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| 1 | 2 | Hemiarthroplasty - Discharge Summary | ADMISSION DIAGNOSES: ,Fracture of the right femoral neck, also history of Alzheimer's dementia, and hypothyroidism.,DISCHARGE DIAGNOSES: , Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.,PROCEDURE PERFORMED: ,Hemiarthroplasty, right hip.,CONSULTATIONS: ,Medicine for management of multiple medical problems including Alzheimer's.,HOSPITAL COURSE: , The patient was admitted on 08/06/2007 after a fall with subsequent fracture of the right hip. The patient was admitted to Orthopedics and consulted Medicine. The patient was actually taken to the operating room, consent signed by durable power of attorney, taken on 08/06/2007, had right hip hemiarthroplasty, recovered without incidence. The patient had continued confusion and dementia, which is apparently his baseline secondary to his Alzheimer's. Brief elevation of white count following the surgery, which did subside. Studies, UA and blood culture were negative. The patient was stable and was discharged to Heartland.,CONDITION ON DISCHARGE: , Stable.,DISCHARGE INSTRUCTIONS:, Transfer to ABC for rehab and continued care. Diabetic diet. Activity, ambulate as tolerated with posterior hip precautions. Rehab potential fair. He will need nursing, Social Work, PT/OT, and nutrition consults. Resume home meds, DVT prophylaxis, aspirin, and compression stockings. Follow up Dr. X in one to two weeks; call 123-4567 for an appointment.discharge summary, femoral neck, orthopedics, rehab, femoral, neck, fracture, dementia, hemiarthroplasty, hip, |
| 2 | 1 | Plantar Fasciotomy | PREOPERATIVE DIAGNOSIS:, Plantar fascitis, left foot.,POSTOPERATIVE DIAGNOSIS: , Plantar fascitis, left foot.,PROCEDURE PERFORMED: , Partial plantar fasciotomy, left foot.,ANESTHESIA:, 10 cc of 0.5% Marcaine plain with TIVA.,HISTORY: ,This 35-year-old Caucasian female presents to ABCD General Hospital with above chief complaint. The patient states she has extreme pain with plantar fascitis in her left foot and has attempted conservative treatment including orthotics without long-term relief of symptoms and desires surgical treatment. The patient has been NPO since mid night. Consent is signed and in the chart. No known drug allergies.,Details Of Procedure: An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on the operating table in supine position with a safety belt across the stomach. Copious amounts of Webril were placed on the left ankle followed by blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was injected into the surgical site both medially and laterally across the plantar fascia. The foot was then prepped and draped in the usual sterile orthopedic fashion. An Esmarch bandage was applied for exsanguination and the pneumatic ankle tourniquet was inflated to 250 mmHg. The foot was then reflected on the operating, stockinet reflected, and the foot cleansed with a wet and dry sponge. Attention was then directed to the plantar medial aspect of the left heel. An approximately 0.75 cm incision was then created in the plantar fat pad over the area of maximal tenderness.,The incision was then deepened with a combination of sharp and blunt dissection until the plantar fascia was palpated. A #15 blade was then used to transect the medial and central bands of the plantar fascia. Care was taken to preserve the lateral fibroids. The foot was dorsiflexed against resistance as the fibers were released and there was noted to be increased laxity after release of the fibers on the plantar aspect of the foot indicating that plantar fascia has in fact been transacted. The air was then flushed with copious amounts of sterile saline. The skin incision was then closed with #3-0 nylon in simple interrupted fashion. Dressings consisted of #0-1 silk, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted throughout all digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to the PACU with vital signs stable and vascular status intact to the left foot. Intraoperatively, an additional 80 cc of 1% lidocaine was injected for additional anesthesia in the case. The patient is to be nonweightbearing on the left lower extremity with crutches. The patient is given postoperative pain prescriptions for Vicodin ES, one q3-4h. p.o. p.r.n. for pain as well as Celebrex 200 mg one p.o. b.i.d. The patient is to follow-up with Dr. X as directed.surgery, foot, plantar fasciotomy, plantar fascitis, plantar fascia, plantar, fasciotomy, ankle, medially, fascitis, fascia |
| 3 | 2 | Hysterectomy - Discharge Summary - 2 | ADMISSION DIAGNOSIS: , Microinvasive carcinoma of the cervix.,DISCHARGE DIAGNOSIS: , Microinvasive carcinoma of the cervix.,PROCEDURE PERFORMED: , Total vaginal hysterectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old, white female, gravida 7, para 5, last period mid March, status post tubal ligation. She had an abnormal Pap smear in the 80s, which she failed to followup on until this year. Biopsy showed a microinvasive carcinoma of the cervix and a cone biopsy was performed on 02/12/2007 also showing microinvasive carcinoma with a 1 mm invasion. She has elected definitive therapy with a total vaginal hysterectomy. She is aware of the future need of Pap smears.,PAST MEDICAL HISTORY: , Past history is significant for seven pregnancies, five term deliveries, and significant past history of tobacco use.,PHYSICAL EXAMINATION: , Physical exam is within normal limits with a taut normal size uterus and a small cervix, status post cone biopsy.,LABORATORY DATA AND DIAGNOSTIC STUDIES: , Chest x-ray was clear. Discharge hemoglobin 10.8.,HOSPITAL COURSE: , She was taken to the operating room on 04/02/2007 where a total vaginal hysterectomy was performed under general anesthesia. There was an incidental cystotomy at the time of the creation of the bladder flap. This was repaired intraoperatively without difficulty. Postoperative, she did very well. Bowel and bladder function returned quickly. She is ambulating well and tolerating a regular diet.,Routine postoperative instructions given and understood. Followup will be in ten days for a cystogram and catheter removal with followup in the office at that time. ,DISCHARGE MEDICATIONS:, Vicodin, Motrin, and Macrodantin at bedtime for urinary tract infection suppression. ,DISCHARGE CONDITION: , Good.,Final pathology report was free of residual disease.discharge summary, pap smear, total vaginal hysterectomy, hysterectomy, microinvasive, carcinoma, cervix, |
| 4 | 4 | Total Knee Arthoplasty - Right - 1 | PREOPERATIVE DIAGNOSIS:, Severe degenerative joint disease of the right knee.,POSTOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right knee.,PROCEDURE:, Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella. All components were cemented with Cobalt G.,ANESTHESIA:, Spinal.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , Less than 60 minutes.,The patient was taken to the Postanesthesia Care Unit in stable condition. The patient tolerated the procedure well.,INDICATIONS: ,The patient is a 51-year-old female complaining of worsening right knee pain. The patient had failed conservative measures and having difficulties with her activities of daily living as well as recurrent knee pain and swelling. The patient requested surgical intervention and need for total knee replacement.,All risks, benefits, expectations, and complications of surgery were explained to her in great detail and she signed informed consent. All risks including nerve and vessel damage, infection, and revision of surgery as well as component failure were explained to the patient and she did sign informed consent. The patient was given antibiotics preoperatively.,PROCEDURE DETAIL: ,The patient was taken to the operating suite and placed in supine position on the operating table. She was placed in the seated position and a spinal anesthetic was placed, which the patient tolerated well. The patient was then moved to supine position again and a well-padded tourniquet was placed on the right thigh. Right lower extremity was prepped and draped in sterile fashion. All extremities were padded prior to this.,The right lower extremity, after being prepped and draped in the sterile fashion, the tourniquet was elevated and maintained for less than 60 minutes in this case. A midline incision was made over the right knee and medial parapatellar arthrotomy was performed. Patella was everted. The infrapatellar fat pad was incised and medial and lateral meniscectomy was performed and the anterior cruciate ligament was removed. The posterior cruciate ligament was intact.,There was severe osteoarthritis of the lateral compartment on the lateral femoral condyle as well as mild-to-moderate osteoarthritis in the medial femoral compartment as well severe osteoarthritis along the patellofemoral compartment. The medial periosteal tissue on the proximal tibia was elevated to the medial collateral ligament and medial collateral ligament was left intact throughout the entirety of the case.,At the extramedullary tibial guide, an extended cut was made adjusting for her alignment. Once this was performed, excess bone was removed. The reamer was placed along on the femoral canal, after which a 6-degree valgus distal cut was made along the distal femur. Once this was performed, the distal femoral size in 3 degrees external rotation, 62.5-mm cutting block was placed in 3 degrees external rotation with anterior and posterior cuts as well as anterior and posterior Chamfer cuts remained in the standard fashion. Excess bone was removed.,Next, the tibia was brought anterior and excised to 71 mm. It was then punched in standard fashion adjusting for appropriate rotation along the alignment of the tibia. Once this was performed, a 71-mm tibial trial was placed as well as a 62.5-mm femoral trial was placed with a 12-mm polyethylene insert.,Next, the patella was cut in the standard fashion measuring 31 mm and a patella bed was placed. The knee was taken for range of motion; had excellent flexion and extension as well as adequate varus and valgus stability. There was no loosening appreciated. There is no laxity appreciated along the posterior cruciate ligament.,Once this was performed, the trial components were removed. The knee was irrigated with fluid and antibiotics, after which the cement was put on the back table, this being Cobalt G, it was placed on the tibia. The tibial components were tagged in position and placed on the femur. The femoral components were tagged into position. All excess cement was removed ___ placement of patella. It was tagged in position. A 12-mm polyethylene insert was placed; knee was held in extension and all excess cement was removed. The cement hardened with the knee in full extension, after which any extra cement was removed.,The wounds were copiously irrigated with saline and antibiotics, and medial parapatellar arthrotomy was closed with #2 Vicryl. Subcutaneous tissue was approximated with #2-0 Vicryl and the skin was closed with staples. The patient was awakened from general anesthetic, transferred to the gurney, and taken into postanesthesia care unit in stable condition. The patient tolerated the procedure well.orthopedic, degenerative joint disease, knee, total knee arthroplasty, biomet, cemented, cobalt g, arthoplasty, osteoarthritis, polyethylene, cruciate, ligament, patella, femoral, tibial, |
| 5 | 1 | Breast Radiation Therapy Followup | DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1. Glucosamine complex.,2. Toprol XL.,3. Alprazolam,4. Hydrochlorothiazide.,5. Dyazide.,6. Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck. She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area. As such, I feel that we could safely re-treat the lower neck. Her weight has increased to 189.5 from 185.2. She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK: On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area. No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY: Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected. No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN: Normal bowel sounds, no hepatomegaly. No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress. Thank you for having allowed me to participate in her care.obstetrics / gynecology, carboplatin, taxol, radiation therapy, breast adenocarcinoma, beam radiotherapy, chest wall, radiotherapy, supraclavicular, lymphadenopathy, adenocarcinoma, breast, |
| 6 | 4 | Hamstring Release | PREOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,POSTOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,PROCEDURE: , Left distal medial hamstring release.,ANESTHESIA: , General anesthesia. Local anesthetic 10 mL of 0.25% Marcaine local.,TOURNIQUET TIME: , 15 minutes.,ESTIMATED BLOOD LOSS: ,Minimal.,COMPLICATIONS: ,There were no intraoperative complications.,DRAIN: ,None.,SPECIMENS: ,None.,HISTORY AND PHYSICAL: ,The patient is a 12-year-old boy born at a 32-week gestation and with drug exposure in utero. The patient has diagnosis of autism as well. The patient presented with bilateral knee flexion contractures, initially worse on right than left. He had right distal medial hamstring release performed in February 2007 and has done quite well and has noted significant improvement in his gait and his ability to play. The patient presents now with worsening left knee flexion contracture, and desires the same procedure to be performed. Risks and benefits of the surgery were discussed. The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure to restore normal anatomy, continued contracture, possible need for other procedures. All questions were answered and mother and son agreed to above plan.,PROCEDURE NOTE: ,The patient was taken to operating room and placed supine on operating table. General anesthesia was administered. The patient received Ancef preoperatively. Nonsterile tourniquet was placed on the upper aspect of the patient's left thigh. The extremity was then prepped and draped in standard surgical fashion. The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg. Esmarch was then removed. A small 3 cm incision was made over the distal medial hamstring. Hamstring tendons were isolated and released in order of semitendinosus, semimembranosus, and sartorius. The wound was then irrigated with normal saline and closed used 2-0 Vicryl and then 4-0 Monocryl. The wound was cleaned and dried and dressed with Steri-Strips. The area was infiltrated with total 10 mL of 0.25% Marcaine. The wound was then covered with Xeroform, 4 x 4s, and Bias. Tourniquet was released at 15 minutes. The patient was then placed in knee immobilizer. The patient tolerated the procedure well and subsequently taken to recovery in stable condition.,POSTOPERATIVE PLAN: , The patient may weight bear as tolerated in his brace. He will start physical therapy in another week or two. The patient restricted from any PE for at least 6 week. He may return to school on 01/04/2008. He was given Vicodin for pain.orthopedic, medial hamstring release, distal medial hamstring release, bilateral knee flexion contractures, bilateral knee, hamstring release, knee flexion, tourniquet, flexion, contractures, hamstring, |
| 7 | 4 | Ruptured Globe Repair - Sclera and Limbus | PREOPERATIVE DIAGNOSIS: , Ruptured globe with uveal prolapse OX.,POSTOPERATIVE DIAGNOSIS:, Ruptured globe with uveal prolapse OX.,PROCEDURE: ,Repair of ruptured globe with repositing of uveal tissue OX.,ANESTHESIA: ,General,SPECIMENS:, None.,COMPLICATIONS:, None.,INDICATIONS: , This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE: , The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was carefully placed to provide exposure. A two-armed 7 mm scleral laceration was seen in the supranasal quadrant. The laceration involved the sclera and the limbus in this area. There was a small amount of iris tissue prolapsed in the wound. The Westcott scissors and 0.12 forceps were used to carefully dissect the conjunctiva away from the wound to provide exposure. A cyclodialysis spatula was used to carefully reposit the prolapsed iris tissue back into the anterior chamber. The anterior chamber remained formed and the iris tissue easily resumed its normal position. The pupil appeared round. An 8-0 nylon suture was used to close the scleral portion of the laceration. Three sutures were placed using the 8-0 nylon suture. Then 9-0 nylon suture was used to close the limbal portion of the wound. After the wound appeared closed, a Superblade was used to create a paracentesis at approximately 2 o'clock. BSS was injected through the paracentesis to fill the anterior chamber. The wound was checked and found to be watertight. No leaks were observed. An 8-0 Vicryl suture was used to reposition the conjunctiva and close the wound. Three 8-0 Vicryl sutures were placed in the conjunctiva. All scleral sutures were completely covered. The anterior chamber remained formed and the pupil remained round and appeared so at the end of the case. Subconjunctival injections of Ancef and dexamethasone were given at the end of the case as well as Tobradex ointment. The lid speculum was carefully removed. The drapes were carefully removed. Sterile saline was used to clean around the XXX eye as well as the rest of the face. The area was carefully dried and an eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia without difficulty. (S)he was taken to the recovery area in good condition. There were no complications.ophthalmology, ruptured globe, bss, subconjunctival, bleeding, conjunctiva, eye patch, infection, limbus, loss of the eye, loss of vision, re-operation, scleral laceration, supranasal quadrant, uveal prolapse, wire lid speculum, iris tissue, anterior chamber, laceration, iris, chamber, ruptured, globe, eye, |
| 8 | 3 | Mediastinal Exploration | TITLE OF OPERATION:, Mediastinal exploration and delayed primary chest closure.,INDICATION FOR SURGERY:, The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. The patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass. The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago. She did not meet the criteria for delayed primary chest closure.,PREOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,POSTOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,ANESTHESIA:, General endotracheal.,COMPLICATIONS:, None.,FINDINGS: , No evidence of intramediastinal purulence or hematoma. At completion of the procedure no major changes in hemodynamic performance.,DETAILS OF THE PROCEDURE: , After obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position. Following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed. The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed. The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned. Through a separate incision and another 15-French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV-PA connection as well as inferior most aspect of the ventriculotomy. The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires. The subcutaneous tissue and skin were closed in layers. There was no evidence of significant increase in central venous pressure or desaturation. The patient tolerated the procedure well. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition.,I was the surgical attending present in the operating room in charge of the surgical procedure throughout the entire length of the case.cardiovascular / pulmonary, mediastinal exploration, delayed primary chest closure, extracorporeal membrane oxygenation, stage i norwood procedure, sano modification, chest closure, infant, mediastinal, exploration, closure, endotracheal, chest |
| 9 | 3 | Normal ROS Template - 5 | REVIEW OF SYSTEMS,GENERAL: Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: Negative rash, negative jaundice.,HEMATOPOIETIC: Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor. No history of strokes, no history of other neurologic conditions.,EYES: Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS: Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT: Negative postnasal drip, negative sore throat.,CARDIOVASCULAR: Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema. No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY: No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL: Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY: Negative frequency, negative urgency, negative dysuria, negative incontinence. No history of STDs. **No history of OB/GYN problems.,MUSCULOSKELETAL: Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC: See psychiatric evaluation.,ENDOCRINE: No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.general medicine, respiratory, gastrointestinal, integumentary, hematopoietic, night sweats, negative allergies, negative weakness, neurologic, throat, weakness |
| 10 | 1 | Total Abdominal Hysterectomy - 2 | PREOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Pelvic pain.,3. Pelvic endometriosis.,PROCEDURE PERFORMED: ,Total abdominal hysterectomy.,ANESTHESIA: , General endotracheal and spinal with Astramorph.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 200 cc.,FLUIDS: ,2400 cc of crystalloids.,URINE OUTPUT: , 100 cc of clear urine.,INDICATIONS:, This is a 40-year-old female gravida-0 with a history of longstanding enlarged fibroid uterus. On ultrasound, the uterus measured 14 cm x 6.5 cm x 7.8 cm. She had received two dosage of Lupron to help shrink the fibroid. Her most recent Pap smear was normal.,FINDINGS: , On a manual exam, the uterus is enlarged approximately 14 to 16 weeks size with multiple fibroids palpated. On laparotomy, the uterus did have multiple pedunculated fibroids, the largest being approximately 7 cm. The bilateral tubes and ovaries appeared normal.,There was evidence of endometriosis on the posterior wall of the uterus as well as the bilateral infundibulopelvic ligament. There was some adhesions of the bowel to the left ovary and infundibulopelvic ligament and as well as to the right infundibulopelvic ligament.,PROCEDURE:, After consent was obtained, the patient was taken to the operating room where spinal anesthetic was first administered and then general anesthetic. The patient was placed in the dorsal supine position and prepped and draped in normal sterile fashion. A Pfannenstiel skin incision was made and carried to the underlying Mayo fashion using the second knife. The fascia was incised in midline and the incision extended laterally using Mayo scissors. The superior aspect of the fascial incision was grasped with Kocher clamps, tented up, and dissected off the underlying rectus muscle both bluntly and sharply with Mayo scissors. Attention was then turned to the inferior aspect of the incision, which in a similar fashion was grasped with Kocher clamps, tented up and dissected off the underlying rectus muscles. The rectus muscles were separated in the midline and the peritoneum was identified, grasped with hemostat, and entered sharply with Metzenbaum scissors. This incision was extended superiorly and inferiorly with good visualization of the bladder. The uterus was then brought up out of the incision. The bowel adhesions were carefully taken down using Metzenbaum scissors. Good hemostasis was noted at this point. The self-retaining retractor was then placed. The bladder blade was placed. The bowel was gently packed with moist laparotomy sponges and held in place with the blade on the GYN extension. The uterus was then grasped with a Lahey clamp and brought up out of the incision. The left round ligament was identified and grasped with Allis clamp and tented up. A hemostat was passed in the avascular area beneath the round ligament. A suture #0 Vicryl was used to suture ligate the round ligament. Two hemostats were placed across the round ligament proximal to the previously placed suture and the Mayo scissors were used to transect the round ligament. An avascular area of the broad ligament was then identified and entered bluntly. The suture of #0 Vicryl was then used to suture ligate the left uterovarian ligament. Two straight Ochsner's were placed across the uterovarian ligament proximal to the previous suture. The ligament was then transected and suture ligated with #0 Vicryl. Attention was then turned to the right round ligament, which in a similar fashion was tented up with an Allis clamp. An avascular area was entered beneath the round ligament using a hemostat and the round ligament was suture ligated and transected. An avascular area of the broad ligament was then entered bluntly and the right uterovarian ligament was then suture ligated with #0 Vicryl.,Two straight Ochsner's were placed across the ligament proximal to previous suture. This was then transected and suture ligated again with #0 Vicryl. The left uterine peritoneum was then identified and grasped with Allis clamps. The vesicouterine peritoneum was then transected and then entered using Metzenbaum scissors. This incision was extended across the anterior portion of the uterus and the bladder flap was taken down. It was sharply advanced with Metzenbaum scissors and then bluntly using a moist Ray-Tec. The Ray-Tec was left in place at this point to ensure that the bladder was below the level of the cervix. The bilateral uterine arteries then were skeletonized with Metzenbaum scissors and clamped bilaterally using straight Ochsner's. Each were then transected and suture ligated with #0 Vicryl. A curved Ochsner was then placed on either side of the cervix. The tissue was transected using a long knife and suture ligated with #0 Vicryl. Incidentally, prior to taking down the round ligaments, a pedunculated fibroid and the right fundal portion of the uterus was injected with Vasopressin and removed using a Bovie. The cervix was then grasped with a Lahey clamp. The cervicovaginal fascia was then taken down first using the long-handed knife and then a back handle of the knife to bring the fascia down below the level of the cervix. A double-pointed scissors were used to enter the vaginal vault below the level of the cervix. A straight Ochsner was placed on the vaginal vault. The Jorgenson scissors were used to amputate the cervix and the uterus off of the underlying vaginal tissue. The vaginal cuff was then reapproximated with #0 Vicryl in a running locked fashion and the pelvis was copiously irrigated. There was a small area of bleeding noted on the underside of the bladder. The bladder was tented up using an Allis clamp and a figure-of-eight suture of #3-0 Vicryl was placed with excellent hemostasis noted at this point. The uterosacral ligaments were then incorporated into the vaginal cuff and the cuff was synched down. A figure-of-eight suture of #0 Vicryl was placed in the midline of the vaginal cuff in attempt to incorporate the bilateral round ligament. The round ligament was too short. It would be a maximal amount of stretch to incorporate, therefore, only the left round ligament was incorporated into the vaginal cuff. The bilateral adnexal areas were then re-peritonealized with #3-0 Vicryl in a running fashion. The bladder flap was reapproximated to the vaginal cuff using one interrupted suture. The pelvis was again irrigated at this point with excellent hemostasis noted. Approximately 200 cc of saline with methylene blue was placed into the Foley to inflate the bladder. There was no spillage of blue fluid into the abdomen. The fluid again was allowed to drain. All sponges were then removed and the bowel was allowed to return to its anatomical position. The peritoneum was then reapproximated with #0 Vicryl in a running fashion. The fascia was reapproximated also with #0 Vicryl in a running fashion. The skin was then closed with staples.,A previously placed Betadine soaked Ray-Tec was removed from the patient's vagina and sponge stick was used to assess any bleeding in the vaginal vault. There was no appreciable bleeding. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2. The patient was taken to the recovery room in satisfactory condition. She will be followed immediately postoperatively within the hospital.surgery, pelvic pain, pelvic endometriosis, astramorph, total abdominal hysterectomy, enlarged fibroid, metzenbaum scissors, vaginal cuff, scissors, vaginal, uterus, ligament, hysterectomy, endometriosis, pedunculated, fibroids, infundibulopelvic, uterovarian, abdominal, laparotomy, peritoneum, |
| 11 | 2 | Single Frontal View - Chest - Pediatric | EXAM:, Single frontal view of the chest.,HISTORY:, Respiratory distress. The patient has a history of malrotation. The patient is back for a re-anastomosis of the bowel with no acute distress.,TECHNIQUE:, Single frontal view of the chest was evaluated and correlated with the prior film dated MM/DD/YY.,FINDINGS:, A single frontal view of the chest was evaluated. It reveals interval placement of an ET tube and an NG tube. ET tube is midway between the patient's thoracic inlet and carina. NG tube courses with the distal tip in the left upper quadrant beneath the left hemidiaphragm. There is no evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions. The mediastinum seen was slightly prominent; however, this may be secondary to thymus and/or technique. There is a slight increase seen with regards to the central pulmonary vessels. Again, this may represent a minimal amount of pulmonary vascular congestion. There is paucity of bowel gas seen in the upper abdomen. The osseous thorax appears to be grossly intact and symmetrical. Slightly low lung volumes, however, this may be secondary to the film being taken on the expiratory phase of respiration.,IMPRESSION:,1. No evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions.,2. Slight prominence to the mediastinum which may be secondary to thymus and/or technique.,3. Slight prominence of some of the central pulmonary vasculature which may represent a minimal amount of vascular congestion.radiology, malrotation, consolidation, pneumothoraces, single frontal view, respiratory distress, vascular congestion, frontal view, effusions, mediastinum, vascular, congestion, respiratory, anastomosis, pulmonary, single, frontal, chest |
