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Pacemaker ICD interrogation. Severe nonischemic cardiomyopathy with prior ventricular tachycardia. | 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. | Pacemaker Interrogation | Cardiovascular / Pulmonary | cardiovascular / pulmonary, cardiomyopathy, ventricular, tachycardia, pacemaker icd interrogation, millivolts, impendence, interrogation, pacemaker, |
Erythema of the right knee and leg, possible septic knee. Aspiration through the anterolateral portal of knee joint. | PREOPERATIVE DIAGNOSES: , Erythema of the right knee and leg, possible septic knee.,POSTOPERATIVE DIAGNOSES:, Erythema of the right knee superficial and leg, right septic knee ruled out.,INDICATIONS: , Mr. ABC is a 52-year-old male who has had approximately eight days of erythema over his knee. He has been to multiple institutions as an outpatient for this complaint. He has had what appears to be prepatellar bursa aspirated with little to no success. He has been treated with Kefzol and 1 g of Rocephin one point. He also reports, in the emergency department today, an attempt was made to aspirate his actual knee joint which was unsuccessful. Orthopedic Surgery was consulted at this time. Considering the patient's physical exam, there is a portal that would prove to be outside of the erythema that would be useful for aspiration of the knee. After discussion of risks and benefits, the patient elected to proceed with aspiration through the anterolateral portal of his knee joint.,PROCEDURE: ,The patient's right anterolateral knee area was prepped with Betadine times two and a 20-gauge spinal needle was used to approach the knee joint approximately 3 cm anterior and 2 cm lateral to the superolateral pole of the patella. The 20-gauge spinal needle was inserted and entered the knee joint. Approximately, 4 cc of clear yellow fluid was aspirated. The patient tolerated the procedure well.,DISPOSITION: , Based upon the appearance of this synovial fluid, we have a very low clinical suspicion of a septic joint. We will send this fluid to the lab for cell count, crystal exam, as well as culture and Gram stain. We will follow these results. After discussion with the emergency department staff, it appears that they tend to try to treat his erythema which appears to be cellulitis with IV antibiotics. | Aspiration - Knee Joint | Orthopedic | orthopedic, knee and leg, anterolateral portal, emergency department, spinal needle, septic knee, knee joint, knee, emergency, department, gauge, spinal, needle, aspiration, anterolateral, portal, aspirated, fluid, septic, erythema, joint, aspiraion, |
Left cardiac catheterization with selective right and left coronary angiography. Post infarct angina. | PREOPERATIVE DIAGNOSIS: , Post infarct angina.,TYPE OF PROCEDURE: , Left cardiac catheterization with selective right and left coronary angiography.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory, and the groin was prepped in the usual fashion. Using 1% lidocaine, the right groin was infiltrated, and using the Seldinger technique, the right femoral artery was cannulated. Through this, a moveable guidewire was then advance to the level of the diaphragm, and through it, a 6 French pigtail catheter was advanced under hemodynamic monitoring to the ascending aorta and inserted into the left ventricle. Pressure measurements were obtained and cineangiograms in the RAO and LAO positions were then obtained. Catheter was then withdrawn and a #6 French non-bleed-back sidearm sheath was then introduced, and through this, a 6 French Judkins left coronary catheter was then advanced under hemodynamic monitoring to the left coronary ostium, engaged. Cineangiograms were obtained of the left coronary system. This catheter was then exchanged for a Judkins right 4 coronary catheter of similar dimension and under hemodynamic monitoring again was advanced to the right coronary ostium, engaged. Cineangiograms were obtained, and the catheter and sheath were then withdrawn. The patient tolerated the procedure well and left the Cardiac Catheterization Laboratory in stable condition. No evidence of hematoma formation or active bleeding. ,COMPLICATIONS: , None. ,TOTAL CONTRAST: , 110 cc of Hexabrix. ,TOTAL FLUOROSCOPY TIME: ,1.8 minutes. ,MEDICATIONS: , Reglan 10 mg p.o., 5 mg p.o. Valium, Benadryl 50 mg p.o. and heparin 3,000 units IV push. | Cardiac Cath & Selective Coronary Angiography | Cardiovascular / Pulmonary | cardiovascular / pulmonary, selective, angiography, post infarct angina, engaged cineangiograms, coronary angiography, hemodynamic monitoring, cardiac catheterization, catheterization, cineangiograms, cardiac, coronary, |
Patient with a history of coronary artery disease, hypertension, diabetes, and stage III CKD. | REASON FOR VISIT: , Acute kidney failure.,HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old Korean gentleman with a history of coronary artery disease, hypertension, diabetes and stage III CKD with a creatinine of 1.8 in May 2006 corresponding with the GFR of 40-41 mL/min. The patient had blood work done at Dr. XYZ's office on June 01, 2006, which revealed an elevation in his creatinine up to 2.3. He was asked to come in to see a nephrologist for further evaluation. I am therefore asked by Dr. XYZ to see this patient in consultation for evaluation of acute on chronic kidney failure. The patient states that he was actually taking up to 12 to 13 pills of Chinese herbs and dietary supplements for the past year. He only stopped about two or three weeks ago. He also states that TriCor was added about one or two months ago but he is not sure of the date. He has not had an ultrasound but has been diagnosed with prostatic hypertrophy by his primary care doctor and placed on Flomax. He states that his urinary dribbling and weak stream had not improved since doing this. For the past couple of weeks, he has had dizziness in the morning. This is then associated with low glucose. However the patient's blood glucose this morning was 123 and he still was dizzy. This was worse on standing. He states that he has been checking his blood pressure regularly at home because he has felt so bad and that he has gotten under 100/60 on several occasions. His pulses remained in the 60s.,ALLERGIES: , None.,MEDICATIONS: , Imdur 20 mg two to three times daily, nitroglycerin p.r.n., insulin 70/30 40/45 units daily, Zetia 10 mg daily, ? Triglide 50 mg daily, Prevacid 30 mg daily, Plavix 75 mg daily, potassium 10 mEq daily, Lasix 60 mg daily, folate 1 mg b.i.d., Niaspan 500 mg daily, atenolol 50 mg daily, enalapril 10 mg b.i.d., glyburide 10 mg b.i.d., Xanax 0.25 mg b.i.d., aspirin 325 mg daily, Tylenol p.r.n., Zantac 150 mg b.i.d., Crestor 5 mg daily, TriCor 145 mg daily, Digitek 0.125 mg daily, Celexa 20 mg daily, and Flomax 0.4 mg daily.,PAST MEDICAL HISTORY:,1. Coronary artery disease status post CABG x 5 in December 2001.,2. Three stents last placed approximately 2002.,3. Heart failure, ejection fraction of 30%.,4. Hypertension since 1985.,5. Diabetes since 1985 with history of laser surgery.,6. Moderate mitral regurgitation.,7. GI bleed.,8. Hyperlipidemia.,9. BPH.,10. Back surgery.,11. Sleep apnea.,SOCIAL HISTORY: , He is a former tailor from Korea. He is divorced. He has one daughter who has brain injury status post severe seizure as a child. He is the primary caregiver. No drug abuse. He quit tobacco and alcohol 15 years ago.,FAMILY HISTORY: , Parents both died in Korea. Has one sister with hypertension and the other sister lives in Detroit and is healthy.,REVIEW OF SYSTEMS: , He has lost about 10 pounds over the past month. He has been fatigue and weak with no appetite. He has occasional chest pain and dyspnea on exertion on fast walking. His lower extremity edema has improved with higher doses of furosemide. He does complain of some early satiety. He complains of urinary frequency, nocturia, weak stream and dribbling. He has never passed the stone. He gets dizzy when his blood sugars are in the 40s to 60s but now this is continuing with him running, glucose is in the 120s. He has some right back pain today and complains of farsightedness. The remainder of review of systems is done and negative per the patient.,PHYSICAL EXAMINATION:, VITAL SIGNS: Pulse 78. Blood pressure 116/60. Height 5'7" per the patient. Weight 78.6 kg. Supine pulse 60 with blood pressure 128/55. Standing pulse 60 with blood pressure of 132/50. GENERAL: He is in no apparent distress, but he is dizzy on standing for prolonged period. Eyes: Pupils equal, round and reactive to light. Extraocular movements are intact. Sclerae not icteric. HEENT: He wears upper and lower dentures. Lips acyanotic. Hearing is grossly intact. Oropharynx is otherwise clear. NECK: Supple. No JVD. No bruits. No masses. HEART: Regular rate and rhythm. No murmurs, rubs or gallops. LUNGS: Clear bilaterally. ABDOMEN: Active bowel sounds. Soft, nontender, and nondistended. No suprapubic tenderness. EXTREMITIES: No clubbing, cyanosis or edema. MUSCULOSKELETAL: 5/5 strength bilaterally. No synovitis, arthritis or gait disturbance. SKIN: Old scars in his low back as well as his left lower extremity. No active rashes, purpura or petechiae. Midline sternotomy scar is well healed. NEUROLOGIC: Cranial nerves II through XII are intact. Reflexes are poor to 1+ bilaterally. 10 g monofilament sensation is intact except for the big toes bilaterally. No asterixis. Finger-to-nose testing is intact. PSYCHIATRIC: Fully alert and oriented.,LABORATORY DATA:, December 2004, creatinine was 1.5. Per report May 2006, creatinine was 1.8 with a BUN of 28. Labs dated 06/01/06, hematocrit was 32.3, white blood cell count 7.2, platelets 263,000, sodium 139, potassium 4.9, chloride 100, CO2 25, BUN 46, creatinine 2.3, glucose 162, albumin 4.7, LFTs are normal. CK was elevated at 653. A1c is 7.6%. LDL cholesterol is 68, HDL is 35. Urinalysis reveals microalbumin to creatinine ratio 59.8. UA was otherwise negative with a pH of 5. Today his urinalysis showed specific gravity 1.020, negative glucose, bilirubin, ketones and blood, 30 mg/dL of protein, pH of 5, negative nitrates, leukocyte esterase. Microscopic exam was bland.,IMPRESSION:,1. Acute on chronic kidney failure. He has underlying stage III CKD with the GFR approximately 41 mL/min. He has episodic hypotension at home and low diastolic pressure here. His weight is down 2 to 3 Kg from June and he may be prerenal. He also has a history of prostatic hypertrophy and obstruction must be investigated. I am also concerned about his use of Chinese herbs which can cause chronic interstitial nephritis. There is no evidence of pyuria today although this can present with a fairly bland sediment. An additional concern is that TriCor can cause an artifactual increase in the creatinine due to changes in metabolism. I think this would be a diagnosis of exclusion.,2. Orthostatic hypotension. He is maintaining systolic but his diastolic pressures are gotten in to a point where he may not be perfusing his brain well.,3. Elevated creatine kinase consistent with myositis. It could be a result of Crestor alone or combination of TriCor and Crestor. I do not think this is enough to cause rhabdomyolysis, however.,RECOMMENDATIONS:,1. The patient was cautioned about using NSAIDs and told to avoid any further Chinese herbs.,2. Recheck labs including CBC with differential, SPEP, uric acid and renal panel.,3. Decrease atenolol to 25 mg daily.,4. Decrease enalapril to 10 mg daily.,5. Decrease Lasix to 20 mg daily.,6. Stop Crestor.,7. Check renal ultrasound.,8. See him back in two weeks for review of the studies. | Acute Kidney Failure | Nephrology | null |
Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain. | REASON FOR REFERRAL: , Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,HISTORY:, This is a 77-year-old white female patient whom I have known for the last about a year or so who has underlying multiple medical problems including hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post aortocoronary bypass surgery about eight years ago at Halifax Medical Center where she had triple vessel bypass surgery with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the left circumflex and right coronary arteries. Since then, she has generally done well. She used to be seeing another cardiologist and apparently she had a stress test in September 2008 and she was otherwise cardiac catheterization and coronary angiography, but the patient declined to have one done and since then she has been on medical therapy.,The patient had been on medical therapy at home and generally doing well. Recently, she had no leg swelling, undue exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea. She denies any rest or exertional chest discomfort. Yesterday evening, she had her dinner and she was sitting around and she felt discomfort in the chest at about 7:00 p.m. The discomfort was a crampy pain in the left lower quadrant area, which seemed to radiating to the center of the abdomen and to the right side and it was off and on lasting for a few minutes at a time and then subsiding. Later on she was nauseous, but she did not have any vomiting. She denied any diarrhea. No history of fever or chills. Since the pain seemed to persist, the patient came to the hospital emergency room at 11:35 p.m. where she was seen and admitted for the same. She was given morphine, Zofran, Demerol, another Zofran, and Reglan as well as Demerol again and she was given intravenous fluids. Subsequently, her pain finally went away and she does not have any pain since about 7:00 a.m. this morning. The patient was admitted however for further workup and treatment. At the time of my examination this afternoon, the patient is sitting, lying in bed and comfortable and has no abdominal pain of any kind. She has not been fed any food, however. The patient also had had pelvis and abdominal CT scan performed, which has been described to be partial small bowel obstruction, internal hernia, volvulus or adhesion most likely in the left flank area. The patient has had left nephrectomy and splenectomy, which has been described. A 1.5-mm solid mass is described to be in the lower pole of the kidney. The patient also has been described to have diverticulosis without diverticulitis on this finding.,Currently however, the patient has no clinical symptoms according to her.,PAST MEDICAL HISTORY:, She has had hypertension and hyperlipidemia for the last 15 years, diabetes mellitus for the last eight years, and coronary artery disease for last about eight years or so. She had a chest and back pain about eight years ago for about two weeks and then subsequently she was reported to be evaluated. She has a small myocardial infarction and then she was under the care of Dr. A and she had aortocoronary bypass surgery at Halifax Medical Center by Dr. B, which was a three-vessel bypass surgery with left internal mammary artery to the left descending artery and saphenous vein graft to the left circumflex and distal right coronary artery respectively.,She had had nuclear stress test with Dr. C on September 3, 2008, which was described to be abnormal with ischemic defects, but I do not think the patient had any further cardiac catheterization and coronary angiography after that. She has been treated medically.,This patient also had an admission to this hospital in May 2008 also for partial small bowel obstruction and cholelithiasis and sigmoid diverticulosis. She was described to have had a hemorrhagic cyst of the right kidney. She has mild arthritis for the last 10 or 15 years. She has a history of GERD for the last 20 years, and she also has a history of peptic ulcer disease in the duodenum, but never had any bleeding. She has a history of diverticulosis as mentioned. No history of TIA or CVA. She has one kidney. She was in a car accident in 1978 and afterwards she had to have left nephrectomy as well as splenectomy because of rupture. The patient has a history of pulmonary embolism once about eight years ago after her aortocoronary bypass surgery. She describes this to be a clot on left lung. I am not sure if she had any long-term treatment, however.,In the past, the patient had aortocoronary bypass surgery in 2003 and incisional hernia surgery in 1979 as well as hysterectomy in 1979 and she had splenectomy and nephrectomy as described in 1978.,FAMILY HISTORY: , Her father died at age of 65 of massive heart attack and mother died at age of 62 of cancer. She had a one brother who died of massive heart attack in his 50s, a brother died at the age of 47 of cancer, and another brother died in his 60s of possible rupture of appendix.,SOCIAL HISTORY: , The patient is a widow. She lives alone. She does have three daughters, two of them live in Georgia and one lives in Tennessee. She did smoke in the past up to one to one and a half packs of cigarettes per day for about 10 years, but she quit long time ago. She never drank any alcohol. She likes to drink one or two cups of tea in a day.,ALLERGIES: , PAXIL.,MEDICATIONS:, Her home medications prior to coming in include some of the following medications, although the exact list is not available in the chart at this stage, but they have been on glyburide, Januvia, lisinopril, metformin, metoprolol, simvastatin, ranitidine, meloxicam, and furosemide.,REVIEW OF SYSTEMS:, Appetite is good. She sleeps good at night. She has no headaches and she has mild joint pains from arthritis.