will be required.  Stepping ultrasound will be performed and utilized in the pre-planning process.  Some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process.  Re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound.  Modifications will be made in real time to add or subtract needles and seeds as required.  This may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.,The brachytherapy must be customized to fit the individual's tumor and prostate.  Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.", Radiology,33
"PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,The child was placed in a Circumstraint board and restrained in the usual fashion.  The area of the penis and scrotum were prepared with povidone iodine solution.  The area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure.  A dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine.  A dorsal slit was made, and the prepuce was dissected away from the glans penis.  A ** Gomco clamp was properly placed for 5 minutes.  During this time, the foreskin was sharply excised using a #10 blade.  With removal of the clamp, there was a good cosmetic outcome and no bleeding.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,PROCEDURE:,  Placement of cholecystostomy tube under ultrasound guidance.,ANESTHESIA: , Xylocaine 1% With Epinephrine.,INDICATIONS: , Patient is a pleasant 75-year-old gentleman who is about one week status post an acute MI who also has acute cholecystitis.  Because it is not safe to take him to the operating room for general anesthetic, I recommended he undergo the above-named procedure.  Procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him and he was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken to the Radiology suite, where the area of interest was identified using ultrasound and prepped with Betadine solution, draped in sterile fashion.  After infiltration with 1% Xylocaine and after multiple attempts, the gallbladder was finally cannulated by Dr. Kindred using the Cook 18-French needle.  The guidewire was then placed and via Seldinger technique, a 10-French pigtail catheter was placed within the gallbladder, secured using the Cook catheter method, and dressings were applied and patient was taken to recovery room in stable condition.", Gastroenterology,14
"DESCRIPTION OF RECORD:  ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system.  Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical.  During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 Hz alpha activity best seen posteriorly.  The alpha activity attenuates with eye opening.,During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,There is no evidence of focal slowing or paroxysmal activity.,IMPRESSION: , Normal awake and drowsy (stage I sleep) EEG for patient's age.", Neurology,22
"Sample Address,RE:  Sample Patient,Dear Doctor:,We had the pleasure of seeing Abc and his mother in the clinic today.  As you certainly know, he is now a 9-month-old male product of a twin gestation complicated by some very mild prematurity.  He has been having problems with wheezing, cough and shortness of breath over the last several months.  You and your partners have treated him aggressively with inhaled steroids and bronchodilator.  Despite this, however; he has had persistent problems with a cough and has been more recently started on both a short burst of prednisolone as well as a more prolonged alternating day course.  ,Although there is no smoke exposure there is a significant family history with both Abc's father and uncle having problems with asthma as well as his older sister.  The parents now maintain separate households and there has been a question about the consistency of his medication administration at his father's house.  ,On exam today, Abc had some scattered rhonchi which cleared with coughing but was otherwise healthy.  ,We spent the majority of our 45-minute just reviewing basic principles of asthma management and I believe that Abc's mother is fairly well versed in this.  I think the most important thing to realize is that Abc probably does have fairly severe childhood asthma and fortunately has avoided hospitalization.  ,I think it would be prudent to continue his alternate day steroids until he is completely symptom free on the days off steroids but it would be reasonable to continue to wean him down to as low as 1.5 milligrams (0.5 milliliters on alternate days).  I have encouraged his mother to contact our office so that we can answer questions if necessary by phone.,Thanks so much for allowing us to be involved in his care.  ,Sincerely,", Pediatrics - Neonatal,29
"CC: ,Falling to left.,HX:, 26y/oRHF fell and struck her head on the ice 3.5 weeks prior to presentation. There was no associated loss of consciousness. She noted a dull headache and severe sharp pain behind her left ear 8 days ago. The pain lasted 1-2 minutes in duration. The next morning she experienced difficulty walking and consistently fell to the left. In addition the left side of her face had become numb and she began choking on food. Family noted her pupils had become unequal in size. She was seen locally and felt to be depressed and admitted to a psychiatric facility. She was subsequently transferred to UIHC following evaluation by a local ophthalmologist.,MEDS:, Prozac and Ativan (both recently started at the psychiatric facility).,PMH: ,1) Right esotropia and hyperopia since age 1year. 2) Recurrent UTI.,FHX:, Unremarkable.,SHX:, Divorced. Lives with children. No spontaneous abortions. Denied ETOH/Tobacco/Illicit Drug use.,EXAM:, BP 138/110.  HR 85.  RR 16.  Temp 37.2C.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, repetition.,CN: Pupils 4/2 decreasing to 3/1 on exposure to light. Optic Disks flat. VFFTC. Esotropia OD, otherwise EOM full. Horizontal nystagmus on leftward gaze. Decreased corneal reflex, OS. Decreased PP/TEMP sensation on left side of face. Light touch testing normal. Decreased gag response on left. Uvula deviates to right. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: Decreased PP and TEMP on right side of body. PROP/VIB intact.,Coord: Difficulty with FNF/HKS/RAM on left. Normal on right side.,Station: No pronator drift. Romberg test not noted.,Gait: unsteady with tendency to fall to left.,Reflexes: 3/3 throughout BUE and Patellae. 2+/2+ Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese. In no acute distress. Otherwise unremarkable.,HEENT: No carotid/vertebral/cranial bruits.,COURSE:, PT/PTT, GS, CBC, TSH, FT4 and Cholesterol screen were all within normal limits. HCT on admission was negative. MRI Brain (done locally 2/2/93) was reviewed and a left lateral medullary stroke was appreciated. The patient underwent a cerebral angiogram on 2/3/93 which revealed significant narrowing of the left vertebral artery beginning at C2 and extending to and involving the basilar artery. There is severe, irregular narrowing of the horizontal portion above the posterior arch of C1. The findings were felt consistent with a left vertebral artery dissection. Neuro-opthalmology confirmed a left Horner's pupil by clinical exam and history. Cookie swallow study was unremarkable. The Patient was placed on Heparin then converted to Coumadin. The PT on discharge was 17.,She remained on Coumadin for 3 months and then was switched to ASA for 1 year. An Otolaryngologic evaluation on 10/96 noted true left vocal cord paralysis with full glottic closure. A prosthesis was made and no surgical invention was done.", Neurology,22
"CHIEF COMPLAINT: , Possible exposure to ant bait.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it.  It had 11 mL of this fluid in it.  She spilled it on her, had it on her hands.  Parents were not sure whether she ingested any of it.  So, they brought her in for evaluation.  They did not note any symptoms of any type.,PAST MEDICAL HISTORY: , Negative.  Generally very healthy.,REVIEW OF SYSTEMS: , The child has not been having any coughing, gagging, vomiting, or other symptoms.  Acting perfectly normal.  Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes.  They did not witness that she ingested any, but did not see anything her mouth.,MEDICATIONS: , None.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  Stable vital signs and normal pulse oximetry.  GENERAL:  The child is very active, cheerful youngster, in no distress whatsoever.  HEENT:  Unremarkable.  Oral mucosa is clear, moist, and well hydrated.  I do not see any evidence of any sort of liquid on the face.  Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso.  Apparently, she had some on her hands that has been wiped off.,EMERGENCY DEPARTMENT COURSE:,  I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case.,IMPRESSION: , Exposure to ant bait.,PLAN: , At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely.  She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation.  So, the patient is discharged in stable condition.", General Medicine,15
"PROCEDURE: , Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE:  ,Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The X-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in the prone position on the treatment table, pillow under the chest, and head rotated contralateral to the side being treated.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 25-gauge 3.5-inch spinal needle was gently guided into the groove between the SAP and sacrum through the dorsal ramus of the L5 and the lateral and superior border of the posterior sacral foramen with the lateral branches of S1, S2, and S3.  Multiple fluoroscopic views were used to ensure proper needle placement.  Approximately 0.25 mL of nonionic contrast agent was injected showing no concurrent vascular dye pattern.  Finally, the treatment solution, consisting of 0.5% of bupivacaine was injected to each area.  All injected medications were preservative free.  Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS: , This was then repeated on the left side.,COMPLICATIONS: , None.,DISCUSSION:  ,Postprocedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to resume normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes or changes in bowel or bladder function.,Follow up appointment was made at the PM&R Spine Clinic in approximately 1 week.", Surgery,38
"HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old Hispanic male who was seen initially in the office February 15, 2006, with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.  The patient at that time stated that he had established diagnosis of liver cirrhosis.  Since the last visit the patient was asked to sign a lease of information form and we sent request for information from the doctor the patient saw before, Dr. X in Las Cruces and his primary care physician in Silver City, and unfortunately we did not get any information from anybody.  Also the patient had admission in Gila Medical Center with epigastric pain, diarrhea, and confusion.  He spent 3 days in the hospital.  He was followed by Dr. X and unfortunately we also do not have the information of what was wrong with the patient.  From the patient's report he was diagnosed with some kind of viral infection.  At the time of admission he had a lot of epigastric pain, nausea, vomiting, fever, and chills.,PHYSICAL EXAMINATION,VITAL SIGNS:  Weight 107, height 6 feet 1 inch, blood pressure 128/67, heart rate 74, saturation 98%; pain is 3/10 with localization of the pain in the epigastric area.,HEENT:  PERRLA.  EOM intact.  Oropharynx is clear of lesions.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.,LUNGS:  Clear to auscultation and percussion bilateral.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs, rubs, or gallops.,ABDOMEN:  Not tender, not distended.  Splenomegaly about 4 cm under the costal margin.  No hepatomegaly.  Bowel sounds present.,MUSCULOSKELETAL:  No cyanosis, no clubbing, no pitting edema.,NEUROLOGIC:  Nonfocal.  No asterixis.  No costovertebral tenderness.,PSYCHE:  The patient is oriented x4, alert and cooperative.,LABORATORY DATA: , We were able to collect lab results from Medical Center; we got only CMP from the hospital which showed glucose level 79, BUN 9, creatinine 0.6, sodium 136, potassium 3.5, chloride 104, CO2 23.7, calcium 7.3, total protein 5.9, albumin 2.5, total bilirubin 5.63.  His AST 56, ALT 37, alkaline phosphatase 165, and his ammonia level was 53.  We do not have any other results back.  No hepatitis panels.  No alpha-fetoprotein level.  The patient told me today that he also got an ultrasound of the abdomen and the result was not impressive, but we do not have this result despite calling medical records in the hospital to release this information.,ASSESSMENT AND PLAN:,  The patient is a 55-year-old with established diagnosis of liver cirrhosis, unknown cause.,1.  Epigastric pain.  The patient had chronic pain syndrome, he had multiple back surgeries, and he has taken opiate for a prolonged period of time.  In the office twice the patient did not have any abdominal pain on physical exam.  His pain does not sound like obstruction of common bile duct and he had these episodes of abdominal pain almost continuously.  He probably requires increased level of pain control with increased dose of opiates, which should be addressed with his primary care physician.,2.  End-stage liver disease.  Of course, we need to find out the cause of the liver cirrhosis.  We do not have hepatitis panel yet and we do not have information about the liver biopsy which was performed before.  We do not have any information of any type of investigation in the past.  Again, patient was seen by gastroenterologist already in Las Cruces, Dr. X.  The patient was advised to contact Dr. X by himself to convince him to send available information because we already send release information form signed by the patient without any result.  It will be not reasonable to repeat unnecessary tests in that point in time.,We are waiting for the hepatitis panel and alpha-fetoprotein level.  We will also need to get information about ultrasound which was done in Gila Medical Center, but obviously no tumor was found on this exam of the liver.  We have to figure out hepatitis status for another reason if he needs vaccination against hepatitis A and B.  Until now we do not know exactly what the cause of the patient's end-stage liver disease is and my differential diagnosis probably is hepatitis C.  The patient denied any excessive alcohol intake, but I could not preclude alcohol-related liver cirrhosis also.  We will need to look for nuclear antibody if it is not done before.  PSC is extremely unlikely but possible.  Wilson disease also possible diagnosis but again, we first have to figure out if these tests were done for the patient or not.  Alpha1-antitrypsin deficiency will be extremely unlikely because the patient has no lung problem.  On his end-stage liver disease we already know that he had low platelet count splenomegaly.  We know that his bilirubin is elevated and albumin is very low.  I suspect that at the time of admission to the hospital the patient presented with encephalopathy.  We do not know if INR was checked to look for coagulopathy.  The patient had an EGD in 2005 as well as colonoscopy in Silver City.  We have to have this result to evaluate if the patient had any varices and if he needs any intervention for that.,At this point in time, I recommended the patient to continue to take lactulose 50 mL 3 times daily.  The patient tolerated it well; no diarrhea at this point in time.  I also recommended for him to contact his primary care physician for increased dose of opiates for him.  As a primary prophylaxis of GI bleeding in patient with end-stage liver disease we will try to use Inderal.  The patient got a prescription for 10 mg pills.  He will take 10 mg twice daily and we will gradually increase his dose until his heart rate will drop to 25% from 75% to probably 60-58.  The patient was educated how to use Inderal and he was explained why we decided to use this medication.  The patient will hold this medication if he is orthostatic or bradycardic.,Again, the patient and his wife were advised to contact all offices they have seen before to get information about what tests were already done and if on the next visit in 2 weeks we still do not have any information we will need to repeat all these tests I mentioned above.,We also discussed nutrition issues.  The patient was provided information that his protein intake is supposed to be about 25 g per day.  He was advised not to over-eat protein and advised not to starve.  He also was advised to stay away from alcohol.  His next visit is in 2 weeks with all results available.", Gastroenterology,14
"REASON FOR ADMISSION:,  Penile injury and continuous bleeding from a penile laceration.,HISTORY OF PRESENT ILLNESS:,  The patient is an 18-year-old detainee who was brought by police officers because of a penile injury and bleeding.  He is otherwise healthy.  He tried to insert a marble in his penis four days ago.  He told me that he grabbed the skin on the top of the penis and moved it away from the penis shaft and then using a toothbrush that he made in to a knife object he pierced the skin through from both sides and then kept moving the toothbrush to dilate and make a way for the marble.  Then he inserted a heart-shaped marble in one of the puncture wounds and inserted it under the skin and kept it there.  He was not significantly bleeding and essentially the bleeding stopped from both puncture wounds that he has.  Then today four days after that procedure, he was taking a bath today and he thinks because of the weight he felt a gush in his pants and he looked and he saw the bleeding come out.  He was bleeding so much that he started dripping to the sides of his legs.  So, he was brought to the hospital.  Actually after being seen by two nurses at the facility where he was at the detention center where he was at and they actually did the dressing twice and it was twice soaked with blood.  He came here and was continuously bleeding from that area that we had to change the dressing twice and he is actually still bleeding especially from one of the laceration, the one on the right side of the penis.  The marble also still can be felt underneath the skin.  There is no urethral bleeding.  He did urinate today without difficulty, without hematuria or dysuria.  There is pain in the lacerations.  No erythema in the skin or swelling in the penis and no other injuries.  He did this procedure for sexual pleasure as he said.,PAST MEDICAL HISTORY: , Unremarkable.,PAST SURGICAL HISTORY:  ,Tonsillectomy.,MEDICATION: , He took only ibuprofen.  No regular medication.,ALLERGIES: , None.,SOCIAL HISTORY:  ,He has been in detention for two months for immigration problems.  No drugs.  No alcohol.  No smoking.  He used to work in fast food chain.,FAMILY HISTORY: , Noncontributory to this illness.,REVIEW OF SYSTEMS: , Aside from the pain in the penis and continuous bleeding, he is basically asymptomatic and review of systems is unremarkable.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a young Hispanic male, lying in bed, appear comfortable in no apparent distress.,VITAL SIGNS:  Temperature 97.8, heart rate 99, respiratory rate 20, blood pressure 142/100, and saturation is 98% on room air.,ENT:  Sclerae nonicteric.  Pupils reactive to light.  Nostrils are normal.  Oral cavity is clear.,NECK:  Supple.  Trachea midline.  No JVD.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Normal S1 and S2.  No murmurs or gallops.,ABDOMEN:  Soft, nontender, and nondistended.  Positive bowel sounds.,EXTREMITIES:  Pulses strong bilaterally.  No edema.,GENITAL:  Testicles appear normal.  The penis shaft has two lacerations on both sides, one of them is bleeding.  They measure about 5 to 6 mm on the right side, about 3 or 4 mm on the left side.  The one on the right side is bleeding much more than the other one.  There is a marble that can be felt and it is freely mobile underneath the skin of the dorsum of the penis.  There is no bleeding from the meatus or discharge and no other injuries were seen by inspection.,LABORATORY DATA:,  White count 11.1, hemoglobin 14.5, hematocrit 43.5, and platelets 303,000.  Coags unremarkable.  Glucose 106, creatinine 0.8, sodium 141, potassium 4, and calcium 9.7.  Urinalysis unremarkable.,IMPRESSION: , The patient with a penile laceration that is continuously bleeding from inserting a marble four days ago, which is still underneath the skin of the shaft of the penis.  No other injuries that can be seen and no other evidence of secondary bacterial infection at this time.  The patient is currently refusing removal of the marble and insisting on just repairing the laceration and he is having discussion with Dr. X.,PLAN:,1.  The patient will be admitted to the hospital and will follow Dr. X's recommendation.,2.  The patient was offered a repair of those lacerations, to stop the bleeding as well as the removal of the marble and he is currently considering that and discussing that with Dr. X.,3.  Prophylactic antibiotics to prevent infection.,4.  He has mild hypertension, which is likely due to stress and pain and also the leukocytosis probably can be explained by that.  This will be monitored.,5.  Monitor H&H to determine if he needs any transfusion at this time.  He does not need that.,6.  IV fluid for hydration and volume resuscitation at this time.,7.  Pain management.,8.  Topical care for the wound VAC after repair.,Time spent in evaluation and management of this patient including discussions about this procedure and the harm that can happen if he chooses to keep the penis including permanent damage and infection to the penis was 65 minutes.,I had clearly explained to the patient in detail about the possibility of permanent penile damage that could affect erection and future sexual functioning as well as significant infection if a foreign object was retained in the penis under the skin and he verbalized understanding of this.", Urology,39
"MALE PHYSICAL EXAMINATION,Eye:  Eyelids normal color, no edema.  Conjunctivae with no erythema, foreign body, or lacerations.  Sclerae normal white color, no jaundice.  Cornea clear without lesions.  Pupils equally responsive to light.  Iris normal color, no lesions.  Anterior chamber clear.  Lacrimal ducts normal.  Fundi clear.,Ear:  External ear has no erythema, edema, or lesions.  Ear canal unobstructed without edema, discharge, or lesions.  Tympanic membranes clear with normal light reflex.  No middle ear effusions.,Nose:  External nose symmetrical.  No skin lesions.  Nares open and free of lesions.  Turbinates normal color, size and shape.  Mucus clear.  No internal lesions.,Throat:  No erythema or exudates.  Buccal mucosa clear.  Lips normal color without lesions.  Tongue normal shape and color without lesion.  Hard and soft palate normal color without lesions.  Teeth show no remarkable features.  No adenopathy.  Tonsils normal shape and size.  Uvula normal shape and color.,Neck:  Skin has no lesions.  Neck symmetrical.  No adenopathy, thyromegaly, or masses.  Normal range of motion, nontender.  Trachea midline.,Chest:  Symmetrical.  Clear to auscultation bilaterally.  No wheezing, rales or rhonchi.  Chest nontender.  Normal lung excursion.  No accessory muscle use.,Cardiovascular:  Heart has regular rate and rhythm with no S3 or S4.  Heart rate is normal.,Abdominal:  Soft, nontender, nondistended, bowel sounds present.  No hepatomegaly, splenomegaly, masses, or bruits.,Genital:  Penis normal shape without lesions.  Testicles normal shape and contour without tenderness.  Epididymides normal shape and contour without tenderness.  Rectum normal tone to sphincter.  Prostate normal shape and contour without nodules.  Stool hemoccult negative.  No external hemorrhoids.  No skin lesions.,Musculoskeletal:  Normal strength all muscle groups.  Normal range of motion all joints.  No joint effusions.  Joints normal shape and contour.  No muscle masses.,Foot:  No erythema.  No edema.  Normal range of motion all joints in the foot.  Nontender.  No pain with inversion, eversion, plantar or dorsiflexion.,Ankle:  Anterior and posterior drawer test negative.  No pain with inversion, eversion, dorsiflexion, or plantar flexion.  Collateral ligaments intact.  No joint effusion, erythema, edema, crepitus, ecchymosis, or tenderness.,Knee:  Normal range of motion.  No joint effusion, erythema, nontender.  Anterior and posterior drawer tests negative.  Lachman's test negative.  Collateral ligaments intact.  Bursas nontender without edema.,Wrist:  Normal range of motion.  No edema or effusion, nontender.  Negative Tinel and Phalen tests.  Normal strength all muscle groups.,Elbow:  Normal range of motion.  No joint effusion or erythema.  Normal strength all muscle groups.  Nontender.  Olecranon bursa flat and nontender, no edema.  Normal supination and pronation of forearm.  No crepitus.,Hip:  Negative swinging test.  Trochanteric bursa nontender.  Normal range of motion.  Normal strength all muscle groups.  No pain with eversion and inversion.  No crepitus.  Normal gait.,Psychiatric:  Alert and oriented times four.  No delusions or hallucinations, no loose associations, no flight of ideas, no tangentiality.  Affect is appropriate.  No psychomotor slowing or agitation.  Eye contact is appropriate.", Office Notes,25
"PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1.  Lumbar discogram L2-3.,2.  Lumbar discogram L3-4.,3.  Lumbar discogram L4-5.,4.  Lumbar discogram L5-S1.,ANESTHESIA:  ,IV sedation.,PROCEDURE IN DETAIL:  ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table.  The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained.  We then proceeded to prepare the low back with a Betadine solution and draped sterile.  Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space.  A metallic marker was then placed laterally and a needle entrance point was determined.  A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections.  A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus.  We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:,  Acute gangrenous cholecystitis with cholelithiasis.,OPERATION PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,FINDINGS:  ,The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.,COMPLICATIONS:  ,None.,EBL: , Scant.,SPECIMEN REMOVED: , Gallbladder with stones.,DESCRIPTION OF PROCEDURE:  ,The patient was prepped and draped in the usual sterile fashion under general anesthesia.  A curvilinear incision was made below the umbilicus.  Through this incision, the camera port was able to be placed into the peritoneal cavity under direct visualization.  Once this complete, insufflation was begun.  Once insufflation was adequate, additional ports were placed in the epigastrium as well as right upper quadrant.  Once all four ports were placed, the right upper quadrant was then explored.  The patient had significant adhesions of omentum and colon to the liver, the gallbladder constituting definitely an acute cholecystitis.  This was taken down using Bovie cautery to free up visualization of the gallbladder.  The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall.  Adhesions were further taken down between the omentum, the colon, and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area.  Once the adhesions were fully removed, the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction.  At this point, due to the patient's gallbladder being very necrotic, it was deemed that the patient should have a drain placed.  The cystic duct and cystic artery were serially clipped and transected.  The gallbladder was removed from the gallbladder fossa removing the entire gallbladder.  Adequate hemostasis with Bovie cautery was achieved.  The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port.  A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3-0 nylon suture.  Next, the right upper quadrant was copiously irrigated out using the suction irrigator.  Once this was complete, the additional ports were able to be removed.  The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure-of-8 fashion.  All skin incisions were injected using Marcaine 1/4 percent plain.  The skin was reapproximated further using 4-0 Monocryl sutures in a subcuticular technique.  The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition.", Radiology,33
"PROCEDURE PERFORMED: , Inguinal herniorrhaphy.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.  The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated.  The external oblique was then incised with a scalpel, and this incision was carried out to the external ring using Metzenbaum scissors.  Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was placed around the cord structures at the level of the pubic tubercle.  This Penrose drain was then used to retract the cord structures as needed.  Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures.  The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery.  Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature.  The sac was excised and went to  Pathology.  The ends of the suture were then cut and the stump retracted back into the abdomen.,The Penrose drain was removed.  The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The incision in the external oblique was approximated using a 3-0 Vicryl in a running fashion, thus reforming the external ring.  The skin incision was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped and draped with benzoin, and Steri-Strips were applied.  A dressing consisting of a 2 x 2 and OpSite was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.", Urology,39