| 12 | 2 | CT Maxillofacial | EXAM: ,CT maxillofacial for trauma.,FINDINGS: , CT examination of the maxillofacial bones was performed without contrast. Coronal reconstructions were obtained for better anatomical localization.,There is normal appearance to the orbital rims. The ethmoid, sphenoid, and frontal sinuses are clear. There is polypoid mucosal thickening involving the floor of the maxillary sinuses bilaterally. There is soft tissue or fluid opacification of the ostiomeatal complexes bilaterally. The nasal bones appear intact. The zygomatic arches are intact. The temporomandibular joints are intact and demonstrate no dislocations or significant degenerative changes. The mandible and maxilla are intact. There is soft tissue swelling seen involving the right cheek.,IMPRESSION:,1. Mucosal thickening versus mucous retention cyst involving the maxillary sinuses bilaterally. There is also soft tissue or fluid opacification of the ostiomeatal complexes bilaterally.,2. Mild soft tissue swelling about the right cheek.radiology, ethmoid, sphenoid, frontal sinuses, mandible, maxilla, ct examination, maxillofacial bones, mucosal thickening, maxillary sinuses, ct, maxillofacial |
| 13 | 1 | LEEP | DIAGNOSIS:,1. Broad-based endocervical poly.,2. Broad- based pigmented, raised nevus, right thigh.,OPERATION:,1. LEEP procedure of endocervical polyp.,2. Electrical excision of pigmented mole of inner right thigh.,FINDINGS: , There was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised with a wire loop. Also, there was a butt-based, 1-cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal.,PROCEDURE: , With the patient in the supine position, general anesthesia was administered. The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.,An insulated posterior weighted retractor was put in. Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation. The endocervical polyp on the posterior lip of the cervix was excised.,Then changing from a 50 of coagulation and 5 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding. The wire loop was attached, and the pigmented raised nevus on the inner thigh was excised with the wire loop. Cautery of the base was done, and then it was closed with figure-of-eight 3-0 Vicryl sutures. A band-aid was applied over this.,Rechecking the cervix, no bleeding was noted. The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition.surgery, endocervical polyp, pigmented mole, polyp, leep tenaculum, leep, cervix, endocervical, pigmented |
| 14 | 1 | Cholangiopancreatography (Endoscopic) | PROCEDURE:, Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,INDICATION FOR THE PROCEDURE:, Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,MEDICATIONS:, General anesthesia.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, aspiration, and post ERCP pancreatitis.,DESCRIPTION OF PROCEDURE:, After informed consent and appropriate sedation, the duodenoscope was inserted into the oropharynx, down the esophagus, and into the stomach. The scope was then advanced through the pylorus to the ampulla. The ampulla had a markedly abnormal appearance, as it was enlarged and very prominent. It extended outward with an almost polypoid shape. It had what appeared to be adenomatous-appearing mucosa on the tip. There also was ulceration noted on the tip of this ampulla. The biliary and pancreatic orifices were identified. This was located not at the tip of the ampulla, but rather more towards the base. Cannulation was performed with a Wilson-Cooke TriTome sphincterotome with easy cannulation of the biliary tree. The common bile duct was mildly dilated, measuring approximately 12 mm. The intrahepatic ducts were minimally dilated. There were no filling defects identified. There was felt to be a possible stricture within the distal common bile duct, but this likely represented an anatomic variant given the abnormal shape of the ampulla. The patient has no evidence of obstruction based on lab work and clinically. Nevertheless, it was decided to proceed with brush cytology of this segment. This was done without any complications. There was adequate drainage of the biliary tree noted throughout the procedure. Multiple efforts were made to access the pancreatic ductal anatomy; however, because of the shape of the ampulla, this was unsuccessful. Efforts were made to proceed in a long scope position, but still were unsuccessful. Next, biopsies were obtained of the ampulla away from the biliary orifice. Four biopsies were taken. There was some minor oozing which had ceased by the end of the procedure. The stomach was then decompressed and the endoscope was withdrawn.,FINDINGS:,1. Abnormal papilla with bulging, polypoid appearance, and looks adenomatous with ulceration on the tip; biopsies taken.,2. Cholangiogram reveals mildly dilated common bile duct measuring 12 mm and possible distal CBD stricture, although I think this is likely an anatomic variant; brush cytology obtained.,3. Unable to access the pancreatic duct.,RECOMMENDATIONS:,1. NPO except ice chips today.,2. Will proceed with MRCP to better delineate pancreatic ductal anatomy.,3. Follow up biopsies and cytology.surgery, cholangiogram, ercp, endoscopic, endoscopic retrograde cholangiopancreatography, mrcp, wilson-cooke tritome sphincterotome, abdominal pain, ampulla, bile duct, brush cytology, cholangiopancreatography, pancreatitis, papilla, polypoid, retrograde cholangiopancreatography, cholangiopancreatography with brush cytology, brush cytology and biopsy, shape of the ampulla, pancreatic ductal anatomy, common bile duct, cannulation, brush, pancreatic, cytology |
| 15 | 1 | Delivery Note - 7 | DELIVERY NOTE:, The patient is a 29-year-old gravida 6, para 2-1-2-3, who has had an estimated date of delivery at 01/05/2009. The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes at 2000 hours on 12/26/2008. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting. She was Group B Streptococcus positive, however, was 5 cm dilated. The patient was started on Group B Streptococcus prophylaxis with ampicillin. She received a total of three doses throughout her labor. Her pregnancy was complicated by scanty prenatal care. She would frequently miss visits. At 37 weeks, she claims that she had a suspicious bump on her left labia. There was apparently no fluid or blistering of the lesion. Therefore, it was not cultured by the provider; however, the patient was sent for serum HSV antibody levels, which she tested positive for both HSV1 and HSV2. I performed a bright light exam and found no lesions anywhere on the vulva or in the vault as per sterile speculum exam and consulted with Dr. X, who agreed that since the patient seems to have no active lesion that she likely has had a primary outbreak in the past and it is safe to proceed with the vaginal delivery. The patient requested an epidural anesthetic, which she received with very good relief. She had IV Pitocin augmentation of labor and became completely dilated per my just routine exam just after 6 o'clock and was set up for delivery and the patient pushed very effectively for about one and a half contractions. She delivered a viable female infant on 12/27/2008 at 0626 hours delivering over an intact perineum. The baby delivered in the occiput anterior position. The baby was delivered to the mother's abdomen where she was warm, dry, and stimulated. The umbilical cord was doubly clamped and then cut. The baby's Apgars were 8 and 9. The placenta was delivered spontaneously intact. There was a three-vessel cord with normal insertion. The fundus was massaged to firm and Pitocin was administered through the IV per unit protocol. The perineum was inspected and was found to be fully intact. Estimated blood loss was approximately 400 mL. The patient's blood type is A+. She is rubella immune and as previously mentioned, GBS positive and she received three doses of ampicillin.obstetrics / gynecology, nitrazine pull and fern, rupture of membranes, spontaneous, membranes, nitrazine, streptococcus, pitocin, perineum, hsv, laborNOTE,: 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., |
| 16 | 1 | Tarsectomy | PREOPERATIVE DIAGNOSES:,1. Painful enlarged navicula, right foot.,2. Osteochondroma of right fifth metatarsal.,POSTOPERATIVE DIAGNOSES:,1. Painful enlarged navicula, right foot.,2. Osteochondroma of right fifth metatarsal.,PROCEDURE PERFORMED:,1. Partial tarsectomy navicula, right foot.,2. Partial metatarsectomy, right foot.,HISTORY: ,This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint. The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin. She states that she has been diagnosed with hereditary osteochondromas. She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back. The patient desires surgical treatment at this time.,PROCEDURE: ,An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap. Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal. Foot was then prepped and draped in the usual sterile orthopedic fashion.,Foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was then inflated to 250 mmHg. The foot was lowered as well as the operating table. The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge. Attention was then directed to the navicular region on the right foot. The area was palpated until the bony prominence was noted. A curvilinear incision was made over the area of bony prominence. At that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site. The incision was then deepened with #15 blade. All vessels encountered were ligated for hemostasis. The dissection was carried down to the level of the capsule and periosteum. A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone. The periosteum and the capsule were then reflected from the navicular bone at this time. A bony prominence was noted both medially and plantarly to the navicular bone. An osteotome and mallet were then used to resect the enlarged portion of the navicular bone. After resection with an osteotome there was noted to be a large plantar shelf. The surrounding soft tissues were then freed from this plantar area. Care was taken to protect the attachments of the posterior tibial tendon as much as possible. Only minimal resection of its attachment to the fiber was performed in order to expose the bone. Sagittal saw was then used to resect the remaining plantar medial prominent bone. The area was then smoothed with reciprocating rasp until no sharp edges were noted. The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted. The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl. The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed.,Attention was then directed to the fifth metatarsal. There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal. Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal. The incision was then deepened with #15 blade. Care was taken to preserve the extensor tendon. The incision was then created over the capsule and periosteum of the fifth metatarsal head. Capsule and periosteum were reflected both dorsally, laterally, and plantarly. At that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal. A sagittal saw was used to resect both of these osteal prominences.,All remaining sharp edges were then smoothed with reciprocating rasp. The area was inspected for the remaining bony prominences and none was noted. The area was flushed with copious amounts of sterile saline. The capsule and periosteum were then reapproximated with #3-0 Vicryl. Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line. Running #5-0 subcutaneous stitch was then performed. Steri-Strips were applied to both surgical sites. Dressings consisted of Adaptic, soaked in Betadine, 4x4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,The patient tolerated the above procedure and anesthesia well without complications. The patient was transferred to the PACU with vital signs stable and vascular status intact. The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated. The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise.surgery, navicula, metatarsal, osteochondroma, tarsectomy, metatarsectomy, painful enlarged navicula, navicular bone, foot, bony, capsule, periosteum, navicular, incision, bone |
| 17 | 1 | Total Abdominal Hysterectomy - 3 | PREOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Abnormal uterine bleeding.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Abnormal uterine bleeding.,PROCEDURE PERFORMED: , Total abdominal hysterectomy with a uterosacral vault suspension.,ANESTHESIA: , General with endotracheal tube as well as spinal with Astramorph.,ESTIMATED BLOOD LOSS: , 150 cc.,URINE OUTPUT: ,250 cc of clear urine at the end of the procedure.,FLUIDS:, 2000 cc of crystalloids.,COMPLICATIONS: , None.,TUBES: , None.,DRAINS: ,Foley to gravity.,PATHOLOGY: , Uterus, cervix, and multiple fibroids were sent to pathology for review.,FINDINGS: ,On exam, under anesthesia, normal appearing vulva and vagina, a massively enlarged uterus approximately 20 weeks' in size with irregular contours suggestive of fibroids.,Operative findings demonstrated a large fibroid uterus with multiple subserosal and intramural fibroids as well as there were some filmy adnexal adhesions bilaterally. The appendix was normal appearing. The bowel and omentum were normal appearing. There was no evidence of endometriosis. Peritoneal surfaces and vesicouterine peritoneum as well as appendix and cul-de-sac were all free of any evidence of endometriosis.,PROCEDURE:, After informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the Operating Room where first a spinal anesthesia with Astramorph was obtained without any difficulty. She then underwent a general anesthesia with endotracheal tube also without any difficulty. She was then examined under anesthesia with noted findings as above. The patient was then placed in dorsal supine position and prepped and draped in the usual sterile fashion.. A vertical skin incision was made 1 cm below the umbilicus extending down to 2 cm above the pubic symphysis. This was made with a first knife and then carried down to the underlying layer of the fascia with the second knife. Fascia was excised in the midline and extended superiorly and inferiorly with the Mayo scissors. The rectus muscle was then separated in the midline. The peritoneum identified and entered bluntly. The peritoneal incision was then extended superiorly and inferiorly with external visualization of the bladder. The uterus was markedly evident upon entering the peritoneal cavity. The uterus was then exteriorized and noted to have the findings as above. At this point, approximately 10 cc of vasopressin 20 units and 30 cc was injected into the uterine fundus and multiple fibroids were removed by using the incision with the Bovie and then using a blunt and the sharp dissection and grasping with Lahey clamps. Once the debulking of the uterus was felt appropriate to proceed with the hysterectomy, the uterus was then reapproximated with a few #0 Vicryl sutures in a figure-of-eight fashion. The round ligaments were identified bilaterally and clamped with the hemostats and transacted with the Metzenbaum scissors. The round ligaments were then bilaterally tied with the #0 tie and noted to be hemostatic. The uterovarian vessels bilaterally were then isolated through a vascular window created from taking down the round ligaments. The uterovarian vessels bilaterally were #0 tied and then doubly clamped with straight Ochsner clamps and transacted and suture tied with a Heaney hand stitch fashion, and both uterine and ovarian vessels were noted to be hemostatic. At this time, the attention was then turned to the vesicouterine peritoneum, which was tented up with Allis clamps and the bladder flap was then created sharply with Russian pickups and the Metzenbaum scissors. Then the bladder was bluntly dissected off the underlying cervix with a moist Ray-Tec sponge down to the level of the cervix.,At this point, the uterus was pulled on traction and the uterosacral ligaments were easily visualized. Using #2-0 PDS suture, the suture was placed through both uterosacral ligaments distally with a backhand stitch fashion throwing the sutures from lateral to medial. These sutures were then tagged and saved for later. The uterine vessels were then identified bilaterally and skeletonized, then clamped with straight Ochsner clamps balancing off the cervix, and the uterine vessels were then transacted and suture ligated with #0 Vicryl and noted to be hemostatic. In a similar fashion, the broad ligament down to the level of the cardinal ligaments was clamped with curved Ochsner and transacted and suture ligated and noted to be hemostatic. At this point, the Lahey clamp was placed on the cervix and the cervix was tented up. The pubocervical vesical fascia was transacted with long knife. Then while protecting posteriorly, using the double-pointed scissors, the vagina was entered with double-pointed scissors at the level of the cervix and was grasped with a straight Ochsner clamp. The uterus and cervix were then amputated using the Jorgenson scissors and the cuff was outlined with Ochsner clamps. The cuff was then copiously painted with Betadine soaked sponge. The Betadine-soaked sponge was placed in the patient's vagina. Then the cuff was then closed with a #0 Vicryl in a running locked fashion to make sure to bring the ipsilateral cardinal ligaments into the vaginal cuff. This was accomplished with one #0 Vicryl running stitch and then an Allis clamp was placed in the midsection portion of the cuff and tented up and a #0 Vicryl figure-of-eight was placed in the midsection portion of the cuff. At this time, the uterosacral ligaments previously tagged needle was brought through the cardinal ligament and the uterosacral ligament on the ipsilateral side. The needle was cut off and these were then tagged with the hemostats. The cuff was then closed by taking the running suture and bringing back through the posterior peritoneum, grabbing part of the uterosacral and midsection portion of the posterior peritoneum of the uterosacral and then tying the cuff down to bunch and cuff together. The suture in the midportion of the cuff was then used to tie down the round ligaments bilaterally to the cuff. The abdomen was copiously irrigated with warm normal saline. All areas were noted to be hemostatic. Then the previously tagged uterosacral sutures were then tied bringing the vaginal cuff angles down to the uterosacral ligaments. The abdomen was then once again copiously irrigated with warm normal saline. All areas were noted to be hemostatic. The sigmoid colon was replaced back into the hollow of the sacrum. Then the omentum was pulled over the bowel. After the myomectomy was performed, the GYN Balfour was placed into the patient's abdomen and the bowel was packed away with moist laparotomy sponges. The GYN Balfour was then removed. Packing sponges were removed and the fascia was then closed in an interrupted figure-of-eight fashion with #0 Vicryl.,Skin was closed with staples. The patient tolerated the procedure well. The sponge, lap, and needle counts were correct x2. The sponge from the patient's vagina was removed and the vagina was noted to be hemostatic. The patient would be followed throughout her hospital stay.nan |
| 18 | 1 | Nasal Septal Reconstruction | PREOPERATIVE DIAGNOSES:,1. Chronic nasal obstruction secondary to deviated nasal septum.,2. Inferior turbinate hypertrophy.,POSTOPERATIVE DIAGNOSES:,1. Chronic nasal obstruction secondary to deviated nasal septum.,2. Inferior turbinate hypertrophy.,PROCEDURE PERFORMED:,1. Nasal septal reconstruction.,2. Bilateral submucous resection of the inferior turbinates.,3. Bilateral outfracture of the inferior turbinates.,ANESTHESIA:, General endotracheal tube.,BLOOD LOSS: , Minimal less than 25 cc.,INDICATIONS: , The patient is a 51-year-old female with a history of chronic nasal obstruction. On physical examination, she was derived to have a severely deviated septum with an S-shape deformity as well as turbinate hypertrophy present along the inferior turbinates contributing to the obstruction.,PROCEDURE: ,After all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained. The patient was brought to the Operating Suite where she was placed in the supine position and general endotracheal intubation was delivered by the Department of Anesthesia. The patient was rotated 90 degrees away. Nasal pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavities. These were then removed and the nasal septum as well as the turbinates were localized with the mixture of 1% lidocaine with 1:100000 epinephrine solution. The nasal pledgets were then reinserted as the patient was prepped in the usual fashion. The nasal pledgets were again removed and the turbinates as well as an infraorbital nerve block was performed with 0.25% Marcaine solution. The nasal vestibules were then cleansed with a pHisoHex solution. A #15 blade scalpel was then used to make an incision along the length of the caudal septum. The mucoperichondrial junction was then identified with the aid of cotton-tipped applicator as well as the stitch scissor. Once the plane was identified, the mucosal flap on the left side of the septum was elevated with the aid of a Cottle. At this point it should be mentioned that the patient's septum was significantly deviated with a large S-shape deformity obstructing both the right and left nasal cavity with the convex portion present in the left nasal cavity. Again, the Cottle elevator was used to raise the mucosal flap down to the level of the septal spur. At this point, the septal knife was used to make a crossover incision through the cartilage just anterior to the septal spur. Again, the mucosal flap was elevated in the right nasal septum. Now Knight scissors were used to remove the ascending portion of the nasal cartilage, which was then removed with a Takahashi forceps. A Cottle elevator was used to further elevate the mucosal flap off the septal spur on the left side. Removal of the spur was performed with the aid of the septal knife as well as a 3 mm straight chisel. Once all ascending cartilage has been removed, inspection of the nasal cavity revealed patent passages with the exception of inferior turbinates that were very hypertrophied and was felt to be contributing to the patient's symptoms. Therefore, the turbinates were again localized and a #15 blade scalpel was used to make a vertical incision dissected down to the chondral bone. The XPS microdebrider with the inferior turbinate blade was then inserted through the incision and a submucous resection was performed by passing the microdebrider along the length of the bone. Once the submucosal tissue had been resected, an outfracture procedure was performed so as to fully open the nasal passages. Inspection revealed very patent and nonobstructive nasal passages. Now the caudal incision was reapproximated with #4-0 chromic suture. Finally, a #4-0 fast absorbing plain gut suture was used to approximate the mucosal surface of the septum in a running whipstitch fashion. Finally, Merocel packing was placed and the patient was retuned to the Department of Anesthesia for awakening and taken to the recovery room without incident.ent - otolaryngology, chronic nasal obstruction, nasal septum, inferior turbinate hypertrophy, nasal septal reconstruction, submucous resection, inferior turbinates, outfracture, nasal septal, nasal pledgets, nasal cavity, nasal obstruction, turbinate hypertrophy, mucosal flap, septal, septum, turbinates, nasal, cavity, chronic, hypertrophy, obstruction, mucosal, |
| 19 | 1 | Brachytherapy | PREOPERATIVE DIAGNOSIS:, Prostate cancer.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer.,OPERATIONS: , Brachytherapy, iodine-125 seed implantation, and cystoscopy.,ANESTHESIA:, LMA.,ESTIMATED BLOOD LOSS: , Minimal.,Total number of seeds placed, 63. Needles, 24.,BRIEF HISTORY OF THE PATIENT: , This is a 57-year-old male who was seen by us for elevated PSA. The patient had a prostate biopsy with T2b disease, Gleason 6. Options such as watchful waiting, robotic prostatectomy, seed implantation with and without radiation were discussed. Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, incontinence, rectal dysfunction, voiding issues, burning pain, unexpected complications such as fistula, rectal injury, urgency, frequency, bladder issues, need for chronic Foley for six months, etc., were discussed. The patient understood all the risks, benefits, and options, and wanted to proceed with the procedure. The patient was told that there could be other unexpected complications. The patient has history of urethral stricture. The patient was told about the risk of worsening of the stricture with radiation. Consent was obtained.,DETAILS OF THE OPERATION: , The patient was brought to the OR. Anesthesia was applied. The patient was placed in the dorsal lithotomy position. The patient had SCDs on. The patient was given preop antibiotics. The patient had done bowel prep the day before. Transrectal ultrasound was performed. The prostate was measured at about 32 gm. The images were transmitted to the computer system for radiation oncologist to determine the dosing etc. Based on the computer analysis, the grid was placed. Careful attention was drawn to keep the grid away from the patient. There was a centimeter distance between the skin and the grid. Under ultrasound guidance, the needles were placed, first in the periphery of the prostate, a total of 63 seeds were placed throughout the prostate. A total of 24 needles was used. Careful attention was drawn to stay away from the urethra. Under longitudinal ultrasound guidance, all the seeds were placed. There were no seeds visualized in the bladder under ultrasound. There was only one needle where the seeds kind of dragged as the needle was coming out on the left side and were dropped out of position. Other than that, all the seeds were very well distributed throughout the prostate under fluoroscopy. Please note that the Foley catheter was in place throughout the procedure. Prior to the seed placement, the Foley was attempted to be placed, but we had to do it using a Glidewire to get the Foley in and we used a Councill-tip catheter. The patient has had history of bulbar urethral stricture. Pictures were taken of the strictures in the pre-seed placement cysto time frame. We needed to do the cystoscopy and Glidewire to be able to get the Foley catheter in. At the end of the procedure, again cystoscopy was done, the entire bladder was visualized. The stricture was wide open. The prostate was slightly enlarged. The bladder appeared normal. There was no sheath inside the urethra or in the bladder. The cysto was done using 30-degree and 70-degree lens. At the end of the procedure, a Glidewire was placed, and 18 Councill-tip catheter was placed. The plan was for Foley to be left in place overnight since the patient has history of urethral strictures. The patient is to follow up tomorrow to have the Foley removed. The patient could also be shown to have it removed at home.,The patient was brought to Recovery in stable condition at the end of the procedure. The patient tolerated the procedure well.urology, iodine-125 seed implantation, seed implantation, prostate cancer, cystoscopy, brachytherapy, councill tip catheter, brachytherapy iodine, ultrasound, catheter, urethral, prostate, |
| 20 | 3 | Esophagogastroduodenoscopy - 2 | PROCEDURE:, Esophagogastroduodenoscopy with biopsy.,REASON FOR PROCEDURE:, The child with history of irritability and diarrhea with gastroesophageal reflux. Rule out reflux esophagitis, allergic enteritis, and ulcer disease, as well as celiac disease. He has been on Prevacid 7.5 mg p.o. b.i.d. with suboptimal control of this irritability.,Consent history and physical examinations were performed. The procedure, indications, alternatives available, and complications i.e. bleeding, perforation, infection, adverse medication reactions, possible need for blood transfusion, and surgery associated complication occur were discussed with the mother who understood and indicated this. Opportunity for questions was provided and informed consent was obtained.,MEDICATIONS: ,General anesthesia.,INSTRUMENT: , Olympus GIF-XQ 160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,FINDINGS: , With the patient in the supine position intubated under general anesthesia, the endoscope was inserted without difficulty into the hypopharynx. The proximal, mid, and distal esophagus had normal mucosal coloration and vascular pattern. Lower esophageal sphincter appeared normal and was located at 25 cm from the central incisors. A Z-line was identified within the lower esophageal sphincter. The endoscope was advanced into the stomach, which was distended with excess air. The rugal folds flattened completely. The gastric mucosa was entirely normal. No hiatal hernia was seen and the pyloric valve appeared normal. The endoscope was advanced into first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern. Ampule of Vater was identified and found to be normal. Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology. Additional two antral biopsies were obtained for CLO testing. Excess air was evacuated from the stomach. The scope was removed from the patient who tolerated the procedure well. The patient was taken to recovery room in satisfactory condition.,IMPRESSION:, Normal esophagus, stomach, and duodenum.,PLAN:, Histologic evaluation and CLO testing. Continue Prevacid 7.5 mg p.o. b.i.d. I will contact the parents next week with biopsy results and further management plans will be discussed at that time.gastroenterology, olympus gif-xq 160, diarrhea, gastroesophageal, esophagitis, reflux, clo testing, esophagogastroduodenoscopy with biopsy, endoscope, esophagus, stomach, duodenum, esophagogastroduodenoscopy |