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 90 per minute and regular, blood pressure 140/90 mmHg, respirations 18, and temperature of 98.5 degree Fahrenheit. Moderate obesity is present.,CARDIAC: Carotid upstroke is slightly diminished, but no clear bruit heard.,LUNGS: Slightly decreased air entry at both bases. No rales or rhonchi heard.,CARDIOVASCULAR: PMI in the left fifth intercostal space in the midclavicular line. Regular heart rhythm. S1 and S2 normal. S4 is present. No S3 heard. Short ejection systolic murmur grade I/VI is present at the left lower sternal border of the apex, peaking in LV systole, no diastolic murmur heard.,ABDOMEN: Soft, obese, no tenderness, no masses felt. Bowel sounds are present.,EXTREMITIES: Bilateral trace edema. The extremities are heavy. There is no pitting at this stage. No clubbing or cyanosis. Distal pulses are fair.,CENTRAL NERVOUS SYSTEM: Without any obvious focal deficits.,LABORATORY DATA: , Includes an electrocardiogram, which shows normal sinus rhythm, left atrial enlargement, and right bundle branch block. This is overall unchanged compared to previous electrocardiogram, which also has the same present. Nuclear stress test from 2008 was described to show ejection fraction of 49% and inferior and posterolateral ischemia. Otherwise, laboratory data includes on this patient at this stage WBC 18.3, hemoglobin 15.5, hematocrit is 47.1, and platelet count is 326,000. Electrolytes, sodium 137, potassium 5.2, chloride 101, CO2 27, BUN 34, creatinine 1.2, calcium 9.5, and magnesium 1.7. AST and ALT are normal. Albumin is 4.1. Lipase and amylase are normal. INR is 0.92. Urinalysis is relatively unremarkable except for trace protein. Chest x-ray has been described to show elevated left hemidiaphragm and median sternotomy sutures. No infiltrates seen. Abdomen and pelvis CAT scan findings are as described before with suggestion of partial small bowel obstruction and internal hernia. Volvulus or adhesions have been considered. Left nephrectomy and splenectomy demonstrated right kidney has a 1.5 cm solid mass at the lower pole suspicious for neoplasm according to the radiologist's description and there is diverticulosis.,IMPRESSION:,1. Coronary artery disease and prior aortocoronary bypass surgery, currently clinically the patient without any angina.,2. Possible small old myocardial infarction.,3. Hypertension with hypertensive cardiovascular disease.,4. Non-insulin-dependent diabetes mellitus.,5. Moderate obesity.,6. Hyperlipidemia.,7. Chronic non-pitting leg edema.,8. Arthritis.,9. GERD and positive history of peptic ulcer disease.,CONCLUSION:,1. Past left nephrectomy and splenectomy after an accident and injury and rupture of the spleen.,2. Abnormal nuclear stress test in September 2008, but no further cardiac studies performed, such as cardiac catheterization.,3. Lower left quadrant pain, which could be due to diverticulosis.,4. Diverticulosis and partial bowel obstruction.,RECOMMENDATION:,1. At this stage, the patient's cardiac medication should be continued if the patient is allowed p.o. intake. | Cardiac Consultation - 6 | Cardiovascular / Pulmonary | null |
Vaginal discharge with a foul odor. | CHIEF COMPLAINT: , Vaginal discharge with a foul odor.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old African-American female who states that for the past week she has been having thin vaginal discharge which she states is gray in coloration. The patient states that she has also had frequency of urination. The patient denies any burning with urination. She states that she is sexually active and does not use condoms. She does have three sexual partners. The patient states that she has had multiple yeast infections in the past and is concerned that she may have one again. The patient also states that she has had sexually transmitted diseases in her teens, but has not had one in many years. The patient does state that she has never had HIV testing. The patient states that she has not had any vaginal bleeding and does not have any abdominal pain. The patient denies fevers or chills, nausea or vomiting, headaches or head trauma. The patient also denies skin rashes or lesions. She does state, however, there is one area of roughened skin on her right forearm that she is concerned it may be an infection of the skin. The patient is G2 P2. She has had some irregular Pap smears in the past. Her last Pap smear was approximately 6 to 12 months ago. The patient has had frequent urinary tract infections in the past.,PAST MEDICAL HISTORY:,1. Bronchitis.,2. Urinary tract infections.,3. Vaginal candidiasis.,PAST SURGICAL HISTORY: , Cyst removal of the right breast.,SOCIAL HISTORY: , The patient does smoke approximately half a pack of cigarettes per day. She denies alcohol or illicit drug use.,MEDICATIONS: , None.,ALLERGIES:, No known medical allergies.,PHYSICAL EXAMINATION:,GENERAL: This is an African-American female who appears her stated age of 25 years. She is well nourished, well developed, and in no acute distress. The patient is pleasant.,VITAL SIGNS: Afebrile. Blood pressure is mildly over 96/68, pulse is 68, respiratory rate 12, and pulse oximetry of 98% on room air.,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, nondistended. Positive bowel sounds throughout.,SKIN: Warm, dry and intact. No rash or lesion.,PSYCH: Alert and oriented to person, place, and time.,NEUROLOGIC: Cranial nerves II through XII are intact bilaterally. No focal deficits are appreciated.,GENITOURINARY: The pelvic exam done shows external genitalia without abnormalities or lesions. There is a white-to-yellow discharge. Transformation zone is identified. The cervix is mildly friable. Vaginal vault is without lesions. There is no adnexal tenderness. No adnexal masses. No cervical motion tenderness. Cervical swabs and vaginal cultures are obtained.,DIAGNOSTIC STUDIES: , Urinalysis shows 3+ bacteria, however, there are no wbc's. No squamous epithelial cells and no other signs of infection. There is no glucose. The patient's cervical swabs and cultures are obtained and there are positive clue cells. Negative Trichomonas. Negative fungal elements and Chlamydia and gonorrhea are pending at this time. Urinalysis is sent for culture and sensitivity.,ASSESSMENT:,: Gardnerella bacterial vaginosis.,PLAN: , The patient will be treated with metronidazole 500 mg p.o. twice a day x7 days. The patient will follow up with her primary care provider., | Gardnerella Bacterial Vaginosis | Obstetrics / Gynecology | null |
He awoke one morning and had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. The next day he woke up and he had double vision again. | 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 | Diplopia | Ophthalmology | null |
Flexible sigmoidoscopy. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon. | PROCEDURE IN DETAIL: , Following a barium enema prep and lidocaine ointment to the rectal vault, perirectal inspection and rectal exam were normal. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon. Withdrawal notes an otherwise normal descending, rectosigmoid and rectum. Retroflexion noted no abnormality of the internal ring. No hemorrhoids were noted. Withdrawal from the patient terminated the procedure. | Flex Sig - 2 | Gastroenterology | gastroenterology, flexible sigmoidoscopy, flex sig, colonoscope, olympus video colonoscope, rectumNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., |
Possible CSF malignancy. This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. 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. | 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. | Lumbar Puncture | Neurology | null |
Right ear pain with drainage - otitis media and otorrhea. | CHIEF COMPLAINT:, Right ear pain with drainage.,HISTORY OF PRESENT ILLNESS:, This is a 12-year-old white male here with his mother for complaints of his right ear hurting. Mother states he has been complaining for several days. A couple of days ago she noticed drainage from the right ear. The patient states it has been draining for several days and it has a foul smell to it. He has had some low-grade fever. The patient was seen in the office about a week ago with complaints of a sore throat, headache and fever. The patient was evaluated for Strep throat which was negative and just had been doing supportive care. He did have a recent airplane ride a couple of weeks ago also. There has been no cough, shortness of breath or wheezing. No vomiting or diarrhea.,PHYSICAL EXAM:,General: He is alert in no distress.,Vital Signs: Temperature: 99.1 degrees.,HEENT: Normocephalic, atraumatic. Pupils equal, round and react to light. The left TM is clear. The right TM is poorly visualized secondary to purulent secretions in the right ear canal. There is no erythema of the ear canals. Nares is patent. Oropharynx is clear. The patient does wear braces.,Neck: Supple.,Lungs: Clear to auscultation.,Heart: Regular. No murmur.,ASSESSMENT:,1. Right otitis media.,2. Right otorrhea.,PLAN:, Ceftin 250 mg by mouth twice a day for 10 days. Ciprodex four drops to the right ear twice a day. The patient is to return to the office in two weeks for followup. | Ear Pain - Drainage | ENT - Otolaryngology | ent - otolaryngology, drainage, ear hurting, ear pain, otitis media, otorrhea, ear pain with drainage, otitis, media, ear, |
Laparoscopic lysis of adhesions, attempted laparoscopic pyeloplasty, and open laparoscopic pyeloplasty. Right ureteropelvic junction obstruction, severe intraabdominal adhesions, and retroperitoneal fibrosis. | 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. | Laparoscopic Pyeloplasty | Nephrology | nephrology, retroperitoneal, fibrosis, pyeloplasty, laparoscopic, lysis of adhesions, ureteropelvic junction obstruction, laparoscopic pyeloplasty, ureteropelvic junction, junction, ureteropelvic, intraabdominal, adhesions, |
Patient with a history of right upper pons and right cerebral peduncle infarction. | FAMILY HISTORY AND SOCIAL HISTORY:, Reviewed and remained unchanged.,MEDICATIONS:, List remained unchanged including Plavix, aspirin, levothyroxine, lisinopril, hydrochlorothiazide, Lasix, insulin and simvastatin.,ALLERGIES:, She has no known drug allergies.,FALL RISK ASSESSMENT: , Completed and there was no history of falls.,REVIEW OF SYSTEMS: ,Full review of systems again was pertinent for shortness of breath, lack of energy, diabetes, hypothyroidism, weakness, numbness and joint pain. Rest of them was negative.,PHYSICAL EXAMINATION:,Vital Signs: Today, blood pressure was 170/66, heart rate was 66, respiratory rate was 16, she weighed 254 pounds as stated, and temperature was 98.0.,General: She was a pleasant person in no acute distress.,HEENT: Normocephalic and atraumatic. No dry mouth. No palpable cervical lymph nodes. Her conjunctivae and sclerae were clear.,NEUROLOGICAL EXAMINATION:, Remained unchanged.,Mental Status: Normal.,Cranial Nerves: Mild decrease in the left nasolabial fold.,Motor: There was mild increased tone in the left upper extremity. Deltoids showed 5-/5. The rest showed full strength. Hip flexion again was 5-/5 on the left. The rest showed full strength.,Reflexes: Reflexes were hypoactive and symmetrical.,Gait: She was mildly abnormal. No ataxia noted. Wide-based, ambulated with a cane.,IMPRESSION: , Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis, has been clinically stable with mild improvement. She is planned for surgical intervention for the internal carotid artery.,RECOMMENDATIONS: , At this time, again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes. She will continue to follow with endocrinology for diabetes and thyroid problems. I have recommended a strict control of her blood sugar, optimizing cholesterol and blood pressure control, regular exercise and healthy diet and I have discussed with Ms. A and her daughter to give us a call for post surgical recovery. I will see her back in about four months or sooner if needed. | Consult - Cerebral Peduncle Infarction | Neurology | neurology, internal carotid artery, cerebral peduncle infarction, carotid artery, blood pressure, upper pons, infarction, cerebral, peduncle, |
A 44-year-old woman with a history of rheumatoid arthritis admitted to the hospital with chest pain. MI has been ruled out. She has been referred for an exercise echocardiogram. | 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. | Exercise Stress Test - 1 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, ecg/echocardiogram, exercise stress test, ecg, wall motion abnormalities, target heart rate, hypertension, echocardiogram |