"EXAM:,MRI RIGHT SHOULDER,CLINICAL:, A 32-year-old male with shoulder pain.,FINDINGS:,This is a second opinion interpretation of the examination performed on 02/16/06.,Normal supraspinatus tendon without surface fraying, gap or fiber retraction and there is no muscular atrophy.,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is no subluxation of the tendon under the transverse humeral ligament and the intracapsular portion of the tendon is normal.,Normal humeral head without fracture or subluxation.,There is myxoid degeneration within the superior labrum (oblique coronal images #47-48), but there is no discrete tear. The remaining portions of the labrum are normal without osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is a persistent os acromiale, and there is minimal reactive marrow edema on both sides of the synchondrosis, suggesting that there may be instability (axial images #3 and 4). There is no diastasis of the acromioclavicular joint itself. There is mild narrowing of the subacromial space secondary to the os acromiale, in the appropriate clinical setting, this may be acting as an impinging lesion (sagittal images #56-59).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There are no effusions or masses.,IMPRESSION:,Changes in the superior labrum compatible with degeneration without a discrete surfacing tear.,There is a persistent os acromiale, and there is reactive marrow edema on both sides of the synchondrosis suggesting instability. There is also mild narrowing of the subacromial space secondary to the os acromiale. This may be acting as an impinging lesion in the appropriate clinical setting.,There is no evidence of a rotator cuff tear.", Orthopedic,27
"HISTORY OF PRESENT ILLNESS: , The patient presents today for followup, history of erectile dysfunction, last visit started on Cialis 10 mg.  He indicates that he has noticed some mild improvement of his symptoms, with no side effect.  On this dose, he is having firm erection, able to penetrate, lasting for about 10 or so minutes.  No chest pain, no nitroglycerin usage, no fever, no chills.  No dysuria, gross hematuria, fever, chills.  Daytime frequency every three hours, nocturia times 0, good stream.  He does have a history of elevated PSA and biopsy June of this year was noted for high grade PIN, mid left biopsy, with two specimens being too small to evaluate.  PSA 11.6.  Dr. X's notes are reviewed.,IMPRESSION:  ,1.  Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects.  The patient has multiple risk factors, but denies using any nitroglycerin or any cardiac issues at this time.  We reviewed options of increasing the medication, versus trying other medications, options of penile prosthesis, Caverject injection use as well as working pump is reviewed.,2.  Elevated PSA in a patient with a recent biopsy showing high-grade PIN, as well as two specimens not being large enough to evaluate.  The patient tells me he has met with his primary care physician and after discussion, he is in consideration of repeating a prostate ultrasound and biopsy.  However, he would like to meet with Dr. X to discuss these prior to biopsy.,PLAN: , Following detailed discussion, the patient wishes to proceed with Cialis 20 mg, samples are provided as well as Levitra 10 mg, may increase this to 20 mg and understand administration of each and contraindication as well as potential side effects are reviewed.  The patient not to use them at the same time.  Will call if any other concern.  In the meantime, he is scheduled to meet with Dr. X, with a prior PSA in consideration of a possible repeating prostate ultrasound and biopsy.  He declined scheduling this at this time.  All questions answered.", SOAP / Chart / Progress Notes,35
"ADMITTING DIAGNOSES:,1. Hematuria.,2. Benign prostatic hyperplasia.,3. Osteoarthritis.,DISCHARGE DIAGNOSES:,1. Hematuria, resolved.,2. Benign prostatic hyperplasia.,3. Complex renal cyst versus renal cell carcinoma or other tumor.,4. Osteoarthritis.,HOSPITAL COURSE:, This is a 77-year-old African-American male who was previously well until he began having gross hematuria and clots passing through his urethra on the day of admission. He stated that he never had blood in his urine before, however, he does have a past history of BPH and he had a transurethral resection of prostate more than 10 years ago. He was admitted to a regular bed. Dr. G of Urology was consulted for evaluation of his hematuria. During the workup for this, he had a CT of the abdomen and pelvis with and without contrast with early and late-phase imaging for evaluation of the kidneys and collecting system. At that time, he was shown to have multiple bilateral renal cysts with one that did not meet classification as a simple cyst and ultrasound was recommended.,He had an ultrasound done of the cyst which showed a 2.1 x 2.7 cm mass arising from the right kidney which, again, did not fit ultrasound criteria for a simple cyst and they recommended further evaluation by an MRI as this could be a hemorrhagic cyst or a solid mass or tumor, so an MRI was scheduled on the day of discharge for further evaluation of this. The report was not back at discharge. The patient had a cystoscopy and transurethral resection of prostate as well with entire resection of the prostate gland. Pathology on this specimen showed multiple portions of prostatic tissue which was primarily fibromuscular, and he was diagnosed with nonprostatic hyperplasia. His urine slowly cleared. He tolerated a regular diet with no difficulties in his activities of daily living, and his Foley was removed on the day of discharge.,He was started on ciprofloxacin, Colace, and Lasix after the transurethral resection and continued these for a short course. He is asked to continue the Colace as an outpatient for stool softening for comfort.,DISCHARGE MEDICATIONS:, Colace 100 mg 1 b.i.d.,DISCHARGE FOLLOWUP PLANNING:, The patient is to follow up with his primary care physician at ABCD, Dr. B or Dr. J, the patient is unsure of which, in the next couple weeks. He is to follow up with Dr. G of  Urology in the next week by phone in regards to the patient's MRI and plans for a laparoscopic partial renal resection biopsy. This is scheduled for the week after discharge potentially by Dr. G, and the patient will discuss the exact time later this week. The patient is to return to the emergency room or to our clinic if he has worsening hematuria again or no urine output.", Urology,39
"REASON FOR CONSULTATION: , Pneumatosis coli in the cecum.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 87-year-old gentleman who was admitted on 10/27/07 with weakness and tiredness with aspiration pneumonia.  The patient is very difficult to obtain information from; however, he appears to be having frequent nausea and vomiting with an aspiration pneumonia and abdominal discomfort.  In addition, this hospitalization, he has undergone an upper endoscopy, which found a small ulcer after dropping his hematocrit and becoming anemic.  He had a CT scan on Friday, 11/02/07, which apparently showed pneumatosis and his cecum worrisome for ischemic colitis as well as bilateral hydronephrosis and multiple liver lesions, which could be metastatic disease versus cysts.  In discussions with the patient, he had multiple bowel movements yesterday and is currently passing flatus and has epigastric pain.,PAST MEDICAL HISTORY:  ,Obtained from the medical chart.  Chronic obstructive pulmonary disease, history of pneumonia, and aspiration pneumonia, osteoporosis, alcoholism, microcytic anemia.,MEDICATIONS: , Per his current medical chart.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient had a long history of smoking but quit many years ago.  He does have chronic alcohol use.,PHYSICAL EXAMINATION:,GENERAL:  A very thin white male who is dyspneic and having difficulty breathing at the moment.,VITAL SIGNS:  Afebrile.  Heart rate in the 100s to 120s at times with atrial fibrillation.  Respiratory rate is 17-20.  Blood pressure 130s-150s/60s-70s.,NECK:  Soft and supple, full range of motion.,HEART:  Regular.,ABDOMEN:  Distended with tenderness mainly in the upper abdomen but very difficult to localize due to his difficulty providing information.  He does appear to have tenderness but does not have rebound and does not have peritoneal signs.,DIAGNOSTICS: , A CT scan done on 11/02/07 shows pneumatosis in the cecum with an enlarged cecum filled with stool and air fluid levels with chronically dilated small bowel.,ASSESSMENT: , Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.,PLAN: , The patient appears to have pneumatosis from a CT scan 2 days ago.  Nothing was done about it at that time as the patient appeared to not be symptomatic, but he continues to have nausea and vomiting with abdominal pain, but the fact that pneumatosis was found 2 days ago and the patient has survived this long indicates this may be a benign process at the moment, and I would recommend getting a repeat CT scan to assess it further to see if there is worsening of pneumatosis versus resolution to further evaluate the liver lesions and make decisions regarding planning at that time.  The patient has frequent desaturations secondary to his aspiration pneumonia, and any surgical procedure or any surgical intervention would certainly require intubation, which would then necessitate long-term ventilator care as he is not someone who would be able to come off of a ventilator very well in his current state.  So we will look at the CT scan and make decisions based on the findings as far as that is concerned.", Gastroenterology,14
"1.  Pelvic tumor.,2.  Cystocele.,3.  Rectocele.,POSTOPERATIVE DIAGNOSES:,1.  Degenerated joint.,2.  Uterine fibroid.,3.  Cystocele.,4.  Rectocele.,PROCEDURE PERFORMED:  ,1.  Total abdominal hysterectomy.,2.  Bilateral salpingooophorectomy.,3.  Repair of bladder laceration.,4.  Appendectomy.,5.  Marshall-Marchetti-Krantz cystourethropexy.,6.  Posterior colpoperineoplasty.,GROSS FINDINGS:  The patient had a history of a rapidly growing mass on the abdomen, extending from the pelvis over the past two to three months.  She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus.  Curettings were negative for malignancy.  The patient did have a large cystocele and rectocele, and a collapsed anterior and posterior vaginal wall.,Upon laparotomy, there was a giant uterine tumor extending from the pelvis up to the above the umbilicus compatible with approximately four to five-month pregnancy.  The ovaries appeared to be within normal limits.  There was marked adherence between the bladder and the giant uterus and mass with edema and inflammation, and during dissection, a laceration inadvertently occurred and it was immediately recognized.  No other pathology noted from the abdominal cavity or adhesions.  The upper right quadrant of the abdomen compatible with a previous gallbladder surgery.  The appendix is in its normal anatomic position.  The ileum was within normal limits with no Meckel's diverticulum seen and no other gross pathology evident.  There was no evidence of metastasis or tumors in the left lobe of the liver.,Upon frozen section, diagnosis of initial and partial is that of a degenerating uterine fibroid rather than a malignancy.,OPERATIVE PROCEDURE:  The patient was taken to the Operating Room, prepped and draped in the low lithotomy position under general anesthesia.  A midline incision was made around the umbilicus down to the lower abdomen.  With a #10 Bard Parker blade knife, the incision was carried down through the fascia.  The fascia was incised in the midline, muscle fibers were splint in the midline, the peritoneum was grasped with hemostats and with a #10 Bard Parker blade after incision was made with Mayo scissors.  A Balfour retractor was placed into the wound.  This giant uterus was soft and compatible with a possible leiomyosarcoma or degenerating fibroid was handled with care.  The infundibular ligament on the right side was isolated and ligated with #0 Vicryl suture brought to an avascular area, doubly clamped and divided from the ovary and the ligament again re-ligated with #0 Vicryl suture.  The right round ligament was ligated with #0 Vicryl suture, brought to an avascular space within the broad ligament and divided from the uterus.  The infundibulopelvic ligament on the left side was treated in a similar fashion as well as the round ligament.  An attempt was made to dissect the bladder flap from the anterior surface of the uterus and this was remarkably edematous and difficult to do, and during dissection the bladder was inadvertently entered.  After this was immediately recognized, the bladder flap was wiped away from the anterior surface of the uterus.  The bladder was then repaired with a running locking stitch #0 Vicryl suture incorporating serosal muscularis mucosa and then the second layer of overlapping seromuscular sutures were used to make a two-layer closure of #0 Vicryl suture.  After removing the uterus, the bladder was tested with approximately 400 cc of sterile water and there appeared to be no leak.  Progressing and removing of the uterus was then carried out and the broad ligament was clamped bilaterally with a straight Ochsner forceps and divided from the uterus with Mayo scissors, and the straight Ochsner was placed by #0 Vicryl suture thus controlling the uterine blood supply.  The cardinal ligaments containing the cervical blood supply was serially clamped bilaterally with a curved Ochsner forceps, divided from the uterus with #10 Bard Parker blade knife and a curved Ochsner was placed by #0 Vicryl suture.  The cervix was again grasped with a Lahey tenaculum and pubovesicocervical ligament was entered and was divided using #10 Bard Parker blade knife and then the vaginal vault and with a double pointed sharp scissors.  A single-toothed tenaculum was placed on the cervix and then the uterus was removed from the vagina using hysterectomy scissors.  The vaginal cuff was then closed using a running #0 Vicryl suture in locking stitch incorporating all layers of the vagina, the cardinal ligaments of the lateral aspect and uterosacral ligaments on the posterior aspect.  The round ligaments were approximated to the vaginal cuff with #0 Vicryl suture and the bladder flap approximated to the round ligaments with #000 Vicryl suture.  The ______ was re-peritonealized with #000 Vicryl suture and then the cecum brought into the incision.  The pelvis was irrigated with approximately 500 cc of water.  The appendix was grasped with Babcock forceps.  The mesoappendix was doubly clamped with curved hemostats and divided with Metzenbaum scissors.  The curved hemostats were placed with #00 Vicryl suture.  The base of the appendix was ligated with #0 plain gut suture, doubly clamped and divided from the distal appendix with #10 Bard Parker blade knife, and the base inverted with a pursestring suture with #00 Vicryl.  No bleeding was noted.  Sponge, instrument, and needle counts were found to be correct.  All packs and retractors were removed.  The peritoneum muscle fascia was closed in single-layer closure using running looped #1 PDS, but prior to closure, a Marshall-Marchetti-Krantz cystourethropexy was carried out by dissecting the space of Retzius identifying the urethra in the vesical junction approximating the periurethral connective tissue to the symphysis pubis with interrupted #0 Vicryl suture.  Following this, the abdominal wall was closed as previously described and the skin was closed using skin staples.  Attention was then turned to the vagina, where the introitus of the vagina was grasped with an Allis forceps at the level of the Bartholin glands.  An incision was made between the mucous and the cutaneous junction and then a midline incision was made at the posterior vaginal mucosa in a tunneling fashion with Metzenbaum scissors.  The flaps were created bilaterally by making an incision in the posterior connective tissue of the vagina and wiping the rectum away from the posterior vaginal mucosa, and flaps were created bilaterally.  In this fashion, the rectocele was reduced and the levator ani muscles were approximated in the midline with interrupted #0 Vicryl suture.  Excess vaginal mucosa was excised and the vaginal mucosa closed with running #00 Vicryl suture.  The bulbocavernosus and transverse perinei muscles were approximated in the midline with interrupted #00 Vicryl suture.  The skin was closed with a running #000 plain gut subcuticular stitch.  The vaginal vault was packed with a Betadine-soaked Kling gauze sponge.  Sterile dressing was applied.  The patient was sent to recovery room in stable condition.", Obstetrics / Gynecology,24
"PROCEDURE: , Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,PATIENT PROFILE:,  This is a 42-year-old female.  Refer to note in patient chart for documentation of history and physical.  Due to the nature of the patient's increasing pain, surgery is recommended.  The alternatives, risks and benefits of surgery were discussed with the patient.  The patient verbalized understanding of the risks as well as the alternatives to surgery.  The patient wished to proceed with operative intervention.  A signed and witnessed informed consent was placed on the chart.  Prior to initiation of the procedure, patient identification and proposed procedure were verified by the surgeon in the pre-op area, and the operative site was marked by the patient and verified by the surgeon.,PRE-OP DIAGNOSIS: , Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,POST-OP DIAGNOSIS:,  Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,ANESTHESIA: , General - Endotracheal.,FINDINGS:,ACROMION:,1.  There was a medium-sized (5 - 10 mm) anterior acromial spur.,2.  The subacromial bursa was inflamed.,3.  The subacromial bursa was thickened.,4.  There was thickening of the coracoacromial ligament.,LIGAMENTS / CAPSULE: , Joint capsule within normal limits.,LABRUM: , The labrum is within normal limits.,ROTATOR CUFF: , Full thickness tear of the supraspinatus tendon, 5 mm anterior to posterior, by 10 mm medial to lateral.  Muscles and Tendons:  The biceps tendon is within normal limits.,JOINT:,  Normal appearance of the glenoid and humeral surfaces.,DESCRIPTION OF PROCEDURE:,PATIENT POSITIONING: , Following induction of anesthesia, the patient was placed in the beach-chair position on the standard operating table.  All body parts were well padded and protected to make sure there were no pressure points.  Subsequently, the surgical area was prepped and draped in the appropriate sterile fashion with Betadine.,INCISION TYPE:,1.  Scope Ports:  Anterior Portal.,2.  Scope Ports:  Posterior Portal.,3.  Scope Ports:  Accessory Anterior Portal.,INSTRUMENTS AND METHODS:,1.  The arthroscope and instruments were introduced into the shoulder joint through the arthroscopic portals.,2.  The subacromial space and bursa, biceps tendon, coracoacromial and glenohumeral ligaments, biceps tendon, rotator cuff, supraspinatus, subscapularis, infraspinatus, teres minor, capsulo-labral complex, capsule, glenoid labrum, humeral head, and glenoid, including the inner and outer surfaces of the rotator cuff, were visualized and probed.,3.  The subacromial bursa, subacromial soft tissues and frayed rotator cuff tissue were resected and debrided using a motorized resector and 4.5 Synovial Resector.,4.  The anterior portion of the acromion and acromial spur were resected with the 5.5 acromionizer burr.  Approximately 5 mm of bone was removed.  The coracoacromial ligament was released with the bony resection.  The shoulder joint was thoroughly irrigated.,5.  The edges of the cuff tissue were prepared, prior to the fixation, using the motorized resector.,6.  The supraspinatus tendon was reattached and sutured using the arthroscopic knot pusher and Mitek knotless anchor system and curved pointed suture passer and large bore cannula (to pass the sutures).  The repair was accomplished in a side-to-side and a tendon-to-bone fashion using three double loaded Mitek G IV suture anchors with 1 PDS suture.,7.  The repair was stable to palpation with the probe and watertight.,8.  The arthroscope and instruments were removed from the shoulder.,PATHOLOGY SPECIMEN: , No pathology specimens.,WOUND CLOSURE:,  The joint was thoroughly irrigated with 7 L of sterile saline.  The portal sites were infiltrated with 1% Xylocaine.  The skin was closed with 4-0 Vicryl using interrupted subcuticular technique.,DRAINS / DRESSING:,  Applied sterile dressing including gauze, iodoform gauze and Elastoplast.,SPONGE / INSTRUMENT / NEEDLE COUNTS:,  Final counts were correct.", Surgery,38
"REASON FOR CONSULTATION: , New-onset seizure.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures.  Although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone.  The typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time.  Mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted.  There have been no recent changes in her Keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her.,PAST MEDICAL HISTORY: , Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces.  She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.,PAST SURGICAL HISTORY: , She has undergone no surgical procedures.,FAMILY MEDICAL HISTORY: , There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt.  There is no other significant neurological history on the paternal side of the family.,SOCIAL HISTORY: , Currently lives with her mom, dad, and two siblings.  She is at home full time and does not attend day care.,REVIEW OF SYSTEMS:  ,Clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness.,PHYSICAL EXAMINATION:,Vital Signs:  Weight was 15.6 kg.  She was afebrile.  Remainder of her vital signs were stable and within normal ranges for her age as per the medical record.,General:  She was awake, alert, and oriented.  She was in no acute distress, only slightly flustered when trying to place the EEG leads.,HEENT:  Showed normocephalic and atraumatic head.  Her conjunctivae were nonicteric and sclerae were clear.  Her eye movements were conjugate in nature.  Her tongue and mucous membranes were moist.,Neck:  Trachea appeared to be in the midline.,Chest:  Clear to auscultation bilaterally without crackles, wheezes or rhonchi.,Cardiovascular:  Showed a normal sinus rhythm without murmur.,Abdomen:  Showed soft, nontender, and nondistended, with good bowel sounds.  There was no hepatomegaly or splenomegaly, or other masses noted on examination.,Extremities:  Showed IV placement in the right upper extremity with appropriate restraints from the IV.  There was no evidence of clubbing, cyanosis or edema throughout.  She had no functional deformities in any of her peripheral limbs.,Neurological:  From neurological standpoint, her cranial nerves were grossly intact throughout.  Her strength was good in the bilateral upper and lower extremities without any distal to proximal variation.  Her overall resting tone was normal.  Sensory examination was grossly intact to light touch throughout the upper and lower extremities.  Reflexes were 1+ in bilateral patella.  Toes were downgoing bilaterally.  Coordination showed accurate striking ability and good rapid alternating movements.  Gait examination was deferred at this time due to EEG lead placement.,ASSESSMENT:,  A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.,RECOMMENDATIONS,1.  For now, we will go ahead and try to capture EEG as long as she tolerates it; however, if she would require sedation, I would defer the EEG until further adjustments to seizure medications are made and we will see her response to these medications.,2.  As per the above, I will increase her Keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day.  If further spells are noted, we may increase upwards again to around 4.5 to 5 mL each day.,3.  I do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her EEG findings.  EEG, hopefully, will be able to be reviewed first thing tomorrow morning; however, I would not delay discharge the patient to wait on the EEG results.  The patient has been discharged and we will contact the family as an outpatient.,4.  The patient will need followup arrangement with me in 5 to 6 weeks' time, so we may recheck and see how she is doing and arrange for further followup then.", Consult - History and Phy.,5
"REASON FOR CONSULTATION: , Hemoptysis.,HISTORY OF PRESENT ILLNESS: , The patient is an 80-year-old African-American male, very well known to my service, with a past medical history significant for asbestos exposure.  The patient also has a very extensive cardiac history that would be outlined below.  He is being admitted with worsening shortness of breath and constipation.  He is also complaining of cough and blood mixed with sputum production, but there is no fever.,PAST MEDICAL HISTORY,1.  Benign prostatic hypertrophy.,2.  Peptic ulcer disease.,3.  Atrial fibrillation.,4.  Coronary artery disease.,5.  Aortic valve replacement in 1991, St. Jude mechanical valve #23.,6.  ICD implantation.,7.  Peripheral vascular disease.,8.  CABG in 1991 and 1998.,9.  Congestive heart failure, EF 40%.,10.  Asbestos exposure.,MEDICATIONS,1.  Coumadin 6 mg alternating with 9 mg.,2.  Prevacid 30 mg once a day.,3.  Diovan 160 mg every day.,4.  Flomax 0.4 mg every day.,5.  Coreg 25 mg in the morning and 12.5 mg at night.,6.  Aldactone 25 mg a day.,7.  Lasix 20 mg a day.,8.  Zocor 40 mg every day.,ALLERGIES,1. DARVOCET.,2. CLONIDINE.,PHYSICAL EXAMINATION,GENERAL:  The patient is an elderly male; awake, alert, and oriented, in no acute distress.,VITAL SIGNS:  Blood pressure is 136/80, pulse is 70, respiratory rate is 20, temperature 99.3, pulse oximetry 96% on 2 L nasal cannula.,HEENT:  Significant for peripheral cyanosis.,NECK:  Supple.,LUNGS:  Bibasilar crackles with decreased breath sounds in the left base.,CARDIOVASCULAR:  Regular rate and rhythm with murmur and metallic click.,ABDOMEN:  Soft and benign.,EXTREMITIES:  1+ cyanosis.  No clubbing.  No edema.,LABORATORY DATA:,  Shows a white count of 6.9, hemoglobin 10.6, hematocrit 31.2, and platelet count 160,000.  CK 266, PTT 37, PT 34, and INR 3.7.  Sodium 141, potassium 4.2, chloride 111, CO2 23, BUN 18, creatinine 1.7, glucose 91, calcium 8.6, total protein 6.1, albumin 3.3, total bilirubin 1.4, alkaline phosphatase 56, and troponin I 0.085 and 0.074.,DIAGNOSTIC STUDIES: , Chest x-ray shows previous sternotomy with ICD implantation and aortic valve mechanical implant with left-sided opacification of the diaphragm worrisome for pleural effusion.,ASSESSMENT,1.  Hemoptysis.,2.  Acute bronchitis.,3.  Coagulopathy.,4.  Asbestos exposure.,5.  Left pleural effusion.,RECOMMENDATIONS,1.  Antibiotics.", General Medicine,15
"PROCEDURES PERFORMED: , Esophagogastroduodenoscopy.,PREPROCEDURE DIAGNOSIS: , Dysphagia.,POSTPROCEDURE DIAGNOSIS: , Active reflux esophagitis, distal esophageal stricture, ring due to reflux esophagitis, dilated with balloon to 18 mm.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives.  Risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications.  Vital signs were monitored by blood pressure, heart rate, and oxygen saturation.  Supplemental O2 given.  Specifics of the procedure discussed.  The procedure was discussed with father and mother as the patient is mentally challenged.  He has no complaints of dysphagia usually for solids, better with liquids, worsening over the last 6 months, although there is an emergency department report from last year.  He went to the emergency department yesterday with beef jerky.,All of this reviewed.  The patient is currently on Cortef, Synthroid, Tegretol, Norvasc, lisinopril, DDAVP.  He is being managed for extensive past history due to an astrocytoma, brain surgery, hypothyroidism, endocrine insufficiency.  He has not yet undergone significant workup.  He has not yet had an endoscopy or barium study performed.  He is developmentally delayed due to the surgery, panhypopituitarism.,His family history is significant for his father being of mine, also having reflux issues, without true heartburn, but distal esophageal stricture.  The patient does not smoke, does not drink.  He is living with his parents.  Since his emergency department visitation yesterday, no significant complaints.,Large male, no acute distress.  Vital signs monitored in the endoscopy suite.  Lungs clear.  Cardiac exam showed regular rhythm.  Abdomen obese but soft.  Extremity exam showed large hands.  He was a Mallampati score A, ASA classification type 2.,The procedure discussed with the patient, the patient's mother.  Risks, benefits, and alternatives discussed.  Potential alternatives for dysphagia, such as motility disorder, given his brain surgery, given the possibility of achalasia and similar discussed.  The potential need for a barium swallow, modified barium swallow, and similar discussed.  All questions answered.  At this point, the patient will undergo endoscopy for evaluation of dysphagia, with potential benefit of the possibility to dilate him should there be a stricture.  He may have reflux symptoms, without complaining of heartburn.  He may benefit from a trial of PPI.  All of this reviewed.  All questions answered.,", Gastroenterology,14