| 21 | 1 | Ear Cartilage Graft | PREOPERATIVE DIAGNOSES: ,1. Posttraumatic nasal deformity.,2. Nasal obstruction.,3. Nasal valve collapse.,4. Request for cosmetic change with excellent appearance of nose.,POSTOPERATIVE DIAGNOSES:,1. Posttraumatic nasal deformity.,2. Nasal obstruction.,3. Nasal valve collapse.,4. Request for cosmetic change with excellent appearance of nose.,OPERATIVE PROCEDURES:,1. Left ear cartilage graft.,2. Repair of nasal vestibular stenosis using an ear cartilage graft.,3. Cosmetic rhinoplasty.,4. Left inferior turbinectomy.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is with symptomatic nasal obstruction and fixed nasal valve collapse following a previous nasal fracture and attempted repair. We discussed with the patient the indications, risks, benefits, alternatives, and complications of the proposed surgical procedure, she had her questions asked and answered. Preoperative imaging was performed in consultation with regard to aesthetic results and communicated via the computerized imager. The patient had questions asked and answered. Informed consent was obtained.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed in supine position. The appropriate level of general endotracheal anesthesia was induced. The patient was converted to the lounge chair position, and the nose was anesthetized and vasoconstricted in the usual fashion. Procedure began with an inverted going incision and elevation of the skin of the nose in the submucoperichondrial plane over the medial crural footplates and lower lateral cartilages and up over the dorsum. The septal angle was approached and submucoperichondrial flaps were elevated. Severe nasal septal deviation to the right hand side and evidence of an old fracture with a separate alignment of the cartilaginous nose from the bony nose was encountered. The upper laterals were divided and medial and lateral osteotomies were carried out. Inadequate septal cartilage was noted to be present for use as spreader graft; therefore, left postauricular incision was made, and the conchal bowl cartilage graft was harvested, and it was closed with 3-0 running locking chromic with a sterile cotton ball pressure dressing applied. Ear cartilage graft was then placed to put two spreader grafts on the left and one the right. The two on the left extended all the way up to the caudal tip, the one on the right just primarily the medial wall. It was placed in such a way to correct a caudal dorsal deviation of the nasal tip septum. The upper lateral cartilage was noted to be of the same width and length in size. Yet, the left lower cartilage was scarred and adherent to the upper lateral cartilage. The upper lateral cartilages were noted to be excessive of uneven length with the right being much taller than the left and that was shortened to the same length. The scar bands were released in the lower lateral cartilages to the upper lateral cartilages to allow free mobilization of the lower lateral cartilages. A middle crus stitch was used to unite the domes, and then the nose was projected by suturing the medial crural footplates of the caudal septum in deep projected fashion. Crushed ear cartilage was then placed in the pockets above the spreader grafts in the area of the deficient dorsal nasal height and the lateral nasal sidewall height. The spreader brought an excellent aesthetic appearance to the nose. We left more than 1 cm of dorsal and caudal support for the nasal tip and dorsum height. Mucoperichondrial flaps were closed with 4-0 plain gut suture. The skin was closed with 5-0 chromic and 6-0 fast absorbing gut. Doyle splints were placed on each side of nasal septum and secured with 3-0 nylon and a Denver splint was applied. The patient was awakened in the operating room and taken to the recovery room in good condition.ent - otolaryngology, nasal deformity, nasal obstruction, nasal valve, cartilage, cartilaginous, crural, graft, nasal fracture, postauricular, rhinoplasty, septal cartilage, submucoperichondrial, turbinectomy, vestibular, ear cartilage graft, posttraumatic nasal deformity, vestibular stenosis, ear cartilage, cartilage graft, cartilages, caudal, nasal, nose, obstruction, repair, stenosis |
| 22 | 4 | Three Views - Foot | EXAM: ,Three views of the right foot.,REASON FOR EXAM: , Right foot trauma.,FINDINGS: , Three views of the right foot were obtained. There are no comparison studies. There is no evidence of fractures or dislocations. No significant degenerative changes or obstructive osseous lesions were identified. There are no radiopaque foreign bodies.,IMPRESSION: , Negative right foot.podiatry, three views, radiopaque, fractures, foot trauma |
| 23 | 1 | Control of Parapharyngeal Hemorrhage | PREOPERATIVE DIAGNOSIS: , Postoperative hemorrhage.,POSTOPERATIVE DIAGNOSIS:, Postoperative hemorrhage.,SURGICAL PROCEDURE: ,Examination under anesthesia with control of right parapharyngeal space hemorrhage.,ANESTHESIA: ,General endotracheal technique.,SURGICAL FINDINGS: , Right lower pole bleeder cauterized with electrocautery with good hemostasis.,INDICATIONS FOR SURGERY: , The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy. Previously, in the day she had undergone a tonsillectomy with adenoidectomy and was recovering without difficulty. However, in the PACU after a coughing spell she began bleeding from the right oropharynx, and was taken back to the operative suite for control of hemorrhage.,DESCRIPTION OF SURGERY: ,The patient was placed supine on the operating room table and general anesthetic was administered, once appropriate anesthetic findings achieved the patient was intubated and then prepped and draped in usual sterile manner for a parapharyngeal space hemorrhage. A Crowe-Davis type mouth gag was introduced in the oropharynx and under operating headlight the oropharynx was clearly visualized. There was a small bleeder present at the inferior mid pole of the right oropharynx in the tonsillar fossa, this area was cauterized with suction cautery and irrigated. There was no other bleeding noted. The patient was repositioned and the mouth gag, the tongue was rotated to the left side of the mouth and the right parapharyngeal space carefully examined. There was a small amount of oozing noted in the right tonsillar bed, and this was cauterized with suction cautery. No other bleeding was noted and the patient was recovered from general anesthetic. She was extubated and left the operating room in good condition to postoperative recovery room area. Prior to extubation the patient's tonsillar fossa were injected with a 6 mL of 0.25% Marcaine with 1:100,000 adrenalin solution to facilitate postoperative analgesia and hemostasis.surgery, obstructive adenotonsillar hypertrophy, tonsillar fossa, suction cautery, postoperative hemorrhage, parapharyngeal space, anesthesia, oropharynx, parapharyngeal, tonsillectomy, hemorrhage, |
| 24 | 4 | Phacoemulsification & Cataract Extraction - 4 | PREOPERATIVE DIAGNOSIS: ,Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,PROCEDURE: , Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation. ME 30, AC 25.0 diopter lens was used.,COMPLICATIONS: ,None.,ANESTHESIA: , Local 2%, peribulbar lidocaine.,PROCEDURE NOTE: ,Right eye was prepped and draped in the normal sterile fashion. Lid speculum placed in his right eye. Paracentesis made supratemporally. Viscoat injected into the anterior chamber. A 2.8 mm metal keratome blade was then used to fashion a clear corneal beveled incision temporally. This was followed by circular capsulorrhexis and hydrodissection of the nucleus would be assessed. Nuclear material removed via phacoemulsification. Residual cortex removed via irrigation and aspiration. The posterior capsule was clear and intact. Capsular bag was then filled with Provisc solution. The wound was enlarged to 3.5 mm with the keratoma. The lens was folded in place into the capsular bag. Residual Provisc was irrigated from the eye. The wound was secured with one 10-0 nylon suture. The lid speculum was removed. One drop of 5% povidone-iodine prep was placed into the eye as well as a drop of Vigamox and TobraDex ointment. He had a patch placed on it. The patient was transported to the recovery room in stable condition.ophthalmology, provisc, intraocular lens implantation, intraocular lens, lens implantation, lid speculum, capsular bag, cataract extraction, phacoemulsification, cataract, intraocular |
| 25 | 1 | Keller Bunionectomy | PROCEDURE: , Keller Bunionectomy.,For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient. An appropriate consent form was signed, indicating that the patient understands the procedure and its possible complications.,This 59 year-old female was brought to the operating room and placed on the surgical table in a supine position. Following anesthesia, the surgical site was prepped and draped in the normal sterile fashion.,Attention was then directed to the right foot where, utilizing a # 15 blade, a 6 cm. linear incision was made over the 1st metatarsal head, taking care to identify and retract all vital structures. The incision was medial to and parallel to the extensor hallucis longus tendon. The incision was deepened through subcutaneous underscored, retracted medially and laterally - thus exposing the capsular structures below, which were incised in a linear longitudinal manner, approximately the length of the skin incision. The capsular structures were sharply underscored off the underlying osseous attachments, retracted medially and laterally.,Utilizing an osteotome and mallet, the exostosis was removed, and the head was remodeled with the Liston bone forceps and the bell rasp. The surgical site was then flushed with saline. The base of the proximal phalanx of the great toe was osteotomized approximately 1 cm. distal to the base and excised to toto from the surgical site.,Superficial closure was accomplished using Vicryl 5-0 in a running subcuticular fashion. Site was dressed with a light compressive dressing. The tourniquet was released. Excellent capillary refill to all the digits was observed without excessive bleeding noted.,ANESTHESIA: , local.,HEMOSTASIS: , Accomplished with pinpoint electrocoagulation.,ESTIMATED BLOOD LOSS: , 10 cc.,MATERIALS:, None.,INJECTABLES:, Agent used for local anesthesia was Lidocaine 2% without epi.,PATHOLOGY:, Sent no specimen.,DRESSINGS: , Site was dressed with a light compressive dressing.,CONDITION: , Patient tolerated procedure and anesthesia well. Vital signs stable. Vascular status intact to all digits. Patient recovered in the operating room.,SCHEDULING: , Return to clinic in 2 week (s).surgery, keller bunionectomy, metatarsal head, incision, capsular, osteotome, compressive dressing, keller, bunionectomy, |
| 26 | 3 | Normal Female ROS Template | CONSTITUTIONAL:, Normal; negative for fever, weight change, fatigue, or aching.,HEENT:, Eyes normal; Negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects. Ears normal; Negative for hearing or balance problems. Nose normal; Negative for runny nose, sinus problems, or nosebleeds. Mouth normal; Negative for dental problems, dentures, or bleeding gums. Throat normal; Negative for hoarseness, difficulty swallowing, or sore throat.,CARDIOVASCULAR:, Normal; Negative for angina, previous MI, irregular heartbeat, heart murmurs, bad heart valves, palpitations, swelling of feet, high blood pressure, orthopnea, paroxysmal nocturnal dyspnea, or history of stress test, arteriogram, or pacemaker implantation.,PULMONARY: , Normal; Negative for cough, sputum, shortness of breath, wheezing, asthma, or emphysema.,GASTROINTESTINAL: , Normal; Negative for pain, vomiting, heartburn, peptic ulcer disease, change in stool, rectal pain, hernia, hepatitis, gallbladder disease, hemorrhoids, or bleeding.,GENITOURINARY:, Normal female OR male; Negative for incontinence, UTI, dysuria, hematuria, vaginal discharge, abnormal bleeding, breast lumps, nipple discharge, skin or nipple changes, sexually transmitted diseases, incontinence, yeast infections, or itching.,SKIN: , Normal; Negative for rashes, keratoses, skin cancers, or acne.,MUSCULOSKELETAL: , Normal; Negative for back pain, joint pain, joint swelling, arthritis, joint deformity, problems with ambulation, stiffness, osteoporosis, or injuries.,NEUROLOGIC: , Normal; Negative for blackouts, headaches, seizures, stroke, or dizziness.,PSYCHIATRIC: , Normal; Negative for anxiety, depression, or phobias.,ENDOCRINE:, Normal; Negative for diabetes, thyroid, or problems with cholesterol or hormones.,HEMATOLOGIC/LYMPHATIC: , Normal; Negative for anemia, swollen glands, or blood disorders.,IMMUNOLOGIC: , Negative; Negative for steroids, chemotherapy, or cancer.,VASCULAR:, Normal; Negative for varicose veins, blood clots, atherosclerosis, or leg ulcers.general medicine, cough, sputum, shortness of breath, fever, weight, fatigue, aching, nose, throat, swelling, disease, incontinence, bleeding, heartbeat, blood, joint, |
| 27 | 1 | Vertebroplasty | PREOPERATIVE DIAGNOSIS:, T11 compression fracture with intractable pain.,POSTOPERATIVE DIAGNOSIS:, T11 compression fracture with intractable pain.,OPERATION PERFORMED:, Unilateral transpedicular T11 vertebroplasty.,ANESTHESIA:, Local with IV sedation.,COMPLICATIONS:, None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion. The patient was given sedation and monitored. Using AP and lateral fluoroscopic projections the T11 compression fracture was identified. Starting from the left side local anesthetic was used for skin wheal just lateral superior to the 10 o'clock position of the lateral aspect of the T11 pedicle on the left. The 13-gauge needle and trocar were then taken and placed to 10 o'clock position on the pedicle. At this point using AP and lateral fluoroscopic views, the needle and trocar were advanced into the vertebral body using the fluoroscopic images and making sure that the needle was lateral to the medial wall of the pedicle of the pedicle at all times. Once the vertebral body was entered then using lateral fluoroscopic views, the needle was advanced to the junction of the anterior one third and posterior two thirds of the body. At this point polymethylmethacrylate was mixed for 60 seconds. Once the consistency had hardened and the __________ was gone, incremental dose of the cement were injected into the vertebral body. It was immediately seen that the cement was going cephalad into the vertebral body and was exiting through the crack in the vertebra. A total 1.2 cc of cement was injected. On lateral view, the cement crushed to the right side as well. There was some dye infiltration into the disk space. There was no dye taken whatsoever into the posterior aspect of the epidural space or intrathecal canal.,At this point, as the needle was slowly withdrawn under lateral fluoroscopic images, visualization was maintained to ensure that none of the cement was withdrawn posteriorly into the epidural space. Once the needle was withdrawn safely pressure was held over the site for three minutes. There were no complications. The patient was taken back to the recovery area in stable condition and kept flat for one hour. Should be followed up the next morning.surgery, transpedicular, vertebroplasty, fluoroscopic views, fluoroscopic images, epidural space, compression fracture, vertebral body, compression, pedicle, fluoroscopic, vertebral, needle |
| 28 | 2 | Airway Compromise & Foreign Body - ER Visit | HISTORY OF PRESENT ILLNESS:, The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone.,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract.,ALLERGIES: ,No known drug allergies.,CURRENT MEDICATIONS: , Prevacid, Humulin, Diprivan, Proventil, Unasyn, and Solu-Medrol.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , Negative for illicit drugs, alcohol, and tobacco.,PHYSICAL EXAMINATION: ,Please see the hospital chart.,LABORATORY DATA: , Please see the hospital chart.,HOSPITAL COURSE: , The patient was taken to the operating room by Dr. X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed. The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated. If not she would require tracheostomy. The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated. She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home. So, the patient is being prepared for discharge at this point. We will have Dr. X evaluate her before she leaves to make sure I do not have any problem with her going home. Dr. Y feels she could be discharged today and will have her return to see him in a week.consult - history and phy., diabetes, hypertension, asthma, cholecystectomy, fishbone, foreign body, airway compromise, airway, |
| 29 | 1 | Anterior Cervical Discectomy & Fusion - 7 | PREOPERATIVE DIAGNOSIS:, C4-C5, C5-C6 stenosis.,PREOPERATIVE DIAGNOSIS: , C4-C5, C5-C6 stenosis.,PROCEDURE: , C4-C5, C5-C6 anterior cervical discectomy and fusion.,COMPLICATIONS: , None.,ANESTHESIA: , General.,INDICATIONS OF PROCEDURE: , The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms. Her MRI showed stenosis at portion of C4 to C6. I discussed the procedure as well as risks and complications. She wishes to proceed with surgery. Risks will include but are not limited to infection, hemorrhage, spinal fluid leak, worsened neurologic deficit, recurrent stenosis, requiring further surgery, difficulty with fusion requiring further surgery, long-term hoarseness of voice, difficulty swallowing, medical anesthesia risk.,PROCEDURE: ,The patient was taken to the operating room on 10/02/2007. She was intubated for anesthesia. TEDS and boots as well as Foley catheter were placed. She was placed in a supine position with her neck in neutral position. Appropriate pads were also used. The area was prepped and draped in usual sterile fashion. Preoperative localization was taken. _____ not changed. Incision was made on the right side in transverse fashion over C5 vertebral body level. This was made with a #10 blade knife and further taken down with pickups and scissors. The plane between the esophagus and carotid artery was carefully dissected both bluntly and sharply down to the anterior aspect of the cervical spine. Intraoperative x-ray was taken. Longus colli muscles were retracted laterally. Caspar retractors were used. Intraoperative x-ray was taken. I first turned by attention at C5-C6 interspace. This was opened with #15 blade knife. Disc material was taken out using pituitary as well as Kerrison rongeur. Anterior aspects were taken down. End plates were arthrodesed using curettes. This was done under distraction. Posterior longitudinal ligament was opened with a nerve hook and Kerrison rongeur. Bilateral foraminotomies were done. At this point, I felt that there was a good decompression. The foramen appeared to be opened. Medtronic cage was then encountered and sent few millimeters. This was packed with demineralized bone matrix. The distraction was then taken down. The cage appeared to be strong. This procedure was then repeated at C4-C5. A 42-mm AcuFix plate was then placed between C4 and C6. This was carefully screwed and locked. The instrumentation appeared to be strong. Intraoperative x-ray was taken. Irrigation was used. Hemostasis was achieved. The platysmas was closed with 3-0 Vicryl stitches. The subcutaneous was closed with 4-0 Vicryl stitches. The skin was closed with Steri-strips. The area was clean and dry and dressed with Telfa and Tegaderm. Soft cervical collar was placed for the patient. She was extubated per anesthesia and brought to the recovery in stable condition.surgery, anterior cervical discectomy, fusion, infection, hemorrhage, spinal fluid leak, anesthesia, foley catheter, teds, anterior cervical, cervical discectomy, anterior, cervical, discectomy, stenosis, |
| 30 | 1 | Foreskin - Followup | REASON FOR VISIT: , Follow up consultation, second opinion, foreskin.,HISTORY OF PRESENT ILLNESS: , A 2-week-old who at this point has otherwise been doing well. He has a relatively unremarkable foreskin. At this point in time, he otherwise seems to be doing reasonably well. The question is about the foreskin. He otherwise has no other significant issues. Severity low, ongoing since birth two weeks. Thank you for allowing me to see this patient in consultation.,PHYSICAL EXAMINATION:, Male exam. Normal and under the penis, report normal uncircumcised 2-week-old. He has a slightly insertion on the penile shaft from the median raphe of the scrotum.,IMPRESSION: , Slightly high insertion of the median raphe. I see no reason he cannot be circumcised as long as they are careful and do a very complete Gomco circumcision. This kid should otherwise do reasonably well.,PLAN: ,Follow up as needed. But my other recommendation is that this kid as I went over with the mother may actually do somewhat better if he simply has a formal circumcision at one year of age, but may do well with a person who is very accomplished doing a Gomco circumcision.urology, formal circumcision, median raphe, penis, gomco circumcision, gomco, circumcision, foreskin, |
| 31 | 3 | Discharge Summary - 13 | 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 |
| 32 | 1 | Vasectomy - 4 | PROCEDURE: , Elective male sterilization via bilateral vasectomy.,PREOPERATIVE DIAGNOSIS: ,Fertile male with completed family.,POSTOPERATIVE DIAGNOSIS:, Fertile male with completed family.,MEDICATIONS: ,Anesthesia is local with conscious sedation.,COMPLICATIONS: , None.,BLOOD LOSS: , Minimal.,INDICATIONS: ,This 34-year-old gentleman has come to the office requesting sterilization via bilateral vasectomy. I discussed the indications and the need for procedure with the patient in detail, and he has given consent to proceed. He has been given prophylactic antibiotics.,PROCEDURE NOTE: , Once satisfactory sedation have been obtained, the patient was placed in the supine position on the operating table. Genitalia was shaved and then prepped with Betadine scrub and paint solution and were draped sterilely. The procedure itself was started by grasping the right vas deferens in the scrotum, and bringing it up to the level of the skin. The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath. The vas was brought out of the incision carefully. A 2-inch segment was isolated, and 1-inch segment was removed. The free ends were cauterized and were tied with 2-0 silk sutures in such a fashion that the ends double back on themselves. After securing hemostasis with a cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Attention was now turned to the left side. The vas was grasped and brought up to the level of the skin. The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath. The vas was brought out of the incision carefully. A 2-inch segment was isolated, and 1-inch segment was removed. The free ends were cauterized and tied with 2-0 silk sutures in such a fashion that the ends double back on themselves. After securing hemostasis with the cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Bacitracin ointment was applied as well as dry sterile dressing. The patient was awakened and was returned to Recovery in satisfactory condition.urology, sterilization, vas, fertile male, bilateral vasectomy, vasectomy, cauterized, |
| 33 | 4 | Bunionectomy & Flexor Tenotomy | PREOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammertoe, bilateral third, fourth, and fifth toes.,POSTOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammertoe, bilateral third, fourth, and fifth toes.,PROCEDURE PERFORMED:,1. Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2. Proximal interphalangeal joint arthroplasty, bilateral fifth toes.,3. Distal interphalangeal joint arthroplasty, bilateral third and fourth toes.,4. Flexor tenotomy, bilateral third toes.,HISTORY:, This is a 36-year-old female who presented to ABCD preoperative holding area after keeping herself n.p.o. since mid night for surgery on her painful bunion to her right foot and her painful hammertoes to both feet. The patient has a history of sharp pain, which is aggravated by wearing shoes and ambulation. She has tried multiple conservative methods and treatment such as wide shoes and accommodative padding, all of which provided inadequate relief. At this time, she desires attempted surgical correction. The risks versus benefits of the procedure have been discussed in detail by Dr. Kaczander with the patient and the consent is available on the chart.,PROCEDURE IN DETAIL:, After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with a safety strap placed across her waist for her protection.,Copious amounts of Webril were applied about both ankles and a pneumatic ankle tourniquet was applied over the Webril. After adequate IV sedation was administered, a total of 18 cc of a 0.5% Marcaine plain was used to anesthetize the right foot, performing a Mayo block and a bilateral third, fourth, and fifth digital block. Next, the foot was prepped and draped in the usual aseptic fashion bilaterally. The foot was elevated off the table and an Esmarch bandage was used to exsanguinate the right foot. The pneumatic ankle tourniquet was elevated on the right foot to 200 mmHg. The foot was lowered into operative field and the sterile stockinet was reflected proximally. Attention was directed to the right first metatarsophalangeal joint, it was found to be contracted and there was lateral deviation of the hallux. There was decreased range of motion of the first metatarsophalangeal joint. A dorsolinear incision was made with a #10 blade, approximately 4 cm in length. The incision was deepened to the subcutaneous layer with a #15 blade. Any small veins traversing the subcutaneous layer were ligated with electrocautery. Next, the medial and lateral wound margins were undermined sharply. Care was taken to avoid the medial neurovascular bundle and the lateral extensor hallucis longus tendon. Next, the first metatarsal joint capsule was identified. A #15 blade was used to make a linear capsular incision down to the bone. The capsular periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound. The PASA was found to be within normal limits. There was a hypertrophic medial eminence noted. A sagittal saw was used to remove the hypertrophic medial eminence. A 0.045 inch Kirschner wire was placed into the central medial aspect of the metatarsal head as an access guide. A standard lateral release was performed. The fibular sesamoid was found to be in the interspace, but was relocated onto the metatarsal head properly. Next, a sagittal saw was used to perform a long arm Austin osteotomy. The K-wire was removed. The capital fragment was shifted laterally and impacted into the head. A 0.045 inch Kirschner wire was used to temporarily fixate the osteotomy. A 2.7 x 16 mm Synthes, fully threaded cortical screw was throne using standard AO technique. A second screw was throne, which was a 2.0 x 12 mm Synthes cortical screw. Excellent fixation was achieved and the screws tightly perched the bone. Next, the medial overhanging wedge was removed with a sagittal saw. A reciprocating rasp was used to smooth all bony prominences. The 0.045 inch Kirschner wire was removed. The screws were checked again for tightness and found to be very tight. The joint was flushed with copious amounts of sterile saline. A #3-0 Vicryl was used to close the capsular periosteal tissues with simple interrupted suture technique. A #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted technique. A #5-0 Monocryl was used to close the skin in a running subcuticular fashion.,Attention was directed to the right third digit, which was found to be markedly contracted at the distal interphalangeal joint. A #15 blade was used to make two convergent semi-elliptical incisions over the distal interphalangeal joint. The incision was deepened with a #15 blade. The wedge of skin was removed in full thickness. The long extensor tendon was identified and the distal and proximal borders of the wound were undermined. The #15 blade was used to transect the long extensor tendon, which was reflected proximally. The distal interphalangeal joint was identified and the #15 blade was placed in the joint and the medial and lateral collateral ligaments were released. Crown and collar scissors were used to release the planar attachment to the head of the middle phalanx. Next, a double action bone cutter was used to resect the head of the middle phalanx. The toe was dorsiflexed and was found to have an excellent rectus position. A hand rasp was used to smooth all bony surfaces. The joint was flushed with copious amounts of sterile saline. The flexor tendon was found to be contracted, therefore, a flexor tenotomy was performed through the dorsal incision. Next, #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures. A #4-0 nylon was used to close the skin and excellent cosmetic result was achieved.,Attention was directed to the fourth toe, which was found to be contracted at the distal interphalangeal joint and abducted and varus rotated. An oblique skin incision with two converging semi-elliptical incisions was created using #15 blade. The rest of the procedure was repeated exactly the same as the above paragraph to the third toe on the right foot. All the same suture materials were used. However, there was no flexor tenotomy performed on this toe, only on the third toe bilaterally.,Attention was directed to the fifth right digit, which was found to be contracted at the proximal interphalangeal joint. A linear incision approximately 2 cm in length was made with a #15 blade over the proximal interphalangeal joint. Next, a #15 blade was used to deepen the incision to the subcutaneous layer. The medial and lateral margins were undermined sharply to the level of the long extensor tendon. The proximal interphalangeal joint was identified and the tendon was transected with the #15 blade. The tendon was reflected proximally, off the head of the proximal phalanx. The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound. A double action bone nibbler was used to remove the head of the proximal phalanx. A hand rasp was used to smooth residual bone. The joint was flushed with copious amounts of saline. A #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures. A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress sutures.,A standard postoperative dressing consisting of saline-soaked #0-1 silk, 4 x 4s, Kerlix, Kling, and Coban were applied. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,Attention was directed to the left foot. The foot was elevated off the table and exsanguinated with an Esmarch bandage and the pneumatic ankle tourniquet was elevated to 200 mmHg. Attention was directed to the left fifth toe, which was found to be contracted at the proximal interphalangeal joint. The exact same procedure, performed to the right fifth digit, was performed on this toe, with the same materials being used for suture and closure.,Attention was then directed to the left fourth digit, which was found to contracted and slightly abducted and varus rotated. The exact same procedure as performed to the right fourth toe was performed, consisting of two semi-elliptical skin incisions in an oblique angle. The same suture material were used to close the incision.,Attention was directed to the left third digit, which was found to be contracted at the distal interphalangeal joint. The same procedure performed on the right third digit was also performed. The same suture materials were used to close the wound and the flexor tenotomy was also performed at this digit. A standard postoperative dressing was also applied to the left foot consisting of the same materials as described for the right foot. The pneumatic tourniquet was released and immediate hyperemic flush was noted to the digits. The patient tolerated the above anesthesia and procedure without complications. She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the foot. She was given postoperative shoes and will be partial weighbearing with crutches. She was admitted short-stay to Dr. Kaczander for pain control. She was placed on Demerol 50 and Vistaril 25 mg IM q3-4h. p.r.n. for pain. She will have Vicodin 5/500 one to two p.o. q.4-6h. p.r.n. for moderate pain. She was placed on Subq. heparin and given incentive spirometry 10 times an hour. She will be discharged tomorrow. She is to ice and elevate both feet today and rest as much as possible.,Physical Therapy will teach her crutch training today. X-rays were taken in the postoperative area and revealed excellent position of the screws and correction of bunion deformity as well as the hammertoe deformities.podiatry, hallux abductovalgus, hammertoe, bunionectomy, flexor, tenotomy, interphalangeal, arthroplasty, screw fixation, osteotomy, interphalangeal joint arthroplasty, distal interphalangeal joint, interphalangeal joint, flexor tenotomy, proximal interphalangeal, joint arthroplasty, distal interphalangeal, distal, blade, proximal, foot, joint, toes, tendon, |