The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission. | IDENTIFYING DATA: ,The patient is a 40-year-old white male. He is married, on medical leave from his job as a tree cutter, and lives with his wife and five children.,CHIEF COMPLAINT AND REACTION TO HOSPITALIZATION: ,The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.,HISTORY OF PRESENT ILLNESS: ,The patient was very sleepy this morning, only minimally cooperative with interview. Additional information taken from the emergency room records that accompanied him from Hospital yesterday as well as from his wife, who I contacted by telephone. The patient was apparently at his stable baseline when discharged from the Hospital on 01/21/10, status post back surgery following a work-related injury. The patient returned to Emergency Room on the evening prior to admission complaining of severe back pain. His ER course is notable for yelling, spitting, and striking multiple staff members. The patient was originally to be admitted for pain control, but when he threatened to leave, he was referred to MHPs, who subsequently detained him for 72 hours for dangerousness to others. On interview, the patient reports only hazy memories of these incidences and states this behavior was secondary to his pain and his medications. He was contrite about the violence. When his wife was contacted by telephone, she agreed with this assessment and reports that he has a history of domestic violence usually in the setting of alcohol and illicit substance intoxication, but denies any events in the last 3 years.,His wife reports that after discharge from the hospital, on 01/21/10, he was prescribed Percocet, Soma, hydroxyzine, and Valium. He essentially exhausted his approximately 10 days' supply of these agents on the morning of 01/23/10, and as above believes that this was responsible for his presentation yesterday. She reports that she has been in contact with him since his arrival in our facility and reports that he is "back to normal." She denies feeling that he currently represents a threat to her or her five children. She was unaware of his mental health history, but denies that he has received care for any condition since they were married three years ago.,PAST PSYCHIATRIC HISTORY: , The patient has a history of Involuntary Treatment Act of 72 hours in our facility in 2004 or 2005 for assaultive behaviors; however, these records are not currently available for review. The patient denies any outpatient mental health treatment before or since this hospitalization. He describes his mental health diagnosis of bipolar affective disorder; however, he denies a history of dramatic mood swings in the absence of illicit substances or alcohol intoxication.,PAST MEDICAL HISTORY:, Notable for status post back surgery, discharged from Hospital on 01/21/10.,MEDICATIONS:, From discharge from Hospital on 01/21/10, include Percocet, Valium, Soma, and Vistaril, doses and frequency are not currently known. His wife reports that he was discharged with approximately 10 days' supply of these agents.,SOCIAL AND DEVELOPMENTAL HISTORY: ,The patient is employed as a tree cutter, currently on medical leave for the last 2 months following a back injury. He lives with his wife and children. He has a history of domestic violence, but not recently. Other details of occupational, educational history not currently known.,SUBSTANCE AND ALCOHOL HISTORY:, Records indicate a previous history of methamphetamine and alcohol abuse/dependence. The wife states that he has not consumed either since 12/07. Of note, urine tox screen at Hospital was positive for marijuana.,LEGAL HISTORY: ,The patient has been charged with domestic violence in the past, but his wife denies any repeat instances since in the last 3 years. It is not known whether the patient is currently on probation.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAMINATION:,Attitude: The patient is only minimally cooperative with interview secondary to being sleepy, and after repeated attempts to ask questions, he rolled over and went to bed.,Appearance: He is unkempt and there are multiple visible tattoos on his biceps.,Psychomotor: There is no obvious psychomotor agitation or retardation. There are no obvious extrapyramidal symptoms of tardive dyskinesia.,Affect: His affect is notably restricted probably due to the fact that he is sleepy.,Mood: Describes his mood as "okay.",Speech: Speech is normal rate, volume, and tone.,Thought Processes: His thought processes appear to be linear.,Thought Content: His thought content is notable for his expressions of contrition about violence at Hospital last night. He denies suicidal or homicidal ideation.,Cognitive Assessment: Cognitively, he is alert and oriented to person, place, and date but not situation. Attributes this to not really remembering the events at Hospital that resulted in this hospitalization.,Judgment and Insight: His insight and judgment are both appear to be improving.,Assets: Include his supportive wife and the fact he has been able to remain alcohol and methamphetamine sobriety for the last 3 years.,Limitations: Include his back injury and possible need for improvement of health treatment engagement.,FORMULATION: ,This is a 40-year-old white male, who was admitted for an acute agitation in the setting of misuse of prescribed opiates, Soma, hydroxyzine, and Valium. He appears much improved from his condition at Hospital last night and I suspect that his behavior is most likely attributed to delirium and this since resolved. He reports historical diagnosis of bipolar affective disorder, however, the details of this diagnosis are not currently available for review.,DIAGNOSES:,AXIS I: Delirium, resolved (recent mental status changes likely secondary to misuse of prescribed opiates, Soma, Valium, and hydroxyzine.) Rule out bipolar affective disorder.,AXIS II: Deferred.,AXIS III: Chronic pain status post back surgery.,AXIS IV: Appears to be moderate. He is currently on medical leave from his job.,AXIS V: Global Assessment of Functioning is currently 50 (his GAF was 20 approximately 24 hours ago).,ESTIMATED LENGTH OF STAY:, Three days.,PLAN:, I will hold psychiatric medications for now given the patient's fairly rapid improvement as he cleared from the condition, I suspect is likely due to misuse of prescribed medications. The patient will be placed on CIWA protocol given that one of the medications he overused was Valium. Of note, he does not currently appear to be withdrawing and I anticipate that his CIWA will be discontinued prior to discharge. I would like to increase the database regarding the details of his historical diagnosis of bipolar affective disorder before pursuing referrals for outpatient mental health care. The internal medicine service will evaluate for treatment for any underlying medical problems specifically to provide recommendations regarding pain management. | Psych Consult - Assaultive Behavior | Psychiatry / Psychology | null |
Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery. | DIAGNOSIS: , Aortic valve stenosis with coronary artery disease associated with congestive heart failure. The patient has diabetes and is morbidly obese.,PROCEDURES: , Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.,ANESTHESIA: , General endotracheal,INCISION: , Median sternotomy,INDICATIONS: , The patient presented with severe congestive heart failure associated with the patient's severe diabetes. The patient was found to have moderately stenotic aortic valve. In addition, The patient had significant coronary artery disease consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system. The patient also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to the patient's right system. It was decided to perform a valve replacement as well as coronary artery bypass grafting procedure.,FINDINGS: , The left ventricle is certainly hypertrophied· The aortic valve leaflet is calcified and a severe restrictive leaflet motion. It is a tricuspid type of valve. The coronary artery consists of a large left anterior descending artery which is associated with 60% stenosis but a large obtuse marginal artery which has a tight proximal stenosis.,The radial artery was used for the left anterior descending artery. Flow was excellent. Looking at the targets in the posterior descending artery territory, there did not appear to be any large branches. On the angiogram these vessels appeared to be quite small. Because this is a chronically occluded vessel and the patient has limited conduit due to the patient's massive obesity, attempt to bypass to this area was not undertaken. The patient was brought to the operating room,PROCEDURE: , The patient was brought to the operating room and placed in supine position. A median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh. The patient weighs nearly three hundred pounds. There was concern as to taking down the left internal mammary artery. Because the radial artery appeared to be a good conduit The patient would have arterial graft to the left anterior descending artery territory. The patient was cannulated after the aorta and atrium were exposed and full heparinization.,The patient went on cardiopulmonary bypass and the aortic cross-clamp was applied Cardioplegia was delivered through the coronary sinuses in a retrograde manner. The patient was cooled to 32 degrees. Iced slush was applied to the heart. The aortic valve was then exposed through the aortic root by transverse incision. The valve leaflets were removed and the #23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures. At this point, aortotomy was closed.,The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow. Proximal anastomosis was then carried out to the foot of the aorta. The left anterior descending artery does not have severe disease but is also a very good target and the radial artery was anastomosed to this target in an end-to-side manner. The two proximal anastomoses were then carried out to the root of the aorta.,The patient came off cardiopulmonary bypass after aortic cross-clamp was released. The patient was adequately warmed. Protamine was given without adverse effect. Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples. | Aortic Valve Replacement | Cardiovascular / Pulmonary | cardiovascular / pulmonary, coronary artery bypass grafting, saphenous vein graft, radial artery graft, coronary artery disease, congestive heart failure, descending artery territory, aortic cross clamp, aortic valve replacement, coronary artery bypass, obtuse marginal artery, anterior descending artery, mechanical valve, artery bypass, bypass grafting, marginal artery, radial artery, aortic valve, coronary artery, anterior descending, descending artery, valve, artery, aortic, grafting, |
A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future. | HISTORY OF PRESENT ILLNESS: , See chart attached.,MEDICATIONS: , Tramadol 50 mg every 4 to 6 hours p.r.n., hydrocodone 7.5 mg/500 mg every 6 hours p.r.n., zolpidem 10 mg at bedtime, triamterene 37.5 mg, atenolol 50 mg, vitamin D, TriCor 145 mg, simvastatin 20 mg, ibuprofen 600 mg t.i.d., and Lyrica 75 mg.,FAMILY HISTORY: , Mother is age 78 with history of mesothelioma. Father is alive, but unknown medical history as they have been estranged. She has a 51-year-old sister with history of multiple colon polyps. She has 2 brothers, 1 of whom has schizophrenia, but she knows very little about their medical history. To the best of her knowledge, there are no family members with stomach cancer or colon cancer.,SOCIAL HISTORY: , She was born in Houston, Texas and moved to Florida about 3 years ago. She is divorced. She has worked as a travel agent. She has 2 sons ages 24 and 26, both of whom are alive and well. She smokes a half a pack of cigarettes per day for more than 35 years. She does not consume alcohol.,REVIEW OF SYSTEMS: , As per the form filled out in our office today is positive for hypertension, weakness in arms and legs, arthritis, pneumonia, ankle swelling, getting full quickly after eating, loss of appetite, weight loss, which is stated as fluctuating up and down 4 pounds, trouble swallowing, heartburn, indigestion, belching, nausea, diarrhea, constipation, change in bowel habits, change in consistency, rectal bleeding, hemorrhoids, abdominal discomfort and cramping associated with constipation, hepatitis A or infectious hepatitis in the past, and smoking and alcohol as previously stated. Otherwise, review of systems is negative for strokes, paralysis, gout, cataracts, glaucoma, respiratory difficulties, tuberculosis, chest pain, heart disease, kidney stones, hematuria, rheumatic fever, scarlet fever, cancer, diabetes, thyroid disease, seizure disorder, blood transfusions, anemia, jaundice, or pruritus.,PHYSICAL EXAMINATION: ,Weight 152 pounds. Height is 5 feet 3 inches. Blood pressure 136/80. Pulse 68. In general: She is a well-developed and well-nourished female who ambulates with the assistance of a cane. Neurologically nonfocal. Awake, alert, and oriented x 3. HEENT: Head normocephalic, atraumatic. Sclerae anicteric. Conjunctivae are pink. Mouth is moist without any obvious oral lesions. Neck is supple. There is no submandibular, submaxillary, axillary, supraclavicular, or epitrochlear adenopathy appreciable. Lungs are clear to auscultation bilaterally. Heart: Regular rate and rhythm without obvious gallops or murmurs. Abdomen is soft, nontender with good bowel sounds. No organomegaly or masses are appreciable. Extremities are without clubbing, cyanosis, and/or edema. Skin is warm and dry. Rectal was deferred and will be done at the time of the colonoscopy.,IMPRESSION:,1. A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future.,2. Reports of recurrent bright red blood per rectum, mostly on the toilet paper over the past year. Bleeding most likely consistent with internal hemorrhoids; however, she needs further evaluation for colon polyps or colon cancer.,3. Alternations between constipation and diarrhea for the past several years with some lower abdominal cramping and discomfort particularly associated with constipation. She is on multiple medications including narcotics and may have developed narcotic bowel syndrome.,4. A long history of pyrosis, dyspepsia, nausea, and belching for many years relieved by antacids. She may likely have underlying gastroesophageal reflux disease.,5. A 1-year history of some early satiety and fluctuations in her weight up and down 4 pounds. She may also have some GI dysmotility including gastroparesis.,6. Report of dysphagia to solids over the past several years with a history of a bone spur in her cervical spine. If this bone spur is pressing anteriorly, it could certainly cause recurrent symptoms of dysphagia. Differential also includes peptic stricture or Schatzki's ring, and even remotely, the possibility of an esophageal malignancy.,7. A history of infectious hepatitis in the past with some recent mild elevations in AST and ALT levels without clear etiology. She may have some reaction to her multiple medications including her statin drugs, which can cause mild elevations in transaminases. She may have some underlying fatty liver disease and differential could include some form of viral hepatitis such as hepatitis B or even C.,PLAN:,1. We have asked her to follow up with her primary care physician with regard to this recent elevation in her transaminases. She will likely have the lab tests repeated in the future, and if they remain persistently elevated, we will be happy to see her in the future for further evaluation if her primary care physician would like.,2. Discussed reflux precautions and gave literature for further review.,3. Schedule an upper endoscopy with possible esophageal dilatation, as well as colonoscopy with possible infrared coagulation of suspected internal hemorrhoids. Both procedures were explained in detail including risks and complications such as adverse reaction to medication, as well as respiratory embarrassment, infection, bleeding, perforation, and possibility of missing a small polyp or tumor.,4. Alternatives including upper GI series, flexible sigmoidoscopy, barium enema, and CT colonography were discussed; however, the patient agrees to proceed with the plan as outlined above.,5. Due to her sister's history of colon polyps, she will likely be advised to have a repeat colonoscopy in 5 years or perhaps sooner pending the results of her baseline examination., | Consult - Multiple Colon Polyps | Gastroenterology | gastroenterology, mesothelioma, risk for colon cancer, constipation, diarrhea, multiple colon polyps, colon cancer, colon polyps, colon, cancer, polyps, |