"CHIEF COMPLAINT:,  The patient comes for bladder instillation for chronic interstitial cystitis.,SUBJECTIVE:,  The patient is crying today when she arrives in the office saying that she has a lot of discomfort.  These bladder instillations do not seem to be helping her.  She feels anxious and worried.  She does not think she can take any more pain.  She is debating whether or not to go back to Dr. XYZ and ask for the nerve block or some treatment modality to stop the pain because she just cannot function on a daily basis and care for her children unless she gets something done about this, and she fears these bladder instillations because they do not seem to help.  They seem to be intensifying her pain.  She has the extra burden of each time she comes needing to have pain medication one way or another, thus then we would not allow her to drive under the influence of the pain medicine.  So, she has to have somebody come with her and that is kind of troublesome to her.  We discussed this at length.  I did suggest that it was completely appropriate for her to decide.  She will terminate these if they are that uncomfortable and do not seem to be giving her any relief, although I did tell her that occasionally people do have discomfort with them and then after the completion of the instillations, they do better and we have also had some people who have had to terminate the instillations because they were too uncomfortable and they could not stand it and they went on to have some other treatment modality.  She had Hysterectomy in the past.,MEDICATIONS: , Premarin 1.25 mg daily, Elmiron 100 mg t.i.d., Elavil 50 mg at bedtime, OxyContin 10 mg three tablets three times a day, Toprol XL 25 mg daily.,ALLERGIES:,  Compazine and Allegra.,OBJECTIVE:,Vital Signs:  Weight:  140 pounds.  Blood pressure:  132/90.  Pulse:  102.  Respirations:  18.  Age:  27.,PLAN:,  We discussed going for another evaluation by Dr. XYZ and seeking his opinion.  She said that she called him on the phone the other day and told him how miserable she was and he told her that he really thought she needed to complete.  The instillations give that a full trial and then he would be willing to see her back.  As we discussed these options and she was encouraged to think it over and decide what she would like to do for I could not makeup her mind for her.  She said she thought that it was unreasonable to quit now when she only had two or three more treatments to go, but she did indicate that the holiday weekend coming made her fearful and if she was uncomfortable after today’s instillation which she did choose to take then she would choose to cancel Friday’s appointment, also that she would not feel too badly over the holiday weekend.  I thought that was reasonable and agreed that that would work out.,PROCEDURE:,:  She was then given 10 mg of morphine subcutaneously because she did not feel she could tolerate the discomfort in the instillation without pain medicine.  We waited about 20 minutes.  The bladder was then instilled and the urethra was instilled with lidocaine gel which she tolerated and then after a 10-minute wait, the bladder was instilled with DMSO, Kenalog, heparin, and sodium bicarbonate, and the catheter was removed.  The patient retained the solution for one hour, changing position every 15 minutes and then voided to empty the bladder.  She seemed to tolerate it moderately well.  She is to call and let me know what she wishes to do about the Friday scheduled bladder instillation if she tolerated this then she is going to consider trying it.  If not, she will cancel and will start over next week or she will see Dr. Friesen.", Consult - History and Phy.,5
"FINAL DIAGNOSES:,  Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks.  The patient underwent a 2-day induction.  On the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress.  During the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration.  Secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication.  There was a slightly enlarged blood loss at approximately 1200 mL, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees Fahrenheit temperature right at delivery.  It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay.  The patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees Fahrenheit.  The maternal tachycardia resolved within a day.  The patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns.  The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20%.  It should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively.  Therefore, there was anemia but not an unexplained anemia.,PHYSICAL EXAMINATION ON DISCHARGE: , Includes the stable vital signs, afebrile state.  An alert and oriented patient who is desirous at discharge.  Full range of motion, all extremities; fully ambulatory.  Pulse is regular and strong.  Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus.  The incision is beautiful and soft and nontender.  There is scant lochia and there is minimal edema.,LABORATORY STUDIES: , Include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge.,FOLLOWUP: , For the patient includes pelvic rest, regular diet.  Follow up with me in 1 to 2 weeks.  Motrin 800 mg p.o. q.8h. p.r.n. cramps, Tylenol No.  3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d.", Discharge Summary,10
"PREOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,POSTOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,PROCEDURE PERFORMED: , Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,ANESTHESIA:,  LMA.,EBL: , Minimal.,FLUIDS: , Crystalloid.  The patient was given antibiotics, 1 g of Ancef and the patient was on oral antibiotics at home.,BRIEF HISTORY: , The patient is a 61-year-old female with history of recurrent uroseptic stones.  The patient had stones x2, 1 was already removed, second one came down, had recurrent episode of sepsis, stent was placed.  Options were given such as watchful waiting, laser lithotripsy, shockwave lithotripsy etc.  Risks of anesthesia, bleeding, infection, pain, need for stent, and removal of the stent were discussed.  The patient understood and wanted to proceed with the procedure.,DETAILS OF THE PROCEDURE: , The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A 0.035 glidewire was placed in the left system.  Using graspers, left-sided stent was removed.  A semirigid ureteroscopy was done.  A stone was visualized in the mid to upper ureter.  Using laser, the stone was broken into 5 to 6 small pieces.  Using basket extraction, all the pieces were removed.  Ureteroscopy all the way up to the UPJ was done, which was negative.  There were no further stones.  Using pyelograms, the rest of the system appeared normal.  The entire ureter on the left side was open and patent.  There were no further stones.  Due to the edema and the surgery, plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours.  Over the 0.035 glidewire, a 26 double-J stent was placed.  There was a nice curl in the kidney and one in the bladder.  The patient tolerated the procedure well.  Please note that the string was kept in place and the patient was to remove the stent the next day.  The patient's family was instructed how to do so.  The patient had antibiotics and pain medications at home.  The patient was brought to recovery room in a stable condition.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,POSTOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,OPERATION PERFORMED: , Open repair of right pectoralis major tendon.,ANESTHESIA:,  General with an interscalene block.,COMPLICATIONS:,  None.,Needle and sponge counts were done and correct.,INDICATION FOR OPERATION:  ,The patient is a 26-year-old right hand dominant male who works in sales, who was performing heavy bench press exercises when he felt a tearing burning pain severe in his right shoulder.  The patient presented with mild bruising over the proximal arm of the right side with x-ray showing no fracture.  Over concerns for pectoralis tendon tear, he was sent for MRI evaluation where a complete rupture of a portion of the pectoralis major tendon was noted.  Due to the patient's young age and active lifestyle surgical treatment was recommended in order to obtain best result.  The risks and benefits of the procedure were discussed in detail with the patient including, but not limited to scarring, infection, damage to blood vessels and nerves, re-rupture, need further surgery, loss of range of motion, inability to return to heavy activity such as weight lifting, complex usual pain syndrome, and deep vein thrombosis as well as anesthetic risks.  Understanding all risks and benefits, the patient desires to proceed with surgery as planned.,FINDINGS:,1.  Following deltopectoral approach to the right shoulder, the pectoralis major tendon was encountered.  The clavicular head was noted to be intact.  There was noted to be complete rupture of the sternal head of the pectoralis major tendon with an oblique-type tear having some remaining cuff on the humerus and some tendon attached to the retracted portion.,2.  Following freeing of adhesions using tracks and sutures, the pectoralis major tendon was able to reapproximated to its insertion site on the humerus just lateral to the biceps.,3.  A soft tissue repair was performed with #5 FiberWire suture and a single suture anchor of 5 x 5 bioabsorbable anchor was placed in order to decrease tension at the repair site.  Following repair of soft tissue and using the bone anchor, there was noted to be good apposition of the tendon with edges and a solid repair.,OPERATIVE REPORT IN DETAIL: , The patient was identified in the preop holding area.  His right shoulder was identified, marked his appropriate surgical site after verification with the patient.  He was then taken to the operating room where he was transferred to the operative table in supine position and placed under general anesthesia by anesthesiology team.  He then received prophylactic antibiotics.  A time-out was then undertaken verifying the correct patient, extremity, surgery performed, administration of antibiotics, and the availability of equipment.  At this point, the patient was placed to a modified beech chair position with care taken to ensure all appropriate pressure points were padded and there was no pressure over the eyes.  The right upper extremity was then prepped and draped in the usual sterile fashion.  Preoperative markings were still visible at this point.  A deltopectoral incision was made utilizing the inferior portion.  Dissection was carried down.  The deltoid was retracted laterally.  The clavicular head of the pectoralis major was noted to be intact with the absence of the sternal insertion.  There was a small cuff of tissue left on the proximal humerus associated with the clavicular head.  Gentle probing medially revealed the end of the sternal retracted portion, traction sutures of #5 Ethibond were used in this to allow for retraction and freeing from light adhesion.  This allowed reapproximation of the retracted tendon to the tendon stump.  At this point, a repair using #5 FiberWire was then performed of the pectoralis major tendon back to stump on the proximal humerus noting good apposition of the tendon edges and no gapping of the repair site.  At this point, a single metal suture anchor was attempted to be implanted just lateral to the insertion of the pectoralis in order to remove tension off the repair site; however, the inserted device attached to the metal anchor broke during insertion due to significant hardness of the bone.  For this reason, the starting hole was tapped and a 5x5 bioabsorbable anchor was placed, doubly loaded.  The sutures were then weaved through the lateral aspect of the torn tendon and a modified Krackow type performed and sutured thereby relieving tension off the soft tissue repair.  At this point, there was noted to be excellent apposition of the soft tissue ends and a solid repair to gentle manipulation.  Aggressive external rotation was not performed.  The wound was then copiously irrigated.  The cephalic vein was not injured during the case.  The skin was then closed using a 2-0 Vicryl followed by a 3-0 subcuticular Prolene suture with Steri-Strips.  Sterile dressing was then placed.  Anesthesia was then performed, interscalene block.  The patient was then awakened from anesthesia and transported to postanesthesia care in stable condition in a shoulder immobilizer with the arm adducted and internally rotated.,Plan for this patient, the patient will remain in the shoulder immobilizer until followup visit in approximately 10 days.  We will then start a gentle Codman type exercises and having limited motion until the 4-6 week point based on the patient's progression.", Surgery,38
"HISTORY OF PRESENT ILLNESS: , Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first emerged.  He, since 10:17 p.m. on 01/17/10, noted recurrence of his atrial fibrillation, called our office this morning, that is despite being on flecainide, atenolol, and he is maintained on Coumadin.,The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred and we see that on his 12-lead EKG here.  Otherwise, no chest pain.,PAST MEDICAL HISTORY: , Significant for atrial fibrillation/atrial flutter and again he had atrial fibrillation more persistently in 2006, but more recently it has been atrial flutter and that is despite use of antiarrhythmics including flecainide.  He completed a stress test in my office within the past several weeks that was normal without evidence of ischemia.  Other medical history is significant for hyperlipidemia.,MEDICATIONS:,As outpatient,,1.  Atenolol 25 mg once a day.,2.  Altace 2.5 mg once a day.,3.  Zocor 20 mg once a day.,4.  Flecainide 200 in the morning and 100 in the evening.,5.  Coumadin as directed by our office.,ALLERGIES: , TO MEDICATIONS ARE NONE.  HE DENIES SHRIMP, SEA FOOD OR DYE ALLERGY.,FAMILY HISTORY: , He has a nephew who was his sister's son who passed away at age 22 reportedly from an MI, but was reported to have hypertrophic cardiomyopathy as well.  The patient has previously met with the electrophysiologist, Dr. X, at General Hospital and it sounds like he had a negative EP study.,SOCIAL HISTORY: , The patient does not smoke cigarettes, abuse alcohol nor drink any caffeine.  No use of illicit drugs.  He has been married for 22 years and he is actually accompanied throughout today's cardiology consultation by his wife.  He is not participating in regular exercises now because he states since starting flecainide, he has gotten sluggish.  He is employed as an attorney and while he states that overall his mental stress is better, he has noted more recent mental stress this past weekend when he was taking his daughter back to college.,REVIEW OF SYSTEMS: , He denies any history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi.  There are some questions especially as his wife has told me that he may have obstructive sleep apnea and not had a formal sleep study.,PHYSICAL EXAM: , Blood pressure 156/93, pulse is 100, respiratory rate 18.  On general exam, he is a pleasant overweight gentleman, in no acute distress.  HEENT:  Shows cranium is normocephalic and atraumatic.  He has moist mucosal membranes.  Neck veins are not distended.  There are no carotid bruits.  Visible skin warm and perfused.  Affect appropriate.  He is quite oriented and pleasant.  No significant kyphoscoliosis on recumbent back exam.  Lungs are clear to auscultation anteriorly.  No wheezes.  No egophony.  Cardiac Exam:  S1, S2.  Regular rate, controlled.  No significant murmurs, rubs or gallops.  PMI is nondisplaced.  Abdomen is soft, nondistended, appears benign.  Extremities without significant edema.  Pulses grossly intact.,DIAGNOSTIC STUDIES/LAB DATA:,  Initial ECG shows atrial flutter.,IMPRESSION: , Mr. A is a 50-year-old gentleman with a history of paroxysmal atrial fibrillation in the past, more recently is having breakthrough atrial flutter despite flecainide and we had performed a transesophageal echocardiogram-guided cardioversion for him in late 12/20/09, who now has another recurrence within the past 41 hours or so.  I have reviewed again with him in detail regarding risks, benefits, and alternatives of proceeding with cardioversion, which the patient is in favor of.  After in depth explanation of the procedure with him that there would be more definitive resumption of normal sinus rhythm by using electrocardioversion with less long-term side effects, past the acute procedure, alternatives being continued atrial flutter with potential for electrophysiologic consultation for ablation and/or heart rate control with anticoagulation, which the patient was not interested nor was I primarily recommending as the next step, and risks including, but not limited to and the patient was aware and this was all done in the presence of his wife that this is not an all-inclusive list, but the risks include but not limited to oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, which would be less likely as I did confirm with the patient that he had been n.p.o. for greater than 15 hours, risk of induction of other arrhythmias including tachyarrhythmias requiring further management including cardioversion or risk of bradyarrhythmias, in the past when we had a cardioverter with 150 joules, he did have a 5.5-second pause especially while he is on antiarrhythmic therapy, statistically less significant risk of CVA, although we cannot really make that null.  The patient expressed understanding of this risk, benefit, and alternative analysis.  I invited questions from him and his wife and once their questions were answered to their self-stated satisfaction, we planned to go forward with the procedure.,PROCEDURE NOTE:  ,The patient received a total of 7 mg of Versed and 50 micrograms of fentanyl utilizing titrate-down sedation with good effect and this was after the appropriate time-out procedure had been done as per the Medical Center universal protocol with appropriate identification of the patient, position, procedure documentation, procedure indication, and there were no questions.  The patient did actively participate in this time-out procedure.  After the universal protocol was done, he then received the cardioversion attempt with 50 joules using ""lollipop posterior patch"" with hands-driven paddle on the side, which was 50 joules of synchronized biphasic energy.  There was successful resumption of normal sinus rhythm, in fact this time there was not a significant pause as compared to when he had this done previously in late 12/09 and this sinus rhythm was confirmed by a 12-lead EKG.,IMPRESSION: , Cardioversion shows successful resumption of normal sinus rhythm from atrial flutter and that is while the patient has been maintained on Coumadin and his INR is 3.22.  We are going to watch him and discharge him from the Medical Center area on his current flecainide of 200 mg in the morning and 100 mg in the evening, atenolol 25 mg once a day, Coumadin _____ as currently being diagnosed.  I had previously discussed with the patient and he was agreeable with meeting with his electrophysiologist again, Dr. X, at Electrophysiology Unit at General Hospital and I will be planning to place a call for Dr. X myself.  Again, he has no ischemia on this most recent stress test and I suppose in the future it may be reasonable to get obstructive sleep apnea evaluation and that may be one issue promulgating his symptoms.,I had previously discussed the case with Dr. Y who is the patient's general cardiologist as well as updated his wife at the patient's bedside regarding our findings.", Consult - History and Phy.,5
"HISTORY: , Advanced maternal age and hypertension.,FINDINGS:,  There is a single live intrauterine pregnancy with a vertex lie, posterior placenta, and adequate amniotic fluid.  The amniotic fluid index is 23.2 cm.  Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of delivery of 03/28/08.  Based on fetal measurements obtained today, estimated fetal weight is 3249 plus or minus 396 g, 7 pounds 3 ounces plus or minus 14 ounces, which places the fetus in the 66th percentile for the estimated gestational age.  Fetal heart motion at a rate of 156 beats per minute is documented.  The cord Doppler ratio is normal at 2.2.  The biophysical profile score, assessing fetal breathing movement, gross body movement, fetal tone, and qualitative amniotic fluid volume is 8/8.,IMPRESSION:,1.  Single live intrauterine pregnancy in vertex presentation with an estimated gestational age of 36 weeks 4 days and established due date of 03/28/08.,2.  Biophysical profile (BPP) score 8/8.", Radiology,33
"REASON FOR CONSULT:,  Evaluation of alcohol withdrawal and dependance as well as evaluation of anxiety.,HISTORY OF PRESENT ILLNESS: , This is a 50-year-old male who was transferred from Sugar Land ER to ABCD Hospital for admission to the MICU for acute alcohol withdrawal.  The patient had been on a drinking binge for the past 12 days prior to admission and had not been eating.  He reported that he called 911 secondary to noticing bilious vomiting and dry heave.  The patient has been drinking for the past 25 years and has noted it to be a problem for at least the past 3 years.  He has been away from work secondary to alcohol cravings and drinking.  He has also experienced marital and family conflict as a result of his drinking habit.  On average, the patient drinks 5 to 8 glasses or cups of vodka or rum per day, and on the weekend, he tends to drink more heavily.  He reports a history of withdrawal symptoms, but denied history of withdrawal seizures.  His longest period of sobriety was one year, and this was due to the assistance of attending AA meetings.  The patient reports problems with severe insomnia, more so late insomnia and low self esteem as a result of feeling guilty about what he has done to his family due to his drinking habit.  He reports anxiety that is mostly related to concern about his wife's illness and fear of his wife leaving him secondary to his drinking habits.  He denies depressive symptoms.  He denies any psychotic symptoms or perceptual disturbances.  There are no active symptoms of withdrawal at this time.,PAST PSYCHIATRIC HISTORY: , There are no previous psychiatric hospitalizations or evaluations.  The patient denies any history of suicidal attempts.  There is no history of inpatient rehabilitation programs.  He has attended AA for periodic moments throughout the past few years.  He has been treated with Antabuse before.,PAST MEDICAL HISTORY:,  The patient has esophagitis, hypertension, and fatty liver (recently diagnosed).,MEDICATIONS: , His outpatient medications include Lotrel 30 mg p.o. q.a.m. and Restoril 30 mg p.o. q.h.s.,Inpatient medications are Vitamin supplements, potassium chloride, Lovenox 40 mg subcutaneously daily, Lactulose 30 mL q.8h., Nexium 40 mg IV daily, Ativan 1 mg IV p.r.n. q.6-8h.,ALLERGIES:,  No known drug allergies.,FAMILY HISTORY: , Distant relatives with alcohol dependance.  No other psychiatric illnesses in the family.,SOCIAL HISTORY:,  The patient has been divorced twice.  He has two daughters one from each marriage, ages 15 and 22.  He works as a geologist at Petrogas.  He has limited contact with his children.  He reports that his children's mothers have turned them against him.  He and his wife have experienced marital discord secondary to his alcohol use.  His wife is concerned that he may loose his job because he has skipped work before without reporting to his boss.  There are no other illicit drugs except alcohol that the patient reports.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 98, pulse 89, and respiratory rate 20, and blood pressure is 129/83.,MENTAL STATUS EXAMINATION:,  This is a well-groomed male.  He appears his stated age.  He is lying comfortably in bed.  There are no signs of emotional distress.  He is pleasant and engaging.  There are no psychomotor abnormalities.  No signs of tremulousness.  His speech is with normal rate, volume, and inflection.  Mood is reportedly okay.  Affect euthymic.  Thought content, no suicidal or homicidal ideations.  No delusions.  Thought perception, there are no auditory or visual hallucinations.  Thought process, Logical and goal directed.  Insight and judgment are fair.  The patient knows he needs to stop drinking and knows the hazardous effects that drinking will have on his body.,LABORATORY DATA:,  CBC:  WBC 5.77, H&H 14 and 39.4 respectively, and platelets 102,000.  BMP:  Sodium 140, potassium 3, chloride 104, bicarbonate 26, BUN 13, creatinine 0.9, glucose 117, calcium 9.5, magnesium 2.1, phosphorus 2.9, PT 13.4, and INR 1.0.  LFTs:  ALT 64, AST 69, direct bilirubin 0.5, total bilirubin 1.3, protein 5.8, and albumin 4.2.  PFTs within normal limits.,IMAGING:,  CAT scan of the abdomen and pelvis reveals esophagitis and fatty liver.  No splenomegaly.,ASSESSMENT:,  This is a 50-year-old male with longstanding history of alcohol dependence admitted secondary to alcohol withdrawal found to have derangement in liver function tests and a fatty liver.  The patient currently has no signs of withdrawal.  The patient's anxiety is likely secondary to situation surrounding his wife and their marital discord and the effect of chronic alcohol use.  The patient had severe insomnia that is likely secondary to alcohol use.  Currently, there are no signs of primary anxiety disorder in this patient.,DIAGNOSES:,  Axis I:  Alcohol dependence.,Axis II:  Deferred.,Axis III:  Fatty liver, esophagitis, and hypertension.,Axis IV:  Marital discord, estranged from children.,Axis V:  Global assessment of functioning equals 55.,RECOMMENDATIONS:,1.  Continue to taper off p.r.n. Ativan and discontinue all Ativan prior to discharge, benzodiazepine use, also on the same receptor as alcohol and prolonged use can cause relapse in the patient.  Discontinue outpatient Restoril.  The patient has been informed of the hazards of using benzodiazepines along with alcohol.,2.  Continue Alcoholics Anonymous meetings to maintain abstinence.,3.  Recommend starting Campral 666 mg p.o. t.i.d. to reduce alcohol craving.,4.  Supplement with multivitamin, thiamine, and folate upon discharge and before.  Marital counseling strongly advised as well as individual therapy for patient once sobriety is reached.  Referral has been given to the patient and his wife for the sets of counseling #713-263-0829.,5.  Alcohol education and counseling provided during consultation.,6.  Trazodone 50 mg p.o. q.h.s. for insomnia.,7.  Follow up with PCP in 1 to 2 weeks.", Consult - History and Phy.,5
"OPERATION: , Left lower lobectomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  After general endotracheal anesthesia was induced, the appropriate monitoring devices were placed.  The patient was placed in the right lateral decubitus position.  The left chest and back were prepped and draped in a sterile fashion.  A right lateral thoracotomy incision was made.  Subcutaneous flaps were raised.  The anterior border of the latissimus dorsi was freed up, and the muscle was retracted posteriorly.  The posterior border of the pectoralis was freed up and it was retracted anteriorly.  The 5th intercostal space was entered.,The inferior pulmonary ligament was then taken down with electrocautery.  The major fissure was then taken down and arteries identified.  The artery was dissected free and it was divided with an Endo GIA stapler.  The vein was then dissected free and divided with an Endo GIA stapler.  The bronchus was then cleaned of all nodal tissue.  A TA-30 green loaded stapler was then placed across this, fired, and main bronchus divided distal to the stapler.,Then the lobe was removed and sent to pathology where margins were found to be free of tumor.  Level 9, level 13, level 11, and level 6 nodes were taken for permanent cell specimen.  Hemostasis noted.  Posterior 28-French and anterior 24-French chest tubes were placed.,The wounds were closed with #2 Vicryl.  A subcutaneous drain was placed.  Subcutaneous tissue was closed with running 3-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.", Surgery,38
"REASON FOR CONSULT:,  Altered mental status.,HPI:,  The patient is 77-year-old Caucasian man with benign prostatic hypertrophy, status post cardiac transplant 10 years ago who was admitted to the Physical Medicine and Rehab Service for inpatient rehab after suffering a right cerebellar infarct last month.  Last night, he became confused and he eloped from the unit.  When he was found, he became combative.  This a.m., he continued to be aggressive and required administration of four-point soft restraints in addition to Haldol 1 mg intramuscularly.  There was also documentation of him having paranoid thoughts that his wife was going out spending his money instead of being with him in the hospital.  Given this presentation, Psychiatry was consulted to evaluate and offer management recommendations.,The patient states that he does remember leaving the unit looking for his wife, but does not recall becoming combative, needing restrains and emergency medications.  He reports feeling fine currently, denying any complaints.  The patient's wife notes that her husband might be confused and disoriented due to being in the hospital environment.  She admits that he has some difficulty with memory for sometime and becomes irritable when she is not around.  However, he has never become as combative as he has this particular episode.,He negates any symptoms of depression or anxiety.  He also denies any hallucinations or delusions.  He endorses problems with insomnia.  At home, he takes temazepam.  His wife and son note that the temazepam makes him groggy and disoriented at times when he is at home.,PAST PSYCHIATRIC HISTORY:,  He denies any prior psychiatric treatment or intervention.  However, he was placed on Zoloft 10 years ago after his heart transplant, in addition to temazepam for insomnia.  During this hospital course, he was started on Seroquel 20 mg p.o. q.h.s. in addition to Aricept 5 mg daily.  He denies any history of suicidal or homicidal ideations or attempts.,PAST MEDICAL HISTORY:,1.  Heart transplant in 1997.,2.  History of abdominal aortic aneurysm repair.,3.  Diverticulitis.,4.  Cholecystectomy.,5.  Benign prostatic hypertrophy.,ALLERGIES:,  MORPHINE AND DEMEROL.,MEDICATIONS:,1.  Seroquel 50 mg p.o. q.h.s., 25 mg p.o. q.a.m.,2.  Imodium 2 mg p.o. p.r.n., loose stool.,3.  Calcium carbonate with vitamin D 500 mg b.i.d.,4.  Prednisone 5 mg p.o. daily.,5.  Bactrim DS Monday, Wednesday, and Friday.,6.  Flomax 0.4 mg p.o. daily.,7.  Robitussin 5 mL every 6 hours as needed for cough.,8.  Rapamune 2 mg p.o. daily.,9.  Zoloft 50 mg p.o. daily.,10.  B vitamin complex daily.,11.  Colace 100 mg b.i.d.,12.  Lipitor 20 mg p.o. q.h.s.,13.  Plavix 75 mg p.o. daily.,14.  Aricept 5 mg p.o. daily.,15.  Pepcid 20 mg p.o. daily.,16.  Norvasc 5 mg p.o. daily.,17.  Aspirin 325 mg p.o. daily.,SOCIAL HISTORY:,  The patient is a retired paster and missionary to Mexico.  He is still actively involved in his church.  He denies any history of alcohol or substance abuse.,MENTAL STATUS EXAMINATION:,  He is an average-sized white male, casually dressed, with wife and son at bedside.  He is pleasant and cooperative with good eye contact.  He presents with paucity of speech content; however, with regular rate and rhythm.  He is tremulous which is worse with posturing also some increased motor tone noted.  There is no evidence of psychomotor agitation or retardation.  His mood is euthymic and supple and reactive, appropriate to content with reactive affect appropriate to content.  His thoughts are circumstantial but logical.  He defers most of his responses to his wife.  There is no evidence of suicidal or homicidal ideations.  No presence of paranoid or bizarre delusions.  He denies any perceptual abnormalities and does not appear to be responding to internal stimuli.  His attention is fair and his concentration impaired.  He is oriented x3 and his insight is fair.  On mini-mental status examination, he has scored 22 out of 30.  He lost 1 for time, lost 1 for immediate recall, lost 2 for delayed recall, lost 4 for reverse spelling and could not do serial 7s.  On category fluency, he was able to name 17 animals in one minute.  He was unable to draw clock showing 2 minutes after 10.  His judgment seems limited.,LABORATORY DATA:,  Calcium 8.5, magnesium 1.8, phosphorous 3, pre-albumin 27, PTT 24.8, PT 14.1, INR 1, white blood cell count 8.01, hemoglobin 11.5, hematocrit 35.2, and platelet count 255,000.  Urinalysis on January 21, 2007, showed trace protein, trace glucose, trace blood, and small leukocyte esterase.,DIAGNOSTIC DATA:,  MRI of brain with and without contrast done on January 21, 2007, showed hemorrhagic lesion in right cerebellar hemisphere with diffuse volume loss and chronic ischemic changes.,ASSESSMENT:,AXIS I:,1.  Delirium resulting due to general medical condition versus benzodiazepine ,intoxication/withdrawal.,2.  Cognitive disorder, not otherwise specified, would rule out vascular dementia.,3.  Depressive disorder, not otherwise specified.", Psychiatry / Psychology,32
"PREOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes, bilateral intraabdominal testes.,PROCEDURE: , Examination under anesthesia and laparoscopic right orchiopexy.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FLUIDS RECEIVED:  ,110 mL of crystalloid.,INTRAOPERATIVE FINDINGS: , Atrophic bilateral testes, right is larger than left.  The left had atrophic or dysplastic vas and epididymis.,TUBES AND DRAINS: , No tubes or drains were used.,INDICATIONS FOR OPERATION:  ,The patient is a 7-1/2-month-old boy with bilateral nonpalpable testes.  Plan is for exploration, possible orchiopexy.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then palpated and again both testes were nonpalpable.  Because of this, a laparoscopic approach was then elected.  We then sterilely prepped and draped the patient, put an 8-French feeding tube in the urethra, attached to bulb grenade for drainage.  We then made an infraumbilical incision with a 15-blade knife and then further extended with electrocautery and with curved mosquito clamps down to the rectus fascia where we made stay sutures of 3-0 Monocryl on the anterior and posterior sheaths and then opened up the fascia with the curved Metzenbaum scissors.  Once we got into the peritoneum, we placed a 5-mm port with 0-degree short lens.  Insufflation was then done with carbon dioxide up to 10 to 12 mmHg.  We then evaluated.  There was no bleeding noted.  He had a closed ring on the left with a small testis that was evaluated and found to have short vessels as well as atrophic or dysplastic vas, which was barely visualized.  The right side was also intraabdominal, but slightly larger, had better vessels, had much more recognizable vas, and it was closer to the internal ring.  So, we elected to do an orchiopexy on the right side.  Using the laparoscopic 3- and 5-mm dissecting scissors, we then opened up the window at the internal ring through the peritoneal tissue, then dissected it medially and laterally along the line of the vas and along the line of the vessels up towards the kidney, mid way up the abdomen, and across towards the bladder for the vas.  We then used the Maryland dissector to gently tease this tissue once it was incised.  The gubernaculum was then divided with electrocautery and the laparoscopic scissors.  We were able to dissect with the hook dissector in addition to the scissors the peritoneal shunts with the vessels and the vas to the point where we could actually stretch and bring the testis across to the other side, left side of the ring.  We then made a curvilinear incision on the upper aspect of the scrotum on the right with a 15-blade knife and extended down the subcutaneous tissue with electrocautery.  We used the curved tenotomy scissors to make a subdartos pouch.  Using a mosquito clamp, we were able to go in through the previous internal ring opening, grasped the testis, and then pulled it through in a proper orientation.  Using the hook electrode, we were able to dissect some more of the internal ring tissue to relax the vessels and the vas, so there was no much traction.  Using 2 stay sutures of 4-0 chromic, we tacked the testis to the base of scrotum into the middle portion of the testis.  We then closed the upper aspect of the subdartos pouch with a 4-0 chromic and then closed the subdartos pouch and the skin with subcutaneous 4-0 chromic.  We again evaluated the left side and found again that the vessels were quite short.  The testis was more atrophic, and the vas was virtually nonexistent.  We will go back at a later date to try to bring this down, but it will be quite difficult and has a higher risk for atrophy because of the tissue that is present.  We then removed the ports, closed the fascial defects with figure-of-eight suture of 3-0 Monocryl, closed the infraumbilical incision with two Monocryl stay sutures to close the fascial sheath, and then used 4-0 Rapide to close the skin defects, and then using Dermabond tissue adhesives, we covered all incisions.  At the end of the procedure, the right testis was well descended within the scrotum, and the feeding tube was removed.  The patient had IV Toradol and was in stable condition upon transfer to recovery room.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  Cataract, nuclear sclerotic, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, nuclear sclerotic, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with intraocular lens implantation, right eye.,ANESTHESIA: , Topical tetracaine, intracameral lidocaine, monitored anesthesia care.,IOL: , AMO Model SI40 NB, power *** diopters.,INDICATIONS FOR SURGERY: , This patient has been experiencing difficulty with eyesight regarding activities in their daily life.  There has been a progressive and gradual decline in the visual acuity.  By examination, this was found to be related to cataracts.  The risks, benefits, and alternatives (including observation or spectacles) were discussed in detail.  The patient accepted these risks and elected to proceed with cataract surgery.  All questions were answered and informed consent was obtained.,Questions were answered in personal conference with the patient to ensure that the patient had a good grasp of the operative goals, risks, and alternatives involved as well as the postoperative instructions.  A preoperative surgical history and physical examination was done to ensure that the patient was in optimal general health for cataract surgery.  To minimize and decrease the chance of bacterial infection, the patient was started on a course of antibiotic drops for two days prior to surgery.,DESCRIPTION OF PROCEDURE:  ,The patient was identified and the procedure was verified.  The pupil was dilated per protocol.  The patient was taken to the operating room and placed in a comfortable supine position.  The operative table was placed in Trendelenburg head-up tilt to decrease orbital congestion and posterior vitreous pressure.  The patient was prepped and draped in the usual ophthalmic sterile fashion.  The lids and periorbita were prepped with full-strength Betadine solution with care taken to concentrate on sterilizing the eyelid margins.  The conjunctival cul-de-sac was also prepped in dilute Betadine solution.  The fornices were also prepped.  The drape was done meticulously to ensure complete eyelash inclusion.,An eyelid speculum was placed to separate the eyelids.  A paracentesis site was made.  Intracameral preservative-free lidocaine was injected.  Amvisc Plus was then used to stabilize the anterior chamber.  A 3-mm diamond blade was then used to carefully construct a clear corneal incision in the temporal location.  A 25-gauge pre-bent cystotome was used to begin a capsulorrhexis.  The capsular flap was removed.  A 27-gauge blunt cannula was used for hydrodissection.  The lens was able to be freely rotated within the capsular bag.  Divide-and-conquer technique was used for phacoemulsification.  After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment.  Each of the four nuclear quadrants was phacoemulsified.  Aspiration was used to remove remaining cortex with the I/A handpiece.  Viscoelastic was used to re-inflate the capsular bag.  The intraocular lens was injected into the capsular bag.  The lens was then dialed into position.  The lens was well-centered and stable.  Viscoelastic was aspirated.  BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure along with stromal hydration.  A Weck-Cel sponge was used to check both incision sites for leaks and none were identified.  The incision sites remained well approximated and dry with a well-formed anterior chamber and well-centered intraocular lens.  The eyelid speculum was removed and the patient was cleaned free of Betadine.  Zymar and Pred Forte drops were applied.  A firm eye shield was taped over the operative eye.  The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed.  All questions were answered.  The discharge instructions were also reviewed with the patient by the discharging nurse.  The patient was comfortable and was discharged with followup in 24 hours.", Surgery,38
"PREOPERATIVE DIAGNOSES:,1.  Neuromuscular dysphagia.,2.  Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSES:,1.  Neuromuscular dysphagia.,2.  Protein-calorie malnutrition.,PROCEDURES PERFORMED:,1.  Esophagogastroduodenoscopy with photo.,2.  Insertion of a percutaneous endoscopic gastrostomy tube.,ANESTHESIA:,  IV sedation and local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well without difficulty.,BRIEF HISTORY:  ,The patient is a 50-year-old African-American male who presented to ABCD General Hospital on 08/18/2003 secondary to right hemiparesis from a CVA.  The patient deteriorated with several CVAs and had became encephalopathic requiring a ventilator-dependency with respiratory failure.  The patient also had neuromuscular dysfunction.  After extended period of time, per the patient's family request and requested by the ICU staff, decision to place a feeding tube was decided and scheduled for today.,INTRAOPERATIVE FINDINGS: , The patient was found to have esophagitis as well as gastritis via EGD and was placed on Prevacid granules.,PROCEDURE: , After informed written consent, the risks and benefits of the procedure were explained to the patient and the patient's family.  First, the EGD was to be performed.,The Olympus endoscope was inserted through the mouth, oropharynx and into the esophagus.  Esophagitis was noted.  The scope was then passed through the esophagus into the stomach.  The cardia, fundus, body, and antrum of the stomach were visualized.  There was evidence of gastritis.  The scope was passed into the duodenal bulb and sweep via the pylorus and then removed from the duodenum retroflexing on itself in the stomach looking at the hiatus.  Next, attention was made to transilluminating the anterior abdominal wall for the PEG placement.  The skin was then anesthetized with 1% lidocaine.  The finder needle was then inserted under direct visualization.  The catheter was then grasped via the endoscope and the wire was pulled back up through the patient's mouth.  The Ponsky PEG tube was attached to the wire.  A skin nick was made with a #11 blade scalpel.  The wire was pulled back up through the abdominal wall point and Ponsky PEG back up through the abdominal wall and inserted into position.  The endoscope was then replaced confirming position.  Photograph was taken.  The Ponsky PEG tube was trimmed and the desired attachments were placed and the patient did tolerate the procedure well.  We will begin tube feeds later this afternoon.", Gastroenterology,14
"INDICATION: , Paroxysmal atrial fibrillation.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 55-year-old white female with multiple myeloma.  She is status post chemotherapy and autologous stem cell transplant.  Latter occurred on 02/05/2007.  At that time, she was on telemetry monitor and noticed to be in normal sinus rhythm.,As part of study protocol for investigational drug for prophylaxis against mucositis, she had electrocardiogram performed on 02/06/2007.  This demonstrated underlying rhythm of atrial fibrillation with rapid ventricular response at 125 beats per minute.  She was subsequently transferred to telemetry for observation.  Cardiology consultation was requested.  Prior to formal consultation, the patient did have an echocardiogram performed on 02/06/2007, which showed a structurally normal heart with normal left ventricular (LV) systolic function, ejection fraction of 60%, aortic sclerosis without stenosis, a trivial pericardial effusion with no evidence for immunocompromise and mild tricuspid regurgitation with normal pulmonary atrial pressures.  Overall, essentially normal heart.,At the time of my evaluation, the patient felt somewhat jittery and nervous, but otherwise asymptomatic.,PAST MEDICAL HISTORY:,  Multiple myeloma, diagnosed in June of 2006, status post treatment with thalidomide and Coumadin.  Subsequently, with high-dose chemotherapy followed by autologous stem cell transplant.,PAST SURGICAL HISTORY: , Cosmetic surgery of the nose and forehead.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,CURRENT MEDICATIONS,1.  Acyclovir 400 mg p.o. b.i.d.,2.  Filgrastim 300 mcg subcutaneous daily.,3.  Fluconazole 200 mg daily.,4.  Levofloxacin 250 mg p.o. daily.,5.  Pantoprazole 40 mg daily.,6.  Ursodiol 300 mg p.o. b.i.d.,7.  Investigational drug is directed ondansetron 24 mg p.r.n.,FAMILY HISTORY: , Unremarkable.  Father and mother both alive in their mid 70s.  Father has an unspecified heart problem and diabetes.  Mother has no significant medical problems.  She has one sibling, a 53-year-old sister, who has a pacemaker implanted for unknown reasons.,SOCIAL HISTORY: , The patient is married.  Has four adult children.  Good health.  She is a lifetime nonsmoker, social alcohol drinker.,REVIEW OF SYSTEMS: , Prior to treatment for her multiple myeloma, she was able to walk four miles nonstop.  Currently, she has dyspnea on exertion on the order of one block.  She denies any orthopnea or paroxysmal nocturnal dyspnea.  She denies any lower extremity edema.  She has no symptomatic palpitations or tachycardia.  She has never had presyncope or syncope.  She denies any chest pain whatsoever.  She denies any history of coagulopathy or bleeding diathesis.  Her oncologic disorder is multiple myeloma.  Pulmonary review of systems is negative for recurrent pneumonias, bronchitis, reactive airway disease, exposure to asbestos or tuberculosis.  Gastrointestinal (GI) review of systems is negative for known gastroesophageal reflux disease, GI bleed, and hepatobiliary disease.  Genitourinary review of systems is negative for nephrolithiasis or hematuria.  Musculoskeletal review of systems is negative for significant arthralgias or myalgias.  Central nervous system (CNS) review of systems is negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.  Psychiatric review of systems is negative for known affective or cognitive disorders.,PHYSICAL EXAMINATION,GENERAL:  This is a well-nourished, well-developed white female who appears her stated age and somewhat anxious.,VITAL SIGNS:  She is afebrile at 97.4 degrees Fahrenheit with a heart rate ranging from 115 to 150 beats per minute, irregularly irregular.  Respirations are 20 breaths per minute and blood pressure ranges from 90/59 to 107/68 mmHg.  Oxygen saturation on room air is 94%.,HEENT:  Benign being normocephalic and atraumatic.  Extraocular motions are intact.  Her sclerae are anicteric and conjunctivae are noninjected.  Oral mucosa is pink and moist.,NECK:  Jugular venous pulsations are normal.  Carotid upstrokes are palpable bilaterally.  There is no audible bruit.  There is no lymphadenopathy or thyromegaly at the base of the neck.,CHEST:  Cardiothoracic contour is normal.  Lungs, clear to auscultation in all lung fields.,CARDIAC:  Irregularly irregular rhythm and rate.  S1, S2 without a significant murmur, rub, or gallop appreciated.  Point of maximal impulse is normal, no right ventricular heave.,ABDOMEN:  Soft with active bowel sounds.  No organomegaly.  No audible bruit.  Nontender.,LOWER EXTREMITIES:  Nonedematous.  Femoral pulses were deferred.,LABORATORY DATA: , EKG, electrocardiogram showed underlying rhythm of atrial fibrillation with a rate of 125 beats per minute.  Nonspecific ST-T wave abnormality is seen in the inferior leads only.,White blood cell count is 9.8, hematocrit of 30 and platelets 395.  INR is 0.9.  Sodium 136, potassium 4.2, BUN 43 with a creatinine of 2.0, and magnesium 2.9.  AST and ALT 60 and 50.  Lipase 343 and amylase 109.  BNP 908.  Troponin was less than 0.02.,IMPRESSION: , A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.,Currently enrolled in a blinded study, where she may receive a drug for prophylaxis against mucositis, which has at least one reported incident of acceleration of preexisting tachycardia.,RECOMMENDATIONS,1.  Atrial fibrillation.  The patient is currently hemodynamically stable, tolerating her dysrhythmia.  However, given the risk of thromboembolic complications, would like to convert to normal sinus rhythm if possible.  Given that she was in normal sinus rhythm approximately 24 hours ago, this is relatively acute onset within the last 24 hours.  We will initiate therapy with amiodarone 150 mg intravenous (IV) bolus followed by mg/minute at this juncture.  If she does not have spontaneous cardioversion, we will consider either electrical cardioversion or anticoagulation with heparin within 24 hours from initiation of amiodarone.,As part of amiodarone protocol, please check TSH.  Given her preexisting mild elevation of transaminases, we will follow LFTs closely, while on amiodarone.,2.  Thromboembolic risk prophylaxis, as discussed above.  No immediate indication for anticoagulation.  If however she does not have spontaneous conversion within the next 24 hours, we will need to initiate therapy.  This was discussed with Dr. X.  Preference would be to run intravenous heparin with PTT of 45 during her thrombocytopenic nadir and initiation of full-dose anticoagulation once nadir is resolved.,3.  Congestive heart failure.  The patient is clinically euvolemic.  Elevated BNP possibly secondary to infarct or renal insufficiency.  Follow volume status closely.  Follow serial BNPs.,4.  Followup.  The patient will be followed while in-house, recommendations made as clinically appropriate.", Consult - History and Phy.,5
"SUBJECTIVE:,  The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation.  The patient is doing fairly well.  This afternoon, she called me because heart rate was in the range of 120 to 140.  The patient is lying down.  She does have shortness of breath, but denies any other significant symptoms.,PAST MEDICAL HISTORY:,  History of mastectomy, chest tube placement, and atrial fibrillation; chronic.,MEDICATIONS:,1.  Cardizem, which is changed to 60 mg p.o. t.i.d.,2.  Digoxin 0.25 mg daily.,3.  Coumadin, adjusted dose.,4.  Clindamycin.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse 122 and blood pressure 102/68.,LUNGS:  Air entry decreased.,HEART:  PMI is displaced.  S1 and S2 are irregular.,ABDOMEN:  Soft and nontender.,IMPRESSION:,1.  Pulmonary disorder with lung mass.,2.  Pleural effusion.,3.  Chronic uncontrolled atrial fibrillation secondary to pulmonary disorder.,RECOMMENDATIONS:,1.  From cardiac standpoint, follow with pulmonary treatment.,2.  The patient has an INR of 2.09.  She is on anticoagulation.  Atrial fibrillation is chronic with the rate increased.,Adjust the medications accordingly as above.", SOAP / Chart / Progress Notes,35
"HISTORY OF PRESENT ILLNESS: , The patient is a 26-year-old female, referred to Physical Therapy for low back pain.  The patient has a history of traumatic injury to low back.  The patient stated initial injury occurred eight years ago, when she fell at a ABC Store.  The patient stated she received physical therapy, one to two visits and received modality treatment only, specifically electrical stimulation and heat pack per patient recollection.  The patient stated that she has had continuous low-back pain at varying degrees for the past eight years since that fall.  The patient gave birth in August 2008 and since the childbirth, has experienced low back pain.  The patient also states that she fell four to five days ago, while mopping her floor.  The patient stated that she landed on her tailbone and symptoms have increased since that fall.  The patient stated that her initial physician examination with Dr. X was on 01/10/09, and has a followup appointment on 02/10/09.,PAST MEDICAL HISTORY: , The patient denies high blood pressure, diabetes, heart disease, lung disease, thyroid, kidney, or bladder dysfunctions.  The patient stated that she quit smoking prior to her past childbirth and is currently not pregnant.  The patient has had a C-section and also an appendectomy.  The patient was involved in a motor vehicle accident four to five years ago and at that time, the patient did not require any physical therapy nor did she report any complaints of increased back pain following that accident.,MEDICATIONS: , Patient currently states she is taking:,1.  Vicodin 500 mg two times a day.,2.  Risperdal.,3.  Zoloft.,4.  Stool softeners.,5.  Prenatal pills.,DIAGNOSTIC IMAGERY:  ,The patient states she has not had an MRI performed on her lumbar spine.  The patient also states that Dr. X took x-rays two weeks ago, and no fractures were found at that time.  Per physician note, dated 12/10/08, Dr. X dictated that the x-ray showed an anterior grade 1 spondylolisthesis of L5 over S1, and requested Physical Therapy to evaluate and treat.,SUBJECTIVE:  ,The patient states that pain is constant in nature with a baseline of 6-7/10 with pain increasing to 10/10 during the night or in cold weather.  The patient states that pain is dramatically less, when the weather is warmer.  The patient also states that pain worsens as the day progresses, in that she also hard time getting out of bed in the morning.  The patient states that she does not sleep at night well and sleeps less than one hour at a time.,Aggravating factors include, sitting for periods greater than 20 minutes or lying supine on her back.  Easing factors include side lying position in she attempts to sleep.,OBJECTIVE: , AGE:  26 years old.  HEIGHT:  5 feet 2 inches.  WEIGHT:  The patient is an obese 26-year-old female.,ACTIVE RANGE OF MOTION: , Lumbar spine, flexion, lateral flexion and rotation all within functional limits without complaints of pain or soreness while performing them during evaluation.,PALPATION:  ,The patient complained of bilateral SI joint point tenderness.  The patient also complained of left greater trochanter hip point tenderness.  The patient also complained of bilateral paraspinal tenderness on cervical spine to lumbar spine.,STRENGTH:  ,RIGHT LOWER EXTREMITY:,Knee extension 5/5, hip flexion 5/5, knee flexion 4/5, internal and external hip rotation was 4/5.  With manual muscle testing of knee flexion, hip, internal and external rotation, the patient reports an increase in right SI joint pain to 8/10.,LEFT LOWER EXTREMITY:,Hip flexion 5/5, knee extension 5/5, knee flexion 4/5, hip internal and external rotation 4/5, with slight increase in pain level with manual muscle testing and resistance.  It must be noted that PT did not apply as much resistance during manual muscle testing, secondary to the 8/10 pain elicited during the right lower extremity.,NEUROLOGICAL:  ,The patient subjectively complains of numbness with tingling in her bilateral extremities when she sits longer than 25 minutes.  However, they subside when she stands.  The patient did complain of this numbness and tingling during the evaluation and the patient was seated for a period of 20 minutes.  Upon standing, the patient stated that the numbness and tingling subsides almost immediately.  The patient stated that Dr. X told her that he believes that during her past childbirth when the epidural was being administered that there was a possibility that a sensory nerve may have been also affected during the epidural less causing the numbness and tingling in her bilateral lower extremities.  The patient does not demonstrate any sensation deficits with gentle pressure to the lumbar spine and during manual muscle testing.,GAIT:  ,The patient ambulated out of the examination room, while carrying her baby in a car seat.,ASSESSMENT:  ,The patient is a 26-year-old overweight female, referred to Physical Therapy for low back pain.  The patient presents with lower extremity weakness, which may be contributing to her lumbosacral pain, in that she has poor lumbar stabilization with dynamic ADLs, transfers, and gait activity when fatigued.  At this time, the patient may benefit from skilled physical therapy to address her decreased strength and core stability in order to improve her ADL, transfer, and mobility skills.,PROGNOSIS: , The patient's prognosis for physical therapy is good for dictated goals.,SHORT-TERM GOALS TO BE ACHIEVED IN TWO WEEKS:,1.  The patient will be able to sit for greater than 25 minutes without complaints of paraesthesia or pain in her bilateral lower extremities or bilateral SI joints.,2.  The patient will increase bilateral hip internal and external rotation to 4/5 with SI joint pain less than or equal to 5/10.,3.  The patient will report 25% improvement in her functional and ADL activities.,4.  Pain will be less than 4/10 while performing __________ while at PT session.,LONG-TERM GOALS TO BE ACCOMPLISHED IN ONE MONTH:,1.  The patient will be independent with home exercise program.,2.  Bilateral hamstring, bilateral hip internal and external rotation strength to be 4+/5 with SI joint pain less than or equal to 2/10, while performing manual muscle test.,3.  The patient will report 60% improvement or greater in functional transfers in general ADL activity.,4.  The patient will be able to sit greater than or equal to 45 minutes without complaint of lumbosacral pain.,5.  The patient will be able to sleep greater than 2 hours without pain.,TREATMENT PLAN:,1.  Therapeutic exercises to increase lower extremity strength and assist with lumbar sacral stability.", Orthopedic,27
"REASON FOR NEUROLOGICAL CONSULTATION: , Cervical spondylosis and kyphotic deformity.  The patient was seen in conjunction with medical resident Dr. X. I personally obtained the history, performed examination, and generated the impression and plan.,HISTORY OF PRESENT ILLNESS: ,The patient is a 45-year-old African-American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain.  This has subsequently resolved.  She started vigorous workouts in November 2005.  In March of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician.  By her report, she had a nerve conduction study and a diagnosis of radiculopathy was made.  She had an MRI of lumbosacral spine, which was within normal limits.  She then developed a tingling sensation in the right middle toe.  Symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe.  She then started getting sensory sensations in the left hand and arm.  She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg.  Symptoms have been mildly progressive.  She is unaware of any trigger other than the vigorous workouts as mentioned above.  She has no associated bowel or bladder symptoms.  No particular position relieves her symptoms.,Workup has included two MRIs of the C-spine, which were personally reviewed and are discussed below.  She saw you for consultation and the possibility of surgical decompression was raised.  At this time, she is somewhat reluctant to go through any surgical procedure.,PAST MEDICAL HISTORY:,1.  Ocular migraines.,2.  Myomectomy.,3.  Infertility.,4.  Hyperglycemia.,5.  Asthma.,6.  Hypercholesterolemia.,MEDICATIONS: , Lipitor, Pulmicort, Allegra, Xopenex, Patanol, Duac topical gel, Loprox cream, and Rhinocort.,ALLERGIES: , Penicillin and aspirin.,Family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet.  Of note, she does not drink or smoke.  She is married with two adopted children.  She is a paralegal specialist.  She used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,REVIEW OF SYSTEMS: , She does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,PHYSICAL EXAMINATION: , On examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds.  Pain scale is 0.  A full general and neurological examination was personally performed and is documented on the chart.  Of note, she has a normal general examination.  Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk.  She has mild postural tremor in both arms.  She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities.  Motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis.  She has hyperreflexia in her lower extremities, worse on the left.  Babinski's are downgoing.,PERTINENT DATA:  ,MRI of the brain from 05/02/06 and MRI of the C-spine from 05/02/06 and 07/25/06 were personally reviewed.  MRI of the brain is broadly within normal limits.  MRI of the C-spine reveals large central disc herniation at C6-C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema.  There is also a fairly large disc at C3-C4 with cord deformity and partial effacement of the subarachnoid space.  I do not appreciate any cord edema at this level.,IMPRESSION AND PLAN:  ,The patient is a 45-year-old female with cervical spondylosis with a large C6-C7 herniated disc with mild cord compression and signal change at that level.  She has a small disc at C3-C4 with less severe and only subtle cord compression.  History and examination are consistent with signs of a myelopathy.,Results were discussed with the patient and her mother.  I am concerned about progressive symptoms.  Although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis.  If she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis.  I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation.  I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem.  I have recommended that she wear a hard collar while driving.  The results of my consultation were discussed with you telephonically.", Consult - History and Phy.,5