| 34 | 2 | Hip Fracture - Rehab Consult | ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay. He had left hip fracture identified on x-rays at that time. Pain and inability to ambulate brought him in. He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia. His medical issues are under good control. The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03. The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension. Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy. He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions.,PAST MEDICAL HISTORY: , Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation. Remote history of subdural hematoma precluding the use of Coumadin. History of depression, panic attacks on Doxepin. Perioperative anemia. Swallowing difficulties.,ALLERGIES:, Zyloprim, penicillin, Vioxx, NSAIDs.,CURRENT MEDICATIONS,1. Heparin.,2. Albuterol inhaler.,3. Combivent.,4. Aldactone.,5. Doxepin.,6. Xanax.,7. Aspirin.,8. Amiodarone.,9. Tegretol.,10. Synthroid.,11. Colace.,SOCIAL HISTORY: , Lives in a 1-story home with 1 step down; wife is there. Speech and language pathology following with current swallowing dysfunction. He is minimum assist for activities of daily living, bed mobility.,REVIEW OF SYSTEMS:, Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain.,PHYSICAL EXAMINATION,HEENT: Oropharynx clear.,CV: Regular rate and rhythm without murmurs, rubs or gallops.,LUNGS: Clear to auscultation bilaterally.,ABDOMEN: Nontender, nondistended. Bowel sounds positive.,EXTREMITIES: Without clubbing, cyanosis, or edema.,NEUROLOGIC: There are no focal motor or sensory losses to the lower extremities. Bulk and tone normal in the lower extremities. Wound site has healed well with staples out.,IMPRESSION ,1. Status post left hip fracture and hemiarthroplasty.,2. History of panic attack, anxiety, depression.,3. Myocardial infarction with stent placement.,4. Hypertension.,5. Hypothyroidism.,6. Subdural hematoma.,7. Seizures.,8. History of chronic obstructive pulmonary disease. Recent respiratory insufficiency.,9. Renal insufficiency.,10. Recent pneumonia.,11. O2 requiring.,12. Perioperative anemia.,PLAN: , Rehab transfer as soon as medically cleared.nan |
| 35 | 3 | Hypertension - Consult | HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall. Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock. When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped. Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker. An ECG this morning showing normal sinus rhythm with frequent APCs. Her potassium at that time was 3.1. She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior. She denies any chest pain nor shortness of breath prior to or since the fall. She states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,PAST CARDIAC HISTORY: , She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure. On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement. She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative. She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant. She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker. She does have a history of significant hypertension in the past. She has had dizzy spells and denies clearly any true syncope. She has had bradycardia in the past from beta-blocker therapy.,MEDICATIONS ON ADMISSION:,1. Multivitamin p.o. daily.,2. Aspirin 325 mg once a day.,3. Lisinopril 40 mg once a day.,4. Felodipine 10 mg once a day.,5. Klor-Con 20 mEq p.o. b.i.d.,6. Omeprazole 20 mg p.o. daily presumably for GERD.,7. MiraLax 17 g p.o. daily.,8. Lasix 20 mg p.o. daily.,ALLERGIES: , PENICILLIN. IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST.,FAMILY HISTORY:, She states her brother died of an MI suddenly in his 50s.,SOCIAL HISTORY: , She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs. She is retired from Morse Chain and delivering newspapers. She is widowed. She lives alone but has family members who live either on her property or adjacent to it.,REVIEW OF SYSTEMS: , She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers. She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use. She does note occasional peripheral edema. She is not aware of prior history of MI. She denies diabetes. She does have a history of GERD. She notes feeling depressed at times because of living alone. She denies rheumatologic conditions including psoriasis or lupus. Remainder of review of systems is negative times 15 except as described above.,PHYSICAL EXAM: ,Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%. On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive. HEENT: Shows cranium is normocephalic and atraumatic. She has moist mucosal membranes. Neck veins were not distended. There are no carotid bruits. Lungs: Clear to auscultation anteriorly without wheezes. She is relatively immobile because of her left hip fracture. Cardiac Exam: S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound. There is also a soft holosystolic murmur heard. There is no rub or gallop. PMI is nondisplaced. Abdomen is soft and nondistended. Bowel sounds present. Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema. Pulses appear grossly intact. Affect is appropriate. Visible skin warm and perfused. She is not able to move because of left hip fracture easily in bed.,DIAGNOSTIC STUDIES/LAB DATA: , Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob. No clear pulmonary vascular congestion. Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06. Troponin was 0.03 followed by 0.18. INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,EKGs are reviewed. Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes. She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior. Followup EKG done this morning shows normal sinus rhythm with frequent APCs.,IMPRESSION: ,She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery. Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected. There has been no atrial fibrillation documented. I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath. She actually describes feeling good exercise capacity prior to this fall. Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that. Continued optimization of electrolytes. The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil. The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery. I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge. Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist.general medicine, hypokalemia, shortness of breath, atrial tachycardia, sinus rhythm, hip fracture, atrial, tachycardia, rhythm, apcs, cardiac, regurgitation, aortic, hypertension, pulmonary, |
| 36 | 3 | Gen Med Consult - 38 | Chief Complaint:, Abdominal pain, nausea and vomiting.,History of Present Illness:, A 50-year-old Asian female comes to The Methodist Hospital on January 2, 2001, complaining of a 3-day history of abdominal pain. The pain is described as crampy in the central part of her abdomen, and is associated with nausea and vomiting during the previous 24 hours. The patient denied passing any stool or gas per rectum for the previous 24 hours. She had been admitted recently to the hospital from December 19 to December 23, 2000, with a three-week history of fevers to 101.8, diaphoresis, anorexia, malaise and skin "lumps". She described a total of three "lumps". The first one started as a pin-sized lesion that grew up and then disappeared, the other two didn't resolve. They were described as "erythematous nodular lesions on the extensor surface of the left arm." A punch biopsy was obtained from these skin lesions, showing deep dermis and subcutaneous adipose tissue that contained "multiple granulomas composed of histiocytes and multinucleated giant cells without caseating necrosis". However, one granuloma in the deep dermis, showed a hint of central necrosis. Special stains for acid - fast bacilli and fungi were reported as negative. No atypia or malignancy was noted. A CT scan of the chest was obtained on December 19, 2000 and showed numerous masses with spiculated borders bilaterally, predominately in the upper lobes and superior segments of the lower lobes. No cavitary lesions, mediastinal masses or definite hilar adenopathy were reported. The patient underwent bronchoscopy and transbronchial biopsy which showed fragments of bronchial mucosa and wall with underlying lung parenchyma. Minimal to mild interstitial lymphocytes with a few microfoci of neutrophils were seen. They were also able to appreciate intra-alveolar fibrinous exudates. One of the blood cultures drawn on December 19, 2000 grew Streptococcus mitis.,The patient was discharged on ethambutol 1200 mg po qd, clarithromycin 500 mg po bid, ampicillin 500 mg po q 6h and fluconazole 200 mg po qd.,Past Medical History:,1. Post-streptococcal glomerulonephritis at age 10.,2. End stage renal disease diagnosed in 1994, on peritoneal dialysis until 1996.,3. Cadaveric transplant in October 1996,4. Steroid induced diabetes mellitus,5. Hypertension,Past Surgical History:,1. Total abdominal hysterectomy in January 1996,2. Cesarean section X2 in 1996 and 1997,3. Appendectomy in 1971,4. Insertion of peritoneal dialysis catheter in 1994,5. Cadaveric transplant in October 1996,Social History:,The patient denies a history of smoking, drinking or intravenous drug use. She came to the United States in 1973. She works as a nurse in a newborn nursery. Her hobby is gardening. She traveled to Las Vegas on May 2000 and stayed for 6 months. She denied ill contacts or pets.,Allergies:, Ciprofloxacin and Enteric coated aspirin,Medications:, prednisone 20 mg po qd, enalapril 2.5 mg po qd, clonidine patch TTS 3 1/week, Prograf 5 mg po bid, ranitidine 150 mg po bid, furosemide 40 mg po bid, atorvastatin 10 mg po qd, multivitamins 1 tab po qd, estrogen patch, fluconazole 200 mg po qd, metformin 500 mg po bid, glyburide 10 mg po qd, clarithromycin 500 mg po bid, ethambutol 1200 mg po qd, ampicillin 500 mg po q 6h.,Family History:, She described a family history of hypertension. Her mother died after a myocardial infarction at age 59. Her father was diagnosed with congestive heart failure and had a pacemaker placed.,Review of systems:, Non-contributory. The patient denied fever, chills, ulcers, liver disease or history of gallstones.,Vaccines: The patient was vaccinated with BCG before starting elementary school in the Philippines.,Physical Examination:, At the time of the examination the patient was alert and oriented times three and in no acute distress. She was well nourished.,BP 106/60 lying down; HR 86; RR 12; T 96.1° F; Hgt. =5' 2"; Wgt. =121 lbs.,SKIN: There was no rash or skin lesions.,HEENT: She had no oral lesions and moist mucous membranes. No icterus was noted.,NECK: Her neck was supple without lymphadenopathy or thyromegaly.,LUNGS: Crackles at the right lower base with normal respiratory excursion and no dullness to percussion.,HEART: IV/VI crescendo - decrescendo systolic murmur was heard at the second intercostal space with radiation to the neck.,ABDOMEN: The abdomen was distended. Bowel sounds were normal. No hepatosplenomegaly, tenderness or rebound tenderness could be detected during the examination.,EXTREMITIES: No cyanosis, clubbing or edema was noted.,RECTAL: Normal rectal exam. Guaiac negative.,NEUROLOGIC: Normal and non-focal.,Hospital Course:, The patient was admitted and a nasogastric tube was placed. IV fluids were started. A KUB was obtained showing an abnormal bowel gas pattern. Multiple loops of distended bowel were noted in the mid abdomen. Air and feces were noted within the colon in the right side. An Abdominal CT scan was obtained. There was a small amount of perihepatic fluid noted. The liver and spleen were normal. The kidneys were atrophic. The gallbladder was moderately distended. There was marked dilatation of the small bowel proximally and distally. There was gas and contrast material in the colon. A diagnostic procedure was performed.nan |
| 37 | 4 | Neuropsychological Evaluation - 5 | PROBLEMS AND ISSUES:,1. Headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment.,2. Some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercise daily.,HISTORY OF PRESENT ILLNESS: , The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. I obtained and documented a full history and physical examination. I reviewed the new patient questionnaire, which she completed prior to her arrival today. I also reviewed the results of tests, which she had brought with her.,Briefly, she is a 60-year-old woman initially from Ukraine, who had headaches since age 25. She recalls that in 1996 when her husband died her headaches became more frequent. They were pulsating. She was given papaverine, which was successful in reducing the severity of her symptoms. After six months of taking papaverine, she no longer had any headaches. In 2004, her headaches returned. She also noted that she had "zig-zag lines" in her vision. Sometimes she would not see things in her peripheral visions. She had photophobia and dizziness, which was mostly lightheadedness. On one occasion she almost had a syncope. Again she has started taking Russian medications, which did help her. The dizziness and headaches have become more frequent and now occur on average once to twice per week. They last two hours since she takes papaverine, which stops the symptoms within 30 minutes.,PAST MEDICAL HISTORY: ,Her past medical history is significant for injury to her left shoulder, gastroesophageal reflux disorder, diabetes, anxiety, and osteoporosis.,MEDICATIONS:, Her medications include hydrochlorothiazide, lisinopril, glipizide, metformin, vitamin D, Centrum multivitamin tablets, Actos, lorazepam as needed, Vytorin, and Celexa.,ALLERGIES: , She has no known drug allergies.,FAMILY HISTORY: ,There is family history of migraine and diabetes in her siblings.,SOCIAL HISTORY: , She drinks alcohol occasionally.,REVIEW OF SYSTEMS: , Her review of systems was significant for headaches, pain in her left shoulder, sleeping problems and gastroesophageal reflex symptoms. Remainder of her full 14-point review of system was unremarkable.,PHYSICAL EXAMINATION:, On examination, the patient was pleasant. She was able to speak English fairly well. Her blood pressure was 130/84. Heart rate was 80. Respiratory rate was 16. Her weight was 188 pounds. Her pain score was 0/10. Her general exam was completely unremarkable. Her neurological examination showed subtle weakness in her left arm due to discomfort and pain. She had reduced vibration sensation in her left ankle and to some degree in her right foot. There was no ataxia. She was able to walk normally. Reflexes were 2+ throughout.,She had had a CT scan with constant, which per Dr. X's was unremarkable. She reports that she had a brain MRI two years ago which was also unremarkable.,IMPRESSION AND PLAN:, The patient is a delightful 60-year-old chemist from Ukraine who has had episodes of headaches with nausea, photophobia, and dizziness since her 20s. She has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms. Her diagnosis is consistent with vestibular migraine. I do not see evidence of multiple sclerosis, Ménière's disease, or benign paroxysmal positional vertigo.,I talked to her in detail about the importance of following a migraine diet. I gave her instructions including a list of foods times, which worsen migraine. I reviewed this information for more than half the clinic visit. I would like to start her on amitriptyline at a dose of 10 mg at time. She will take Motrin at a dose of 800 mg as needed for her severe headaches.,She will make a diary of her migraine symptoms so that we can find any triggering food items, which worsen her symptoms. I encouraged her to walk daily in order to improve her fitness, which helps to reduce migraine symptoms.neurology, nausea, dizziness, migraine, peripheral neuropathy, diabetic neuropathy, neuropathy, positional vertigo, photophobia and dizziness, neurology consultation, tunnel vision, vestibular migraine, migraine symptoms, headaches, photophobia, ataxia, |
| 38 | 1 | Laparoscopic Cholecystectomy - 10 | PREOPERATIVE DIAGNOSIS: , Biliary colic and biliary dyskinesia.,POSTOPERATIVE DIAGNOSIS:, Biliary colic and biliary dyskinesia.,PROCEDURE PERFORMED:, Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:, None.,DISPOSITION: ,The patient tolerated the procedure well and was transferred to recovery in stable condition.,BRIEF HISTORY: ,This patient is a 42-year-old female who presented to Dr. X's office with complaints of upper abdominal and back pain, which was sudden onset for couple of weeks. The patient is also diabetic. The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia. The patient was then scheduled for laparoscopic cholecystectomy for biliary colic and biliary dyskinesia.,INTRAOPERATIVE FINDINGS: , The patient's abdomen was explored. There was no evidence of any peritoneal studding or masses. The abdomen was otherwise within normal limits. The gallbladder was easily visualized. There was an intrahepatic gallbladder. There was no evidence of any inflammatory change.,PROCEDURE:, After informed written consent, the risks and benefits of the procedure were explained to the patient. The patient was brought into the operating suite.,After general endotracheal intubation, the patient was prepped and draped in normal sterile fashion. Next, an infraumbilical incision was made with a #10 scalpel. The skin was elevated with towel clips and a Veress needle was inserted. The abdomen was then insufflated to 15 mmHg of pressure. The Veress needle was removed and a #10 blade trocar was inserted without difficulty. The laparoscope was then inserted through this #10 port and the abdomen was explored. There was no evidence of any peritoneal studding. The peritoneum was smooth. The gallbladder was intrahepatic somewhat. No evidence of any inflammatory change. There were no other abnormalities noted in the abdomen. Next, attention was made to placing the epigastric #10 port, which again was placed under direct visualization without difficulty. The two #5 ports were placed, one in the midclavicular and one in the anterior axillary line again in similar fashion under direct visualization. The gallbladder was then grasped out at its fundus, elevated to patient's left shoulder. Using a curved dissector, the cystic duct was identified and freed up circumferentially. Next, an Endoclip was used to distal and proximal to the gallbladder, Endoshears were used in between to transect the cystic duct. The cystic artery was transected in similar fashion. Attention was next made in removing the gallbladder from the liver bed using electrobovie cautery and spatulated tip. It was done without difficulty. The gallbladder was then grasped via the epigastric port and removed without difficulty and sent to pathology. Hemostasis was maintained using electrobovie cautery. The liver bed was then copiously irrigated and aspirated. All the fluid and air was then aspirated and then all ports were removed under direct visualization. The two #10 ports were then closed in the fascia with #0 Vicryl and a UR6 needle. The skin was closed with a running subcuticular #4-0 undyed Vicryl. 0.25% Marcaine was injected and Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and was transferred to Recovery in stable condition.surgery, electrobovie cautery, laparoscopic cholecystectomy, biliary colic, biliary dyskinesia, biliary, laparoscopic, cholecystectomy, colic, abdomen, dyskinesia, gallbladder |
| 39 | 1 | Bunionectomy - Austin - Akin | PREOPERATIVE DIAGNOSIS:, Bunion, right foot.,POSTOPERATIVE DIAGNOSIS:, Bunion, right foot.,PROCEDURE PERFORMED:, Austin/akin bunionectomy, right foot.,HISTORY: , This 77-year-old African-American female presents to ABCD General Hospital with the above chief complaint. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful. The patient has attempted conservative treatment without long-term relief of symptoms and desires surgical treatment.,PROCEDURE DETAILS:, An IV was instituted by Department of Anesthesia in the preop holding area. The patient was transported to the operating room and placed on the operating table in the supine position with a safety strap across her lap. Copious amounts of Webril were placed around the right ankle followed by blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected in a Mayo block type fashion. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated to the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was inflated to 250 mmHg. The foot was lowered to the operating field and the stockinet was reflected. The foot was cleansed with wet and dry sponge.,Attention was directed to the bunion deformity on the right foot. An approximately 6 cm dorsal medial incision was created over the first metatarsophalangeal joint. The incision was then deepened with a #15 blade. All vessels encountered were ligated with hemostasis. The skin and subcutaneous tissue were then undermined off of the capsule medially. A dorsal linear capsular incision was then created over the first metatarsophalangeal joint. The periosteum and capsule were then reflected off of the first metatarsal. There was noted to be a prominent medial eminence. The articular cartilage was healthy for patient's age and race. Attention was then directed to the first interspace where a lateral release was performed.. A combination of sharp and blunt dissection was carried out until the adductor tendon insertions were identified. The adductor tendons were transected as well as a lateral capsulotomy was performed. The extensor digitorum brevis tendon was identified and transected. Care was taken to preserve the extensor hallucis longus to make sure that tendon that was transected was the extensor hallucis brevis at the _______ digitorum. Extensor hallucis brevis tendon was transected and care was taken to preserve the extensor halucis longus tendon. Attention was then directed to medial eminence, which was resected with a sagittal saw. Sagittal was then used to create a long dorsal arm outside the Austin type osteotomy and the first metatarsal. The head of the first metatarsal was then translocated laterally until correction of the intermetatarsal angle was noted. The head was intact. A 0.45 K-wire was inserted through subcutaneously from proximal medial to distal lateral. A second K-wire was then inserted from distal lateral to proximal plantar medial. Adequate fixation was noted at the osteotomy site. The K-wires were bent, cut, and pin caps were placed. Attention was then directed to the proximal phalanx of the hallux. The capsular periostem was reflected off of the base of the proximal phalanx. A sagittal was then used to create an akin osteotomy closing wedge. The apex was lateral and the base of the wedge was medial. The wedge was removed in the total and the osteotomy site was then feathered until closure was achieved without compression. Two 0.45 K-wires were then inserted, one from distal medial to proximal lateral and the second from distal lateral to proximal medial across the osteotomy site. Adequate fixation was noted at the osteotomy site and the osteotomy was closed. The toe was noted to be in a markedly more rectus position. Sagittal saw was then used to resect the remaining prominent medial eminence. The area was then smoothed with a reciprocating rasp. There was noted to be a small osteophytic formation laterally over first metatarsal head that was removed with a rongeur and smoothed with a reciprocating rasp. The area was then inspected for any remaining short bony edges, none were noted.,Copious amounts of sterile saline was then used to flush the surgical site. The capsule was closed with #3-0 Vicryl. Subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular #5-0 Vicryl. Steri-Strips were applied and 1 cc of dexamethasone phosphate was injected into the surgical site.,Dressings consisted of #0-1 silk, copious Betadine, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the right foot. A _______ cast was then applied postoperatively. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported from the operating room to the PACU with vital signs stable and vascular status intact to the right foot. The patient was given postoperative pain prescription for Tylenol #3 and instructed to take one q4-6h. p.o. p.r.n. for pain. The patient is to follow up with Dr. X in his office as directed.surgery, austin/akin bunionectomy, hallucis brevis, bunion deformity, extensor hallucis, osteotomy site, foot, austin, bunionectomy |
| 40 | 4 | Radiologic Exam - Spine | EXAM: , Cervical, lumbosacral, thoracic spine flexion and extension.,HISTORY: , Back and neck pain.,CERVICAL SPINE,FINDINGS: ,AP, lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable.neurology, radiologic exam, ap, back, cervical, oblique views, alignment, disc space, extension, fixation, flexion, foramina, intervertebral, lateral views, lumbosacral, neck, neck pain, oblique, odontoid view, pain, physiologic, projections, spine, subluxation, thoracic, flexion and extension, thoracic spine, vertebral |
| 41 | 4 | MRI T-L Spine - Schistosomiasis | CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with "pins & needles" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.nan |
| 42 | 2 | Dobutamine Stress Test - 1 | DOBUTAMINE STRESS ECHOCARDIOGRAM,REASON FOR EXAM: , Chest discomfort, evaluation for coronary artery disease.,PROCEDURE IN DETAIL: , The patient was brought to the cardiac center. Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute. The patient maximized at 30 mcg/kg per minute. Images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145. Maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.,Wall motion assessed at all levels as well as at recovery.,The patient got nauseated, had some mild shortness of breath. No angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.,The resting heart rate was 78 with the resting blood pressure 186/98. Heart rate reduced by the vasodilator effects of dobutamine to 130/80. Maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.,The EKG at rest showed sinus rhythm with no ST-T wave depression suggestive of ischemia or injury. Incomplete right bundle-branch block was seen. The maximal stress test EKG showed sinus tachycardia. There was subtle upsloping ST depression in III and aVF, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no ST elevation seen.,No ventricular tachycardia or ventricular ectopy seen during the test. The heart rate recovered in a normal fashion after using metoprolol 5 mg.,The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.,The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose. All walls mentioned were augmented in a normal fashion. At maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation. EF improved to about 70%.,The wall motion score was unchanged.,IMPRESSION:,1. Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.,2. Negative EKG criteria for ischemia.,3. Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view. This is considered the negative dobutamine stress echocardiogram test, medical management.radiology, chest discomfort, coronary artery disease, predicted heart rate, dobutamine stress echocardiogram, anterolateral wall, echocardiogram test, wall motion, stress echocardiogram, short axis, dobutamine stress, heart rate, dobutamine, stress, ekg, echocardiogram, artery, ischemia, heart |
| 43 | 1 | Suction, Dilation, & Curettage - 1 | PREOPERATIVE DIAGNOSIS: ,Incomplete abortion.,POSTOPERATIVE DIAGNOSIS: ,Incomplete abortion.,PROCEDURE PERFORMED:, Suction dilation and curettage.,ANESTHESIA: ,General and nonendotracheal by Dr. X.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,SPECIMENS: , Endometrial curettings.,DRAINS: , None.,FINDINGS: ,On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina. There was a large amount of tissue obtained on the procedure.,PROCEDURE: ,The patient was taken to the operating room where a general anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic. Next, a weighted speculum was placed in the vagina. The anterior lip of cervix was grasped with the vulsellum tenaculum and due to the patient already being dilated approximately 2 cm, no cervical dilation was needed. A size 12 straight suction curette was used and connected to the suction and was placed in the cervix and a suction curettage was performed. Two passes were made with the suction curettage. Next, a sharp curettage was performed obtaining a small amount of tissue and this was followed by third suction curettage and then a final sharp curettage was performed, which revealed a good uterine cry on all sides of the uterus. After the procedure, the vulsellum tenaculum was removed. The cervix was seemed to be hemostatic. The weighted speculum was removed. The patient was given 0.25 mg of Methergine IM approximately half-way through the procedure. After the procedure, a second bimanual exam was performed and the patient's uterus had significantly decreased in size. It is now approximately eight to ten-week size. The patient was taken from the operating room in stable condition after she was cleaned. She will be discharged on today. She was given Methergine, Motrin, and doxycycline for her postoperative care. She will follow-up in one week in the office.surgery, uterus, anteverted, dorsal lithotomy position, weighted speculum, mobile uterus, vulsellum tenaculum, bimanual exam, vagina, tenaculum, dilation, bimanual, cervix, suction, curettage, |
