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REASON FOR TRANSFER:, Need for cardiac catheterization done at ABCD.,TRANSFER DIAGNOSES:,1. Coronary artery disease.,2. Chest pain.,3. History of diabetes.,4. History of hypertension.,5. History of obesity.,6. A 1.1 cm lesion in the medial aspect of the right parietal lobe.,7. Deconditioning.,CONSULTATIONS: , Cardiology.,PROCEDURES:,1. Echocardiogram.,2. MRI of the brain.,3. Lower extremity Duplex ultrasound.,HOSPITAL COURSE: , Please refer to my H&P for full details. In brief, the patient is a 64-year-old male with history of diabetes, who presented with 6 hours of chest pressure. He was brought in by a friend. The friend states that the patient deteriorated over the last few weeks to the point that he is very short of breath with exertion. He apparently underwent a cardiac workup 6 months ago that the patient states he barely passed. His vital signs were stable on admission. He was ruled out for myocardial infarction with troponin x2. An echocardiogram showed concentric LVH with an EF of 62%. I had Cardiology come to see the patient, who reviewed the records from Fountain Valley. Based on his stress test in the past, Dr. X felt the patient needed to undergo a cardiac cath during his inpatient stay.,The patient on initial presentation complained of, what sounded like, amaurosis fugax. I performed an MRI, which showed a 1 cm lesion in the right parietal lobe. I was going to call Neurology at XYZ for evaluation. However, secondary to his indication for transfer, this could be followed up at ABCD with Dr. Y.,The patient is now stable for transfer for cardiac cath.,Discharged to ABCD.,DISCHARGE CONDITION:, Stable.,DISCHARGE MEDICATIONS:,1. Aspirin 325 mg p.o. daily.,2. Lovenox 40 mg p.o. daily.,3. Regular Insulin sliding scale.,4. Novolin 70/30, 15 units b.i.d.,5. Metformin 500 mg p.o. daily.,6. Protonix 40 mg p.o. daily.,DISCHARGE FOLLOWUP: , Followup to be arranged at ABCD after cardiac cath.nan

Doctor's Address,Dear Doctor:,This letter serves as an introduction to my patient, A, who will be seeing you in the near future. He is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia. He has been treated by Dr. X through the pediatric neurology clinic. He saw Dr. X recently and she noted that he was having difficulty with mouth breathing, which was contributing to some of his speech problems. She also noted and confirmed that he has significant tonsillar hypertrophy. The concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech. Therefore, I ask for your opinion on this matter.,For his chronic allergic rhinitis symptoms, he is currently on Flonase two sprays to each nostril once a day. He also has been taking Zyrtec 10 mg a day with only partial relief of the symptoms. He does have an allergy to penicillin.,I appreciate your input on his care. If you have any questions regarding, please feel free to call me through my office. Otherwise, I look forward to hearing back from you regarding his evaluation.neurology, peech, swallowing, breathing, bulbar cerebral palsy, mouth breathing, cerebral palsy, hypotoniaNOTE,: 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.

PREOPERATIVE DIAGNOSIS: , Right pleural mass.,POSTOPERATIVE DIAGNOSIS: , Mesothelioma.,PROCEDURES PERFORMED:,1. Flexible bronchoscopy.,2. Mediastinoscopy.,3. Right thoracotomy.,4. Parietal pleural biopsy.,CONSULTS:,Consults obtained during this hospitalization included:,1. Radiation Oncology.,2. Pulmonary Medicine.,3. Medical Oncology.,4. Cancer Center Team consult.,5. Massage therapy consult.,HOSPITAL COURSE:, The patient's hospital course was unremarkable. Her pain was well controlled with an epidural that was placed by Anesthesia. At the time of discharge, the patient was ambulatory. She was discharged with home oxygen available. She was discharged with albuterol nebulizer treatments, treatments were to be q.i.d. She was discharged with a prescription for Vicodin for pain control. She is to follow up with Dr. X in the office in one week with a chest x-ray. She is instructed not to lift, push or pull anything greater than 10 pounds. She is instructed not to drive until after she sees us in the office and is off her pain medications.discharge summary, flexible bronchoscopy, mediastinoscopy, right thoracotomy, pleural biopsy, pleural mass, mesothelioma, oncology,

PREOPERATIVE DIAGNOSIS:, Melena.,POSTOPERATIVE DIAGNOSIS:, Solitary erosion over a fold at the GE junction, gastric side.,PREMEDICATIONS: , Versed 5 mg IV.,REPORTED PROCEDURE:, The Olympus gastroscope was used. The scope was placed in the upper esophagus under direct visit. The esophageal mucosa was entirely normal. There was no evidence of erosions or ulceration. There was no evidence of varices. The body and antrum of the stomach were normal. They pylorus duodenum bulb and descending duodenum are normal. There was no blood present within the stomach.,The scope was then brought back into the stomach and retroflexed in order to inspect the upper portion of the body of the stomach. When this was done, a prominent fold was seen lying along side the GE junction along with gastric side and there was a solitary erosion over this fold. The lesion was not bleeding. If this fold were in any other location of the stomach, I would consider the fold, but at this location, one would have to consider that this would be an isolated gastric varix. As such, the erosion may be more significant. There was no bleeding. Obviously, no manipulation of the lesion was undertaken. The scope was then straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1. Solitary erosion overlying a prominent fold at the gastroesophageal junction, gastric side – may simply be an erosion or may be an erosion over a varix.,2. Otherwise unremarkable endoscopy - no evidence of a bleeding lesion of the stomach.,PLAN:,1. Liver profile today.,2. Being Nexium 40 mg a day.,3. Scheduled colonoscopy for next week.surgery, ge junction, melena, olympus gastroscope, solitary erosion, descending duodenum, esophageal mucosa, esophagus, gastric side, pylorus duodenum bulb, stomach, liver profile, colonoscopy, ge junction gastric, junction gastric, endoscopy, duodenum, scope, solitary, junction, gastric, erosion,

PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest. The right groin was prepped and draped in usual manner. Under 2% lidocaine anesthesia, the right femoral artery was entered. A 6-French sheath was placed. The patient was already on anticoagulation. Selective coronary angiograms were then performed using a left and a 3DRC catheter. The catheters were reviewed. The catheters were then removed and an Angio-Seal was placed. There was some hematoma at the cath site.,RESULTS,1. The left main was free of disease.,2. The left anterior descending and its branches were free of disease.,3. The circumflex was free of disease.,4. The right coronary artery was free of disease. There was no gradient across the aortic valve.,IMPRESSION: , Normal coronary angiogram.,emergency room reports, cardiac catheterization, coronary angiogram, angiogram

PREOPERATIVE DIAGNOSIS: , Cataract to right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract to right eye.,PROCEDURE PERFORMED: ,Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.,LENS IMPLANT USED: ,See below.,COMPLICATIONS: , Posterior capsular hole, vitreous prolapse.,ANESTHESIA: ,Topical.,PROCEDURE IN DETAIL: ,The patient was identified in the preoperative holding area before being escorted back to the operating room suite. Hemodynamic monitoring was begun. Time-out was called and the patient eye operated upon and lens implant intended were verbally verified. Three drops of tetracaine were applied to the operative eye. The patient was then prepped and draped in usual sterile fashion for intraocular surgery. A lid speculum was placed. Two paracentesis sites were created approximately 120 degrees apart straddling the temple using a slit knife. The anterior chamber was irrigated with a dilute 0.25% solution of non-preserved lidocaine and filled with Viscoat. The clear corneal temporal incision was fashioned. The anterior chamber was entered by introducing a keratome. The continuous tear capsulorrhexis was performed using the bent needle cystotome and completed with Utrata forceps. The cataractous lens was then hydrodissected and phacoemulsified using a modified phaco-chop technique. Following removal of the last nuclear quadrant, there was noted to be a posterior capsular hole nasally. This area was tamponaded with Healon. The anterior chamber was swept with a cyclodialysis spatula and there was noted to be vitreous prolapse. An anterior vitrectomy was then performed bimanually until the vitreous was cleared from the anterior chamber area. The sulcus area of the lens was then inflated using Healon and a V9002 16.0 diopter intraocular lens was unfolded and centered in the sulcus area with haptic secured in the sulcus. There was noted to be good support. Miostat was injected into the anterior chamber and viscoelastic agent rinsed out of the eye with Miostat. Gentle bimanual irrigation, aspiration was performed to remove remaining viscoelastic agents anteriorly. The pupil was noted to constrict symmetrically. Wounds were checked with Weck-cels and found to be free of vitreous. BSS was used to re-inflate the anterior chamber to normal depth as confirmed by tactile pressure at about 12. All corneal wounds were then hydrated, checked and found to be watertight and free of vitreous. A single 10-0 nylon suture was placed temporarily as prophylaxis and the knot buried. Lid speculum was removed. TobraDex ointment, light patch and a Soft Shield were applied. The patient was taken to the recovery room, awake and comfortable. We will follow up in the morning for postoperative check. He will not be given Diamox due to his sulfa allergy. The intraoperative course was discussed with both he and his wife.ophthalmology, intraocular lens implant, lid speculum, cataract extraction, anterior vitrectomy, anterior chamber, eye, intraocular, extraction, hemodynamic, implant, vitrectomy, vitreous, cataract, lens,

EXAM: , Single frontal view of the chest.,HISTORY: , Atelectasis. Patient is status-post surgical correction for ASD.,TECHNIQUE: , A single frontal view of the chest was evaluated and correlated with the prior film dated mm/dd/yy.,FINDINGS:, Current film reveals there is a right-sided central venous catheter, the distal tip appears to be in the superior vena cava. Endotracheal tube with the distal tip appears to be in appropriate position, approximately 2 cm superior to the carina. Sternotomy wires are noted. They appear in appropriate placement. There are no focal areas of consolidation to suggest pneumonia. Once again seen is minimal amount of bilateral basilar atelectasis. The cardiomediastinal silhouette appears to be within normal limits at this time. No evidence of any pneumothoraces or pleural effusions.,IMPRESSION:,1. There has been interval placement of a right-sided central venous catheter, endotracheal tube, and sternotomy wires secondary to patient's most recent surgical intervention.,2. Minimal bilateral basilar atelectasis with no significant interval changes from the patient's most recent prior.,3. Interval decrease in the patient's heart size which may be secondary to the surgery versus positional and technique.radiology, atrial septal defect, central venous catheter, bilateral basilar atelectasis, single frontal view, distal tip, endotracheal tube, sternotomy wires, basilar atelectasis, atrial, venous, catheter, endotracheal, tube, sternotomy, atelectasis, chest, asd

PREOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,POSTOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,OPERATION PERFORMED:,1. Bilateral myringotomies.,2. Insertion of Shepard grommet draining tubes.,ANESTHESIA: , General, by mask.,ESTIMATED BLOOD LOSS: , Less than 1 mL.,COMPLICATIONS:, None.,FINDINGS: ,The patient had a long history of persistent recurrent infections and was placed on antibiotics for the same. At this point in time, he had a small amount of thick mucoid material in both middle ear spaces with middle ear mucosa somewhat inflamed, but no active acute infection at this point in time.,PROCEDURE:, With the patient under adequate general anesthesia with the mask delivery of anesthesia, he had his ear canals cleaned utilizing an operating microscope and all foul cerumen had been removed from both sides. Bilateral inferior radial myringotomies were performed, first on the right and then on the left. Middle ear spaces were suctioned of small amount of thick mucoid material on both sides and then Shepard grommet draining tubes were inserted on either side. Floxin drops were then instilled bilaterally to decrease any clotting within the tubes, and then cotton ball was placed in the external meatus bilaterally. At this point, the patient was awakened and returned to the recovery room, satisfactory, with no difficulty encountered.surgery, serous otitis media, floxin drops, shepard grommet, cerumen, cotton ball, middle ear, mucoid, myringotomies, tubes, shepard grommet draining tubes, serous otitis, shepard, grommet, insertion

PREOPERATIVE DIAGNOSIS: ,Left communicating hydrocele.,POSTOPERATIVE DIAGNOSIS: , Left communicating hydrocele.,ANESTHESIA: , General.,PROCEDURE: ,Left inguinal hernia and hydrocele repair.,INDICATIONS: , The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele. The fluid size tends to fluctuate with time but has been relatively persistent for the past year. I met with the patient's mom and also spoke with his father by phone in the past couple of months and explained the diagnosis of patent processus vaginalis for communicating hydrocele and talked to them about the surgical treatment and options. All their questions have been answered and the patient is fit for operation today.,OPERATIVE FINDINGS: ,The patient had a very thin patent processus vaginalis leading to a rather sizeable hydrocele sac in the left hemiscrotum. We probably drained around 10 to 15 mL of fluid from the hydrocele sac. The processus vaginalis was clearly seen back to the peritoneal reflection where a high ligation was successfully performed. There were no other abnormalities noted in the inguinal scrotal region.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had an uneventful induction of inhalation anesthetic. A peripheral IV was placed, and we conducted a surgical time-out to reiterate all of The patient's important identifying information and to confirm that we were indeed going to perform a left inguinal hernia and hydrocele repair. After preparation and draping was done with chlorhexidine based prep solution, a local infiltration block as well as an ilioinguinal and iliohypogastric nerve block was performed with 0.25% Marcaine with dilute epinephrine. A curvilinear incision was made low in the left inguinal area along one of prominent skin folds. Soft tissue dissection was carried down through Scarpa's layer to the external oblique fascia, which was then opened to expose the underlying spermatic cord structures. The processus vaginalis was dissected free from the spermatic cord structures, and the distal hydrocele sac was widely opened and drained of its fluid contents. The processus vaginalis was cleared back to peritoneal reflection at the deep inguinal ring and a high ligation was performed there using both the transfixing and a mass ligature of 3-0 Vicryl. After the excess hydrocele and processus vaginalis tissue was excised, the spermatic cord structures were replaced and the external oblique and Scarpa's layers were closed with interrupted 3-0 Vicryl sutures. Subcuticular 5-0 Monocryl and Steri-Strips were used for the final skin closure. The patient tolerated the operation well. He was awakened and taken to the recovery room in good condition. Blood loss was minimal. No specimen was submitted.,urology, hydrocele, hydrocele repair, hernia, inguinal, fluid collection, tunica vaginalis, peritesticular space, hydrocele sac, spermatic cord, cord structures, inguinal hernia, communicating hydrocele, fluid, vaginalis

PREOPERATIVE DIAGNOSIS: , Degenerative arthritis of left knee.,POSTOPERATIVE DIAGNOSIS:, Degenerative arthritis of left knee.,PROCEDURE PERFORMED: , NexGen left total knee replacement.,ANESTHESIA: , Spinal.,TOURNIQUET TIME: Approximately 66 minutes.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Approximately 50 cc.,COMPONENTS: , A NexGen stemmed tibial component size 5 was used, 10 mm cruciate retaining polyethylene surface, a NexGen cruciate retaining size E femoral component, and a size 38 9.5 mm thickness All-Poly Patella.,BRIEF HISTORY:, The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs. She wishes to proceed with arthroplasty at this time.,PROCEDURE: ,The patient was taken to the Operative Suite at ABCD General Hospital on 09/11/03. She was placed on the operating table. Department of Anesthesia administered a spinal anesthetic. Once adequately anesthetized, the left lower extremity was prepped and draped in the usual sterile fashion. An Esmarch was applied and a tourniquet was inflated to 325 mmHg on the left thigh. A longitudinal incision was made over the anterior portion of the knee and this was taken down through the subcutaneous tissue to the level of the patella retinaculum. A medial peripatellar arthrotomy was then made and taken down to the level of the tibial tubercle. Care was then ensured that the patellar tendon was not violated. The proximal tibia was then skeletonized both medially and laterally to the level of the axis through the joint line. Again care was ensured that the patellar tendon was not avulsed from the insertion on the tibia. The intramedullary canal was then opened using a drill and the anterior sizing guide was then placed. Rongeur was used to take out any osteophytes and the size of approximately size E. At this point, the epicondyle axis guide was then inserted and aligned in a proper orientation. The anterior cutting guide was then placed. Care was checked for the amount of resection that the femur would be notched and the oscillating saw was used to cut the anterior portion of the femur. After this was performed, this was removed and the distal femoral cutting guide was then placed. The left knee placed in 5 degrees of valgus, guide was then placed, and a standard distal cut was then taken. After the cuts were ensured further to be leveled and they were, and we proceeded to place the finishing guide size E and distal femur. This was placed slightly in lateral position and secured in position with spring tense and head lift tense. Once adequately secured and placed in the appropriate orientation, the alignment was again verified with the epicondyle axis and appeared to be externally rotated appropriately. The chamfer cuts and anterior and posterior cuts were then made as well as the notch cut using the reciprocating and oscillating saws. After this was performed, the guide was removed and all bony fragments were then removed. Attention was then directed to the tibia. The external tibial alignment guide was then placed and pinned to the proximal tibia in a proper position. Care was ensured if it is was a varus or valgus and the appropriate. The femur gauge was then used to provide us appropriate amount of bony resection. This was then pinned and secured into place. Ligament retractors were used to protect the collateral ligaments and the tip proximal tibial cut was then made. This bony portion was then removed and remaining meniscal fragments were removed as well as the ACL till adequate exposure was obtained. Trial components were then inserted into position and taken the range of motion and found to have good and full excellent range of motion stability. The trial components were then removed. The tibia was then stemmed in standard fashion after the tibial plate was placed in some degree of external rotation with appropriate alignment. After it was stemmed and broached, these were removed and the patella was then incised, a size 41 patella reamer blade was then used and was taken down, a size 38 patella button was then placed intact. Again the trial components were placed back into position. Patella button was placed and the tracking was evaluated. They tracked centrally with no touch technique. Again, all components were now removed and the knee was then copiously irrigated and suctioned dry. Once adequately suctioned dry, the tibial portion was cemented and packed into place. Also excess cement was removed. The femoral component was then cemented into position. All excess cement was removed. A size 12 poly was then inserted in trial to provide compression at cement adhered. The patella was then cemented and held into place. All components were held under compression until cement had adequately adhered all excess cement was then removed. The knee was then taken through range of motion and size 12 felt to be slightly too big, this was removed and the size 10 trial was replaced, and again had excellent varus and valgus stability with full range of motion and felt to be the articulate surface of choice. The knee was again copiously irrigated and suctioned dry. One last check in the posterior aspect of the knee for any loose bony fragments or osteophytes was performed, there were none found and a final articulating surface was impacted and locked into place. After this, the knee was taken again for final range of motion and found to have excellent position, stability, and good alignment of the components. The knee was once again copiously irrigated, and the tourniquet was deflated. Bovie cautery was used to cauterize the knee bleeding that was seen until good hemostasis obtained. A drain was then placed deep to the retinaculum and the retinaculum repair was performed using #2-0 Ethibond and oversewn with a #1 Vicryl. This was flexed and the repair was found held securely. At this point, the knee was again copiously irrigated and suctioned dry. The subcutaneous tissue was closed with #2-0 Vicryl, and the skin was approximated with skin staples. Sterile dressing with Adaptic, 4x4s, ABDs, and Kerlix rolls was then applied. The patient was then transferred back to the gurney in a supine position.,DISPOSITION: , The patient tolerated well with no complications, to PACU in satisfactory condition.orthopedic, degenerative arthritis, nexgen stemmed tibial component, all-poly patella, nexgen cruciate, total knee replacement, patellar tendon, proximal tibia, epicondyle axis, bony fragments, patella button, tibial, knee, arthritis, nexgen, patella

INDICATION: , Aortic stenosis.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION: ,Procedure and complications explained to the patient in detail. Informed consent was obtained. The patient was anesthetized in the throat with lidocaine spray. Subsequently, 3 mg of IV Versed was given for sedation. The patient was positioned and transesophageal probe was introduced without any difficulty. Images were taken. The patient tolerated the procedure very well without any complications. Findings as mentioned below.,FINDINGS:,1. Left ventricle is in normal size and dimension. Normal function. Ejection fraction of 60%.,2. Left atrium and right-sided chambers are of normal size and dimension.,3. Mitral, tricuspid, and pulmonic valves are structurally normal.,4. Aortic valve reveals annular calcification with fibrocalcific valve leaflets with decreased excursion.,5. Left atrial appendage is clean without any clot or smoke effect.,6. Atrial septum intact. Study was negative.,7. Doppler study essentially benign.,8. Aorta essentially benign.,9. Aortic valve planimetry valve area average about 1.3 cm2 consistent with moderate aortic stenosis.,SUMMARY:,1. Normal left ventricular size and function.,2. Benign Doppler flow pattern.,3. Aortic valve area of 1.3 cm2 planimetry.,radiology, aortic valve, ejection fraction, planimetry, ventricular, transesophageal, echocardiogram, atrial septum, septum intact, transesophageal echocardiogram, aortic stenosis, doppler, aortic, valves

DATE OF ADMISSION: , MM/DD/YYYY.,DATE OF DISCHARGE: , MM/DD/YYYY.,ADMITTING DIAGNOSIS:, Peritoneal carcinomatosis from appendiceal primary.,DISCHARGE DIAGNOSIS: , Peritoneal carcinomatosis from appendiceal primary.,SECONDARY DIAGNOSIS: , Diarrhea.,ATTENDING PHYSICIAN: , AB CD, M.D.,SERVICE: , General surgery C, Surgery Oncology.,CONSULTING SERVICES:, Urology.,PROCEDURES DURING THIS HOSPITALIZATION:, On MM/DD/YYYY, ,1. Cystoscopy, bilaterally retrograde pyelograms, insertion of bilateral externalized ureteral stents.,2. Exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, IPHC with mitomycin-C.,HOSPITAL COURSE: , The patient is a pleasant 56-year-old gentleman with no significant past medical history who after an extensive workup for peritoneal carcinomatosis from appendiceal primary was admitted on MM/DD/YYYY. He was admitted to General Surgery C Service for a routine preoperative evaluation including baseline labs, bowel prep, urology consult for ureteral stent placement. The patient was taken to the operative suite on MM/DD/YYYY and was first seen by Urology for a cystoscopy with bilateral ureteral stent placement. Dr. XYZ performed an exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, and IPHC with mitomycin-C. The procedure was without complications. The patient was observed closely in the ICU for one day postoperatively for persistent tachycardia after extubation. He was then transferred to the floor where he has done exceptionally well.,On postoperative day #2, the patient passed flatus and we were able to start a clear liquid diet. We advanced him as tolerated to a regular health select diet by postoperative day #4. His pain was well controlled throughout this hospitalization, initially with a PCA pump, which he very seldomly used. He was then switched over to p.o. pain medicines and has required very little for adequate pain control. By postoperative date #2, the patient had been out of bed and ambulating in the hallways. The patient's only problem was with some mild diarrhea on postoperative days #3 and 4. This was thought to be a result of his right hemicolectomy. A C. diff toxin was sent and came back negative and he was started on Imodium to manage his diarrhea. His post-splenectomy vaccines including pneumococcal, HiB, and meningococcal vaccines were administered during his hospitalization.,On the day of discharge, the patient was resting comfortably in the bed without complaints. He had been afebrile throughout his hospitalization and his vital signs were stable. Pertinent physical exam findings include that his abdomen was soft, nondistended and nontender with bowel sounds present throughout. His midline incision is clean, dry, and intact and staples are in place. He is just six days postop, he will go home with his staples in place and they will be removed on his follow-up appointment.,CONDITION AT DISCHARGE: ,The patient was discharged in good and stable condition.,DISCHARGE MEDICATIONS:,1. Multivitamins daily.,2. Lovenox 40 mg in 0.4 mL solution inject subcutaneously once daily for 14 days.,3. Vicodin 5/500 mg and take one tablet by mouth every four hours as needed for pain.,4. Phenergan 12.5 mg tablets, take one tablet by mouth every six hours p.r.n. for nausea.,5. Imodium A-D tablets take one tablet by mouth b.i.d. as needed for diarrhea.,DISCHARGE INSTRUCTIONS:, The patient was instructed to contact us with any questions or concerns that may arise. In addition, he was instructed to contact us, if he would have fevers greater than 101.4, chills, nausea or vomitting, continuing diarrhea, redness, drainage, or warmth around his incision site. He will be seen in about one week's time in Dr. XYZ's clinic and his staples will be removed at that time.,FOLLOW-UP APPOINTMENT: , The patient will be seen by Dr. XYZ in clinic in one week's time.nan

PROBLEMS LIST:,1. Nonischemic cardiomyopathy.,2. Branch vessel coronary artery disease.,3. Congestive heart failure, NYHA Class III.,4. History of nonsustained ventricular tachycardia.,5. Hypertension.,6. Hepatitis C.,INTERVAL HISTORY: , The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications. However, he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest. He has history of orthopnea and PND. He has gained a few pounds of weight but denied to have any palpitation, presyncope, or syncope.,REVIEW OF SYSTEMS: , Positive for right upper quadrant pain. He has occasional nausea, but no vomiting. His appetite has decreased. No joint pain, TIA, seizure or syncope. Other review of systems is unremarkable.,I reviewed his past medical history, past surgical history, and family history.,SOCIAL HISTORY: , He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.,ALLERGIES: , He has no known drug allergies.,MEDICATIONS:, I reviewed his medication list in the chart. He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 91 per minute and regular, blood pressure 151/102 in the right arm and 152/104 in the left arm, weight 172 pounds, which is about 6 pounds more than last visit in 11/07. HEENT: Atraumatic and normocephalic. No pallor, icterus or cyanosis. NECK: Supple. Jugular venous distention 5 cm above the clavicle present. No thyromegaly. LUNGS: Clear to auscultation. No rales or rhonchi. Pulse ox was 98% on room air. CVS: S1 and S2 present. S3 and S4 present. ABDOMEN: Soft and nontender. Liver is palpable 5 cm below the right subcostal margin. EXTREMITIES: No clubbing or cyanosis. A 1+ edema present.,ASSESSMENT AND PLAN:, The patient has hypertension, nonischemic cardiomyopathy, and branch vessel coronary artery disease. Clinically, he is in NYHA Class III. He has some volume overload and was not unfortunately taking Lasix as prescribed. I have advised him to take Lasix 40 mg p.o. b.i.d. I also increased the dose of hydralazine from 75 mg t.i.d. to 100 mg t.i.d. I advised him to continue to take Toprol and lisinopril. I have also added Aldactone 25 mg p.o. daily for survival advantage. I reinforced the idea of not using cocaine. He states that it was a mistake, may be somebody mixed in his drink, but he has not intentionally taken any cocaine. I encouraged him to find a primary care provider. He will come for a BMP check in one week. I asked him to check his blood pressure and weight. I discussed medication changes and gave him an updated list. I have asked him to see a gastroenterologist for hepatitis C. At this point, his Medicaid is pending. He has no insurance and finds hard to find a primary care provider. I will see him in one month. He will have his fasting lipid profile, AST, and ALT checked in one week.general medicine, congestive heart failure, hypertension, cardiomyopathy, coronary artery disease, ventricular tachycardia, nonischemic cardiomyopathy, branch vessel, nyha class, nonischemic, tachycardia, orthopnea,

CHIEF COMPLAINT: , "I want my colostomy reversed.",HISTORY OF PRESENT ILLNESS: , Mr. A is a pleasant 43-year-old African-American male who presents to our clinic for a colostomy reversal as well as repair of an incisional hernia. The patient states that in November 2007, he presented to High Point Regional Hospital with sharp left lower quadrant pain and was emergently taken to Surgery where he woke up with a "bag." According to some notes that were faxed to our office from the surgeon in High Point who performed his initial surgery, Dr. X, the patient had diverticulitis with perforated sigmoid colon, and underwent a sigmoid colectomy with end colostomy and Hartmann's pouch. The patient was unaware of his diagnosis; therefore, we discussed that with him today in clinic. The patient also complains of the development of an incisional hernia since his surgery in November. He was seen back by Dr. X in April 2008 and hopes that Dr. X may reverse his colostomy and repair his hernia since he did his initial surgery, but because the patient has lost his job and has no insurance, he was referred to our clinic by Dr. X. Currently, the patient does state that his hernia bothers him more so than his colostomy, and if it were not for the hernia then he may just refrain from having his colostomy reversed; however, the hernia has grown in size and causing him significant discomfort. He feels that he always has to hold his hand over the hernia to prevent it from prolapsing and causing him even more discomfort.,PAST MEDICAL AND SURGICAL HISTORY:,1. Gastroesophageal reflux disease.,2. Question of hypertension.,3. Status post sigmoid colectomy with end colostomy and Hartmann's pouch in November 2007 at High Point Regional.,4. Status post cholecystectomy.,7. Status post unknown foot surgery.,MEDICATIONS:, None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives in Greensboro. He smokes one pack of cigarettes a day and has done so for 15 years. He denies any IV drug use and has an occasional alcohol.,FAMILY HISTORY: ,Positive for diabetes, hypertension, and coronary artery disease.,REVIEW OF SYSTEMS: , Please see history of present illness; otherwise, the review of systems is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 95.9, pulse 67, blood pressure 135/79, and weight 208 pounds.,GENERAL: This is a pleasant African-American male appearing his stated age in no acute distress.,HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Moist mucous membranes. Extraocular movements intact.,NECK: Supple, no JVD, and no lymphadenopathy.,CARDIOVASCULAR: Regular rate and rhythm.,LUNGS: Clear to auscultation bilaterally.,ABDOMEN: Soft, nontender, and nondistended with a left lower quadrant stoma. The stoma is pink, protuberant, and productive. The patient also has a midline incisional hernia approximately 6 cm in diameter. It is reducible. Otherwise, there are no further hernias or masses noted.,EXTREMITIES: No clubbing, cyanosis or edema.,ASSESSMENT AND PLAN: ,This is a 43-year-old gentleman who underwent what sounds like a sigmoid colectomy with end colostomy and Hartmann's pouch in November of 2007 secondary to perforated colon from diverticulitis. The patient presents for reversal of his colostomy as well as repair of his incisional hernia. I have asked the patient to return to High Point Regional and get his medical records including the operative note and pathology results from his initial surgery so that I would have a better idea of what was done during his initial surgery. He stated that he would try and do this and bring the records to our clinic on his next appointment. I have also set him up for a barium enema to study the rectal stump. He will return to us in two weeks at which time we will review his radiological studies and his medical records from the outside hospital and determine the best course of action from that point. This was discussed with the patient as well as his sister and significant other in the clinic today. They were in agreement with this plan. We also called the social worker to come and help the patient get more ostomy appliances, as he stated that he had no more and he was having to reuse the existing ostomy bag. To my understanding, his social worker, as well as the ostomy nurses were able to get him some assistance with this.,nan

PREOPERATIVE DIAGNOSIS: ,Tracheal stenosis and metal stent complications.,POSTOPERATIVE DIAGNOSIS: ,Tracheal stenosis and metal stent complications.,ANESTHESIA: ,General endotracheal.,ENDOSCOPIC FINDINGS:,1. Normal true vocal cords.,2. Subglottic stenosis down to 5 mm with mature cicatrix.,3. Tracheal granulation tissue growing through the stents at the midway point of the stents.,5. Three metallic stents in place in the proximal trachea.,6. Distance from the true vocal cords to the proximal stent, 2 cm.,7. Distance from the proximal stent to the distal stent, 3.5 cm.,8. Distance from the distal stent to the carina, 8 cm.,9. Distal airway is clear.,PROCEDURES:,1. Rigid bronchoscopy with dilation.,2. Excision of granulation tissue tumor.,3. Application of mitomycin-C.,4. Endobronchial ultrasound.,TECHNIQUE IN DETAIL: ,After informed consent was obtained from the patient and her husband, she was brought to the operating theater after sequence induction was done. She had a Dedo laryngoscope placed. Her airways were inspected thoroughly with findings as described above. She was intermittently ventilated with an endotracheal tube placed through the Dedo scope. Her granulation tissue was biopsied and then removed with a microdebrider. Her proximal trachea was dilated with a combination of balloon, Bougie, and rigid scopes. She tolerated the procedure well, was extubated, and brought to the PACU.cardiovascular / pulmonary, tracheal stenosis, dedo scope, bronchoscopy, cicatrix, dilation, endotracheal, granulation, metal stent, mitomycin-c, proximal trachea, vocal cords, endobronchial ultrasound, granulation tissue, proximal, tracheal, stent,