Patient with atrial fibrillation with slow ventricular response, partially due to medications. | HISTORY OF PRESENT ILLNESS:, The patient is known to me secondary to atrial fibrillation with slow ventricular response, partially due to medications, at least when I first saw him in the office on 01/11/06. He is now 77 years old. He is being seen on the Seventh Floor. The patient is in Room 7607. The patient has a history of recent adenocarcinoma of the duodenum that was found to be inoperable, since it engulfed the porta hepatis. The workup began with GI bleeding. He was seen in my office on 01/11/06 for preop evaluation due to leg edema. A nonocclusive DVT was diagnosed in the proximal left superficial femoral vein. Both legs were edematous, and bilateral venous insufficiency was also present. An echocardiogram demonstrated an ejection fraction of 50%. The patient was admitted to the hospital and treated with a Greenfield filter since anticoagulant was contraindicated. Additional information on the echocardiogram, where a grossly dilated left atrium, moderately severely dilated right atrium. The rhythm was, as stated before, atrial fibrillation with slow atrioventricular conduction and an intraventricular conduction delay on the monitor strip. There was mild to moderate tricuspid regurgitation, mild pulmonic insufficiency. The ejection fraction was considered low normal, since it was estimated 50 to 54%. The patient received blood while in the hospital due to anemia. The leg edema improved while lying down, suggesting that the significant element of venous insufficiency was indeed present. The patient, who was diabetic, received consultation by Dr. R. He was also a chronic hypertensive and was treated for that with ACE inhibitors. The atrial fibrillation was slow, and no digitalis or beta blockers were recommended at the same time. As a matter of fact, they were discontinued. Now, the patient denied any shortness of breath or chest pain throughout this hospitalization, and cardiac nuclear studies performed earlier demonstrated no reversible ischemia.,ALLERGIES:, THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,His diabetes was suspected to be complicated with neuropathy due to tingling in both feet. He received his immunizations with flu in 2005 but did not receive Pneumovax.,SOCIAL HISTORY:, The patient is married. He had 1 child who died at the age of 26 months of unknown etiology. He quit smoking 6 years ago but dips (smokeless) tobacco.,FAMILY HISTORY:, Mother had cancer, died at 70. Father died of unknown cause, and brother died of unknown cause.,FUNCTIONAL CAPACITY:, The patient is wheelchair bound at the time of his initial hospitalization. He is currently walking in the corridor with assistance. Nocturia twice to 3 times per night.,REVIEW OF SYSTEMS:,OPHTHALMOLOGIC: Uses glasses.,ENT: Complains of occasional sinusitis.,CARDIOVASCULAR: Hypertension and atrial fibrillation.,RESPIRATORY: Normal.,GI: Colon bleeding. The patient believes he had ulcers.,GENITOURINARY: Normal.,MUSCULOSKELETAL: Complains of arthritis and gout.,INTEGUMENTARY: Edema of ankles and joints.,NEUROLOGICAL: Tingling as per above. Denies any psychiatric problems.,ENDOCRINE: Diabetes, NIDDM.,HEMATOLOGIC AND LYMPHATIC: The patient does not use any aspirin or anticoagulants and is not of anemia.,LABORATORY:, Current EKG demonstrates atrial fibrillation with incomplete left bundle branch block pattern. Q waves are noticed in the inferior leads. Nonprogression of the R-wave from V1 to V4 with small R-waves in V5 and V6 are suggestive of an old anterior and inferior infarcts. Left ventilator hypertrophy and strain is suspected.,PHYSICAL EXAMINATION:,GENERAL: On exam, the patient is alert, oriented and cooperative. He is mildly pale. He is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus.,VITAL SIGNS: Blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. Pulse oximetry is 100.,NECK: Without JVD, bruit, or thyromegaly. The neck is supple.,CHEST: Symmetric. There is no heave or retraction.,HEART: The heart sounds are irregular and no significant murmurs could be auscultated.,LUNGS: Clear to auscultation.,ABDOMEN: Exam was deferred.,LEGS: Without edema. Pulses: Dorsalis pedis pulse was palpated bilaterally.,MEDICATIONS:, Current medications include enalapril, low dose enoxaparin, Fentanyl patches. He is no longer on fluconazole. He is on a sliding scale as per Dr. Holden. He is on lansoprazole (Prevacid), Toradol, piperacillin/tazobactam, hydralazine p.r.n., Zofran, Dilaudid, Benadryl, and Lopressor p.r.n.,ASSESSMENT AND PLAN:, The patient is a very pleasant elderly gentleman with intractable/inoperable malignancy. His cardiac issues are chronic and most likely secondary to long term hypertension and diabetes. He has chronic atrial fibrillation. I do not envision a scenario whereby he will become a candidate for management of this arrhythmia beyond weight control. He is also not a candidate for anticoagulation, which is, in essence, a part and parcel of the weight control. Reason being is high likelihood for GI bleeding, especially given the diagnosis of invasive malignancy with involvement of multiple organs and lymph nodes. At this point, I agree with the notion of hospice care. If his atrioventricular conduction becomes excessive, occasional nondihydropyridine calcium channel blocker such as diltiazem or beta blockers would be appropriate; otherwise, I would keep him off those medications due to evidence of slow conduction in the presence of digitalis and beta blockers. | Cardiac Consultation - 3 | Cardiovascular / Pulmonary | null |
Generalized abdominal pain, nausea, diarrhea, and recent colonic resection. CT abdomen with and without contrast and CT pelvis with contrast. 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. | 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. | CT Abdomen & Pelvis - 8 | Gastroenterology | gastroenterology, abdominal pain, nausea, diarrhea, colonic resection, axial ct images, ct abdomen, isovue, inflammatory, urinary, bladder, abdominal, colonic, wall, thickening, axial, bowel, contrast, attenuation, pelvis, ct, abdomen |
MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis. | CC:, Progressive lower extremity weakness.,HX: ,This 54 y/o RHF presented on 7/3/93 with a 2 month history of lower extremity weakness. She was admitted to a local hospital on 5/3/93 for a 3 day h/o of progressive BLE weakness associated with incontinence and BLE numbness. There was little symptom of upper extremity weakness at that time, according to the patient. Her evaluation was notable for a bilateral L1 sensory level and 4/4 strength in BLE. A T-L-S Spine MRI revealed a T4-6 lipomatosis with anterior displacement of the cord without cord compression. CSF analysis yielded: opening pressure of 14cm H20, protein 88, glucose 78, 3 lymphocytes and 160 RBC, no oligoclonal bands or elevated IgG index, and negative cytology. Bone marrow biopsy was negative. B12, Folate, and Ferritin levels were normal. CRP 5.2 (elevated). ANA was positive at 1:5,120 in speckled pattern. Her hospital course was complicated by deep venous thrombosis, which recurred after heparin was stopped to do the bone marrow biopsy. She was subsequently placed on Coumadin. EMG/NCV testing revealed " lumbosacral polyradiculopathy with axonal degeneration and nerve conduction block." She was diagnosed with atypical Guillain-Barre vs. polyradiculopathy and received a single course of Decadron; and no plasmapheresis or IV IgG. She was discharged home o 6/8/93.,She subsequently did not improve and after awaking from a nap on her couch the day of presentation, 7/3/93, she found she was paralyzed from the waist down. There was associated mild upper lumbar back pain without radiation. She had had no bowel movement or urination since that time. She had no recent trauma, fever, chills, changes in vision, dysphagia or upper extremity deficit.,MEDS:, Coumadin 7.5mg qd, Zoloft 50mg qd, Lithium 300mg bid.,PMH:, 1) Bi-polar Affective Disorder, dx 1979 2) C-section.,FHX:, Unremarkable.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM: ,BP118/64, HR103, RR18, Afebrile.,MS: ,A&O to person, place, time. Speech fluent without dysarthria. Lucid thought processes.,CN: ,Unremarkable.,MOTOR:, 5/5 strength in BUE. Plegic in BLE. Flaccid muscle tone.,SENSORY:, L1 sensory level (bilaterally) to PP and TEMP, without sacral sparing. Proprioception was lost in both feet.,CORD: ,Normal in BUE.,Reflexes were 2+/2+ in BUE. They were not elicited in BLE. Plantar responses were equivocal, bilaterally.,RECTAL: ,Poor rectal tone. stool guaiac negative. She had no perirectal sensation.,COURSE:, CRP 8.8 and ESR 76. FVC 2.17L. WBC 1.5 (150 bands, 555 neutrophils, 440 lymphocytes and 330 monocytes), Hct 33%, Hgb 11.0, Plt 220K, MCV 88, GS normal except for slightly low total protein (8.0). LFT were normal. Creatinine 1.0. PT and PTT were normal. ABCG 7.46/25/79/96% O2Sat. UA notable for 1+ proteinuria. EKG normal.,MRI L-spine, 7/3/93, revealed an area of abnormally increased T2 signal extending from T12 through L5. This area causes anterior displacement of the spinal cord and nerve roots. The cauda equina are pushed up against the posterior L1 vertebral body. There bilaterally pulmonary effusions. There is also abnormally increased T2 signal in the center of the spinal cord extending from the mid thoracic level through the conus. In addition, the Fila Terminale appear thickened. There is increased signal in the T3 vertebral body suggestion a hemangioma. The findings were felt consistent with a large epidural lipoma displacing the spinal cord anteriorly. there also appeared spinal cord swelling and increased signal within the spinal cord which suggests an intramedullary process.,CSF analysis revealed: protein 1,342, glucose 43, RBC 4,900, WBC 9. C3 and C$ complement levels were 94 and 18 respectively (normal) Anticardiolipin antibodies were negative. Serum Beta-2 microglobulin was elevated at 2.4 and 3.7 in the CSF and Serum, respectively. It was felt the patient had either a transverse myelitis associated with SLE vs. partial cord infarction related to lupus vasculopathy or hypercoagulable state. She was place on IV Decadron. Rheumatology felt that a diagnosis of SLE was likely. Pulmonary effusion analysis was consistent with an exudate. She was treated with plasma exchange and place on Cytoxan.,On 7/22/93 she developed fever with associated proptosis and sudden loss of vision, OD. MRI Brain, 7/22/93, revealed a 5mm thick area of intermediate signal adjacent to the posterior aspect of the right globe, possibly representing hematoma. Ophthalmology felt she had a central retinal vein occlusion; and it was surgically decompressed.,She was placed on prednisone on 8/11/93 and Cytoxan was started on 8/16/93. She developed a headache with meningismus on 8/20/93. CSF analysis revealed: protein 1,002, glucose2, WBC 8,925 (majority were neutrophils). Sinus CT scan negative. She was placed on IV Antibiotics for presumed bacterial meningitis. Cultures were subsequently negative. She spontaneously recovered. 8/25/93, cisternal tap CSF analysis revealed: protein 126, glucose 35, WBC 144 (neutrophils), RBC 95, Cultures negative, cytology negative. MRI Brain scan revealed diffuse leptomeningeal enhancement in both brain and spinal canal.,DSDNA negative. She developed leukopenia in 9/93, and she was switched from Cytoxan to Imuran. Her LFT's rose and the Imuran was stopped and she was placed back on prednisone.,She went on to have numerous deep venous thrombosis while on Coumadin. This required numerous hospital admissions for heparinization. Anticardiolipin antibodies and Protein C and S testing was negative. | MRI Spine - Epidural Lipoma | Neurology | null |
The patient was exercised according to standard Bruce protocol for 9 minutes. | REASON FOR EXAMINATION:, Abnormal EKG.,FINDINGS: , The patient was exercised according to standard Bruce protocol for 9 minutes achieving maximal heart rate of 146 resulting in 85% of age-predicted maximal heart rate. Peak blood pressure was 132/60. The patient did not experience any chest discomfort during stress or recovery. The test was terminated due to leg fatigue and achieving target heart rate.,Electrocardiogram during stress and recovery did not reveal an additional 1 mm of ST depression compared to the baseline electrocardiogram. Technetium was injected at 5 minutes into stress.,IMPRESSION:,1. Good exercise tolerance.,2. Adequate heart rate and blood pressure response.,3. This maximal treadmill test did not evoke significant and diagnostic clinical or electrocardiographic evidence for significant occlusive coronary artery disease., | Treadmill Test | Cardiovascular / Pulmonary | cardiovascular / pulmonary, ekg, st depression, maximal heart rate, treadmill test, bruce protocol, blood pressure, heart rate, treadmill, electrocardiogram, |
Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma. | PREOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained. This patient is obtunded, intubated, and septic. This is an emergent procedure with 2-physician emergency consent signed and on the chart.,PROCEDURE: , The patient's right chest was prepped and draped in sterile fashion. The site of insertion was anesthetized with 1% Xylocaine, and an incision was made. Blunt dissection was carried out 2 intercostal spaces above the initial incision site. The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly. The chest tube was placed.,A postoperative chest x-ray is pending at this time.,The patient tolerated the procedure well and was taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:, 10 mL,COMPLICATIONS:, None.,SPONGE COUNT: , Correct x2. | Chest Tube Insertion in ER | Cardiovascular / Pulmonary | cardiovascular / pulmonary, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion, |
Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx). | CC: ,Headache (HA),HX:, 10 y/o RHM awoke with a bilateral parieto-occipital HA associated with single episode of nausea and vomiting, 2 weeks prior to presentation. The nausea and vomiting resolved and did not recur. However, he continued to experience similar HA 3-4 times per week during the early morning upon awakening. He never felt the HA awakened him from sleep. The HA were partially relieved by Tylenol or Advil, and he distracted himself from the pain by remaining active. One week prior to presentation, he started to experience short episodes of blurred vision and diplopia. He also became fatigued, less active, and frequently yawned.,He had no prior history of HA and he and his family denied any sign or symptom of focal weakness or numbness, dysphagia, dysarthria, or loss of consciousness.,The patient underwent an MRI brain scan prior to transfer to UIHC. This revealed a mass in the left frontal region adjacent to the left temporal horn. The mass was an inhomogeneous blend of signals on T1 and T2 images giving a suggestion of acute bleeding, hemosiderin deposition and multiple vessels within the mass.,MEDS:, None.,PMH:, 1) He was a 7# 15oz. product of a full term, uncomplicated pregnancy and spontaneous vaginal delivery. His post-partum course was unremarkable. 2)Developmental milestones were reached at the appropriate times; though he was diagnosed with dyslexia 4 years ago. 3) No significant illnesses or hospitalizations.,FHX:, MGF (meningioma). PGF (lymphoma). Mother (migraine HA). Father and 22yr old brother are alive and well.,SHX: ,lives with parents and attends mainstream 5th grade classes.,EXAM:, BP124/93 HR96 RR20 37.9C (tympanic),MS: A & O to person, place, time. Cooperative and interactive. Speech fluent and without dysarthria.,CN: EOM intact. VFFTC, Pupils 3/3 decreasing to 2/2 on exposure to light. Fundoscopy: optic disks flat, no evidence of hemorrhage. The rest of the CN exam was unremarkable.,MOTOR: full strength throughout all 4 extremities. Normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station: no pronator drift or Romberg sign,Gait: unremarkable.,Reflexes: 2+ in RUE and RLE. 3 in LUE and LLE. Plantar responses were flexor, bilaterally.,HEENT: no meningismus. no cranial bruits. no skull defects palpated.,GEN EXAM: unremarkable.,COURSE:, GS, PT/PTT, CBC were unremarkable. The MRI finding above lead to a differential diagnosis of Venous Angioma, Arteriovenous Malformation, Ependymoma, Neurocytoma, Glioma: all with associated hemorrhage.,He underwent cerebral angiography on 1/25/93. Upon injection of the RCCA an avascular mass was identified in the right temporal lobe displacing the anterior choroidal artery, and temporal branches of the middle cerebral arteries. The internal cerebral vein is displaced to the left suggesting mass effect. There is a hypoplastic A1 segment and fetal origin of the LPCA. The mass was felt by neuroradiology to represent a hematoma.,He underwent a right frontal craniotomy, 1/28/93. Pathological evaluation of the resected tissue was consistent with a vascular malformation with inclusive reactive glial tissue and evidence of recurrent and remote hemorrhage. There were dilated vascular channels having walls of variable thickness, but without evidence of elastic lamina by elastic staining. This was consistent with venous angioma/malformation. | Cerebral Angiogram | Neurology | null |