| 44 | 1 | Vaginal Hysterectomy - Laparoscopic-Assisted | PREOPERATIVE DIAGNOSES,1. Abnormal uterine bleeding.,2. Uterine fibroids.,POSTOPERATIVE DIAGNOSES,1. Abnormal uterine bleeding.,2. Uterine fibroids.,OPERATION PERFORMED: , Laparoscopic-assisted vaginal hysterectomy.,ANESTHESIA: , General endotracheal anesthesia.,DESCRIPTION OF PROCEDURE: ,After adequate general endotracheal anesthesia, the patient was placed in dorsal lithotomy position, prepped and draped in the usual manner for a laparoscopic procedure. A speculum was placed into the vagina. A single tooth tenaculum was utilized to grasp the anterior lip of the uterine cervix. The uterus was sounded to 10.5 cm. A #10 RUMI cannula was utilized and attached for uterine manipulation. The single-tooth tenaculum and speculum were removed from the vagina. At this time, the infraumbilical area was injected with 0.25% Marcaine with epinephrine and infraumbilical vertical skin incision was made through which a Veress needle was inserted into the abdominal cavity. Aspiration was negative; therefore the abdomen was insufflated with carbon dioxide. After adequate insufflation, Veress needle was removed and an 11-mm separator trocar was introduced through the infraumbilical incision into the abdominal cavity. Through the trocar sheath, the laparoscope was inserted and adequate visualization of the pelvic structures was noted. At this time, the suprapubic area was injected with 0.25% Marcaine with epinephrine. A 5-mm skin incision was made and a 5-mm trocar was introduced into the abdominal cavity for instrumentation. Evaluation of the pelvis revealed the uterus to be slightly enlarged and irregular. The fallopian tubes have been previously interrupted surgically. The ovaries appeared normal bilaterally. The cul-de-sac was clean without evidence of endometriosis, scarring or adhesions. The ureters were noted to be deep in the pelvis. At this time, the right cornu was grasped and the right fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected without difficulty. The remainder of the uterine vessels and anterior and posterior leaves of the broad ligament, as well as the cardinal ligament was coagulated and transected in a serial fashion down to level of the uterine artery. The uterine artery was identified. It was doubly coagulated with bipolar electrocautery and transected. A similar procedure was carried out on the left with the left uterine cornu identified. The left fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected. The remainder of the cardinal ligament, uterine vessels, anterior, and posterior sheaths of the broad ligament were coagulated and transected in a serial manner to the level of the uterine artery. The uterine artery was identified. It was doubly coagulated with bipolar electrocautery and transected. The anterior leaf of the broad ligament was then dissected to the midline bilaterally, establishing a bladder flap with a combination of blunt and sharp dissection. At this time, attention was made to the vaginal hysterectomy. The laparoscope was removed and attention was made to the vaginal hysterectomy. The RUMI cannula was removed and the anterior and posterior leafs of the cervix were grasped with Lahey tenaculum. A circumferential injection with 0.25% Marcaine with epinephrine was made at the cervicovaginal portio. A circumferential incision was then made at the cervicovaginal portio. The anterior and posterior colpotomies were accomplished with a combination of blunt and sharp dissection without difficulty. The right uterosacral ligament was clamped, transected, and ligated with #0 Vicryl sutures. The left uterosacral ligament was clamped, transected, and ligated with #0 Vicryl suture. The parametrial tissue was then clamped bilaterally, transected, and ligated with #0 Vicryl suture bilaterally. The uterus was then removed and passed off the operative field. Laparotomy pack was placed into the pelvis. The pedicles were evaluated. There was no bleeding noted; therefore, the laparotomy pack was removed. The uterosacral ligaments were suture fixated into the vaginal cuff angles with #0 Vicryl sutures. The vaginal cuff was then closed in a running fashion with #0 Vicryl suture. Hemostasis was noted throughout. At this time, the laparoscope was reinserted into the abdomen. The abdomen was reinsufflated. Evaluation revealed no further bleeding. Irrigation with sterile water was performed and again no bleeding was noted. The suprapubic trocar sheath was then removed under laparoscopic visualization. The laparoscope was removed. The carbon dioxide was allowed to escape from the abdomen and the infraumbilical trocar sheath was then removed. The skin incisions were closed with #4-0 Vicryl in subcuticular fashion. Neosporin and Band-Aid were applied for dressing and the patient was taken to the recovery room in satisfactory condition. Estimated blood loss was approximately 100 mL. There were no complications. The instrument, sponge, and needle counts were correct.obstetrics / gynecology, abnormal uterine bleeding, laparoscopic-assisted vaginal hysterectomy, uterine fibroids, bipolar electrocautery, vaginal hysterectomy, vicryl sutures, tooth, uterine, uterosacral, laparoscope, electrocautery, hysterectomy, laparoscopic, coagulated, vaginal, ligament, transected |
| 45 | 1 | HPV Consult | He has no voiding complaints and no history of sexually transmitted diseases.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , Back surgery with a fusion of L5-S1.,MEDICATIONS: , He does take occasional Percocet for his back discomfort.,ALLERGIES:, HE HAS NO ALLERGIES.,SOCIAL HISTORY:, He is a smoker. He takes rare alcohol. His employment is that he does dynamite work and actually putting in the dynamite in large holes for destroying ground to that pipeline can be laid. He travels to anywhere for his work. He is married with one son.,FAMILY HISTORY: , Negative for prostate cancer, kidney cancer, bladder cancer, enlarged prostate or kidney disease.,REVIEW OF SYSTEMS:, Negative for tremors, headaches, dizzy spells, numbness, tingling, feeling hot or cold, tired or sluggishness, abdominal pain, nausea or vomiting, indigestion, heartburn, fevers, chills, weight loss, wheezing, frequent cough, shortness of breath, chest pain, varicose veins, high blood pressure, skin rash, joint pain, ear infections, sore throat, sinus problems, hay fever, blood clotting problems, depressive affect or eye problems.,PHYSICAL EXAMINATION,GENERAL: The patient is afebrile. His vital signs are stable. He is 177 pounds, 5 feet, 8 inches. Blood pressure 144/66. He is healthy appearing. He is alert and oriented x 3.,HEART: Regular rate and rhythm.,LUNGS: Clear to auscultation.,ABDOMEN: Soft and nontender. His penis is circumcised. He has a pedunculated cauliflower-like lesion on the dorsum of the penis at approximately 12 o'clock. It is very obvious and apparent. He also has a mildly raised brown lesion that the patient states has been there ever since he can remember and has not changed in size or caliber. His testicles are descended bilaterally. There are no masses.,ASSESSMENT AND PLAN: , This is likely molluscum contagiosum (genital warts) caused by HPV. I did state to the patient that this is likely a viral infection that could have had a long incubation period. It is not clear where this came from but it is most likely sexually transmitted. He is instructed that he should use protected sex from this point on in order to try and limit the transmission. Regarding the actual lesion itself, I did mention that we could apply a cream of Condylox, which could take up to a month to work. I also offered him C02 laser therapy for the genital warts, which is an outpatient procedure. The patient is very interested in something quick and effective such as a CO2 laser procedure. I did state that the recurrence rate is significant and somewhere as high as 20% despite enucleating these lesions. The patient understood this and still wished to proceed. There is minimal risk otherwise except for those inherent in laser injury and accidental injury. The patient understood and wished to proceed.urology, sexually transmitted, molluscum contagiosum, genital warts, hpv, |
| 46 | 1 | Total Hip Replacement | PREOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,POSTOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,PROCEDURES PERFORMED: , Total hip replacement on the right side using the following components:,1. Zimmer trilogy acetabular system 10-degree elevated rim located at the 12 o'clock position.,2. Trabecular metal modular acetabular system 48 mm in diameter.,3. Femoral head 32 mm diameter +0 mm neck length.,4. Alloclassic SL offset stem uncemented for taper.,ANESTHESIA: , Spinal.,DESCRIPTION OF PROCEDURE IN DETAIL:, The patient was brought into the operating room and was placed on the operative table in a lateral decubitus position with the right side up. After review of allergies, antibiotics were administered and time out was performed. The right lower extremity was prepped and draped in a sterile fashion. A 15 cm to 25 cm in length, an incision was made over the greater trochanter. This was angled posteriorly. Access to the tensor fascia lata was performed. This was incised with the use of scissors. Gluteus maximus was separated. The bursa around the hip was identified, and the bleeders were coagulated with the use of Bovie. Hemostasis was achieved. The piriformis fossa was identified, and the piriformis fossa tendon was elevated with the use of a Cobb. It was detached from the piriformis fossa and tagged with 2-0 Vicryl. Access to the capsule was performed. The capsule was excised from the posterior and superior aspects. It was released also in the front with the use of a Mayo scissors. The hip was then dislocated. With the use of an oscillating saw, the femoral neck cut was performed. The acetabulum was then visualized and debrided from soft tissues and osteophytes. Reaming was initiated and completed for a 48 mm diameter cap without complications. The trial component was put in place and was found to be stable in an anatomic position. The actual component was then impacted in the acetabulum. A 10-degree lip polyethylene was also placed in the acetabular cap. Our attention was then focused to the femur. With the use of a cookie cutter, the femoral canal was accessed. The broaching process was initiated for No.4 trial component. Trialing of the hip with the hip flexed at 90 degrees and internally rotated to 30 degrees did not demonstrate any obvious instability or dislocation. In addition, in full extension and external rotation, there was no dislocation. The actual component was inserted in place and hemostasis was achieved again. The wound was irrigated with normal saline. The wound was then closed in layers. Before performing that the medium-sized Hemovac drain was placed in the wound. The tensor fascia lata was closed with 0 PDS and the wound was closed with 2-0 Monocryl. Staples were used for the skin. The patient recovered from anesthesia without complications.,EBL: , 50 mL.,IV FLUIDS: , 2 liters.,DRAINS: , One medium-sized Hemovac.,COMPLICATIONS: , None.,DISPOSITION: , The patient was transferred to the PACU in stable condition. She will be weightbearing as tolerated to the right lower extremity with posterior hip precautions. We will start the DVT prophylaxis after the removal of the epidural catheter.surgery, total hip replacement, epidural catheter, tensor fascia lata, hemostasis was achieved, medium sized hemovac, tensor fascia, fascia lata, trial component, medium sized, sized hemovac, total hip, hip replacement, hip osteoarthritis, piriformis fossa, total, hip, acetabular, extremity, tensor, fascia, hemostasis, acetabulum, dislocation, hemovac, replacement, osteoarthritis, femoral, piriformis, fossa, components, anesthesia, |
| 47 | 4 | MRI C-Spine - C5-6 Disk Herniation | CC:, Right shoulder pain.,HX: ,This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck (Lhermitte's phenomena). She denied any history of neck/back/head trauma.,She had been taking Naprosyn with little relief.,PMH: ,1) Catamenial Headaches. 2) Allergy to Macrodantin.,SHX/FHX:, Smokes 2ppd cigarettes.,EXAM: ,Vital signs were unremarkable.,CN: unremarkable.,Motor: full strength throughout. Normal tone and muscle bulk.,Sensory: No deficits on LT/PP/VIB/TEMP/PROP testing.,Coord/Gait/Station: Unremarkable.,Reflexes: 2/2 in BUE except 2+ at left biceps. 1+/1+BLE except an absent right ankle reflex.,Plantar responses were flexor bilaterally. Rectal exam: normal tone.,IMPRESSION:, C-spine lesion.,COURSE: ,MRI C-spine revealed a central C5-6 disk herniation with compression of the spinal cord at that level. EMG/NCV showed normal NCV, but 1+ sharps and fibrillations in the right biceps (C5-6), brachioradialis (C5-6), triceps (C7-8) and teres major; and 2+ sharps and fibrillations in the right pronator terres. There was increased insertional activity in all muscles tested on the right side. The findings were consistent with a C6-7 radiculopathy.,The patient subsequently underwent C5-6 laminectomy and her symptoms resolved.neurology, shoulder pain, stiffness, numbness, lhermitte's phenomena, c-spine lesion, disk herniation, mri c spine, reflexes, biceps, mri, disk, shoulder, spine, herniation, |
| 48 | 2 | Headache - Office Visit | She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and diabetic neuropathy. She was referred to Dr. XYZ and will be seeing him on August 8, 2006.,She was also never referred to the endocrine clinic to deal with her poor diabetes control. Her last hemoglobin A1c was 10.,PAST MEDICAL HISTORY:, Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy.,MEDICATIONS: , Glyburide, Avandia, metformin, lisinopril, Lipitor, aspirin, metoprolol and Zonegran.,PHYSICAL EXAMINATION:, Blood pressure was 140/70, heart rate was 76, respiratory rate was 18, and weight was 226 pounds. On general exam she has an area of tenderness on palpation in the left parietal region of her scalp. Neurological exam is detailed on our H&P form. Her neurological exam is within normal limits.,IMPRESSION AND PLAN:, For her headaches we are going to titrate Zonegran up to 200 mg q.h.s. to try to maximize the Zonegran therapy. If this is not effective, when she comes back on August 7, 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica. We also discussed with Ms. Hawkins the possibility of nerve block injection; however, at this point she is not interested.,She will be seeing Dr. XYZ for her neuropathies.,We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult.office notes, nerve conduction studies, emg, zonegran therapy, ulnar neuropathy, endocrine clinic, diabetes control, neurological exam, headache, zonegran |
| 49 | 3 | Appendectomy Laparoscopic - 1 | PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:, Acute suppurative appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and Marcaine 0.25% local.,INDICATIONS:, This 29-year-old female presents to ABCD General Hospital Emergency Department on 08/30/2003 with history of acute abdominal pain. On evaluation, it was noted that the patient has clinical findings consistent with acute appendicitis. However, the patient with additional history of loose stools for several days prior to event. Therefore, a CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis. There was no evidence of colitis on the CAT scan. With this in mind and the patient's continued pain at present, the patient was explained the risks and benefits of appendectomy. She agreed to procedure and informed consent was obtained.,GROSS FINDINGS: , The appendix was removed without difficulty with laparoscopic approach. The appendix itself noted to have a significant inflammation about it. There was no evidence of perforation of the appendix.,PROCEDURE DETAILS:, The patient was placed in supine position. After appropriate anesthesia was obtained and sterile prep and drape completed, a #10 blade scalpel was used to make a curvilinear infraumbilical incision. Through this incision, a Veress needle was utilized to create a CO2 pneumoperitoneum of 15 mmHg. The Veress needle was then removed. A 10 mm trocar was then introduced through this incision into the abdomen. A video laparoscope was then inserted and the above noted gross findings were appreciated upon evaluation. Initially, bilateral ovarian cysts were appreciated, however, there was no evidence of acute disease on evaluation. Photodocumentation was obtained.,A 5 mm port was then placed in the right upper quadrant. This was done under direct visualization and a blunt grasper was utilized to mobilize the appendix. Next, a 12 mm port was placed in the left lower quadrant lateral to the rectus musculature under direct visualization. Through this port, the dissector was utilized to create a small window in the mesoappendix. Next, an EndoGIA with GI staples was utilized to fire across the base of the appendix, which was done noting it to be at the base of the appendix. Next, staples were changed to vascular staples and the mesoappendix was then cut and vessels were then ligated with vascular staples. Two 6 X-loupe wires with EndoGIA were utilized in this prior portion of the procedure. Next, an EndoCatch was placed through the 12 mm port and the appendix was placed within it. The appendix was then removed from the 12 mm port site and taken off the surgical site. The 12 mm port was then placed back into the abdomen and CO2 pneumoperitoneum was recreated. The base of the appendix was reevaluated and noted to be hemostatic. Aspiration of warm saline irrigant then done and noted to be clear. There was a small adhesion appreciated in the region of the surgical site. This was taken down with blunt dissection without difficulty. There was no evidence of other areas of disease. Upon re-exploration with a video laparoscope in the abdomen and after this noting the appendix base to be hemostatic and intact. The instruments were removed from the patient and the port sites were then taken off under direct visualization. The CO2 pneumoperitoneum was released into the air and the fascia was approximated in the 10 mm and 12 mm port sites with #0 Vicryl ligature x2. Marcaine 0.25% was then utilized in all three incision sites and #4-0 Vicryl suture was used to approximate the skin and all three incision sites. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and taken to Postoperative Care Unit in stable condition and monitored under General Medical Floor on IV antibiotics, pain medications, and return to diet.gastroenterology, abdomen, pelvis, laparoscopic appendectomy, suppurative appendicitis, veress needle, acute appendicitis, appendix, appendectomy, pneumoperitoneum, laparoscopic, appendicitis |
| 50 | 2 | Hematuria & Urinary Retention | REASON FOR CONSULTATION:, Hematuria and urinary retention.,BRIEF HISTORY: , The patient is an 82-year-old, who was admitted with the history of diabetes, hypertension, hyperlipidemia, coronary artery disease, presented with urinary retention and pneumonia. The patient had hematuria, and unable to void. The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed. Foley catheter was repositioned 18 Coude was used. About over a liter of fluids of urine was obtained with light pink urine, which was irrigated. The bladder and the suprapubic area returned to normal after the Foley placement. The patient had some evidence of clots upon irrigation. The patient has had a chest CT, which showed possible atelectasis versus pneumonia.,PAST MEDICAL HISTORY: ,Coronary artery disease, diabetes, hypertension, hyperlipidemia, Parkinson's, and CHF.,FAMILY HISTORY: ,Noncontributory.,SOCIAL HISTORY: , Married and lives with wife.,HABITS:, No smoking or drinking.,REVIEW OF SYSTEMS: , Denies any chest pain, denies any seizure disorder, denies any nausea, vomiting. Does have suprapubic tenderness and difficulty voiding. The patient denies any prior history of hematuria, dysuria, burning, or pain.,PHYSICAL EXAMINATION:,VITAL SIGNS: The patient is afebrile. Vitals are stable.,GENERAL: The patient is a thin gentleman,GENITOURINARY: Suprapubic area was distended and bladder was palpated very easily. Prostate was 1+. Testes are normal.,LABORATORY DATA: , The patient's white counts are 20,000. Creatinine is normal.,ASSESSMENT AND PLAN:,1. Pneumonia.,2. Dehydration.,3. Retention.,4. BPH.,5. Diabetes.,6. Hyperlipidemia.,7. Parkinson's.,8. Congestive heart failure.,About 30 minutes were spent during the procedure and the Foley catheter was placed, Foley was irrigated and significant amount of clots were obtained. Plan is for urine culture, antibiotics. Plan is for renal ultrasound to rule out any pathology. The patient will need cystoscopy and evaluation of the prostate. Apparently, the patient's PSA is 0.45, so the patient is at low to no risk of prostate cancer at this time. Continued Foley catheter at this point. We will think about starting the patient on alpha-blockers once the patient's over all medical condition is improved and stable.nan |
| 51 | 3 | Rheumatoid Arthritis - H&P | CHIEF COMPLAINT:, This 26 year old male presents today for treatment of suspected rheumatoid arthritis. Associated signs and symptoms include aching, joint pain, and symmetrical joint swelling bilateral. Patient denies any previous history, related trauma or previous treatments for this condition. Condition has existed for 2 weeks. He indicates the problem location is the right hand and left hand. Patient indicates no modifying factors. Severity of condition is slowly worsening. Onset was unknown.,ALLERGIES:, Patient admits allergies to aspirin resulting in GI upset, disorientation.,MEDICATION HISTORY: , Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD.,PAST MEDICAL HISTORY:, Past medical history is unremarkable.,PAST SURGICAL HISTORY: , Patient admits past surgical history of (+) appendectomy in 1989.,FAMILY HISTORY: , Patient admits a family history of rheumatoid arthritis associated with maternal grandmother.,SOCIAL HISTORY: ,Patient denies alcohol use. Patient denies illegal drug use. Patient denies STD history. Patient denies tobacco use.,REVIEW OF SYSTEMS: , Neurological: (+) paralysis Musculoskeletal: (+) joint pain (+) joint swelling (+) stiffness Cardiovascular: (+) ankle swelling Neurological: (-) numbness,Musculoskeletal: (-) back pain (chronic) (-) decreased ROM (-) episodic weakness,Cardiovascular: (-) chest pressure Respiratory: (-) breathing difficulties, respiratory symptoms (-) sleep apnea,PHYSICAL EXAM: , BP Standing: 120/84 HR: 79 Temp: 98.6 Height: 5 ft. 8 in. Weight: 168 lbs. Patient is a 26 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus. Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Palpation of skin shows no abnormalities.,HEENT: Inspection of head and face shows no abnormalities. Hair growth and distribution is normal. Examination of scalp shows no abnormalities. Conjunctiva and lids reveal no signs or symptoms of infection. Pupil exam reveals round and reactive pupils without afferent pupillary defect. Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral. Bilateral retinas reveal normal color, contour, and cupping. Inspection of ears reveals no abnormalities. Otoscopic examination reveals no abnormalities. Examination of oropharynx reveals no abnormalities and tissues pink and moist. ENT: Inspection of ears reveals no abnormalities. Examination of larynx reveals no abnormalities. Inspection of nose reveals no abnormalities.,Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable. Thyroid examination reveals no abnormalities and smooth and symmetric gland with no enlargement, tenderness or masses noted. Lymphatic: Neck lymph nodes are normal.,Respiratory: Assessment of respiratory effort reveals even respirations without use of accessory muscles and no intercostal retractions noted. Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion. Auscultation of lungs reveals clear lung fields and no rubs noted.,Cardiovascular: Heart auscultation reveals normal S1 and S2 and no murmurs, gallop, rubs or clicks. Examination of peripheral vascular system reveals full to palpation, varicosities absent, extremities warm to touch and no edema.,Abdomen: Abdominal contour is slightly rounded. Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities. Palpation of spleen reveals no abnormalities.,Musculoskeletal: Gait and station examination reveals normal arm swing, with normal heel-toe and tandem walking. Inspection and palpation of bones, joints and muscles is unremarkable. Muscle strength is 5/5 for all groups tested. Muscle tone is normal.,Neurologic/Psychiatric: Psychiatric: Oriented to person, place and time. Mood and affect normal and appropriate to situation. Testing of cranial nerves reveals no deficits. Coordination is good. Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.,TEST & X-RAY RESULTS:, Rheumatoid factor: 52 U/ml. Sed rate: 31 mm/hr. C4 complement: 19 mg/dl.,IMPRESSION: , Rheumatoid arthritis.,PLAN:, ESR ordered; automated. Ordered RBC. Ordered quantitative rheumatoid factor. Return to clinic in 2 week (s).,PRESCRIPTIONS:, Vioxx Dosage: 12.5 mg tablet Sig: BID Dispense: 30 Refills: 2 Allow Generic: Nonan |
| 52 | 3 | Open Cholecystectomy | 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, |
| 53 | 2 | Nephrology Consultation - 3 | PAST MEDICAL/SURGICAL HISTORY: , Briefly, his past medical history is significant for hypertension of more than 5 years, asthma, and he has been on Advair and albuterol. He was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008. His past surgical history is only significant for left AV fistula on the wrist done in 04/2008. He still has urine output. He has no history of blood transfusion.,PERSONAL AND SOCIAL HISTORY: , He is a nonsmoker. He denies any alcohol. No illicit drugs. He used to work as the custodian at the nursing home, but now on disability since 03/2008. He is married with 2 sons, ages 5 and 17 years old.,FAMILY HISTORY:, No similar illness in the family, except for hypertension in his one sister and his mom, who died at 61 years old of congestive heart failure. His father is 67 years old, currently alive with asthma. He also has one sister who has hypertension. The rest of the 6 siblings are alive and well.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Singulair 10 mg once daily, Cardizem 365 mg once daily, Coreg 25 mg once daily, hydralazine 100 mg three times a day, Lanoxin 0.125 mg once daily, Crestor 10 mg once daily, lisinopril 10 mg once daily, Phoslo 3 tablets with meals, and Advair 250 mg inhaler b.i.d.,REVIEW OF SYSTEMS: , Significant only for asthma. No history of chest pain normal MI. He has hypertension. He occasionally will develop colds especially with weather changes. GI: Negative. GU: Still making urine about 1-3 times per day. Musculoskeletal: Negative. Skin: He complains of dry skin. Neurologic: Negative. Psychiatry: Negative. Endocrine: Negative. Hematology: Negative.,PHYSICAL EXAMINATION: , A pleasant 41-year-old African-American male who stands 5 feet 6 inches and weighs about 193 pounds. HEENT: Anicteric sclera, pink conjunctiva, no cervical lymphadenopathy. Chest: Equal chest expansion. Clear breath sounds. Heart: Distinct heart sounds, regular rhythm with no murmur. Abdomen: Soft, nontender, flabby, no organomegaly. Extremities: Poor peripheral pulses. No cyanosis and no edema.,ASSESSMENT AND PLAN:, This is a 49-year old African-American male who was diagnosed with end-stage renal disease secondary to hypertension. He is on hemodialysis since 02/2008. Overall, I think that he is a reasonable candidate for a kidney transplantation and should undergo a complete pretransplant workup with pulmonary clearance because of his chronic asthma. Other than that, I think that he is a reasonable candidate for transplant.,I would like to thank you for allowing me to participate in the care of your patient. Please feel free to contact me if there are any questions regarding his case.consult - history and phy., kidney transplantation, pretransplant, transplant clinic, renal disease, secondary, kidney, hemodialysis, renal, asthma, transplantation, hypertension |
| 54 | 2 | Brain MRI - Pituitary Adenoma | CC:, Orthostatic lightheadedness.,HX:, This 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. The dizziness worsened when moving into upright positions. In addition, he complained of intermittent throbbing holocranial headaches, which did not worsen with positional change, for the past several weeks. He had lost 40 pounds over the past year and denied any recent fever, SOB, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes.,He had a 100+ pack-year history of tobacco use and continued to smoke 1 to 2 packs per day. He has a history of sinusitis.,EXAM:, BP 98/80 mmHg and pulse 64 BPM (supine); BP 70/palpable mmHG and pulse 84BPM (standing). RR 12, Afebrile. Appeared fatigued.,CN: unremarkable.,Motor and Sensory exam: unremarkable.,Coord: Slowed but otherwise unremarkable movements.,Reflexes: 2/2 and symmetric throughout all 4 extremities. Plantar responses were flexor, bilaterally.,The rest of the neurologic and general physical exam was unremarkable.,LAB:, Na 121 meq/L, K 4.2 meq/L, Cl 90 meq/L, CO2 20meq/L, BUN 12mg/DL, CR 1.0mg/DL, Glucose 99mg/DL, ESR 30mm/hr, CBC WNL with nl WBC differential, Urinalysis: SG 1.016 and otherwise WNL, TSH 2.8 IU/ML, FT4 0.9ng/DL, Urine Osmolality 246 MOSM/Kg (low), Urine Na 35 meq/L,,COURSE:, The patient was initially hydrated with IV normal saline and his orthostatic hypotension resolved, but returned within 24-48hrs. Further laboratory studies revealed: Aldosterone (serum)<2ng/DL (low), 30 minute Cortrosyn Stimulation test: pre 6.9ug/DL (borderline low), post 18.5ug/DL (normal stimulation rise), Prolactin 15.5ng/ML (no baseline given), FSH and LH were within normal limits for males. Testosterone 33ng/DL (wnl). Sinus XR series (done for history of headache) showed an abnormal sellar region with enlarged sella tursica and destruction of the posterior clinoids. There was also an abnormal calcification seen in the middle of the sellar region. A left maxillary sinus opacity with air-fluid level was seen. Goldman visual field testing was unremarkable. Brain CT and MRI revealed suprasellar mass most consistent with pituitary adenoma. He was treated with Fludrocortisone 0.05 mg BID and within 24hrs, despite discontinuation of IV fluids, remained hemodynamically stable and free of symptoms of orthostatic hypotension. His presumed pituitary adenoma continues to be managed with Fludrocortisone as of this writing (1/1997), though he has developed dementia felt secondary to cerebrovascular disease (stroke/TIA).radiology, brain ct, goldman, mri, orthostatic, adenoma, generalized weakness, hypotension, lightheadedness, malaise, pituitary, sinus opacity, suprasellar mass, brain ct and mri, orthostatic hypotension, pituitary adenoma, brain, sinusitis, sellar, |