PREOPERATIVE DIAGNOSIS:, Critical left carotid stenosis.,POSTOPERATIVE DIAGNOSIS: , Critical left carotid stenosis.,PROCEDURE PERFORMED:, Left carotid endarterectomy with endovascular patch angioplasty.,ANESTHESIA:, Cervical block.,GROSS FINDINGS: ,The patient is a 57-year-old black female with chronic renal failure. She does have known critical carotid artery stenosis. She wishes to undergo bilateral carotid endarterectomy, however, it was felt necessary by Dr. X to perform cardiac catheterization. She was admitted to the hospital yesterday with chest pain. She has been considered for coronary artery bypass grafting. I have been asked to address the carotid stenosis, left being more severe, this was addressed first. Intraoperatively, an atherosclerotic plaque was noted in the common carotid artery extending into the internal carotid artery. The internal carotid artery is quite torturous. The external carotid artery was occluded at its origin. When the endarterectomy was performed, the external carotid artery back-bled nicely. The internal carotid artery had good backflow bleeding noted.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite and placed in the supine position. Then neck, shoulder, and chest wall were prepped and draped in appropriate manner. Longitudinal incision was created along the anterior border of the left sternocleidal mastoid muscle and this was taken through the subcutaneous tissue and platysmal muscle utilizing electrocautery.,Utilizing both blunt and sharp dissections, the common carotid artery, the internal carotid artery beyond the atherosclerotic back, the external carotid artery, and the superior thyroid artery were isolated and encircled with a umbilical tape. During the dissection, facial veins were ligated with #4-0 silk ligature prior to dividing them. Also during the dissection, ansa cervicalis, hypoglossal, and vagus nerve identified and preserved. There was some inflammation above the carotid bulb, but this was not problematic.,The patient had been administered 5000 units of aqueous heparin after allowing adequate circulating time. The internal carotid artery is controlled with Heifitz clip followed by the external carotid artery and the superior thyroid artery being controlled with Heifitz clips. The common carotid artery was controlled with profunda clamp. The patient remained neurologically intact. A longitudinal arteriotomy was created along the posterior lateral border of the common carotid artery. This was extended across the lobe on to the internal carotid artery. An endarterectomy was then performed. The ________ intima was cleared of all debris and the ________ was flushed with copious amounts of heparinized saline. As mentioned before, the internal carotid artery is quite torturous. This was shortened by imbricating the internal carotid artery with horizontal mattress stitches of #7-0 Prolene suture.,The wound was copiously irrigated, rather an endovascular patch was then brought on to the field. This was cut to shape and length. This was sutured in place with continuous running #6-0 Prolene suture. The suture line began at both sites. The suture was tied in the center along the anterior and posterior walls. Prior to completing the closure, the common carotid artery was flushed. The internal carotid artery permitted to back bleed. The clamp was placed after completing the closure. The clamp was placed at the origin of the internal carotid artery. Flow was first directed into the external carotid artery then into the internal carotid artery. The patient remained neurologically intact. Topical ________ Gelfoam was utilized. Of note, during the endarterectomy, the patient did receive an additional 7000 units of aqueous heparin. The wound was copiously irrigated with antibiotic solution. Sponge, needle, and all counts were correct. All surgical sites were inspected. Good hemostasis noted. The incision was closed in layers with absorbable suture. Stainless steel staples approximated skin. Sterile dressings were applied. The patient tolerated the procedure well, grossly neurologically intact.surgery, carotid stenosis, carotid endarterectomy, endovascular patch angioplasty, cervical block, carotid artery, common carotid artery, external carotid artery, endovascular patch, common carotid, external carotid, angioplasty, artery, endovascular, neurologically, carotid, stenosis, endarterectomy

PREOPERATIVE DIAGNOSIS: , Microscopic hematuria.,POSTOPERATIVE DIAGNOSIS:, Microscopic hematuria with lateral lobe obstruction, mild.,PROCEDURE PERFORMED: , Flexible cystoscopy.,COMPLICATIONS: , None.,CONDITION: , Stable.,PROCEDURE: , The patient was placed in the supine position and sterilely prepped and draped in the usual fashion. After 2% lidocaine was instilled, the anterior urethra is normal. The prostatic urethra reveals mild lateral lobe obstruction. There are no bladder tumors noted.,IMPRESSION:, The patient has some mild benign prostatic hyperplasia. At this point in time, we will continue with conservative observation.,PLAN: , The patient will follow up as needed.surgery, benign prostatic hyperplasia, urethra, lateral lobe obstruction, flexible cystoscopy, microscopic hematuria, cystoscopy, hematuria, obstruction,

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,PROCEDURE:, Phacoemulsification with intraocular lens placement, right eye.,ANESTHESIA: , Monitored anesthesia care,ESTIMATED BLOOD LOSS: , None,COMPLICATIONS:, None,SPECIMENS:, None,PROCEDURE IN DETAIL: , The patient had previously been examined in the clinic and was found to have a visually significant cataract in the right eye. The patient had the risks and benefits of surgery discussed. After discussion, the patient decided to proceed and the consent was signed.,On the day of surgery, the patient was taken from the holding area to the operating suite by the anesthesiologist and monitors were placed. Following this, the patient was sterilely prepped and draped in the usual fashion. After this, a lid speculum was placed, preservative-free lidocaine drops were placed, and the SuperSharp blade was used to make an anterior chamber paracentesis. Preservative-free lidocaine was instilled into the anterior chamber, and then Viscoat was instilled into the eye.,The 3.0 diamond keratome was then used to make a clear corneal temporal incision. Following this, the cystotome was used to make a continuous tear-type capsulotomy. After this, BSS was used to hydrodissect and hydrodelineate the lens. The phacoemulsification unit was used to remove the cataract. The I&A unit was used to remove the residual cortical material. Following this, Provisc was used to inflate the bag. The lens, a model SA60AT of ABCD diopters, serial #1234, was inserted into the bag and rotated into position using the Lester pusher.,After this, the residual Provisc was removed. Michol was instilled and then the corneal wound was hydrated with BSS, and the wound was found to be watertight. The lid speculum was removed. Acular and Vigamox drops were placed. The patient tolerated the procedure well without complications and will be followed up in the office tomorrow.surgery, capsulotomy, diopters, intraocular lens placement, lid speculum, anterior chamber, phacoemulsification, lens, cataract, intraocular

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,PROCEDURE: , Anterior cervical discectomy with fusion C5-C6.,PROCEDURE IN DETAIL: , The patient was placed in supine position. The neck was prepped and draped in the usual fashion. An incision was made from midline to the anterior border of the sternocleidomastoid in the right side. Skin and subcutaneous tissue were divided sharply. Trachea and esophagus were retracted medially. Carotid sheath was retracted laterally. Longus colli muscles were dissected away from the vertebral bodies of C5-C6. We confirmed our position by taking intraoperative x-rays. We then used the operating microscope and cleaned out the disk completely. We then sized the interspace and then tapped in a #7 mm cortical cancellous graft. We then used the DePuy Dynamic plate with 14-mm screws. Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision. The wound was closed in layers using 2-0 Vicryl for muscle and fascia. The blood loss was less than 10-20 mL. No complication. Needle count, sponge count, and cottonoid count was correct.orthopedic, carotid sheath, jackson-pratt drain, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, herniated nucleus, nucleus pulposus, spinal stenosis, discectomy, fusion, herniated, nucleus, pulposus, spinal, stenosis, anterior

DIAGNOSIS AT ADMISSION:, Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,DIAGNOSES AT DISCHARGE,1. Chronic obstructive pulmonary disease exacerbation and acute bronchitis.,2. Congestive heart failure.,3. Atherosclerotic cardiovascular disease.,4. Mild senile-type dementia.,5. Hypothyroidism.,6. Chronic oxygen dependent.,7. Do not resuscitate/do not intubate.,HOSPITAL COURSE: , The patient was admitted from the office by Dr. X. She was placed on the usual medications that included Synthroid 0.05 mg a day, enalapril 5 mg a day, Imdur 30 mg a day, Lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and Atrovent nebulizers q.4 h., potassium chloride 10 mEq 2 tablets per day, Lasix 40 mg a day, Humibid L.A. 600 mg b.i.d. She was placed on oral Levaquin after a load of 500 mg and 250 mg a day. She was given oxygen, encouraged to eat, and suctioned as needed.,Laboratory data included a urinalysis that had 0-2 WBCs per high power field and urine culture was negative, blood cultures x2 were negative, TSH was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, CO2 34, glucose 105, BUN 17, creatinine 0.9, and calcium 9.1. Digoxin was 1.3. White blood cell count was 6100 with a normal differential, H&H 37.4/12.1, platelets 335,000. Chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate. There is a question if there is mild fluid overload.,The patient improved with the above regimen. By discharge, her lungs fell back to her baseline. She had no significant shortness of breath. Her O2 saturations were stable. Her vital signs were stable.,She is discharged home to follow up with me in a week and a half.,Her daughter has been spoken to by phone and she will notify me if she worsens or has problems.,PROGNOSIS: ,Guarded.discharge summary, chronic obstructive pulmonary disease exacerbation, chronic obstructive pulmonary disease, pulmonary, copd, discharge, bronchitis,

PREOPERATIVE DIAGNOSES,1. Right buccal space abscess/cellulitis.,2. Nonrestorable caries teeth #1, #29, and #32.,POSTOPERATIVE DIAGNOSES,1. Right buccal space abscess/cellulitis.,2. Nonrestorable caries teeth #1, #29, and #32.,PROCEDURE,1. Incision and drainage of right buccal space abscess.,2. Extraction of teeth #1, #29, and #32.,ANESTHESIA,GETA,EBL,20 mL.,IV FLUIDS,900 mL.,URINE OUTPUT,Not measured.,COMPLICATIONS,None.,SPECIMENS,1. Aerobic culture was sent from the right buccal space abscess/cellulitis.,2. Anaerobic culture from the same space was also obtained.,PROCEDURE IN DETAIL,The patient was identified in the appropriate holding area and transported to #13. The patient was intubated by anesthesia orotracheally using a #7 ET tube. The patient was induced in effective sleep using a propofol and gas inhalation anesthetics. Following intubation, the patient's mouth was cleaned with chlorhexidine and a toothbrush following placement of a throat pack. At that point, approximately 5 mL of 2% lidocaine with 1:20,000 epinephrine was injected for a right inferior alveolar block, as well as local infiltration in the right long buccal nerve area as well as the right cheek area. Local infiltration also was done near the tooth #32. At this point, a periosteal elevator was used to loosen up the gingival tissue of the teeth #1, #29, and #32; and all 3 teeth were extracted using simple extraction, using elevators and forceps. In addition, the previous Penrose drain was removed by removing the suture, and the incision that was used for I&D on the previous day was extended laterally. A hemostat was used to puncture through to the right buccal space. Approximately, 2.5 to 3 mL of purulence was drained, and that was used for Gram stain and culture, as mentioned above. Following copious irrigation of the area, following the extraction and following the incision and drainage, 2 quarter-inch Penrose drains were placed in the anterior as well as the posterior section of the incision into the buccal space. At this point copious irrigation was done again, the throat pack was removed, and the procedure was ended. Note that the patient was extubated without incident. Dr. B was present for all critical aspects of patient care.surgery, abscess, #7 et tube, aerobic culture, anaerobic culture, extraction of teeth, geta, alveolar block, buccal space, caries, cellulitis, copious irrigation, extraction, teeth, nonrestorable caries teeth, buccal space abscess, nonrestorable caries, caries teeth, throat pack, buccal,

CHIEF COMPLAINT: , Severe back pain and sleepiness.,The patient is not a good historian and history was obtained from the patient's husband at bedside.,HISTORY OF PRESENT ILLNESS: ,The patient is a 76-year-old obese Caucasian female with past medical conditions that includes hypertension, history of urinary incontinence, dementia, and chronic back pain, basically brought by the husband to the emergency room because of having excruciating back pain. As per the husband, the patient has this back pain for about almost 1 year and seeing Dr. X in Neurosurgery and had an epidural injection x2, and then the patient's pain somewhat got better between, but last time the patient went to see Dr. X, the patient given injection and the patient passed out, so the doctor stopped giving any other epidural injection. The patient has severe pain and all in all, the patient cries at home. As per the husband, the patient woke up in the morning with severe pain, unable to eat, drink today, and crying in the morning, so brought her to the emergency room for further evaluation. The patient denied any history of fever, cough, chest pain, diarrhea, dysuria or polyuria. While I was examining the patient, the patient explained about possible diagnosis and treatment plan and possible nursing home discharge for pain control. The patient passed out for about 3 to 4 minutes, unable to respond to even painful stimuli. The patient's heart rate went down to 50s and blood pressure was 92 systolic, so the patient was later on given IV fluid and blood pressure checked. The patient woke up after 5 to 6 minutes, so the patient was later on evaluated for admission because of near syncopal episode.,PAST MEDICAL CONDITIONS:, Include hypertension, dementia, urinary incontinence, chronic back pain, and degenerative joint disease of the spine. No history of diabetes, stroke or coronary artery disease.,SURGICAL HISTORY: , Include left total hip replacement many years ago, history of hysterectomy, and appendectomy in the young age.,ALLERGIES: , DENIED.,CURRENT MEDICATIONS: , According to the list shows the patient takes hydrocodone 10/325 mg every 6 hours, Flexeril 10 mg p.o. at bedtime, and Xanax 0.25 mg p.o. 4 times a day. The patient also takes Neurontin 200 mg 3 times a day, propranolol 10 mg twice a day, oxybutynin 5 mg p.o. twice a day, Namenda 10 mg p.o. daily, and Aricept 10 mg p.o. daily.,SOCIAL HISTORY: , She lives with her husband, usually walks with a walker and wheelchair-bound, does not walk much as per the husband knows. No history of alcohol abuse or smoking.,PHYSICAL EXAMINATION:,GENERAL: Currently lying in the bed without apparent distress, very lethargic.,VITAL SIGNS: Pulse rate of 55, blood pressure is 92/52, after IV fluid came up to 105/58.,CHEST: Shows bilateral air entry present, clear to auscultate.,HEART: S1 and S2 regular.,ABDOMEN: Soft, nondistended, and nontender.,EXTREMITIES: Shows the patient's straight leg raising to be only up to 30% causing the patient severe back pain.,IMAGING: , The patient's x-ray of the lumbosacral spine done shows there is a L1 compression fracture with some osteophyte formation in the lumbar spine suggestive of degenerative joint disease.,LABORATORY DATA: , The patient's lab test is not done currently, but previous lab test done in 3/2009 seems to be in acceptable range.,IMPRESSION: , The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes in front of me with a low blood pressure.,1. Vasovagal syncope versus polypharmacy because of 3 to 4 medications and muscle relaxants.,2. Osteoporosis of the spine with L1 compression fracture causing the patient severe pain.,3. Hypertension, now hypotension.,4. Incontinence of the bladder.,5. Dementia, most likely Alzheimer type.,PLAN AND SUGGESTION: , Initial plan was to send the patient to the nursing home, but because of the patient's low blood pressure and heart rate low, we will admit the patient to DOU for 23-hour observation, start the patient on IV fluid, normal saline, 20 mEq KCl, and Protonix 40 mg, and we will also continue the patient's Namenda and Aricept. I will hold the patient's hydrocodone. I will hold the Flexeril and I will also hold gabapentin at this moment. We will give the patient's pain control with Percocet and very minimal morphine sulfate as needed. Also give the patient calcium with vitamin D and physical therapy. We will also order a blood test and further management will be based on the patient's all test results. I also explained to the husband that tomorrow if the patient is better and more alert and awake, then we will send her to the nursing care versus home, it depends on the pain control.nan

PREOPERATIVE DIAGNOSIS:, Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate.,POSTOPERATIVE DIAGNOSIS:, Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum.,OPERATION:, Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty.,ANESTHESIA:, General anesthetics.,HISTORY: , This is a 51-year-old gentleman here with his wife. She confirms the history of loud snoring at night with witnessed apnea. The result of the sleep study was reviewed. This showed moderate sleep apnea with significant desaturation. The patient was unable to tolerate treatment with CPAP. At the office, we observed large tonsils and elongation and thickening of the uvula as well as redundant soft tissue of the palate. A tortuous appearance of the septum also was observed. This morning, I talked to the patient and his wife about the findings. I reviewed the CT images. He has no history of sinus infections and does not recall a history of nasal trauma. We discussed the removal of tonsils and uvula and soft palate tissue and the hope that this would help with his airway. Depending on the findings of surgery, I explained that I might remove that bone spur that we are seeing within the nasal passage. I will get the best look at it when he is asleep. We discussed recovery as well. He visited with Dr. XYZ about the anesthetic produce.,PROCEDURE:,: General tracheal anesthetic was administered by Dr. XYZ and Mr. Radke. Afrin drops were placed in both nostrils and a cottonoid soaked with Afrin was placed in each side of the nose. A Crowe-Davis mouth gag was placed. The tonsils were very large and touched the uvula. The uvula was relatively long and very thick and there were redundant folds of soft palate mucosa and prominent posterior and anterior tonsillar pillars. Also, there was a cryptic appearance of the tonsils but there was no acute redness or exudate. Retraction of the soft palate permitted evaluation of the nasopharynx with the mirror and the choanae were patent and there was no adenoid tissue present. A very crowded pharynx was appreciated. The tonsils were first removed using electrodissection technique. Hemostasis was achieved with the electrocautery and with sutures of 0 plain catgut. The tonsil fossae were injected with 0.25% Marcaine with 1:200,000 epinephrine. There already was more room in the pharynx, but the posterior pharyngeal wall was still obscured by the soft palate and uvula. The uvula was grasped with the Alice clamp. I palpated the posterior edge of the hard palate and calculated removal of about a third of the length of the soft palate. We switched over from the Bayonet cautery to the blunt needle tip electrocautery. The planned anterior soft palate incision was marked out with the electrocautery from the left anterior tonsillar pillar rising upwards and then extending horizontally across the soft palate to include all of the uvula and a portion of the soft palate, and the incision then extended across the midline and then inferiorly to meet the right anterior tonsillar pillar. This incision was then deepened with the electrocautery on a cutting current. The uvular artery just to the right of the midline was controlled with the suction electrocautery. The posterior soft palate incision was made parallel to the anterior soft palate incision but was made leaving a longer length of mucosa to permit closure of the palatoplasty. A portion of the redundant soft palate mucosa tissue also was included with the resection specimen and the tissue including the soft palate and uvula was included with the surgical specimen as the tonsils were sent to pathology. The tonsil fossae were injected with 0.25% Marcaine with 1:200,000 epinephrine. The soft palate was also injected with 0.25% Marcaine with 1:200,000 epinephrine. The posterior tonsillar pillars were then brought forward to close to the anterior tonsillar pillars and these were sutured down to the tonsil bed with interrupted 0 plain catgut sutures. The posterior soft palate mucosa was advanced forward and brought up to the anterior soft palate incision and closure of the soft palate wound was then accomplished with interrupted 3-0 chromic catgut sutures. A much improved appearance of the oropharynx with a greatly improved airway was appreciated. A moist tonsil sponge was placed into the nasopharynx and the mouth gag was removed. I removed the cottonoids from both nostrils. Speculum exam showed the inferior turbinates were large, the septum was tortuous and it angulated to the right and then sharply bent back to the left. The septum was injected with 0.25% Marcaine with 1:200,000 epinephrine using a separate syringe and needle. A #15 blade was used to make a left cheilion incision.,Mucoperichondrium and mucoperiosteum were elevated with the Cottle elevator. When we reached the deflected portion of the vomer, this was separated from the septal cartilage with a Freer elevator. The right-sided mucoperiosteum was elevated with the Freer elevator and then with Takahashi forceps and with the 4 mm osteotome, the deflected portion of the septal bone from the vomer was resected. This tissue also was sent as a separate specimen to pathology. The intraseptal space was irrigated with saline and suctioned. The nasal septal mucosal flaps were then sutured together with a quilting suture of 4-0 plain catgut. I observed no evidence of purulent secretion or polyp formation within the nostrils. The inferior turbinates were then both outfractured using a knife handle, and now there was a much more patent nasal airway on both sides. There was good support for the nasal tip and the dorsum and there was good hemostasis within the nose. No packing was used in the nostrils. Polysporin ointment was introduced into both nostrils. The mouth gag was reintroduced and the pack removed from the nasopharynx. The nose and throat were irrigated with saline and suctioned. An orogastric tube was placed and a moderate amount of clear fluid suctioned from the stomach and this tube was removed. Sponge and needle count were reported correct. The mouth gag having been withdrawn, the patient was then awakened and returned to recovery room in a satisfactory condition. He tolerated the operation excellently. Estimated blood loss was about 15-20 cc. In the recovery room, I observed that he was moving air well and I spoke with his wife about the findings of surgery.surgery, obstructive sleep apnea syndrome, afrin drops, bayonet cautery, cpap, cottle elevator, crowe-davis, freer elevator, obstructive sleep apnea, tonsillectomy, hypertrophy, mouth gag, nasal, nasal passage, nasal septum, nasopharynx, nostrils, palate, pharynx, septal cartilage, septoplasty, sleep apnea, soft palate, tonsils, uvula, uvulopalatopharyngoplasty, hypertrophy of tonsils, anterior tonsillar pillars, soft palate incision, palate incision, tonsillar pillars, incision

HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old male who was brought in by EMS with a complaint of a decreased level of consciousness. The patient apparently lives with his wife and was found to have a decreased status since the last one day. The patient actually was seen in the emergency room the night before for injuries of the face and for possible elderly abuse. When the Adult Protective Services actually went to the patient's house, he was found to be having decreased consciousness for a whole day by his wife. Actually the night before, he fell off his wheelchair and had lacerations on the face. As per his wife, she states that the patient was given an entire mg of Xanax rather than 0.125 mg of Xanax, and that is why he has had decreased mental status since then. The patient's wife is not able to give a history. The patient has not been getting Sinemet and his other home medications in the last 2 days. ,PAST MEDICAL HISTORY: ,Parkinson disease.,MEDICATIONS:, Requip, Neurontin, Sinemet, Ambien, and Xanax.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.,PHYSICAL EXAMINATION:,GENERAL:general medicine, level of consciousness, parkinson disease, altered mental status, dehydration, elderly abuse, decreased level of consciousness, ems, parkinson, consciousness, xanax, sinemet, decreased,

PREOPERATIVE DIAGNOSES: , Phimosis and adhesions.,POSTOPERATIVE DIAGNOSES: ,Phimosis and adhesions.,PROCEDURES PERFORMED: , Circumcision and release of ventral chordee.,ANESTHESIA: ,Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid. The patient was given antibiotics preop.,BRIEF HISTORY: , This is a 43-year-old male who presented to us with significant phimosis, difficulty retracting the foreskin. The patient had buried penis with significant obesity issues in the suprapubic area. Options such as watchful waiting, continuation of slowly retracting the skin, applying betamethasone cream, and circumcision were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, and CVA risks were discussed. The patient had discussed this issue with Dr Khan and had been approved to get off of the Plavix. Consent had been obtained. Risk of scarring, decrease in penile sensation, and unexpected complications were discussed. The patient was told about removing the dressing tomorrow morning, okay to shower after 48 hours, etc. Consent was obtained.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the OR. Anesthesia was applied. The patient was placed in supine position. The patient was prepped and draped in usual sterile fashion. Local MAC anesthesia was applied. After draping, 17 mL of mixture of 0.25% Marcaine and 1% lidocaine plain were applied around the dorsal aspect of the penis for dorsal block. The patient had significant phimosis and slight ventral chordee. Using marking pen, the excess foreskin was marked off. Using a knife, the ventral chordee was released. The urethra was intact. The excess foreskin was removed. Hemostasis was obtained using electrocautery. A 5-0 Monocryl stitches were used for 4 interrupted stitches and horizontal mattresses were done. The patient tolerated the procedure well. There was excellent hemostasis. The penis was straight. Vaseline gauze and Kerlix were applied. The patient was brought to the recovery in stable condition. Plan was for removal of the dressing tomorrow. Okay to shower after 48 hours.urology, phimosis, adhesions, release of ventral chordee, ventral chordee, circumcision, penis, chordee, foreskin,

PREOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,POSTOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,PROCEDURE PERFORMED: , Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,ANESTHESIA:, LMA.,EBL: , Minimal.,FLUIDS: , Crystalloid. The patient was given antibiotics, 1 g of Ancef and the patient was on oral antibiotics at home.,BRIEF HISTORY: , The patient is a 61-year-old female with history of recurrent uroseptic stones. The patient had stones x2, 1 was already removed, second one came down, had recurrent episode of sepsis, stent was placed. Options were given such as watchful waiting, laser lithotripsy, shockwave lithotripsy etc. Risks of anesthesia, bleeding, infection, pain, need for stent, and removal of the stent were discussed. The patient understood and wanted to proceed with the procedure.,DETAILS OF THE PROCEDURE: , The patient was brought to the OR. Anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was prepped and draped in usual sterile fashion. A 0.035 glidewire was placed in the left system. Using graspers, left-sided stent was removed. A semirigid ureteroscopy was done. A stone was visualized in the mid to upper ureter. Using laser, the stone was broken into 5 to 6 small pieces. Using basket extraction, all the pieces were removed. Ureteroscopy all the way up to the UPJ was done, which was negative. There were no further stones. Using pyelograms, the rest of the system appeared normal. The entire ureter on the left side was open and patent. There were no further stones. Due to the edema and the surgery, plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours. Over the 0.035 glidewire, a 26 double-J stent was placed. There was a nice curl in the kidney and one in the bladder. The patient tolerated the procedure well. Please note that the string was kept in place and the patient was to remove the stent the next day. The patient's family was instructed how to do so. The patient had antibiotics and pain medications at home. The patient was brought to recovery room in a stable condition.nephrology, laser lithotripsy, shockwave lithotripsy, double-j stent, distal ureteral stone, ureteral stone, basket extraction, cystopyelogram, laser, lithotripsy, stones, string, ureteroscopy, stone, stent,

CC: ,Gait difficulty.,HX: ,This 59 y/o RHF was admitted with complaint of gait difficulty. The evening prior to admission she noted sudden onset of LUE and LLE weakness. She felt she favored her right leg, but did not fall when walking. She denied any associated dysarthria, facial weakness, chest pain, SOB, visual change, HA, nausea or vomiting.,PMH:, tonsillectomy, adenoidectomy, skull fx 1954, HTN, HA.,MEDS: ,none on day of exam.,SHX: ,editorial assistant at newspaper, 40pk-yr Tobacco, no ETOH/Drugs.,FHX: ,noncontributory,ADMIT EXAM: ,P95 R20, T36.6, BP169/104,MS: A&O to person, place and time. Speech fluent and without dysarthria, Naming-comprehension-reading intact. Euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light, Fundi flat, VFFTC, EOMI, Face symmetric with intact sensation, Gag-shrug-corneal reflexes intact, Tongue ML with full ROM,Motor: Full strength throughout right side. Mildly decreased left grip and left extensor hallucis longus. Biceps/Triceps/Wrist flexors and extensor were full strength on left. However she demonstrated mild LUE pronator drift and had difficulty standing on her LLE despite full strength on bench testing of the LLE.,Sensory: No deficit to PP/T/Vib/Prop/ LT,Coord: decreased speed and magnitude of FNF, Finger tapping and HKS, on left side only.,Station: mild LUE upward drift.,Gait: tendency to drift toward the left. Difficulty standing on LLE.,Reflexes were symmetric, plantar responses were flexor bilaterally.,Gen exam unremarkable.,COURSE: ,Admit Labs: ESR, PT/PTT, GS, UA, EKG, and HCT were unremarkable. Hgb 13.9, Hct 41%, Plt 280k, WBC 5.5.,The patient was diagnosed with a probable lacunar stroke and entered into the TOAST study (Trial of ORG10172[a low molecular weight heparin] in Acute Stroke Treatment).,Carotid Duplex: 16-49%RICA and 0-15%LICA stenosis with anterograde vertebral artery flow, bilaterally. Transthoracic echocardiogram showed mild mitral regurgitation, mild tricuspid regurgitation and a left to right shunt. There was no evidence of blood clot.,Hospital course: 5 days after admission the patient began to complain of proximal LLE and left flank pain. On exam, she had weakness of the quadriceps and hip flexors of the LLE. Her pain increased with left hip flexion. In addition, she complained of paresthesias about the lateral aspect of the medial anterior left thigh; and upon on sensory testing, she had decreased PP/TEMP sensation in a left femoral nerve distribution. She denied any back/neck pain and the rest of her neurologic exam remained unchanged from admission.,Abdominal CT Scan, 2/4/96, revealed a large left retroperitoneal iliopsoas hematoma.,Hgb 8.9g/dl. She was transfused with 4 units of pRBCs. She underwent surgical decompression and evacuation of the hematoma via a posterior flank approach on 2/6/96. Her postoperative course was uncomplicated. She was discharged home on ASA.,At follow-up, on 2/23/96, she complained of left sided paresthesias (worse in the LLE than in the LUE) and feeling of "swollen left foot." These symptoms had developed approximately 1 month after her stroke. Her foot looked normal and her UE strength was 5/4+ proximally and distally, and LE strength 5/4+ proximally and 5/5- distally. She was ambulatory. There was no evidence of LUE upward drift. A somatosensory evoked potential study revealed an absent N20 and normal P14 potentials. This was suggestive of a lesion involving the right thalamus which might explain her paresthesia/dysesthesia as part of a Dejerine-Roussy syndrome.nan

PREOPERATIVE DIAGNOSES: ,Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,POSTOPERATIVE DIAGNOSES: , Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,OPERATIVE PROCEDURE: , Bilateral myringotomies with insertion of Santa Barbara T-tube.,ANESTHESIA: , General mask.,FINDINGS:, The patient is an 8-year-old white female with chronic eustachian tube dysfunction and TM atelectasis, was taken to the operating room for tubes. At the time of surgery, she has had an extruding right Santa Barbara T-tube and severe left TM atelectasis with retraction. There was a scant amount of fluid in both middle ear clefts.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position, and general mask anesthesia was established. The right ear was draped in normal sterile fashion. Cerumen was removed from the external canal. The extruding Santa Barbara T-tube was identified and atraumatically removed. A fresh Santa Barbara T-tube was atraumatically inserted and Ciloxan drops applied.,The attention was then directed to the left side where severe TM atelectasis was identified. With a mask anesthetic, the eardrum elevated. A radial incision was made in the inferior aspect of the tympanic membrane and middle ear fluid aspirated. A Santa Barbara T-tube was then inserted without difficulty and 5 drops Ciloxan solution applied. Anesthesia was then reversed and the patient taken to recovery room in satisfactory condition.surgery, tympanic membrane, cerumen, ciloxan, santa barbara t-tube, tm atelectasis, atelectasis, eardrum, eustachian tube, eustachian tube dysfunction, middle ear, middle ear fluid, myringotomies, atelectasis and chronic eustachian, santa barbara t tube, myringotomies with insertion, chronic eustachian tube, barbara t tube, santa barbara, insertion, tube, tympanic

PROCEDURE PERFORMED: , Esophagogastroduodenoscopy performed in the emergency department.,INDICATION: , Melena, acute upper GI bleed, anemia, and history of cirrhosis and varices.,FINAL IMPRESSION,1. Scope passage massive liquid in stomach with some fresh blood near the fundus, unable to identify source due to gastric contents.,2. Endoscopy following erythromycin demonstrated grade I esophageal varices. No stigmata of active bleeding. Small amount of fresh blood within the hiatal hernia. No definite source of bleeding seen.,PLAN,1. Repeat EGD tomorrow morning following aggressive resuscitation and transfusion.,2. Proton-pump inhibitor drip.,3. Octreotide drip.,4. ICU bed.,PROCEDURE DETAILS: ,Prior to the procedure, physical exam was stable. During the procedure, vital signs remained within normal limits. Prior to sedation, informed consent was obtained. Risks, benefits, and alternatives including, but not limited to risk of bleeding, infection, perforation, adverse reaction to medication, failure to identify pathology, pancreatitis, and death explained to the patient and his wife, who accepted all risks. The patient was prepped in the left lateral position. IV sedation was given to a total of fentanyl 100 mcg and midazolam 4 mg for the initial EGD. An additional 50 mcg of fentanyl and 2 mg of midazolam were given following erythromycin. Scope tip of the Olympus gastroscope was passed into the esophagus. Proximal, middle, and distal thirds of the esophagus were well visualized. There was fresh blood in the esophagus, which was washed thoroughly, but no source was seen. No evidence of varices was seen. The stomach was entered. The stomach was filled with very large clot and fresh blood and liquid, which could not be suctioned due to the clot burden. There was a small amount of bright red blood near the fundus, but a source could not be identified due to the clot burden. Because of this, the gastroscope was withdrawn. The patient was given 250 mg of erythromycin in the Emergency Department and 30 minutes later, the scope was repassed. On the second look, the esophagus was cleared. The liquid gastric contents were cleared. There was still a moderate amount of clot burden in the stomach, but no active bleeding was seen. There was a small grade I esophageal varices, but no stigmata of bleed. There was also a small amount of fresh blood within the hiatal hernia, but no source of bleeding was identified. The patient was hemodynamically stable; therefore, a decision was made for a second look in the morning. The scope was withdrawn and air was suctioned. The patient tolerated the procedure well and was sent to recovery without immediate complications.surgery, gi bleed, anemia, cirrhosis, stomach, fundus, hiatal hernia, esophagogastroduodenoscopy, erythromycin, varices, esophagus,

PREOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,POSTOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,PROCEDURE PERFORMED: , Scarf bunionectomy procedure of the first metatarsal of the left foot.,ANESTHESIA:, IV sedation with local.,HISTORY: , This patient is a 55-year-old female who presents to ABCD preoperative holding area after keeping herself n.p.o., since mid night for surgery for her painful left bunion. The patient has had increasing pain over time and is having difficulty ambulating and wearing shoes. The patient has failed to conservative treatment and desires surgical correction at this time. Risks versus benefits of the procedure have been explained in detail by Dr. X, and consent is available on the chart for review.,PROCEDURE IN DETAIL:, After an IV established by the Department of Anesthesia, the patient was given preoperatively 600 mg of clindamycin intravenously. The patient was then taken to the Operating Suite via cart and was placed on the operating table in a supine position and a safety strap was placed across her waist for protection. Next, a pneumatic ankle tourniquet was applied over her left ankle with copious amounts of Webril for the patient's protection. After adequate IV sedation was applied, the patient was given a local injection consisting of 17 cc of 4.5 cc 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1.0 cc of Solu-Medrol mixture in the standard Mayo block to the left foot. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was then elevated, the Esmarch was applied and the tourniquet was inflated to 250 mmHg. The foot was then lowered to the operating field.,A sterile stockinet was reflected and the attention was directed to the first metatarsophalangeal joint of the left foot. After sufficient anesthesia, using a #10 blade a linear incision was made approximately 5 to 6 cm in length over the first metatarsophalangeal joint dorsally, just near to the extensor hallucis longus tendon. Then using a fresh #15 blade, this incision was deepened through the skin into the subcutaneous layer after all small traversing veins were ligated and cauterized with electrocautery. A neurovascular bundle was identified and reflected medially. Laterally the extensor hallucis longus tendon was identified and protected with retraction as well. Care was then taken to undermine the medial and lateral margins of the first metatarsophalangeal joint carefully. The first metatarsophalangeal joint capsule was then identified and using a #15 blade, a linear incision made down to the bone through the joint capsule. The periosteum was reflected and elevated off of its bone and the metatarsal head as well as the base of the proximal phalanx to a small degree. Noted was a large hypertrophic bone spur on the dorsal medial aspect of the first metatarsal head as well as some small osteophytes along the medial portion of the proximal phalanx. Care was then taken to reflect and dissect the periosteum off of the shaft of the first metatarsal proximally into the proximal portion of the metatarsal close to the first metatarsocuneiform joint. The bone cortex was noted to be intact and in good condition. Following this, using a sagittal saw with a #138 blade, the attention was directed to the medial hypertrophic bone of the first metatarsal head. In the sagittal plane with the blade angulated from dorsolateral to proximal medial, the medial eminence of bone was resected. Plantarly it was noted that the tibial sesamoid groove was intact and the sesamoid apparatus was intact as well. Following this bone cut, 0.45 K-wire was inserted from medial to lateral through the medial portion of the first metatarsal head directed in the dorsal third of the metatarsal head. Then using the Reese osteotomy guide, the guide was directed from the distal portion of the metatarsal head proximally to the proximal portion of the first metatarsal. A second 0.45 K-wire was inserted proximally as well. Following this, using the sagittal saw with the #138 blade a transverse linear osteotomy cut was made through the first metatarsal from medial to lateral. After reaching the distal as well as the proximal portions of the bone and ensuring that cortex was cut on both the medial as well as lateral side, the Reese osteotomy guide was removed and the dorsal and plantar incision cuts were made. This began with the dorsal distal cut, which extended from medial to lateral with the dorsal portion of the blade angled proximally about five degrees through the dorsal third of the distal first metatarsal. Following this, attention was directed proximally and an incision osteotomy cut through the bone was made, directed medially to laterally with the inferior portion of the blade angled distally to transect the cortex of the bone. Following this, the distal portion of the osteotomy cut was freely movable and was able to be translocated medially. The head was then slit medially several millimeters until it was noted to be in good position and no chopping was present in the medullary canal of the bone. Following this, the bone was stabilized using a 0.45 K-wire distally as well as proximally directed from dorsal to planar direction. Next using the normal AO manner, the distal cortex was drilled from dorsal to plantar with a 2.0 mm drill bit and then over drilled proximally with the cortex using a 2.7 mm drill bit. The proximal cortex was then _________ and then the drill hole was measured and it was determined to be 18 mm in length from dorsal to plantar cortex. Then using 2.7 mm tap, the thread holes were placed and using an 18 x 2.7 mm screw ___________ was achieved and good apposition of the bone and tightness were achieved. Intramedullary sludge was noted to exit from the osteotomy cut. Following this, attention was directed proximally and the 0.45 K-wire was removed and the holes were predrilled using a 2.0 mm screw then over-drilled using 2.7 mm screw and counter sucked. Following this, the holes were measured, found to 20 mm in length and the drill hole was tapped using a 2.7 mm tap. Following this, a 20 mm full threaded screw was inserted and tightened. Good intramedullary sludge was noted and compression was achieved. Attention was then directed to the distal screw where it was once again tightened and found to be in good position with good bite. Following this, range of motion was performed on the first metatarsophalangeal joint and some lateral deviation of the hallux was noted. Based on this, a lateral release was performed. The extensor hallucis longus tendon was identified and was transected medially and a linear incision was placed down using a #15 blade into the first interspace. The incision was then deepened with sharp and blunt dissection and using a curved hemostat, the transverse as well as the oblique fibers of the abductor hallucis tendon were identified and transected. Care was taken to perform lateral release around the fibular sesamoid through these suspensory ligaments as well as the transverse metatarsal ligament and the collateral ligament. Upon completion of this, the hallux was noted to be in a rectus position with good alignment. The area was then flushed and irrigated with copious amounts of sterile saline. After this, attention was directed back to the medial capsule and a medial capsulorrhaphy was performed and the capsule was closed using #3-0 Vicryl suture. Subcutaneous tissues were closed using #3-0 and #4-0 Vicryl sutures to close in layers. The skin was then reapproximated and closed using #5-0 Monocryl suture. Following this, the incisions were dressed and bandaged in the normal manner using Owen silk, 4x4s, Kling, and Kerlix as well as Coban dressing. The tourniquet was then dropped with a total tourniquet time of 99 minutes at 250 mmHg. The patient followed the procedure and the anesthesia well and vascular status was intact as noted by immediate hyperemia to digits one through five of the left foot. The patient was then transferred back to the cart and escorted on the cart to the Postanesthesia Care Unit. Following this, the patient was given prescription for Vicoprofen total #20 to be taken one every six hours as necessary for moderate to severe pain. The patient was also given prescription for clindamycin to be taken 300 mg four times a day. The patient was given surgical shoe and was placed in a posterior sling. The patient was given crutches and instructed to use them for ambulation. The patient was instructed to keep her foot iced and elevated and to remain nonweightbearing over the weekend. The patient will follow up with Dr. X on Tuesday morning at 11'o clock in his Livonia office. The patient was concerned about any possible allergic reaction to medication and was placed on codeine and antibiotics due to that. The patient has Dr. X's pager and will contact him over this weekend if she has any problems or complaints or return to Emergency Department if any difficulty should arise. X-rays were taken and the patient was discharged home upon completion of this.surgery, hallux abductovalgus deformity, scarf bunionectomy, metatarsal, bunion, hallux abductovalgus, metatarsophalangeal joint, dorsally, foot, bone, abductovalgus

PREOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,POSTOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,PROCEDURE: , Ultrasound-guided right pleurocentesis.,ANESTHESIA: , Local with lidocaine.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient and his mother, the chest was scanned with portable ultrasound. Findings revealed a normal right hemidiaphragm, a moderate right pleural effusion without septation or debris, and no gliding sign of the lung on the right. Using sterile technique and with ultrasound as a guide, a pleural catheter was inserted and serosanguinous fluid was withdrawn, a total of 1 L. The patient tolerated the procedure well. Portable x-ray is pending.cardiovascular / pulmonary, pleural effusion, dyspnea, gliding sign, hemidiaphragm, pleural catheter, pleurocentesis, respiratory, serosanguinous fluid, ultrasound, pleural,

DIAGNOSIS:, Nuclear sclerotic and cortical cataract, right eye.,OPERATION:, Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.,PROCEDURE:, The patient was taken to the operating room and placed on the table in the supine position. Cardiac monitor and oxygen at 5 liters per minute were connected by the nursing staff. Local anesthesia was obtained using 2% lidocaine, 0/75% Marcaine, 0.5 cc Wydase with 6 cc of this solution used in a paribulbar injection, followed by ten minutes of digital massage. The patient was then prepped and draped in the usual sterile fashion for eye surgery. With the Zeiss operating microscopy in position, a lid speculum was inserted and a 4-0 black silk bridal suture placed in the superior rectus muscle. With Westcott scissors, a fornix-based conjunctival flap was made. The surgical limbus was identified and hemostasis obtained with wet-field cautery. With a 57-Beaver blade, a corneoscleral groove was made and shelved into clear cornea. A stab incision was made at 2 o'clock with a 15-degree blade. With a 3.0 mm keratome, the shelved groove was attended into the anterior chamber. Viscoelastic was inserted into the anterior chamber and anterior capsulotomy was performed in a continuous-tear technique. Hydrodissection was performed with Balanced Salt Solution. Phacoemulsification was performed in a two-headed nuclear fracture technique. The remaining cortical material was removed with irrigation and aspiration handpiece. The posterior capsule remained intact and vacuumed with minimal suction. The posterior chamber intraocular lens was obtained. It was inspected, irrigated, inserted into the posterior chamber without difficulty. Inspection revealed the intraocular lens to be in good position with intact capsule and well-approximated wound. There was no aqueous leak even with digital pressure. The conjunctiva was pulled back into position with wet-field cautery. A subconjunctival injection with 20 mg Gatamycine and 0.5 cc Celestone was given. Tobradex ointment was instilled into the eye, which was patched and shielded appropriately, after removing the lid speculum and bridle suture. The patient tolerated the procedure well and was sent to the recovery room in good condition, to be followed in attending physician office the next day.ophthalmology, extracapsular cataract extraction, phacoemulsification, nuclear sclerotic, cortical cataract, extraction with intraocular lens, cataract extraction, intraocular lens, intraocular, extracapsular, implantation, conjunctival, cataract, chamberNOTE

PREOPERATIVE DIAGNOSES:,1. Hallux abductovalgus deformity, right foot.,2. Tailor bunion deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux abductovalgus deformity, right foot.,2. Tailor bunion deformity, right foot.,PROCEDURES PERFORMED: ,Tailor bunionectomy, right foot, Weil-type with screw fixation.,ANESTHESIA: , Local with MAC, local consisting of 20 mL of 0.5% Marcaine plain.,HEMOSTASIS:, Pneumatic ankle tourniquet at 200 mmHg.,INJECTABLES:, A 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate.,MATERIAL: , A 2.4 x 14 mm, 2.4 x 16 mm, and 2.0 x 10 mm OsteoMed noncannulated screw. A 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, and 5-0 nylon.,COMPLICATIONS: , None.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS:, Minimal.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed on the operating table in the usual supine position. At this time, a pneumatic ankle tourniquet was placed on the patient's right ankle for the purpose of maintaining hemostasis. Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site. The right foot was then scrubbed, prepped, and draped in the usual aseptic manner. An Esmarch bandage was then used to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet inflated to 200 mmHg. Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3.5 cm in length was made. The incision was carried deep utilizing both sharp and blunt dissections. All major neurovascular structures were avoided. At this time, through the original skin incision, attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified. This was then incised fully exposing the tendon and the abductor hallucis muscle. This was then resected from his osseous attachments and a small tenotomy was performed. At this time, a small lateral capsulotomy was also performed. Lateral contractures were once again reevaluated and noted to be grossly reduced.,Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision. The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw, the head of the first metatarsal and medial eminence was resected and passed from the operative field. A 0.045 inch K-wire was then driven across the first metatarsal head in order to act as an access dye. The patient was then placed in the frog-leg position, and two osteotomy cuts were made, one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position. The dorsal arm was made longer than the plantar arm to accommodate for fixation. At this time, the capital fragment was resected and shifted laterally into a more corrected position. At this time, three portions of the 0.045-inch K-wire were placed across the osteotomy site in order to access temporary forms of fixation. Two of the three of these K-wires were removed in sequence and following the standard AO technique two 3.4 x 15 mm and one 2.4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site. Compression was noted to be excellent. All guide wires and 0.045-inch K-wires were then removed. Utilizing an oscillating bone saw, the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field. The wound was then once again flushed with copious amounts of sterile normal saline. At this time, utilizing both 2-0 and 3-0 Vicryl, the periosteal and capsular layers were then reapproximated. At this time, the skin was then closed in layers utilizing 4-0 Vicryl and 4-0 nylon. At this time, attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension. Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided.,A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal. Utilizing an oscillating bone saw, the lateral eminence was resected and passed from the operative field. Utilizing the sagittal saw, a Weil-type osteotomy was made at the fifth metatarsal head. The head was then shifted medially into a more corrected position. A 0.045-inch K-wire was then used as a temporary fixation, and a 2.0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site. This was noted to be in correct position and compression was noted to be excellent. Utilizing a small bone rongeur, the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field. The wound was once again flushed with copious amounts of sterile normal saline. The periosteal and capsular layers were reapproximated utilizing 3-0 Vicryl, and the skin was then closed utilizing 4-0 Vicryl and 4-0 nylon. At this time, 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site. The right foot was then dressed with Xeroform gauze, fluffs, Kling, and Ace wrap, all applied in mild compressive fashion. The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot. The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot. After a brief period of postoperative monitoring, the patient was discharged to home with proper written and verbal discharge instructions, which included to keep dressing clean, dry, and intact and to follow up with Dr. A. The patient is to be nonweightbearing to the right foot. The patient was given a prescription for pain medications on nonsteroidal anti-inflammatory drugs and was educated on these. The patient tolerated the procedure and anesthesia well. Dr. A was present throughout the entire case.orthopedic, tailor bunionectomy, weil-type, screw fixation, hallux, abductovalgus, bunion, tailor, deformity, metatarsal, phalangeal, capsulotomy, abductor, hallucis,

TECHNICAL SUMMARY: , The patient was recorded from 2:15 p.m. on 08/21/06 through 1:55 p.m. on 08/25/06. The patient was recorded digitally using the 10-20 system of electrode placement. Additional temporal electrodes and single channels of EOG and EKG were also recorded. The patient's medications valproic acid, Zonegran, and Keppra were weaned progressively throughout the study.,The occipital dominant rhythm is 10 to 10.5 Hz and well regulated. Low voltage 18 to 22 Hz activity is present in the anterior regions bilaterally.,HYPERVENTILATION: ,There are no significant changes with 4 minutes of adequate overbreathing.,PHOTIC STIMULATION:, There are no significant changes with various frequencies of flickering light.,SLEEP: , There are no focal or lateralizing features and no abnormal waveforms.,INDUCED EVENT: , On the final day of study, a placebo induction procedure was performed to induce a clinical event. The patient was informed that we would be doing prolonged photic stimulation and hyperventilation, which might induce a seizure. At 1:38 p.m., the patient was instructed to begin hyperventilation. Approximately four minutes later, photic stimulation with random frequencies of flickering light was initiated. Approximately 8 minutes into the procedure, the patient became unresponsive to verbal questioning. Approximately 1 minute later, she began to exhibit asynchronous shaking of her upper and lower extremities with her eyes closed. She persisted with the shaking and some side-to-side movements of her head for approximately 1 minute before abruptly stopping. Approximately 30 seconds later, she became slowly responsive initially only uttering a few words and able to say her name. When asked what had just occurred, she replied that she was asleep and did not remember any event. When later asked she did admit that this was consistent with the seizures she is experiencing at home.,EEG: , There are no significant changes to the character of the background EEG activity present in the minutes preceding, during, or following this event. Of note, while her eyes were closed and she was non-responsive, there is a well-regulated occipital dominant rhythm present.,IMPRESSION:, The findings of this patient's 95.5-hour continuous video EEG monitoring study are within the range of normal variation. No epileptiform activity is present. One clinical event was induced with hyperventilation and photic stimulation. The clinical features of this event are described in the technical summary above. There was no epileptiform activity associated with this event. This finding is consistent with a non-epileptic pseudoseizure.neurology, video eeg monitoring study, eog, ekg, abnormal waveforms, photic stimulation, hyperventilation, eeg monitoring study, eeg monitoring, monitoring study, eeg, monitoring

CHIEF COMPLAINT: , Bladder cancer.,HISTORY OF PRESENT ILLNESS:, The patient is a 68-year-old Caucasian male with a history of gross hematuria. The patient presented to the emergency room near his hometown on 12/24/2007 for evaluation of this gross hematuria. CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall. Urology referral was initiated and the patient was sent to be evaluated by Dr. X. He eventually underwent a bladder biopsy on 01/18/08, which demonstrated high-grade transitional cell carcinoma without any muscularis propria in the specimen. Additionally, the patient underwent workup for a right adrenal lesion, which was noted on the initial CT scan. This workup involved serum cortisol analysis as well as potassium and aldosterone and ACTH level measurement. All of this workup was found to be grossly negative. Secondary to the absence of muscle in the specimen, the patient was taken back to the operating room on 02/27/08 by Dr. X and the tumor was noted to be very large with significant tumor burden as well as possible involvement of the bladder neck. At that time, the referring urologist determined the tumor to be too large and risky for local resection, and the patient was referred to ABCD Urology for management and diagnosis. The patient presents today for evaluation by Dr. Y.,PAST MEDICAL HISTORY: , Includes condyloma, hypertension, diabetes mellitus, hyperlipidemia, undiagnosed COPD, peripheral vascular disease, and claudication. The patient denies coronary artery disease.,PAST SURGICAL HISTORY:, Includes bladder biopsy on 01/18/08 without muscularis propria in the high-grade TCC specimen and a gun shot wound in 1984 followed by exploratory laparotomy x2. The patient denies any bowel resection or GU injury at that time; however, he is unsure.,CURRENT MEDICATIONS:,1. Metoprolol 100 mg b.i.d.,2. Diltiazem 120 mg daily.,3. Hydrocodone 10/500 mg p.r.n.,4. Pravastatin 40 mg daily.,5. Lisinopril 20 mg daily.,6. Hydrochlorothiazide 25 mg daily.,FAMILY HISTORY: , Negative for any GU cancer, stones or other complaints. The patient states he has one uncle who died of lung cancer. He denies any other family history.,SOCIAL HISTORY: , The patient smokes approximately 2 packs per day times greater than 40 years. He does drink occasional alcohol approximately 5 to 6 alcoholic drinks per month. He denies any drug use. He is a retired liquor store owner.,PHYSICAL EXAMINATION:,GENERAL: He is a well-developed, well-nourished Caucasian male, who appears slightly older than stated age. VITAL SIGNS: Temperature is 96.7, blood pressure is 108/57, pulse is 75, and weight of 193.8 pounds. HEAD AND NECK: Normocephalic atraumatic. LUNGS: Demonstrate decreased breath sounds globally with small rhonchi in the inferior right lung, which is clear somewhat with cough. HEART: Regular rate and rhythm. ABDOMEN: Soft and nontender. The liver and spleen are not palpably enlarged. There is a large midline defect covered by skin, of which the fascia has numerous holes poking through. These small hernias are of approximately 2 cm in diameter at the largest and are nontender. GU: The penis is circumcised and there are no lesions, plaques, masses or deformities. There is some tenderness to palpation near the meatus where 20-French Foley catheter is in place. Testes are bilaterally descended and there are no masses or tenderness. There is bilateral mild atrophy. Epididymidis are grossly within normal limits bilaterally. Spermatic cords are grossly within normal limits. There are no palpable inguinal hernias. RECTAL: The prostate is mildly enlarged with a small focal firm area in the midline near the apex. There is however no other focal nodules. The prostate is grossly approximately 35 to 40 g and is globally firm. Rectal sphincter tone is grossly within normal limits and there is stool in the rectal vault. EXTREMITIES: Demonstrate no cyanosis, clubbing or edema. There is dark red urine in the Foley bag collection.,LABORATORY EXAM:, Review of laboratory from outside facility demonstrates creatinine of 2.38 with BUN of 42. Additionally, laboratory exam demonstrates a grossly normal serum cortisol, ACTH, potassium, aldosterone level during lesion workup. CT scan was reviewed from outside facility, report states there is left kidney atrophy without hydro or stones and there is thickened left bladder wall and posterior margins with a balloon inflated in the prostate at the time of the exam. There is a 3.1 cm right heterogeneous adrenal nodule and there are no upper tract lesions or stones noted.,IMPRESSION:, Bladder cancer.,PLAN: ,The patient will undergo a completion TURBT on 03/20/08 with bilateral retrograde pyelograms at the time of surgery. Preoperative workup and laboratory as well as paper work were performed in clinic today with Dr. Y. The patient will be scheduled for anesthesia preop. The patient will have urine culture redrawn from his Foley or penis at the time of preoperative evaluation with anesthesia. The patient was counseled extensively approximately 45 minutes on the nature of his disease and basic prognostic indicators and need for additional workup and staging. The patient understands these instructions and also agrees to quit smoking prior to his next visit. This patient was seen in evaluation with Dr. Y who agrees with the impression and plan.urology, retrograde pyelogram, bladder biopsy, muscularis propria, bladder cancer, gross hematuria, bladder wall, ct scan, bladder, hematuria,

PREOPERATIVE DIAGNOSIS: , Need for intravenous access.,POSTOPERATIVE DIAGNOSIS: , Need for intravenous access.,PROCEDURE PERFORMED: ,Insertion of a right femoral triple lumen catheter.,ANESTHESIA: , Includes 4 cc of 1% lidocaine locally.,ESTIMATED BLOOD LOSS: , Minimum.,INDICATIONS:, The patient is an 86-year-old Caucasian female who presented to ABCD General Hospital secondary to drainage of an old percutaneous endoscopic gastrostomy site. The patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.,PROCEDURE:, The patient's legal guardian was talked to. All questions were answered and consent was obtained. The patient was sterilely prepped and draped. Approximately 4 cc of 1% lidocaine was injected into the inguinal site. A strong femoral artery pulse was felt and triple lumen catheter Angiocath was inserted at 30-degree angle cephalad and aspirated until a dark venous blood was aspirated. A guidewire was then placed through the needle. The needle was then removed. The skin was ________ at the base of the wire and a dilator was placed over the wire. The triple lumen catheters were then flushed with bacteriostatic saline. The dilator was then removed from the guidewire and a triple lumen catheter was then inserted over the guidewire with the guidewire held at all times.,The wire was then carefully removed. Each port of the lumen catheter was aspirated with 10 cc syringe with normal saline till dark red blood was expressed and then flushed with bacteriostatic normal saline and repeated on the remaining two ports. Each port was closed off and also kept off. Straight needle suture was then used to suture the triple lumen catheter down to the skin. Peristatic agent was then placed at the site of the lumen catheter insertion and a Tegaderm was then placed over the site. The surgical site was then sterilely cleaned. The patient tolerated the full procedure well. There were no complications. The nurse was then contacted to allow for access of the triple lumen catheter.surgery, intravenous access, catheter, femoral triple lumen catheter, triple lumen catheter, lumen, ventilator, respiratory, guidewire

POSTOPERATIVE DIAGNOSIS:, Chronic adenotonsillitis.,PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA: ,General endotracheal tube.,ESTIMATED BLOOD LOSS:, Minimum, less than 5 cc.,SPECIMENS:, Right and left tonsils 2+, adenoid pad 1+. There was no adenoid specimen.,COMPLICATIONS: , None.,HISTORY: , The patient is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy. The patient has had approximately four to five episodes of adenotonsillitis per year for the last three to four years.,PROCEDURE: , Informed consent was properly obtained from the patient's parents and the patient was taken to the operating room #3 and was placed in a supine position. He was placed under general endotracheal tube anesthesia by the Department of Anesthesia. The bed was then rolled away from Department of Anesthesia. A shoulder roll was then placed beneath the shoulder blades and a blue towel was then fashioned as a turban wrap. The McIvor mouth gag was carefully positioned into the patient's mouth with attention to avoid the teeth.,The retractor was then opened and the oropharynx was visualized. The adenoid pad was then visualized with a laryngeal mirror. The adenoids appeared to be 1+ and non-obstructing. There was no evidence of submucosal cleft palate palpable. There was no evidence of bifid uvula. A curved Allis clamp was then used to grasp the superior pole of the right tonsil. The tonsil was then retracted inferiorly and medially. Bovie cautery was used to make an incision on the mucosa of the right anterior tonsillar pillar to find the appropriate plane of dissection. The tonsil was then dissected out within this plane using a Bovie. Tonsillar sponge was re-applied to the tonsillar fossa. Suction cautery was then used to adequately obtain hemostasis with the tonsillar fossa. Attention was then directed to the left tonsil. The curved Allis was used to grasp the superior pole of the left tonsil and it was retracted inferiorly and medially. Bovie cautery was used to make an incision in the mucosa of the left anterior tonsillar pillar and define the appropriate plane of dissection. The tonsil was then dissected out within this plane using the Bovie. Next, complete hemostasis was achieved within the tonsillar fossae using suction cautery. After adequate hemostasis was obtained, attention was directed towards the adenoid pad. The adenoid pad was again visualized and appeared 1+ and was non-obstructing. Decision was made to use suction cautery to cauterize the adenoids. Using a laryngeal mirror under direct visualization, the adenoid pad was then cauterized with care to avoid the eustachian tube orifices as well as the soft palate and inferior turbinates. After cauterization was complete, the nasopharynx was again visualized and tonsillar sponge was applied. Adequate hemostasis was achieved. The tonsillar fossae were again visualized and no evidence of bleeding was evident. The throat pack was removed from the oropharynx and the oropharynx was suctioned. There was no evidence of any further bleeding. A flexible suction catheter was then used to suction out the nasopharynx to the oropharynx. The suction catheter was also used to suction up the stomach. Final look revealed no evidence of further bleeding and 10 mg of Decadron was given intraoperatively.,DISPOSITION: ,The patient tolerated the procedure well and the patient was transported to the recovery room in stable condition.ent - otolaryngology, chronic adenotonsillitis, tonsillectomy, adenoidectomy, adenoid, tonsils, tonsillar fossa, tonsillar fossae, suction cautery, adenotonsillitis, oropharynx, hemostasis, cautery, suction, tonsillar

PREOPERATIVE DIAGNOSIS: , Right profound mixed sensorineural conductive hearing loss.,POSTOPERATIVE DIAGNOSIS:, Right profound mixed sensorineural conductive hearing loss.,PROCEDURE PERFORMED:, Right middle ear exploration with a Goldenberg TORP reconstruction.,ANESTHESIA:, General ,ESTIMATED BLOOD LOSS:, Less than 5 cc.,COMPLICATIONS:, None.,DESCRIPTION OF FINDINGS:, The patient consented to revision surgery because of the profound hearing loss in her right ear. It was unclear from her previous operative records and CT scan as to whether or not she was a reconstruction candidate. She had reports of stapes fixation as well as otosclerosis on her CT scan.,At surgery, she was found to have a mobile malleus handle, but her stapes was fixed by otosclerosis. There was no incus. There was no specific round window niche. There was a very minute crevice; however, exploration of this area did not reveal a niche to a round window membrane. The patient had a type of TORP prosthesis, which had tilted off the footplate anteriorly underneath the malleus handle.,DESCRIPTION OF THE PROCEDURE:, The patient was brought to the operative room and placed in supine position. The right face, ear, and neck prepped with ***** alcohol solution. The right ear was draped in the sterile field. External auditory canal was injected with 1% Xylocaine with 1:50,000 epinephrine. A Fisch indwelling incision was made and a tympanomeatal flap was developed in a 12 o'clock to the 7 o'clock position. Meatal skin was elevated, middle ear was entered. This exposure included the oval window, round window areas. There was a good cartilage graft in place and incorporated into the posterior superior ***** of the drum. The previous prosthesis was found out of position as it had tilted out of position anteriorly, and there was no contact with the footplate. The prosthesis was removed without difficulty. The patient's stapes had an arch, but the ***** was atrophied. Malleus handle was mobile. The footplate was fixed. Consideration have been given to performing a stapedectomy with a tissue seal and then returning later for prosthesis insertion; however, upon inspection of the round window area, there was found to be no definable round window niche, no round window membrane. The patient was felt to have obliterated otosclerosis of this area along with the stapes fixation. She is not considered to be a reconstruction candidate under the current circumstances. No attempt was made to remove bone from the round window area. A different style of Goldenberg TORP was placed on the footplate underneath the cartilage support in hopes of transferring some sound conduction from the tympanic membrane to the footplate. The fit was secure and supported with Gelfoam in the middle ear. The tympanomeatal flap was returned to anatomic position supported with Gelfoam saturated Ciprodex. The incision was closed with #4-0 Vicryl and individual #5-0 nylon to the skin, and a sterile dressing was applied.surgery, conductive hearing loss, goldenberg, meatal skin, torp, torp reconstruction, ear, ear exploration, handle, malleus, otosclerosis, sensorineural, stapedectomy, tympanomeatal, middle ear exploration, hearing loss, malleus handle, middle ear, middle

CC:, Left sided weakness.,HX:, 74 y/o RHF awoke from a nap at 11:00 AM on 11/22/92 and felt weak on her left side. She required support on that side to ambulate. In addition, she felt spoke as though she "was drunk." Nevertheless, she was able to comprehend what was being spoken around her. Her difficulty with speech completely resolved by 12:00 noon. She was brought to UIHC ETC at 8:30AM on 11/23/92 for evaluation.,MEDS:, none. ,ALLERGIES:, ASA/ PCN both cause rash.,PMH:, 1)?HTN. 2)COPD. 3)h/o hepatitis (unknown type). 4)Macular degeneration.,SHX:, Widowed; lives alone. Denied ETOH/Tobacco/illicit drug use.,FHX:, unremarkable.,EXAM: , BP191/89 HR68 RR16 37.2C,MS: A & O to person, place and time. Speech fluent; without dysarthria. Intact naming, comprehension, and repetition.,CN: Central scotoma, OS (old). Mild upper lid ptosis, OD (old per picture). Lower left facial weakness.,Motor: Mild Left hemiparesis (4+ to 5- strength throughout affected side). No mention of muscle tone in chart.,Sensory: unremarkable.,Coord: impaired FNF and HKS movement secondary to weakness.,Station: Left pronator drift. No Romberg sign seen.,Gait: Left hemiparetic gait with decreased LUE swing.,Reflexes: 3/3+ biceps and triceps. 3/3+ patellae. 2/3+ ankles with 3-4beats of non-sustained ankle clonus on left. Plantars: Left babinski sign; and flexor on right.,General Exam: 2/6 SEM at left sternal border.,COURSE:, GS, CBC, PT, PTT, CK, ESR were within normal limits. ABC 7.4/46/63 on room air. EKG showed a sinus rhythm with right bundle branch block. MRI brain, 11/23/95, revealed a right pontine pyramidal tract infarction. She was treated with Ticlopidine 250mg bid. On 11/26/92, her left hemiparesis worsened. A HCT, 11/27/92, was unremarkable. The patient was treated with IV Heparin. This was discontinued the following day when her strength returned to that noted on 11/23/95. On 11/27/92, she developed angina and was ruled out for MI by serial EKG and cardiac enzyme studies. Carotid duplex showed 0-15% bilateral ICA stenosis and antegrade vertebral artery flow bilaterally. Transthoracic echocardiogram revealed aortic insufficiency only. Transesophageal echocardiogram revealed trivial mitral and tricuspid regurgitation, aortic valvular fibrosis. There was calcification and possible thrombus seen in the descending aorta. Cardiology did not feel the later was an indication for anticoagulation. She was discharged home on Isordil 20 tid, Metoprolol 25mg q12hours, and Ticlid 250mg bid.neurology, mri brain, pontine stroke, difficulty with speech, hemiparesis, pontine pyramidal tract infarct, weakness, mri, brain, pyramidal, echocardiogram, pontine, infarct,

EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.,FINDINGS:,Examination was performed on 9/1/05.,There is marked supraspinatus tendinosis and extensive tearing of the substance of the tendon and articular surface, extending into the myotendinous junction as well. There is still a small rim of tendon along the bursal surface, although there may be a small tear at the level of the rotator interval. There is no retracted tendon or muscular atrophy (series #6 images #6-17).,Normal infraspinatus tendon.,There is subscapularis tendinosis with fraying and partial tearing of the superior most fibers extending to the level of the rotator interval (series #9 images #8-13; series #3 images #8-14). There is no complete tear, gap or fiber retraction and there is no muscular atrophy.,There is tendinosis and superficial tearing of the long biceps tendon within the bicipital groove, and there is high grade (near complete) partial tearing of the intracapsular portion of the tendon. The biceps anchor is intact. There are degenerative changes in the greater tuberosity of the humerus but there is no fracture or subluxation.,There is degeneration of the superior labrum and there is a small nondisplaced tear in the posterior superior labrum at the one to two o’clock position (series #6 images #12-14; series #3 images #8-10; series #9 images #5-8). There is a small sublabral foramen at the eleven o’clock position (series #9 image #6). There is no osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is hypertrophic osteoarthropathy of the acromioclavicular joint with narrowing of the subacromial space and flattening of the superior surface of the supraspinatus musculotendinous junction, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion (series #8 images #3-12).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments. There is minimal fluid within the glenohumeral joint. There is no atrophy of the deltoid muscle.,IMPRESSION:, There is extensive supraspinatus tendinosis and partial tearing as described. There is no retracted tendon or muscular atrophy, but there may be a small tear along the anterior edge of the tendon at the level of the rotator interval, and this associated partial tearing of the superior most fibers of the subscapularis tendon. There is also a high-grade partial tear of the long biceps tendon as it courses under the transverse humeral ligament. There is no evidence of a complete tear or retracted tendon. Small nondisplaced posterior superior labral tear. Outlet narrowing from the acromioclavicular joint, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion.orthopedic, level of the rotator, impinging lesion, rotator interval, retracted tendon, muscular atrophy, partial tearing, tendon, mri, shoulder, rotator, superior, tear,

CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM: ,Shortness of breath for two weeks and a history of pneumonia. The patient also has a history of left lobectomy.,TECHNIQUE: , Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: , There is no evidence of any acute pulmonary arterial embolism.,The main pulmonary artery is enlarged showing a diameter of 4.7 cm.,Cardiomegaly is seen with mitral valvular calcifications.,Postsurgical changes of a left upper lobectomy are seen. Left lower lobe atelectasis is noted. A 7 mm and a 5 mm pulmonary nodule are seen within the left lower lobe (image #12). A small left pleural effusion is noted.,Right lower lobe atelectasis is present. There is a right pleural effusion, greater than as seen on the left side. A right lower lobe pulmonary nodule measures 1.5 cm. There is a calcified granuloma within the right lower lobe.,IMPRESSION:,1. Negative for pulmonary arterial embolism.,2. Enlargement of the main pulmonary artery as can be seen with pulmonary arterial hypertension.,3. Cardiomegaly with mitral valvular calcifications.,4. Postsurgical changes of a left upper lobectomy.,5. Bilateral pleural effusions, right greater than left with bilateral lower lobe atelectasis.,6. Bilateral lower lobe nodules, pulmonary nodules, and interval followup in three months to confirm stability versus further characterization with prior studies is advised.radiology, shortness of breath, pneumonia, pulmonary embolism, isovue-300, axial ct images, ct angiography, lower lobe, pulmonary, lobectomy, isovue, angiography, arterial, atelectasis, pleural, ct, embolism,

PREOPERATIVE DIAGNOSIS: , Left canal cholesteatoma.,POSTOPERATIVE DIAGNOSIS: , Left canal cholesteatoma.,OPERATIVE PROCEDURE:,1. Left canal wall down tympanomastoidectomy with ossicular chain reconstruction.,2. Microdissection.,3. NIM facial nerve monitoring for three hours.,COMPLICATIONS: ,None.,FINDINGS:, There is an extremely large canal cholesteatoma, which eroded most of the posterior and superior canal wall. There was a significant amount of myringosclerosis and tympanosclerosis. There is some mild erosion of the lenticular process of the incus. The facial nerve was normal. We removed the incus, removed the head of the malleus, and placed a titanium-PORP from the stapes capitulum to a cartilage graft.,PROCEDURE: , The patient was taken to the operating room, placed under general anesthetic and intubated without difficulty. The NIM facial nerve monitoring electrodes were positioned and monitoring was performed throughout the procedure. There was no abnormal activity during this case. We inspected the ear canal, identified the huge defect, which was completely filled with cerumen. Through the ear canal, we removed as much as we could and then infiltrated the canal and postauricular area with 1:100,000 of epinephrine.,We prepped and draped the ear in a sterile fashion. We reopened the previously used postauricular incision and dissected down the mastoid cortex. We reflected the soft tissues anteriorly to the level of the ear canal and identified where the ear canal skin entered the defect in the mastoid bone. A #6 cutting bur was used to drill down the mastoid cortex and identified this cholesteatoma which was then carefully dissected out. We went all the way to the mastoid antrum. We finished a complete mastoidectomy with identification of the tegmen, sigmoid sinus. We removed the lateral aspect of the mastoid tip. We lowered the facial ridge. The incudostapedial joint was already membranous in nature, we went ahead and used the joint knife and removed the incus. We separated the incus from the stapes and then removed it. We used a malleus head nipper to remove the head of the malleus and then we continued to saucerize the entire mastoid cavity.,There was no cholesteatoma within the middle ear space, but there was roughly 40% surface area perforation. The remaining portion of the tympanic membrane was extremely calcified and myringosclerotic; this was removed. There was also a large focus of tympanosclerosis between the stapes crura, which was impinging the ability of the stapes to move. We carefully dissected this out. This did seem to improve the mobility of the stapes somewhat. At this point, there was a near total perforation. There was only a minimal amount of anterior remnant of the drum left. We tried to go ahead and harvest the temporalis fascia, but there was really only wisps of this fascia in place. He had already had a previous tympanoplasty, but even outside the areas where the graft was taken, the temporalis muscle was quite atrophied and lumpy, and I suspect this was due to his chronic disease and long history of corticosteroid usage. We harvested a few pieces as best as we could. We went ahead and did a meatoplasty by making a canal incision in the 6 o'clock and 12 o'clock positions. We excised cartilage posteriorly and inferiorly to enlarge the meatus. This cartilage was thin and used for cartilage tympanoplasty. We placed some Gelfoam in the middle ear space and placed the cartilage on the top of it. We did cut a titanium-PORP of the proper side and placed on top of the stapes capitulum to interface with the cartilage cap. A few other small pieces of temporalis fascia were used to bulge through the surrounding edges of the cartilage and make sure that it was medial to any remnant of ear canal and tympanic membrane remnants. We placed a layer of Gelfoam lateral to the graft, closed the postauricular incision in layers and put 2 Merocel packs in the ear. Glasscock dressing was applied. The patient was awakened from anesthesia and taken to the recovery room in stable condition. He will be given antibiotics and pain medicines and he will be given instructions to follow up with me in one week.surgery, cholesteatoma, gelfoam, glasscock dressing, microdissection, nim, canal, canal wall, cerumen, facial nerve, incus, myringosclerosis, ossicular chain reconstruction, titanium-porp, tympanomastoidectomy, tympanosclerosis, facial nerve monitoring, ear canal, cartilage, ear,

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:nan

PREOPERATIVE DIAGNOSIS:, History of perforated sigmoid diverticuli with Hartmann's procedure.,POSTOPERATIVE DIAGNOSES: ,1. History of perforated sigmoid diverticuli with Hartmann's procedure.,2. Massive adhesions.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Lysis of adhesions and removal.,3. Reversal of Hartmann's colostomy.,4. Flexible sigmoidoscopy.,5. Cystoscopy with left ureteral stent.,ANESTHESIA: , General.,HISTORY: , This is a 55-year-old gentleman who had a previous perforated diverticula. Recommendation for reversal of the colostomy was made after more than six months from the previous surgery for a sigmoid colon resection and Hartmann's colostomy.,PROCEDURE: ,The patient was taken to the operating room placed into lithotomy position after being prepped and draped in the usual sterile fashion. A cystoscope was introduced into the patient's urethra and to the bladder. Immediately, no evidence of cystitis was seen and the scope was introduced superiorly, measuring the bladder and immediately a #5 French ____ was introduced within the left urethra. The cystoscope was removed, a Foley was placed, and wide connection was placed attaching the left ureteral stent and Foley. At this point, immediately the patient was re-prepped and draped and immediately after the ostomy was closed with a #2-0 Vicryl suture, immediately at this point, the abdominal wall was opened with a #10 blade Bard-Parker down with electrocautery for complete hemostasis through the midline.,The incision scar was cephalad due to the severe adhesions in the midline. Once the abdomen was entered in the epigastric area, then massive lysis of adhesions was performed to separate the small bowel from the anterior abdominal wall. Once the small bowel was completely free from the anterior abdominal wall, at this point, the ostomy was taken down with an elliptical incision with cautery and then meticulous dissection with Metzenbaum scissors and electrocautery down to the anterior abdominal wall, where a meticulous dissection was carried with Metzenbaum scissors to separate the entire ostomy from the abdominal wall. Immediately at this point, the bowel was dropped within the abdominal cavity, and more lysis of adhesions was performed cleaning the left gutter area to mobilize the colon further down to have no tension in the anastomosis. At this point, the rectal stump, where two previous sutures with Prolene were seen, were brought with hemostats. The rectal stump was free in a 360 degree fashion and immediately at this point, a decision to perform the anastomosis was made. First, a self-retaining retractor was introduced in the abdominal cavity and a bladder blade was introduced as well. Blue towel was placed above the small bowel retracting the bowel to cephalad and at this point, immediately the rectal stump was well visualized, no evidence of bleeding was seen, and the towels were placed along the edges of the abdominal wound. Immediately, the pursestring device was fired approximately 1 inch from the skin and on the descending colon, this was fired. The remainder of the excess tissue was closed with Metzenbaum scissors and immediately after dilating #25 and #29 mushroom tip from the T8 Ethicon was placed within the colon and then #9-0 suture was tied. Immediately from the anus, the dilator #25 and #29 was introduced dilating the rectum. The #29 EEA was introduced all the way anteriorly to the staple line and this spike from the EEA was used to perforate the rectum and then the mushroom from the descending colon was attached to it. The EEA was then fired. Once it was fired and was removed, the pelvis was filled with fluid. Immediately both doughnuts were ____ from the anastomosis. A Doyen was placed in both the anastomosis. Colonoscope was introduced. No bubble or air was seen coming from the anastomosis. There was no evidence of bleeding. Pictures of the anastomosis were taken. The scope then was removed from the patient's rectum. Copious amount of irrigation was used within the peritoneal cavity. Immediately at this point, all complete sponge and instrument count was performed. First, the ostomy site was closed with interrupted figure-of-eight #0 Vicryl suture. The peritoneum was closed with running #2-0 Vicryl suture. Then, the midline incision was closed with a loop PDS in cephalad to caudad and caudad to cephalad tight in the middle. Subq tissue was copiously irrigated and the staples on the skin.,The iodoform packing was placed within the old ostomy site and then the staples on the skin as well. The patient did tolerate the procedure well and will be followed during the hospitalization. The left ureteral stent was removed at the end of the procedure. _____ were performed. Lysis of adhesions were performed. Reversal of colostomy and EEA anastomosis #29 Ethicon.gastroenterology, reversal of hartmann's colostomy, flexible sigmoidoscopy, cystoscopy, ureteral stent, lysis of adhesions, exploratory laparotomy, hartmann's colostomy, abdominal wall, immediately, adhesions, colostomy, sigmoidoscopy, bowel, anastomosis, abdominal

HISTORY OF PRESENT ILLNESS:, History as provided primarily by the patient's daughter, as well as the referring physician revealed an approximately two-year history of colon cancer initially diagnosed when the patient presented with a swelling in his groin. Approximately one month ago, he presented with abdominal pain and presented to the hospital with transverse colon obstruction. He had a diverting colostomy performed approximately one month ago. Approximately two weeks ago, he was admitted to hospital with infection of this with chronically swollen lower extremities and is home now for approximately one week. He was deemed not to be a candidate for chemotherapy or radiation on the basis of extensive disease, as well as a longstanding history of cirrhosis with esophageal varices. Additional history includes an enlarged heart and chronic lower extremity edema associated with trauma from his time as an army infantryman in Korea many decades ago. The patient is alert and lives alone, although the daughter Ruby is in from out of town for several weeks to care for him. He denies any particular problems with the exception of itch and a site of leakage around his ostomy site. His appetite is notably improved since discharge from hospital and both he and his daughter believe he has gained a few pounds of weight. His stooling is regular. There is no fever. Of greatest concern to his daughter is a possibility that his colostomy might be reversible and at the recommendation of some of the physicians at the referring hospital, he was to have had a PET scan to assess whether the ostomy is reversible for various reasons, primarily insurance. The PET scan has not been done and the family is quite concerned about a potential surgical intervention. The patient denies anxiety or depression and there is no history of same. He was married for over 50 years and now widowed for nearly 10. He is a stepfather to five children and he has seven of his own, all in all raising 12 children. His daughters, Ruby and Camilla are most involved with the patient's care. The patient is retired, worked in supermarkets for many years when he is very proud of his time as an infantryman in Korea. He did sustain an injury to the right eye during his service. He has lots of children, grandchildren, and great-grandchildren and seems to derive great pleasure from them. He denies spiritual or religious distress. As to advanced directives, the patient appears not to have any significant advanced directives, written or oral. Family apparently is working on a "plan.",MEDICATIONS:, Medications include Toprol 12.5 mg twice daily, Lasix 20 mg daily, ranitidine 75 mg daily, potassium 20 mEq daily, Benadryl 25-50 mg at the hour of sleep as needed, not typically taken and a prescription in the house for Keflex 500 mg q.i.d. for red legs has not yet begun.,PHYSICAL EXAMINATION:, Examination reveals am alert pale, but thin gentleman with evident wasting. He is seated and walks without assistance. His blood pressure is 135/75. Pulse is 80. Respiratory rate is 14. He is afebrile. Head is without icterus. Pupils are equal and round. He has a red dry tongue without leaking mucosal lesions. There is no jugular venous distention. The chest has increased AP diameter with good air entry bilaterally. There is a systolic ejection murmur heard over the entire precordium. The rate is regular. The abdomen, he has a right-sided colostomy with a prolapsed bowel. There is an area of approximately 5 cm x 8 cm of erythema adjacent to the ostomy. The skin is intact. The bowel sounds are active. There is no tenderness in the abdomen and no palpable masses. Extremities show chronic lymphedema. The right lower extremity has an 8 cm x 10 cm patch over the anterior shin that is darkened, but not red and not warm. The distal pulses are intact. Rectal exam shows no external nor internal hemorrhoids. No mass is felt and no blood on the gloved finger. Neurologically, he is alert. He is oriented times three. His speech is clear. His mood appears to be good. His short-term memory is intact. There is no focal neurological deficit.,ASSESSMENT:, A 77-year-old gentleman with apparent widespread intra-abdominal spread of rectal cancer. Status post bowel obstruction. Comorbid cirrhosis with esophageal varices. No history of bleeding. The patient has had significant clinical and functional decline and I expect that his prognosis would be measured in weeks to months. The patient lives alone and is currently being very well cared for his daughter from out of town. She will be leaving in a few weeks. There is another in-town daughter; however, she works and has a large family.,PLAN:, I will communicate with the patient's referring physician to ascertain what clinical course and data is available. A moisture barrier will be applied to his peri-ostomy wound today and we would reassess within 24 hours. It would be appropriate for a family meeting to be scheduled to review the family and the patient's understanding of his clinical condition and to begin to address an appropriate plan of care for the patient's inevitable decline.,I spoke with Dr. Abc, who informed me that family has in their possession a disc with the CAT scan results. We will try to ask radiologic colleagues when we obtain the disc to give us a formal reading so that we might better understand the patient's clinical condition and better inform family of his clinical status.hospice - palliative care, hospice, cat scan results, hospice nurse, pet scan, abdominal pain, admitted to hospital, cirrhosis, colon cancer, colon obstruction, esophageal varices, longstanding, moisture barrier, referring physician, health, colon, cancer,

PROCEDURES PERFORMED:, Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.,PROCEDURE CODES: , 64640 times three, 64614 times four, 95873 times four.,PREOPERATIVE DIAGNOSIS: , Spastic quadriparesis secondary to traumatic brain injury, 907.0.,POSTOPERATIVE DIAGNOSIS:, Spastic quadriparesis secondary to traumatic brain injury, 907.0.,ANESTHESIA:, MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient's brother. The patient was brought to the minor procedure area and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine. The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active EMG stimulation. Approximately 7 mL was injected on the right side and 5 mL on the left side. At all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol. The musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active EMG stimulation. Approximately 5 mL of 5% phenol was injected in this location. Injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified using active EMG stimulation. Approximately 150 units was injected in the knee extensors bilaterally, 100 units in the left pectoralis major, and 50 units in the left wrist flexors. Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL. The patient tolerated the procedure well and no complications were encountered.surgery, spastic quadriparesis, emg stimulation, emg, botulinum toxin injection, traumatic brain, brain injury, phenol neurolysis, toxin injection, musculocutaneous nerve, obturator nerves, pectoralis major, wrist flexors, knee extensors, active emg, botulinum toxin, toxin, injection, stimulus, neurolysis, musculocutaneous, extensors, botulinum, phenol

PROCEDURE: , Sigmoidoscopy.,INDICATIONS:, Performed for evaluation of anemia, gastrointestinal Bleeding.,MEDICATIONS: , Fentanyl (Sublazine) 0.1 mg IV Versed (midazolam) 1 mg IV,BIOPSIES: , No BRUSHINGS:,PROCEDURE:, A history and physical examination were performed. The procedure, indications, potential complications (bleeding, perforation, infection, adverse medication reaction), and alternative available were explained to the patient who appeared to understand and indicated this. Opportunity for questions was provided and informed consent obtained. After placing the patient in the left lateral decubitus position, the sigmoidoscope was inserted into the rectum and under direct visualization advanced to 25 cm. Careful inspection was made as the sigmoidoscope was withdrawn. The quality of the prep was good. The procedure was stopped due to patient discomfort. The patient otherwise tolerated the procedure well. There were no complications.,FINDINGS: , Was unable to pass scope beyond 25 cm because of stricture vs very short bends secondary to multiple previous surgeries. Retroflexed examination of the rectum revealed small hemorrhoids. External hemorrhoids were found. Other than the findings noted above, the visualized colonic segments were normal.,IMPRESSION: , Internal hemorrhoids External hemorrhoids Unable to pass scope beyond 25 cm due either to stricture or very sharp bend secondary to multiple surgeries. Unsuccessful Sigmoidoscopy. Otherwise Normal Sigmoidoscopy to 25 cm. External hemorrhoids were found.gastroenterology, gastrointestinal bleeding, gastrointestinal, sigmoidoscope, rectum, anemia, bleeding, sigmoidoscopy, hemorrhoids,

CHIEF COMPLAINT: , Right shoulder pain.,HISTORY: , The patient is a pleasant, 31-year-old, right-handed, white female who injured her shoulder while transferring a patient back on 01/01/02. She formerly worked for Veteran's Home as a CNA. She has had a long drawn out course of treatment for this shoulder. She tried physical therapy without benefit and ultimately came to a subacromion decompression in November 2002. She had ongoing pain and was evaluated by Dr. X who felt that she had a possible brachial plexopathy. He also felt she had a right superficial radial neuritis and blocked this with resolution of her symptoms. He then referred her to ABCD who did EMG testing, demonstrating a right suprascapular neuropathy although a C5 radiculopathy could not be ruled out. MRI testing on the cervical spine was then done which was negative for disk herniation and she underwent suprascapular nerve decompression of the scapular notch on 12/18/03. She finally went to an anterior axillary nerve block because of ongoing pain in the anterior shoulder again by Dr. X. She comes to me for impairment rating. She has no chronic health problems otherwise, fevers, chills, or general malaise. She is not working. She is right-hand dominant. She denies any prior history of injury to her shoulder.,PAST MEDICAL HISTORY:, Negative aside from above.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: ,Please see above.,REVIEW OF SYSTEMS:, Negative aside from above.,PHYSICAL EXAMINATION: ,A pleasant, age appropriate woman, moderately overweight, in no apparent distress. Normal gait and station, normal posture, normal strength, tone, sensation and deep tendon reflexes with the exception of 4+/5 strength in the supraspinatus musculature on the right. She has decreased motion in the right shoulder as follows. She has 160 degrees of flexion, 155 degrees of abduction, 35 degrees of extension, 25 degrees of adduction, 45 degrees of internal rotation and 90 degrees of external rotation. She has a positive impingement sign on the right.,ASSESSMENT:, Right shoulder impingement syndrome, right suprascapular neuropathy.,DISCUSSION: , With a reasonable degree of medical certainty, she is at maximum medical improvement and she does have an impairment based on AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition. The reason for this impairment is the incident of 01/01/02. For her suprascapular neuropathy, she is rated as a grade IV motor deficit which I rate as a 13% motor deficit. This is multiplied by a maximum upper extremity impairment for involvement of the suprascapular nerve of 16% which produces a 2% impairment of the upper extremity when the two values are multiplied together, 2% impairment of the upper extremity. For her lack of motion in the shoulder she also has additional impairment on the right. She has a 1% impairment of the upper extremity due to lack of shoulder flexion. She has a 1% impairment of the upper extremity due to lack of shoulder abduction. She has a 1% impairment of the upper extremity due to lack of shoulder adduction. She has a 1% impairment of the upper extremity due to lack of shoulder extension. There is no impairment for findings in shoulder external rotation. She has a 3% impairment of the upper extremity due to lack of shoulder internal rotation. Thus the impairment due to lack of motion in her shoulder is a 6% impairment of the upper extremity. This combines with the 2% impairment of the upper extremity due to weakness in the suprascapular nerve root distribution to produce an 8% impairment of the upper extremity which in turn is a 5% impairment of the whole person based on the AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition, stated with a reasonable degree of medical certainty.ime-qme-work comp etc., ama guide, evaluation of permanent impairment, impairment rating, permanent impairment, suprascapular nerve, suprascapular neuropathy, injured, extremity, shoulder, impairment, neuropathy, suprascapular,

PREOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,POSTOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,OPERATIONS PERFORMED,1. Left hip arthroscopic debridement.,2. Left hip arthroscopic femoral neck osteoplasty.,3. Left hip arthroscopic labral repair.,ANESTHESIA: , General.,OPERATION IN DETAIL: , The patient was taken to the operating room, where he underwent general anesthetic. His bilateral lower extremities were placed under traction on the Hana table. His right leg was placed first. The traction post was left line, and the left leg was placed in traction. Sterile Hibiclens and alcohol prep and drape were then undertaken. A fluoroscopic localization was undertaken. Gentle traction was applied. Narrow arthrographic effect was obtained. Following this, the ProTrac portal was made under the fluoro visualization, and then, a direct anterolateral portal made and a femoral neck portal made under direct visualization. The diagnostic arthroscopy showed the articular surface to be intact with a moderate anterior lip articular cartilage delamination injury that propagated into the acetabulum. For this reason, the acetabular articular cartilage was taken down and stabilized. This necessitated takedown of the anterior lip of the acetabulum and subsequent acetabular osteoplasty debridement with associated labral repair. The labrum was repaired using absorbable Smith & Nephew anchors with a sliding SMC knot. After stabilization of the labrum and the acetabulum, the ligamentum teres was assessed and noted to be stable. The remnant articular surface of the femoral artery and acetabulum was stable. The posterior leg was stable. The traction was left half off, and the anterolateral aspect of the head and neck junction was identified. A stable femoral neck decompression was accomplished starting laterally and proceeding anteriorly. This terminated with the hip coming out of traction and indeterminable flexion. A combination of burs and shavers was utilized to perform a stable femoral neck osteoplasty decompression. The decompression was completed with thorough irrigation of the hip. The cannula was removed, and the portals were closed using interrupted nylon. The patient was placed into a sterile bandage and anesthetized intraarticularly with 10 mL of ropivacaine subcutaneously with 20 mL of ropivacaine and at this point was taken to the recovery room. He tolerated the procedure very well with no signs of complications.surgery, labral repair, femoral neck osteoplasty, arthroscopic debridement, femoroacetabular impingement, arthroscopic, femoroacetabular, impingement, debridement, osteoplasty, acetabulum

PREOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2. Cervical spondylosis with herniated nucleus pulposus, C5-C6.,POSTOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2. Cervical spondylosis with herniated nucleus pulposus, C5-C6.,OPERATIVE PROCEDURES,1. Anterior cervical discectomy with decompression, C5-C6.,2. Arthrodesis with anterior interbody fusion, C5-C6.,3. Spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium).,4. Implant using PEEK 7 mm.,5. Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: ,1200 cc of crystalloids.,URINE OUTPUT: , No Foley catheter.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,INDICATIONS FOR THE OPERATION:, This is a case of a very pleasant 38-year-old Caucasian female who has been complaining over the last eight years of neck pain and shoulder pain radiating down across the top of her left shoulder and also across her shoulder blades to the right side, but predominantly down the left upper extremity into the wrist. The patient has been diagnosed with fibromyalgia and subsequently, has been treated with pain medications, anti-inflammatories and muscle relaxants. The patient's symptoms continued to persist and subsequently, an MRI of the C-spine was done, which showed disc desiccation, spondylosis and herniated disk at C5-C6, an EMG and CV revealed a presence of mild-to-moderate carpal tunnel syndrome. The patient is now being recommended to undergo decompression and spinal instrumentation and fusion at C5-C6. The patient understood the risks and benefits of the surgery. Risks include but not exclusive of bleeding and infection. Bleeding can be in the form of soft tissue bleeding, which may compromise airway for which she can be brought emergently back to the operating room for emergent evacuation of the hematoma as this may cause weakness of all four extremities, numbness of all four extremities, as well as impairment of bowel and bladder function. This could also result in dural tear with its attendant symptoms of headache, nausea, vomiting, photophobia, and posterior neck pain as well as the development of pseudomeningocele. Should the symptoms be severe or the pseudomeningocele be large, she can be brought back to the operating room for repair of the CSF leak and evacuation of the pseudomeningocele. There is also the risk of pseudoarthrosis and nonfusion, for which she may require redo surgery at this level. There is also the possibility of nonimprovement of her symptoms in about 10% of cases. The patient understands this risk on top of the potential injury to the esophagus and trachea as well as the carotid artery. There is also the risk of stroke, should an undiagnosed plaque be propelled into the right cerebral circulation. The patient also understands that there could be hoarseness of the voice secondary to injury to the recurrent laryngeal nerve. She understood these risks on top of the risks of anesthesia and gave her consent for the procedure.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room, awake, alert and not in any form of distress. After smooth induction and intubation, the patient was positioned supine on the operating table with the neck placed on hyperextension and the head supported on a foam doughnut. A marker was placed. This verified the level to be at the C5-C6 level and incision was then marked in a transverse fashion starting from the midline extending about 5 mm beyond the anterior border of the sternocleidomastoid muscle. The area was then prepped with DuraPrep after the head was turned 45 degrees to the left.,After sterile drapes were laid out, an incision was made using a scalpel blade #10. Wound edge bleeders were carefully controlled with bipolar coagulation and the platysma was cut using a hot knife in a transverse fashion. Dissection was then carried underneath the platysma superiorly inferiorly. The anterior border of the sternocleidomastoid was identified and dissection was carried out lateral to the esophagus to trachea as well as medial to the carotid sheath in the sternocleidomastoid muscle. The prevertebral fascia was noted to be taken her case with a lot of fat deposition. Bipolar coagulation of bleeders was done; however, branch of the superior thyroid artery was ligated with Hemoclips x4. After this was completed, a localizing x-ray verified the marker to be at the C6-C7 level. We proceeded to strip the longus colli muscles off the vertebral body of the C5 and C6. Self-retaining retractor was then laid down. An anterior osteophyte was carefully drilled using a Midas 5-mm bur and the disk together with the inferior endplate of C5 and the superior endplate of C6 was also drilled down with the Midas 5-mm bur. This was later followed with a 3-mm bur and the disk together with posterior longitudinal ligament was removed using Kerrison's ranging from 1 to 4 mm. The herniation was noted on the right. However, there was significant neuroforaminal stenosis on the left. Decompression on both sides was done and after this was completed, a Valsalva maneuver showed no evidence of any CSF leakage. The area was then irrigated with saline with bacitracin solution. A 7 mm implant with its inferior packed with Vitoss was then laid down and secured in place with four 14 x 4.0 mm screws and plate 18 mm, all of which were titanium. X-ray after this placement showed excellent position of all these implants and screws and _____ and the patient's area was also irrigated with saline with bacitracin solution. A round French 10 JP drain was then laid down and exteriorized through a separate stab incision on the patient's right inferiorly. The catheter was then anchored to the skin with a nylon 3-0 stitch and connected to a sterile draining system. The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl subcuticular 4-0 Stitch for the dermis, and the wound was reinforced with Dermabond. Dressing was placed only at the exit site of the catheter. C-collar was placed. The patient was extubated and transferred to recovery.nan

SUBJECTIVE:, The patient is a 76-year-old white female who presents to the clinic today originally for hypertension and a med check. She has a history of hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones. Since her last visit she has been followed by Dr. Kumar. Those issues are stable. She has had no fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure.,PAST MEDICAL HISTORY:, She has an intolerance to Prevacid.,CURRENT MEDICATIONS:, Evista 60 daily, Levothroid 0.05 mg daily, Claritin 10 daily, Celebrex 200 daily, HCTZ 25 daily and amitriptyline p.r.n.,PAST SURGICAL HISTORY:, Bilateral mastectomies, tonsillectomy, EGD, flex sig in 2001 and a heart cath.,FAMILY HISTORY: , Father passed away at 81; mother of multiple myeloma at 83.,SOCIAL HISTORY:, She is married. A 76-year-old who used to smoke a pack a day and quit in 1985. She is retired.,REVIEW OF SYSTEMS:, Essentially negative in HEENT, chest, cardiovascular, GI, GU, musculoskeletal, or neurologic.,OBJECTIVE:, Temperature is 97.5 degrees. Blood pressure is 168/70. Pulse is 88. Weight is 129 pounds.,GENERAL: She is an elderly 76-year-old in no acute distress.,HEENT: Atraumatic. Extraocular muscles were intact. Pupils equal, round and reactive to light and accommodation. Tympanic membranes are clear, dry and intact. Sinuses and throat are clear. Neck is soft, supple. No meningeal signs are present. No thyromegaly is present.,CHEST: Clear to auscultation.,CARDIOVASCULAR: Regular rate and rhythm without murmur.,ABDOMEN: Soft, nontender. Bowel sounds are positive. No organomegaly or peritoneal signs are present.,EXTREMITIES: Moving all extremities. Peripheral pulses are normal. No edema is present.,NEUROLOGIC: Alert and oriented. Cranial nerves II-XII grossly intact. Strength 5+/5 globally. Reflexes 2+/IV globally. Romberg is negative. There is no numbness, tingling, weakness or other neurologic deficit present.,BREASTS: Surgically absent but there are no lumps, lesions, masses, discharge or adenopathy present.,BACK: Straight.,SKIN: Clear.,GENITALIA: Deferred as she has been followed by Dr. XYZ many times this year. She does have a history of some elevated cholesterol.,ASSESSMENT:,1. Hypertension, suboptimal control.,2. Hypothyroidism.,3. Arthritis.,4. Allergic rhinitis.,5. History of kidney stones.,6. Osteoporosis.,PLAN:,1. CBC, complete metabolic profile, UA for hypertension.,2. Chest x-ray for history of breast cancer.,3. DEXA scan, full body for osteoporosis.,4. Flex is up to date.,5. Pneumovax has been given in the last five years.,6. Lipid profile for elevated cholesterol.,7. Refill meds.,8. Follow up every three to six months for blood pressure check or sooner p.r.n. problems.nan

PREOPERATIVE DIAGNOSES:,1. Chondromalacia patella.,2. Patellofemoral malalignment syndrome.,POSTOPERATIVE DIAGNOSES:,1. Grade-IV chondromalacia patella.,2. Patellofemoral malalignment syndrome.,PROCEDURE PERFORMED:,1. Diagnostic arthroscopy with partial chondroplasty of patella.,2. Lateral retinacular release.,3. Open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws.,ANESTHESIA:, General.,COMPLICATIONS: , None.,TOURNIQUET TIME: , Approximately 70 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , Grade-IV chondromalacia noted to the central and lateral facet of the patella. There was a grade II to III chondral changes to the patellar groove. The patella was noted to be displaced laterally riding on the edge of the lateral femoral condyle. The medial lateral meniscus showed small amounts of degeneration, but no frank tears were seen. The articular surfaces and the remainder of the knee appeared intact. Cruciate ligaments also appeared intact to direct stress testing.,HISTORY: ,This is a 36-year-old Caucasian female with a long-standing history of right knee pain. She has been diagnosed in the past with chondromalacia patella. She has failed conservative therapy. It was discussed with her the possibility of a arthroscopy lateral release and a tubercle transfer (anterior medialization of the tibial tubercle) to release stress from her femoral patellofemoral joint. She elected to proceed with the surgical intervention. All risks and benefits of the surgery were discussed with her. She was in agreement with the treatment plan.,PROCEDURE: , On 09/04/03, she was taken to Operating Room at ABCD General Hospital. She was placed supine on the operating table with the general anesthesia administered by the Anesthesia Department. Her leg was placed in a Johnson knee holder and sterilely prepped and draped in the usual fashion. A stab incision was made in inferolateral and parapatellar regions. Through this the cannula was placed and the knee was inflated with saline solution. Intraoperative pictures were obtained. The above findings were noted. Second portal site was initiated in the inferomedial parapatellar region. Through this, a arthroscopic shaver was placed and the chondroplasty in the patella was performed and removed the loose articular debris. Next, the camera was placed through the inferomedial portal. An arthroscopic Bovie was placed through the inferolateral portal. A release of lateral retinaculum was then performed using the Bovie. Hemostasis was controlled with electrocautery. Next, the knee was suctioned dry. An Esmarch was used to exsanguinate the lower extremity. Tourniquet was inflated to 325 mmHg. An oblique incision was made along the medial parapatellar region of the knee. The subcuticular tissues were carefully dissected and the hemostasis was again controlled with electrocautery. The retinaculum was then incised in line with the incision. The patellar tendon was identified. The lateral and medial border of the tibial tubercle were cleared of all soft tissue debris. Next, an osteotome was then used to cut the tibial tubercle to 45 degree angle leaving the base of the bone incision intact. The tubercle was then pushed anteriorly and medially decreasing her Q-angle and anteriorizing the tibial tubercle. It was then held in place with a Steinmann pin. Following this, a two 4.5 mm cannulated screws, partially threaded, were drilled in place using standard technique to help fixate the tibial tubercle. There was excellent fixation noted. The Q-angle was noted to be decreased to approximately 15 degrees. She was transferred approximately 1 cm in length. The wound was copiously irrigated and suctioned dry. The medial retinaculum was then plicated causing further medialization of the patella. The retinaculum was reapproximated using #0 Vicryl. Subcuticular tissue were reapproximated with #2-0 Vicryl. Skin was closed with #4-0 Vicryl running PDS suture. Sterile dressing was applied to the lower extremities. She was placed in a Donjoy knee immobilizer locked in extension. It was noted that the lower extremity was warm and pink with good capillary refill following deflation of the tourniquet. She was transferred to recovery room in apparent stable and satisfactory condition.,Prognosis of this patient is poor secondary to the advanced degenerative changes to the patellofemoral joint. She will remain in the immobilizer approximately six weeks allowing the tubercle to reapproximate itself to the proximal tibia.surgery, diagnostic arthroscopy, patellofemoral malalignment syndrome, cannulated, partial chondroplasty, retinacular, chondromalacia patella, tibial tubercle, patella, tubercle, arthroscopy, tourniquet, chondroplasty, chondromalacia, patellofemoral,