"CC:, Lethargy.,HX:, This 28y/o RHM was admitted to a local hospital on 7/14/95 for marked lethargy. He had been complaining of intermittent headaches and was noted to have subtle changes in personality for two weeks prior to 7/14/95. On the morning of 7/14/95, his partner found him markedly lethargic and complaingin of abdominal pain and vomiting. He denied fevers, chills, sweats, cough, CP, SOB or diarrhea. Upon evaluation locally, he had a temperature of 99.5F and appeared lethargic. He also had anisocoria with left pupil 0.5mm bigger than the right. There was also question of left facial weakness. An MRI was obtained and revealed a large left hemispheric mass lesion with surrounding edema and mass effect. He was given 10mg of IV Decardron,100gm of IV Mannitol, intubated and hyperventilated and transferred to UIHC.,He was admitted to the Department of Medicine on 7/14/95, and transferred to the Department of Neurology on 7/17/95, after being extubated.,MEDS ON ADMISSION:, Bactrim DS qd, Diflucan 100mg qd, Acyclovir 400mg bid, Xanax, Stavudine 40mg bid, Rifabutin 300mg qd.,PMH:, 1) surgical correction of pyoloric stenosis, age 1, 2)appendectomy, 3) HIV/AIDS dx 1991. He was initially treated with AZT, then DDI. He developed chronic diarrhea and was switched to D4T in 1/95. However, he developed severe neuropathy and this was stopped 4/95. The diarrhea recured. He has Acyclovir resistant genital herpes and generalized psoriasis. He most recent CD4 count (within 1 month of admission) was 20.,FHX:, HTN and multiple malignancies of unknown type.,SHX:, Homosexual, in monogamous relationship with an HIV infected partner for the past 3 years.,EXAM: ,7/14/95 (by Internal Medicine): BP134/80, HR118, RR16 on vent, 38.2C, Intubated.,MS: Somnolent, but opened eyes to loud voices and would follow most commands.,CN: Pupils 2.5/3.0 and ""equally reactive to light."" Mild horizontal nystagmus on rightward gaze. EOM were otherwise intact.,MOTOR: Moved 4 extremities well.,Sensory/Coord/Gait/Station/Reflexes: not done.,Gen EXAM: Penil ulcerations.,EXAM:, 7/17/96 (by Neurology): BP144/73, HR59, RR20, 36.0, extubated.,MS: Alert and mildly lethargic. Oriented to name only. Thought he was a local hospital and that it was 1/17/1994. Did not understand he had a brain lesion.,CN: Pupils 6/5.5 decreasing to 4/4 on exposure to light. EOM were full and smooth. No RAPD or light-near dissociation. papilledema (OU). Right lower facial weakness and intact facial sensation to PP testing. Gag-shrug and corneal responses were intact, bilaterally. Tongue midline.,MOTOR: Grade 5- strength on the right side.,Sensory: no loss of sensation on PP/VIB/PROP testing.,Coord: reduced speed and accuracy on right FNF and right HKS movements.,Station: RUE pronator drift.,Gait: not done.,Reflexes: 2+/2 throughout. Babinski sign present on right and absent on left.,Gen Exam: unremarkable except for the genital lesion noted by Internal medicine.,COURSE:, The outside MRI was reviewed and was notable for the left frontal/parietal mass lesion with surround edema. The mass inhomogenously enhanced with gadolinium contrast.,The findings were consistent most with lymphoma, though toxoplasmosis could not be excluded. He refused brain biopsy and was started on empiric treatment for toxoplasmosis. This consisted of Pyrimethamine 75mg qd and Sulfadiazine 2 g bid. He later became DNR and was transferred at his and his partner's request Back to a local hospital.,He never returned for follow-up.", Neurology,22
"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.", Radiology,33
"PREOPERATIVE DIAGNOSIS: , Antibiotic-associated diarrhea.  ,POSTOPERATIVE DIAGNOSIS:  ,Antibiotic-associated diarrhea.  ,OPERATION PERFORMED: , Colonoscopy with random biopsies and culture.,INDICATIONS: , The patient is a 50-year-old woman who underwent hemorrhoidectomy approximately one year ago.  She has been having difficulty since that time with intermittent diarrhea and abdominal pain.  She states this happens quite frequently and can even happen when she uses topical prednisone for her ears or for her eyes.  She presents today for screening colonoscopy, based on the same.,OPERATIVE COURSE:  , The risks and benefits of colonoscopy were explained to the patient in detail.  She provided her consent.  The morning of the operation, the patient was transported from the preoperative holding area to the endoscopy suite.  She was placed in the left lateral decubitus position.  In divided doses, she was given 7 mg of Versed and 125 mcg of fentanyl.  A digital rectal examination was performed, after which time the scope was intubated from the anus to the level of the hepatic flexure.  This was intubated fairly easily; however, the patient was clearly in some discomfort and was shouting out, despite the amount of anesthesia she was provided.  In truth, the pain she was experiencing was out of proportion to any maneuver or difficulty with the procedure.  While more medication could have been given, the patient is actually a fairly thin woman and diminutive and I was concerned that giving her any more sedation may lead to respiratory or cardiovascular collapse.  In addition, she was really having quite some difficulty staying still throughout the procedure and was putting us all at some risk.  For this reason, the procedure was aborted at the level of the hepatic flexure.  She was noted to have some pools of stool.  This was suctioned and sent to pathology for C difficile, ova and parasites, and fecal leukocytes.  Additionally, random biopsies were performed of the colon itself.  It is unfortunate we were unable to complete this procedure, as I would have liked to have taken biopsies of the terminal ileum.  However, given the degree of discomfort she had, again, coupled with the relative ease of the procedure itself, I am very suspicious of irritable bowel syndrome.  The patient tolerated the remainder of the procedure fairly well and was sent to the recovery room in stable condition, where it is anticipated she will be discharged to home.,PLAN:,  She needs to follow up with me in approximately 2 weeks' time, both to follow up with her biopsies and cultures.  She has been given a prescription for VSL3, a probiotic, to assist with reculturing the rectum.  She may also benefit from an antispasmodic and/or anxiolytic.  Lastly, it should be noted that when she next undergoes endoscopic procedure, propofol would be indicated.", Gastroenterology,14
"PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Abnormal uterine bleeding.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Abnormal uterine bleeding.,PROCEDURE PERFORMED: , Total abdominal hysterectomy with a uterosacral vault suspension.,ANESTHESIA: , General with endotracheal tube as well as spinal with Astramorph.,ESTIMATED BLOOD LOSS: , 150 cc.,URINE OUTPUT:  ,250 cc of clear urine at the end of the procedure.,FLUIDS:,  2000 cc of crystalloids.,COMPLICATIONS: , None.,TUBES: , None.,DRAINS:  ,Foley to gravity.,PATHOLOGY: , Uterus, cervix, and multiple fibroids were sent to pathology for review.,FINDINGS:  ,On exam, under anesthesia, normal appearing vulva and vagina, a massively enlarged uterus approximately 20 weeks' in size with irregular contours suggestive of fibroids.,Operative findings demonstrated a large fibroid uterus with multiple subserosal and intramural fibroids as well as there were some filmy adnexal adhesions bilaterally.  The appendix was normal appearing.  The bowel and omentum were normal appearing.  There was no evidence of endometriosis.  Peritoneal surfaces and vesicouterine peritoneum as well as appendix and cul-de-sac were all free of any evidence of endometriosis.,PROCEDURE:,  After informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the Operating Room where first a spinal anesthesia with Astramorph was obtained without any difficulty.  She then underwent a general anesthesia with endotracheal tube also without any difficulty.  She was then examined under anesthesia with noted findings as above.  The patient was then placed in dorsal supine position and prepped and draped in the usual sterile fashion..  A vertical skin incision was made 1 cm below the umbilicus extending down to 2 cm above the pubic symphysis.  This was made with a first knife and then carried down to the underlying layer of the fascia with the second knife.  Fascia was excised in the midline and extended superiorly and inferiorly with the Mayo scissors.  The rectus muscle was then separated in the midline.  The peritoneum identified and entered bluntly.  The peritoneal incision was then extended superiorly and inferiorly with external visualization of the bladder.  The uterus was markedly evident upon entering the peritoneal cavity.  The uterus was then exteriorized and noted to have the findings as above.  At this point, approximately 10 cc of vasopressin 20 units and 30 cc was injected into the uterine fundus and multiple fibroids were removed by using the incision with the Bovie and then using a blunt and the sharp dissection and grasping with Lahey clamps.  Once the debulking of the uterus was felt appropriate to proceed with the hysterectomy, the uterus was then reapproximated with a few #0 Vicryl sutures in a figure-of-eight fashion.  The round ligaments were identified bilaterally and clamped with the hemostats and transacted with the Metzenbaum scissors.  The round ligaments were then bilaterally tied with the #0 tie and noted to be hemostatic.  The uterovarian vessels bilaterally were then isolated through a vascular window created from taking down the round ligaments.  The uterovarian vessels bilaterally were #0 tied and then doubly clamped with straight Ochsner clamps and transacted and suture tied with a Heaney hand stitch fashion, and both uterine and ovarian vessels were noted to be hemostatic.  At this time, the attention was then turned to the vesicouterine peritoneum, which was tented up with Allis clamps and the bladder flap was then created sharply with Russian pickups and the Metzenbaum scissors.  Then the bladder was bluntly dissected off the underlying cervix with a moist Ray-Tec sponge down to the level of the cervix.,At this point, the uterus was pulled on traction and the uterosacral ligaments were easily visualized.  Using #2-0 PDS suture, the suture was placed through both uterosacral ligaments distally with a backhand stitch fashion throwing the sutures from lateral to medial.  These sutures were then tagged and saved for later.  The uterine vessels were then identified bilaterally and skeletonized, then clamped with straight Ochsner clamps balancing off the cervix, and the uterine vessels were then transacted and suture ligated with #0 Vicryl and noted to be hemostatic.  In a similar fashion, the broad ligament down to the level of the cardinal ligaments was clamped with curved Ochsner and transacted and suture ligated and noted to be hemostatic.  At this point, the Lahey clamp was placed on the cervix and the cervix was tented up.  The pubocervical vesical fascia was transacted with long knife.  Then while protecting posteriorly, using the double-pointed scissors, the vagina was entered with double-pointed scissors at the level of the cervix and was grasped with a straight Ochsner clamp.  The uterus and cervix were then amputated using the Jorgenson scissors and the cuff was outlined with Ochsner clamps.  The cuff was then copiously painted with Betadine soaked sponge.  The Betadine-soaked sponge was placed in the patient's vagina.  Then the cuff was then closed with a #0 Vicryl in a running locked fashion to make sure to bring the ipsilateral cardinal ligaments into the vaginal cuff.  This was accomplished with one #0 Vicryl running stitch and then an Allis clamp was placed in the midsection portion of the cuff and tented up and a #0 Vicryl figure-of-eight was placed in the midsection portion of the cuff.  At this time, the uterosacral ligaments previously tagged needle was brought through the cardinal ligament and the uterosacral ligament on the ipsilateral side.  The needle was cut off and these were then tagged with the hemostats.  The cuff was then closed by taking the running suture and bringing back through the posterior peritoneum, grabbing part of the uterosacral and midsection portion of the posterior peritoneum of the uterosacral and then tying the cuff down to bunch and cuff together.  The suture in the midportion of the cuff was then used to tie down the round ligaments bilaterally to the cuff.  The abdomen was copiously irrigated with warm normal saline.  All areas were noted to be hemostatic.  Then the previously tagged uterosacral sutures were then tied bringing the vaginal cuff angles down to the uterosacral ligaments.  The abdomen was then once again copiously irrigated with warm normal saline.  All areas were noted to be hemostatic.  The sigmoid colon was replaced back into the hollow of the sacrum.  Then the omentum was pulled over the bowel.  After the myomectomy was performed, the GYN Balfour was placed into the patient's abdomen and the bowel was packed away with moist laparotomy sponges.  The GYN Balfour was then removed.  Packing sponges were removed and the fascia was then closed in an interrupted figure-of-eight fashion with #0 Vicryl.,Skin was closed with staples.  The patient tolerated the procedure well.  The sponge, lap, and needle counts were correct x2.  The sponge from the patient's vagina was removed and the vagina was noted to be hemostatic.  The patient would be followed throughout her hospital stay.", Obstetrics / Gynecology,24
"CYSTOSCOPY & VISUAL URETHROTOMY,OPERATIVE NOTE:,  The patient was placed in the dorsal lithotomy position and prepped and draped in the usual manner under satisfactory general anesthesia.  A Storz urethrotome sheath was inserted into the urethra under direct vision.  Visualization revealed a stricture in the bulbous urethra.  This was intubated with a 0.038 Teflon-coated guidewire, and using the straight cold urethrotomy knife, it was incised to 12:00 to allow free passage of the scope into the bladder.  Visualization revealed no other lesions in the bulbous or membranous urethra.  Prostatic urethra was normal for age.  No foreign bodies, tumors or stones were seen within the bladder.  Over the guidewire, a #16-French Foley catheter with a hole cut in the tip with a Cook cutter was threaded over the guidewire and inserted into the bladder and inflated with 10 mL of sterile water.,He was sent to the recovery room in stable condition.", Urology,39
"PROCEDURE PERFORMED: , Umbilical hernia repair.,PROCEDURE:,  After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine.  The patient was prepped and draped in the usual sterile manner.,A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.  The sac was cleared of overlying adherent tissue, and the fascial defect was delineated.  The fascia was cleared of any adherent tissue for a distance of 1.5 cm from the defect.  The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures.  The umbilicus was then re-formed using 4-0 Vicryl to tack the umbilical skin to the fascia.,The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The skin was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.", Gastroenterology,14
"PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES: , Rectal bleeding and perirectal abscess.,POSTOPERATIVE DIAGNOSIS: , Perianal abscess.,MEDICATIONS:,  MAC.,DESCRIPTION OF PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  The preparation was excellent and all surfaces were well seen.  The mucosa throughout the colon and in the terminal ileum was normal, with no evidence of colitis.  Special attention was paid to the rectum, including retroflexed views of the distal rectum and the anorectal junction.  There was no evidence of either inflammation or a fistulous opening.  The scope was withdrawn.  A careful exam of the anal canal and perianal area demonstrated a jagged 8-mm opening at the anorectal junction posteriorly (12 o'clock position).  Some purulent material could be expressed through the opening.  There was no suggestion of significant perianal reservoir of inflamed tissue or undrained material.  Specifically, the posterior wall of the distal rectum and anal canal were soft and unremarkable.  In addition, scars were noted in the perianal area.  The first was a small dimpled scar, 1 cm from the anal verge in the 11 o'clock position.  The second was a dimpled scar about 5 cm from the anal verge on the left buttock's cheek.  There were no other abnormalities noted.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Normal colonoscopy to the terminal ileum.,2.  Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.,RECOMMENDATIONS:,1.  Continue antibiotics.,2.  Followup with Dr. X.,3.  If drainage persists, consider surgical drainage.", Surgery,38
"HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging.  She was doing well until about 2 days ago, when she developed gagging.  No vomiting.  No fever.  She has history of constipation.  She normally passes stool every two days after giving an enema.  No rectal bleeding.  She was brought to the Hospital with some loose stool.  She was found to be dehydrated.  She was given IV fluid bolus, but then she started bleeding from G-tube site.  There was some fresh blood coming out of the G-tube site.  She was transferred to PICU.  She is hypertensive.  Intensivist Dr. X requested me to come and look at her, and do upper endoscopy to find the site of bleeding.,PAST MEDICAL HISTORY: , PEHO syndrome, infantile spasm, right above knee amputation, developmental delay, G-tube fundoplication.,PAST SURGICAL HISTORY: , G-tube fundoplication on 05/25/2007.  Right above knee amputation.,ALLERGIES:,  None.,DIET: , She is NPO now, but at home she is on PediaSure 4 ounces 3 times a day through G-tube, 12 ounces of water per day.,MEDICATIONS: , Albuterol, Pulmicort, MiraLax 17 g once a week, carnitine, phenobarbital, Depakene and Reglan.,FAMILY HISTORY:,  Positive for cancer.,PAST LABORATORY EVALUATION: , On 12/27/2007; WBC 9.3, hemoglobin 7.6, hematocrit 22.1, platelet 132,000.  KUB showed large stool with dilated small and large bowel loops.  Sodium 140, potassium 4.4, chloride 89, CO2 21, BUN 61, creatinine 2, AST 92 increased, ALT 62 increased, albumin 5.3, total bilirubin 0.1.  Earlier this morning, she had hemoglobin of 14.5, hematocrit 41.3, platelets 491,000.  PT 58 increased, INR 6.6 increased, PTT 75.9 increased.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99 degrees Fahrenheit, pulse 142 per minute, respirations 34 per minute, weight 8.6 kg.,GENERAL:  She is intubated.,HEENT:  Atraumatic.  She is intubated.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Distended.  Decreased bowel sounds.,GENITALIA:  Grossly normal female.,CNS:  She is sedated.,IMPRESSION: , A 3-year-old female patient with history of passage of blood through G-tube site with coagulopathy.  She has a history of G-tube fundoplication, developmental delay, PEHO syndrome, which is progressive encephalopathy optic atrophy.,PLAN:  ,Plan is to give vitamin K, FFP, blood transfusion.  Consider upper endoscopy.  Procedure and informed consent discussed with the family.", Gastroenterology,14
"PREOPERATIVE DIAGNOSES:,1.  Partial rotator cuff tear with impingement syndrome.,2.  Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.,POSTOPERATIVE DIAGNOSES:,1.  Partial rotator cuff tear with impingement syndrome.,2.  Degenerative osteoarthritis of acromioclavicular joint, left shoulder.,PROCEDURE PERFORMED:,1.  Arthroscopy with arthroscopic rotator cuff debridement.,2.  Anterior acromioplasty.,3.  Mumford procedure left shoulder.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operative Suite, Room #1 at ABCD General Hospital.  This was done in a modified beach chair position with interscalene and subsequent general anesthetic.,HISTORY AND GROSS FINDINGS: , This is a 38-year-old morbidly obese white male suffering increasing pain in his left shoulder for a number of months prior to surgical intervention.  He was refractory to conservative outpatient therapy.  He had injection of his AC joint, which removed symptoms but was not long lasting.  After discussing the alternatives of the care as well as advantages and disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Intraarticular viewing of the joint revealed a partial rotator cuff tear on the supraspinatus insertion on the joint side.  All else was noted to be intact including the glenohumeral joint, the long head of the biceps, and the labrum.  The remainder of the rotator cuff observed was noted to be intact.  Subacromially, the patient was noted to have increased synovitis.  Degenerative changes were noted upon observation of the distal clavicle.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table.  After receiving interscalene block anesthetic by Anesthesia Department, the patient was placed in modified beach chair position.  He was prepped and draped in the usual sterile manner.  Portals were created posteriorly and anteriorly from outside to in.  A full and complete diagnostic intraarticular arthroscopy was carried out.  Debridement was carried out through a 3.5 meniscal shaver to the 4.2 meniscal shaver to the undersurface of the partial tear of the rotator cuff.  Retrospectively it was approximately 25% of the generalized thickness.,Attention was then turned to the subacromial region.  The scope was directed subacromially.  A portal was created laterally.  Ultimately, the patient needed a general anesthetic once we were closer to the distal clavicle.  Gross bursectomy was carried out with a 4.2 meniscal shaver.  #18-gauge spinal needles have been placed to outline the anterior acromion prior to this.,It was difficult to control the patient's blood pressure with systolics ranging anywhere from 165 or 170 up to 200.  Because of this and difficulties with his anesthetic, it was elected to change to an open procedure.  Thus, the patient was anesthetized safely and secured.  An oblique incision was carried at the cross Langer's line across the outlet of the shoulder through the skin and subcutaneous tissue.  Hemostasis was controlled via electrocoagulation.  Flaps were created.  Anterior deltoid was reflected inferiorly.  Anterior acromioplasty was carried out with a saw then a Micro-Aire and then a beaver-tail rasp.  An excellent decompression was present.  CA ligament had been previously resected.  We then took the incision over the distal clavicle.  The end of the distal clavicle approximately 12 mm to 14 mm was isolated and removed with the Micro-Aire saw.  The beaver-tail rasp was utilized to smooth off the edges.  Pain buster catheter was placed deep to closure of the AC capsule and then to the deltoid with interrupted #1 Vicryl.  Transosseous sutures were placed across the acromion and the deltoid was elevated and closed with the same.  A superficial running #2-0 Vicryl suture was utilized for deltoid closure distally.  Interrupted #2-0 Vicryl was utilized to subcutaneous fat closure, running #4-0 subcuticular stitch for skin closure and Adaptic, 4x4s, ABDs, and Elastoplast tape placed for compression dressing.  0.25% Marcaine was flooded into the joint prior to the skin closure.  Pain buster catheter was hooked up.  The patient's arm was placed in arm sling.  He was safely transferred to the PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.", Orthopedic,27
"PREOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes, bilateral intraabdominal testes.,PROCEDURE: , Examination under anesthesia and laparoscopic right orchiopexy.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FLUIDS RECEIVED:  ,110 mL of crystalloid.,INTRAOPERATIVE FINDINGS: , Atrophic bilateral testes, right is larger than left.  The left had atrophic or dysplastic vas and epididymis.,TUBES AND DRAINS: , No tubes or drains were used.,INDICATIONS FOR OPERATION:  ,The patient is a 7-1/2-month-old boy with bilateral nonpalpable testes.  Plan is for exploration, possible orchiopexy.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then palpated and again both testes were nonpalpable.  Because of this, a laparoscopic approach was then elected.  We then sterilely prepped and draped the patient, put an 8-French feeding tube in the urethra, attached to bulb grenade for drainage.  We then made an infraumbilical incision with a 15-blade knife and then further extended with electrocautery and with curved mosquito clamps down to the rectus fascia where we made stay sutures of 3-0 Monocryl on the anterior and posterior sheaths and then opened up the fascia with the curved Metzenbaum scissors.  Once we got into the peritoneum, we placed a 5-mm port with 0-degree short lens.  Insufflation was then done with carbon dioxide up to 10 to 12 mmHg.  We then evaluated.  There was no bleeding noted.  He had a closed ring on the left with a small testis that was evaluated and found to have short vessels as well as atrophic or dysplastic vas, which was barely visualized.  The right side was also intraabdominal, but slightly larger, had better vessels, had much more recognizable vas, and it was closer to the internal ring.  So, we elected to do an orchiopexy on the right side.  Using the laparoscopic 3- and 5-mm dissecting scissors, we then opened up the window at the internal ring through the peritoneal tissue, then dissected it medially and laterally along the line of the vas and along the line of the vessels up towards the kidney, mid way up the abdomen, and across towards the bladder for the vas.  We then used the Maryland dissector to gently tease this tissue once it was incised.  The gubernaculum was then divided with electrocautery and the laparoscopic scissors.  We were able to dissect with the hook dissector in addition to the scissors the peritoneal shunts with the vessels and the vas to the point where we could actually stretch and bring the testis across to the other side, left side of the ring.  We then made a curvilinear incision on the upper aspect of the scrotum on the right with a 15-blade knife and extended down the subcutaneous tissue with electrocautery.  We used the curved tenotomy scissors to make a subdartos pouch.  Using a mosquito clamp, we were able to go in through the previous internal ring opening, grasped the testis, and then pulled it through in a proper orientation.  Using the hook electrode, we were able to dissect some more of the internal ring tissue to relax the vessels and the vas, so there was no much traction.  Using 2 stay sutures of 4-0 chromic, we tacked the testis to the base of scrotum into the middle portion of the testis.  We then closed the upper aspect of the subdartos pouch with a 4-0 chromic and then closed the subdartos pouch and the skin with subcutaneous 4-0 chromic.  We again evaluated the left side and found again that the vessels were quite short.  The testis was more atrophic, and the vas was virtually nonexistent.  We will go back at a later date to try to bring this down, but it will be quite difficult and has a higher risk for atrophy because of the tissue that is present.  We then removed the ports, closed the fascial defects with figure-of-eight suture of 3-0 Monocryl, closed the infraumbilical incision with two Monocryl stay sutures to close the fascial sheath, and then used 4-0 Rapide to close the skin defects, and then using Dermabond tissue adhesives, we covered all incisions.  At the end of the procedure, the right testis was well descended within the scrotum, and the feeding tube was removed.  The patient had IV Toradol and was in stable condition upon transfer to recovery room.", Urology,39