| 55 | 3 | Liver Biopsy | TITLE OF PROCEDURE: , Percutaneous liver biopsy.,ANALGESIA: , 2% Lidocaine.,ALLERGIES: , The patient denied any allergy to iodine, lidocaine or codeine.,PROCEDURE IN DETAIL: ,The procedure was described in detail to the patient at a previous clinic visit and by the medical staff today. The patient was told of complications which might occur consisting of bleeding, bile peritonitis, bowel perforation, pneumothorax, or death. The risks and benefits of the procedure were understood, and the patient signed the consent form freely.,With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion. The area was prepped and cleaned with povidone iodine following which the skin, subcutaneous tissue, and serosal surfaces were infiltrated with 2% lidocaine down to the capsule of the liver. Next, a small incision was made with a Bard-Parker #11 scalpel. A 16-gauge modified Klatskin needle was inserted through the incision and into the liver on one occasion with the patient in deep expiration. Liver cores measuring *** cm were obtained and will be sent to Pathology for routine histologic study.,POST-PROCEDURE COURSE AND DISPOSITION: , The patient will remain under close observation in the medical treatment room for four to six hours and then be discharged home without medication. Normal activities can be resumed tomorrow. The patient is to contact me if severe abdominal or chest pain, fever, melena, light-headedness or any unusual symptoms develop. An appointment will be made for the patient to see me in the clinic in the next few weeks to discuss the results of the liver biopsy so that management decisions can be made.,COMPLICATIONS:, None.,RECOMMENDATIONS: , Prior to discharge, hepatitis A and B vaccines will be recommended. Risks and benefits for vaccination have been addressed and the patient will consider this option.gastroenterology, bile peritonitis, bowel perforation, pneumothorax, klatskin needle, mid axillary, liver biopsy, percutaneous, lidocaine, biopsy, liver |
| 56 | 1 | Clear Corneal Temporal Incision | CLEAR CORNEAL TEMPORAL INCISION (NO STITCHES),DESCRIPTION OF OPERATION: , Under satisfactory local anesthesia, the patient was appropriately prepped and draped. A lid speculum was placed in the fissure of the right eye.,The secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon's 7:30 position and the anterior chamber re-formed using viscoelastic. The primary incision was then made using a 3-mm diamond keratome at the surgeon's 5 o'clock position and additional viscoelastic injected into the anterior chamber as needed. The capsulorrhexis was then performed in a standard circular tear fashion. The nucleus was then separated from its cortical attachments by hydrodissection and emulsified in the capsular bag. The residual cortex was then aspirated from the bag and the bag re-expanded using viscoelastic. The posterior chamber intraocular lens was then inspected, irrigated, coated with Healon and folded, and then placed into the capsular bag under direct visualization. The lens was noted to center well. The residual viscoelastic was then removed from the eye and the eye re-formed using balanced salt solution. The eye was then checked and found to be watertight; therefore, no suture was used. The lid speculum and the drapes were then removed and the eye treated with Maxitrol ointment.,A shield was applied and the patient returned to the recovery room in good condition.surgery, clear corneal temporal incision, intraocular lens, corneal temporal incision, lid speculum, incision, temporal, chamber, corneal, viscoelastic, eyeNOTE,: 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. |
| 57 | 2 | Consult - Palpitations & Presyncope | HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations. Symptoms occur three to four times per year and follow no identifiable pattern. She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so. Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate. The last two episodes, the most recent of which was yesterday, were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision. On neither occasion did she lose consciousness.,Yesterday, she had a modestly active morning taking a walk with her dogs and performing her normal routines. While working on a computer, she had a spell. Palpitations persisted for a short time thereafter as outlined in the hospital's admission note prompting her to seek evaluation at the hospital. She was in sinus rhythm on arrival and has been asymptomatic since.,No history of exogenous substance abuse, alcohol abuse, or caffeine abuse. She does have a couple of sodas and at least one to two coffees daily. She is a nonsmoker. She is a mother of two. There is no family history of congenital heart disease. She has had no history of thoracic trauma. No symptoms to suggest thyroid disease.,No known history of diabetes, hypertension, or dyslipidemia. Family history is negative for ischemic heart disease.,Remote history is significant for an ACL repair, complicated by contact urticaria from a neoprene cast.,No regular medications prior to admission.,The only allergy is the neoprene reaction outlined above.,PHYSICAL EXAMINATION: , Vital signs as charted. Pupils are reactive. Sclerae nonicteric. Mucous membranes are moist. Neck veins not distended. No bruits. Lungs are clear. Cardiac exam is regular without murmurs, gallops, or rubs. Abdomen is soft without guarding, rebound masses, or bruits. Extremities well perfused. No edema. Strong and symmetrical distal pulses.,A 12-lead EKG shows sinus rhythm with normal axis and intervals. No evidence of preexcitation.,LABORATORY STUDIES: , Unremarkable. No evidence of myocardial injury. Thyroid function is pending.,Two-dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease.,IMPRESSION/PLAN: , Episodic palpitations over a nine-year period. Outpatient workup would be appropriate. Event recorder should be obtained and the patient can be seen again in the office upon completion of that study. Suppressive medication (beta-blocker or Cardizem) was discussed with the patient for symptomatic improvement, though this would be unlikely to be a curative therapy. The patient expresses a preference to avoid medical therapy if possible.,Thank you for this consultation. We will be happy to follow her both during this hospitalization and following discharge. Caffeine avoidance was discussed as well.,ADDENDUM: , During her initial evaluation, a D-dimer was mildly elevated to 5. CT scan showed no evidence of pulmonary embolus. Lower extremity venous ultrasound is pending; however, in the absence of embolization to the pulmonary vasculature, this would be an unlikely cause of palpitations. In addition, no progression over the nine-year period that she has been symptomatic suggests that this is an unlikely cause.,consult - history and phy., presyncope, palpitations, episodic palpitations, beta-blocker, ultrasound, palpitations and presyncope, sinus rhythm, heart disease, heart |
| 58 | 2 | Motor Vehicle Accident | CHIEF COMPLAINT: , Motor vehicle accident.,HISTORY OF PRESENT ILLNESS: , This is a 32-year-old Hispanic female who presents to the emergency department today via ambulance. The patient was brought by ambulance following a motor vehicle collision approximately 45 minutes ago. The patient states that she was driving her vehicle at approximately 40 miles per hour. The patient was driving a minivan. The patient states that the car in front of her stopped too quickly and she rear-ended the vehicle ahead of her. The patient states that she was wearing her seatbelt. She was driving. There were no other passengers in the van. The patient states that she was restrained by the seatbelt and that her airbag deployed. The patient denies hitting her head. She states that she does have some mild pain on the left aspect of her neck. The patient states that she believes she may have passed out shortly after the accident. The patient states that she also has some pain low in her abdomen that she believes is likely due to the steering wheel or deployment on the airbag. The patient denies any pain in her knees, ankles, or feet. She denies any pain in her shoulders, elbows, and wrists. The patient does state that she is somewhat painful throughout the bones of her pelvis as well. The patient did not walk after this accident. She was removed from her car and placed on a backboard and immobilized. The patient denies any chest pain or difficulty breathing. She denies any open lacerations or abrasions. The patient has not had any headache, nausea or vomiting. She has not felt feverish or chilled. The patient does states that there is significant deformity to the front of the vehicle that she was driving, which again was a minivan. There were no oblique vectors or force placed on this accident. The patient had straight rear-ending of the vehicle in front of her. The pain in her abdomen is most significant pain currently and she ranks it at 5 out of 10. The patient states that her last menstrual cycle was at the end of May. She does not believe that she could be pregnant. She is taking oral birth control medications and also has an intrauterine device to prevent pregnancy as the patient is on Accutane.,PAST MEDICAL HISTORY:, No significant medical history other than acne.,PAST SURGICAL HISTORY:, None.,SOCIAL HABITS: , The patient denies tobacco, alcohol or illicit drug usage.,MEDICATIONS:, Accutane.,ALLERGIES: , No known medical allergies.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL: This is a Hispanic female who appears her stated age of 32 years. She is well-nourished, well-developed, in no acute distress. The patient is pleasant. She is immobilized on a backboard and also her cervical spine is immobilized as well on a collar. The patient is without capsular retractions, labored respirations or accessory muscle usage. She responds well and spontaneously.,VITAL SIGNS: Temperature 98.2 degrees Fahrenheit, blood pressure 129/84, pulse 75, respiratory rate 16, and pulse oximetry 97% on room air.,HEENT: Head is normocephalic. There is no crepitus. No bony step-offs. There are no lacerations on the scalp. Sclerae are anicteric and noninjected. Fundoscopic exam appears normal without papilledema. External ocular movements are intact bilaterally without nystagmus or entrapment. Nares are patent and free of mucoid discharge. Mucous membranes are moist and free of exudate or lesions.,NECK: Supple. No thyromegaly. No JVD. No carotid bruits. Trachea is midline. There is no stridor.,HEART: Regular rate and rhythm. Clear S1 and S2. No murmur, rub or gallop is appreciated.,LUNGS: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi.,ABDOMEN: Soft, nontender with the exception of mild-to-moderate tenderness in the bilateral lower pelvic quadrants. There is no organomegaly here. Positive bowel sounds are auscultated throughout. There is no rigidity or guarding. Negative CVA tenderness bilaterally.,EXTREMITIES: No edema. There are no bony abnormalities or deformities.,PERIPHERAL VASCULAR: Capillary refill is less than two seconds in all extremities. The patient does have intact dorsalis pedis and radial pulses bilaterally.,PSYCHIATRIC: Alert and oriented to person, place, and time. The patient recalls all events regarding the accident today.,NEUROLOGIC: Cranial nerves II through XII are intact bilaterally. No focal deficits are appreciated. The patient has equal and strong distal and proximal muscle group strength in all four extremities. The patient has negative Romberg and negative pronator drift.,LYMPHATICS: No appreciable adenopathy.,MUSCULOSKELETAL: The patient does have pain free range of motion at the bilateral ankles, bilateral knees, bilateral hips, bilateral shoulders, bilateral elbows, and bilateral wrists. There are no bony abnormalities identified. The patient does have some mild tenderness over palpation of the bilateral iliac crests.,SKIN: Warm, dry, and intact. No lacerations. There are no abrasions other than a small abrasion on the patient's abdomen just inferior to the umbilicus. No lacerations and no sites of trauma or bleeding are identified.,DIAGNOSTIC STUDIES: , The patient does have multiple x-rays done. There is an x-ray of the pelvis, which shows normal pelvis and right hip. There is also a CT scan of the cervical spine that shows no evidence of acute traumatic bony injury of the cervical spine. There is some prevertibral soft tissue swelling from C5 through C7. This is nonspecific and could be due to prominence of upper esophageal sphincter. The CT scan of the brain without contrast shows no evidence of acute intracranial injury. There is some mucus in the left sphenoid sinus. The patient also has emergent CT scan without contrast of the abdomen. The initial studies show some dependent atelectasis in both lungs. There is also some low density in the liver, which could be from artifact or overlying ribs; however, a CT scan with contrast is indicated. A CT scan with contrast is obtained and this is found to be normal without bleeding or intraabdominal or pelvic abnormalities. The patient has laboratory studies done as well. CBC is within normal limits without anemia, thrombocytopenia or leukocytosis. The patient has a urine pregnancy test, which is negative and urinalysis shows no blood and is normal.,EMERGENCY DEPARTMENT COURSE: , The patient was removed from the backboard within the first half hour of her emergency department stay. The patient has no significant bony deformities or abnormalities. The patient is given a dose of Tylenol here in the emergency department for treatment of her pain. Her pain is controlled with medication and she is feeling more comfortable and removed from the backboard. The patient's CT scans of the abdomen appeared normal. She has no signs of bleeding. I believe, she has just a contusion and abrasion to her abdomen from the seatbelt and likely from the airbag as well. The patient is able to stand and walk through the emergency department without difficulty. She has no abrasions or lacerations.,ASSESSMENT AND PLAN:, Multiple contusions and abdominal pain, status post motor vehicle collision. Plan is the patient does not appear to have any intraabdominal or pelvic abnormities following her CT scans. She has normal scans of the brain and her C-spine as well. The patient is in stable condition. She will be discharged with instructions to return to the emergency department if her pain increases or if she has increasing abdominal pain, nausea or vomiting. The patient is given a prescription for Vicodin and Flexeril to use it at home for her muscular pain.nan |
| 59 | 1 | I&D - Gluteal Abscess | PREOPERATIVE DIAGNOSES,1. Postoperative wound infection.,2. Left gluteal abscess.,3. Intraperitoneal pigtail catheter.,POSTOPERATIVE DIAGNOSES,1. Postoperative wound infection. There was an intraperitoneal foreign body.,2. Left gluteal abscess.,3. Intraperitoneal pigtail catheter.,PROCEDURES,1. Incision and drainage (I&D) of gluteal abscess.,2. Removal of pigtail catheter.,3. Limited exploratory laparotomy with removal of foreign body and lysis of adhesions.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was transferred to the operating room where a time-out process was followed. Under general endotracheal anesthesia, first of all the patient was positioned in the left lateral decubitus and the left gluteal area was prepped and draped in the usual fashion. The opening of the abscess was probed and there was a tract of about 20 cm going subcutaneously upward. I proceeded to enlarge the drainage area and to some degree unroofing the tract partially and then the area was débrided and then packed with iodoform gauze and a temporary dressing was applied.,Then, the patient was placed in a supine position, and I proceeded to remove the pigtail catheter after dividing it to undo its locking mechanism. It came out without any difficulty. Then, the colostomy was protected and draped apart, and the patient's abdomen was prepped and draped in the usual fashion. My initial idea was to just drain and debride the wound infection, which had a sinus tract at lower end of the midline incision. I initially probed the wound with a hemostat and this had at least 12 cm long tract and I proceeded to excise the badly scarred skin that was on top of it and then continued the dissection to the fascia and I realized that the sinus tract was going through the fascia into the abdomen. Very carefully, I started dividing the fascia. Of course, there were several small bowel loops adhered to the area. The dissection was quite tedious for a while. Initially, I thought that may be there was an enterocutaneous fistula in the area, but then I realized that the tissue that was interpreted as an intestinal mucosa was actually a very smooth __________ tissue that was walling the sinus tract. I made a laparotomy of about 10 cm and I carefully dissected the bowel of the fascia. There was an area at the bottom which looked like a foreign body and initially I thought there was a mesh that can be used to close the abdomen, but later on this substance floated out by self and it was an elongated strip, maybe about 6 cm, which we sent to Pathology for examination. Initially, I have obtained a sample for culture and sensitivity for aerobic and anaerobic organisms.,I was very happy that we were not really dealing with enterocutaneous fistula. The area was irrigated generously with saline and then we closed the fascia with number of interrupted figure-of-eight sutures of heavy PPS. The subcutaneous tissue and the skin were left open and packed with Betadine-soaked sponges.,A dressing was applied. A small dressing was applied to the area where we removed the pigtail catheter and also we went down to the gluteal area and put a formal dressing in that area. The patient tolerated the procedure well. Estimated blood loss was minimal, and he was sent to the ICU and also made acute care because of the need for a laparotomy, which we were not anticipating.surgery, intraperitoneal pigtail catheter, postoperative wound infection, foreign body, intraperitoneal, exploratory laparotomy, enterocutaneous fistula, wound infection, sinus tract, gluteal abscess, pigtail catheter, i&d, abscess, laparotomy, fascia, pigtail, catheter, gluteal, incision, foreign |
| 60 | 1 | Delivery Note - 6 | DELIVERY NOTE: , This is an 18-year-old, G2, P0 at 35-4/7th weeks by a stated EDC of 01/21/09. The patient is a patient of Dr. X's. Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She also has a history of tobacco abuse with asthma. She was admitted here and labor was confirmed with rupture of membranes. She was initially 5, 70%, -1. Her bag was ruptured, IUPC was placed. She received an epidural for pain control and Pitocin augmentation was performed. She progressed for several hours to complete and to push, then pushed for approximately 15 minutes to deliver a vigorous female infant from OA presentation. Delivery of the head was manual assisted. The shoulders and the rest of body then followed without difficulty. Baby was bulb suctioned, had a vigorous cry. Cord was clamped twice and cut and the infant was handed to the awaiting nursing team. Placenta then delivered spontaneously and intact, was noted to have a three-vessel cord. The inspection of the perineum revealed it to be intact. There was a hymenal remnant/skin tag that was protruding from the vaginal introitus. I discussed this with the patient. She opted to have it removed. This was performed and I put a single interrupted suture 3-0 Vicryl for hemostasis. Further inspection revealed bilateral superficial labial lacerations that were hemostatic and required no repair. Overall EBL is 300 mL. Mom and baby are currently doing well. Cord gases are being sent due to prematurity.,surgery, preterm, rupture of membranes, preterm contractions, contractions, pregnancy, deliveryNOTE,: 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. |
| 61 | 1 | Intraocular Lens Implant | TITLE OF OPERATION: ,1. Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.,2. A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,INDICATION FOR SURGERY: ,The patient is a 62-year-old white male who underwent cataract surgery in 09/06. This was complicated by posterior capsule rupture. An intraocular lens implant was not attempted. He developed corneal edema and a preretinal hemorrhage. He is aware of the risks, benefits, and alternatives of the surgery and now wishes to proceed with secondary scleral suture fixated posterior chamber intraocular lens implant in the left eye, vitrectomy, endolaser, and penetrating keratoplasty.,PREOP DIAGNOSIS: ,1. Preretinal hemorrhage.,2. Diabetic retinopathy.,3. Aphakia.,4. Corneal edema.,POSTOP DIAGNOSIS: ,1. Preretinal hemorrhage.,2. Diabetic retinopathy.,3. Aphakia.,4. Corneal edema.,ANESTHESIA: , General.,SPECIMEN: ,1. Donor corneal swab sent to Microbiology.,2. Donor corneal scar rim sent to Eye Pathology.,3. The patient's cornea sent to Eye Pathology.,PROS DEV IMPLANT: ,ABC Laboratories 16.0 diopter posterior chamber intraocular lens, serial number 123456.,NARRATIVE: , Informed consent was obtained, and all questions were answered. The patient was brought to the preoperative holding area, where the operative left eye was marked. He was brought to the operating room and placed in the supine position. EKG leads were placed. General anesthesia was induced. The left ocular surface and periorbital skin were disinfected and draped in the standard fashion for eye surgery after a shield and tape were placed over the unoperated right eye. A lid speculum was placed. The posterior segment infusion was placed by the vitreoretinal service. Peritomy was performed at the 3 and 9 o'clock limbal positions. A large Flieringa ring was then sutured to the conjunctival surface using 8-0 silk sutures tied in an interrupted fashion. The cornea was then measured and was found to accommodate a 7.5-mm trephine. The center of the cornea was marked. The keratoprosthesis was identified.,A 7.5-mm trephine blade was then used to incise the anterior corneal surface. This was done after a paracentesis was placed at the 1 o'clock position and viscoelastic was used to dissect peripheral anterior synechiae. Once the synechiae were freed, the above-mentioned trephination of the anterior cornea was performed. Corneoscleral scissors were then used to excise completely the central cornea. The keratoprosthesis was placed in position and was sutured with six interrupted 8-0 silk sutures. This was done without difficulty. At this point, the case was turned over to the vitreoretinal team, which will dictate under a separate note. At the conclusion of the vitreoretinal procedure, the patient was brought under the care of the cornea service. The 9-0 Prolene sutures double armed were then placed on each lens haptic loop. The keratoprosthesis was removed. Prior to this removal, scleral flaps were made, partial thickness at the 3 o'clock and 9 o'clock positions underneath the peritomies. Wet-field cautery also was performed to achieve hemostasis. The leading hepatic sutures were then passed through the bed of the scleral flap. These were drawn out of the eye and then used to draw the trailing hepatic into the posterior segment of the eye followed by the optic. The trailing hepatic was then placed into the posterior segment of the eye as well. The trailing haptic sutures were then placed through the opposite scleral flap bed and were withdrawn. These were tied securely into position with the IOL nicely centered. At this point, the donor cornea punched at 8.25 mm was then brought into the field. This was secured with four cardinal sutures. The corneal button was then sutured in place using a 16-bite 10-0 nylon running suture. The knot was secured and buried after adequate tension was adjusted. The corneal graft was watertight. Attention was then turned back to the IOL sutures, which were locked into position. The ends were trimmed. The flaps were secured with single 10-0 nylon sutures to the apex, and the knots were buried. At this point, the case was then turned back over to the vitreoretinal service for further completion of the retinal procedure. The patient tolerated the corneal portions of the surgery well and was turned over to the retina service in good condition, having tolerated the procedure well. No complications were noted. The attending surgeon, Dr. X, performed the entire procedure. No complications of the procedure were noted. The intraocular lens was selected from preoperative calculations. No qualified resident was available to assist.surgery, vitrectomy, endolaser, keratoplasty, intraocular lens implant, preretinal hemorrhage, scleral flaps, intraocular, keratoprosthesis, chamber, implant, scleral, vitreoretinal, lens, sutures, eye, |
| 62 | 1 | OB/GYN Consultation - 4 | CHIEF COMPLAINT - REASON FOR VISIT: ,Pelvic Pain and vaginal discharge.,ABNORMAL PAP HISTORY:, Date of abnormal pap: 1998. Findings: High grade squamous intraepithelial lesions. Previous colposcopic exam and biopsies showed mild dysplasia or CIN 1. Patient is sexually active and has had 1 partner. There is no history of STD’s.,PELVIC PAIN HISTORY:, The patient complains of a gradual onset of pelvic pain 1 year ago and states condition is recurrent. Location of pain is left lower quadrant. Severity is moderately severe, intermittent and lasts for 2 hours. Quality of pain is crampy, sharp and variable. Pain requires NSAIDs. Menstrual quality is light, flow lasts for 7 days and interval lasts for 28 days. There was no radiation of pain.,VAGINITIS HISTORY:, Symptoms have lasted for 2 weeks and persistent. Discharge appears thin, white and with odor. Denies any itching sensation. Denies irritation. The patient denies any self treatment.,PERSONAL / SOCIAL HISTORY:, Tobacco history: Smoke’s 1 pack of cigarettes per day. Denies the past history of alcohol. Denies past / present illegal drug use of any kind. Marital Status: Married.,PAST MEDICAL HISTORY:, Negative.,FAMILY MEDICAL HISTORY:, Negative.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, There are no current medications.,PAST SURGICAL HISTORY:, D & C. 1993,REVIEW OF SYSTEMS:,Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,Genitourinary: Patient denies any genitourinary problems.,Gynecological: Refer to current history.,Pulmonary: Denies cough, dyspnea, tachypnea, hemoptysis.,GU: Denies frequency, nocturia and hematuria.,Neuro: Denies any problems, no seizures, no numbness, no dizziness.,PHYSICAL EXAMINATION:,Vital Signs: Weight: 104. BP: 100/70.,Chest: Lungs have equal bilateral expansion and are clear to percussion and auscultation.,Cardiovascular / Heart: Regular heart rate and rhythm without murmur or gallop.,Breast: No palpable masses. No dimpling or retraction. No discharge. No axillary lymphadenopathy.,Abdomen: Tenderness is located in the left upper quadrant. Tenderness is mild. Bowel sounds are normal. No masses palpated.,Gynecologic: Inspection reveals the external genitalia to be normal anatomically. Cervix appears inflamed, bloody discharge and without aceto-white areas. Vagina appears normal. Vaginal discharge was white and watery. Uterus is normal anteverted. The uterus is normal size and shape, tender to movement and movable. Bladder not tender. ,Rectal: No additional findings.,LAB / TESTS:, Hgb: 17.1 U/A: pH 6.0, spgr 1.025, trace protein, trace blood,IMPRESSION / DIAGNOSIS,1. Endometritis / Endomyometritis (615.9). ,2. Cervicitis - Endocervicitis (616.0). ,3. Pelvic Pain (625.9).,PLAN:, Pap smear done. Take metronidazole first then the Doxycycline. Return in three weeks for reevaluation.,MEDICATIONS PRESCRIBED: ,Metronidazole 500 mg #14 1 BID for 7 days. Doxycycline 100 mg #14 1 BID.nan |
| 63 | 1 | Pleurocentesis | 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.surgery, pleural effusion, dyspnea, gliding sign, hemidiaphragm, pleural catheter, pleurocentesis, respiratory, serosanguinous fluid, ultrasound, pleural, |