Insertion of a right brachial artery arterial catheter and a right subclavian vein triple lumen catheter. Hyperpyrexia/leukocytosis, ventilator-dependent respiratory failure, and acute pancreatitis. | PREOPERATIVE DIAGNOSES:,1. Hyperpyrexia/leukocytosis.,2. Ventilator-dependent respiratory failure.,3. Acute pancreatitis.,POSTOPERATIVE DIAGNOSES:,1. Hyperpyrexia/leukocytosis.,2. Ventilator-dependent respiratory failure.,3. Acute pancreatitis.,PROCEDURE PERFORMED:,1. Insertion of a right brachial artery arterial catheter.,2. Insertion of a right subclavian vein triple lumen catheter.,ANESTHESIA: , Local, 1% lidocaine.,BLOOD LOSS:, Less than 5 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 46-year-old Caucasian female admitted with severe pancreatitis. She was severely dehydrated and necessitated some fluid boluses. The patient became hypotensive, required many fluid boluses, became very anasarcic and had difficulty with breathing and became hypoxic. She required intubation and has been ventilator-dependent in the Intensive Care since that time. The patient developed very high temperatures as well as leukocytosis. Her lines required being changed.,PROCEDURE:,1. RIGHT BRACHIAL ARTERIAL LINE: ,The patient's right arm was prepped and draped in the usual sterile fashion. There was a good brachial pulse palpated. The artery was cannulated with the provided needle and the kit. There was good arterial blood return noted immediately. On the first stick, the Seldinger wire was inserted through the needle to cannulate the right brachial artery without difficulty. The needle was removed and a catheter was inserted over the Seldinger wire to cannulate the brachial artery. The femoral catheter was used in this case secondary to the patient's severe edema and anasarca. We did not feel that the shorter catheter would provide enough length. The catheter was connected to the system and flushed without difficulty. A good waveform was noted. The catheter was sutured into place with #3-0 silk suture and OpSite dressing was placed over this.,2. RIGHT SUBCLAVIAN TRIPLE LUMEN CATHETER: ,The patient was prepped and draped in the usual sterile fashion. 1% Xylocaine was used to anesthetize an area just inferior and lateral to the angle of the clavicle. Using the anesthetic needle, we checked down to the soft tissues anesthetizing, as we proceeded to the angle of the clavicle, this was also anesthetized. Next, a #18 gauge thin walled needle was used following the same track to the angle of clavicle. We roughed the needle down off the clavicle and directed it towards the sternal notch. There was good venous return noted immediately. The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein. The needle was then removed. A small skin nick was made with a #11 blade scalpel and the provided dilator was used to dilate the skin, soft tissue and vein. Next, the triple lumen catheter was inserted over the guidewire without difficulty. The guidewire was removed. All the ports aspirated and flushed without difficulty. The catheter was sutured into place with #3-0 silk suture and a sterile OpSite dressing was also applied. The patient tolerated the above procedures well. A chest x-ray has been ordered, however, it has not been completed at this time, this will be checked and documented in the progress notes. | Triple Lumen Catheter Insertion | Cardiovascular / Pulmonary | cardiovascular / pulmonary, hyperpyrexia, leukocytosis, ventilator-dependen, respiratory failure, pancreatitis, brachial artery, arterial catheter, subclavian vein, triple lumen catheter, catheter, brachial, needle, |
Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized. | EXAM: , CTA chest pulmonary angio.,REASON FOR EXAM: , Evaluate for pulmonary embolism.,TECHNIQUE: , Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.,FINDINGS: , There are no filling defects in the main or main right or left pulmonary arteries. No central embolism. The proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below. There is no evidence of a central embolism.,As seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35. Just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm. Given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed. However, there is considerable change in the appearance of the lung fields. There are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis. There are also extensive right lung consolidations, all new or increased significantly from the prior examination. Again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded. There is no pneumothorax in the interval.,On the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here. There is aortic root and arch and descending thoracic aortic calcification. There are scattered regions of soft plaque intermixed with this. The heart is not enlarged. The left axilla is intact in regards to adenopathy. The inferior thyroid appears unremarkable.,Limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound. Spleen, adrenal glands, and upper kidneys appear unremarkable. Visualized portions of the pancreas are unremarkable.,There is extensive rib destruction in the region of the chest wall mass. There are changes suggesting prior trauma to the right clavicle.,IMPRESSION:,1. Again demonstrated is a large right chest wall mass.,2. No central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.,3. New bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.,4. See above regarding other findings. | Chest Pulmonary Angio | Cardiovascular / Pulmonary | cardiovascular / pulmonary, chest pulmonary embolism, chest pulmonary embolism protocol, bilateral pleural effusions, chest wall mass, metastatic disease, pulmonary, isovue, subsegmental, metastatic, disease, mass, lung, embolism, chest, angio |
Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel. | 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. | Facetectomy & Foraminotomy | Orthopedic | null |
Left and right heart catheterization and selective coronary angiography. Coronary artery disease, severe aortic stenosis by echo. | INDICATION:, Coronary artery disease, severe aortic stenosis by echo.,PROCEDURE PERFORMED:,1. Left heart catheterization.,2. Right heart catheterization.,3. Selective coronary angiography.,PROCEDURE: , The patient was explained about all the risks, benefits and alternatives to the procedure. The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in usual sterile fashion. After local anesthesia with 2% lidocaine, 6-French sheath was inserted in the right femoral artery and 7-French sheath was inserted in the right femoral vein. Then right heart cath was performed using 7-French Swan-Ganz catheter. Catheter was placed in the pulmonary capillary wedge position. Pulmonary capillary wedge pressure, PA pressure was obtained, cardiac output was obtained, then RV, RA pressures were obtained. The right heart catheter _______ pulled out. Then selective coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheter. Then attempt was made to cross the aortic valve with 6-French pigtail catheter, but it was unsuccessful. After the procedure, catheters were pulled out, sheath was pulled out and hemostasis was obtained by manual pressure. The patient tolerated the procedure well. There were no complications.,HEMODYNAMICS:,1. Cardiac output was 4.9 per liter per minute. Pulmonary capillary wedge pressure, mean was 7, PA pressure was 20/14, RV 26/5, RA mean pressure was 5.,2. Coronary angiography, left main is calcified _______ dense complex.,3. LAD proximal 70% calcified stenosis present and patent stent to the mid LAD and diagonal 1 is a moderate-size vessel, has 70% stenosis. Left circumflex has diffuse luminal irregularities. OM1 has 70% stenosis, is a moderate-size vessel. Right coronary is dominant and has minimal luminal irregularities.,SUMMARY: , Three-vessel coronary artery disease with aortic stenosis by echo with normal pulmonary artery systolic pressure.,RECOMMENDATION: , Aortic valve replacement with coronary artery bypass surgery. | Heart Catheterization & Angiography | Cardiovascular / Pulmonary | cardiovascular / pulmonary, lad proximal, femoral artery, sheath, catheter, selective coronary angiography, coronary artery disease, pulmonary capillary wedge, capillary wedge, coronary angiography, coronary artery, heart catheterization, catheterization, heart, artery, stenosis, angiography, pressure, coronary |
The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission. | IDENTIFYING DATA: ,The patient is a 40-year-old white male. He is married, on medical leave from his job as a tree cutter, and lives with his wife and five children.,CHIEF COMPLAINT AND REACTION TO HOSPITALIZATION: ,The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.,HISTORY OF PRESENT ILLNESS: ,The patient was very sleepy this morning, only minimally cooperative with interview. Additional information taken from the emergency room records that accompanied him from Hospital yesterday as well as from his wife, who I contacted by telephone. The patient was apparently at his stable baseline when discharged from the Hospital on 01/21/10, status post back surgery following a work-related injury. The patient returned to Emergency Room on the evening prior to admission complaining of severe back pain. His ER course is notable for yelling, spitting, and striking multiple staff members. The patient was originally to be admitted for pain control, but when he threatened to leave, he was referred to MHPs, who subsequently detained him for 72 hours for dangerousness to others. On interview, the patient reports only hazy memories of these incidences and states this behavior was secondary to his pain and his medications. He was contrite about the violence. When his wife was contacted by telephone, she agreed with this assessment and reports that he has a history of domestic violence usually in the setting of alcohol and illicit substance intoxication, but denies any events in the last 3 years.,His wife reports that after discharge from the hospital, on 01/21/10, he was prescribed Percocet, Soma, hydroxyzine, and Valium. He essentially exhausted his approximately 10 days' supply of these agents on the morning of 01/23/10, and as above believes that this was responsible for his presentation yesterday. She reports that she has been in contact with him since his arrival in our facility and reports that he is "back to normal." She denies feeling that he currently represents a threat to her or her five children. She was unaware of his mental health history, but denies that he has received care for any condition since they were married three years ago.,PAST PSYCHIATRIC HISTORY: , The patient has a history of Involuntary Treatment Act of 72 hours in our facility in 2004 or 2005 for assaultive behaviors; however, these records are not currently available for review. The patient denies any outpatient mental health treatment before or since this hospitalization. He describes his mental health diagnosis of bipolar affective disorder; however, he denies a history of dramatic mood swings in the absence of illicit substances or alcohol intoxication.,PAST MEDICAL HISTORY:, Notable for status post back surgery, discharged from Hospital on 01/21/10.,MEDICATIONS:, From discharge from Hospital on 01/21/10, include Percocet, Valium, Soma, and Vistaril, doses and frequency are not currently known. His wife reports that he was discharged with approximately 10 days' supply of these agents.,SOCIAL AND DEVELOPMENTAL HISTORY: ,The patient is employed as a tree cutter, currently on medical leave for the last 2 months following a back injury. He lives with his wife and children. He has a history of domestic violence, but not recently. Other details of occupational, educational history not currently known.,SUBSTANCE AND ALCOHOL HISTORY:, Records indicate a previous history of methamphetamine and alcohol abuse/dependence. The wife states that he has not consumed either since 12/07. Of note, urine tox screen at Hospital was positive for marijuana.,LEGAL HISTORY: ,The patient has been charged with domestic violence in the past, but his wife denies any repeat instances since in the last 3 years. It is not known whether the patient is currently on probation.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAMINATION:,Attitude: The patient is only minimally cooperative with interview secondary to being sleepy, and after repeated attempts to ask questions, he rolled over and went to bed.,Appearance: He is unkempt and there are multiple visible tattoos on his biceps.,Psychomotor: There is no obvious psychomotor agitation or retardation. There are no obvious extrapyramidal symptoms of tardive dyskinesia.,Affect: His affect is notably restricted probably due to the fact that he is sleepy.,Mood: Describes his mood as "okay.",Speech: Speech is normal rate, volume, and tone.,Thought Processes: His thought processes appear to be linear.,Thought Content: His thought content is notable for his expressions of contrition about violence at Hospital last night. He denies suicidal or homicidal ideation.,Cognitive Assessment: Cognitively, he is alert and oriented to person, place, and date but not situation. Attributes this to not really remembering the events at Hospital that resulted in this hospitalization.,Judgment and Insight: His insight and judgment are both appear to be improving.,Assets: Include his supportive wife and the fact he has been able to remain alcohol and methamphetamine sobriety for the last 3 years.,Limitations: Include his back injury and possible need for improvement of health treatment engagement.,FORMULATION: ,This is a 40-year-old white male, who was admitted for an acute agitation in the setting of misuse of prescribed opiates, Soma, hydroxyzine, and Valium. He appears much improved from his condition at Hospital last night and I suspect that his behavior is most likely attributed to delirium and this since resolved. He reports historical diagnosis of bipolar affective disorder, however, the details of this diagnosis are not currently available for review.,DIAGNOSES:,AXIS I: Delirium, resolved (recent mental status changes likely secondary to misuse of prescribed opiates, Soma, Valium, and hydroxyzine.) Rule out bipolar affective disorder.,AXIS II: Deferred.,AXIS III: Chronic pain status post back surgery.,AXIS IV: Appears to be moderate. He is currently on medical leave from his job.,AXIS V: Global Assessment of Functioning is currently 50 (his GAF was 20 approximately 24 hours ago).,ESTIMATED LENGTH OF STAY:, Three days.,PLAN:, I will hold psychiatric medications for now given the patient's fairly rapid improvement as he cleared from the condition, I suspect is likely due to misuse of prescribed medications. The patient will be placed on CIWA protocol given that one of the medications he overused was Valium. Of note, he does not currently appear to be withdrawing and I anticipate that his CIWA will be discontinued prior to discharge. I would like to increase the database regarding the details of his historical diagnosis of bipolar affective disorder before pursuing referrals for outpatient mental health care. The internal medicine service will evaluate for treatment for any underlying medical problems specifically to provide recommendations regarding pain management. | Psych Consult - Assaultive Behavior | Psychiatry / Psychology | null |
Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation. | 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. | Bunionectomy & Osteotomy | Orthopedic | orthopedic, hallux interphalangeus, osteotomy, bunionectomy, akin, wire fixation, screw fixation, painful bunion, metatarsophalangeal joint, pneumatic ankle, metatarsal head, foot, toe, sagittal, metatarsal |