CHIEF COMPLAINT: ,Blood in toilet.,HISTORY: , Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet. They did not note any urine or stool in the toilet and the patient had no acute complaints. The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events. The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints. There is no other history provided by the nursing staff from XYZ. There apparently were no clots noted within there. She does not have a history of being on anticoagulants.,PAST MEDICAL HISTORY: , Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.,PAST SURGICAL HISTORY: ,Unknown.,SOCIAL HISTORY: , No tobacco or alcohol.,MEDICATIONS: , Listed in the medical records.,ALLERGIES:, No known drug allergies.,PHYSICAL EXAMINATION: , VITAL SIGNS: Stable.,GENERAL: This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress.,HEENT: Visually normal. Pupils are reactive. TMs, canals, nasal mucosa, and oropharynx are intact.,NECK: No lymphadenopathy or JVD.,HEART: Regular rate and rhythm. S1, S2. No murmurs, gallops, or rubs.,LUNGS: Clear to auscultation. No wheeze, rales, or rhonchi.,ABDOMEN: Benign, flat, soft, nontender, and nondistended. Bowel sounds active. No organomegaly or mass noted.,GU/RECTAL: External rectum was normal. No obvious blood internally. There is no stool noted within the vault. There is no gross amount of blood noted within the vault. Guaiac was done and was trace positive. Visual examination anteriorly during the rectal examination noted no blood within the vaginal region.,EXTREMITIES: No significant abnormalities.,WORKUP: , CT abdomen and pelvis was negative. CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%. CMP also within normal limits. PTT, PT, and INR were normal. Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization.,ER COURSE:, Uneventful. I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient. We have decided to send the patient back to XYZ with observation by the staff there. She will have a CBC done daily for the next 3 days with results to Dr. X. They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood.,ASSESSMENT: , Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.nan

IDENTIFYING DATA: , The patient is a 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.,CHIEF COMPLIANT: , "I'm here because I'm different." The patient exhibits poor insight into illness and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of bipolar affective disorder and poor outpatient compliance. According to mental health professionals, he had not been compliant with medications or outpatient followup, and over the past several weeks, the patient had become increasingly labile. The patient had expressed grandiose delusions that he is Martin Luther King, and was found recently at a local church agitated throwing a pew and a lectern and required Tasering by police. On admission interview, the patient remains euphoric with poor insight.,PAST PSYCHIATRIC HISTORY: , History of bipolar affective disorder. The patient has been treated with Depakote and Seroquel, but has had no recent treatment or followup. Dates of previous hospitalizations are not known.,PAST MEDICAL HISTORY: , None known.,CURRENT MEDICATIONS: , None.,FAMILY SOCIAL HISTORY: , Unemployed. The patient resides independently. The patient denies recent substance abuse, although tox screen was positive for benzodiazepines.,LEGAL HISTORY: , Need to increase database.,FAMILY PSYCHIATRIC HISTORY: , Need to increase database.,MENTAL STATUS EXAMINATION: ,Attitude: Suspicious, but cooperative.,Appearance: Shows appropriate hygiene and grooming.,Psychomotor Behavior: Within normal limits. No agitation or retardation. No EPS or TDS noted.,Affect: Labile.,Mood: Euphoric.,Speech: Pressured.,Thoughts: Disorganized.,Thought Content: Remarkable for grandiose delusions as noted. The patient denies auditory hallucinations.,Psychosis: Grandiose delusions as noted above.,Suicidal/Homicidal Ideation: The patient denies on admission.,Cognitive Assessment: Grossly intact. The patient is oriented x 3.,Judgment: Poor shown by noncompliance to the outpatient treatment.,Assets: Include stable physical status.,Limitations: Include recurrent psychosis.,FORMULATION: , The patient with a history of bipolar affective disorder, was admitted for increasing mood lability and noncompliance to the outpatient treatment.,INITIAL IMPRESSION:,AXIS I: BAD, manic with psychosis.,AXIS II: None.,AXIS III: None known.,AXIS IV: Severe.,AXIS V: 10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN: , The patient will be restarted on Depakote for mood lability and Seroquel for psychosis and his response will be monitored closely. The patient will be evaluated for more structural outpatient followup following stabilization.nan

REASON FOR CT SCAN: , The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan performed on January 16, 2008. I changed the shunt setting from 1.5 to 2.0 on February 12, 2008 and his family obtained this repeat CT scan to determine whether his subdural effusions were improving.,CT scan from 03/11/2008 demonstrates frontal horn span at the level of foramen of Munro of 2.6 cm. The 3rd ventricular contour which is flat with a 3rd ventricular span of 10 mm. There is a single shunt, which enters on the right occipital side and ends in the left lateral ventricle. He has symmetric bilateral subdurals that are less than 1 cm in breadth each, which is a reduction from the report from January 16, 2008, which states that he had a subdural hygroma, maximum size 1.3 cm on the right and 1.1 cm on the left.,ASSESSMENT: , The patient's subdural effusions are still noticeable, but they are improving at the setting of 2.0.,PLAN: , I would like to see the patient with a new head CT in about three months, at which time we can decide whether 2.0 is the appropriate setting for him to remain at or whether we can consider changing the shunt setting.radiology, ct scan, subdural, adult hydrocephalus, bilateral effusions, shunt setting, subdural effusions, hydrocephalus, ventricular, scan, ct,

PREOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS:, Acute hemorrhagic cholecystitis.,PROCEDURE PERFORMED: , Open cholecystectomy.,ANESTHESIA: , Epidural with local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN: ,Gallbladder.,BRIEF HISTORY: ,The patient is a 73-year-old female who presented to ABCD General Hospital on 07/23/2003 secondary to a fall at home from which the patient suffered a right shoulder as well as hip fracture. The patient subsequently went to the operating room on 07/25/2003 for a right hip hemiarthroplasty per the Orthopedics Department. Subsequently, the patient was doing well postoperatively, however, the patient does have severe O2 and steroid-dependent COPD and at an extreme risk for any procedure. The patient began developing abdominal pain over the course of the next several days and a consultation was requested on 08/07/2003 for surgical evaluation for upper abdominal pain. During the evaluation, the patient was found to have an acute acalculous cholecystitis in which nonoperative management was opted for and on 08/08/03, the patient underwent a percutaneous cholecystostomy tube placement to drain the gallbladder. The patient did well postdrainage. The patient's laboratory values and biliary values returned to normal and the patient was planned for a removal of the tube with 48 hours of the tubing clamp. However, once the tube was removed, the patient re-obstructed with recurrent symptoms and a second tube was needed to be placed; this was done on 08/16/2003. A HIDA scan had been performed, which showed no cystic duct obstruction. A tube cholecystogram was performed, which showed no cystic or common duct obstruction. There was abnormal appearance of the gallbladder, however, the pathway was patent. Thus after failure of two nonoperative management therapies, extensive discussions were made with the family and the patient's only option was to undergo a cholecystectomy. Initial thoughts were to do a laparoscopic cholecystectomy, however, with the patient's severe COPD and risk for ventilator management, the options were an epidural and an open cholecystectomy under local was made and to be performed.,INTRAOPERATIVE FINDINGS: ,The patient's gallbladder had some patchy and necrosis areas. There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder. The patient also had no plane between the gallbladder and the liver bed.,OPERATIVE PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and discussed with the patient's family. The patient was brought to the operating room after an epidural was performed per anesthesia. Local anesthesia was given with 1% lidocaine. A paramedian incision was made approximately 5 cm in length with a #15 blade scalpel. Next, hemostasis was obtained using electro Bovie cautery. Dissection was carried down transrectus in the midline to the posterior rectus fascia, which was grasped with hemostats and entered with a #10 blade scalpel. Next, Metzenbaum scissors were used to extend the incision and the abdomen was entered . The gallbladder was immediately visualized and brought up into view, grasped with two ring clamps elevating the biliary tree into view. Dissection with a ______ was made to identify the cystic artery and cystic duct, which were both easily identified. The cystic artery was clipped, two distal and one proximal to the gallbladder cutting between with Metzenbaum scissors. The cystic duct was identified. A silk tie #3-0 silk was placed one distal and one proximal with #3-0 silk and then cutting in between with a Metzenbaum scissors. The gallbladder was then removed from the liver bed using electro Bovie cautery. A plane was created. The hemostasis was obtained using the electro Bovie cautery as well as some Surgicel. The gallbladder was then removed as specimen, sent to pathology for frozen sections for diagnosis, of which the hemorrhagic cholecystitis was diagnosed on frozen sections. Permanent sections are still pending. The remainder of the fossa was hemostatic with the Surgicel and attention was next made to closing the abdomen. The peritoneum as well as posterior rectus fascia was approximated with a running #0 Vicryl suture and then the anterior rectus fascia was closed in interrupted figure-of-eight #0 Vicryl sutures. Skin staples were used on the skin and sterile dressings were applied and the patient was transferred to recovery in stable condition.gastroenterology, open cholecystectomy, hemorrhagic, gallbladder, serosal, liver bed, acute acalculous, acalculous cholecystitis, cystic duct, bovie cautery, rectus fascia, metzenbaum scissors, fascia, cholecystitis, cholecystectomy, cystic,

PREOPERATIVE DIAGNOSIS:, Osteomyelitis, right hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, right hallux.,PROCEDURE PERFORMED:, Amputation distal phalanx and partial proximal phalanx, right hallux.,ANESTHESIA:, TIVA/local.,HISTORY:, This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity. The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics, which he failed. The patient after a multiple conservative treatments such as wound care antibiotics, the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis. The patient desires to attempt a surgical correction. The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X. The consent was available on the chart for review.,PROCEDURE IN DETAIL: , After patient was taken to the operating room via cart and placed on the operating table in the supine position, a safety strap was placed across his waist. Adequate IV sedation was administered by the Department of Anesthesia and a total of 3.5 cc of 1:1 mixture 1% lidocaine and 0.5% Marcaine plain were injected into the right hallux as a digital block. The foot was prepped and draped in the usual aseptic fashion lowering the operative field.,Attention was directed to the hallux where there was a full-thickness ulceration to the distal tip of the hallux measuring 0.5 cm x 0.5 cm. There was a ________ tract, which probed through the distal phalanx and along the sides of the proximal phalanx laterally. The toe was 2.5 times to the normal size. There were superficial ulcerations in the medial arch of both feet secondary to history of a burn, which were not infected. The patient had dorsalis pedis and posterior tibial pulses that were found to be +2/4 bilaterally preoperatively. X-ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx. A #10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx. The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact. Next, the distal phalanx was disarticulated at the interphalangeal joint and removed. The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology. Next, the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected. Therefore, a sagittal saw was used to resect approximately 0.75 cm of the distal aspect of head of the proximal phalanx. This bone was also sent off for culture and was labeled proximal margin. Next, the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected. The flexor tendon distally was gray discolored and was not viable. A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally. None was found. No purulent drainage or abscess was found. The proximal margin of the surgical site tissue was viable and healthy. There was no malodor. Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology. Next, copious amounts of gentamicin and impregnated saline were instilled into the wound.,A #3-0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension. The plantar flap was viable and was debulked with Metzenbaum scissors. The flap was folded dorsally and reapproximated carefully with #3-0 nylon with a combination of simple interrupted and vertical mattress sutures. Iris scissors were used to modify and remodel the plantar flap. An excellent cosmetic result was achieved. No tourniquet was used in this case. The patient tolerated the above anesthesia and surgery without apparent complications. A standard postoperative dressing was applied consisting of saline-soaked Owen silk, 4x4s, Kerlix, and Coban. The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot. He will be readmitted to Dr. Katzman where we will continue to monitor his blood pressure and regulate his medications. Plan is to continue the antibiotics until further IV recommendations.,He will be nonweightbearing to the right foot and use crutches. He will elevate his right foot and rest the foot, keep it clean and dry. He is to follow up with Dr. X on Monday or Tuesday of next week.surgery, osteomyelitis, phalanx, phalanx amputation, proximal margin, plantar flap, distal phalanx, proximal phalanx, proximal, hallux, amputation, foot, plantarly, distal

PREOPERATIVE DIAGNOSIS:, Worrisome skin lesion, left hand.,POSTPROCEDURE DIAGNOSIS:, Worrisome skin lesion, left hand.,PROCEDURE:, The patient gave informed consent for his procedure. After informed consent was obtained, attention was turned toward the area of interest, which was prepped and draped in the usual sterile fashion.,Local anesthetic medication was infiltrated around and into the area of interest. There was an obvious skin lesion there and this gentleman has a history of squamous cell carcinoma. A punch biopsy of the worrisome skin lesion was obtained with a portion of the normal tissue included. The predominant portion of the biopsy was of the lesion itself.,Lesion was removed. Attention was turned toward the area. Pressure was held and the area was hemostatic.,The skin and the area were closed with 5-0 nylon suture. All counts were correct. The procedure was closed. A sterile dressing was applied. There were no complications. The patient had no neurovascular deficits, etc., after this minor punch biopsy procedure.,surgery, skin lesion, squamous cell carcinoma, punch biopsy,

PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Perforated Meckel's diverticulum.,PROCEDURES PERFORMED:,1. Diagnostic laparotomy.,2. Exploratory laparotomy.,3. Meckel's diverticulectomy.,4. Open incidental appendectomy.,5. Peritoneal toilet.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: ,300 ml.,URINE OUTPUT: , 200 ml.,TOTAL FLUID:, 1600 mL.,DRAIN:, JP x1 right lower quadrant and anterior to the rectum.,TUBES:, Include an NG and a Foley catheter.,SPECIMENS: , Include Meckel's diverticulum and appendix.,COMPLICATIONS: , Ventilator-dependent respiratory failure with hypoxemia following closure.,BRIEF HISTORY: , This is a 45-year-old Caucasian gentleman presented to ABCD General Hospital with acute onset of right lower quadrant pain that began 24 hours prior to this evaluation.,The pain was very vague and progressed in intensity. The patient has had anorexia with decrease in appetite. His physical examination revealed the patient to be febrile with the temperature of 102.4. He had right lower quadrant and suprapubic tenderness with palpation with Rovsing sign and rebound consistent with acute surgical abdomen. The patient was presumed acute appendicitis and was placed on IV antibiotics and recommended that he undergo diagnostic laparoscopy with possible open exploratory laparotomy. He was explained the risks, benefits, and complications of the procedure and gave informed consent to proceed.,OPERATIVE FINDINGS: , Diagnostic laparoscopy revealed purulent drainage within the region of the right lower quadrant adjacent to the cecum and terminal ileum. There was large amounts of purulent drainage. The appendix was visualized, however, it was difficult to be visualized secondary to the acute inflammatory process, purulent drainage, and edema. It was decided given the signs of perforation and purulent drainage within the abdomen that we would convert to an open exploratory laparotomy. Upon exploration of the ileum, there was noted to be a ruptured Meckel's diverticulum, this was resected. Additionally, the appendix appeared normal without evidence of perforation and/or edema and a decision to proceed with incidental appendectomy was performed. The patient was irrigated with copious amounts of warmth normal saline approximately 2 to 3 liters. The patient was closed and did develop some hypoxemia after closure. He remained ventilated and was placed on a large amount of ________. His hypoxia did resolve and he remained intubated and proceed to the Critical Care Complex or postop surgical care.,OPERATIVE PROCEDURE:, The patient was brought to the operative suite and placed in the supine position. He did receive preoperative IV antibiotics, sequential compression devices, NG tube placement with Foley catheter, and heparin subcutaneously. The patient was intubated by the Anesthesia Department. After adequate anesthesia was obtained, the abdomen was prepped and draped in the normal sterile fashion with Betadine solution. Utilizing a #10 blade scalpel, an infraumbilical incision was created. The Veress needle was inserted into the abdomen. The abdomen was insufflated to approximately 15 mmHg. A #10 mm ablated trocar was inserted into the abdomen and a video laparoscope was inserted and the abdomen was explored and the above findings were noted. A right upper quadrant 5 mm port was inserted to help with manipulation of bowel and to visualize the appendix. Decision was then made to convert to exploratory laparotomy given the signs of acute perforation. The instruments were then removed. The abdomen was then deflated. Utilizing ________ #10 blade scalpel, a midline incision was created from the xiphoid down to level of the pubic symphysis.,The incision was carried down with a #10 blade scalpel and the bleeding was controlled along the way with electrocautery. The posterior layer of the rectus fascia and peritoneum was opened carefully with the scissors as the peritoneum had already been penetrated during laparoscopy. Incision was carried down to the midline within the linea alba. Once the abdomen was opened, there was noted to be gross purulent drainage. The ileum was explored and there was noted to be a perforated Meckel's diverticulum. Decision to resect the diverticulum was performed.,The blood supply to the Meckel's diverticulum was carefully dissected free and a #3-0 Vicryl was used to tie off the blood supply to the Meckel's diverticulum. Clamps were placed to the proximal supply to the Meckel's diverticulum was tied off with #3-0 Vicryl sutures. The Meckel's diverticulum was noted to be completely free and was grasped anteriorly and utilizing a GIA stapling device, the diverticulum was transected. There was noted to be a hemostatic region within the transection and staple line looked intact without evidence of perforation and/or leakage. Next, decision was decided to go ahead and perform an appendectomy. Mesoappendix was doubly clamped with hemostats and cut with Metzenbaum scissors. The appendiceal artery was identified and was clamped between two hemostats and transected as well. Once the appendix was completely freed of the surrounding inflammation and adhesion. A plain gut was placed at the base of the appendix and tied down. The appendix was milked distally with a straight stat and clamped approximately halfway. A second piece of plain gut suture was used to ligate above and then was transected with a #10 blade scalpel. The appendiceal stump was then inverted with a pursestring suture of #2-0 Vicryl suture. Once the ________ was completed, decision to place a JP drain within the right lower quadrant was performed. The drain was positioned within the right lower quadrant and anterior to the rectum and brought out through a separate site in the anterior abdominal wall. It was sewn in place with a #3-0 nylon suture. The abdomen was then irrigated with copious amounts of warmed normal saline. The remainder of the abdomen was unremarkable for pathology. The omentum was replaced over the bowel contents and utilizing #1-0 PDS suture, the abdominal wall, anterior and posterior rectus fascias were closed with a running suture. Once the abdomen was completely closed, the subcutaneous tissue was irrigated with copious amounts of saline and the incision was closed with staples. The previous laparoscopic sites were also closed with staples. Sterile dressings were placed over the wound with Adaptic and 4x4s and covered with ABDs. JPs replaced with bulb suction. NG tube and Foley catheter were left in place. The patient tolerated this procedure well with exception of hypoxemia which resolved by the conclusion of the case.,The patient will proceed to the Critical Care Complex where he will be closely evaluated and followed in his postoperative course. To remain on IV antibiotics and we will manage ventilatory-dependency of the patient.nan

PREOPERATIVE DIAGNOSIS:, Left elbow with retained hardware.,POSTOPERATIVE DIAGNOSIS: , Left elbow with retained hardware.,PROCEDURE: , ,1. Left elbow manipulation.,2. Hardware removal of left elbow.,ANESTHESIA: ,Surgery was performed under general anesthesia.,COMPLICATIONS:, There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,INTRAOPERATIVE FINDING: , Preoperatively, the patient is 40 to 100 degrees range of motion with limited supination and pronation of about 20 degrees. We increased his extension and flexion to about 20 to 120 degrees and the pronation and supination to about 40 degrees.,LOCAL ANESTHETIC: ,10 mL of 0.25% Marcaine.,HISTORY AND PHYSICAL: , The patient is a 10-year-old right-hand dominant male, who threw himself off a quad on 10/10/2007. The patient underwent open reduction and internal fixation of his left elbow fracture dislocation. The patient also sustained a nondisplaced right glenoid neck fracture. The patient's fracture has healed without incident, although he had significant postoperative stiffness for which he is undergoing physical therapy, as well as use of a Dynasplint. The patient is neurologically intact distally. Given the fact that his fracture has healed, surgery was recommended for hardware removal to decrease his irritation with elbow extension from the hardware. Risks and benefits of the surgery were discussed. The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, continued postoperative stiffness. All questions were answered and the parents agreed to the above plan.,PROCEDURE: ,The patient was taken to the operating room and placed supine on the operating table. General anesthesia was then administered. The patient's left upper extremity was then prepped and draped in a standard surgical fashion. Using fluoroscopy, the patient's K-wire was located. An incision was made over his previous scar. A subcutaneous dissection then took place in the plane between the subcutaneous fat and muscles. The K-wires were easily palpable. A small incision was made into the triceps, which allowed for visualization of the two pins, which were removed without incident. The wound was then irrigated. The triceps split was now closed using #2-0 Vicryl. The subcutaneous tissue was also closed using #2-0 Vicryl and the skin with #4-0 Monocryl. The wound was clean and dry and dressed with Steri-Strips, Xeroform, and 4 x 4s, as well as bias. A total of 10 mL of 0.25% Marcaine was injected into the incision, as well as the joint line. At the beginning of the case, prior to removal of the hardware, the arm was taken through some strenuous manipulations with improvement of his extension to 20 degrees, flexion to 130 degrees and pronation supination to about 40 degrees.,DIAGNOSTIC IMPRESSION: ,The postoperative films demonstrated no fracture, no retained hardware. The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will restart physical therapy and Dynasplint in 3 days. The patient is to follow up in 1 week's time for a wound check. The patient was given Tylenol No. 3 for pain.orthopedic, k-wires, dynasplint, elbow manipulation, hardware removal, retained hardware, elbow, hardware,

PREOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Multiple strokes.,POSTOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Multiple strokes.,PROCEDURES PERFORMED:,1. Tracheostomy.,2. Thyroid isthmusectomy.,ANESTHESIA: , General endotracheal tube.,BLOOD LOSS: , Minimal, less than 25 cc.,INDICATIONS:, The patient is a 50-year-old gentleman who presented to the Emergency Department who had had multiple massive strokes. He had required ventilator assistance and was transported to the ICU setting. Because of the numerous deficits from the stroke, he is expected to have a prolonged ventilatory course and he will be requiring long-term care.,PROCEDURE: , After all risks, benefits, and alternatives were discussed with multiple family members in detail, informed consent was obtained. The patient was brought to the Operative Suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube. The neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt-tip marker. The skin was then anesthetized with a mixture of 1% lidocaine and 1:100,000 epinephrine solution. The patient was prepped and draped in usual fashion. The surgeons were gowned and gloved. A vertical skin incision was then made with a #15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage. Blunt dissection was then carried down until the fascia overlying the strap muscles were identified. At this point, the midline raphe was identified and the strap muscles were separated utilizing the Bovie cautery. Once the strap muscles have been identified, palpation was performed to identify any arterial aberration. A high-riding innominate was not identified. At this point, it was recognized that the thyroid gland was overlying the trachea could not be mobilized. Therefore, dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland, which was then doubly clamped and ligated with Bovie cautery. Suture ligation with #3-0 Vicryl was then performed on the thyroid gland in a double interlocking fashion. This cleared a significant portion of the trachea. The overlying pretracheal fascia was then cleared with use of pressured forceps as well as Bovie cautery. Now, a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea. The second tracheal ring was identified. The Bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based. At this point, the anesthetist was appropriately alerted to deflate the endotracheal tube cuff. The airway was entered and inferior to the base, window was created. The anesthetist then withdrew the endotracheal tube until the tip of the tube was identified. At this point, a #8 Shiley tracheostomy tube was inserted freely into the tracheal lumen. The balloon was inflated and the ventilator was attached. He was immediately noted to have return of the CO2 waveform and was ventilating appropriately according to the anesthetist. Now, all surgical retractors were removed. The baseplate of the tracheostomy tube was sutured to the patient's skin with #2-0 nylon suture. The tube was further secured around the patient's neck with IV tubing. Finally, a drain sponge was placed. At this point, procedure was felt to be complete. The patient was returned to the ICU setting in stable condition where a chest x-ray is pending.ent - otolaryngology, ventilator-dependent respiratory failure, multiple strokes, thyroid, thyroid isthmusectomy, ventilator dependent, respiratory failure, strap muscles, thyroid gland, endotracheal tube, cricoid cartilage, bovie cautery, tracheostomy, ventilator, strokes, cartilage, tracheal, isthmusectomy

REASON FOR CONSULTATION: , New murmur with bacteremia.,HISTORY OF PRESENT ILLNESS:, The patient is an 84-year-old female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever. The patient states that apart from the fever, she was having no other symptoms and denies any previous cardiac history. She denies any orthopnea or paroxysmal nocturnal dyspnea. Denies any edema, chest pain, palpitations, or syncope. She has had TIAs in the past, but none recently.,PAST MEDICAL HISTORY:, Significant for diabetes, hypertension, and TIA.,MEDICATIONS: , Include:,1. Acidophilus supplement.,2. Cholestyramine.,3. Creon 20 three times daily.,4. Diovan 160 mg twice daily.,6. Lantus 10 daily.,7. Norvasc 5 mg daily.,8. NovoLog 70/30, 10 units at 12 noon daily.,9. Pamelor 15 mL every evening.,10. Vitamin D3 one tablet weekly.,ALLERGIES: , THE PATIENT IS ALLERGIC TO CODEINE, COREG, AND VANCOMYCIN.,FAMILY HISTORY: ,The patient's daughter apparently has history of a murmur, but no diagnosis of congenital heart disease. The patient's father died in his 80s of CHF.,SOCIAL HISTORY: , The patient denies ever having smoked, denies any significant alcohol use, and lives with her daughter in Pasadena.,REVIEW OF SYSTEMS: , The patient has had fever and chills. She has also had some jaundice. Denies any nausea or vomiting. Denies any chest pain or abdominal pain. Denies orthopnea, paroxysmal nocturnal dyspnea or edema. She has had TIAs in the past, but denies any recent neurological symptoms such as motor weakness or focal sensory deficits. Denies melena or hematochezia. All other systems were reviewed and were found to be negative.,PHYSICAL EXAMINATION,GENERAL: An elderly Caucasian female, awake and alert, and in no distress.,VITAL SIGNS: Temperature is 98.8, heart rate 96, sinus, blood pressure 138/55, respiratory rate 20, and oxygen saturation 92%.,HEAD AND NECK: Her head is atraumatic. She is normocephalic. Her neck is supple. There is no JVD. No palpable adenopathy or thyromegaly. There is some icterus of the sclerae bilaterally. Oral mucosa is moist.,CHEST: Symmetrical expansion with normal percussion note. There are no inspiratory crackles or expiratory wheeze.,CARDIAC: Heart sounds S1 and S2 are regular. There is a 2/6 systolic murmur heard through the precordium. There is no gallop or rub. There is no palpable thrill or retrosternal lift.,ABDOMEN: Soft, nondistended, and nontender with normal bowel sounds. No audible bruits.,EXTREMITIES: No pitting edema, no clubbing, no cyanosis, and peripheral pulses are 2+.,NEUROLOGIC: She exhibits no focal motor or sensory findings.,LABORATORY DATA: , The patient's sodium was 133, potassium 2.8, chloride 99, bicarbonate 31, glucose 75, BUN 12, creatinine 0.8, calcium 8.6, total bilirubin 3.2, AST 63, and ALT 43. White count 5.4, hemoglobin 9.1, hematocrit 26.6, and platelet count 128,000. Lipase less than 10.,DIAGNOSTIC IMAGING: , The patient had a CT scan of the abdomen that demonstrated a pancreatic mass with biliary obstruction. Previous biliary stent was present.,EKG shows normal sinus rhythm. There are no acute ST-T changes.,ASSESSMENT: , This is an 84-year-old female with newly found murmur. No previous history of heart disease. This murmur has occurred in the setting of fever and bacteremia. The patient also has a pancreatic mass with jaundice, history of hypertension, and now has hyponatremia and hypokalemia.,PLAN: ,The patient should undergo an echocardiogram to assess for the possibility of endocarditis, which may be contributing to her symptoms. Blood pressure control should be maintained with Diovan and Norvasc. Potassium should be replaced, and hyponatremia should be on proactive.nan

PREOPERATIVE DIAGNOSIS:, Aortic stenosis.,POSTOPERATIVE DIAGNOSIS: ,Aortic stenosis.,PROCEDURES PERFORMED,1. Insertion of a **-mm Toronto stentless porcine valve.,2. Cardiopulmonary bypass.,3. Cold cardioplegia arrest of the heart.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 300 cc.,INTRAVENOUS FLUIDS: , 1200 cc of crystalloid.,URINE OUTPUT: , 250 cc.,AORTIC CROSS-CLAMP TIME: , **,CARDIOPULMONARY BYPASS TIME TOTAL: , **,PROCEDURE IN DETAIL:, After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next the neck, chest and legs were prepped and draped in the standard surgical fashion. We used a #10-blade scalpel to make a midline median sternotomy incision. Dissection was carried down to the left of the sternum using Bovie electrocautery. The sternum was opened with a sternal saw. The chest retractor was positioned. Next, full-dose heparin was given. The pericardium was opened. Pericardial stay sutures were positioned. After obtaining adequate ACT, we prepared to place the patient on cardiopulmonary bypass. A 2-0 double pursestring of Ethibond suture was placed in the ascending aorta. Through this was passed an aortic cannula connected to the arterial side of the cardiopulmonary bypass machine. Next a 3-0 Prolene pursestring was placed in the right atrial appendage. Through this was passed our venous cannula connected to the venous portion of the cardiopulmonary bypass machine. A 4-0 U-stitch was placed in the right atrium. A retrograde cardioplegia catheter was positioned at this site. Next, scissors were used to dissect out the right upper pulmonary vein. A 4-0 Prolene pursestring was placed in the right upper pulmonary vein. Next, a right-angle sump was placed at this position. We then connected our retrograde cardioplegia catheter to the cardioplegia solution circuit. Bovie electrocautery was used to dissect the interface between the aorta and pulmonary artery. The aorta was completely encircled. Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta. We then prepared to cross-clamp the aorta. We went down on our flows and cross-clamped the aorta. We backed up our flows. We then gave antegrade and retrograde cold blood cardioplegia solution circuit so as to arrest the heart. The patient had some aortic insufficiency so we elected, after initially arresting the heart, to open the aorta and transect it and then give direct ostial infusion of cardioplegia solution circuit. Next, after obtaining complete diastolic arrest of the heart, we turned our attention to exposing the aortic valve, and 4-0 Tycron sutures were placed in the commissures. In addition, a 2-0 Prolene suture was placed in the aortic wall so as to bring the aortic wall and root up into view. Next, scissors were used to excise the diseased aortic valve leaflets. Care was taken to remove all the calcium from the aortic annulus. We then sized up the aortic annulus which came out to be a **-mm stentless porcine Toronto valve. We prepared the valve. Next, we placed our proximal suture line of interrupted 4-0 Tycron sutures for the annulus. We started with our individual commissural stitches. They were connected to our valve sewing ring. Next, we placed 5 interrupted 4-0 Tycron sutures in a subannular fashion at each commissural position. After doing so, we passed 1 end of the suture through the sewing portion of the Toronto stentless porcine valve. The valve was lowered into place and all of the sutures were tied. Next, we gave another round of cold blood antegrade and retrograde cardioplegia. Next, we sewed our distal suture line. We began with the left coronary cusp of the valve. We ran a 5-0 RB needle up both sides of the valve. Care was taken to avoid the left coronary ostia. This procedure was repeated on the right cusp of the stentless porcine valve. Again, care was taken to avoid any injury to the coronary ostia. Lastly, we sewed our non-coronary cusp. This was done without difficulty. At this point we inspected our aortic valve. There was good coaptation of the leaflets, and it was noted that both the left and the right coronary ostia were open. We gave another round of cold blood antegrade and retrograde cardioplegia. The antegrade portion was given in a direct ostial fashion once again. We now turned our attention to closing the aorta. A 4-0 Prolene double row of suture was used to close the aorta in a running fashion. Just prior to closing, we de-aired the heart and gave a warm shot of antegrade and retrograde cardioplegia. At this point, we removed our aortic cross-clamp. The heart gradually regained its electromechanical activity. We placed 2 atrial and 2 ventricular pacing wires. We removed our aortic vent and oversewed that site with another 4-0 Prolene on an SH needle. We removed our retrograde cardioplegia catheter. We oversewed that site with a 5-0 Prolene. By now, the heart was de-aired and resumed normal electromechanical activity. We began to wean the patient from cardiopulmonary bypass. We then removed our venous cannula and suture ligated that site with a #2 silk. We then gave full-dose protamine. After knowing that there was no evidence of a protamine reaction, we removed the aortic cannula. We buttressed that site with a 4-0 Prolene on an SH needle. We placed a mediastinal chest tube and brought it out through the skin. We also placed 2 Blake drains, 1 in the left chest and 1 in the right chest, as the patient had some bilateral pleural effusions. They were brought out through the skin. The sternum was closed with #7 wires in an interrupted figure-of-eight fashion. The fascia was closed with #1 Vicryl. We closed the subcu tissue with 2-0 Vicryl and the skin with 4-0 PDS.cardiovascular / pulmonary, cardioplegia, toronto stentless porcine valve, tycron sutures, coronary ostia, porcine valve, retrograde cardioplegia, cardiopulmonary bypass, sutures, valve, insertion, toronto, aortic, stentless, chest, coronary, porcine, cardiopulmonary, prolene, atrial, bypass, heart, aorta,

HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old woman who reports that on the 30th of October 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic. I do not have the records from this hospital admission, but apparently the epidural was administered for approximately 14 to 18 hours. She was sitting up during the epidural.,She did not notice any difference in her lower extremities at the time she had the epidural; however, she reports that she was extremely sleepy and may not have been aware of any change in strength or sensation in her lower extremities at that time. She delivered on the 31st of October, by Cesarean section, because she had failed to progress and had pyrexia.,She also had a Foley catheter placed at that time. On the 1st of November 2008, they began to mobilize her and it was at that time that she first noticed that she could not walk. She was aware that she could not move her legs at all, and then within a few days, she was aware that she could move toes in the left foot but could not move her right foot at all. Since that time, there has been a gradual improvement in strength to the point that she now has limited movement in her left leg and severely restricted movement in her right leg. She is not able to walk by herself, and needs assistance to stand. She was discharged from hospital after the Cesarean section on the 3rd of November. Unfortunately, we do not have the records and we do not know what the discussion was between the anesthesiologist and the patient at the time of discharge. She was then seen at ABC Hospital on November 05, 2008. She had an MRI scan of her spine, which showed no evidence of an abnormality, specifically there were no cord changes and no evidence of a hematoma. She also had an EMG study at that time by Dr. X, which was abnormal but not diagnostic and this was repeated again in December. At the present time, she also complains of a pressure in both her legs and in her thighs. She complains that her right foot hurts and that she has some hyperesthesia there. She has been taking gabapentin to try to reduce the discomfort, although she is on a very low dose and the effect is minimal. She has no symptoms in her arms, her bowel and bladder function is normal, and her bulbar function is normal. There is no problem with her vision, swallowing, or respiratory function.,PAST MEDICAL HISTORY: , Unremarkable except as noted above. She has seasonal allergies.,CURRENT MEDICATIONS:, Gabapentin 300 mg b.i.d., Centrum once a day, and another multivitamin.,ALLERGIES: , She has no medication allergies, but does have seasonal allergies.,FAMILY HISTORY: , There is a family history of diabetes and hypertension. There is no family history of a neuropathy or other neurological disease. She has one child, a son, born on October 31, 2008.,SOCIAL HISTORY: , The patient is a civil engineer, who currently works from home. She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby. She does not smoke and does not drink and has never done either.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS: P 74, BP 144/75, and a pain score of 0.,GENERAL: Her general physical examination was unremarkable.,CARDIOVASCULAR: Normal first and second heart sound, regular pulse with normal volume.,RESPIRATORY: Unremarkable, both lung bases were clear, and respiration was normal.,GI: Unremarkable, with no organomegaly and normal bowel sounds.,NEUROLOGICAL EXAM:,MSE: The patient's orientation was normal, fund of knowledge was normal, memory was normal, speech was normal, calculation was normal, and immediate and long-term recall was normal. Executive function was normal.,CRANIAL NERVES: The cranial nerve examination II through XII was unremarkable. Both disks were normal, with normal retina. Pupils were equal and reactive to light. Eye movements were full. Facial sensation and strength was normal. Bulbar function was normal. The trapezius had normal strength.,MOTOR: Muscle tone showed a slight increase in tone in the lower extremities, with normal tone in the upper extremities. Muscle strength was 5/5 in all muscle groups in the upper extremities. In the lower extremities, the hip flexors were 1/5 bilaterally, hip extensors were 1/5 bilaterally, knee extension on the right was 1/5 and on the left was 3-/5, knee flexion was 2/5 on the right and 3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 on the left, foot plantar flexion was 4-/5 on the right and 4+/5 on the left, toe extension was 0/5 on the right and 4-/5 on the left, toe flexion was 4-/5 on the right and 4+/5 on the left.,REFLEXES: Reflexes in the upper extremities were 2+ bilaterally. In the lower extremities, they were 0 bilaterally at the knee and ankles. The abdominal reflexes were present above the umbilicus and absent below the umbilicus. The plantar responses were mute. The jaw reflex was normal.,SENSATION: Vibration was moderately decreased in the right great toe and was mildly decreased in the left great toe. There was a sensory level to light touch at approximately T7 posteriorly and approximately T9 anteriorly. There was a range of sensation, but clearly there was a decrease in sensation below this level but not complete loss of sensation. To pain, the sensory level is even less clear, but appeared to be at about T7 on the right side. In the lower extremities, there was a slight decrease in pin and light touch in the right great toe compared to the left. There was no evidence of allodynia or hyperesthesia. Joint position sense was mildly reduced in the right toe and normal on the left.,COORDINATION: Coordination for rapid alternating movements and finger-to-nose testing was normal. Coordination could not be tested in the lower extremities.,GAIT: The patient was unable to stand and therefore we were unable to test gait or Romberg's. There was no evidence of focal back tenderness.,REVIEW OF OUTSIDE RECORDS: , I have reviewed the records from ABC Hospital, including the letter from Dr. Y and the EMG report dated 12/17/2008 from Dr. X. The EMG report shows evidence of a lumbosacral polyradiculopathy below approximately T6. The lower extremity sensory responses are essentially normal; however, there is a decrease in the amplitude of the motor responses with minimal changes in latency. I do have the MRI of lumbar spine report from 11/06/2008 with and without contrast. This showed a minimal concentric disc bulge of L4-L5 without disc herniation, but was otherwise unremarkable. The patient brought a disc with a most recent MRI study; however, we were unable to open this on our computers. The verbal report is that the study was unremarkable except for some gadolinium enhancement in the lumbar nerve roots. A Doppler of the lower extremities showed no evidence of deep venous thrombosis in either lower extremity. Chest x-ray showed some scoliosis on the lumbar spine, curve to the left, but no evidence of other abnormalities. A CT pelvis study performed on November 07, 2008 showed some nonspecific fluid in the subcutaneous fat of the back, posterior to L4 and L5 levels; however, there were no pelvic masses or other abnormalities. We were able to obtain an update of the report from the MRI of the lumbar spine with and without contrast dated 12/30/2008. The complete study included the cervical, thoracic, and lumbar spine. There was diffuse enhancement of the nerve roots of the cauda equina that had increased in enhancement since prior exam in November. It was also reported that the patient was given intravenous methylprednisolone and this had had no effect on strength in her lower extremities.,IMPRESSION: , The patient has a condition that is temporarily related to the epidural injection she was given at the end of October 2008, prior to her Cesarean section. It appears she became aware of weakness within two days of the administration of the epidural, she was very tired during the epidural and may have missed some change in her neurological function. She was severely weak in both lower extremities, slightly worse on the right than the left. There has been some interval improvement in her strength since the beginning of November 2008. Her EMG study from the end of December is most consistent with a lumbosacral polyradiculopathy. The MRI findings of gadolinium enhancement in the lumbar nerve roots would be most consistent with an inflammatory radiculitis most likely related to the epidural anesthesia or administration of the epidural. There had been no response to IV methylprednisolone given to her at ABC. The issue of having a lumbar puncture to look for evidence of inflammatory cells or an elevated protein had been discussed with her at both ABC and by myself. The patient did not wish to consider a lumbar puncture because of concerns that this might worsen her condition. At the present time, she is able to stand with aid but is unable to walk. There is no evidence on her previous EMG of a demyelinating neuropathy.,RECOMMENDATIONS:,1. The diagnostic issues were discussed with the patient at length. She is informed that this is still early in the course of the problem and that we expect her to show some improvement in her function over the next one to two years, although it is unclear as to how much function she will regain.,2. She is strongly recommended to continue with vigorous physical therapy, and to continue with the plan to mobilize her as much as possible, with the goal of trying to get her ambulatory. If she is able to walk, she will need bilateral AFOs for her ankles, to improve her overall mobility. I am not prescribing these because at the present time she does not need them.,3. We discussed increasing the dose of gabapentin. The paresthesias that she has may indicate that she is actually regaining some sensory function, although there is a concern that as recovery continues, she may be left with significant neuropathic pain. If this is the case, I have advised her to increase her gabapentin dose from 300 mg b.i.d. gradually up to 300 mg four times a day and then to 600 mg to 900 mg four times a day. She may need other neuropathic pain medications as needed. She will determine whether her current symptoms are significant enough to require this increase in dosage.,4. The patient will follow up with Dr. Y and his team at ABC Hospital. She will also continue with physical therapy within the ABC system.nan

FINAL DIAGNOSES:, Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks. The patient underwent a 2-day induction. On the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress. During the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration. Secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication. There was a slightly enlarged blood loss at approximately 1200 mL, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees Fahrenheit temperature right at delivery. It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay. The patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees Fahrenheit. The maternal tachycardia resolved within a day. The patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns. The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20%. It should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively. Therefore, there was anemia but not an unexplained anemia.,PHYSICAL EXAMINATION ON DISCHARGE: , Includes the stable vital signs, afebrile state. An alert and oriented patient who is desirous at discharge. Full range of motion, all extremities; fully ambulatory. Pulse is regular and strong. Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus. The incision is beautiful and soft and nontender. There is scant lochia and there is minimal edema.,LABORATORY STUDIES: , Include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge.,FOLLOWUP: , For the patient includes pelvic rest, regular diet. Follow up with me in 1 to 2 weeks. Motrin 800 mg p.o. q.8h. p.r.n. cramps, Tylenol No. 3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d.obstetrics / gynecology, delivered pregnancy, fetal intolerance, induction, pelvic rest, low transverse cesarean section, cholestasis of pregnancy, cesarean section, pregnancy, fetal, tachycardia, cholestasis

EXAM: , Barium enema.,CLINICAL HISTORY: , A 4-year-old male with a history of encopresis and constipation.,TECHNIQUE: ,A single frontal scout radiograph of the abdomen was performed. A rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed via spot fluoroscopic images. A post-evacuation overhead radiograph of the abdomen was performed.,FINDINGS:, The scout radiograph demonstrates a nonobstructive gastrointestinal pattern. There are no suspicious calcifications seen or evidence of gross free intraperitoneal air. The visualized lung bases and osseous structures are within normal limits.,The rectum and colon is of normal caliber throughout its course. There is no evidence of obstruction, as contrast is seen to flow without difficulty into the right colon and cecum. A small amount of contrast is seen to opacify small bowel loops on the post-evacuation image. There is also opacification of a normal-appearing appendix documented.,IMPRESSION: , Normal barium enema.gastroenterology, encopresis and constipation, scout radiograph, post evacuation, barium enema, encopresis, constipation, evacuation, colon, radiograph, contrast, enema, barium,

PREOPERATIVE DIAGNOSES:,1. Depressed anterior table frontal sinus fracture on the right side.,2. Right nasoorbital ethmoid fracture.,3. Right orbital blowout fracture with entrapped periorbita.,4. Nasal septal and nasal pyramid fracture with nasal airway obstruction.,POSTOPERATIVE DIAGNOSES:,1. Depressed anterior table frontal sinus fracture on the right side.,2. Right nasoorbital ethmoid fracture.,3. Right orbital blowout fracture with entrapped periorbita.,4. Nasal septal and nasal pyramid fracture with nasal airway obstruction.,OPERATION:,1. Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus.,2. Transconjunctival exploration of right orbital floor with release of entrapped periorbita.,3. Open reduction of nasal septum and nasal pyramid fracture with osteotomy.,ANESTHESIA:, General endotracheal anesthesia.,PROCEDURE: , The patient was placed in the supine position. Under affects of general endotracheal anesthesia, head and neck were prepped and draped with pHisoHex solution and draped in the appropriate sterile fashion. A gull-wing incision was drawn over the forehead scalp. Hair was removed along the suture line and incision was made to skin and subcutaneous tissue of the scalp down to, but not including the pericranium. An inferiorly based forehead flap was then elevated to the superior orbital rim. The depression of the anterior table of the frontal sinus was noted. An incision was made more posterior creating an inferiorly based pericranial flap. The supraorbital nerve was axing from the supraorbital foramen and the supraorbital foramen was converted to a groove in order to allow further inferior displacement and positioning of the forehead flap. These allowed exposure of the medial orbital wall on the right side. The displaced fractures of the right medial orbital wall were repositioned through coronal approach. ,Further reduction of the nose intranasally also allowed the ethmoid fracture to be aligned more appropriately in the medial wall. The anterior table fracture was satisfactorily reduced. Multiple 1.3-mm screws and plate fixation were utilized to recontour the anterior forehead. A mucocele was removed from the frontal sinus and there was no significant destruction of the posterior wall. A sinus seeker was utilized and passed into the nasofrontal duct without difficulty. It was felt that the frontal sinus obliteration would not be necessary.,At this point, the pericranial flap was folded in a fan-folded fashion on top of the plate and screw and hardware and fixed in position with the sutures to remain better contour of the forehead. At this point, the nose was significantly shifted to the left and an open reduction of the nasal fracture was performed by osteotomies, which were made medially, laterally, and percutaneous transverse osteotomy of the nasal bone on the right side. There is significant depression of the nasal bone on the left side. A medial osteotomy was performed on the left side mobilizing nasal pyramid satisfactorily. There is a high septal deviation, which would not allow complete correction of the deviation. It was felt that this would best be left for a later date. Open reduction rhinoplasty could be performed with spread of cartilage grafting in order to straighten the septum high dorsally. Local infiltration anesthesia 1% Xylocaine with 1:100,000 epinephrine was infiltrated in the conjunctival fornix of the right lower eyelid as well as the inferior orbital rim. An incision was made in the palpebral conjunctiva and capsular palpebral fascia beneath the tarsal plate preseptal approach to the inferior orbital rim was performed in this fashion. Dissection proceeded down to the inferior orbital rim and subperiosteal dissection was performed over the orbital floor. Hemostasis was achieved with electrocautery. There was entrapped periorbita, which was released to the fractures, which were repositioned, but not fixed in position. The forced ductions were performed, which demonstrated release of the periorbit satisfactorily. The conjunctival incision was closed with an interrupted simple 6-0 plain gut suture. The nasal pyramid was satisfactorily mobilized as well as the nasal septum and brought back to midline position with the help of a Boies elevator for the septum. The coronal incision was closed with interrupted 3-0 PDS suture for the galea and deep subcutaneous tissue and the skin closed with interrupted surgical staples. Nose was dressed with Steri-Strips. Mastisol Orthoplast splint was prepared after the Doyle splints were placed in the nose and secured with 3-0 Prolene suture and the nose packed with two Kennedy Merocel sponges. A supportive mildly compressive dressing with fluffs, Kerlix, and 4-inch Ace were applied. The patient tolerated the procedure well and was returned to recovery room in satisfactory condition.surgery, frontal sinus, nasal septal, transconjunctival, anterior table, ethmoid, ethmoid fracture, gull-wing incision, nasal airway obstruction, nasal pyramid, nasoorbital, osteotomy, phisohex, periorbita, depressed anterior table, nasal pyramid fracture, sinus fractures, inferior orbital, pyramid fracture, entrapped periorbita, orbital, fractures, nasal, frontal, forehead, sinus,

REASON FOR EXAM: , Vegetation and bacteremia.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION: , The procedure and its complications were explained to the patient in detail and formal consent was obtained. The patient was brought to special procedure unit. His throat was anesthetized with lidocaine spray. Subsequently, 2 mg of IV Versed was given for sedation. The patient was positioned. Probe was introduced without any difficulty. The patient tolerated the procedure very well. Probe was taken out. No complications were noted. Findings are as mentioned below.,FINDINGS:,1. Left ventricle has normal size and dimensions with normal function. Ejection fraction of 60%.,2. Left atrium and right-sided chambers were of normal size and dimensions.,3. Left atrial appendage is clean without any clot or smoke effect.,4. Atrial septum is intact. Bubble study was negative.,5. Mitral valve is structurally normal.,6. Aortic valve reveals echodensity suggestive of vegetation.,7. Tricuspid valve was structurally normal.,8. Doppler reveals moderate mitral regurgitation and moderate-to-severe aortic regurgitation.,9. Aorta is benign.,IMPRESSION:,1. Normal left ventricular size and function.,2. Echodensity involving the aortic valve suggestive of endocarditis and vegetation.,3. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.cardiovascular / pulmonary, ventricle, atrium, atrial, septum, mitral valv, aortic valve, tricuspid valve, doppler, ventricular size, transesophageal echocardiogram, severe aortic, bacteremia, transesophageal, echocardiogram, echodensity, vegetation, valve, aortic,

PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES: , Rectal bleeding and perirectal abscess.,POSTOPERATIVE DIAGNOSIS: , Perianal abscess.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum. The preparation was excellent and all surfaces were well seen. The mucosa throughout the colon and in the terminal ileum was normal, with no evidence of colitis. Special attention was paid to the rectum, including retroflexed views of the distal rectum and the anorectal junction. There was no evidence of either inflammation or a fistulous opening. The scope was withdrawn. A careful exam of the anal canal and perianal area demonstrated a jagged 8-mm opening at the anorectal junction posteriorly (12 o'clock position). Some purulent material could be expressed through the opening. There was no suggestion of significant perianal reservoir of inflamed tissue or undrained material. Specifically, the posterior wall of the distal rectum and anal canal were soft and unremarkable. In addition, scars were noted in the perianal area. The first was a small dimpled scar, 1 cm from the anal verge in the 11 o'clock position. The second was a dimpled scar about 5 cm from the anal verge on the left buttock's cheek. There were no other abnormalities noted. The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Normal colonoscopy to the terminal ileum.,2. Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.,RECOMMENDATIONS:,1. Continue antibiotics.,2. Followup with Dr. X.,3. If drainage persists, consider surgical drainage.surgery, olympus, colonoscope, rectal bleeding, perianal abscess, terminal ileum, anal verge, anorectal, fistulous, ileum, verge, rectum, anal, perianal, colonoscopy, abscess

PROCEDURE:, Subcutaneous ulnar nerve transposition.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. Dissection was carried down to the ulnar nerve. Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected.,Osborne's fascia was released, an ulnar neurolysis performed, and the ulnar nerve was mobilized. Six cm of the medial intermuscular septum was excised, and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly.,The subcutaneous plane just superficial to the flexor-pronator mass was developed. Meticulous hemostasis was maintained with bipolar electrocautery. The nerve was transposed anteriorly, superficial to the flexor-pronator mass. Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve.,A semicircular medially based flap of flexor-pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating. The subcutaneous tissue and skin were closed with simple interrupted sutures. Marcaine with epinephrine was injected into the wound. The elbow was dressed and splinted. The patient was awakened and sent to the recovery room in good condition, having tolerated the procedure well.neurosurgery, neurolysis, ulnar, periosteal, flexor-pronator mass, ulnar nerve transposition, medial intermuscular septum, nerve transposition, intermuscular septum, flexor pronator, ulnar nerve, nerve

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.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,

CHILD PHYSICAL EXAMINATION,VITAL SIGNS: Birth weight is ** grams, length **, occipitofrontal circumference **. Character of cry was lusty.,GENERAL APPEARANCE: Well.,BREATHING: Unlabored.,SKIN: Clear. No cyanosis, pallor, or icterus. Subcutaneous tissue is ample.,HEAD: Normal. Fontanelles are soft and flat. Sutures are opposed.,EYES: Normal with red reflex x2.,EARS: Patent. Normal pinnae, canals, TMs.,NOSE: Patent nares.,MOUTH: No cleft.,THROAT: Clear.,NECK: No masses.,CHEST: Normal clavicles.,LUNGS: Clear bilaterally.,HEART: Regular rate and rhythm without murmur.,ABDOMEN: Soft, flat. No hepatosplenomegaly. The cord is three vessel.,GENITALIA: Normal ** genitalia **with testes descended bilaterally.,ANUS: Patent.,SPINE: Straight and without deformity.,EXTREMITIES: Equal movements.,MUSCLE TONE: Good.,REFLEXES: Moro, grasp, and suck are normal.,HIPS: No click or clunk.consult - history and phy., child physical examination, physical, genitalia, child,

REASON FOR CONSULTATION: ,Abnormal echocardiogram findings and followup. Shortness of breath, congestive heart failure, and valvular insufficiency.,HISTORY OF PRESENT ILLNESS: ,The patient is an 86-year-old female admitted for evaluation of abdominal pain and bloody stools. The patient has colitis and also diverticulitis, undergoing treatment. During the hospitalization, the patient complains of shortness of breath, which is worsening. The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion. This consultation is for further evaluation in this regard. As per the patient, she is an 86-year-old female, has limited activity level. She has been having shortness of breath for many years. She also was told that she has a heart murmur, which was not followed through on a regular basis.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, nonsmoker, cholesterol status unclear, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY: ,Nonsignificant.,PAST SURGICAL HISTORY: , No major surgery.,MEDICATIONS: , Presently on Lasix, potassium supplementation, Levaquin, hydralazine 10 mg b.i.d., antibiotic treatments, and thyroid supplementation.,ALLERGIES: ,AMBIEN, CARDIZEM, AND IBUPROFEN.,PERSONAL HISTORY:, She is a nonsmoker. Does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: ,Basically GI pathology with diverticulitis, colitis, hypothyroidism, arthritis, questionable hypertension, no prior history of coronary artery disease, and heart murmur.,REVIEW OF SYSTEMS,CONSTITUTIONAL: Weakness, fatigue, and tiredness.,HEENT: History of cataract, blurred vision, and hearing impairment.,CARDIOVASCULAR: Shortness of breath and heart murmur. No coronary artery disease.,RESPIRATORY: Shortness of breath. No pneumonia or valley fever.,GASTROINTESTINAL: No nausea, vomiting, hematemesis, or melena.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: Arthritis and severe muscle weakness.,SKIN: Nonsignificant.,NEUROLOGICAL: No TIA or CVA. No seizure disorder.,ENDOCRINE/HEMATOLOGICAL: As above.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 84, blood pressure of 168/74, afebrile, and respiratory rate 16 per minute.,HEENT/NECK: Head is atraumatic and normocephalic. Neck veins flat. No significant carotid bruits appreciated.,LUNGS: Air entry bilaterally fair. No obvious rales or wheezes.,HEART: PMI displaced. S1, S2 with systolic murmur at the precordium, grade 2/6.,ABDOMEN: Soft and nontender.,EXTREMITIES: Chronic skin changes. Feeble pulses distally. No clubbing or cyanosis.,DIAGNOSTIC DATA: , EKG: Normal sinus rhythm. No acute ST-T changes.,Echocardiogram report was reviewed.,LABORATORY DATA:, H&H 13 and 39. BUN and creatinine within normal limits. Potassium within normal limits. BNP 9290.,IMPRESSION:,1. The patient admitted for gastrointestinal pathology, under working treatment.,2. History of prior heart murmur with echocardiogram findings as above. Basically revealed normal left ventricular function with left atrial enlargement, large pleural effusion, and severe mitral regurgitation and tricuspid regurgitation.,RECOMMENDATIONS:,1. From cardiac standpoint, conservative treatment. Possibility of a transesophageal echocardiogram to assess valvular insufficiency adequately well discussed extensively.,2. After extensive discussion, given her age 86, limited activity level, and no intention of undergoing any treatment in this regard from a surgical standpoint, the patient does not wish to proceed with a transesophageal echocardiogram.,3. Based on the above findings, we will treat her medically with ACE inhibitors and diuretics and see how she fares. She has a normal LV function.nan

PREOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Hiatal hernia.,POSTOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Hiatal hernia.,3. Enterogastritis.,PROCEDURE PERFORMED: ,Esophagogastroduodenoscopy, photography, and biopsy.,GROSS FINDINGS: , The patient has a history of epigastric abdominal pain, persistent in nature. She has a history of severe gastroesophageal reflux disease, takes Pepcid frequently. She has had a history of hiatal hernia. She is being evaluated at this time for disease process. She does not have much response from Protonix.,Upon endoscopy, the gastroesophageal junction is approximately 40 cm. There appeared to be some inflammation at the gastroesophageal junction and a small 1 cm to 2 cm hiatal hernia. There is no advancement of the gastric mucosa up into the lower one-third of the esophagus. However there appeared to be inflammation as stated previously in the gastroesophageal junction. There was some mild inflammation at the antrum of the stomach. The fundus of the stomach was within normal limits. The cardia showed some laxity to the lower esophageal sphincter. The pylorus is concentric. The duodenal bulb and sweep are within normal limits. No ulcers or erosions.,OPERATIVE PROCEDURE: , The patient is taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position. The patient was given IV sedation using Demerol and Versed. Olympus videoscope was inserted into the hypopharynx and upon deglutition passed into the esophagus. Using air insufflation, panendoscope was advanced down the esophagus into the stomach along the greater curvature of the stomach through the pylorus into the duodenal bulb and sweep and the above gross findings were noted. Panendoscope was slowly withdrawn carefully examining the lumen of the bowel. Photographs were taken with the pathology present. Biopsy was obtained of the antrum of the stomach and also CLO test. The biopsy is also obtained of the gastroesophageal junction at 12, 3, 6 and 9 o' clock positions to rule out occult Barrett's esophagitis. Air was aspirated from the stomach and the panendoscope was removed. The patient sent to recovery room in stable condition.gastroenterology, biopsy, gastroesophageal reflux, gastroesophageal reflux disease, duodenal bulb, gastroesophageal junction, hiatal hernia, enterogastritis, endoscopy, esophagogastroduodenoscopy, gastroesophageal,

CC:, Episodic mental status change and RUE numbness, and chorea (found on exam).,HX:, This 78y/o RHM was referred for an episode of unusual behavior and RUE numbness. In 9/91, he experienced near loss of consciousness, generalized weakness, headache and vomiting. Evaluation at that time revealed an serum glucose of >500mg/dL and he was placed on insulin therapy with subsequent resolution of his signs and symptoms. Since then, he became progressively more forgetful, and at the time of evaluation, 1/17/93, had lost his ability to perform his job repairing lawn mowers. His wife had taken over the family finances.,He had also been "stumbling," when ambulating, for 2 months prior to presentation. He was noted to be occasionally confused upon awakening for last several months. On 1/15/93, he was lying on a couch when he suddenly began throwing pillows and blankets for no apparent reason. There had been no change in sleep, appetite, or complaint of depression.,In addition, for two months prior to presentation, he had been experiencing 10-15minute episodes of RUE numbness. There was no face or lower extremity involvement.,During the last year he had developed unusual movements of his extremities.,MEDS:, NPH Humulin 12U qAM and 6U qPM. Advil prn.,PMH:, 1) Traumatic amputation of the 4th and 5th digits of his left hand. 2) Hospitalized for an unknown "nervous" condition in the 1940's.,SHX/FHX:, Retired small engine mechanic who worked in a poorly ventilated shop. Married with 13 children. No history of ETOH, Tobacco or illicit drug use. Father had tremors following a stroke. Brother died of brain aneurysm. No history of depression, suicide, or Huntington's disease in family.,ROS:, no history of CAD, Renal or liver disease, SOB, Chest pain, fevers, chills, night sweats or weight loss. No report of sign of bleeding.,EXAM:, BP138/63 HR65 RR15 36.1C,MS: Alert and oriented to self, season; but not date, year, or place. Latent verbal responses and direction following. Intact naming, but able to repeat only simple but not complex phrases. Slowed speech, with mild difficulty with word finding. 2/3 recall at one minute and 0/3 at 3 minutes. Knew the last 3 presidents. 14/27 on MMSE: unable to spell "world" backwards. Unable to read/write for complaint of inability to see without glasses.,CN: II-XII appeared grossly intact. EOM were full and smooth and without unusual saccadic pursuits. OKN intact. Choreiform movements of the tongue were noted.,Motor: 5/5 strength throughout with Guggenheim type resistance. there were choreiform type movements of all extremities bilaterally. No motor impersistence noted.,Sensory: unreliable.,Cord: "normal" FNF, HKS, and RAM, bilaterally.,Station: No Romberg sign.,Gait: unsteady and wide-based.,Reflexes: BUE 2/2, Patellar 2/2, Ankles Trace/Trace, Plantars were flexor bilaterally.,Gen Exam: 2/6 Systolic ejection murmur in aortic area.,COURSE:, No family history of Huntington's disease could be elicited from relatives. Brain CT, 1/18/93: bilateral calcification of the globus pallidi and a high attenuation focus in the right occipital lobe thought to represent artifact. Carotid duplex, 1/18/93: RICA 0-15%, LICA 16-49% stenosis and normal vertebral artery flow bilaterally. Transthoracic Echocardiogram (TTE),1/18/93: revealed severe aortic fibrosis or valvular calcification with "severe" aortic stenosis in the face of "normal" LV function. Cardiology felt the patient the patient had asymptomatic aortic stenosis. EEG, 1/20/93, showed low voltage Delta over the left posterior quadrant and intermittent background slowing over the same region consistent with focal dysfunction in this quadrant. MRI Brain, 1/22/93: multiple focal and more confluent areas of increased T2 signal in the periventricular white matter, more prominent on the left; in addition, there were irregular shaped areas of increased T2 signal and decreased T1 signal in both cerebellar hemispheres; and age related atrophy; incidentally, there is a cavum septum pellucidum et vergae and mucosal thickening of the maxillary sinuses. Impression: diffuse bilateral age related ischemic change, age related atrophy and maxillary sinus disease. There were no masses or areas of abnormal enhancement. TSH, FT4, Vit B12, VDRL, Urine drug and heavy metal screens were unremarkable. CSF,1/19/93: glucose 102 (serum glucose 162mg/dL), Protein 45mg/dL, RBC O, WBC O, Cultures negative. SPEP negative. However serum and CSF beta2 microglobulin levels were elevated at 2.5 and 3.1mg/L, respectively. Hematology felt these may have been false positives. CBC, 1/17/93: Hgb 10.4g/dL (low), HCT 31% (low), RBC 3/34mil/mm3 (low), WBC 5.8K/mm3, Plt 201K/mm3. Retic 30/1K/mm3 (normal). Serum Iron 35mcg/dL (low), TIBC 201mcg/dL (low), FeSat 17% (low), CRP 0.1mg/dL (normal), ESR 83mm/hr (high). Bone Marrow Bx: normal with adequate iron stores. Hematology felt the finding were compatible with anemia of chronic disease. Neuropsychologic evaluation on 1/17/93 revealed significant impairments in multiple realms of cognitive function (visuospatial reasoning, verbal and visual memory, visual confrontational naming, impaired arrhythmatic, dysfluent speech marked by use of phrases no longer than 5 words, frequent word finding difficulty and semantic paraphasic errors) most severe for expressive language, attention and memory. The pattern of findings reveals an atypical aphasia suggestive of left temporo-parietal dysfunction. The patient was discharged1/22/93 on ASA 325mg qd. He was given a diagnosis of senile chorea and dementia (unspecified type). 6/18/93 repeat Neuropsychological evaluation revealed moderate decline in all areas tested reflecting severe dementia.radiology, episodic mental status change, huntington's disease, brain ct, transthoracic echocardiogram, carotid duplex, mental status change, ct brain, basal ganglia, mental status, globus pallidi, aortic stenosis, maxillary sinuses, rue numbness, basal, ganglia, globus, pallidi, therapy, chorea, ct, rue, brain,