| 64 | 2 | Discharge Summary - 10 | ADMITTING DIAGNOSES:, Hiatal hernia, gastroesophageal reflux disease reflux.,DISCHARGE DIAGNOSES:, Hiatal hernia, gastroesophageal reflux disease reflux.,SECONDARY DIAGNOSIS: , Postoperative ileus.,PROCEDURES DONE: , Hiatal hernia repair and Nissen fundoplication revision.,BRIEF HISTORY: , The patient is an 18-year-old male who has had a history of a Nissen fundoplication performed six years ago for gastric reflux. Approximately one year ago, he was involved in a motor vehicle accident and CT scan at that time showed that he had a hiatal hernia. Over the past year, this has caused him an increasing number of problems, including chest pain when he eats, and shortness of breath after large meals. He is also having reflux symptoms again. He presents to us for repair of the hiatal hernia and revision of the Nissen fundoplication.,HOSPITAL COURSE: , Mr. A was admitted to the adolescent floor by Brenner Children's Hospital after his procedure. He was stable at that time. He did complain of some nausea. However, he did not have any vomiting at that time. He had an NG tube in and was n.p.o. He also had a PCA for pain management as well as Toradol. On postoperative day #1, he complained of not being able to urinate, so a Foley catheter was placed. Over the next several days, his hospital course proceeded as follows. He continued to complain of some nausea; however, he did not ever have any vomiting. Eventually, the Foley catheter was discontinued and he had excellent urine output without any complications. He ambulated frequently. He remained n.p.o. for three days. He also had the NG tube in during that time. On postoperative day #4, he began to have some flatus, and the NG tube was discontinued. He was advanced to a liquid diet and tolerated this without any complications. At this time, he was still using the PCA for pain control. However, he was using it much less frequently than on days #1 and #2 postoperatively. After tolerating the full liquid diet without any complications, he was advanced to a soft diet and his pain medications were transitioned to p.o. medications rather than the PCA. The PCA was discontinued. He tolerated the soft diet without any complications and continued to have flatus frequently. On postoperative day #6, it was determined that he was stable for discharge to home as he was taking p.o. without any complications. His pain was well controlled with p.o. pain medications. He was passing gas frequently, had excellent urine output, and was ambulating frequently without any issues.,DISCHARGE CONDITION:, Stable.,DISPOSITION: , Discharged to home.,DISCHARGE INSTRUCTIONS: , The patient was discharged to home with instructions for maintaining a soft diet. It was also recommended that he does not drink any soda postoperatively. He is instructed to keep his incision site clean and dry and it was also recommended that he avoid any heavy lifting. He will be able to attend school when it starts in a few weeks. However, he is not going to be able to play football in the near future. He was given prescription for pain medication upon discharge. He is instructed to contact Pediatric Surgery if he has any fevers, any nausea and vomiting, any chest pain, any constipation, or any other concerns.discharge summary, |
| 65 | 2 | Urgent Cardiac Cath | 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 |
| 66 | 3 | Normal Child Exam Template | 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.general medicine, child physical examination, physical, genitalia, child, |
| 67 | 2 | CT Head and C Spine | CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD WITHOUT CONTRAST,TECHNIQUE:, Noncontrast axial CT images of the head were obtained.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection. The ventricles and cortical sulci are normal in shape and configuration. The gray/white matter junctions are well preserved. There is no calvarial fracture. The visualized paranasal sinuses and mastoid air cells are clear.,IMPRESSION: , Negative for acute intracranial disease.,CT CERVICAL SPINE,TECHNIQUE: ,Noncontrast axial CT images of the cervical spine were obtained. Sagittal and coronal images were obtained.,FINDINGS:, Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms. No fracture or subluxation is seen. Anterior and posterior osteophyte formation is seen at C5-C6. No abnormal anterior cervical soft tissue swelling is seen. No spinal compression is noted. The atlanto-dens interval is normal. There is a large retention cyst versus polyp within the right maxillary sinus.,IMPRESSION:,1. Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms.,2. Degenerative disk and joint disease at C5-C6.,3. Retention cyst versus polyp of the right maxillary sinus.radiology, muscle spasms, cervical lordosis, intracranial hemorrhage, motor vehicle collision, axial ct images, ct head, ct, anterior, cyst, polyp, maxillary, contrast, intracranial, sinuses, spine, axial, head, cervical, noncontrast |
| 68 | 1 | Tongue Lesion Biopsy | PREOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,POSTOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,PROCEDURE PERFORMED: ,Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.,ANESTHESIA: , General.,FINDINGS: , An ulceration in the right lateral base of tongue region. This was completely excised.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS:, None.,DRAINS:, None.,CONDITION:, Stable.,PROCEDURE: ,The patient placed supine in position under general anesthesia. First a Sweetheart gag was placed in the patient's mouth and the mouth was elevated. The lesion in the tongue could be seen. Then, it was injected with 1% lidocaine and 1:100,00 epinephrine. After 5 minutes of waiting, then an elliptical incision was made around this mass with electrocautery and then it was sharply dissected off the muscular layer and removed in total. Suction cautery was used for hemostasis. Then, 3 simple interrupted #4-0 Vicryl sutures were used to close the wound and procedure was then terminated at that time.surgery, excisional biopsy, tongue lesion, mouth, biopsy, |
| 69 | 4 | Bronchoscopy - Pediatric | FLEXIBLE BRONCHOSCOPY,The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit. I explained to the parents that the possible risks include: irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax. A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back. The sample will then be sent for testing. The flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.,The parents seem to understand, had the opportunity to ask questions and were satisfied with the information. A booklet containing the description of the procedure and other information was provided.pediatrics - neonatal, flexible bronchoscopy, pediatric intensive care unit, bleeding, bronchi, bronchoalveolar lavage, bronchoscopy, conscious sedation, nasal mucosa, nasopharynx, pneumothorax, respiratory, pediatric flexible bronchoscopyNOTE,: 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. |
| 70 | 1 | D&C & Laparoscopy - 2 | PREOPERATIVE DIAGNOSIS: , Incidental right adnexal mass on ultrasound.,POSTOPERATIVE DIAGNOSES:,1. Complex left ovarian cyst.,2. Bilateral complex adnexae.,3. Bilateral hydrosalpinx.,4. Chronic pelvic inflammatory disease.,5. Massive pelvic adhesions.,PROCEDURE PERFORMED:,1. Dilation and curettage (D&C).,2. Laparoscopy.,3. Enterolysis.,4. Lysis of the pelvic adhesions.,5. Left salpingo-oophorectomy.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,SPECIMENS: , Endometrial curettings and left ovarian mass.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,DRAINS:, None.,FINDINGS: , On bimanual exam, the patient has a slightly enlarged, anteverted, freely mobile uterus with an enlarged left adnexa. Laparoscopically, the patient has massive pelvic adhesions with completely obliterated posterior cul-de-sac and adnexa.,No adnexal structures were initially able to be visualized until after the lysis of adhesions. Eventually we found a normal appearing right ovary, severely scarred right and left fallopian tubes, and a enlarged complex cystic left ovary. There was a normal-appearing appendix and liver, and the vesicouterine junction appeared within normal limits. There were significant adhesions from the small bowel to the bilateral adnexa in the posterior surface of the uterus.,PROCEDURE: ,The patient was taken to the operating room where a general anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic. Next, a weighted speculum was placed in the vagina and anterior wall of the vagina was elevated with the uterine sound and the anterior lip of the cervix was grasped with a vulsellum tenaculum. The uterus was then sounded to 12 cm. The cervix was then serially dilated with Hank dilators to a size #20 Hank. Next a Telfa pad was placed on the weighted speculum and a short curettage was performed obtaining a large amount of endometrial tissue. Next, the uterine manipulator was placed in the cervix and attached to the anterior lip of the cervix. At this point, the vulsellum tenaculum and weighted speculum were removed. Next, attention was turned to the abdomen where an approximately 2 cm incision was made immediately inferior to the umbilicus. The superior aspect of the umbilicus was grasped with a towel clamp and Veress needle was inserted through this incision. Small amount of normal saline was injected into Veress needle and seemed to drop freely. So, the Veress needle was connected to he CO2 gas, which was started at the lower setting. It was seen to flow freely with a normal resistance so the gas was advanced to the higher setting. The abdomen was then insufflated to an adequate distention. Next, the Veress needle was removed and a size #11 step trocar was inserted. Next, the introducer was removed from the trocar and the laparoscope was inserted through this port and the port was also connected to the CO2 gas. At this point, the initial operative findings were seen. Next, a size #5 step trocar was inserted approximately two fingerbreadths above the pubic symphysis in the midline. This was done by making a 1 cm incision with the skin knife, introducing a Veress needle with Ethicon sheet, and the Veress needle was then removed and the #5 port was introduced under direct visualization. A size #5 port was also placed approximately six fingerbreadths to the right of the umbilicus in a similar manner also under direct visualization. A blunt probe was inserted suprapubically along with a grasper in the right upper quadrant. These were used to see the above operative findings. Next, a size #12 mm port was introduced approximately seven fingerbreadths to the left of the umbilicus under direct visualization. Through this, a Harmonic scalpel was inserted.,The Harmonic scalpel along with the grasper was used to meticulously address the adhesions along the right adnexa in the posterior cul-de-sac. Care was taken at all times to avoid the bowel and the ureters. The fallopian tubes appeared massively scarred and completely obliterated from disease. After the right adnexa had been freed to the point where we could visualize the ovary and the posterior cul-de-sac was clearing off then we could visualize the uterosacral ligaments. Attention was turned to the left adnexa, which appeared to contain a cystic structure, but it was unclear at the beginning of the procedure what the structure was. Adhesions were carefully taken down from the bowel to the left fallopian tube and ovary, and sidewall. The adhesions were then carefully removed from the inferior aspect of the ovary also with the Harmonic scalpel. At intermittent points throughout the procedure, the suction irrigator was used to irrigate and suck blood and irrigation out of the pelvis to watch for any bleeding. At this point, the Harmonic scalpel was removed and another laparoscopic needle with a 60 cc syringe was inserted and this was used to aspirate approximately 30 cc of serosanguineous fluid from the cystic structure. Next, the needle was removed and the ligature device was inserted. This was used to clamp across the fallopian tube initially and then after the fallopian tube was ligated, the uterovarian ligament was clamped and ligated with the ligature device. Next, the fallopian tube was removed from the ovary with the ligature device in approximately 3 clamping and ligations. Then, the attention was turned to the inferior aspect of the ovary. First the infundibulopelvic ligament was identified, clamped with a ligature device, and ligated. Next, the ovary was bluntly dissected from the ovarian fossa with attention to the left ureter. Next, the ligature device was used to clamp and ligate the broad ligament immediately inferior to the ovary across. Then the ovary was completely bluntly dissected out of the ovarian fossa and completely separated from the pelvis. This was grasped with a clamp. The ligature device was removed from the #12 and a EndoCatch bag was inserted to the size #12 port. The left ovary was placed in this EndoCatch bag, which was then removed along with the whole port from the left upper quadrant. Next, the pelvis was copiously irrigated and suctioned of all blood and extra fluid. At this point, the remaining two size #5 ports were removed under direct visualization. The camera was removed and the abdomen was desufflated. Next, an introducer was replaced on a #11 port. The #11 port was removed. Next, the fascia in the left upper quadrant port was identified and grasped with Ochsner clamps, tented up, and closed with a single interrupted suture of #0 Vicryl on a UR-6 needle. Next, all skin incisions were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion. The incisions were cleaned, injected with 0.25% Marcaine, and then adjusted with Steri-Strips and bandage appropriately.,The patient was taken from the operating room in stable condition and should be observed overnight in the hospital.nan |
| 71 | 4 | Phacoemulsification & Lens Implantation - 5 | PREOPERATIVE DIAGNOSIS:, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,OPERATION PERFORMED: , Phacoemulsification with IOL, right eye.,ANESTHESIA:, Topical with MAC.,COMPLICATIONS,: None.,ESTIMATED BLOOD LOSS: , None.,PROCEDURE IN DETAIL: After appropriate consent was obtained, the patient was brought to the operating room and then prepared and draped in the usual sterile fashion per Ophthalmology. A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat. A 2.75-mm keratome then made a stab incision at the 2 o'clock position through which an anterior capsulorrhexis was performed using cystotome and Utrata. BSS on blunt cannula, hydrodissector, and spun the nucleus after which phacoemulsification divided the nucleus in 3 quadrants each was subsequently cracked and removed through phacoemulsification I&A. Healon was injected into the posterior capsule and a XXX lens was then placed with a shooter into the posterior capsule and rotated into position with I&A, which then removed all remaining cortex as well as viscoelastic material. BSS on blunt cannula hydrated all wounds, which were noted to be free of leak and lid speculum was removed. Under microscope, the anterior chamber being soft and well formed. Pred Forte, Vigamox, and Iopidine were placed in the eye. A shield was placed over the eye. The patient was followed to recovery where he was noted to be in good condition.ophthalmology, lid speculum, lens, iol, viscoat, posterior, capsule, cataract, speculum, incision, phacoemulsification |
| 72 | 2 | MRI Brain and C-T Spine | 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 |
| 73 | 1 | Cystourethroscopy & TURP - 1 | PREOPERATIVE DIAGNOSES:,1. Urinary retention.,2. Benign prostate hypertrophy.,POSTOPERATIVE DIAGNOSES:,1. Urinary retention.,2. Benign prostate hypertrophy.,PROCEDURES PERFORMED:,1. Cystourethroscopy.,2. Transurethral resection of prostate (TURP).,ANESTHESIA:, Spinal.,RESECTION TIME:, Less than one hour.,INDICATION FOR PROCEDURE: ,This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.,PROCEDURE: PROCEDURE: , Informed written consent was obtained. The patient was taken to the operative suite, administered spinal anesthetic and placed in dorsal lithotomy position. She was sterilely prepped and draped in normal fashion. A #27-French resectoscope was inserted utilizing the visual obturator blanching the bladder. The bladder was visualized in all quadrants, no bladder tumors or stones were noted. Ureteral orifices were visualized and did appear to be near the enlarged median lobe. Prostate showed trilobar prostatic enlargement. There were some cellules and tuberculations noted. The visual obturator was removed. The resectoscope was then inserted utilizing the #26 French resectoscope loop. Resection was performed initiating at the bladder neck and at the median lobe.,This was taken down to the circular capsular fibers. Attention was then turned to the left lateral lobe and this was resected from 12 o'clock to 3 o'clock down to the capsular fibers maintaining hemostasis along the way and taking care not to resect beyond the level of the verumontanum. Ureteral orifices were kept out of harm's way throughout the case. Resection was then performed from the 3 o'clock position to the 6 o'clock position in similar fashion. Attention was then turned to the right lateral lobe and this was resected again in a similar fashion maintaining hemostasis along the way. The resectoscope was then moved to the level of the proximal external sphincter and trimming of the apex was performed. Open prostatic fossa was noted. All chips were evacuated via Ellik evacuator and #24 French three-way Foley catheter was inserted and irrigated. Clear return was noted. The patient was then hooked up to better irrigation. The patient was cleaned, reversed for anesthetic, and transferred to recovery room in stable condition.,PLAN: ,We will admit with antibiotics, pain control, and bladder irrigation possible void trial in the morning.surgery, urinary retention, transurethral resection of prostate, prostate, enlarged, obstructive voiding symptoms, benign prostate hypertrophy, ureteral orifices, prostate hypertrophy, cystourethroscopy, turp, hypertrophy, resectoscope, urinary, bladder, resection, |
| 74 | 4 | Neck & Lower Back Pain - Consult | CHIEF COMPLAINT:, Neck and lower back pain.,VEHICULAR TRAUMA HISTORY:, Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient’s vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off the road into a utility pole. The other vehicle had reportedly been driven by a drunk driver and ran a traffic signal. Estimated impact speed was 80 m.p.h. The driver of the other vehicle was reportedly cited by police. The patient was transiently unconscious and came to the scene. There was immediate onset of headaches, neck and lower back pain. The patient was able to exit the vehicle and was subsequently transported by Rescue Squad to St. Thomas Memorial Hospital, evaluated in the emergency room and released.,NECK AND LOWER BACK PAIN HISTORY:, The patient relates the persistence of pain since the motor vehicle accident. Symptoms began immediately following the MVA. Because of persistent symptoms, the patient subsequently sought chiropractic treatment. Neck pain is described as severe. Neck pain remains localized and is non-radiating. There are no associated paresthesias. Back pain originates in the lumbar region and radiates down both lower extremities. Back pain is characterized as worse than the neck pain. There are no associated paresthesias.nan |
| 75 | 1 | Calcaneal Lengthening Osteotomy | PREOPERATIVE DIAGNOSES:, Left calcaneal valgus split.,POSTOPERATIVE DIAGNOSES:, Left calcaneal valgus split.,PROCEDURES: ,1. Left calcaneal lengthening osteotomy with allograft.,2. Partial plantar fasciotomy.,3. Posterior subtalar and tibiotalar capsulotomy.,4. Short leg cast placed.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME: , 69 minutes.,The patient in local anesthetic of 20 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS: ,None.,SPECIMENS: , None.,HISTORY AND PHYSICAL: , The patient is a 13-year-old female who had previous bilateral feet correction at 1 year of age. Since that time, the patient has developed significant calcaneal valgus deformity with significant pain. Radiographs confirmed collapse of the spinal arch, as well as valgus position of the foot. Given the patient's symptoms, surgery is recommended for calcaneal osteotomy and Achilles lengthening. Risks and benefits of surgery were discussed with the mother. Risks of surgery include risk of anesthesia; infection; bleeding; changes in sensation in most of extremity; hardware failure; need for later hardware removal; possible nonunion; possible failure to correct all the deformity; and need for other surgical procedures. The patient will need to be strict nonweightbearing for at least 6 weeks and wear a brace for up to 6 months. All questions were answered and parents agreed to the above surgical plan.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operating table. General anesthesia was then administered. The patient received Ancef preoperatively. A bump was placed underneath the left buttock. A nonsterile tourniquet was placed on the upper aspect of the left thigh. The extremity was then prepped and draped in a standard surgical fashion. The patient had a previous incision along the calcaneocuboid lateral part of the foot. This was marked and extended proximally through the Achilles tendon. Extremity was wrapped in Esmarch. Tourniquet inflation was noted to be 250 mmHg. Decision was then made to protect the sural nerve. There was one sensory nervous branch that did cross the field though it was subsequently sharply ligated because it was in the way. Dissection was carried down to Achilles tendon, which was subsequently de-lengthened with the distal half performed down the lateral thigh. Proximal end was tacked with an 0 Ethibond suture and subsequently repaired end-on-end at length with the heel in neutral. Dissection was then carried on the lateral border of the foot with identification of the peroneal longus and valgus tendons, which were removed from the sheath and retracted dorsally. At this time, we also noted that calcaneocuboid joint appeared to be fused. The area between the anterior and middle facets were plicated on fluoroscopy for planned osteotomy. This was performed with a saw. After a partial plantar fasciotomy was performed, this was released off an abductor digiti minimi. The osteotomy was completed with an osteotome and distracted with the lamina spreader. A tricortical allograft was then shaped and subsequently impacted into this area. Final positioning was checked with multiple views of fluoroscopy. It was subsequently fixed using a 0.94 K-wire and drilled from the heel anteriorly. A pin was subsequently bent and cut short at the level of the skin. The wound was then irrigated with normal saline. The Achilles was repaired with this tie. Please note during the case, it was noted the patient had continued significant stiffness despite the Achilles lengthening. A posterior capsulotomy of the tibiotalar and subtalar joints were performed with increased 10 degrees of dorsiflexion. Wound was then closed using #2-0 Vicryl and #4-0 Monocryl. The surgical field was irrigated with 0.25% Marcaine and subsequently injected with more Marcaine at the end of the case. The wound was clean and dry and dressed with Steri-Strips and Xeroform. Skin was dressed with Xeroform and 4 x 4's. Everything was wrapped with 4 x 4's in sterile Webril. The tourniquet was released after 69 minutes. A short-leg cast was then placed with good return of capillary refill to his toes. The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for elevation, ice packs, neurovascular checks, and pain control. The patient to be strict nonweightbearing. We will arrange for her to get a wheelchair. The patient will then follow up in about 10 to 14 days for a cast check, as well as pain control. The patient will need an AFO script at that time. Intraoperative findings are relayed to the parents.surgery, calcaneal lengthening, osteotomy, allograft, plantar fasciotomy, capsulotomy, calcaneal valgus split, partial plantar fasciotomy, short leg cast, achilles lengthening, calcaneal valgus, tourniquet, plantar, valgus, achilles, calcaneal, |
| 76 | 2 | Cerebral Angiogram - Lateral Medullary Syndrome | CC: ,Falling to left.,HX:, 26y/oRHF fell and struck her head on the ice 3.5 weeks prior to presentation. There was no associated loss of consciousness. She noted a dull headache and severe sharp pain behind her left ear 8 days ago. The pain lasted 1-2 minutes in duration. The next morning she experienced difficulty walking and consistently fell to the left. In addition the left side of her face had become numb and she began choking on food. Family noted her pupils had become unequal in size. She was seen locally and felt to be depressed and admitted to a psychiatric facility. She was subsequently transferred to UIHC following evaluation by a local ophthalmologist.,MEDS:, Prozac and Ativan (both recently started at the psychiatric facility).,PMH: ,1) Right esotropia and hyperopia since age 1year. 2) Recurrent UTI.,FHX:, Unremarkable.,SHX:, Divorced. Lives with children. No spontaneous abortions. Denied ETOH/Tobacco/Illicit Drug use.,EXAM:, BP 138/110. HR 85. RR 16. Temp 37.2C.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, repetition.,CN: Pupils 4/2 decreasing to 3/1 on exposure to light. Optic Disks flat. VFFTC. Esotropia OD, otherwise EOM full. Horizontal nystagmus on leftward gaze. Decreased corneal reflex, OS. Decreased PP/TEMP sensation on left side of face. Light touch testing normal. Decreased gag response on left. Uvula deviates to right. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: Decreased PP and TEMP on right side of body. PROP/VIB intact.,Coord: Difficulty with FNF/HKS/RAM on left. Normal on right side.,Station: No pronator drift. Romberg test not noted.,Gait: unsteady with tendency to fall to left.,Reflexes: 3/3 throughout BUE and Patellae. 2+/2+ Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese. In no acute distress. Otherwise unremarkable.,HEENT: No carotid/vertebral/cranial bruits.,COURSE:, PT/PTT, GS, CBC, TSH, FT4 and Cholesterol screen were all within normal limits. HCT on admission was negative. MRI Brain (done locally 2/2/93) was reviewed and a left lateral medullary stroke was appreciated. The patient underwent a cerebral angiogram on 2/3/93 which revealed significant narrowing of the left vertebral artery beginning at C2 and extending to and involving the basilar artery. There is severe, irregular narrowing of the horizontal portion above the posterior arch of C1. The findings were felt consistent with a left vertebral artery dissection. Neuro-opthalmology confirmed a left Horner's pupil by clinical exam and history. Cookie swallow study was unremarkable. The Patient was placed on Heparin then converted to Coumadin. The PT on discharge was 17.,She remained on Coumadin for 3 months and then was switched to ASA for 1 year. An Otolaryngologic evaluation on 10/96 noted true left vocal cord paralysis with full glottic closure. A prosthesis was made and no surgical invention was done.radiology, horner's pupil, mri brain, otolaryngologic, cerebral angiogram, cerebral angiogram lateral, medullary syndrome, vertebral artery, angiogram, syndrome, falling, narrowing, medullary, vertebral, cerebral, |
| 77 | 3 | Lung Biopsy Pathology Report | CLINICAL HISTORY:, A 48-year-old smoker found to have a right upper lobe mass on chest x-ray and is being evaluated for chest pain. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan. The lower lobe mass was approximately 1 cm in diameter and the upper lobe mass was 4 cm to 5 cm in diameter. The patient was referred for surgical treatment.,SPECIMEN:,A. Lung, wedge biopsy right lower lobe,B. Lung, resection right upper lobe,C. Lymph node, biopsy level 2 and 4,D. Lymph node, biopsy level 7 subcarinal,FINAL DIAGNOSIS:,A. Wedge biopsy of right lower lobe showing: Adenocarcinoma, Grade 2, Measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin.,B. Right upper lobe lung resection showing: Adenocarcinoma, grade 2, measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin. Two (2) hilar lymph nodes with no metastatic tumor.,C. Lymph node biopsy at level 2 and 4 showing seven (7) lymph nodes with anthracosis and no metastatic tumor.,D. Lymph node biopsy, level 7 subcarinal showing (5) lymph nodes with anthracosis and no metastatic tumor.,COMMENT: ,The morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe. This suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor, there is isolated nests of tumor cells within the air spaces. Furthermore, immunoperoxidase stain for Ck-7, CK-20 and TTF are performed on both the right lower and right upper lobe nodule. The immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe.,cardiovascular / pulmonary, pet scan, wedge biopsy, morphology, lung wedge biopsy, lymph node biopsy, lymph node, lower lobe, tumor, biopsy, lobe, lung, mass, lymph, node |
| 78 | 4 | Premature retina and vitreous | OCULAR FINDINGS: , Anterior chamber space: Cornea, iris, lens, and pupils all unremarkable on gross examination in each eye.,Ocular adnexal spaces appear very good in each eye.,Cyclomydril x2 was used to dilate the pupil in each eye.,Medial spaces are clear and the periphery is still hazy in each eye.,Ocular disc space, normal size and shape with a pink color with clear margin in each eye.,Macular spaces are normal in appearance for the age in each eye.,Posterior pole. No dilated blood vessels seen in each eye.,Periphery: The peripheral retina is still hazy and retinopathy of prematurity cannot be ruled out at this time in each eye.,IMPRESSION: ,Premature retina and vitreous, each eye.,PLAN: ,Recheck in two weeks.,ophthalmology, eye ocular, premature retina, pupils, periphery, premature, vitreous, retina, eye, |