Congestive heart failure (CHF). The patient is a 75-year-old gentleman presented through the emergency room. Symptoms are of shortness of breath, fatigue, and tiredness. Main complaints are right-sided and abdominal pain. Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure. | REASON FOR CONSULTATION: , Congestive heart failure.,HISTORY OF PRESENT ILLNESS: , The patient is a 75-year-old gentleman presented through the emergency room. Symptoms are of shortness of breath, fatigue, and tiredness. Main complaints are right-sided and abdominal pain. Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure. Given history and his multiple risk factors and workup recently, which has been as mentioned below, the patient was admitted for further evaluation. Incidentally, his x-ray confirms pneumonia.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, active smoker, cholesterol elevated, questionable history of coronary artery disease, and family history is positive.,FAMILY HISTORY: , Positive for coronary artery disease.,PAST SURGICAL HISTORY: , The patient denies any major surgeries.,MEDICATIONS: ,Aspirin, Coumadin adjusted dose, digoxin, isosorbide mononitrate 120 mg daily, Lasix, potassium supplementation, gemfibrozil 600 mg b.i.d., and metoprolol 100 mg b.i.d.,ALLERGIES: , None reported.,PERSONAL HISTORY:, Married, active smoker, does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, smoking history, coronary artery disease, cardiomyopathy, COPD, and presentation as above. The patient is on anticoagulation on Coumadin, the patient does not recall the reason.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: Weakness, fatigue, and tiredness.,HEENT: History of blurry vision and hearing impaired. No glaucoma.,CARDIOVASCULAR: Shortness of breath, congestive heart failure, and arrhythmia. Prior history of chest pain.,RESPIRATORY: Bronchitis and pneumonia. No valley fever.,GASTROINTESTINAL: No nausea, vomiting, hematemesis, melena, or abdominal pain.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: No arthritis or muscle weakness.,SKIN: Non-significant.,NEUROLOGICAL: No TIA. No CVA or seizure disorder.,ENDOCRINE: Non-significant.,HEMATOLOGICAL: Non-significant.,PSYCHOLOGICAL: Anxiety. No depression.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 60, blood pressure of 129/73, afebrile, and respiratory rate 16 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Supple. Neck veins flat.,LUNGS: Air entry bilaterally decreased in the basilar areas with scattered rales, especially right side greater than left lung.,HEART: PMI displaced. S1 and S2, regular. Systolic murmur.,ABDOMEN: Soft and nontender.,EXTREMITIES: Trace edema of the ankle. Pulses are feebly palpable. Clubbing plus. No cyanosis.,CNS: Grossly intact.,MUSCULOSKELETAL: Arthritic changes.,PSYCHOLOGICAL: Normal affect.,LABORATORY AND DIAGNOSTIC DATA: , EKG shows sinus bradycardia, intraventricular conduction defect. Nonspecific ST-T changes.,Laboratories noted with H&H 10/32 and white count of 7. INR 1.8. BUN and creatinine within normal limits. Cardiac enzyme profile first set 0.04, BNP of 10,000.,Nuclear myocardial perfusion scan with adenosine in the office done about a couple of weeks ago shows ejection fraction of 39% with inferior reversible defect.,IMPRESSION: , The patient is a 75-year-old gentleman admitted for: | Consult - Congestive Heart Failure | Cardiovascular / Pulmonary | null |
Right radical nephrectomy and assisted laparoscopic approach. | PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE: , Right radical nephrectomy and assisted laparoscopic approach.,ANESTHESIA: ,General.,PROCEDURE IN DETAIL: ,The patient underwent general anesthesia with endotracheal intubation. An orogastric was placed and a Foley catheter placed. He was placed in a modified flank position with the hips rotated to 45 degrees. Pillow was used to prevent any pressure points. He was widely shaved, prepped, and draped. A marking pen was used to delineate a site for the Pneumo sleeve in the right lower quadrant and for the trocar sites in the midline just above the umbilicus and halfway between the xiphoid and the umbilicus. The incision was made through the premarked site through the skin and subcutaneous tissue. The aponeurosis of the external oblique was incised in the direction of its fibers. Muscle-splitting incision was made in the internal oblique and transversus abdominis. The peritoneum was opened and the Pneumo sleeve was placed in the usual fashion being sure that no bowel was trapped inside the ring. Then, abdominal insufflation was carried out through the Pneumo sleeve and the scope was passed through the Pneumo sleeve to visualize placement of the trocars in the other two positions. Once this had been completed, the scope was placed in the usual port and dissection begun by taking down the white line of Toldt, so that the colon could be retracted medially. This exposed the duodenum, which was gently swept off the inferior vena cava and dissection easily disclosed the takeoff of the right renal vein off the cava. Next, attention was directed inferiorly and the ureter was divided between clips and the inferior tongue of Gerota fascia was taken down, so that the psoas muscle was exposed. The attachments lateral to the kidney was taken down, so that the kidney could be flipped anteriorly and medially, and this helped in exposing the renal artery. The renal artery had been previously noticed on the CT scan to branch early and so each branch was separately ligated and divided using the stapler device. After the arteries had been divided, the renal vein was divided again using a stapling device. The remaining attachments superior to the kidney were divided with the Harmonic scalpel and also utilized the stapler, and the specimen was removed. Reexamination of the renal fossa at low pressures showed a minimal degree of oozing from the adrenal gland, which was controlled with Surgicel. Next, the port sites were closed with 0 Vicryl utilizing the passer and doing it over the hand to prevent injury to the bowel and the right lower quadrant incision for the hand port was closed in the usual fashion. The estimated blood loss was negligible. There were no complications. The patient tolerated the procedure well and left the operating room in satisfactory condition. | Nephrectomy - Radical | Nephrology | nephrology, renal mass, foley catheter, gerota fascia, muscle-splitting incision, pneumo sleeve, endotracheal, laparoscopic, nephrectomy, orogastric, renal fossa, right lower quadrant, trocar, umbilicus, vena cava, renal, pneumo, radical, |
Laparoscopic bilateral tubal ligation with Falope rings. | 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. | Tubal Ligation | Obstetrics / Gynecology | obstetrics / gynecology, sterilization, laparoscopic bilateral tubal ligation with falope rings, falope ring applicator, laparoscopic bilateral tubal ligation, bilateral tubal ligation, veress needle, tubal ligation, falope rings, anesthesia, tubal, ligation, falope |
A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom. | REASON FOR ADMISSION: , Hepatic encephalopathy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Native American male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom. He said that he was doing fine prior to that and denied having any complaints. He was sitting watching TV and he felt sleepy. So, he went to the bathroom to urinate before going to bed and while he was trying to lift the seat, he tripped and fell and hit his head on the back. His head hit the toilet seat. Then, he started having bleeding and had pain in the area with headache. He did not lose consciousness as far as he can tell. He went and woke up his sister. This happened somewhere between 10:30 and 11 p.m. His sister brought a towel and covered the laceration on the back of his head and called EMS, who came to his house and brought him to the emergency room, where he was found to have a laceration on the back of his head, which was stapled and a CT of the head was obtained and ruled out any acute intracranial pathology. On his lab work, his ammonia was found to be markedly elevated at 106. So, he is being admitted for management of this. He denied having any abdominal pain, change in bowel habits, GI bleed, hematemesis, melena, or hematochezia. He said he has been taking his medicines, but he could not recall those. He denied having any symptoms prior to this fall. He said earlier today he also fell. He also said that this was an accidental fall caused by problem with his walker. He landed on his back at that time, but did not have any back pain afterwards.,PAST MEDICAL HISTORY:,1. Liver cirrhosis caused by alcohol. This is per the patient.,2. He thinks he is diabetic.,3. History of intracranial hemorrhage. He said it was subdural hematoma. This was traumatic and happened seven years ago leaving him with the right-sided hemiparesis.,4. He said he had a seizure back then, but he does not have seizures now.,PAST SURGICAL HISTORY:,1. He has a surgery on his stomach as a child. He does not know the type.,2. Surgery for a leg fracture.,3. Craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma.,MEDICATIONS: , He does not remember his medications except for the lactulose and multivitamins.,ALLERGIES: , Dilantin.,SOCIAL HISTORY: , He lives in Sacaton with his sister. He is separated from his wife who lives in Coolidge. He smokes one or two cigarettes a day. Denies drug abuse. He used to be a heavy drinker, quit alcohol one year ago and does not work currently.,FAMILY HISTORY:, Negative for any liver disease.,REVIEW OF SYSTEMS:,GENERAL: Denies fever or chills. He said he was in Gilbert about couple of weeks ago for fever and was admitted there for two days. He does not know the details.,ENT: No visual changes. No runny nose. No sore throat.,CARDIOVASCULAR: No syncope, chest pain, or palpitations.,RESPIRATORY: No cough or hemoptysis. No dyspnea.,GI: No abdominal pain. No nausea or vomiting. No GI bleed. History of alcoholic liver disease.,GU: No dysuria, hematuria, frequency, or urgency.,MUSCULOSKELETAL: Denies any acute joint pain or swelling.,SKIN: No new skin rashes or itching.,CNS: Had a seizure many years ago with no recurrences. Left-sided hemiparesis after subdural hematoma from a fight/trauma.,ENDOCRINE: He thinks he has diabetes but does not know if he is on any diabetic treatment.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 97.7, heart rate 83, respiratory rate 18, blood pressure 125/72, and saturation 98% on room air.,GENERAL: The patient is lying in bed, appears comfortable, very pleasant Native American male in no apparent distress.,HEENT: His skull has a scar on the left side from previous surgery. On the back of his head, there is a laceration, which has two staples on. It is still oozing minimally. It is tender. No other traumatic injury is noted. Eyes, pupils react to light. Sclerae anicteric. Nostrils are normal. Oral cavity is clear with no thrush or exudate.,NECK: Supple. Trachea midline. No JVD. No thyromegaly.,LYMPHATICS: No cervical or supraclavicular lymphadenopathy.,LUNGS: Clear to auscultation bilaterally.,HEART: Normal S1 and S2. No murmurs or gallops. Regular rate and rhythm.,ABDOMEN: Soft, distended, nontender. No organomegaly or masses.,LOWER EXTREMITIES: +1 edema bilaterally. Pulses strong bilaterally. No skin ulcerations noted. No erythema.,SKIN: Several spider angiomas noted on his torso and upper extremities consistent with liver cirrhosis.,BACK: No tenderness by exam.,RECTAL: No masses. No abscess. No rectal fissures. Guaiac was performed by me and it was negative.,NEUROLOGIC: He is alert and oriented x2. He is slow to some extent in his response. No asterixis. Right-sided spastic hemiparesis with increased tone, increased reflexes, and weakness. Increased tone noted in upper and lower extremities on the right compared to the left. Deep tendon reflexes are +3 on the right and +2 on the left. Muscle strength is decreased on the right, more pronounced in the lower extremity compared to the upper extremity. The upper extremity is +4/5. Lower extremity is 3/5. The left side has a normal strength. Sensation appears to be intact. Babinski is upward on the right, equivocal on the left.,PSYCHIATRIC: Flat affect. Mood appeared to be appropriate. No active hallucinations or psychotic symptoms.,LABORATORY DATA: | Hepatic Encephalopathy | Neurology | null |
The patient with gradual onset of a headache problem, located behind both eyes. | 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: | Migraine without Aura - Consult | Neurology | null |
MRI left knee without contrast. | EXAM:,MRI OF THE LEFT KNEE WITHOUT CONTRAST,CLINICAL:,Left knee pain. Twisting injury.,FINDINGS:,The images reveal a sizable joint effusion. The joint effusion appears to be complex with mixed signal intensity material within. The patella is slightly laterally tilted towards the left. The mid portion of the patella cartilage shows some increased signal and focal injury to the patellar cartilage is suspected. Mildly increased bone signal overlying the inferolateral portion of the patella is identified. No significant degenerative changes about the patella can be seen. The quadriceps tendon as well as the infrapatellar ligament both look intact. There is some prepatellar soft tissue edema.,The bone signal shows a couple of small areas of cystic change in the proximal aspect of the tibia. NO significant areas of bone edema are appreciated.,There is soft tissue edema along the lateral aspect of the knee. There is a partial tear of the lateral collateral ligament complex. The medial collateral ligament complex looks intact. A small amount of edema is identified immediately adjacent to the medial collateral ligament complex.,The posterior cruciate ligament looks intact. The anterior cruciate ligament is thickened with significant increased signal. I suspect at least a high grade partial tear.,The posterior horn of the medial meniscus shows some myxoid degenerative changes. The posterior horn and anterior horn of the lateral meniscus likewise shows myxoid degenerative type changes. I don’t see a definite tear extending to the articular surface.,IMPRESSION:,Sizeable joint effusion which is complex and may contain blood products.,Myxoid degenerative type changes medial and lateral meniscus with no definite evidence of a tear.,Soft tissue swelling and partial tear of the lateral collateral ligament complex.,At least high grade partial tear of the anterior cruciate ligament with significant thickening and increased signal of this structure.,The posterior cruciate ligament is intact.,Injury to the patellar cartilage as above. | MRI Knee - 4 | Orthopedic | orthopedic, lateral collateral ligament, medial collateral ligament, posterior cruciate ligament, anterior cruciate ligament, collateral ligament complex, myxoid degenerative, partial tear, collateral ligament, ligament complex, cruciate ligament, mri, effusion, cartilage, collateral, cruciate, knee, tear, ligament |
Leaking anastomosis from esophagogastrectomy. Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. | PREOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,POSTOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,PROCEDURE: , Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,COMPLICATIONS:, None. ,ANESTHESIA: , General oroendotracheal intubation. ,PROCEDURE: , After adequate general anesthesia was administered, the patient's abdomen was prepped and draped aseptically. Sutures and staples were removed. The abdomen was opened. The were some very early stage adhesions that were easy to separate. Dissection was carried up toward the upper abdomen where the patient was found to have a stool filled descended colon. This was retracted caudally to expose the stomach. There were a number of adhesions to the stomach. These were carefully dissected to expose initially the closure over the gastrotomy site. Initially this looked like this was leaking but it was actually found to be intact. The pyloroplasty was identified and also found to be intact with no evidence of leakage. Further dissection up toward the hiatus revealed an abscess collection. This was sent for culture and sensitivity and was aspirated and lavaged. Cavity tracked up toward the hiatus. Stomach itself appeared viable, there was no necrotic sections. Upper apex of the stomach was felt to be viable also. I did not pull the stomach and esophagus down into the abdomen from the mediastinum, but placed a sucker up into the mediastinum where additional turbid fluid was identified. Carefully placed a 10 mm flat Jackson-Pratt drain into the mediastinum through the hiatus to control this area of leakage. Two additional Jackson-Pratt drains were placed essentially through the gastrohepatic omentum. This was the area that most of the drainage had collected in. As I had previously discussed with Dr. Sageman I did not feel that mobilizing the stomach to redo the anastomosis in the chest would be a recoverable situation for the patient. I therefore did not push to visualize any focal areas of the anastomosis with the intent of repair. Once the drains were secured, they were brought out through the anterior abdominal wall and secured with 3-0 silk sutures and secured to bulb suction. The midline fascia was then closed using running #2 Prolene sutures bolstered with retention sutures. Subcutaneous tissue was copiously lavaged and then the skin was closed with loosely approximated staples. Dry gauze dressing was placed. The patient tolerated the procedure well, there were no complications. | Exploratory Laparotomy | Gastroenterology | gastroenterology, drainage, oroendotracheal, intubation, intra abdominal, abdominal abscesses, jackson pratt, exploratory laparotomy, anastomosis, esophagogastrectomy, mediastinum, abdomen, stomach |