"PREOPERATIVE DIAGNOSIS:,  Nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES:,  Kelman phacoemulsification with posterior chamber intraocular lens, right eye.,ANESTHESIA:,  Topical.,COMPLICATIONS:,  None.,INDICATION: , This is a 40-year-old male, who has been noticing problems with blurry vision.  They were found to have a visually significant cataract.  The risks, benefits, and alternatives of cataract surgery to the right eye were discussed and they did agree to proceed.,DESCRIPTION OF PROCEDURE:,  After informed consent was obtained, the patient was taken to the operating room.  A drop of tetracaine was instilled in the right eye and the right eye was prepped and draped in the usual sterile ophthalmic fashion.  A paracentesis was created at ** o'clock.  The anterior chamber was filled with Viscoat.  A clear corneal incision was made at ** o'clock with the 3-mm diamond blade.  A continuous curvilinear capsulorrhexis was begun with a cystotome and completed with Utrata forceps.  The lens was hydrodissected with a syringe filled with 2% Xylocaine and found to rotate freely within the capsular bag.  The nucleus was removed with the phacoemulsification handpiece in a stop and chop fashion.  The residual cortex was removed with the irrigation/aspiration handpiece.  The capsular bag was filled with Provisc and a model SI40, 15.0 diopter, posterior chamber intraocular lens was inserted into the capsular bag without complications and was found to rotate and center well.  The residual Provisc was removed with the irrigation/aspiration handpiece.  The wounds were hydrated and the eye was filled to suitable intraocular pressure with balanced salt solution.  The wounds were found to be free from leak.  Zymar and Pred Forte were instilled postoperatively.  The eye was covered with the shield.,The patient tolerated the procedure well and there were no complications.  He will follow up with us in one day.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Chronic plantar fasciitis, right foot.,POSTOPERATIVE DIAGNOSIS:,  Chronic plantar fasciitis, right foot.,PROCEDURE: , Open plantar fasciotomy, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY:,  The patient has had a longstanding history of foot problems.  The foot problem has been progressive in nature and has not been responsive to conservative care despite multiple attempts at conservative care.  The preoperative discussion with the patient including alternative treatment options, the procedure itself was explained, and risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, falling arch, digital contracture, and the postoperative management were discussed.  The patient has been advised, although no guarantee for success could be given, most of the patients have improved function and less pain.  All questions were thoroughly answered.  The patient requested for surgical repair since the problem has reached a point to interfere with normal daily activities.  The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF THE PROCEDURE:  ,The patient was given 1 g Ancef for antibiotic prophylaxis 30 minutes prior to the procedure.  The patient was brought to the operating room and placed in the supine position.  Following a light IV sedation, a posterior tibial nerve block and local infiltrate of the operative site was performed with 10 mL, and a 1:1 mixture of 1% lidocaine with epinephrine, and 0.25% Marcaine was affected.  The lower extremity was prepped and draped in the usual sterile manner.  Balance anesthesia was obtained.,PROCEDURE:, Plantar fasciotomy, right foot.  The plantar medial tubercle of the calcaneus was palpated and a vertical oblique incision, 2 cm in length with the distal aspect overlying the calcaneal tubercle was affected. Blunt dissection was carried out to expose the deep fascia overlying the abductor hallucis muscle belly and the medial plantar fascial band.  A periosteal elevator did advance laterally across the inferior aspect of the medial and central plantar fascial bands, creating a small and narrow soft tissue tunnel.  Utilizing a Metzenbaum scissor, transection of the medial two-third of the plantar fascia band began at the junction of the deep fascia of the abductor hallucis muscle belly and medial plantar fascial band, extending to the lateral two-thirds of the band.  The lateral plantar fascial band was left intact.  Visualization and finger probe confirmed adequate transection.  The surgical site was flushed with normal saline irrigation.,The deep layer was closed with 3-0 Vicryl and the skin edges coapted with combination of 1 horizontal mattress and simples.  The dressing consisted of Adaptic, 4 x 4, conforming bandages, and an ACE wrap to provide mild compression.  The patient tolerated the procedure and anesthesia well, and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact.  A walker boot was dispensed and applied.  The patient will be allowed to be full weightbearing to tolerance, in the boot to encourage physiological lengthening of the release of plantar fascial band.,The next office visit will be in 4 days.  The patient was given prescriptions for Keflex 500 mg 1 p.o. three times a day x10 days and Lortab 5 mg #40, 1 to 2 p.o. q.4-6 h. p.r.n. pain, 2 refills, along with written and oral home instructions.  After a short recuperative period, the patient was discharged home with vital signs stable and in no acute distress.", Orthopedic,27
"CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD WITHOUT CONTRAST,TECHNIQUE:,  Noncontrast axial CT images of the head were obtained.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection.  The ventricles and cortical sulci are normal in shape and configuration.  The gray/white matter junctions are well preserved.  There is no calvarial fracture.  The visualized paranasal sinuses and mastoid air cells are clear.,IMPRESSION: , Negative for acute intracranial disease.,CT CERVICAL SPINE,TECHNIQUE:  ,Noncontrast axial CT images of the cervical spine were obtained.  Sagittal and coronal images were obtained.,FINDINGS:,  Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms.  No fracture or subluxation is seen.  Anterior and posterior osteophyte formation is seen at C5-C6.  No abnormal anterior cervical soft tissue swelling is seen.  No spinal compression is noted.  The atlanto-dens interval is normal.  There is a large retention cyst versus polyp within the right maxillary sinus.,IMPRESSION:,1.  Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms.,2.  Degenerative disk and joint disease at C5-C6.,3.  Retention cyst versus polyp of the right maxillary sinus.", Neurology,22
"REASON FOR CONSULTATION:,  Acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.,HISTORY OF PRESENTING ILLNESS:  ,Briefly, this is a 36-year-old robust Caucasian gentleman with no significant past medical or surgical history, who works as a sales representative, doing a lot of traveling by plane and car and attending several sales shows, developed acute shortness of breath with an episode of syncope this weekend and was brought in by paramedics to Hospital.  A V/Q scan revealed multiple pulmonary perfusion defects consistent with high probability pulmonary embolism.  A Doppler venous study of the lower extremity also revealed nonocclusive right popliteal vein thrombosis.  A CT of the abdomen and pelvis revealed normal-appearing liver, spleen, and pancreas; however, the right kidney appeared smaller compared to left and suggesting possibility of renal infarct.  Renal function on admission was within normal range; however, serial renal function showed rapid increase in creatinine to 5 today.  He has been on intravenous heparin and hemodialysis is being planned for tomorrow.  Reviewing his history, there is no family members with hypercoagulable state or prior history of any thrombotic complication.  He denies any recent injury to his lower extremity and in fact denied any calf pain or swelling.,PAST MEDICAL AND SURGICAL HISTORY:  ,Unremarkable.,SOCIAL HISTORY: , He is married and has 1 son.  He has a brother who is healthy.  There is no history of tobacco use or alcohol use.,FAMILY HISTORY:,  No family history of hypercoagulable condition.,MEDICATIONS:  ,Advil p.r.n.,ALLERGIES: , NONE.,REVIEW OF SYSTEMS: , Essentially unremarkable except for sudden onset dyspnea on easy exertion complicated with episode of syncope.  He denied any hemoptysis.  He denied any calf swelling or pain.  Lately, he has been traveling and has been sitting behind a desk for a long period of time.,PHYSICAL EXAMINATION:,GENERAL:  He is a robust young gentleman, awake, alert, and hemodynamically stable.,HEENT:  Sclerae anicteric.  Conjunctivae normal.  Oropharynx normal.,NECK:  No adenopathy or thyromegaly.  No jugular venous distention.,HEART:  Regular.,LUNGS:  Bilateral air entry.,ABDOMEN:  Obese and benign.,EXTREMITIES:  No calf swelling or calf tenderness appreciated.,SKIN:  No petechiae or ecchymosis.,NEUROLOGIC:  Nonfocal.,LABORATORY FINDINGS:,  Blood count obtained showed a white count of 16.8, hemoglobin 14.8 g percent, hematocrit 44.6%, MCV 94, and platelet count 209,000.  Liver profile normal.  Thyroid study revealed a TSH of 1.3.  Prothrombin time/INR 1.5, partial thromboplastin time 78.6 seconds.  Renal function, BUN 44 and creatinine 5.7.  Echocardiogram revealed left ventricular hypertrophy with ejection fraction of 65%, no intramural thrombus noted.,IMPRESSION:,1.  Bilateral pulmonary embolism, most consistent with emboli from right lower extremity, on intravenous heparin, rule out hereditary hypercoagulable state.,2.  Leukocytosis, most likely leukemoid reaction secondary to acute pulmonary embolism/renal infarction, doubt presence of myeloproliferative disorder.,3.  Acute renal failure secondary to embolic right renal infarction.,4.  Obesity.,PLAN: , From hematologic standpoint, we will await hypercoagulable studies, which have all been sent on admission to see if a hereditary component is at play.  For now, we will continue intravenous heparin and subsequent oral anticoagulation with Coumadin.  In view of worsening renal function, may need temporary hemodialysis until renal function improves.  I discussed at length with the patient's wife at the bedside.", Consult - History and Phy.,5
"REASON FOR CONSULT:, Anxiety.,CHIEF COMPLAINT:,  ""I felt anxious yesterday."",HPI:,  A 69-year-old white female with a history of metastatic breast cancer, depression, anxiety, recent UTI, and obstructive uropathy, admitted to the ABCD Hospital on February 6, 2007, for lightheadedness, weakness, and shortness of breath.  The patient was consulted by Psychiatry for anxiety.  I know this patient from a previous consult.  During this recent admission, the patient has experienced anxiety and had a panic attack yesterday with ""syncopal episodes.""  She was given Ativan 0.25 mg on a p.r.n. basis with relief after one to two hours.  The patient was seen by Abc, MD, and Def, Ph.D.  The laboratories were reviewed and were positive for UTI, and anemia is also present.  The TSH level was within normal limits.  She previously responded well to trazodone for depression, poor appetite, and decreased sleep and anxiety.  A low dose of Klonopin was also helpful for sedation.,PAST MEDICAL HISTORY:,  Metastatic breast cancer to bone.  The patient also has a history of hypertension, hypothyroidism, recurrent UTI secondary to obstruction of left ureteropelvic junction, cholelithiasis, chronic renal insufficiency, Port-A-Cath placement, and hydronephrosis.,PAST PSYCHIATRIC HISTORY:,  The patient has a history of depression and anxiety.  She was taking Remeron 15 mg q.h.s., Ambien 5 mg q.h.s. on a p.r.n. basis, Ativan 0.25 mg every 6 hours on a p.r.n. basis, and Klonopin 0.25 mg at night while she was at home.,FAMILY HISTORY:,  There is a family history of colorectal cancer, lung cancer, prostate cancer, cardiac disease, and Alzheimer disease in the family.,SOCIAL HISTORY:,  The patient is married and lives at home with her husband.  She has a history of smoking one pack per day for 18 years.  The patient quit in 1967.  According to the chart, the patient also drinks wine everyday for the last 50 years, usually one to two drinks per day.,MEDICATIONS:,1.  Klonopin 0.25 mg p.o. every evening.,2.  Fluconazole 200 mg p.o. daily.,3.  Synthroid 125 mcg p.o. everyday.,4.  Remeron 15 mg p.o. at bedtime.,5.  Ceftriaxone IV 1 g in 1/2 NS every 24 hours.,P.R.N. MEDICATIONS:,1.  Tylenol 650 mg p.o. every 4 hours.,2.  Klonopin 0.5 mg p.o. every 8 hours.,3.  Promethazine 12.5 mg every 4 hours.,4.  Ambien 5 mg p.o. at bedtime.,ALLERGIES:,No known drug allergies,LABORATORY DATA:,These laboratories were done on February 6,2007, sodium 137, potassium 3.9, chloride 106, bicarbonate 21, BUN 35, creatinine 1.5, glucose 90.  White blood cell 5.31, hemoglobin 11.2, hematocrit 34.7, platelet count 152000.  TSH level 0.88.  The urinalysis was positive for UTI.,MENTAL STATUS EXAMINATION:,GENERAL APPEARANCE:  The patient is dressed in a hospital gown.  She is lying in bed during the interview.  She is well groomed with good hygiene.,MOTOR ACTIVITY:  No psychomotor retardation or agitation noted.  Good eye contact.,ATTITUDE:  Pleasant and cooperative.,ATTENTION AND CONCENTRATION:  Normal.  The patient does not appear to be distracted during the interview.,MOOD:  Okay.,AFFECT:  Mood congruent normal affect.,THOUGHT PROCESS:  Logical and goal directed.,THOUGHT CONTENT:  No delusions noted.,PERCEPTION:  Did not assess.,MEMORY:  Not tested.,SENSORIUM:  Alert.,JUDGMENT:  Good.,INSIGHT:  Good.,IMPRESSION:,1.  AXIS I:  Possibly major depression or generalized anxiety disorder.,2.  AXIS II:  Deferred.,3.  AXIS III:  Breast cancer with metastasis, hydronephrosis secondary to chronic uteropelvic junction obstruction status post stent placement, hypothyroidism.,4.  AXIS IV:  Interpersonal stressors.", Consult - History and Phy.,5
"FINAL DIAGNOSIS: ,I. Ligature strangulation.,A. Circumferential ligature with associated ligature furrow of neck.,B. Abrasions and petechial hemorrhages, neck.,C. Petechial hemorrhages, conjunctival surfaces of eyes and skin of face.,II. Craniocerebral injuries.,A. Scalp contusion.,B. Linear, comminuted fracture of right side of skull.,C. Linear pattern of contusions of right cerebral hemisphere.,D. subarachnoid and subdural hemorrhage.,E. Small contusions, tips of temporal lobes.,III. Abrasion of right cheek.,IV. Abrasion/contusion, posterior right shoulder.,V. Abrasions of left lower back and posterior left lower leg.,VI. Abrasion and vancular congestion of vaginal mucosa.,VII. Ligature of right wrist.,TOXICOLOGIC STUDIES ,Blood ethanol - none detected.,Blood drug screen - no drugs detected.,CLINOCOPATHOLIGICAL CORRELATION:, Cause of death of this six year old female is asphyxia by strangulation associated with craniocerebral trauma. ,The body of this six year old female was first seen by me after I was called to an address XYZ, on 12/26/96. I arrived at the scene approximately 8 PM on 12/26 and entered the house where the decedent's body was located at approximately 8:20 PM. ,A brief examination of the body disclosed a ligature around the neck and a ligature around the right wrist. Also noted was a small area of abrasion or contusion below the right ear on the lateral aspect of the right cheek. A prominent dried abrasion was present on the lower left neck. After examining the body, I left the residence at approximately 8:30 PM. ,EXTERNAL EVIDENCE OF INJURY:, Located just below the right ear at the right angle of the mandible, 1.5 inches below the right external auditory canal is a 3/8 x 1/4 inch area of rust colored abrasion. In the lateral aspect of the left lower eyelid on the inner conjunctival surface is a 1 mm in maximum dimension petechial hemorrhage. Very fine, less than 1 mm petechial hemorrhages are present on the skin of the upper eyelids bilaterally as well as on the lateral left cheek. On everything the left upper eyelid there are much smaller, less than 1 mm petechial hemorrhages located on the conjunctival surface. Possible petechial hemorrhages are also seen on the conjunctival surfaces of the right upper and lower eyelids, but liver mortis on this side of the face makes definite identification difficult. ,A deep ligature furrow encircles the entire neck. The width of the furrow varies from one- eight of an inch to five/sixteenths of an inch and is horizontal in orientation, with little upward deviation. The skin of the anterior neck above and below the ligature furrow contains areas of petechial hemorrhage and abrasion encompassing an area measuring approximately 3 x 2 inches. The ligature furrow crosses the anterior midline of the neck just below the laryngeal prominence, approximately at the level of the cricoid cartilage. It is almost completely horizontal with slight upward deviation from the horizontal towards the back of the neck. The midline of the furrow mark on the anterior neck is 8 inches below the top of the head. The midline of the furrow mark on the posterior neck is 6.75 inches below the top of the head. ,The area of abrasion and petechial hemorrhage of the skin of the anterior neck includes on the lower left neck, just to the left of the midline, a roughly triangular, parchment-like rust colored abrasion which measures 1.5 inches in length with a maximum width of 0.75 inches. This roughly triangular shaped abrasion is obliquely oriented with the apex superior and lateral. The remainder of the abrasions and petechial hemorrhages of the skin above and below the anterior projection of the ligature furrow are nonpatterned, purple to rust colored, and present in the midline, right, and left areas of the anterior neck. The skin just above the ligature furrow along the right side of the neck contains petechial hemorrhage composed of multiple confluent very small petechial hemorrhages as well as several larger petechial hemorrhages measuring up to one-sixteenth and one-eight of an inch in maximum dimension. Similar smaller petechial hemorrhages are present on the skin below the ligature furrow on the left lateral aspect of the neck. Located on the right side of the chin is a three-sixteenths by one-eight of an inch area of superficial abrasion. On the posterior aspect of the right shoulder is a poorly demarcated, very superficial focus of abrasion/contusion which is pale purple in color and measures up to three-quarters by one-half inch in maximum dimension. Several linear aggregates of petechial hemorrhages are present in the anterior left shoulder just above deltopectoral groove. These measure up to one inch in length by one-sixteenth to one-eight of an inch in width. On the left lateral aspect of the lower back, approximately sixteen and one-quarter inches and seventeen and one-half inches below the level of the top of the head are two dried rust colored to slightly purple abrasions. The more superior of the two measures one-eight by one-sixteenth of an inch and the more inferior measures three-sixteenths by one-eight of an inch. There is no surrounding contusion identified. On the posterior aspect of the left lower leg, almost in the midline, approximately 4 inches above the level of the heel are two small scratch-like abrasions which are dried and rust colored. They measure one-sixteenth by less than one- sixteenth of an inch and one-eight by less than one-sixteenth of an inch respectively. ,On the anterior aspect of the perineum, along the edges of closure of the labia majora, is a small amount of dried blood. A similar small amount of dried and semifluid blood is present on the skin of the fourchette and in the vestibule. Inside the vestibule of the vagina and along the distal vaginal wall is reddish hyperemia. This hyperemia is circumferential and perhaps more noticeable on the right side and posteriorly. The hyperemia also appears to extend just inside the vaginal orifice. A 1 cm red-purple area of abrasion is located on the right posterolateral area of the 1 x 1 cm hymeneal orifice. The hymen itself is represented by a rim of mucosal tissue extending clockwise between the 2 and 10:00 positions. The area of abrasion is present at approximately the 7:00 position and appears to involve the hymen and distal right lateral vaginal wall and possibly the area anterior to the hymen. On the right labia majora is a very faint area of violent discoloration measuring approximately one inch by three-eighths of an inch. Incision into the underlying subcutaneous tissue discloses no hemorrhage. A minimal amount of semiliquid thin watery red fluid is present in the vaginal vault. No recent or remote anal or other perineal trauma is identified. ,REMAINDER OF EXTERNAL EXAMINATION:, The unembalmed, well developed and well nourished Caucasian female body measures 47 inches in length and weighs an estimated 45 pounds. ,No scalp trauma is identified. The external auditory canals are patent and free of blood. The eyes are green and the pupils equally dilated. The sclerae are white. The nostrils are both patent and contain a small amount of tan mucous material. The teeth are native and in good repair. The tongue is smooth, pink-tan and granular. No buccal mucosal trauma is seen. The frenulum is intact. There is slight drying artifact of the tip of the tongue. On the right cheek is a pattern of dried saliva and mucous material which does not appear to be hemorrhagic. The neck contains no palpable adenopathy or masses and the trachea and larynx are midline. The chest is symmetrical. Breasts are prepubescent. The abdomen is flat and contains no scars. No palpable organomegaly or masses are identified. The external genitalia are that of a prepubescent female. No pubic hair is present. The anus is patent. Examination of the extremities is unremarkable. ,The fingernails of both hands are of sufficient length for clipping. Examination of the back is unremarkable. There is dorsal 3+ to 4+ livor mortis which is nonblanching. Livor mortis is also present on the right side of the face. At the time of the initiation of the autopsy there is mild 1 to 2+ rigor mortis of the elbows and shoulders with more advanced 2 to 3+ rigor mortis of the joints of the lower extremities. ,INTERNAL EXAM:, The anterior chest musculature is well developed. No sternal or rib fractures are identified. ,MEDIASTINUM: ,The mediastinal contents are normally distributed. The 21 gm thymus gland has a normal external appearance. The cut sections are finely lobular and pink-tan. No petechial hemorrhages are seen. The aorta and remainder of the mediastinal structures are unremarkable. ,BODY CAVITIES: ,The right and left thoracic cavities contain approximately 5 cc of straw colored fluid. The pleural surfaces are smooth and glistening. The pericardial sac contains 3-4 cc of straw colored fluid and the epicardium and pericardium are unremarkable. The abdominal contents are normally distributed and covered by a smooth glistening serosa. No intra-abdominal accumulation of fluid or blood is seen. ,LUNGS: ,The 200 gm right lung and 175 gm let lung have a normal lobar configuration. An occasional scattered subpleural petechial hemorrhage is seen on the surface of each lung. The cut sections of the lungs disclose an intact alveolar architecture with a small amount of watery fluid exuding from the cut surfaces with mild pressure. The intrapulmonary bronchi and vasculature are unremarkable. No evidence of consolidation is seen. ,HEART: ,The 100 gm heart has a normal external configuration. There are scattered subepicardial petechial hemorrhages over the anterior surface of the heart. The coronary arteries are normal in their distribution and contain no evidence of atherosclerosis. The tan- pink myocardium is homogeneous and contains no areas of fibrosis or infarction. The endocardium is unremarkable. The valve cusps are thin, delicate and pliable and contain no vegetation or thrombosis. The major vessels enter and leave the heart in the normal fashion. The foramen ovale is closed. ,AORTA AND VENA CAVA: ,The aorta is patent throughout its course as are its major branches. No atherosclerosis is seen. The Vena Cava is unremarkable. ,SPLEEN: ,The 61 gm spleen has a finely wrinkled purple capsule. Cut sections are homogeneous and disclose readily identifiable red and white pulp. No intrinsic abnormalities are identified. ,ADRENALS: ,The adrenal glands are of normal size and shape. A golden yellow cortex surmounts a thin brown-tan medullary area. No intrinsic abnormalities are identified. ", Autopsy,1
"PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,TITLE OF OPERATION:  ,Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Retrobulbar block.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room where retrobulbar anesthesia was induced.  The patient was then prepped and draped using standard procedure.  A wire lid speculum was inserted to keep the eye open and the eye rotated downward with a 0.12.  The anterior chamber was entered by making a small superior limbal incision with a crescent blade and then entering the anterior chamber with a keratome.  The chamber was then filled with viscoelastic and a continuous-tear capsulorrhexis performed.  The phacoemulsification was then instilled in the eye and a linear incision made in the lens.  The lens was then cracked with a McPherson forceps, and the remaining lens material removed with the phacoemulsification tip.  The remaining cortex was removed with an I&A.  The capsular bag was then inflated with viscoelastic and the wound extended slightly with the keratome.  The folding posterior chamber lens was then inserted in the capsular bag and rotated into position.  The remaining viscoelastic was removed from the eye with the I&A.  The wound was checked for watertightness and found to be watertight.  Tobramycin drops were instilled in the eye and a shield placed over it.  The patient tolerated the procedure well.", Ophthalmology,26
"SUMMARY:  ,This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia.  She has had an uneventful postoperative night.  She put out 1175 mL of urine since surgery.  Her incision looks good.  IV site and extremities are unremarkable.,LABORATORY DATA:  ,Her calcium level was 7.5 this morning.  She has been on three Tums orally b.i.d. and I am increasing three Tums orally q.i.d. before meals and at bedtime.,PLAN:,  I will heparin lock her IV, advance her diet, and ambulate her.  I have asked her to increase her prednisone when she goes home.  She will double her regular dose for the next five days.  I will advance her diet.  I will continue to monitor her calcium levels throughout the day.  If they stabilize, I am hopeful that she will be ready for discharge either later today or tomorrow.  She will be given Lortab Elixir 2 to 4 teaspoons orally every four hours p.r.n. pain, dispensed #240 mL with one refill.  Her final calcium dosage will be determined prior to discharge.  I will plan to see her back in the office on the 12/30/08, and she has been instructed to call or return sooner for any problems.", ENT - Otolaryngology,11
"PREOPERATIVE DIAGNOSIS:, Chronic abdominal pain and heme positive stool.,POSTOPERATIVE DIAGNOSES:,1.  Antral gastritis.,2.  Duodenal polyp.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with photos and antral biopsy.,ANESTHESIA: , Demerol and Versed.,DESCRIPTION OF PROCEDURE: , Consent was obtained after all risks and benefits were described.  The patient was brought back into the Endoscopy Suite.  The aforementioned anesthesia was given.  Once the patient was properly anesthetized, bite block was placed in the patient's mouth.  Then, the patient was given the aforementioned anesthesia.  Once he was properly anesthetized, the endoscope was placed in the patient's mouth that was brought down to the cricopharyngeus muscle into the esophagus and from the esophagus to his stomach.  The air was insufflated down.  The scope was passed down to the level of the antrum where there was some evidence of gastritis seen.  The scope was passed into the duodenum and then duodenal sweep where there was a polyp seen.  The scope was pulled back into the stomach in order to flex upon itself and straightened out.  Biopsies were taken for CLO and histology of the antrum.  The scope was pulled back.  The junction was visualized.  No other masses or lesions were seen.  The scope was removed.  The patient tolerated the procedure well.  We will recommend the patient be on some type of a H2 blocker.  Further recommendations to follow.", Surgery,38
"INDICATIONS FOR PROCEDURE:,  Impending open heart surgery for closure of ventricular septal defect in a 4-month-old girl.,Procedures were done under general anesthesia.  The patient was already in the operating room under general anesthesia.  Antibiotic prophylaxis with cefazolin and gentamicin was already given prior to beginning the procedures.,PROCEDURE #1:,  Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #1: , The probe was well lubricated and with digital manipulation, was passed into the esophagus without resistance.  The probe was placed so that the larger diameter was in the anterior-posterior position during insertion.  The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography.  At the end, it was removed without trauma and there was no blood tingeing.  It is to be noted that approximately 30 minutes after removing the cannula, I inserted a 14-French suction tube to empty the stomach and there were a few mL of blood secretions that were suctioned.  There was no overt bleeding.,PROCEDURE #2: , Attempted and unsuccessful insertion of arterial venous lines.,DESCRIPTION OF PROCEDURE #2:,  Both groins were prepped and draped.  The patient was placed at 10 degrees head-up position.  A Cook 4-French double-lumen 8-cm catheter kit was opened.  Using the 21-gauge needle that comes with the kit, several attempts were made to insert central venous and then an arterial line in the left groin.  There were several successful punctures of these vessels, but I was unable to advance Seldinger wire.  After removal of the needles, the area was compressed digitally for approximately 5 minutes.  There was a small hematoma that was not growing.  Initially, the left leg was mildly mottled with prolonged capillary refill of approximately 3 seconds.  Using 1% lidocaine, I infiltrated the vessels of the groin both medial and lateral to the vascular sheath.  Further observation, the capillary refill and circulation of the left leg became more than adequate.  The O2 saturation monitor that was on the left toe functioned well throughout the procedures, from the beginning to the end.  At the end of the procedure, the circulation of the leg was intact.,", Surgery,38