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.surgery, hyperpyrexia, leukocytosis, ventilator-dependen, respiratory failure, pancreatitis, brachial artery, arterial catheter, subclavian vein, triple lumen catheter, catheter, brachial, needle,

CC:, Fall and laceration.,HPI: , Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk. He denies loss of consciousness but says he was dazed for a while after it happened. He complains of pain over the chin and right forehead where he has abrasions. He denies neck pain, back pain, extremity pain or pain in the abdomen.,PMH: , Hypertension.,MEDS:, None.,ROS: , As above. Otherwise negative.,PHYSICAL EXAM: , This is a gentleman in full C-spine precautions on a backboard brought by EMS. He is in no apparent distress. ,Vital Signs: BP 165/95 HR 80 RR 12 Temp 98.4 SpO2 95% ,HEENT: No palpable step offs, there is blood over the right fronto-parietal area where there is a small 1cm laceration and surrounding abrasion. Also, 2 cm laceration over the base of the chin without communication to the oro-pharynx. No other trauma noted. No septal hematoma. No other facial bony tenderness. ,Neck: Nontender ,Chest: Breathing comfortably; equal breath sounds. ,Heart: Regular rhythm.,Abd: Benign.,Ext: No tenderness or deformity; pulses are equal throughout; good cap refill ,Neuro: Awake and alert; slight slurring of speech and cognitive slowing consistent with alcohol; moves all extremities; cranial nerves normal. ,COURSE IN THE ED:, Patient arrived and was placed on monitors. An IV had been placed in the field and labs were drawn. X-rays of the C spine show no fracture and I've removed the C-collar. The lacerations were explored and no foreign body found. They were irrigated and closed with simple interrupted sutures. Labs showed normal CBC, Chem-7, and U/A except there was moderate protein in the urine. The blood alcohol returned at 0.146. A banana bag is ordered and his care will be turned over to Dr. G for further evaluation and care.emergency room reports, loss of consciousness, laceration, fall, course in the ed, placed on monitors, fell and struck, abrasions,

HISTORY OF INJURY AND PRESENT COMPLAINTS: , The patient is a 59-year-old gentleman. He is complaining chiefly of persistent lower back pain. He states the pain is of a rather constant nature. He describes it as a rather constant dull ache, sometimes rather sharp and stabbing in nature, most localized to the right side of his back more so than the left side of his lower back. He states he has difficulty with prolonged standing or sitting. He can only stand for about 5-10 minutes, then he has to sit down. He can only sit for about 15-20 minutes, he has to get up and move about because it exacerbates his back pain. He has difficulty with bending and stooping maneuvers. He describes an intermittent radiating pain down his right leg, down from the right gluteal hip area to the back of the thigh to the calf and the foot. He gets numbness along the lateral aspect of the foot itself. He also describes chronic pain complaints with associated tension in the back of his neck. He states the pain is of a constant nature in his neck. He states he gets pain that radiates into the right shoulder girdle area and the right forearm. He describes some numbness along the lateral aspect of the right forearm. He states he has trouble trying to use his arm at or above shoulder height. He has difficulty pushing, pulling, gripping, and grasping with the right upper extremity. He describes pain at the anterior aspect of his shoulder, in particular. He denies any headache complaints. He is relating his above complaints to two industrial injuries that he sustained while employed with Frito Lay Company as a truck driver or delivery person. He relates an initial injury that occurred on 06/29/1994, when apparently he was stepping out of the cab of his truck. He lost his footing and fell. He reached out to grab the hand railing. He fell backwards on his back and his right shoulder. He had immediate onset of shoulder pain, neck pain, and low back pain. He had pain into his right leg. He initially came under the care of Dr. H, an occupational physician in Modesto. Initially, he did not obtain any MRIs or x-rays. He did undergo some physical therapy and received some medications. Dr. H referred him to Dr. Q, a chiropractor for three visits, which the patient was not certain was very helpful. The patient advises he then changed treating physicians to Dr. N, D.C., whom he had seen previously for some back pain complaints back in 1990. He felt that the chiropractic care was helping his back, neck, and shoulder pain complaints somewhat. He continues with rather persistent pain in his right shoulder. He underwent an MRI of the right shoulder performed on 08/16/1994 which revealed prominent impingement with biceps tenosynovitis as well as supraspinatus tendonitis superimposed by a small pinhole tear of the rotator cuff. The patient was referred to Dr. P, an orthopedic surgeon who suggested some physical therapy for him and some antiinflammatories. He felt that the patient might require a cortisone injection or possibly a surgical intervention. The patient also underwent an MRI of the cervical spine on 08/03/1994, which again revealed multilevel degenerative disc disease in his neck. There is some suggestion of bilateral neuroforaminal encroachment due to degenerative changes and disc bulges, particularly at C5-6 and C6-7 levels. The patient was also seen by Dr. P, a neurologist for a Neurology consult. It is unclear to me as to whether or not Dr. P had performed an EMG or nerve conduction studies of his upper or lower extremities. The patient was off work for approximately six months following his initial injury date that occurred on 06/29/1994. He returned back to regular duty. Dr. N declared him permanent and stationary on 04/04/1995. The patient then had a recurrence or flare-up or possibly new injury, again, particularly to his lower back while working for Frito Lay on 03/29/1997, when he was loading some pallets on the back of a trailer. At that time, he returned to see Dr. N for chiropractic care, who is his primary treating physician. Dr. N took him off work again. He was off work again for approximately another six months, during which time, he was seen by Dr. M, M.D., a neurosurgeon. He had a new MRI of his lumbar spine performed. The MRI was performed on 05/20/1997. It revealed L4-5 disc space narrowing with prominent disc bulge with some mild spinal stenosis. The radiologist had noted he had a prior disc herniation at this level with some improvement from prior exam. Dr. M saw him on 09/18/1997 and noted that there was some improvement in his disc herniation at the L4-5 level following a more recent MRI exam of 05/20/1997, from previous MRI exam of 1996 which revealed a rather prominent right-sided L4-5 disc herniation. Dr. M felt that there was no indication for a lumbar spine surgery, but he mentioned with regards to his cervical spine, he felt that EMG studies of the right upper extremity should be obtained and he may require a repeat MRI of the cervical spine, if the study was positive. The patient did undergo some nerve conduction studies of his lower extremities with Dr. K, M.D., which suggested a possible abnormal EMG with evidence of possible L5 radiculopathy, both right and left. Unfortunately, I had no medical reports from Dr. P suggesting that he may have performed nerve conduction studies or EMGs of the upper and lower extremities. The patient did see Dr. R for a neurosurgical consult. Dr. R evaluated both his neck and lower back pain complaints on several occasions. Dr. R suggested that the patient try some cervical epidural steroid injections and lumbar selective nerve root blocks. The patient underwent these injections with Dr. K. The patient reported only very slight relief temporarily with regards to his back and leg symptoms following the injections. It is not clear from the medical record review whether the patient ever had a cervical epidural steroid injection; it appears that he had some selective nerve root blocks performed in the lumbar spine. Dr. R on 12/15/2004 suggested that the patient had an MRI of the cervical spine revealing a right-sided C5-6 herniated nucleus pulposus which would explain his C-6 distribution numbness. The patient also was noted to have a C4-5 with rather severe degenerative disc disease. He felt the patient might be a candidate for a two-level ACDF at C4-5 and C5-6. Dr. R in another report of 08/11/2004 suggested that the patient's MRI of 05/25/2004 of the lumbar spine reveals multilevel degenerative disc disease. He had an L4-5 slight anterior spondylolisthesis, this may be a transitional vertebrae at the L6 level as well, with lumbarization of S1. He felt that his examination suggested a possible right S1 radiculopathy with discogenic back pain. He would suggest right-sided S1 selective nerve root blocks to see if this would be helpful; if not, he might be a candidate for a lumbar spine fusion, possibly a Dynesys or a fusion or some major spine surgery to help resolve his situation., ,The patient relates that he really prefers a more conservative approach of treatment regarding his neck, back, and right shoulder symptoms. He continued to elect chiropractic care which he has found helpful, but apparently the insurance carrier is no longer authorizing chiropractic care for him. He is currently taking no medications to manage his pain complaints. He states regarding his work status, he was off work again for another six months following the 03/29/1997 injury. He returned back to work and continued to work regular duty up until about a year ago, at which time, he was taken back off work again and placed on TTD status by Dr. N, his primary treating physician. The patient states he has not been back to work since. He has since applied for social security disability and now is receiving social security disability benefits. The patient states he has tried some Myox therapy with Dr. H on 10 sessions, which he found somewhat helpful. Overall, the patient does not feel that he could return back to his usual and customary work capacity as a delivery driver for Frito Lay.,nan

PROCEDURES,1. Arthroscopic rotator cuff repair.,2. Arthroscopic subacromial decompression.,3. Arthroscopic extensive debridement, superior labrum anterior and posterior tear.,PROCEDURE IN DETAIL: , After written consent was obtained from the patient, the patient was brought back into the operating room and identified. The patient was placed on the operating room table in supine position and given general anesthetic. Once the patient was under general anesthetic, a careful examination of the shoulder was performed. It revealed no patholigamentous laxity. The patient was then carefully positioned into a beach-chair position. We maintained the natural alignment of the head, neck, and thorax at all times. The shoulder and upper extremity was then prepped and draped in the usual sterile fashion.,Once we fully prepped and draped, we then began the surgery. We injected the glenohumeral joint with sterile saline with a spinal needle. This consisted of 60 cc of fluid. We then made a posterior incision for our portal, 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion. Through this incision, a blunt trocar and cannula were placed in the glenohumeral joint. Through the cannula, a camera was placed; and the shoulder was insufflated with sterile saline through a preoperative feed. We then carefully examined the glenohumeral joint.,We found the articular surface to be in good condition. There was a superior labral tear (SLAP). This was extensively debrided using a shaver through an anterior portal. We also found a full thickness rotator cuff tear. We then drained the glenohumeral joint. We redirected our camera into the subacromial space. An anterolateral portal was made, both superior and inferior.,We then proceeded to perform a subacromial decompression using high-speed shaver. The bursa was extensively debrided. We then abraded the bone over the footprint of where the rotator cuff is usually attached. The corkscrew anchors were used to perform a rotator cuff repair. Pictures were taken.,Through a separate incision, an indwelling pain catheter was then placed. It was carefully positioned. Pictures were taken. We then drained the joint. All instruments were removed. The patient did receive IV antibiotic preoperatively. All portals were closed using 4-0 nylon sutures.,Xeroform, 4 x 4s, and OpSite were applied over the pain pump. ABD, tape, and a sling were also applied. A Cryo/Cuff was also placed over the shoulder. The patient was taken out of the beach-chair position maintaining the neutral alignment of the head, neck, and thorax. The patient was extubated and brought to the recovery room in stable condition. I then went out and spoke with the family, going over the case, postoperative instructions, and followup care.orthopedic, debridement, superior labrum, patholigamentous, laxity, arthroscopic rotator cuff repair, subacromial decompression, glenohumeral joint, rotator cuff, arthroscopic, decompression, repair, glenohumeral, subacromial, rotator, cuff,

PREOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,POSTOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,PROCEDURE PERFORMED: , Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,ANESTHESIA:, LMA.,EBL: , Minimal.,FLUIDS: , Crystalloid. The patient was given antibiotics, 1 g of Ancef and the patient was on oral antibiotics at home.,BRIEF HISTORY: , The patient is a 61-year-old female with history of recurrent uroseptic stones. The patient had stones x2, 1 was already removed, second one came down, had recurrent episode of sepsis, stent was placed. Options were given such as watchful waiting, laser lithotripsy, shockwave lithotripsy etc. Risks of anesthesia, bleeding, infection, pain, need for stent, and removal of the stent were discussed. The patient understood and wanted to proceed with the procedure.,DETAILS OF THE PROCEDURE: , The patient was brought to the OR. Anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was prepped and draped in usual sterile fashion. A 0.035 glidewire was placed in the left system. Using graspers, left-sided stent was removed. A semirigid ureteroscopy was done. A stone was visualized in the mid to upper ureter. Using laser, the stone was broken into 5 to 6 small pieces. Using basket extraction, all the pieces were removed. Ureteroscopy all the way up to the UPJ was done, which was negative. There were no further stones. Using pyelograms, the rest of the system appeared normal. The entire ureter on the left side was open and patent. There were no further stones. Due to the edema and the surgery, plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours. Over the 0.035 glidewire, a 26 double-J stent was placed. There was a nice curl in the kidney and one in the bladder. The patient tolerated the procedure well. Please note that the string was kept in place and the patient was to remove the stent the next day. The patient's family was instructed how to do so. The patient had antibiotics and pain medications at home. The patient was brought to recovery room in a stable condition.urology, laser lithotripsy, shockwave lithotripsy, double-j stent, distal ureteral stone, ureteral stone, basket extraction, cystopyelogram, laser, lithotripsy, stones, string, ureteroscopy, stone, stent,

PREOPERATIVE DIAGNOSES,1. Herniated nucleus pulposus C2-C3.,2. Spinal stenosis C3-C4.,POSTOPERATIVE DIAGNOSES,1. Herniated nucleus pulposus C2-C3.,2. Spinal stenosis C3-C4.,PROCEDURES,1. Anterior cervical discectomy, C3-C4, C2-C3.,2. Anterior cervical fusion, C2-C3, C3-C4.,3. Removal of old instrumentation, C4-C5.,4. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.,PROCEDURE IN DETAIL: , The patient was placed in the supine position. The neck was prepped and draped in the usual fashion for anterior cervical discectomy. A high incision was made to allow access to C2-C3. Skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially. This exposed the vertebral bodies of C2-C3 and C4-C5 which was bridged by a plate. We placed in self-retaining retractors. With the tooth beneath the blades, the longus colli muscles were dissected away from the vertebral bodies of C2, C3, C4, and C5. After having done this, we used the all-purpose instrumentation to remove the instrumentation at C4-C5, we could see that fusion at C4-C5 was solid.,We next proceeded with the discectomy at C2-C3 and C3-C4 with disc removal. In a similar fashion using a curette to clean up the disc space and the space was fairly widened, as well as drilling up the vertebral joints using high-speed cutting followed by diamond drill bit. It was obvious that the C3-C4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis. With the operating microscope; however, we had good visualization of these nerve roots, and we were able to ___________ both at C2-C3 and C3-C4. We then placed the ABC 55-mm plate from C2 down to C4. These were secured with 16-mm titanium screws after excellent purchase. We took an x-ray which showed excellent position of the plate, the screws, and the graft themselves. The next step was to irrigate the wound copiously with saline and bacitracin solution and s Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision. The wound was closed with 2-0 Vicryl for subcutaneous tissues and Steri-Strips used to close the skin. Blood loss was about 50 mL. No complication of the surgery. Needle count, sponge count, cottonoid count was correct.,The operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb. At the time of surgery, he had total collapse of the C2, C3, and C4 disc with osteophyte formation. At both levels, he has high-grade spinal stenosis at these levels, especially foramen stenosis causing the compression, neck pain, headaches, and arm and shoulder pain. He does have degenerative changes at C5-C6, C6-C7, C7-T1; however, they do not appear to be symptomatic, although x-rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form.neurosurgery, abc plates, osteophyte, cervical, discectomy, cervical fusion, herniated nucleus pulposus, anterior cervical discectomy, nucleus pulposus, vertebral bodies, osteophyte formation, spinal stenosis, cervical discectomy, anterior, instrumentation, vertebral, stenosis, fusion

PREOPERATIVE DIAGNOSIS: , Ruptured distal biceps tendon, right elbow.,POSTOPERATIVE DIAGNOSIS:, Ruptured distal biceps tendon, right elbow.,PROCEDURE PERFORMED: , Repair of distal biceps tendon, right elbow.,PROCEDURE: ,The patient was taken to OR, Room #2 and administered a general anesthetic. The right upper extremity was then prepped and draped in the usual manner. A sterile tourniquet was placed on the proximal aspect of the right upper extremity. The extremity was then elevated and exsanguinated with an Esmarch bandage and tourniquet was inflated to 250 mmHg. Tourniquet time was 74 minutes. A curvilinear incision was made in the antecubital fossa of the right elbow down through the skin. Hemostasis was achieved utilizing electrocautery. Subcutaneous fat was separated and the skin flaps elevated. The _________ was identified. It was incised. The finger was placed approximately up the anterior aspect of the arm and the distal aspect of the biceps tendon was found. There was some serosanguineous fluid from the previous rupture. This area was suctioned clean. The biceps tendon ends were then placed over a sterile tongue blade and were then sharply cut approximately 5 mm to 7 mm from the tip to create a fresh surface. At this point, the #2 fiber wire was then passed through the tendon. Two fiber wires were utilized in a Krackow-type suture. Once this was completed, dissection was taken digitally down into the antecubital fossa in the path where the biceps tendon had been previously. The radial tuberosity was palpated. Just ulnar to this, a curved hemostat was passed through the soft tissues and was used to tent the skin on the radial aspect of the elbow. A skin incision was made over this area. Approximately two inches down to the skin and subcutaneous tissues, the fascia was split and the extensor muscle was also split.,A stat was then attached through the tip of that stat and passed back up through the antecubital fossa. The tails of the fiber wire suture were grasped and pulled down through the second incision. At this point, they were placed to the side. Attention was directed at exposure of the radial tuberosity with a forearm fully pronated. The tuberosity came into view. The margins were cleared with periosteal elevator and sharp dissection. Utilizing the power bur, a trough approximately 1.5 cm wide x 7 mm to 8 mm high was placed in the radial tuberosity. Three small drill holes were then placed along the margin for passage of the suture. The area was then copiously irrigated with gentamicin solution. A #4-0 pullout wire was utilized to pass the sutures through the drill holes, one on each outer hole and two in the center hole. The elbow was flexed and the tendon was then pulled into the trough with the forearm supinated. The suture was tied over the bone islands. Both wounds were then copiously irrigated with gentamicin solution and suctioned dry. Muscle fascia was closed with running #2-0 Vicryl suture on the lateral incision followed by closure of the skin with interrupted #2-0 Vicryl and small staples. The anterior incision was approximated with interrupted #2-0 Vicryl for Subq. and then skin was approximated with small staples. Both wounds were infiltrated with a total of 30 cc of 0.25% Marcaine solution for postop analgesia. A bulky fluff dressing was applied to the elbow, followed by application of a long-arm plaster splint maintaining the forearm in the supinated position. Tourniquet was inflated prior to application of the splint. Circulatory status returned to the extremity immediately. The patient was awakened. He was rather boisterous during his awakening, but care was taken to protect the right upper extremity. He was then transferred to the recovery room in apparent satisfactory condition.orthopedic, ruptured distal biceps tendon, gentamicin solution, antecubital fossa, distal biceps, biceps tendon, tendon, tuberosity, biceps, elbow,

ADMITTING DIAGNOSES:,1. Bradycardia.,2. Dizziness.,3. Diabetes.,4. Hypertension.,5. Abdominal pain.,DISCHARGE DIAGNOSIS:, Sick sinus syndrome. The rest of her past medical history remained the same.,PROCEDURES DONE: , Permanent pacemaker placement after temporary internal pacemaker.,HOSPITAL COURSE: , The patient was admitted to the intensive care unit. Dr. X was consulted. A temporary intracardiac pacemaker was placed. Consultation was requested to Dr. Y. He considered the need to have a permanent pacemaker after reviewing electrocardiograms and telemetry readings. The patient remained in sinus rhythm with severe bradycardias, but all of them one to one transmission. This was considered to be a sick sinus syndrome. Permanent pacemaker was placed on 09/05/2007 with right atrium appendage and right ventricular apex electrode placement. This is a Medtronic pacemaker. After this, the patient remained with pain in the left side of the chest in the upper area as expected, but well controlled. Right femoral artery catheter was removed. The patient remained with good pulses in the right lower extremity with no hematoma. Other problem was the patient's blood pressure, which on 09/05/2007 was found at 180/90. Medication was adjusted to benazepril 20 mg a day. Norvasc 5 mg was added as well. Her blood pressure has remained better, being today 144/74 and 129/76.,FINAL DIAGNOSES: ,Sick sinus syndrome. The rest of her past medical history remained without change, which are:,1. Diabetes mellitus.,2. History of peptic ulcer disease.,3. Hypertension.,4. Insomnia.,5. Osteoarthritis.,PLAN: , The patient is discharged home to continue her previous home medications, which are:,1. Actos 45 mg a day.,2. Bisacodyl 10 mg p.o. daily p.r.n. constipation.,3. Cosopt eye drops, 1 drop in each eye 2 times a day.,4. Famotidine 20 mg 1 tablet p.o. b.i.d.,5. Lotemax 0.5% eye drops, 1 drop in each eye 4 times a day.,6. Lotensin (benazepril) increased to 20 mg a day.,7. Triazolam 0.125 mg p.o. at bedtime.,8. Milk of Magnesia suspension 30 mL daily for constipation.,9. Tylenol No. 3, one to two tablets every 6 hours p.r.n. pain.,10. Promethazine 25 mg IM every 6 hours p.r.n. nausea or vomiting.,11. Tylenol 325 mg tablets every 4 to 6 hours as needed for pain.,12. The patient will finish cefazolin 1 g IV every 6 hours, total 5 dosages after pacemaker placement.,DISCHARGE INSTRUCTIONS: , Follow up in the office in 10 days for staple removal. Resume home activities as tolerated with no starch, sugar-free diet.nan

PREOPERATIVE DIAGNOSES,1. Recurrent acute otitis media, bilateral middle ear effusions.,2. Chronic rhinitis.,3. Recurrent adenoiditis with adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES,1. Recurrent acute otitis media, bilateral middle ear effusions.,2. Chronic rhinitis.,3. Recurrent adenoiditis with adenoid hypertrophy.,FINAL DIAGNOSES,1. Recurrent acute otitis media, bilateral middle ear effusions.,2. Chronic rhinitis.,3. Recurrent adenoiditis with adenoid hypertrophy.,4. Acute and chronic adenoiditis.,OPERATIONS PERFORMED,1. Bilateral myringotomies.,2. Placement of ventilating tubes.,3. Nasal endoscopy.,4. Adenoidectomy.,DESCRIPTION OF OPERATIONS: , The patient was brought to the operating room, endotracheal intubation carried out by Dr. X. Both sides of the patient's nose were then sprayed with Afrin. Ears were inspected then with the operating microscope. The anterior inferior quadrant myringotomy incisions were performed. Then, a modest amount of serous and a trace of mucoid material encountered that was evacuated. The middle ear mucosa looked remarkably clean. Armstrong tubes were inserted. Ciprodex drops were instilled. Ciprodex will be planned for two postoperative days as well. Nasal endoscopy was carried out, and evidence of acute purulent adenoiditis was evident in spite of the fact that clinically the patient has shown some modest improvement following cessation of all milk products. The adenoids were shaved back, flushed with curette through a traditional transoral route with thick purulent material emanating from the crypts, and representative cultures were taken. Additional adenoid tissue was shaved backwards with the RADenoid shaver. Electrocautery was used to establish hemostasis, and repeat nasal endoscopy accomplished. The patient still had residual evidence of inter choanal adenoid tissue, and video photos were taken. That remaining material was resected, guided by the nasal endoscope using the RADenoid shaver to remove the material and flush with the posterior nasopharynx. Electrocautery again used to establish hemostasis. Bleeding was trivial. Extensive irrigation accomplished. No additional bleeding was evident. The patient was awakened, extubated, taken to the recovery room in a stable condition. Discharge anticipated later in the day on Augmentin 400 mg twice daily, Lortab or Tylenol p.r.n. for pain. Office recheck would be anticipated if stable and doing well in approximately two weeks. Parents were instructed to call, however, regarding the outcome of the culture on Monday next week to ensure adequate antibiotic coverage before cessation of the antibiotic.surgery, bilateral middle ear effusions, recurrent acute otitis media, chronic rhinitis, recurrent adenoiditis with adenoid hypertrophy, adenoiditis, bilateral myringotomies, ventilating tubes, nasal endoscopy, adenoidectomy, adenoid hypertrophy, myringotomies, otitis, media, hypertrophy, endoscopy, intubation, nasal,

PREOPERATIVE DIAGNOSIS: , Coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.,DESCRIPTION OF PROCEDURE:,LEFT HEART CATHETERIZATION WITH ANGIOGRAPHY AND MID ABDOMINAL AORTOGRAPHY:,Under local anesthesia with 2% lidocaine with premedication, a right groin preparation was done. Using the percutaneous Seldinger technique via the right femoral artery, a left heart catheterization was performed. Coronary arteriography was performed with 6-French performed coronary catheters. We used a 6-French JR4 and JL4 catheters to take multiple cineangiograms of the right and left coronary arteries. After using the JR4 6-French catheter, nitroglycerin was administered because of the possibility of ostial spasm, and following that, we used a 5-French JR4 catheter for additional cineangiograms of the right coronary artery. A pigtail catheter was placed in the mid abdominal aorta and abdominal aortic injection was performed to rule out abdominal aortic aneurysm, as there was dense calcification in the mid abdominal aorta.,ANALYSIS OF PRESSURE DATA: , Left ventricular end-diastolic pressure was 5 mmHg. On continuous tracing from the left ventricle to the ascending aorta, there is no gradient across the aortic valve. The aortic pressures were normal. Contours of intracardiac pressure were normal.,ANALYSIS OF ANGIOGRAMS:, Selective cineangiograms were obtained with injection of contrast to the left ventricle, coronary arteries, and mid abdominal aorta. A pigtail catheter was introduced into the left ventricle and ventriculogram performed in right anterior oblique position. The mitral valve is competent and demonstrates normal mobility. The left ventricular cavity is normal in size with excellent contractility. Aneurysmal dilatation and/or dyskinesia absent. The aortic valve is tricuspid and normal mobility. The ascending aorta appeared normal.,Pigtail catheter was introduced in the mid abdominal aorta and placed just above the renal arteries. An abdominal aortic injection was performed. Under fluoroscopy, we see heavy dense calcification of the mid abdominal aorta between the renal artery and the bifurcation. There was some difficulty initially with maneuvering the wire pass that area and it was felt that might be a tight stenosis. The abdominal aortogram reveals wide patency of that area with mild intimal irregularity. There is a normal left renal artery, normal right renal artery. The celiac seems to be normal, but what I believe is the splenic artery seen initially at its origin is normal. The common left iliac and common right iliac arteries are essentially normal in this area.,CORONARY ANATOMY:, One notes ostial coronary calcification of the right coronary artery. Cineangiogram obtained with 6-French JR4 and 5-French JR4 catheters. Prior to the introduction of the 5-French JR4 nitroglycerin was administered sublingually. The 6-French JR4 catheters appeared to a show an ostial lesion of over 50%. There was backwash of dye into the aorta, although there is a fine funneling of the ostium towards the proximal right coronary artery. In the proximal portion of the right coronary artery just into the Shepherd turn, there is a 50% smooth tapering of the right coronary artery in the proximal third. Then the artery seems to have a little bit more normal size and it divides into a large posterior descending artery posterolateral branch vessel. The distal portion of the vessel is free of disease. The conus branch is seen arising right at the beginning part of the right coronary artery. We then removed the 6-French catheter and following nitroglycerin and sublingually we placed a 5-French catheter and again finding a stenosis, may be less than 50%. At the ostium of the right coronary artery, calcification again is identified. Backwash of dye noted at the proximal lesion, looked about the same 50% along the proximal turn of the Shepherd turn area.,The left coronary artery is normal, although there is a rim of ostial calcification, but there is no tapering or stenosis. It forms the left anterior descending artery, the ramus branch, and the circumflex artery.,The left anterior descending artery is a very large vessel, very tortuous in its proximal segment, very tortuous in its mid and distal segment. There appears to be some mild stenosis of 10% in the proximal segment. It gives off a large diagonal branch in the proximal portion of the left anterior descending artery and it is free of disease. The remaining portion of the left anterior descending artery is free of disease. Upon injection of the left coronary artery, we see what I believe is the dye enters probably directly into the left ventricle, but via fistula excluding the coronary sinus, and we get a ventriculogram performed. I could not identify an isolated area, but it seems to be from the interventricular septal collaterals that this is taking place.,The ramus branch is normal and free of disease.,The left circumflex artery is a tortuous vessel over the lateral wall and terminating in the inferoposterior wall that is free of disease.,The patient has a predominantly right coronary system. There is no _______ circulation connecting the right and left coronary systems.,The patient tolerated the procedure well. The catheter was removed. Hemostasis was achieved. The patient was transferred to the recovery room in a stable condition.,IMPRESSION:,1. Excellent left ventricular contractility with normal left ventricular cavity size.,2. Calcification of the mid abdominal aorta with wide patency of all vessels. The left and right renal arteries are normal. The external iliac arteries are normal.,3. Essentially normal left coronary artery with some type of interventricular septal to left ventricular fistula.,4. Ostial stenosis of the right coronary artery that appears to be about 50% or greater. The proximal right coronary artery has 50% stenosis as well.,5. Coronary calcification is seen under fluoroscopy at the ostia of the left and right coronary arteries.,RECOMMENDATIONS: ,The patient has heavy calcification of the coronary arteries and continued risk factor management is needed. The ostial lesion of the right coronary artery may be severe. It is at least 50%, but it could be worse. Therefore, she will be evaluated for the possibility of an IVUS and/or _______ analysis of the proximal right coronary artery. We will reevaluate her stress nuclear study as well. Continue aggressive medical therapy.surgery, intimal calcification, stenosis, coronary artery disease, mid abdominal aorta, coronary artery, cardiac catheterization, coronary arteries, descending artery, calcification, mid, proximal, aorta, catheterization, abdominal, cardiac, intimal, coronary, artery,

PREOPERATIVE DIAGNOSIS:, Atypical ductal hyperplasia of left breast.,POSTOPERATIVE DIAGNOSIS: , Atypical ductal hyperplasia of left breast.,PROCEDURE: , Left excisional breast biopsy.,ANESTHESIA: , General.,INDICATIONS: , This is a 66-year-old female who has a history of a right lumpectomy for ductal carcinoma in situ in May 2001. On recent mammogram, she was found to have calcifications in her left breast and a stereotactic biopsy revealed a typical ductal hyperplasia. Excisional biopsy was, therefore, recommended. Her family history was significant in her sister with breast cancer at the age of 34 and daughter at the age 38.,FINDINGS: , The area in question was excised. See details below. There was no gross evidence of malignancy. Final evaluation will per the permanent sections.,PROCEDURE:, Earlier today, the patient underwent a wire localization by Dr. A. She was then taken to the operating room and placed in the supine position. The left breast was prepped and draped in the usual sterile fashion.,A curvilinear incision was made in the upper outer quadrant to include a wire. The skin was incised. Hemostasis was achieved with cautery device where the breast tissue was excised around the wire. The specimens were marked for the long stitch laterally and short stitch superiorly, and fair length superficially. It was noted that the wire was fairly close to the superior deep aspect of the specimen. I, therefore, excised a new superior deep margin. This was performed with electrocautery device, the suture marks and new marks on the specimens. The main specimen itself was sent for ***** and gross inspection. The superior deep margin was soaked in Marcaine and the new margin was sent for permanent sections.,First, I went over to pathology and reviewed the specimen and radiograph with the radiologist Dr. A. This revealed a clip in the tissue excised closer again to the superior deep edge of the tissue. The specimens were then cut in serial fashion by Dr. Rust, the pathologist. There was no gross evidence of malignancy. As noted above, I previously excised the new superior deep margin and this was sent for permanent section. ,The wound was thoroughly irrigated and hemostasis was carefully achieved. The subdermal layer was closed with 4-0 PDS in simple interrupted fashion. The skin was closed with 4-0 Monocryl in a running subcuticular fashion. Steri-Strips and dressings were applied. All sponge, needle, and instrument counts were correct. The patient tolerated the procedure well and was taken to PACU in stable condition.,ESTIMATED BLOOD LOSS: , 5 mL.,COMPLICATIONS: , None.,DRAINS: , None.,SPECIMENS:, Left breast tissue and new superior deep margin.surgery, breast, atypical ductal hyperplasia, breast biopsy, carcinoma in situ, excisional, hyperplasia, instrument counts, mammogram, needle, pathology, specimen, sponge, superior deep margin, ductal hyperplasia, deep margin, hemostasis, biopsy,