Psychosocial Evaluation of patient before kidney transplant. | HISTORY OF PRESENT ILLNESS:, In 2002, the patient had a blood test during her routine screening, which revealed anemia and an elevated creatinine. Two weeks later she saw a nephrologist at ABCDE were she worked at that time. An ultrasound revealed that she had Parenchymal disease in which tissue around the kidney is diseased. No particular treatment was advised. She was laid off 6 months later. In 2004, she began working at The ABCD Hospital and began seeing Dr. A. She was put on Procrit, but could not keep the stringent appointment scheduled for the injection because of her work. She began seeing Dr. B and was put on Procrit and Renagel. She was advised to go on dialysis, but she felt she did not have enough information to such a drastic step. She saw an endocrinologist for some thyroid problem and her blood work showed that her creatinine was now at 7. She was referred to Dr. Xyz who found after a parathyroid scan that she may have an adenoma. Her creatinine is now 7.4.,TREATMENT AND IMPACT OF DISEASE:, She is on several medications. She is not on a renal diet yet. Her energy is good and she is still working full time.,TRANSPLANT FIRST MENTIONED AS TREATMENT OPTION: , She has wanted to transplant ever since dialysis was first mentioned.,EMOTIONAL REACTION TO DIAGNOSIS AND TREATMENT COURSE:, She is frustrated by the lack of information about what exactly has caused her renal failure and has had a real feeling of helplessness in her efforts to pursue this understanding.,OTHER SIGNIFICANT MEDICAL HISTORY/SURGERIES:, She had a Bartholin cyst removed in 2002.,PSYCHIATRIC HISTORY:, None.,COPING STRATEGIES:, She used to exercise vigorously, but has stopped at this time. She enjoys watching movies with her children.,COMPLIANCE:, She feels she watches her diet and medication regimen very closely. She said she communicates daily with Dr. Xyz,PAST AND PRESENT SMOKING:, She began smoking 2 cigarettes a day when she was 22, but stopped after a year.,PAST AND PRESENT ALCOHOL USE:, None.,PAST AND PRESENT DRUG USE:, None.,LEGAL ISSUES:, None.,TATTOOS:, None.,MARITAL STATUS: LENGTH OF THE TIME MARRIED:, She has been married for 25 years.,AGE AND HEALTH OF SPOUSE:, Xyz is 62 and in good health.,CHILDREN:, Four, all are in good health.,FATHER:, Father died in 2001, at the age of 62 of cardiac cancer.,MOTHER:, Dolorous Massey is 63 and in good health.,SIBLINGS:, Ben Doherty died in 1984 at the age of 26 in an automobile accident; Steven Doherty is 46 and is in good health.,PREVIOUS MARRIAGES AND DURATION OF EACH:, None.,PERSONS LIVING IN HOUSEHOLD:, Six.,RELATIONSHIP WITH FAMILY MEMBERS/IDENTIFIED PRIMARY SUPPORT SYSTEM:, She is close to her brother.,HIGHEST LEVEL OF EDUCATION:, She has 2 years of college at ABCD College. She is a licensed LVN.,MILITARY SERVICE:, None. | Psychosocial Eval for Kidney Transplant | Nephrology | null |
A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture. Adenoid hyperplasia bilateral. | 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 | Otitis Media - H&P | Pediatrics - Neonatal | null |
Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft. Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula. | 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. | Fogarty Thrombectomy | Cardiovascular / Pulmonary | cardiovascular / pulmonary, chronic renal failure, thrombosed, gore-tex bridge fistula, arteriovenous, fogarty, thrombectomy, anastomosis, gore tex bridge, fogarty thrombectomy, prolene suture, renal failure, distal anastomosis, bridge fistula, interposition, renal, prolene |
Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques. | PREOPERATIVE DIAGNOSIS:, Right frontotemporal chronic subacute subdural hematoma.,POSTOPERATIVE DIAGNOSIS:, Right frontotemporal chronic subacute subdural hematoma.,TITLE OF THE OPERATION: , Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.,ASSISTANT: , None.,INDICATIONS: , The patient is a 75-year-old man with a 6-week history of decline following a head injury. He was rendered unconscious by the head injury. He underwent an extensive syncopal workup in Mississippi. This workup was negative. The patient does indeed have a heart pacemaker. The patient was admitted to ABCD three days ago and yesterday underwent a CT scan, which showed a large appearance of subdural hematoma. There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes. I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity. The patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room where general and endotracheal anesthesia was obtained. The head was turned over to the left side and was supported on a cushion. There was a roll beneath the right shoulder. The right calvarium was shaved and prepared in the usual manner with Betadine-soaked scrub followed by Betadine paint. Markings were applied. Sterile drapes were applied. A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline. Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia. Weitlaner retractors were inserted. A single bur hole was placed underneath the temporalis muscle. I placed the craniotomy a bit low in order to have better cosmesis. A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm. The bone was set aside. The dura was clearly discolored and very tense. The dura was opened in a cruciate fashion with a #15 blade. There was immediate flow of a thin motor oil fluid under high pressure. Literally the fluid shot out several inches with the first nick in the membranous cavity. The dura was reflected back and biopsy of the membranes was taken and sent for permanent section. The margins of the membrane were coagulated. The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery. The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none. The dura was then closed in a watertight fashion using running locking 4-0 Nurolon. Tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system. The wound was irrigated thoroughly once more and was closed in layers. Muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 Vicryl. Finally, the skin was closed with running locking 3-0 nylon.,Estimated blood loss for the case was less than 30 mL. Sponge and needle counts were correct.,FINDINGS: , Chronic subdural hematoma with multiple septations and thickened subdural membrane.,I might add that the arachnoid was not violated at all during this procedure. Also, it was noted that there was no subarachnoid blood but only subdural blood. | Craniotomy - Frontotemporal | Neurosurgery | neurosurgery, frontotemporal, weitlaner, calvarium, cookie cutter type, craniotomy, dura, frontotemporal craniotomy, galea, hematoma, subdural, subdural hematoma, syncopal, temporalis, subacute subdural hematoma, temporalis muscle, |
Initial obstetrical examination - Normal first pregnancy. Inadequate naternal nutrition. | CHIEF COMPLAINT,: This 32 year-old female presents today for an initial obstetrical examination. Home pregnancy test was positive.,The patient indicates fetal activity is not yet detected (due to early stage of pregnancy). LMP: 02/13/2002 EDD: 11/20/2002 GW: 8.0 weeks. Patient has been trying to conceive for 6 months.,Menses: Onset: 12 years old. Interval: 24-26 days. Duration: 4-6 days. Flow: moderate. Complications: PMS - mild.,Last Pap smear taken on 11/2/2001. Contraception: Patient is currently using none.,ALLERGIES:, Patient admits allergies to venom - bee/wasp resulting in difficulty breathing, severe rash, pet dander resulting in nasal stuffiness. Medication History: None.,PAST MEDICAL HISTORY:, Past medical history is unremarkable. Past Surgical History: Patient admits past surgical history of tonsillectomy in 1980. Social History: Patient admits alcohol use Drinking is described as social, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:, Patient admits a family history of cancer of breast associated with mother.,REVIEW OF SYSTEMS:,Neurological: (+) unremarkable.,Respiratory: (+) difficulty sleeping, (-) breathing difficulties, respiratory symptoms.,Psychiatric: (+) anxious feelings.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Genitourinary: (-) decreased libido, (-) vaginal dryness, (-) vaginal bleeding. Diet is high in empty calories, high in fats and low in fiber.,PHYSICAL EXAM:, BP Standing: 126/84 Resp: 22 HR: 78 Temp: 99.1 Height: 5 ft. 6 in. Weight: 132 lbs.,Pre-Gravid Weight is 125 lbs.,Patient is a 32 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.,Oriented to person, place and time.,Mood and affect normal and appropriate to situation.,HEENT:Head & Face: Examination of head and face is unremarkable.,Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. No edema observed.,Cardiovascular: Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Respiratory: Lungs CTA.,Breast: Chest (Breasts): Breast inspection and palpation shows no abnormal findings.,Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses.,Genitourinary: External genitalia are normal in appearance. Examination of urethra shows no abnormalities. Examination of vaginal vault reveals no abnormalities. Cervix shows no pathology. Uterine portion of bimanual exam reveals contour normal, shape regular and size normal. Adnexa and parametria show no masses, tenderness, organomegaly or nodularity. Examination of anus and perineum shows no abnormalities.,TEST RESULTS: , Urine pregnancy test: positive. CBC results within normal limits. Blood type: O positive. Rh: positive. FBS: 88 mg/dl.,IMPRESSION:, Pregnancy, normal first. Maternal nutrition is inadequate for protein and poor and high in empty calories and junk foods and sweets.,PLAN:, Pap smear submitted for manual screening. Ordered CBC. Ordered blood type. Ordered hemoglobin. Ordered Rh.,Ordered fasting blood glucose.,COUNSELING:, Counseling was given regarding adverse effects of alcohol, physical activity and sexual activity. Educational supplies dispensed to patient.,Return to clinic in 4 week (s).,PRESCRIPTIONS:, NatalCare Plus Dosage: Prenatal Multivitamins tablet Sig: QD Dispense: 60 Refills: 4 Allow Generic: Yes,PATIENT INSTRUCTIONS:, Patient received written information regarding pre-eclampsia and eclampsia. Patient was instructed to restrict activity. Patient instructed to limit caffeine use. Patient instructed to limit salt intake. | OB/GYN - H&P | Obstetrics / Gynecology | null |
Carotid and cerebral arteriogram - abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery. | EXAM: , Carotid and cerebral arteriograms.,INDICATION: , Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,IMPRESSION:,1. Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.,2. Mild stenosis of the right internal carotid artery measured at 20%.,3. Patent bilateral vertebral arteries.,4. No significant disease was identified of the anterior cerebral vessels.,DISCUSSION: ,Carotid and cerebral arteriograms were performed on Month DD, YYYY, previous studies are not available for comparison.,The right groin was sterilely cleansed and draped. Lidocaine 1% buffered with sodium bicarbonate was used as local anesthetic. A 19-French needle was then advanced into the common femoral artery and a wire was advanced. Over the wire, a sheath was placed. A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire. Flushed arteriogram was performed. Arteriogram demonstrated no significant disease of the great vessels at their origins. There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin. The vertebral arteries were widely patent. Following this, the flushed catheter was exchanged for ***** catheter and selective catheterization of the common carotid artery on the right was performed. Carotid and cerebral arteriograms were performed. The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable. The external carotid artery on the right is quite tortuous in its appearance. The internal carotid artery demonstrates a mild plaque creating stenosis, which is measured approximately 20%. Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal. No significant stenosis identified. There is complete cross-filling into the left brain via the right. No significant stenosis was appreciated.,Following this, the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion.,The patient tolerated the procedure well. No complications occurred during or immediately after the procedure. Stasis was achieved of the puncture site using a VasoSeal. The patient will be observed for at least 2-1/2 hours prior to being discharged to home. | Carotid & Cerebral Arteriograms | Cardiovascular / Pulmonary | cardiovascular / pulmonary, carotid, arteriogram, bulb, carotid duplex, catheter, cerebral, distal, femoral artery, internal carotid artery, needle, occlusion, sheath, stenosis, vertebral arteries, vessels, cerebral arteriograms, carotid artery, artery, arteriograms, wire, |
Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI. The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion. | 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. | Lung Cancer & MI - Hospice Cosult | Hematology - Oncology | null |
Left mesothelioma, focal. Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall. | PREOPERATIVE DIAGNOSIS: , Left mesothelioma, focal.,POSTOPERATIVE DIAGNOSIS: , Left pleural-based nodule.,PROCEDURES PERFORMED:,1. Left thoracoscopy.,2. Left mini thoracotomy with resection of left pleural-based mass.,FINDINGS:, Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.,FLUIDS: , 800 mL of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS, TUBES, CATHETERS: , 24-French chest tube in the left thorax plus Foley catheter.,SPECIMENS: , Left pleural-based nodule.,INDICATION FOR OPERATION: ,The patient is a 59-year-old female with previous history of follicular thyroid cancer, approximately 40 years ago, status post resection with recurrence in the 1980s, who had a left pleural-based mass identified on chest x-ray. Preoperative evaluation included a CT scan, which showed focal mass. CT and PET confirmed anterior lesion. Therefore the patient was seen in our thoracic tumor board where it was recommended to have resection performed with chest wall reconstruction. In the outpatient setting, the patient was willing to proceed.,PROCEDURE PERFORMED IN DETAIL: , After informed consent was obtained, the patient identified correctly. She was taken to the operating room where an epidural catheter was placed by Anesthesia without difficulty. She was sedated and intubated with double-lumen endotracheal tube without difficulty. She was positioned with left side up. Appropriate pressure points were padded. The left chest was prepped and draped in the standard surgical fashion. The skin incision was made in the posterior axillary line, approximately 7th intercostal space with #10 blade, taken down through tissues and Bovie electrocautery.,Pleura was entered. There was good deflation of the left lung. __________ port was placed, followed by the 0-degree 10-mm scope with appropriate patient positioning. Posteriorly a pedunculated 2.5 x 3-cm pleural-based mass was identified on the anterior chest wall. There were thin adhesions to the pleura, but no invasion of the chest wall that could be identified. The tumor was very mobile and was on a pedunculated stalk, approximately 1.5 cm. It was felt that this could be resected without the need of chest wall reconstruction because of the narrow stalk.,Therefore a 2nd port was placed in the anterior axillary line approximately 8th intercostal space in the usual fashion. Camera was placed through this port. Laparoscopic scissors were placed through the posterior port, but it was necessary to have another instrument to provide more tension than just gravity. Therefore because of the need to bring the specimen through the chest wall, a small 3-cm thoracotomy was made, which incorporated the posterior port site. This was taken down to the subcutaneous tissue with Bovie electrocautery. Periosteal elevator was used to lift the intercostal muscle off. The ribs were not spread. Through this 3-cm incision, both the laparoscopic scissors as well as Prestige graspers could be placed. Prestige graspers were used to pull the specimen from the chest wall. Care was taken not to injure the capsule. The laparoscopic scissors on cautery were used to resect the parietal pleural off of the chest wall. Care was taken not to transect the stalk. Specimen came off the chest wall very easily. There was good hemostasis.,At this point, the EndoCatch bag was placed through the incision. Specimen was placed in the bag and then removed from the field. There was good hemostasis. Camera was removed. A 24-French chest tube was placed through the anterior port and secured with 2-0 silk suture. The posterior port site was closed 1st with 2-0 Vicryl in a running fashion for the intercostal muscle layer, followed by 2-0 closure of the latissimus fascia as well as subdermal suture, 4-0 Monocryl was used for the skin, followed by Steri-Strips and sterile drapes. The patient tolerated the procedure well, was extubated in the operating room and returned to the recovery room in stable condition. | Thoracoscopy & Thoracotomy - Mesothelioma | Cardiovascular / Pulmonary | cardiovascular / pulmonary, mini thoracotomy, pleural based mass, pleural based nodule, chest wall, mesothelioma focal, pleural, chest, thoracotomy, mesothelioma, laparoscopic, thoracoscopy, |
Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis. | INDICATION:, Acute coronary syndrome.,CONSENT FORM: , The procedure of cardiac catheterization/PCI risks included but not restricted to death, myocardial infarction, cerebrovascular accident, emergent open heart surgery, bleeding, hematoma, limb loss, renal failure requiring dialysis, blood loss, infection had been explained to him. He understands. All questions answered and is willing to sign consent.,PROCEDURE PERFORMED:, Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.,NARRATIVE: , The patient was brought to the cardiac catheterization laboratory in a fasting state. Both groins were draped and sterilized in the usual fashion. Local anesthesia was achieved with 2% lidocaine to the right groin area and a #6-French femoral sheath was inserted via modified Seldinger technique in the right common femoral artery. Selective coronary angiography was performed with #6 French JL4 catheter for the left coronary system and a #6 French JR4 catheter of the right coronary artery. Left ventricular catheterization and angiography was performed at the end of the procedure with a #6-French angle pigtail catheter.,FINDINGS,1. Hemodynamics systemic blood pressure 140/70 mmHg. LVEDP at the end of the procedure was 13 mmHg.,2. The left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20% angiographic stenosis at the take off of the left circumflex artery. The left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30% angiographic stenosis. The left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate-to-severe ostium. The rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk.,The LAD is calcified and diffusely disease in the proximal and mid portion. There is mild nonobstructive disease in the proximal LAD resulting in less than 20% angiographic stenosis.,3. The right coronary artery is dominant. It is septal to be occluded in the mid portion.,The findings were discussed with the patient and she opted for PCI. Angiomax bolus was started. The ACT was checked. It was higher in 300. I have given the patient 600 mg of oral Plavix.,The right coronary artery was engaged using a #6-French JR4 guide catheter. I was unable to cross through this lesion using a BMW wire and a 3.0x8 mm balloon support. I was unable to cross with this lesion using a whisper wire. I was unable to cross with this lesion using Cross-IT 100 wire. I have also used second #6-French Amplatz right I guide catheter. At one time, I have lost flow in the distal vessel. The patient experienced severe chest pain, ST-segment elevation, bradycardia, and hypotension, which responded to intravenous fluids and atropine along with intravenous dopamine.,Dr. X was notified.,Eventually, an Asahi grand slam wire using the same 3.0 x 8 mm Voyager balloon support, I was able to cross into the distal vessel. I have performed careful balloon angioplasty of the mid RCA. I have given nitroglycerin under the nursing several times during the procedure.,I then performed arthrectomy using #5-French export catheter.,I performed more balloon predilation using a 3.0 x16 mm Voyager balloon. I then deployed 4.0 x15 mm, excised, and across the mid RCA at 18 atmospheres with good angiographic result. Proximal to the proximal edge of the stent, there was still some persistent haziness most likely just diseased artery/diffuse plaquing. I decided to cover this segment using a second 4.0 x 15 mm, excised, and two stents were overlapped, the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result.,Left ventricular catheterization was performed with #6-French angle pigtail catheter. The left ventricle is rather smaller in size. The mid inferior wall is minimally hypokinetic, ejection fraction is 70%. There is no evidence of aortic wall stenosis or mitral regurgitation.,Femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and I have performed this as Perclose hemostasis.,CONCLUSIONS,1. Normal left ventricular size and function. Ejection fraction is 65% to 70%. No MR.,2. Successful angioplasty and stenting of the subtotally closed mid RCA. This was hard, organized thrombus, very difficult to penetrate. I have deployed two overlapping 4.0 x15 mm excised and with excellent angiographic result. The RCA is dominant.,3. No moderate disease in the distal left main. Moderate disease in the ostium of the left circumflex artery. Mild disease in the proximal LAD.,PLAN: , Recommend smoking cessation. Continue aspirin lifelong and continue Plavix for at least 12 months. | Angiography & Catheterization - 2 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, acute coronary syndrome, circumflex artery, ventricular catheterization, ventricular angiography, angioplasty, coronary artery, coronary angiography, arthrectomy, femoral angiography, perclose hemostasis, selective coronary angiography, angiographic stenosis, rca, coronary, catheterization, artery, angiography, hemostasis, wire, lad, femoral, angiographic, stenting, proximal, |
Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation. | PAST MEDICAL/SURGICAL HISTORY: , Briefly, his past medical history is significant for hypertension of more than 5 years, asthma, and he has been on Advair and albuterol. He was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008. His past surgical history is only significant for left AV fistula on the wrist done in 04/2008. He still has urine output. He has no history of blood transfusion.,PERSONAL AND SOCIAL HISTORY: , He is a nonsmoker. He denies any alcohol. No illicit drugs. He used to work as the custodian at the nursing home, but now on disability since 03/2008. He is married with 2 sons, ages 5 and 17 years old.,FAMILY HISTORY:, No similar illness in the family, except for hypertension in his one sister and his mom, who died at 61 years old of congestive heart failure. His father is 67 years old, currently alive with asthma. He also has one sister who has hypertension. The rest of the 6 siblings are alive and well.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Singulair 10 mg once daily, Cardizem 365 mg once daily, Coreg 25 mg once daily, hydralazine 100 mg three times a day, Lanoxin 0.125 mg once daily, Crestor 10 mg once daily, lisinopril 10 mg once daily, Phoslo 3 tablets with meals, and Advair 250 mg inhaler b.i.d.,REVIEW OF SYSTEMS: , Significant only for asthma. No history of chest pain normal MI. He has hypertension. He occasionally will develop colds especially with weather changes. GI: Negative. GU: Still making urine about 1-3 times per day. Musculoskeletal: Negative. Skin: He complains of dry skin. Neurologic: Negative. Psychiatry: Negative. Endocrine: Negative. Hematology: Negative.,PHYSICAL EXAMINATION: , A pleasant 41-year-old African-American male who stands 5 feet 6 inches and weighs about 193 pounds. HEENT: Anicteric sclera, pink conjunctiva, no cervical lymphadenopathy. Chest: Equal chest expansion. Clear breath sounds. Heart: Distinct heart sounds, regular rhythm with no murmur. Abdomen: Soft, nontender, flabby, no organomegaly. Extremities: Poor peripheral pulses. No cyanosis and no edema.,ASSESSMENT AND PLAN:, This is a 49-year old African-American male who was diagnosed with end-stage renal disease secondary to hypertension. He is on hemodialysis since 02/2008. Overall, I think that he is a reasonable candidate for a kidney transplantation and should undergo a complete pretransplant workup with pulmonary clearance because of his chronic asthma. Other than that, I think that he is a reasonable candidate for transplant.,I would like to thank you for allowing me to participate in the care of your patient. Please feel free to contact me if there are any questions regarding his case. | Nephrology Consultation - 3 | Nephrology | nephrology, kidney transplantation, pretransplant, transplant clinic, renal disease, secondary, kidney, hemodialysis, renal, asthma, transplantation, hypertension |
GI Consultation due to rectal bleeding, positive celiac sprue panel | 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. | GI Consultation - 1 | Gastroenterology | gastroenterology, bleeding, abdominal discomfort, belching, bloating, bowel, celiac sprue, change in bowel habits, constipation, cramping, diarrhea, gluten-free, nausea, rectal, vomiting, inflammatory arthritis, rectal bleeding, gi, inflammatory, sprue, celiac, gluten, diet, |
Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose. | Thereafter, he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated. On December 5, 2008, Mr. XXXX did undergo a total knee replacement arthroplasty performed by Dr. X.,Thereafter, he did an extensive course of physical therapy, work hardening, and a work conditioning type program.,At the present time, he does complain of significant pain and swelling as related to the right knee. He is unable to crawl and/or kneel. He does state he is able to walk a city block and in fact, he is able to do 20 minutes of a treadmill. Stairs are a significant problem. His pain is a 5 to 6 on a scale of 1 to 10.,He is better when he is resting, sitting, propped up, and utilizing his ice. He is much worse when he is doing any type of physical activity.,He has denied having any previous history of similar problems.,CURRENT MEDICATIONS: ,Over-the-counter pain medication.,ALLERGIES: , NKA.,SURGERIES: , Numerous surgeries as related to the right lower extremity.,SOCIAL HISTORY: , He does admit to one half pack of cigarette consumption per day. He denies any alcohol consumption.,PHYSICAL EXAMINATION: ,On examination today, he is 28-year-old male who is 6 feet 1, weighs 250 pounds. He does not appear to be in distress at this time. One could appreciate 1-2/4 intraarticular effusion. The range of motion is 0 to a 110 degrees of flexion. I could not appreciate any evidence of instability medial, lateral, anterior or posterior. Crepitus is noted with regards to range of motion testing. His strength is 4 to 5 as related to the quadriceps and hamstring.,There is atrophy as related to the right thigh. The patient is able to stand from a seated position and sit from a standing position without difficulty.,RECORDS REVIEW:,1. First report of injury.,2. July 17, 2002, x-rays of the right knee were negative.,3. Notes of the Medina General Hospital Occupational Health, Steven Rodgers, M.D.,4. August 5, 2002, an MRI scan of the right knee which demonstrated peripheral tear of the posterior horn of the medial | Records Review - Orthopedic | Orthopedic | null |
Peripheral effusion on the CAT scan. The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy. She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis. | REASON FOR CONSULT: , Peripheral effusion on the CAT scan.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy. She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis. The patient had a visiting nurse for Christmas and started having abdominal pain, nausea and vomiting for which, she was admitted. She had a CAT scan of the abdomen done, showed moderate pericardial effusion for which cardiology consult was requested. She had an echo done, which shows moderate pericardial effusion with early tamponade. The patient has underlying shortness of breath because of COPD, emphysema and chronic cough. However, denies any dizziness, syncope, presyncope, palpitation. Denies any prior history of coronary artery disease.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , At this time, she is on hydromorphone p.r.n., erythromycin, ceftriaxone, calcium carbonate, Ambien. She is on oxygen and nebulizer.,PAST MEDICAL HISTORY: , History of COPD, emphysema, pneumonia, and lung cancer.,PAST SURGICAL HISTORY: ,Hip surgery and resection of the lung cancer 10 years ago.,SOCIAL HISTORY:, Still smokes, but less than before. Drinks socially.,FAMILY HISTORY:, Noncontributory.,REVIEW OF SYSTEMS: , Denies any syncope, presyncope, palpitations, shortness of breath, cough, nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,GENERAL: The patient is comfortable not in any distress.,VITAL SIGNS: Blood pressure 121/79, Pulse rate 94, respiratory rate 19, and temperature 97.6.,HEENT: Atraumatic and normocephalic.,NECK: Supple. No JVD. No carotid bruit.,CHEST: Breath sounds vesicular. Clear on auscultation.,HEART: PMI could not be localized. S2 and S2 regular. No S3, no S4. No murmur.,ABDOMEN: Soft and nontender. Positive bowel sounds.,EXTREMITIES: No cyanosis, clubbing, or edema. Pulse 2+.,CNS: Alert, awake, and oriented x3.,EKG shows normal sinus rhythm, low voltage.,LABORATORY DATA: , White cell count 7.3, hemoglobin 12.9, hematocrit 38.1, and platelet at 322,000. Sodium 135, potassium 5, BUN 6, creatinine 1.2, glucose 71, alkaline phosphatase 263, total protein 5.3, lipase 414, and amylase 57.,DIAGNOSTIC STUDIES:, Chest x-ray shows left upper lobe airspace disease consistent with pneumonia _______. CT abdomen showed diffuse replacement of the _______ metastasis, hepatomegaly, perihepatic ascites, moderate pericardial effusion, small left _______ sigmoid diverticulosis.,ASSESSMENT:,1. Moderate peripheral effusion with early tamponade, probably secondary to lung cancer.,2. Lung cancer with metastasis most likely.,3. Pneumonia.,4. COPD.,PLAN: , We will get CT surgery consult for pericardial window. Continue present medication. | Peripheral Effusion - Consult | Cardiovascular / Pulmonary | null |
D&C and hysteroscopy. Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining.6. Grade 1+ rectocele. | 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. | D&C & Hysteroscopy Followup | Obstetrics / Gynecology | obstetrics / gynecology, pelvic examinatio, abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, thickened endometrium, intermenstrual, d&c, uterine, bleeding, fibroid, endometrium, hysteroscopy, uterus |
Questionable foreign body, right nose. Belly and back pain. Mild constipation. | 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. | Foreign Body - Right Nose | Pediatrics - Neonatal | null |
Diagnostic laparoscopy and drainage of cyst. | 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. | Laparoscopy - Drainage of Cyst | Obstetrics / Gynecology | obstetrics / gynecology, ovarian cyst, infraumbilical incision, drainage of cyst, diagnostic laparoscopy, laparoscopy, drainage, ovarian, |
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