"HISTORY: , The patient is a 19-year-old boy with a membranous pulmonary atresia, underwent initial repair 12/04/1987 consisting of pulmonary valvotomy and placement of 4 mm Gore-Tex shunt between the ascending aorta and pulmonary artery with a snare.  This was complicated by shunt thrombosis __________ utilizing a 10-mm balloon.  Resulting in significant hypoxic brain injury where he has been left with static encephalopathy and cerebral palsy.  On 04/07/1988, he underwent heart catheterization and balloon pulmonary valvuloplasty utilizing a 10-mm balloon.  He has been followed conservatively since that time.  A recent echocardiogram demonstrated possibly a significant right ventricle outflow tract obstruction with tricuspid valve regurgitation velocity predicting a right ventricular systolic pressure in excess of 180 mmHg.  Right coronary artery to pulmonary artery fistula was also appreciated.  The patient underwent cardiac catheterization to assess hemodynamics associated with his current state of repair.,PROCEDURE:,  The patient was placed under general endotracheal anesthesia breathing on 30% oxygen throughout the case.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 7-French sheath, a 6-French wedge catheter was inserted.  The right femoral vein advanced through the right heart structures out to the branch pulmonary arteries.  This catheter was then exchanged over wire for a 5-French marker pigtail catheter, which was directed into the main pulmonary artery.,Using a 5-French sheath, a 5-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  This catheter was then exchanged for a Judkins right coronary catheter for selective cannulation of the right coronary artery.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the main pulmonary artery and right coronary artery.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:,  Oxygen consumption was assumed to be normal.  Mixed venous saturation was normal with no evidence of intracardiac shunt.  Left-sided heart was fully saturated.  Phasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure.  Right ventricular systolic pressure was mildly elevated at 45% systemic level.  There was a 25 mmHg peak systolic gradient across the outflow tract to the main branch pulmonary arteries.  Phasic branch pulmonary artery pressures were normal.  Right-to-left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending and descending pressures were similar and normal.  The calculated systemic and pulmonary flows were equal and normal.  Vascular resistances were normal.  Angiogram with contrast injection in the main pulmonary artery showed catheter induced pulmonary insufficiency.  The right ventricle appeared mildly hypoplastic with a good contractility and mild tricuspid valve regurgitation.  There is dynamic narrowing of the infundibulum with hypoplastic pulmonary annulus.  The pulmonary valve appeared to be thin and moved well.  The median branch pulmonary arteries were of good size with normal distal arborization.  Angiogram with contrast injection in the right coronary artery showed a non-dominant coronary with a small fistula arising from the proximal right coronary artery coursing over the infundibulum and entering the left facing sinus of the main pulmonary artery.,INITIAL DIAGNOSES:,1.  Membranous pulmonary atresia.,2.  Atrial septal defect.,3.  Right coronary artery to pulmonary artery fistula.,SURGERIES (INTERVENTIONS):  ,1.  Pulmonary valvotomy surgical.,2.  Aortopulmonary artery central shunt.,3.  Balloon pulmonary valvuloplasty.,CURRENT DIAGNOSES:  ,1.  Pulmonary valve stenosis supplemented to hypoplastic pulmonary annulus.,2.  Mild right ventricle outflow tract obstruction due to supple pulmonic narrowing.,3.  Small right coronary artery to main pulmonary fistula.,4.  Static encephalopathy.,5.  Cerebral palsy.,MANAGEMENT: , The case to be discussed with combined Cardiology/Cardiothoracic Surgery case conference.  Given the mild degree of outflow tract obstruction in this sedentary patient, aggressive intervention is not indicated.  Conservative outpatient management is to be recommended.  Further patient care will be directed by Dr. X.", Cardiovascular / Pulmonary,3
"REASON FOR VISIT:,  Postoperative visit for craniopharyngioma.,HISTORY OF PRESENT ILLNESS:,  Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor.  He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor.  Histology returned as craniopharyngioma.  There is some residual disease; however, the visual apparatus was decompressed.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.,MEDICATIONS: , Synthroid 100 mcg per day.,FINDINGS: , On exam, he is awake, alert and oriented x 3.  Pupils are equal and reactive.  EOMs are full.  His visual acuity is 20/25 in the right (improved from 20/200) and the left is 20/200 improved from 20/400.  He has a bitemporal hemianopsia, which is significantly improved and wider.  His motor is 5 out of 5.  There are no focal motor or sensory deficits.  The abdominal incision is well healed.  There is no evidence of erythema or collection.  The lumbar drain was also well healed.,The postoperative MRI demonstrates small residual disease.,Histology returned as craniopharyngioma.,ASSESSMENT: , Postoperative visit for craniopharyngioma with residual disease.,PLANS: , I have recommended that he call.  I discussed the options with our radiation oncologist, Dr. X. They will schedule the appointment to see him.  In addition, he probably will need an MRI prior to any treatment, to follow the residual disease.", SOAP / Chart / Progress Notes,35
"PREOPERATIVE DIAGNOSES,1.  Uncontrolled open angle glaucoma, left eye.,2.  Conjunctival scarring, left eye.,POSTOPERATIVE DIAGNOSES,1.  Uncontrolled open angle glaucoma, left eye.,2.  Conjunctival scarring, left eye.,PROCEDURES: , Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.,ANESTHESIA: ,Retrobulbar block with monitored anesthesia care.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Negligible.,DESCRIPTION OF PROCEDURE:,  The patient was brought to the operating suite where the Anesthesia team established a peripheral IV as well as monitoring lines.  In the preoperative area, the patient received pilocarpine drops.  The patient received IV propofol and once somnolent from this, a retrobulbar block was administered consisting of 2% Xylocaine plain.  Approximately 3 mL were given.  The operative eye then underwent a Betadine prep with respect to the face, lids, lashes, and eye.  During the draping process, care was taken to isolate the lashes.  A screw type speculum was inserted to maintain patency of lids.  A 6-0 Vicryl suture was placed through the superior cornea, and the eye was reflected downward to expose the superior conjunctiva.  A peritomy was performed approximately 8 to 10 mm posterior to the limbus and this flap was dissected forward to the cornea.  All Tenons were removed from the overlying sclera and the area was treated with wet-field cautery to achieve hemostasis.  A 2 mm x 3 mm scleral flap was then outlined with a Micro-Sharp blade.  This was approximately one-half scleral depth in thickness.  A crescent blade was then used to dissect forward the clear cornea.  Hemostasis was again achieved with wet-field cautery.  A Weck-Cel sponge tip soaked in mitomycin was then placed under the conjunctival and tenon flap and left there for two minutes.  The site was then profusely irrigated with balanced salt solution.  A paracentesis wound was made temporarily and then the Micro-Sharp blade was used to enter the anterior chamber at the anterior most margin of the trabeculectomy bed.  A Kelly-Descemet punch was then inserted, and a trabeculectomy was performed.  Iris was withdrawn through the trabeculectomy site and a peripheral iridectomy was performed using Vannas scissors and 0.12 forceps.  The iris was then repositioned into the eye and the anterior chamber was inflated with BSS.  The scleral flap was sutured in place with two 10-0 nylon sutures with knots trimmed, rotated, and buried.  The overlying conjunctiva was then closed with a running 8-0 Vicryl suture on a BV needle.  BSS was irrigated in the anterior chamber and the blood was noted to elevate nicely without leakage.  Antibiotic and steroid drops were placed in the eye as was homatropine 5%.  The antibiotic consisted of Vigamox and the steroid was Econopred Plus.  A patch and shield were placed over the eye after the drape was removed.  The patient was taken to the recovery room in good condition.  She will be seen in followup in the office tomorrow.", Ophthalmology,26
"CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.  She had no difficulty breathing and her cough was described as dry and hacky.  At that time, physical exam showed a right TM, which was red.  Left TM was okay.  She was fairly congested but looked happy and playful.  She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear.  Mom returned to clinic again today because she got much worse overnight.  She was having difficulty breathing.  She was much more congested and her appetite had decreased significantly today.  She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS:  ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY:  ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces.  No complications.  Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY:  ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her respiratory rate was approximately 60 to 65.,GENERAL:  She was very congested and she looked miserable.  She had no retractions at this time.,HEENT:  Her right TM was still red and irritated with no light reflex.  Her nasal discharge was thick and whitish yellow.  Her throat was clear.  Her extraocular muscles were intact.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR EXAM:  She was tachycardic without murmur.,LUNGS:  Revealed diffuse expiratory wheezing.,ABDOMEN:  Soft, nontender, and nondistended.,EXTREMITIES:  Showed no clubbing, cyanosis or edema.,LABORATORY DATA:  ,Her chem panel was normal.  RSV screen is positive.  Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN:  ,RSV bronchiolitis with otitis media.  Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.", Pediatrics - Neonatal,29
"PREOPERATIVE DIAGNOSES:,1.  Term pregnancy.,2.  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1.  Term pregnancy.,2.  Desires permanent sterilization.,PROCEDURE:,1.  Repeat low-transverse cesarean section.,2.  Bilateral tubal ligation.,3.  Extensive anterior abdominal wall/uterine/bladder adhesiolysis.,ANESTHESIA:,  Spinal/epidural with good effect.,FINDINGS:  ,Delivered vigorous male infant from cephalic presentation.  Apgars 9/9.  Birth weight 6 pounds 14 ounces.  Infant suctioned with a bulb upon delivery of the head and body.  Cord clamped and cut and infant passed to pediatric team present.  Complete placenta manually extracted intact with three vessel cord.  Extensive anterior abdominal wall adhesions with the anterior abdominal wall completely adhered to the anterior uterus throughout its entire length of the incision.  In addition, the bladder was involved in adhesion mass complex.  A window was developed surgically at the apical aspect of the incision enabling finger to pass to get behind the dense anterior abdominal wall adhesions.  These adhesions were surgically transected using Bovie cautery technique freeing up the anterior uterine attachment from the anterior abdominal wall.  Upon initial entry through the fibrous layer of the anterior abdominal wall _______ into the serosal and slightly muscular part of the anterior uterus due to the dense adhesion attachment that had occurred from previous surgeries.  Bilateral tubal ligation performed without difficulty via Parkland technique.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,URINE OUTPUT:  ,Per anesthesia records.  Urine cleared postoperatively.,IV FLUIDS:  ,Per anesthesia records.,The patient tolerated the procedure well and was taken to the recovery room in stable condition with stable vital signs.,OPERATIVE TECHNIQUE: , The patient was placed in a supine position after spinal/epidural anesthesia.  She was prepped and draped in the usual manner for repeat cesarean section.  A sharp knife was used to make a Pfannenstiel skin incision at the site of the previous scar.  This was carried through the subcutaneous tissue into the dense fibromuscular and fascial layer with a sharp knife.  This incision was extended laterally with Mayo scissors.  Dense fibromuscular layer was encountered from the patient's previous surgeries.  Upon entry, incision was entered into the serosal and partial muscular layer of the anterior uterus and there was no free area to enter into the peritoneal cavity due to dense fibromuscular adhesions of the entire uterus to the anterior abdominal wall at the length of the incision.  Fascia was previously separated superiorly and inferiorly from the muscular layer.  A surgical window was created at the apical aspect of the incision in the direction of the uterine fundus.  Finger was able to be passed and placed behind the dense adhesions between the uterus through anterior abdominal wall.  This adhesion complex was transacted via Bovie cautery its entire length circumferentially freeing the uterus from its attachment to anterior abdominal wall.  Inferiorly, difficulty was encountered with adhesion separation involving the bladder additionally to the uterus and the anterior abdominal wall.  These adhesions likewise were surgically transacted via sharp, blunt, and electrocautery dissection.  This was successfully done without anterior entry into the bladder.  Smooth pickups and Metzenbaum scissors were then used to do sharp dissection to separated the bladder from its attachment to the lower uterine segment enabling the vesicouterine peritoneal reflection for incision of the uterus.  The uterus was then incised using a sharp knife and low transverse incision.  This was extended with bandage scissors.  The infant was delivered easily from a cephalic presentation.  Bulb suction was done following delivery of the head and body.  The cord clamped and cut and the infant passed to pediatric team present.  Cord segment and cord blood was obtained.  Complete placenta manually extracted intact with three vessel cord.  Vigorous male infant, Apgars 9/9, weight 6 pounds 14 ounces.  Complete placenta with three vessels retrieved.  Uterus was exteriorized from the abdominal cavity.  Wet lap applied to the fundus and dry lap used to remove the remaining membranous tissue from the lining.  Pennington clamps placed at the uterine incision angles and the inferior incision lip.  A #1 chromic suture closed the uterus in running continuous interlocking closure.  Good hemostasis upon completion of the closure.  Laparotomy pads placed in the posterior cul-de-sac to remove any blood or clots.  The uterus was returned to the abdominal cavity, after using #1 chromic suture to close the anterior uterine incision, that was partial thickness through the serosal end of the muscular layer at midline adhesion.  This was closed with chromic suture in a running continuous interlocking closure with good hemostasis.  Attention was then focused on the bilateral tubal ligation.  Babcock clamp placed in the mid fallopian tube and elevated.  Cautery was used to make a window in the avascular segment of the mesosalpinx.  Proximal and distal #1 chromic suture ligation with mid fallopian tube transection performed.  The ligated proximal and distal stumps were then cauterized with Bovie cautery.  This tubal ligation procedure was done in a bilateral fashion.  Upon completion of tubal ligation, uterus was returned to the abdominal cavity.  Left and right gutters examined and found to be clean and dry.  Evaluation of the low uterine segment incision revealed continued hemostasis.  Oozing was encountered in the inferior bladder of dissection and 2-0 chromic suture in running continuous fashion, partial thickness of the bladder to control the oozing at this site was successfully done.  Interceed was then placed on the low uterine incision and the low anterior uterine aspect.  The midline rectus including peritoneum was re-approximated with simple interrupted chromic sutures.  Irrigation of the muscular layer with good hemostasis noted.  The fascia was closed with #1 Vicryl in a running continuous closure.  Subcutaneous tissue was irrigated, additional hemostasis with Bovie cautery.  The skin was closed with staples.", Obstetrics / Gynecology,24
"DESCRIPTION OF OPERATION:,  The patient was brought to the operating room and appropriately identified.  Local anesthesia was obtained with a 50/50 mixture of 2% lidocaine and 0.75% bupivacaine given as a peribulbar block.  The patient was prepped and draped in the usual sterile fashion.  A lid speculum was used to provide exposure to the right eye.,A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants.  Calipers were set at 3.5 mm and a mark was made 3.5 mm posterior to the limbus in the inferotemporal quadrant.,A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark.  The MVR blade was used to make a sclerotomy between the pre-placed sutures.  An 8-0 nylon suture was then pre-placed for later sclerotomy closure.  The infusion cannula was inspected and found to be in good working order.  The infusion cannula was placed in the vitreous cavity and secured with the pre-placed sutures.  The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.,Additional sclerotomies were made 3.5 mm posterior to the limbus in the supranasal and supratemporal quadrants.  The light pipe and vitrectomy handpieces were then placed in the vitreous cavity and a vitrectomy was performed.  There was moderately severe vitreous hemorrhage, which was removed.  Once a view of the posterior pole could be obtained, there were some diabetic membranes emanating along the arcades.  These were dissected with curved scissors and judicious use of the vitrectomy cutter.  There was some bleeding from the inferotemporal frond.  This was managed by raising the intraocular pressure and using intraocular cautery.  The surgical view became cloudy and the corneal epithelium was removed with a beaver blade.  This improved the view.  There is an area suspicious for retinal break near where the severe traction was inferotemporally.  The Endo laser was used to treat in a panretinal scatter fashion to areas that had not received previous treatment.  The indirect ophthalmoscope was used to examine the retinal peripheral for 360 degrees and no tears, holes or dialyses were seen.  There was some residual hemorrhagic vitreous skirt seen.  The soft-tip cannula was then used to perform an air-fluid exchange.  Additional laser was placed around the suspicious area inferotemporally.  The sclerotomies were then closed with 8-0 nylon suture in an X-fashion, the infusion cannula was removed and it sclerotomy closed with the pre-existing 8-0 nylon suture.,The conjunctiva was closed with 6-0 plain gut.  A subconjunctival injection of Ancef and Decadron were given and a drop of atropine was instilled over the eye.  The lid speculum was removed.  Maxitrol ointment was instilled over the eye and the eye was patched.  The patient was brought to the recovery room in stable condition.", Surgery,38
"PREOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,POSTOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,OPERATION PERFORMED:,1.  Bilateral myringotomies.,2.  Insertion of Shepard grommet draining tubes.,ANESTHESIA: , General, by mask.,ESTIMATED BLOOD LOSS: , Less than 1 mL.,COMPLICATIONS:,  None.,FINDINGS:  ,The patient had a long history of persistent recurrent infections and was placed on antibiotics for the same.  At this point in time, he had a small amount of thick mucoid material in both middle ear spaces with middle ear mucosa somewhat inflamed, but no active acute infection at this point in time.,PROCEDURE:,  With the patient under adequate general anesthesia with the mask delivery of anesthesia, he had his ear canals cleaned utilizing an operating microscope and all foul cerumen had been removed from both sides.  Bilateral inferior radial myringotomies were performed, first on the right and then on the left.  Middle ear spaces were suctioned of small amount of thick mucoid material on both sides and then Shepard grommet draining tubes were inserted on either side.  Floxin drops were then instilled bilaterally to decrease any clotting within the tubes, and then cotton ball was placed in the external meatus bilaterally.  At this point, the patient was awakened and returned to the recovery room, satisfactory, with no difficulty encountered.", ENT - Otolaryngology,11
"CHIEF COMPLAINT:,  Head injury.,HISTORY: , This 16-year-old female presents to Children's Hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device.  She struck herself in the head with the flag.  There was no loss of consciousness.  She did feel dizzy.  She complained of a headache.  She was able to walk.  She continued to participate in her flag practice.  She got dizzier.  She sat down for a while and walked and during the second period of walking, she had some episodes of diplopia, felt that she might faint and was assisted to the ground and was transported via paramedic ambulance to Children's Hospital for further evaluation.,PAST MEDICAL HISTORY: , Hypertension.,ALLERGIES:,  DENIED TO ME; HOWEVER, IT IS NOTED BEFORE SEVERAL ACCORDING TO MEDITECH.,CURRENT MEDICATIONS: , Enalapril.,PAST SURGICAL HISTORY: , She had some kind of an abdominal obstruction as an infant.,SOCIAL HISTORY: , She is here with mother and father who lives at home.  There is no smoking at home.  There is second-hand smoke exposure.,FAMILY HISTORY:  ,No noted family history of infectious disease exposure.,IMMUNIZATIONS:,  She is up-to-date on her shots, otherwise negative.,REVIEW OF SYSTEMS:  ,On the 10-plus systems reviewed with the section of those noted on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her temperature 100 degrees, pulse 86, respirations 20, and her initial blood pressure 166/116, and a weight of 55.8 kg.,GENERAL:  She is supine awake, alert, cooperative, and active child.,HEENT:  Head atraumatic, normocephalic.  Pupils equal, round, reactive to light.  Extraocular motions intact and conjugate.  Clear TMs, nose and oropharynx.  Moist oral mucosa without noted lesions.,NECK:  Supple, full painless nontender range motion.,CHEST:  Clear to auscultation, equal, stable to palpation.,HEART:  Regular without rubs or murmurs.,ABDOMEN:  No abdominal bruits are heard.,EXTREMITIES:  Equal femoral pulses are appreciated.  Equal radial and dorsalis pedis pulses are appreciated.  He moves all extremities without difficulty.  Nontender.  No deformity.  No swelling.,SKIN:  There was no significant bruising, lesions or rash about her abdomen.  No significant bruising, lesions or rash.,NEUROLOGIC:  Symmetric face and extremity motion.  Ambulates without difficulty.  She is awake, alert, and appropriate.,MEDICAL DECISION MAKING:,  The differential entertained includes head injury, anxiety, and hypertensive emergency.  She is evaluated in the emergency department with serial blood pressure examinations, which are noted to return to a more baseline state for her 130s/90s.  Her laboratory data shows a mildly elevated creatinine of 1.3.  Urine is within normal.  Urinalysis showing no signs of infection.  Head CT read by staff has no significant intracranial pathology.  No mass shift, bleed or fracture per Dr. X.  A 12-lead EKG reviewed preliminarily by myself noting normal sinus rhythm, normal axis rates of 90.  No significant ST-T wave changes.  No significant change from previous 09/2007 EKG.  Her headache has resolved.  She is feeling better.  I spoke with Dr. X at 0206 hours consulting Nephrology regarding this patient's presentation with the plan for home.  Follow up with her regular doctor.  Blood pressures have normalized for her.  She should return to emergency department on concern.  They are to call the family to Nephrology Clinic next week for optimization of her blood pressure control with a working diagnosis of head injury, hypertension, and syncope.", Emergency Room Reports,12
"PREOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,POSTOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,OPERATION:,  Cysto stent removal.,ANESTHESIA:,  Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,MEDICATIONS: , The patient was on vancomycin and Levaquin was given x1 dose.  The patient was on vancomycin for the last 5 days.,BRIEF HISTORY:  ,The patient is a 53-year-old female who presented with Enterococcus urosepsis.  CT scan showed a lower pole stone with a stent in place.  The stent was placed about 2 months ago, but when patient came in with a possibly UPJ stone with fevers of unknown etiology.  The patient had a stent placed at that time due to the fevers, thinking that this was an urospetic stone.  There was some pus that came out.  The patient was cultured; actually it was negative at that time.  The patient subsequently was found to have lower extremity DVT and then was started on Coumadin.  The patient cannot be taken off Coumadin for the next 6 months due to the significant swelling and high risk for PE.  The repeat films were taken which showed the stone had migrated into the pole.,The stent was intact.  The patient subsequently developed recurrent UTIs and Enterococcus in the urine with fevers.  The patient was admitted for IV antibiotics since the patient could not really tolerate penicillin due to allergy and due to patient being on Coumadin, Cipro, and Levaquin where treatment was little bit more complicated.  Due to drug interaction, the patient was admitted for IV antibiotic treatment.  The thinking was that either the stone or the stent is infected, since the stone is pretty small in size, the stent is very likely possibility that it could have been infected and now it needs to be removed.  Since the stone is not obstructing, there is no reason to replace the stent at this time.  We are unable to do the ureteroscopy or the shock-wave lithotripsy when the patient is fully anticoagulated.  So, the best option at this time is to probably wait and perform the ureteroscopic laser lithotripsy when the patient is allowed to off her Coumadin, which would be probably about 4 months down the road.,Plan is to get rid of the stent and improve patient's urinary symptoms and to get rid of the infection and we will worry about the stone at later point.,DETAILS OF THE OR: , Consent had been obtained from the patient.  Risks, benefits, and options were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed.  The patient understood all the risks and benefits of removing the stent and wanted to proceed.  The patient was brought to the OR.  The patient was placed in dorsal lithotomy position.  The patient was given some IV pain meds.  The patient had received vancomycin and Levaquin preop.  Cystoscopy was performed using graspers.  The stent was removed without difficulty.  Plan was for repeat cultures and continuation of the IV antibiotics.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  Medial meniscal tear, left knee.,POSTOPERATIVE DIAGNOSIS: , Chondromalacia of medial femoral condyle.,PROCEDURE PERFORMED:,1.  Arthroscopy of the left knee.,2.  Left arthroscopic medial meniscoplasty of medial femoral condyle.,3.  Chondroplasty of the left knee as well.,ESTIMATED BLOOD LOSS: , 80 cc.,TOTAL TOURNIQUET TIME: , 19 minutes.,DISPOSITION: , The patient was taken to PACU in stable condition.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 41-year-old male with left knee pain for approximately two years secondary to hockey injury where he did have a prior MCL sprain.  He has had a positive symptomology of locking and pain since then.  He had no frank instability to it, however.,GROSS OPERATIVE FINDINGS: , We did find a tear to the medial meniscus as well as a large area of chondromalacia to the medial femoral condyle.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room.  The left lower extremity was prepped and draped in the usual sterile fashion.  Tourniquet was applied to the left thigh with adequate Webril padding, not inflated at this time.  After the left lower extremity had been prepped and draped in the usual sterile fashion, we applied an Esmarch tourniquet, exsanguinating the blood and inflated the tourniquet to 325 mmHg for a total of 19 minutes.  We established the lateral port of the knee with #11 blade scalpel.  We put in the arthroscopic trocar, instilled with water and inserted the camera.,On inspection of the patellofemoral joint, it was found to be quite smooth.  Pictures were taken there.  There was no evidence of chondromalacia, cracking, or fissuring of the articular cartilage.  The patella was well centered over the trochlear notch.  We then directed the arthroscope to the medial compartment of the knee.  It was felt that there was a tear to the medial meniscus.  We also saw large area of chondromalacia with grade-IV changes to bone over the medial femoral condyle.  This area was debrided with forceps and the arthroscopic shaver.  The cartilage was also smoothened over the medial femoral condyle.  This was curetted after the medial meniscus had been trimmed.  We looked into the notch.  We saw the ACL appeared stable, saw attachments to tibial as well as the femoral insertion with some evidence of laxity, wear and tear.  Attention then was taken to the lateral compartment with some evidence of tear to the lateral meniscus and the arterial surface of both the tibia as well as the femur were pristine in the lateral compartment.  All instruments were removed.  All loose cartilaginous pieces were suctioned from the knee and water was suctioned at the end.  We removed all instruments.  Marcaine was injected into the portal sites.  We placed a sterile dressing and stockinet on the left lower extremity.  He was transferred to the gurney and taken to PACU in stable condition.", Surgery,38
"GENERAL: , A well-developed infant in no acute respiratory distress.,VITAL SIGNS:  ,Initial temperature was XX, pulse XX, respirations XX.  Weight XX grams, length XX cm, head circumference XX cm.,HEENT:  ,Head is normocephalic with anterior fontanelle open, soft, and non-bulging.  Eyes:  Red reflex elicited bilaterally.  TMs occluded with vernix and not well visualized.  Nose and throat are patent without palatal defect.,NECK: , Supple without clavicular fracture.,LUNGS:,  Clear to auscultation.,HEART:,  Regular rate without murmur, click, or gallop present.  Pulses are 2/4 for brachial and femoral.,ABDOMEN:,  Soft with bowel sounds present.  No masses or organomegaly.,GENITALIA: , Normal.,EXTREMITIES: , Without evidence of hip defects.,NEUROLOGIC:  ,The infant has good Moro, grasp, and suck reflexes.,SKIN: , Warm and dry without evidence of rash.", Consult - History and Phy.,5
"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.", Radiology,33