PROCEDURES UNDERTAKEN,1. Left coronary system cineangiography.,2. Right coronary system cineangiography.,3. Cineangiography of SVG to OM.,4. Cineangiography of LIMA to LAD.,5. Left ventriculogram.,6. Aortogram.,7. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.,NARRATIVE:, After all risks and benefits were explained to the patient, informed consent was obtained. The patient was brought to the cardiac catheterization suite. The right groin was prepped in the usual sterile fashion. Right common femoral artery was cannulated using a modified Seldinger technique and a long 6-French AO sheath was introduced secondary to tortuous aorta. Next, Judkins left catheter was used to engage the left coronary system. Cineangiography was recorded in multiple views. Next, Judkins right catheter was used to engage the right coronary system. Cineangiography was recorded in multiple views. Next, the Judkins right catheter was used to engage the SVG to OM. Cineangiography was recorded. Next, the Judkins right was advanced into the left subclavian and exchanged over a long exchange length J-wire for a 4-French left internal mammary artery which was used to engage the LIMA graft to LAD and cineangiography was recorded in multiple views. Next, an angled pigtail catheter was advanced into the left ventricular cavity. LV pressures were measured. LV gram was done and a pullback gradient across the aortic valve was done and recorded. Next, an aortogram was done and recorded. At this point, I decided to proceed with percutaneous intervention of the left circumflex. Therefore, AVA 3.5 guide was used to engage the left coronary artery. Angiomax bolus and drip was started. Universal wire was advanced past the lesion and a 2.5-balloon was advanced first to the proximal lesions and predilations were done at 14 atmospheres and then to the distal lesion and predilatation was done at 12 atmospheres. Next, we attempted to advance a 3.0 x 12 stent to the distal lesion; however, we were unable to pass the stent. Next, second dilatations were done again with the 2.5 balloon at 18 atmospheres; however, we are unable to break the lesion. We next attempted a cutting balloon. Again, we are unable to cross the lesion, therefore a buddy wire technique was used with a PT choice support wire. Again, we were unable to cross the lesion with the stent. We then try to cross with a noncompliant balloon, which we were unsuccessful. We also try to cutting balloon again, we were unsuccessful. Despite multiple dilatations, we were unable to cross anything beyond the noncompliant balloon across the lesion; therefore, finally the procedure was aborted. Final images showed no evidence of dissection, perforation, or further complication. The right groin was filled after taking an image to confirm sheath placement above the bifurcation with excellent results. The patient tolerated the procedure very well without complications, was taken off the operating table and transferred back to cardiac telemetry floor.,DIAGNOSTIC FINDINGS,1. The LV. LVEDP was 4. LVES is approximately 50%-55% with inferobasal hypokinesis. No significant MR. No gradient across the aortic valve.,2. Aortogram. The ascending aorta shows no significant dilatation or evidence of dissection. The valve shows no significant aortic insufficiencies. The abdominal aorta and distal aorta shows significant tortuosities.,3. The left main. The left main coronary artery is a large caliber vessel, bifurcating the LAD and left circumflex with some mild distal disease of about 10%-20%.,4. Left circumflex. The left circumflex vessel is a large caliber vessel gives off a distal branching obtuse marginal branch. The upper pole of the OM shows retrograde filling of the distal graft and also at that point approximately a 70%-80% stenosis. The mid left circumflex is a high-grade 80% diffuse tortuous stenosis.,5. LAD. The LAD is a totally 100% occluded vessel. The LIMA to LAD is patent with only a small-to-moderate caliber LAD. There is a large diagonal branch coming off the proximal portion of the LAD and that proximal LAD showed some diffuse disease upwards of 60%-70%. The diagonal shows proximal 80% stenosis.,6. The right coronary artery: The right coronary artery is 100% occluded. There are retrograde collaterals from left to right to the distal PDA and PLV branches. The SVG to OM is 100% occluded at its take off. The SVG to PDA is not found; however, presumed 100% occluded given that there is collateral flow to the distal right.,7. LIMA to LAD is widely patent.,ASSESSMENT AND PLAN: , Attempted intervention to the left circumflex system, only able to perform plano balloon angioplasty, unable to pass stents, noncompliant balloons or cutting balloon. Final images showed some improvement, however, continued residual stenosis. At this point, the patient will be transferred back to telemetry floor and monitored. We can attempt future intervention or continue aggressive medical management. The patient continues to have residual stenosis in the diagonal; however, due to the length of this procedure, I did not attempt intervention to that diagonal branch. Possible consideration would be a stress test as an outpatient depending on where patient shows ischemia, focus on treatment to that lesion.cardiovascular / pulmonary, coronary system cineangiography, svg to om, lima to lad, ventriculogram, aortogram, percutaneous intervention, circumflex, obtuse marginal branch, balloon angioplasty, coronary artery, balloon, cineangiography, lad,

CC:, Weakness.,HX:, This 30 y/o RHM was in good health until 7/93, when he began experiencing RUE weakness and neck pain. He was initially treated by a chiropractor and, after an unspecified length of time, developed atrophy and contractures of his right hand. He then went to a local neurosurgeon and a cervical spine CT scan, 9/25/92, revealed an intramedullary lesion at C2-3 and an extramedullary lesion at C6-7. He underwent a C6-T1 laminectomy with exploration and decompression of the spinal cord. His clinical condition improved over a 3 month post-operative period, and then progressively worsened. He developed left sided paresthesia and upper extremity weakness (right worse than left). He then developed ataxia, nausea, vomiting, and hyperreflexia. On 8/31/93, MRI C-spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa. On 9/1/93, he underwent suboccipital craniotomy with tumor excision, decompression, and biopsy which was consistent with hemangioblastoma. His symptoms stabilized and he underwent 5040 cGy in 28 fractions to his brain and 3600 cGy in 20 fractions to his cervical and thoracic spinal cord from 9/93 through 1/19/94.,He was evaluated in the NeuroOncology clinic on 10/26/95 for consideration of chemotherapy. He complained of progressive proximal weakness of all four extremities and dysphagia. He had difficulty putting on his shirt and raising his arms, and he had been having increasing difficulty with manual dexterity (e.g. unable to feed himself with utensils). He had difficulty going down stairs, but could climb stairs. He had no bowel or bladder incontinence or retention.,MEDS:, none.,PMH:, see above.,FHX:, Father with Von Hippel-Lindau Disease.,SHX:, retired truck driver. smokes 1-3 packs of cigarettes per day, but denied alcohol use. He is divorced and has two sons who are healthy. He lives with his mother.,ROS:, noncontributory.,EXAM:, Vital signs were unremarkable.,MS: A&O to person, place and time. Speech fluent and without dysarthria. Thought process lucid and appropriate.,CN: unremarkable exept for 4+/4+ strength of the trapezeii. No retinal hemangioblastoma were seen.,MOTOR: 4-/4- strength in proximal and distal upper extremities. There is diffuse atrophy and claw-hands, bilaterally. He is unable to manipulate hads to any great extent. 4+/4+ strength throughout BLE. There is also diffuse atrophy throughout the lower extremities though not as pronounced as in the upper extremities.,SENSORY: There was a right T3 and left T8 cord levels to PP on the posterior thorax. Decreased LT in throughout the 4 extremities.,COORD: difficult to assess due to weakness.,Station: BUE pronator drift.,Gait: stands without assistance, but can only manage to walk a few steps. Spastic gait.,Reflexes: Hyperreflexic on left (3+) and Hyporeflexic on right (1). Babinski signs were present bilaterally.,Gen exam: unremarkable.,COURSE: ,9/8/95, GS normal. By 11/14/95, he required NGT feeding due to dysphagia and aspiration risk confirmed on cookie swallow studies.MRI Brain, 2/19/96, revealed several lesions (hemangioblastoma) in the cerebellum and brain stem. There were postoperative changes and a cyst in the medulla.,On 10/25/96, he presented with a 1.5 week h/o numbness in BLE from the mid- thighs to his toes, and worsening BLE weakness. He developed decubitus ulcers on his buttocks. He also had had intermittent urinary retention for month, chronic SOB and dysphagia. He had been sitting all day long as he could not move well and had no daytime assistance. His exam findings were consistent with his complaints. He had had no episodes of diaphoresis, headache, or elevated blood pressures. An MRI of the C-T spine, 10/26/96, revealed a prominent cervicothoracic syrinx extending down to T10. There was evidence of prior cervical laminectomy of C6-T1 with expansion of the cord in the thecalsac at that region. Multiple intradural extra spinal nodular lesions (hyperintense on T2, isointense on T1, enhanced gadolinium) were seen in the cervical spine and cisterna magna. The largest of which measures 1.1 x 1.0 x 2.0cm. There are also several large ring enhancing lesions in cerebellum. The lesions were felt to be consistent with hemangioblastoma. No surgical or medical intervention was initiated. Visiting nursing was provided. He has since been followed by his local physician

PREOPERATIVE DIAGNOSIS:, Phimosis.,POSTOPERATIVE DIAGNOSES:, Phimosis.,OPERATIONS:, Circumcision.,ANESTHESIA: , LMA.,EBL:, Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , This is a 3-year-old male, who was referred to us from Dr. X's office with phimosis. The patient had spraying of urine and ballooning of the foreskin with voiding. The urine seemed to have collected underneath the foreskin and then would slowly drip out. Options such as dorsal slit, circumcision, watchful waiting by gently pulling the foreskin back were discussed. Risk of anesthesia, bleeding, infection, pain, scarring, and expected complications were discussed. The patient's family understood all the complications and wanted to proceed with the procedure. Consent was obtained using interpreter.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the OR and anesthesia was applied. The patient was placed in supine position. The patient was prepped and draped in usual sterile fashion. All the penile adhesions were released prior to the prepping. The extra foreskin was marked off, 1 x 3 Gamco clamp was used. Hemostasis was obtained after removing the extra foreskin using the Gamco clamp.,Using 5-0 Monocryl, 4 quadrant stitches were placed and horizontal mattress suturing was done. There was excellent hemostasis. Dermabond was applied. The patient was brought to recovery at the end of the procedure in stable condition.urology, ballooning of the foreskin, spraying of urine, gamco clamp, spraying, ballooning, circumcision, urine, phimosis, foreskin

PREOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,POSTOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,TITLE OF THE OPERATION:,1. Biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer.,2. Insertion of left lateral ventriculostomy under Stealth stereotactic guidance.,3. Right suboccipital craniectomy and excision of tumor.,4. Microtechniques for all the above.,5. Stealth stereotactic guidance for all of the above and intraoperative ultrasound.,INDICATIONS: , The patient is a 48-year-old woman with a diagnosis of breast cancer made five years ago. A year ago, she was diagnosed with cranial metastases and underwent whole brain radiation. She recently has deteriorated such that she came to my office, unable to ambulate in a wheelchair. Metastatic workup does reveal multiple bone metastases, but no spinal cord compression. She had a consult with Radiation-Oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery, but the lesions greater than 3 cm needed to be removed. Consequently, this operation is performed.,PROCEDURE IN DETAIL: , The patient underwent a planning MRI scan with Stealth protocol. She was brought to the operating room with fiducial still on her scalp. General endotracheal anesthesia was obtained. She was placed on the Mayfield head holder and rolled into the prone position. She was well padded, secured, and so forth. The neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions. The posterior aspect of the calvarium was shaved and prepared in the usual manner with Betadine soak scrub followed by Betadine paint. This was done only, of course, after fiducial were registered in planning and an excellent accuracy was obtained with the Stealth system. Sterile drapes were applied and the accuracy of the system was confirmed. A biparietal incision was performed. A linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation. A biparietal craniotomy was carried out, carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the Stealth stereotactic system. The dura was opened and reflected back to the midline. An inner hemispheric approach was used to reach the very large metastatic tumor. This was very delicate removing the tumor and the co-surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor. The tumor was wrapped around and included the choroidal vessels. At least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region. Bleeding was quite vigorous in some of the arteries and finally, however, was completely controlled. Complete removal of the tumor was confirmed by intraoperative ultrasound.,Once the tumor had been removed and meticulous hemostasis was obtained, this wound was left opened and attention was turned to the right suboccipital area. A linear incision was made just lateral to the greater occipital nerve. Sharp dissection was carried down in the subcutaneous tissues and Bovie electrocautery was used to reach the skull. A burr hole was placed down low using a craniotome. A craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter. It was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus. Stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum. The ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor, and this was draining CSF relieving pressure in the posterior fossa. Upon opening the craniotomy in the parietal occipital region, the brain was noted to be extremely tight, thus necessitating placement of the ventriculostomy.,At the posterior fossa, a corticectomy was accomplished and the tumor was countered directly. The tumor, as the one above, was removed, both piecemeal and with intraoperative Cavitron Ultrasonic Aspirator. A gross total excision of this tumor was obtained as well.,I then explored underneath the cerebellum in hopes of finding another metastasis in the CP angle; however, this was just over the lower cranial nerves, and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss, this lesion was left alone and to be radiated and that it is less than 3 cm in diameter.,Meticulous hemostasis was obtained for this wound as well.,The posterior fossa wound was then closed in layers. The dura was closed with interrupted and running mattress of 4-0 Nurolon. The dura was watertight, and it was covered with blue glue. Gelfoam was placed over the dural closure. Then, the muscle and fascia were closed in individual layers using #0 Ethibond. Subcutaneous was closed with interrupted inverted 2-0 and 0 Vicryl, and the skin was closed with running locking 3-0 Nylon.,For the cranial incision, the ventriculostomy was brought out through a separate stab wound. The bone flap was brought on to the field. The dura was closed with running and interrupted 4-0 Nurolon. At the beginning of the case, dural tack-ups had been made and these were still in place. The sinuses, both the transverse sinus and sagittal sinus, were covered with thrombin-soaked Gelfoam to take care of any small bleeding areas in the sinuses.,Once the dura was closed, the bone flap was returned to the wound and held in place with the Lorenz microplates. The wound was then closed in layers. The galea was closed with multiple sutures of interrupted 2-0 Vicryl. The skin was closed with a running locking 3-0 Nylon.,Estimated blood loss for the case was more than 1 L. The patient received 2 units of packed red cells during the case as well as more than 1 L of Hespan and almost 3 L of crystalloid.,Nevertheless, her vitals remained stable throughout the case, and we hopefully helped her survival and her long-term neurologic status for this really nice lady.neurosurgery, metastatic lesion, biparietal, mayfield head holder, microtechniques, stealth, craniotomy, excision, fiducial, infratentorial, parietooccipital, stereotactic, suboccipital, subtentorial, ventriculostomy, lesions to the brain, removal of the tumor, parietal occipital region, running locking nylon, biparietal craniotomy, posterior fossa, tumor, brain, dura, lesions,

PREOPERATIVE DIAGNOSIS:, Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:, Acute gangrenous cholecystitis with cholelithiasis.,OPERATION PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,FINDINGS: ,The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.,COMPLICATIONS: ,None.,EBL: , Scant.,SPECIMEN REMOVED: , Gallbladder with stones.,DESCRIPTION OF PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion under general anesthesia. A curvilinear incision was made below the umbilicus. Through this incision, the camera port was able to be placed into the peritoneal cavity under direct visualization. Once this complete, insufflation was begun. Once insufflation was adequate, additional ports were placed in the epigastrium as well as right upper quadrant. Once all four ports were placed, the right upper quadrant was then explored. The patient had significant adhesions of omentum and colon to the liver, the gallbladder constituting definitely an acute cholecystitis. This was taken down using Bovie cautery to free up visualization of the gallbladder. The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall. Adhesions were further taken down between the omentum, the colon, and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area. Once the adhesions were fully removed, the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction. At this point, due to the patient's gallbladder being very necrotic, it was deemed that the patient should have a drain placed. The cystic duct and cystic artery were serially clipped and transected. The gallbladder was removed from the gallbladder fossa removing the entire gallbladder. Adequate hemostasis with Bovie cautery was achieved. The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port. A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3-0 nylon suture. Next, the right upper quadrant was copiously irrigated out using the suction irrigator. Once this was complete, the additional ports were able to be removed. The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure-of-8 fashion. All skin incisions were injected using Marcaine 1/4 percent plain. The skin was reapproximated further using 4-0 Monocryl sutures in a subcuticular technique. The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition.surgery, acute cholecystitis, cholangiogram, cholelithiasis, cholecystitis, gallbladder, gangrenous cholecystitis, bovie cautery, cystic duct, laparoscopic cholecystectomy, laparoscopic, cholecystectomy, cystic, duct,

PREOPERATIVE DIAGNOSES:,1. Pregnancy at 40 weeks.,2. Failure to progress.,3. Premature prolonged rupture of membranes.,4. Group B strep colonization.,POSTOPERATIVE DIAGNOSIS:,1. Pregnancy at 40 weeks.,2. Failure to progress.,3. Premature prolonged rupture of membranes.,4. Group B strep colonization.,5. Delivery of viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cesarean section via Pfannenstiel incision.,ANESTHESIA: ,Spinal.,ESTIMATED BLOOD LOSS: , 1000 cc.,FLUID REPLACEMENT: , 2700 cc crystalloid.,URINE:, 500 cc clear yellow urine in the Foley catheter.,INTRAOPERATIVE FINDINGS: ,Normal appearing uterus, tubes, and ovaries. A viable male neonate with Apgars of 9 and 9 at 1 and 5 minutes respectively. Infant weight equaled to 4140 gm with clear amniotic fluid. The umbilical cord was wrapped around the leg tightly x1. Infant was in a vertex, right occiput anterior position.,INDICATIONS FOR PROCEDURE: ,The patient is a 19-year-old G1 P0 at 41 and 1/7th weeks' intrauterine pregnancy. She presented at mid night on 08/22/03 complaining of spontaneous rupture of membranes, which was confirmed in Labor and Delivery. The patient had a positive group beta strep colonization culture and was started on penicillin. The patient was also started on Pitocin protocol at that time. The patient was monitored throughout the morning showing some irregular contractions every 5 to 6 minutes and then eventually no contractions on the monitor. IUPC was placed without difficulty and contractions appeared to be regular, however, they were inadequate amount of the daily units. The patient was given a rest from the Pitocin. She walked and had a short shower. The patient was then placed back on Pitocin with IUPC in place and we were unable to achieve adequate contractions. Maximum cervical dilation was 5 cm, 80% effaced, negative 2 station, and cephalic position. At the time of C-section, the patient had been ruptured for over 24 hours and it was determined that she would not progress in her cervical dilation, as there was suspected macrosomia on ultrasound. Options were discussed with the patient and family and it was determined that we will take her for C-section today. Consent was signed. All questions were answered with Dr. X present.,PROCEDURE: , The patient was taken to the operative suite where a spinal anesthetic was placed. She was placed in the dorsal supine position with left upward tilt. She was prepped and draped in the normal sterile fashion and her spinal anesthetic was found to adequate. A Pfannenstiel incision was made with a first scalpel and carried through the underlying layer of fascia with a second scalpel. The fascia was incised in the midline and extended laterally using curved Mayo scissors. The superior aspect of the fascial incision was grasped with Ochsner and Kocher clamps and elevated off the rectus muscles. Attention was then turned to the inferior aspect of the incision where Kocher clamps were used to elevate the fascia off the underlying rectus muscle. The rectus muscle was separated in the midline bluntly. The underlying peritoneum was tented up with Allis clamps and incised using Metzenbaum scissors. The peritoneum was then bluntly stretched. The bladder blade was placed. The vesicouterine peritoneum was identified, tented up with Allis' and entered sharply with Metzenbaum scissors. The incision was extended laterally and the bladder flap created digitally. The bladder blade was then reinserted in the lower uterine segment. A low transverse uterine incision was made with a second scalpel. The uterine incision was extended laterally bluntly. The bladder blade was removed and the infant's head was delivered with the assistance of a vacuum. Infant's nose and mouth were bulb suctioned and the body was delivered atraumatically. There was, of note, an umbilical cord around the leg tightly x1.,Cord was clamped and cut. Infant was handed to the waiting pediatrician. Cord gas was sent for pH as well as blood typing. The placenta was manually removed and the uterus was exteriorized and cleared of all clots and debris. The uterine incision was grasped circumferentially with Alfred clamps and closed with #0-Chromic in a running locked fashion. A second layer of imbricating stitch was performed using #0-Chromic suture to obtain excellent hemostasis. The uterus was returned to the abdomen. The gutters were cleared of all clots and debris. The rectus muscle was loosely approximated with #0-Vicryl suture in a single interrupted fashion. The fascia was reapproximated with #0-Vicryl suture in a running fashion. The subcutaneous Scarpa's fascia was then closed with #2-0 plain gut. The skin was then closed with staples. The incision was dressed with sterile dressing and bandage. Blood clots were evacuated from the vagina. The patient tolerated the procedure well. The sponge, lap, and needle counts were correct x2. The mother was taken to the recovery room in stable and satisfactory condition.surgery, c-section, cesarean section, low transverse, pregnancy, rupture of membranes, cervical dilation, kocher clamps, metzenbaum scissors, vicryl suture, pfannenstiel incision, uterine incision, rectus muscles, incision, transverse, colonization, rectus, muscles, bladder, uterine, section, fascia,

REPORT:, The electroencephalogram shows background activity at about 9-10 cycle/second bilaterally. Little activity in the beta range is noted. Waves of 4-7 cycle/second of low amplitude were occasionally noted. Abundant movements and technical artifacts are noted throughout this tracing. Hyperventilation was not performed. Photic stimulation reveals no important changes.,CLINICAL INTERPRETATION:, The electroencephalogram is essentially normal.neurology, beta range, hyperventilation, photic stimulation, electroencephalogramNOTE,: 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.,

EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity. The ears are with normal-appearing pinna. Examination of the canals is normal appearing bilaterally. There is no drainage or erythema noted. The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex. Hearing is grossly intact to finger rubbing and whisper. The nasal mucosa is moist. The septum is midline. There is no evidence of septal hematoma. The turbinates are without abnormality. No obvious abnormalities to the lips. The teeth are unremarkable. The gingivae are without any obvious evidence of infection. The oral mucosa is moist and pink. There are no obvious masses to the hard or soft palate. The uvula is midline. The salivary glands appear unremarkable. The tongue is midline. The posterior pharynx is without erythema or exudate. The tonsils are normal appearing.general medicine, erythema, tympanic, mouth, throat, ears, mucosa, noseNOTE,: 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.,

CHIEF COMPLAINT: , Buttock abscess.,HISTORY OF PRESENT ILLNESS: , This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The patient underwent incision and drainage in the emergency department. She was admitted to the hospitalist service with elevated blood sugars. She has had positive blood cultures. Surgery is consulted today for evaluation.,PAST MEDICAL HISTORY: ,Diabetes type II, poorly controlled, high cholesterol.,PAST SURGICAL HISTORY: , C-section and D&C.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , Insulin, metformin, Glucotrol, and Lipitor.,FAMILY HISTORY: , Diabetes, hypertension, stroke, Parkinson disease, and heart disease.,REVIEW OF SYSTEMS: , Significant for pain in the buttock. Otherwise negative.,PHYSICAL EXAMINATION:,GENERAL: This is an overweight African-American female not in any distress.,VITAL SIGNS: She has been afebrile since admission. Vital signs have been stable. Blood sugars have been in the 200 range.,HEENT: Normal to inspection.,NECK: No bruits or adenopathy.,LUNGS: Clear to auscultation.,CV: Regular rate and rhythm.,ABDOMEN: Protuberant, soft, and nontender.,EXTREMITIES: No clubbing, cyanosis or edema.,RECTAL EXAM: The patient has a drained abscess on the buttock cheek. There is some serosanguineous drainage. There is no longer any purulent drainage. The wound appears relatively clean. I do not see a lot of erythema.,ASSESSMENT AND PLAN: , Left buttock abscess, status post incision and drainage. I do not believe surgical intervention is warranted. I have recommended some local wound care. Please see orders for details.dermatology, buttock pain, pimple, incision and drainage, local wound care, blood sugars, diabetes, buttock, abscess,

OBSERVATIONS: , The forced vital capacity is 2.84 L and forced expiratory volume in 1 second is 1.93 L. The ratio between the two is 68%. Small improvement is noted in the airflows after bronchodilator therapy. Lung volumes are increased with a residual volume of 196% of predicted and total lung capacity of 142% of predicted. Single-breath diffusing capacity is slightly reduced.,IMPRESSION: , Mild-to-moderate obstructive ventilatory impairment. Some improvement in the airflows after bronchodilator therapy.cardiovascular / pulmonary, lung volume, forced expiratory volume, forced vital capacity, airflows, total lung capacity, bronchodilator therapy, bronchodilatorNOTE,: 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.,

PROCEDURE: , Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.,PROCEDURE IN DETAIL: ,The patient was brought to the Catheterization Laboratory. After informed consent, he was medicated with Versed and fentanyl. The right groin was prepped and draped, and infiltrated with 2% Xylocaine. Percutaneously, #6-French arterial sheath was placed. Selective native left and right coronary angiography was performed followed by left ventricular angiography. The patient had a totally occluded right coronary. We initially started with a JR4 guide. We were able to a sport wire through the total occlusion and saw a very tight stenosis. We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated. We then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out. We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion. We finally had to go an AL2 guide, we were concerned that this could cause some proximal dissection. That guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip. The surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire. We then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm Vision stent, where the lesion was and post-dilated it to 18 atmospheres. Routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 Vision balloon and dilate the area and re-establish flow to the small segment. We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres. Final angiography showed resolution of the dissection. We could see a little staining extrinsic to the stent. No perforation and excellent flow. During the intervention, we did give a bolus and drip of Angiomax. At the end of the procedure, we stopped the Angiomax and gave 600 mg of Plavix. We did a right femoral angiogram; however, the Angio-Seal plug could not take, so we used manual pressure and a Femostop. We transported the patient to his room in stable condition.,ANGIOGRAPHIC DATA:, Left main coronary is normal. Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the LAD before it bifurcates into diagonal. The diagonal does appear to have about 50% osteal stenosis. There is a lot of plaquing further down the diagonal, but good flow. The rest of the LAD looked good pass the proximal 60% stenosis and after the diagonal branch. Circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel. The first obtuse marginal had a long 50% narrowing and then the AV groove branch was free of any disease. Some mild collaterals to the right were seen. Right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin. After we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve. Following the balloon angioplasty, we established good flow down the distal vessel. We still had about residual 70% stenosis. When we had to go back with the AL2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection. We re-dilated and then deployed. Repeat angiography now did show some hang up off dye distally. We never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus. After deploying the stent, we had total resolution of the original lesion. We then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large PDA. The posterolateral branch appeared to be occluded in its mid portion. We got a wire through and dilated this. We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent. Repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent. There were no filling defects in the stent and excellent flow. The distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there.,IMPRESSION: , Atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection. Minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch.cardiovascular / pulmonary, heart catheterization, coronary angiography, ventricular angiography, intercoronary stenting, intercoronary, coronary, stenting, stenosis, angiography

CHILD PHYSICAL EXAMINATION,VITAL SIGNS: Birth weight is ** grams, length **, occipitofrontal circumference **. Character of cry was lusty.,GENERAL APPEARANCE: Well.,BREATHING: Unlabored.,SKIN: Clear. No cyanosis, pallor, or icterus. Subcutaneous tissue is ample.,HEAD: Normal. Fontanelles are soft and flat. Sutures are opposed.,EYES: Normal with red reflex x2.,EARS: Patent. Normal pinnae, canals, TMs.,NOSE: Patent nares.,MOUTH: No cleft.,THROAT: Clear.,NECK: No masses.,CHEST: Normal clavicles.,LUNGS: Clear bilaterally.,HEART: Regular rate and rhythm without murmur.,ABDOMEN: Soft, flat. No hepatosplenomegaly. The cord is three vessel.,GENITALIA: Normal ** genitalia **with testes descended bilaterally.,ANUS: Patent.,SPINE: Straight and without deformity.,EXTREMITIES: Equal movements.,MUSCLE TONE: Good.,REFLEXES: Moro, grasp, and suck are normal.,HIPS: No click or clunk.pediatrics - neonatal, child physical examination, physical, genitalia, child,

HISTORY OF PRESENT ILLNESS: , The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back. The patient stated initial injury occurred eight years ago, when she fell at a ABC Store. The patient stated she received physical therapy, one to two visits and received modality treatment only, specifically electrical stimulation and heat pack per patient recollection. The patient stated that she has had continuous low-back pain at varying degrees for the past eight years since that fall. The patient gave birth in August 2008 and since the childbirth, has experienced low back pain. The patient also states that she fell four to five days ago, while mopping her floor. The patient stated that she landed on her tailbone and symptoms have increased since that fall. The patient stated that her initial physician examination with Dr. X was on 01/10/09, and has a followup appointment on 02/10/09.,PAST MEDICAL HISTORY: , The patient denies high blood pressure, diabetes, heart disease, lung disease, thyroid, kidney, or bladder dysfunctions. The patient stated that she quit smoking prior to her past childbirth and is currently not pregnant. The patient has had a C-section and also an appendectomy. The patient was involved in a motor vehicle accident four to five years ago and at that time, the patient did not require any physical therapy nor did she report any complaints of increased back pain following that accident.,MEDICATIONS: , Patient currently states she is taking:,1. Vicodin 500 mg two times a day.,2. Risperdal.,3. Zoloft.,4. Stool softeners.,5. Prenatal pills.,DIAGNOSTIC IMAGERY: ,The patient states she has not had an MRI performed on her lumbar spine. The patient also states that Dr. X took x-rays two weeks ago, and no fractures were found at that time. Per physician note, dated 12/10/08, Dr. X dictated that the x-ray showed an anterior grade 1 spondylolisthesis of L5 over S1, and requested Physical Therapy to evaluate and treat.,SUBJECTIVE: ,The patient states that pain is constant in nature with a baseline of 6-7/10 with pain increasing to 10/10 during the night or in cold weather. The patient states that pain is dramatically less, when the weather is warmer. The patient also states that pain worsens as the day progresses, in that she also hard time getting out of bed in the morning. The patient states that she does not sleep at night well and sleeps less than one hour at a time.,Aggravating factors include, sitting for periods greater than 20 minutes or lying supine on her back. Easing factors include side lying position in she attempts to sleep.,OBJECTIVE: , AGE: 26 years old. HEIGHT: 5 feet 2 inches. WEIGHT: The patient is an obese 26-year-old female.,ACTIVE RANGE OF MOTION: , Lumbar spine, flexion, lateral flexion and rotation all within functional limits without complaints of pain or soreness while performing them during evaluation.,PALPATION: ,The patient complained of bilateral SI joint point tenderness. The patient also complained of left greater trochanter hip point tenderness. The patient also complained of bilateral paraspinal tenderness on cervical spine to lumbar spine.,STRENGTH: ,RIGHT LOWER EXTREMITY:,Knee extension 5/5, hip flexion 5/5, knee flexion 4/5, internal and external hip rotation was 4/5. With manual muscle testing of knee flexion, hip, internal and external rotation, the patient reports an increase in right SI joint pain to 8/10.,LEFT LOWER EXTREMITY:,Hip flexion 5/5, knee extension 5/5, knee flexion 4/5, hip internal and external rotation 4/5, with slight increase in pain level with manual muscle testing and resistance. It must be noted that PT did not apply as much resistance during manual muscle testing, secondary to the 8/10 pain elicited during the right lower extremity.,NEUROLOGICAL: ,The patient subjectively complains of numbness with tingling in her bilateral extremities when she sits longer than 25 minutes. However, they subside when she stands. The patient did complain of this numbness and tingling during the evaluation and the patient was seated for a period of 20 minutes. Upon standing, the patient stated that the numbness and tingling subsides almost immediately. The patient stated that Dr. X told her that he believes that during her past childbirth when the epidural was being administered that there was a possibility that a sensory nerve may have been also affected during the epidural less causing the numbness and tingling in her bilateral lower extremities. The patient does not demonstrate any sensation deficits with gentle pressure to the lumbar spine and during manual muscle testing.,GAIT: ,The patient ambulated out of the examination room, while carrying her baby in a car seat.,ASSESSMENT: ,The patient is a 26-year-old overweight female, referred to Physical Therapy for low back pain. The patient presents with lower extremity weakness, which may be contributing to her lumbosacral pain, in that she has poor lumbar stabilization with dynamic ADLs, transfers, and gait activity when fatigued. At this time, the patient may benefit from skilled physical therapy to address her decreased strength and core stability in order to improve her ADL, transfer, and mobility skills.,PROGNOSIS: , The patient's prognosis for physical therapy is good for dictated goals.,SHORT-TERM GOALS TO BE ACHIEVED IN TWO WEEKS:,1. The patient will be able to sit for greater than 25 minutes without complaints of paraesthesia or pain in her bilateral lower extremities or bilateral SI joints.,2. The patient will increase bilateral hip internal and external rotation to 4/5 with SI joint pain less than or equal to 5/10.,3. The patient will report 25% improvement in her functional and ADL activities.,4. Pain will be less than 4/10 while performing __________ while at PT session.,LONG-TERM GOALS TO BE ACCOMPLISHED IN ONE MONTH:,1. The patient will be independent with home exercise program.,2. Bilateral hamstring, bilateral hip internal and external rotation strength to be 4+/5 with SI joint pain less than or equal to 2/10, while performing manual muscle test.,3. The patient will report 60% improvement or greater in functional transfers in general ADL activity.,4. The patient will be able to sit greater than or equal to 45 minutes without complaint of lumbosacral pain.,5. The patient will be able to sleep greater than 2 hours without pain.,TREATMENT PLAN:,1. Therapeutic exercises to increase lower extremity strength and assist with lumbar sacral stability.nan