"REASON FOR CONSULTATION: , Left flank pain, ureteral stone.,BRIEF HISTORY: , The patient is a 76-year-old female who was referred to us from Dr. X for left flank pain.  The patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient's history.  The patient has had pain in the abdomen and across the back for the last four to five days.  The patient has some nausea and vomiting.  The patient wants something done for the stone.  The patient denies any hematuria, dysuria, burning or pain.  The patient denies any fevers.,PAST MEDICAL HISTORY: , Negative.,PAST SURGICAL HISTORY:  ,Years ago she had surgery that she does not recall.,MEDICATIONS: , None.,ALLERGIES: , None.,REVIEW OF SYSTEMS: , Denies any seizure disorder, chest pain, denies any shortness of breath, denies any dysuria, burning or pain, denies any nausea or vomiting at this time.  The patient does have a history of nausea and vomiting, but is doing better.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Vitals are stable.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft, left-sided flank pain and left lower abdominal pain.,The rest of the exam is benign.,LABORATORY DATA: , White count of 7.8, hemoglobin 13.8, and platelets 234,000.  The patient's creatinine is 0.92.,ASSESSMENT:,1.  Left flank pain.,2.  Left ureteral stone.,3.  Nausea and vomiting.,PLAN: , Plan for laser lithotripsy tomorrow.  Options such as watchful waiting, laser lithotripsy, and shockwave lithotripsy were discussed.  The patient has a pretty enlarged stone.  Failure of the procedure if the stone is significantly impacted into the ureteral wall was discussed.  The patient understood that the success of the surgery may be or may not be 100%, that she may require shockwave lithotripsy if we are unable to get the entire stone out in one sitting.  The patient understood all the risk, benefits of the procedure and wanted to proceed.  Need for stent was also discussed with the patient.  The patient will be scheduled for surgery tomorrow.  Plan for continuation of the antibiotics, obtain urinalysis and culture, and plan for KUB to evaluate for the exact location of the stone prior to surgery tomorrow.", Consult - History and Phy.,5
"HISTORY OF PRESENT ILLNESS:,  A 67-year-old gentleman who presented to the emergency room with chest pain, cough, hemoptysis, shortness of breath, and recent 30-pound weight loss.  He had a CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.  There was also a question of liver metastases at that time.,OPERATION PERFORMED:,  Fiberoptic bronchoscopy with endobronchial biopsies.,The bronchoscope was passed into the airway and it was noted that there was a large, friable tumor blocking the bronchus intermedius on the right.  The tumor extended into the carina, involving the lingula and the left upper lobe, appearing malignant.  Approximately 15 biopsies were taken of the tumor.,Attention was then directed at the left upper lobe and lingula.  Epinephrine had already been instilled and multiple biopsies were taken of the lingula and the left upper lobe and placed in a separate container for histologic review.  Approximately eight biopsies were taken of the left upper lobe.", Surgery,38
"PREOPERATIVE DIAGNOSIS:,  Visually significant nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with posterior chamber intraocular lens implantation, right eye.,ANESTHESIA:,  Monitored anesthesia care with retrobulbar block consisting of 2% lidocaine in an equal mixture with 0.75% Marcaine and Amphadase.,INDICATIONS FOR SURGERY:,  This patient has been experiencing difficulty with eyesight regarding activities of daily living.  There has been a progressive and gradual decline in the visual acuity.  The cataract was believed related to her decline in vision.  The risks, benefits, and alternatives (including with observation or spectacles) were discussed in detail.  The risks as explained included, but are not limited to pain, bleeding, infection, decreased or loss of vision/loss of eye, retinal detachment requiring further surgery, and possible consultation out of town, swelling of the back part of the eye/retina, need for prolonged eye drop use or injections, instability of the lens, and loss of corneal clarity necessitating long-term drop use or further surgery.  The possibility of needing intraocular lens exchange or incorrect lens power was discussed.  Anesthesia option and risks associated with anesthesia and retrobulbar anesthesia were discussed.  It was explained that some or all of these complications might arise at the time of or months to years after surgery.  The patient had a good understanding of the risks with the proposed, elective eye surgery.  The patient accepted these risks and elected to proceed with cataract surgery.  All questions were answered and informed consent was signed and placed in the chart.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified.  The pupil was dilated per protocol.  The patient was taken to the operating room and placed in the supine position.  After intravenous sedation, the retrobulbar block was injected followed by several minutes of digital massage.  No signs of orbital tenseness or retrobulbar hemorrhage were present.,The patient was prepped and draped in the usual ophthalmic sterile fashion.  An eyelid speculum was used to separate the eyelids.  A crescent blade was used to make a clear corneal temporally located incision.  A 1-mm Dual-Bevel blade was used to make a paracentesis site.  The anterior chamber was filled with viscoelastic (Viscoat).  The crescent blade was then used to make an approximate 2-mm long clear corneal tunnel through the temporal incision.  A 2.85-mm keratome blade was then used to penetrate into the anterior chamber through the temporal tunneled incision.  A 25-gauge pre-bent cystotome used to begin a capsulorrhexis.  The capsulorrhexis was completed with the Utrata forceps.  A 27-guage needle was used for hydrodissection and three full and complete fluid waves were noted.  The lens was able to be freely rotated within the capsular bag.  Divide-and-conquer ultrasound was used for phacoemulsification.  After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment.  Each of the four nuclear quadrants was phacoemulsified.  Aspiration was used to remove all remaining cortex.  Viscoelastic was used to re-inflate the capsular bag.  An AMO model SI40NB posterior chamber intraocular lens with power *** diopters and serial number *** was injected into the capsular bag.  The trailing haptic was placed with the Sinskey hook.  The lens was made well centered and stable.  Viscoelastic was aspirated.  BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure.  A Weck-Cel sponge was used to check both incision sites for leaks and none were identified.  The incision sites remained well approximated and dry with a well-formed anterior chamber and eccentric posterior chamber intraocular lens.  The eyelid speculum was removed and the patient was cleaned free of Betadine.  Vigamox and Econopred drops were applied.  A soft eye patch followed by a firm eye shield was taped over the operative eye.  The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed.  All questions were answered.  The discharge instructions were also reviewed with the patient by the discharging nurse.  The patient was comfortable and was discharged with followup in 24 hours.  Complications none.", Ophthalmology,26
"REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  The patient is unable to provide further history.  The patient's son is at the bedside and confirmed his history.  The patient was given IV antibiotics in the emergency room.  He was also given some hydration.,PAST MEDICAL HISTORY:,1.  History of CAD.,2.  History of dementia.,3.  History of CVA.,4.  History of nephrolithiasis.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Ambien.,2.  Milk of magnesia.,3.  Tylenol.,4.  Tramadol.,5.  Soma.,6.  Coumadin.,7.  Zoloft.,8.  Allopurinol.,9.  Digoxin.,10.  Namenda.,11.  Zocor.,12.  BuSpar.,13.  Detrol.,14.  Coreg.,15.  Colace.,16.  Calcium.,17.  Zantac.,18.  Lasix.,19.  Seroquel.,20.  Aldactone.,21.  Amoxicillin.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , The patient lives in a board and care.  No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness, otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is currently afebrile.  Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,GENERAL:  The patient is awake.  Not oriented x3, in no acute distress.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Mucous membranes are dry.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Irregularly irregular, brady.,LUNGS:  Clear to auscultation bilaterally anteriorly.,ABDOMEN:  Positive normoactive bowel sounds.  Soft.  Tenderness in the suprapubic region without rebound.,EXTREMITIES:  No clubbing, cyanosis or edema in upper and lower extremities.", General Medicine,15
"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.", Obstetrics / Gynecology,24
"INFORMANT:,  Dad on phone.  Transferred from ABCD Memorial Hospital, rule out sepsis.,HISTORY:  ,This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease.  The patient had a fever of 100.1 on 09/13/2006 taken rectally, and mom being a nurse, took the baby to the hospital and he was admitted for rule out sepsis.  All the sepsis workup was done, CBC, UA, LP, and CMP, and since a murmur was noted 2/5, he also had an echo done.  The patient was put on ampicillin and cefotaxime.  Echo results came back and they showed patent foramen ovale/ASD with primary pulmonary stenosis and then considering severe congenital heart disease, he was transferred here on vancomycin, ampicillin, and cefotaxime.  The patient was n.p.o. when he came in.  He was on 3/4 L of oxygen.  According to the note, it conveyed that he had some subcostal retractions.  On arriving here, baby looks very healthy.  He has no subcostal retractions.  He is not requiring any oxygen and he is positive for urine and stool.  The stool is although green in color, and in the morning today, he spiked a fever of 100.1, but right now he is afebrile.  ED called that case is a direct admit.,REVIEW OF SYSTEMS:  ,The patient supposedly had fever, some weight loss, poor appetite.  The day he had fever, no rash, no ear pain, no congestion, no rhinorrhea, no throat pain, no neck pain, no visual changes, no conjunctivitis, no cough, no dyspnea, no vomiting, no diarrhea, and no dysuria.  According to mom, baby felt floppy on the day of fever and he also used to have stools every day 4 to 6 which is yellowish-to-green in color, but today the stool we noticed was green in color.  He usually has urine 4 to 5 a day, but the day he had fever, his urine also was low.  Mom gave baby some Pedialyte.,PAST MEDICAL HISTORY:,  None.,HOSPITALIZATIONS:,  Recent transfer from ABCD for the rule out sepsis and heart disease.,BIRTH HISTORY:  ,Born on 08/23/2006 at Memorial Hospital, NSVD, no complications.  Hospital stay 24 hours.  Breast-fed, no formula, no jaundice, 7 pounds 8 ounces.,FAMILY HISTORY:,  None.,SURGICAL HISTORY: , None.,SOCIAL HISTORY:  ,Lives with mom and dad.  Dad is a service manager at GMC; 4-year-old son, who is healthy; and 2 cats, 2 dogs, 3 chickens, 1 frog.  They usually visit to a ranch, but not recently.  No sick contact and no travel.,MEDICATIONS: , Has been on vancomycin, cefotaxime, and ampicillin.,ALLERGIES:,  No allergies.,DIET:,  Breast feeds q.2h.,IMMUNIZATIONS: , No immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 99, pulse 158, respiratory rate 68, blood pressure 87/48, oxygen 100% on room air.,MEASUREMENTS:  Weight 3.725 kg.,GENERAL:  Alert and comfortable and sleeping.,SKIN:  No rash.,HEENT:  Intact extraocular movements.  PERRLA.  No nasal discharge.  No nasal cannula, but no oxygen is flowing active, and anterior fontanelle is flat.,NECK:  Soft, nontender, supple.,CHEST:  CTAP.,GI:  Bowel sounds present.  Nontender, nondistended.,GU:  Bilaterally descended testes.,BACK:  Straight.,NEUROLOGIC:  Nonfocal.,EXTREMITIES:  No edema.  Bilateral pedal pulses present and upper arm pulses are also present.,LABORATORY DATA:,  As drawn on 09/13/2006 at ABCD showed WBC 4.2, hemoglobin 11.8, hematocrit 34.7, platelets 480,000.  Sodium 140, potassium 4.9, chloride 105, bicarbonate 28, BUN 7, creatinine 0.4, glucose 80, CRP 0.5.  Neutrophils 90, bands 7, lymphocytes 27, monocytes 12, and eosinophils 4.  Chest x-ray done on 09/13/2006 read as mild left upper lobe infiltrate, but as seen here, and discussed with Dr. X, we did not see any infiltrate and CBG was normal.  UA and LP results are pending.  Also pending are cultures for blood, LP, and urine.,ASSESSMENT AND PLAN: , This is a 3-week-old Caucasian baby boy admitted for rule out sepsis and congenital heart disease.,INFECTIOUS DISEASE/PULMONARY: , Afebrile with so far 20-hour blood cultures, LP and urine cultures are negative.  We will get all the results from ABCD and until then we will continue to rule out sepsis protocol and put the patient on ampicillin and cefotaxime.  The patient could be having fever due to mild gastroenteritis or urinary tract infection, so to rule out all these things we have to wait for all the results.,CVS: , He had a grade 2/5 murmur status post echo, which showed a patent foramen ovale, as well as primary pulmonary stenosis.  These are the normal findings in a newborn as discussed with Dr. Y, so we will just observe the patient.  He does not need any further workup.,GASTROINTESTINAL: ", Pediatrics - Neonatal,29
"PAST MEDICAL HISTORY:,  Unremarkable, except for diabetes and atherosclerotic vascular disease.,ALLERGIES:,  PENICILLIN.,CURRENT MEDICATIONS:,  Include Glucovance, Seroquel, Flomax, and Nexium.,PAST SURGICAL HISTORY: , Appendectomy and exploratory laparotomy.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,The patient is a non-smoker.  No alcohol abuse.  The patient is married with no children.,REVIEW OF SYSTEMS:,  Significant for an old CVA.,PHYSICAL EXAMINATION:,  The patient is an elderly male alert and cooperative.  Blood pressure 96/60 mmHg.  Respirations were 20.  Pulse 94.  Afebrile.  O2 was 94% on room air.  HEENT:  Normocephalic and atraumatic.  Pupils are reactive.  Oral mucosa is grossly normal.  Neck is supple.  Lungs:  Decreased breath sounds.  Disturbed breath sounds with poor exchange.  Heart:  Regular rhythm.  Abdomen:  Soft and nontender.  No organomegaly or masses.  Extremities:  No cyanosis, clubbing, or edema.,LABORATORY DATA: , Oropharyngeal evaluation done on 11/02/2006 revealed mild oropharyngeal dysphagia with no evidence of laryngeal penetration or aspiration with food or liquid.  Slight reduction in tongue retraction resulting in mild residual remaining in the palatal sinuses, which clear with liquid swallow and double-saliva swallow.,ASSESSMENT:,1.  Cough probably multifactorial combination of gastroesophageal reflux and recurrent aspiration.,2.  Old CVA with left hemiparesis.,3.  Oropharyngeal dysphagia.,4.  Diabetes.,PLAN:,  At the present time, the patient is recommended to continue on a regular diet, continue speech pathology evaluation as well as perform double-swallow during meals with bolus sensation.  He may use Italian lemon ice during meals to help clear sinuses as well.  The patient will follow up with you.  If you need any further assistance, do not hesitate to call me.", Cardiovascular / Pulmonary,3
"REASON FOR CONSULTATION: , We were asked to see the patient in regards to a brain tumor.,HISTORY OF PRESENT ILLNESS: ,She was initially diagnosed in September of this year with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis.  She was seen by Dr. X in our group.  Because of her living arrangement, she elected to have treatment through the hospital radiation department and oncology department.  Details of her treatment are not available at the time of this dictation.  Her family has a packet of Temodar 100-mg pills.  She is admitted now with increasing confusion.  A CT shows increase in size of the lesions compared to the preoperative scan.  We are asked to comment on her treatment at this point.  She herself is confused and is unable to provide further history.  ,PAST MEDICAL HISTORY: , From her old chart:  No known past medical history prior to the diagnosis.,SOCIAL HISTORY:  ,She was living alone and is now living in assisted living.  ,MEDICATIONS,1.  Dilantin 300 mg daily.,2.  Haloperidol 1 mg h.s.,3.  Dexamethasone 4 mg q.i.d. ,4.  Docusate 100 mg b.i.d.,5.  Pen-VK 500 mg daily.,6.  Ibuprofen 600 mg daily.,7.  Zantac 150 mg twice a day.,8.  Temodar 100 mg daily.,9.  Magic Mouthwash daily.,10.  Tylenol #3 as needed.,REVIEW OF SYSTEMS,:  Unable.,PHYSICAL EXAMINATION,GENERAL:  Elderly woman, confused.  ,HEENT:  Normal conjunctivae.  Ears and nose normal.  Mouth normal.,NECK:  Supple.,CHEST: Clear.,HEART:  Normal.,ABDOMEN: Soft, positive bowel sounds.,NEUROLOGIC:  Alert, cranial nerves intact.  Left arm slightly weak.  Left leg slightly weak.,IMPRESSION AND PLAN:,  Glioblastoma multiforme, uncertain as to where she is in cancer treatment.  Given the number of pills in the patient's family's hands, it sounds like she has only been treated recently and therefore it is not surprising that she is showing increased problems related to increased size of the tumor.  We will have to talk with Dr. Y in the Clinic to get a better handle on her treatment regimen.  At this point, I will hold Temodar today and consider restarting it tomorrow if we can get her treatment plan clarified.", Hematology - Oncology,16
"PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1.  Bilateral facet Arthrogram at L34, L45, L5S1.,2.  Bilateral facet injections at L34, L45, L5S1.,3.  Interpretation of radiograph.,ANESTHESIA:  ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS:  ,None.,INDICATION: , Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,SUMMARY OF PROCEDURE: , The patient was admitted to the OR, consent was obtained and signed.  The patient was taken to the Operating room and was placed in the prone position.  Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring.  Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, EKG, respiration and heart rate and at intervals of three minutes for blood pressure.  After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels.,The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view.  A skin wheal was placed with 1% Lidocaine at the L34 facet region on the left.  Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side.  This was performed using the oblique view under fluoroscopy to the enable the view of the ""Scotty Dog,"" After obtaining the ""Scotty Dog"" view the joints were easily seen.  Negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow.  After negative aspiration was verified, 1/8th of a cc of Omnipaque 240 dye was then injected.  Negative aspiration was again performed and 1/2 cc of solution (Solution consisting of 9 cc of 0.5% Marcaine with 1 cc of Triamcinolone) was then injected into the joint.  The needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint.  The 22-gauge needle was then removed.  Pressure was place over the puncture site for approximately one minute.  This exact same procedure was then repeated along the left-sided facets at L45, and L5S1.  This exact same procedure was then repeated on the right side.  At each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,The patient was noted to have tolerated the procedure well without any complications.,Interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, L34, L45, and L5S1.  Visualizing the ""Scotty Dog"" technique under fluoroscopy facilitated this.  Dye spread into each joint space is visualized.  No venous or arterial run-off is noted.  No epidural run-off is noted.  The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis.", Surgery,38
"PREOPERATIVE DIAGNOSES,1.  Bowel obstruction.,2.  Central line fell off.,POSTOPERATIVE DIAGNOSES,1.  Bowel obstruction.,2.  Central line fell off.,PROCEDURE: , Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.,PROCEDURE DETAIL: , This lady has a bowel obstruction.  She was being fed through a central line, which as per the patient was just put yesterday and this slipped out.  At the patient's bedside after obtaining an informed consent, the patient's right deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated and with the patient in Trendelenburg position, she had her right subclavian vein percutaneously cannulated without any difficulty.  A Seldinger technique was used and a triple-lumen catheter was inserted.  There was a good flow through all three ports, which were irrigated with saline prior to connection to the IV solutions.,The catheter was affixed to the skin with sutures and then a dressing was applied.,The postprocedure chest x-ray revealed that there were no complications to the procedure and that the catheter was in good place.", Gastroenterology,14
"CHIEF COMPLAINT:,  This 3-year-old female presents today for evaluation of chronic ear infections bilateral.,ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA: , Associated signs and symptoms include:  cough, fever, irritability and speech and language delay.  Duration (ENT):  Duration of symptom:  12 rounds of antibiotics for otitis media.  Quality of ear problems:  Quality of the pain is throbbing.,ALLERGIES: , No known medical allergies.,MEDICATIONS:,  None currently.,PMH:,  Past medical history is unremarkable.,PSH: , No previous surgeries.,SOCIAL HISTORY:,  Parent admits child is in a large daycare.,FAMILY HISTORY:,  Parent admits a family history of Alzheimer's disease associated with paternal grandmother.,ROS:,  Unremarkable with exception of chief complaint.,PHYSICAL EXAM:,  Temp:  99.6 Weight:  38 lbs.,Patient is a 3-year-old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.,The child is accompanied by her mother who communicates well in English.,Head & Face:  Inspection of head and face shows no abnormalities.  Examination of salivary glands shows no abnormalities.  Facial strength is normal.,Eyes:  Pupil exam reveals PERRLA.,ENT:  Otoscopic examination reveals otitis media bilateral.,Hearing exam using tuning fork shows hearing to be diminished bilateral.,Inspection of left ear reveals drainage of a small amount.,Inspection of nasal mucosa, septum and turbinates reveals no abnormalities.,Frontal and maxillary sinuses all transilluminate well bilaterally.,Inspection of lips, teeth, gums, and palate reveals no gingival hypertrophy, no pyorrhea, healthy gums, healthy teeth and no abnormalities.,Inspection of the tongue reveals normal color, good motility and midline position.,Examination of oropharynx reveals no abnormalities.,Examination of nasopharynx reveals adenoid hypertrophy.,Neck:  Neck exam reveals no abnormalities.,Lymphatic:  No neck or supraclavicular lymphadenopathy noted.,Respiratory:  Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion.  Auscultation of lungs reveal clear lung fields and no rubs noted.,Cardiovascular:  Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Neurological/Psychiatric:  Testing of cranial nerves reveals no deficits.  Mood and affect normal and appropriate to situation.,TEST RESULTS:,  Audiometry test shows conductive hearing loss at 30 decibels and flat tympanogram.,IMPRESSION: , OM, suppurative without spontaneous rupture.  Adenoid hyperplasia bilateral.,PLAN:,  Patient scheduled for myringotomy and tubes, with adenoidectomy, using general anesthesia, as outpatient and scheduled for 08/07/2003.  Surgery will be performed at Children's Hospital.  Pre-operative consent form read and signed by parent.  Common risks and side effects of the procedure and anesthesia were mentioned.  Parent questions elicited and answered satisfactorily regarding planned procedure.  ,EDUCATIONAL MATERIAL PROVIDED: , Hospital preregistration, middle ear infection and myringtomy and tubes surgery.,PRESCRIPTIONS:,  Augmentin  Dosage:  400 mg-57 mg/5 ml powder for reconstitution  Sig:  One PO Q8h  Dispense:  1 Refills:  0  Allow Generic:  No", Consult - History and Phy.,5
"EXAM:,  Renal ultrasound.,HISTORY: , Renal failure, neurogenic bladder, status-post cystectomy.,TECHNIQUE: , Multiple ultrasonographic images of the kidneys were obtained in the transverse and longitudinal planes.,COMPARISON:,  Most recently obtained mm/dd/yy.,FINDINGS:,  The right kidney measures 12 x 5.2 x 4.6 cm and the left kidney measures 12.2 x 6.2 x 4.4 cm.  The imaged portions of the kidneys fail to demonstrate evidence of mass, hydronephrosis or calculus.  There is no evidence of cortical thinning.,Incidentally there is a rounded low-attenuation mass within the inferior aspect of the right lobe of the liver measuring 2.1 x 1.5 x 1.9 cm which has suggestion of some peripheral blood flow.,IMPRESSION:,1.  No evidence of hydronephrosis.,2.  Mass within the right lobe of the liver.  The patient apparently has a severe iodine allergy.  Further evaluation with MRI is recommended.,3.  The results of this examination were given to XXX in Dr. XXX office on mm/dd/yy at XXX,", Radiology,33
"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.,5
"TITLE OF OPERATION:,  Mediastinal exploration and delayed primary chest closure.,INDICATION FOR SURGERY:,  The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification.  The patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass.  The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago.  She did not meet the criteria for delayed primary chest closure.,PREOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,POSTOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS:,  None.,FINDINGS: , No evidence of intramediastinal purulence or hematoma.  At completion of the procedure no major changes in hemodynamic performance.,DETAILS OF THE PROCEDURE: , After obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position.  Following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed.  The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed.  The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned.  Through a separate incision and another 15-French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV-PA connection as well as inferior most aspect of the ventriculotomy.  The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires.  The subcutaneous tissue and skin were closed in layers.  There was no evidence of significant increase in central venous pressure or desaturation.  The patient tolerated the procedure well.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition.,I was the surgical attending present in the operating room in charge of the surgical  procedure throughout the entire length of the case.", Pediatrics - Neonatal,29
"PROCEDURES PERFORMED,1.  Insertion of subclavian dual-port Port-A-Cath.,2.  Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  Next, the chest was prepped and draped in a standard surgical fashion.  A #18-gauge spinal needle was used to aspirate blood from the subclavian vein.  After aspiration of venous blood, Seldinger technique was used to thread a J wire.  The distal tip of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next a #15-blade scalpel was used to make an incision in the skin.  Dissection was carried down to the level of the pectoralis muscle.  A pocket was created.  A dual-port Port-A-Cath was lowered into the pocket and secured with #2-0 Prolene.  Both ports were flushed.  The distal tip was pulled through to the wire exit site with a Kelly clamp.  It was cut to the appropriate length.  Next a dilator and sheath were threaded over the J wire.  The J wire and dilator were removed, and the distal tip of the dual-port Port-A-Cath was threaded over the sheath, which was simultaneously withdrawn.  Both ports of the dual-port Port-A-Cath were flushed and aspirated without difficulty.  The distal tip was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  The wire access site was closed with a 4-0 Monocryl.  The port pocket was closed in 2 layers with 2-0 Vicryl followed by 4-0 Monocryl in a running subcuticular fashion.  Sterile dressing was applied.  The patient tolerated the procedure well and was transferred to the PACU in good condition", Cardiovascular / Pulmonary,3
"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.", General Medicine,15
"DISCHARGE DISPOSITION:,  The patient was discharged by court as a voluntary drop by prosecution.  This was AMA against hospital advice.,DISCHARGE DIAGNOSES:,AXIS I:  Schizoaffective disorder, bipolar type.,AXIS II:  Deferred.,AXIS III:  Hepatitis C.,AXIS IV:  Severe.,AXIS V:  19.,CONDITION OF PATIENT ON DISCHARGE: , The patient remained disorganized.  The patient was suffering from prolactinemia secondary to medications.,DISCHARGE FOLLOWUP:  ,To be arranged per the patient as the patient was discharged by court.,DISCHARGE MEDICATIONS: , A 2-week supply of the following was phoned into the patient's pharmacy:  Seroquel 25 mg p.o. nightly.  Zyprexa 5 mg p.o. b.i.d.,MENTAL STATUS AT THE TIME OF DISCHARGE:,  Attitude was cooperative.  Appearance showed fair hygiene and grooming.  Psychomotor behavior showed restlessness.  No EPS or TD was noted.  Affect was restricted.  Mood remained anxious and speech was pressured.  Thoughts remained tangential, and the patient endorsed paranoid delusions.  The patient denied auditory hallucinations.  The patient denied suicidal or homicidal ideation, was oriented to person and place.  Overall, insight into her illness remained impaired.,HISTORY AND HOSPITAL COURSE: , The patient is a 22-year-old female with a history of bipolar affective disorder, was initially admitted for evaluation of increasing mood lability, disorganization, and inappropriate behaviors.  The patient reportedly was asking her father to have sex with her and tried to pull down her mother's pants.  The patient took her clothing off, was noted to be very disorganized sexually, and religiously preoccupied, and endorsed auditory hallucinations of voices telling her to calm herself and others.  The patient has a history of depression versus bipolar disorder, last hospitalized in Pierce County in 2008, but without recent treatment.  The patient on admission interview was noted to be labile and disorganized.  The patient was initiated on Risperdal M-Tab 2 mg p.o. b.i.d. for psychosis and mood lability, and also medically evaluated by Rebecca Richardson, MD.  The patient remained labile and suspicious during her hospital stay.  The patient continued to be sexually preoccupied and had poor insight into her need for treatment.  The patient denied further auditory hallucinations.  The patient was treated with Seroquel for persistent mood lability and psychosis.  The patient was noted to develop prolactinemia with Risperdal and this was changed to Zyprexa prior to discharge.  The patient remained disorganized, but was given a voluntary drop by prosecution against medical advice when she went to court on 01/11/2010.  The patient was discharged to return home to her parents and was referred to Community Mental Health Agencies.  The patient was thus discharged in symptomatic condition.", Discharge Summary,10