| 79 | 1 | Lumbar Laminotomy & Discectomy | PREOPERATIVE DIAGNOSIS:, Herniated nucleus pulposus of L5-S1 on the left.,POSTOPERATIVE DIAGNOSIS: ,Herniated nucleus pulposus of L5-S1 on the left.,PROCEDURE PERFORMED:, Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMENS: , Disc that was not sent to the lab.,DRAINS: , None.,COMPLICATIONS: , None.,SURGICAL PROGNOSIS: , Remains guarded due to her ongoing pain condition and Tarlov cyst at the L5 nerve root distally.,SURGICAL INDICATIONS: , The patient is a 51-year-old female who has had unrelenting low back pain that radiated down her left leg for the past several months. The symptoms were unrelieved by conservative modalities. The symptoms were interfering with all aspects of daily living and inability to perform any significant work endeavors. She is understanding the risks, benefits, potential complications, as well as all treatment alternatives. She wished to proceed with the aforementioned surgery due to her persistent symptoms. Informed consent was obtained.,OPERATIVE TECHNIQUE: , The patient was taken to OR room #5 where she was given general anesthetic by the Department of Anesthesia. She was subsequently placed on the Jackson spinal table with the Wilson attachment in the prone position. Palpation did reveal the iliac crest and suspected L5-S1 interspace. Thereafter the lumbar spine was serially prepped and draped. A midline incision was carried over the spinal process of L5 to S1. Skin and subcutaneous tissue were divided sharply. Electrocautery provided hemostasis. Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia. Lumbar fascia was identified and the decussation of fibers was identified at the L5-S1 interspace. On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery. This revealed the interspace of suspect level of L5-S1 on the left. A Kocher clamp was placed between the spinous processes of the suspect level of L5-S1. X-ray did confirm the L5-S1 interval. Angled curet was utilized to detach the ligamentum flavum from its bony attachments at the superior edge of S1 lamina and the inferior edge of the L5 lamina. Meticulous dissection was undertaken and the ligamentum flavum was removed. Laminotomy was created with Kerrison rongeur, both proximally and distally. The microscope was positioned and the dura was inspected. A blunt Penfield elevator was then utilized to dissect and identify the L5-S1 nerve root on the left. It was noted to be tented over a disc extrusion. The nerve root was protected and medialized. It was retracted with a nerve root retractor. This did reveal a subligamentous disc herniation at approximately the L5-S1 disc space and neuroforaminal area. A #15 Bard-Parker blade was utilized to create an annulotomy. Medially, disc material was extruding through this annulotomy. Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace. Additional disc material was then removed, both to the right and left of the annulotomy. Up and downbiting pituitary rongeurs were utilized to remove any other loose disc pieces. Once this was completed, the wound was copiously irrigated with antibiotic solution and suctioned dry. The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray did confirm this level. Nerve root was again expected exhibiting the foramina. A foraminotomy was created with a Kerrison rongeur. Once this was created, the nerve root was again inspected and deemed free of tension. It was mobile within the neural foramina. The wound was again copiously irrigated with antibiotic solution and suctioned dry. A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura. Lumbar fascia was then approximated with #1 Vicryl interrupted fashion, subcutaneous tissue with #2-0 Vicryl interrupted fashion, and #4-0 undyed Vicryl was utilized to approximate the skin. Compression dressing was applied. The patient was turned, awoken, and noted to be moving all four extremities without apparent deficits. She was taken to the recovery room in apparent satisfactory condition. Expected surgical prognosis remains guarded due to her ongoing pain syndrome that has been requiring significant narcotic medications.surgery, lumbar laminotomy with discectomy, microscopic assisted, herniated nucleus pulposus, subcutaneous tissue, ligamentum flavum, kerrison rongeur, penfield elevator, lumbar laminotomy, lumbar fascia, nerve root, discectomy, lumbar, laminotomy, herniated, |
| 80 | 4 | Phacoemulsification of Cataract | PREOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,PROCEDURE:, Right phacoemulsification of cataract with intraocular lens implantation.,DESCRIPTION OF THE OPERATION:, Under topical anesthesia with monitored anesthesia care, the patient was prepped, draped and positioned under the operating microscope. A lid speculum was applied to the right eye, and a stab incision into the anterior chamber was done close to the limbus at about the 1 o'clock position with a Superblade, and Xylocaine 1% preservative free 0.25 mL was injected into the anterior chamber, which was then followed by Healon to deepen the anterior chamber. Using a keratome, another stab incision was done close to the limbus at about the 9 o'clock position and with the Utrata forceps, anterior capsulorrhexis was performed, and the torn anterior capsule was totally removed. Hydrodissection and hydrodelineation were performed with the tuberculin syringe filled with BSS. The tip of the phaco unit was introduced into the anterior chamber, and anterior sculpting of the nucleus was performed until about more than two-thirds of the nucleus was removed. Using the phaco tip and the Drysdale hook, the nucleus was broken up into 4 pieces and then phacoemulsified.,The phaco tip was then exchanged for the aspiration/irrigation tip, and cortical materials were aspirated. Posterior capsule was polished with a curette polisher, and Healon was injected into the capsular bag. Using the Monarch intraocular lens inserter, the posterior chamber intraocular lens model SN60WF power +19.50 was placed into the inserter after applying some Healon, and the tip of the inserter was gently introduced through the cornea tunnel wound, into the capsular bag and then the intraocular lens was then inserted inferior haptic first into the back and the superior haptic was placed into the bag with the same instrument. Intraocular lens was then rotated about half a turn with a collar button hook. Healon was removed with the aspiration/irrigation tip, and balanced salt solution was injected through the side port to deepen the anterior chamber. It was found that there was no leakage of fluid through the cornea tunnel wound. For this reason, no suture was applied. Vigamox, Econopred and Nevanac eye drops were instilled and the eye was covered with a perforated shield. The patient tolerated the procedure well. There were no complications.ophthalmology, cataract, implantation, intraocular, intraocular lens, lens implantation, phacoemulsification, capsular bag, capsule, intraocular lens implantation, cornea tunnel wound, phacoemulsification of cataract, cornea tunnel, anterior chamber, anesthesia, cornea, lens, chamber, |
| 81 | 4 | Lobar Holoprosencephaly | CC: ,Delayed motor development.,HX:, This 21 month old male presented for delayed motor development, "jaw quivering" and "lazy eye." He was an 8 pound 10 ounce product of a full term, uncomplicated pregnancy-labor-spontaneous vaginal delivery to a G3P3 married white female mother. There had been no known toxic intrauterine exposures. He had no serious illnesses or hospitalizations since birth. He sat independently at 7 months, stood at 11 months, crawled at 16 months, but did not cruise until 18 months.,He currently cannot walk and easily falls. His gait is reportedly marked by left "intoeing." His upper extremity strength and coordination reportedly appear quite normal and he is able to feed himself, throw and transfer objects easily. He knows greater than 20 words and speaks two-word phrases.,No seizures or unusual behavior were reported except for "quivering" movement of his jaw. This has occurred since birth. In addition the parents have noted transient left exotropia.,PMH: ,As above.,FHX:, Many family members with "lazy eye." No other neurologic diseases declared.,9 and 5 year old sisters who are healthy.,SHX:, lives with parents and sisters.,EXAM:, BP83/67 HR122 36.4C Head circumference 48.0cm Weight 12.68kg (70%) Height 86.0cm (70%),MS: fairly cooperative.,CN: Minimal transient esotropia OS. Tremulous quivering of jaw--increased with crying. No obvious papilledema, though difficult to evaluate due to patient movement.,Motor: sat independently with normal posture and no truncal ataxia. symmetric and normal strength and muscle bulk throughout.,Sensory: withdrew to vibration.,Coordination: unremarkable in BUE.,Station: no truncal ataxia.,Gait: On attempting to walk, his right foot rotated laterally at almost 70degrees. Both lower extremities could rotate outward to 90degrees. There was marked passive eversion at the ankles as well.,Reflexes: 2+/2+ throughout.,Musculoskeletal: pes planovalgus bilaterally.,COURSE: ,CK normal. The parents decided to forego an MRI in 8/90. The patient returned 12/11/92 at age 4 years. He was ambulatory and able to run awkwardly. His general health had been good, but he showed signs developmental delay. Formal evaluation had tested his IQ at 87 at age 3.5 years. He was weakest on tasks requiring visual/motor integration and fine motor and visual discrimination skills. He was 6 months delayed in cognitive development at that time. On exam, age 4 years, he displayed mild right ankle laxity on eversion and inversion, but normal gait. The rest of the neurological exam was normal. Head circumference was 49.5cm (50%) and height and weight were in the 90th percentile. Fragile X analysis and karyotyping were unremarkable.neurology, delayed motor development, jaw quivering, head circumference, truncal ataxia, delayed motor, motor development, lazy eye, jaw, quivering, delayed, intrauterine, |
| 82 | 1 | Recurrent nasal obstruction | CHIEF COMPLAINT: , Recurrent nasal obstruction.,HISTORY OF PRESENT ILLNESS:, The patient is a 5-year-old male, who was last evaluated by Dr. F approximately one year ago for suspected nasal obstruction, possible sleep apnea. Dr. F's assessment at that time was the patient not had sleep apnea and did not truly even seem to have allergic rhinitis. All of his symptoms had resolved when he had seen Dr. F, so no surgical plan was made and no further followup was needed. However, the patient reports again today with his mother that they are now having continued symptoms of nasal obstruction and questionable sleep changes. Again, the mother gives a very confusing sleep history but it does not truly sound like the child is having apneic events that are obstructive in nature. It sounds like he is snoring loudly and does have some nasal obstruction at nighttime. He also is sniffing a lot through his nose. He has been tried on some nasal steroids but they only use this on a p.r.n. basis about one or two days every month and we are unsure if that has even helped at all, probably not. The child is not having any problems with his ears including ear infections or hearing. He is also not having any problems with strep throat.,PAST MEDICAL HISTORY: , Eczema.,PAST SURGICAL HISTORY: , None.,MEDICATIONS:, None.,ALLERGIES:, No known drug allergies.,FAMILY HISTORY: , No family history of bleeding diathesis or anesthesia difficulties.,PHYSICAL EXAMINATION:,VITAL SIGNS: Weight 43 pounds, height 37 inches, temperature 97.4, pulse 65, and blood pressure 104/48.,GENERAL: The patient is a well-nourished male in no acute distress. Listening to his voice today in the clinic, he does not sound to have a hyponasal voice and has a wide range of consonant pronunciation.,NOSE: Anterior rhinoscopy does demonstrate boggy turbinates bilaterally with minimal amount of watery rhinorrhea.,EARS: The patient tympanic membranes are clear and intact bilaterally. There is no middle ear effusion.,ORAL CAVITY: The patient has 2+ tonsils bilaterally. There are clearly nonobstructive. His uvula is midline.,NECK: No lymphadenopathy appreciated.,ASSESSMENT AND PLAN: , This is a 5-year-old male, who presents for repeat evaluation of a possible nasal obstruction, questionable sleep apnea. Again, the mother gives a confusing sleep history but it does not really sound like he is having apneic events. They deny any actual gasping events. It sounds like true obstructive events. He clearly has some symptoms at this point that would suggest possible allergic rhinitis or chronic rhinitis. I think the most appropriate way to proceed would be to first try this child on a nasal corticosteroid and use it appropriately. I have given them prescription for Nasacort Aqua one spray to each nostril twice a day. I instructed them on correct way to use this and the importance to use it on a daily basis. They may not see any benefit for several weeks. I would like to evaluate him in six weeks to see how we are progressing. If he continues to have problems, I think at that point we may consider performing a transnasal exam in the office to examine his adenoid bed and that would really be the only surgical option for this child. He may also need an allergy evaluation at that point if he continues to have problems. However, I would like to be fairly conservative in this child. Should the mother still have concerns regarding his sleeping at our next visit or should his symptoms worsen (I did instruct her call us if it worsens), we may even need to pursue a sleep study just to settle that issue once and for all. We will see him back in six weeks.ent - otolaryngology, recurrent nasal obstruction, allergic rhinitis, apneic events, sleep apnea, nasal obstruction, nasal, apnea, allergic, obstruction, sleep, |
| 83 | 4 | Cataract - Second Opinion | SUBJECTIVE: ,The patient seeks evaluation for a second opinion concerning cataract extraction. She tells me cataract extraction has been recommended in each eye; however, she is nervous to have surgery. Past ocular surgery history is significant for neurovascular age-related macular degeneration. She states she has had laser four times to the macula on the right and two times to the left, she sees Dr. X for this.,OBJECTIVE: , On examination, visual acuity with correction measures 20/400 OU. Manifest refraction does not improve this. There is no afferent pupillary defect. Visual fields are grossly full to hand motions. Intraocular pressure measures 17 mm in each eye. Slit-lamp examination is significant for clear corneas OU. There is early nuclear sclerosis in both eyes. There is a sheet like 1-2+ posterior subcapsular cataract on the left. Dilated examination shows choroidal neovascularization with subretinal heme and blood in both eyes.,ASSESSMENT/PLAN: ,Advanced neurovascular age-related macular degeneration OU, this is ultimately visually limiting. Cataracts are present in both eyes. I doubt cataract removal will help increase visual acuity; however, I did discuss with the patient, especially in the left, cataract surgery will help Dr. X better visualize the macula for future laser treatment so that her current vision can be maintained. This information was conveyed with the use of a translator.,ophthalmology, advanced neurovascular age-related macular degeneration, neurovascular age, macular degeneration, visual acuity, cataract extraction, neurovascular, degeneration, visual, eyes, macular, cataract, |
| 84 | 4 | Speech Therapy Evaluation - 1 | DIAGNOSIS: , Status post brain tumor with removal.,SUBJECTIVE: ,The patient is a 64-year-old female with previous medical history of breast cancer that has metastasized to her lung, liver, spleen, and brain, status post radiation therapy. The patient stated that on 10/24/08 she had a brain tumor removed with subsequent left-sided weakness. The patient was readmitted to ABC Hospital on 12/05/08 and was found to have massive swelling in the brain and a second surgery was performed to reduce the swelling. The patient remained at the acute rehab at ABC until she was discharged home on 01/05/09. The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function. The patient also complains of difficulty with word retrieval and slurring of speech. The patient denies any difficulty with swallowing at this time.,OBJECTIVE: ,Portions of the cognitive linguistic quick test was administered. An oral mechanism exam was performed. A motor speech protocol was completed.,The cognitive linguistic subtests of recalling personal facts, symbol cancellation, confrontational naming, clock drawing, story retelling, generative naming, design and memory, and completion of mazes was administered.,The patient was 100% accurate with recalling personal facts, completion of the symbol cancellation tasks, and with confrontational naming. She had no difficulty with the clock drawing task; however, she has considerable hand tremors, which makes writing difficult. In the storytelling task, she scored within normal limits. She was also within normal limits for generative naming. She did have difficulty with the design, memory, and mazes subtests. She was unable to complete the second maze during the allotted time. The design generation subtest was also completed. She was able to draw four unique designs, and toward the end of the tasks was no longer able to recall the stated direction.,ORAL MECHANISM EXAMINATION:, The patient has mild left facial droop with decreased nasolabial fold. Tongue is at midline, and lingual range of motion and strength are within functional limit. The patient does complain of biting her tongue on occasion, but denied biting the inside of her cheeks. Her AMRs are judged to be within functional limit. Her rate of speech is decreased with a monotonous vocal quality. The decreased rate may be a compensation for decreased word retrieval ability. The patient's speech is judged to be 100% intelligible without background noise.,DIAGNOSTIC IMPRESSION: ,The patient has mild cognitive linguistic deficits in the areas of higher level cognitive function seen in mental flexibility, memory, and executive function.,PLAN OF CARE:, Outpatient skilled speech therapy two times a week for four weeks to include cognitive linguistic treatment.,SHORT-TERM GOALS (THREE WEEKS):,1. The patient will complete deductive reasoning and mental flexibility tasks with greater than 90% accuracy, independently.,2. The patient will complete perspective memory test with 100% accuracy using compensatory strategy.,3. The patient will complete visual perceptual activities, which focus on scanning, flexibility, and problem solving with greater than 90% accuracy with minimal cueing.,4. The patient will listen to and/or read a lengthy narrative and be able to recall at least 6 details after a 15-minute delay, independently.,PATIENT'S GOAL: ,To improve functional independence and cognitive abilities.,LONG-TERM GOAL (FOUR WEEKS): ,Functional cognitive linguistic abilities to improve safety and independence at home and to decrease burden of care on caregiver.,speech - language, linguistic skills, memory, mental flexibility, deductive reasoning, skilled speech therapy, speech therapy, cognitive linguistic, therapy, linguistic, speech, cognitive, |
| 85 | 1 | Bbunionectomy & Metatarsal Osteotomy | PREOPERATIVE DIAGNOSIS: ,Tailor's bunion and neuroma of the second and third interspace of the left foot.,POSTOPERATIVE DIAGNOSIS:, Tailor's bunion and neuroma of the second and third interspace, left foot.,PROCEDURE PERFORMED:,1. Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.,2. Excision of nerve lesion with implantation of the muscle belly of the left second interspace.,3. Excision of nerve lesion in the left third interspace.,ANESTHESIA: ,Monitored IV sedation with local.,HISTORY: ,This is a 37-year-old female who presents to ABCD's preoperative holding area, n.p.o. since mid night, last night for surgery of her painful left second and third interspaces and her left fifth metatarsal. The patient has attempted conservative correction and injections with minimal improvement. The patient desires surgical correction at this time. The patient states that her pain has been increasingly worsening with activity and with time and it is currently difficult for her to ambulate and wear shoes. At this time, the patient desires surgical intervention and correction. The risks versus benefits of the procedure have been explained to the patient in detail by Dr. X and consent was obtained.,PROCEDURE IN DETAIL: , After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was taken to the Operating Suite via cart and placed on the operating table in the supine position. A safety strap was placed across her waist for protection.,Next, a pneumatic ankle tourniquet was applied around her left ankle over copious amounts of Webril for the patient's protection. After adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of a mixture of 4.5 cc of 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1 cc of Solu-Medrol per 10 cc dose was administered to the patient for local anesthesia. The foot was then prepped and draped in the usual sterile orthopedic manner. The foot was then elevated and a tourniquet was then placed at 230 mmHg after applying Esmarch bandage. The foot was then lowered down the operative field and sterile stockinet was draped. The stockinet was then reflected. Attention was then directed to the second intermetatarsal interspace. After testing the anesthesia, a 4 cm incision was placed using a #10 blade over the dorsal surface of the foot in the second intermetatarsal space beginning from proximal third of the metatarsals distally to and beyond the metatarsal head. Then, using #15 blade the incision was deepened through the skin into the subcutaneous tissue. Care was taken to identify and avoid or to cauterize any local encountered vascular structures. Incision was deepened using the combination of blunt and dull dissection using Mayo scissors, hemostat, and a #15 blade. The incision was deepened distally down to the level of the deep transverse metatarsal ligament which was reflected and exposure of the intermetatarsal space was appreciated. The individual branches of the plantar digital nerve were identified extending into the second and third digits plantarly. These endings were dissected distally and cut at their most distal portions. Following this, the nerve was dissected proximally into the common nerve and dissected proximally into the proximal portion of the intermetatarsal space. Using careful meticulous dissection, there was noted to a be a enlarged bulbous mass of fibers and nerve tissue embedded with the adipose tissue. This was also cut and removed. The proximal portion of the nerve stump was identified and care was taken to suture this into the lumbrical muscle to leave no free nerve ending exposed. Following this, the interspace was irrigated with copious amounts of sterile saline and interspace explored for any other portions of nerve which may been missed on the previous dissection. It was noted that no other portions of the nerve were detectable and the proximal free nerve ending was embedded and found to be ________ the lumbrical muscle belly. Following this, the interspace was packed using iodoform gauze packing and was closed in layers with the packing extruding from the wound. Attention was then directed to the third interspace where in a manner as mentioned before. A dorsal linear incision which measured 5 cm was made over the third interspace extending from the proximal portion of the metatarsal distally to the metatarsal head. Like before, using a combination of blunt and dull dissection, with sharp dissection the incision was deepened down with care taken to cauterize all retracting vascular structures which were encountered.,The incision was deepened down to the level of the subcutaneous tissue and then down deeper to the interspace of the third and fourth metatarsal. The dissection was deepened distally down to the level of the transverse intermetatarsal ligament, where upon this was reflected and the nerve fibers to the third and fourth digit plantarly were identified. These were once again dissected distally out and transected at their most distal portions. Care was then taken to dissect the nerve proximally into the proximal metatarsal region. No other branches of the nerve were identified and the nerve in its entirety along with fibrous tissue encountered in the area was removed. The proximal portion of the nerve which remained was not large enough to suture into lumbrical muscle as was done in the previous interspace. Half of the nerve was transected proximally as was feasible and no exposed ending was noted. Incision was then flushed and irrigated using sterile saline. Following this, the incision wound was packed with iodoform gauze packed and closed in layers using as before #4-0 Vicryl and #4-0 nylon suture.,Following this, attention was directed to the fifth metatarsal head where a lateral 4 cm incision was placed along the lateral distal shaft and head of the fifth metatarsal using a fresh #10 blade. The incision was then deepened using #15 blade down to the level of the subcutaneous tissue. Care was taken to reflect any neurovascular structures which were encountered. Following this the incision was deepened down to the level of the periosteum and periosteum was reflected, using the sharp dissection, to expose the head of the metatarsal along with the neck region. After adequate exposure of the fifth metatarsal head was achieved, an oblique incision directed from distal lateral to proximal medial in a sagittal plane was performed and the head of the fifth metatarsal was shifted medially. Following this, an OrthoSorb pin was retrograded through the fifth metatarsal head into the neck of the fifth metatarsal and was cut off first with the lateral surfaces of bone. OrthoSorb pin was noted to be intact and the fifth metatarsal head was in good alignment and position. Following this, the sagittal saw and the #138 blade were used to provide rasping and smoothing of the sharp acute edges of bone laterally. Following this, the periosteum was closed using #4-0 Vicryl and the skin was closed in layers using #4-0 Vicryl and closed with running subcuticular #4-0 Monocryl suture. Upon completion of this, the foot was noted to be in good position with good visual alignment of the fifth metatarsal head and digit. The incisions in foot were then ________ draped in the normal manner using Owen silk, 4 x 4s, Kling, and Kerlix and covered with Coban bandage. The tourniquet was then deflated with the total tourniquet time of 103 minutes at 230 mmHg and immediate hyperemia was noted to end digits one through five of the left foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact. The patient tolerated the procedure well without any complications. The patient was then given prescriptions for Vicoprofen #30 and Augmentin #14 to be taken twice daily. The patient was instructed to followup with Dr. X after the weekend on Tuesday in his office. The patient also given postoperative instructions and was placed in a postoperative shoe and instructed to limit weightbearing to the heel only, ice and elevate her foot 20 minutes every hour as tolerated. The patient also instructed to take her medications and prescriptions as directed. She was given the emergency contact numbers. Postoperative x-rays were taken and the patient was discharged home in stable condition upon conclusion of this.surgery, tailor's bunion, neuroma, nerve lesion, interspace, metatarsal, osteotomy, metatarsal osteotomy, metatarsal head, foot, distally, head, incision, nerve, intermetatarsal, portions, |
| 86 | 1 | Tubal Sterilization & Coagulation | PROCEDURE: ,Laparoscopic tubal sterilization, tubal coagulation.,PREOPERATIVE DIAGNOSIS: , Request tubal coagulation.,POSTOPERATIVE DIAGNOSIS: , Request tubal coagulation.,PROCEDURE: ,Under general anesthesia, the patient was prepped and draped in the usual manner. Manipulating probe placed on the cervix, changed gloves. Small cervical stab incision was made, Veress needle was inserted without problem. A 3 L of carbon dioxide was insufflated. The incision was enlarged. A 5-mm trocar placed through the incision without problem. Laparoscope placed through the trocar. Pelvic contents visualized. A 2nd puncture was made 2 fingerbreadths above the symphysis pubis in the midline. Under direct vision, the trocar was placed in the abdominal cavity. Uterus, tubes, and ovaries were all normal. There were no pelvic adhesions, no evidence of endometriosis. Uterus was anteverted and the right adnexa was placed on a stretch. The tube was grasped 1 cm from the cornual region, care being taken to have the bipolar forceps completely across the tube and the tube was coagulated using amp meter for total desiccation. The tube was grasped again and the procedure was repeated for a separate coagulation, so that 1.5 cm of the tube was coagulated. The structure was confirmed to be tube by looking at fimbriated end. The left adnexa was then placed on a stretch and the procedure was repeated again grasping the tube 1 cm from the cornual region and coagulating it. Under traction, the amp meter was grasped 3 more times so that a total of 1.5 cm of tube was coagulated again. Tube was confirmed by fimbriated end. Gas was lend out of the abdomen. Both punctures repaired with 4-0 Vicryl and punctures were injected with 0.5% Marcaine 10 mL. The patient went to the recovery room in good condition.obstetrics / gynecology, cervix, cervical stab incision, laparoscopic tubal sterilization, tubal sterilization, tubal coagulation, sterilization, laparoscopic, endometriosis |
| 87 | 3 | Bronchoscopy - 8 | PREOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,POSTOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,PROCEDURE:, Bronchoscopy with brush biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was taken to the operating room where he underwent a general endotracheal anesthesia. A time-out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4% lidocaine had been infused into the endotracheal tube. First the trachea and the carina had normal appearance. The scope was passed into the left side and the bronchial system was found to be normal. There were scars and mucoid secretions. Then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and TB. First, the basal lobes were explored and found to be normal. Then, the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated. Then, the bronchi going to the three segments were visualized and no abnormalities or mass were found. Brush biopsy was obtained from one of the segments and sent to Pathology.,The procedure had to be interrupted several times because of the patient's desaturation, but after a few minutes of Ambu bagging, he recovered satisfactorily.,At the end, the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.,cardiovascular / pulmonary, persistent pneumonia, bronchoscopy, brush biopsies, endotracheal tube, biopsies, bronchial, abnormalities, pneumonia, secretions, endotracheal, |
| 88 | 2 | Consult - Alzheimer disease | The patient states that she has been doing fairly well at home. She balances her own checkbook. She does not do her own taxes, but she has never done so in the past. She states that she has no problems with cooking meals, getting her own meals, and she is still currently driving. She denies burning any dishes because she forgot them on the stove or forgetting what she is doing in the middle of a task or getting lost while she is driving around or getting lost in her own home. She states that she is very good remembering the names of her family members and does not forget important birthdays such as the date of birth of her grandchildren. She is unfortunately living alone, and although she seems to miss her grandchildren and is estranged from her son, she denies any symptoms of frank depression. There is unfortunately no one available to us to corroborate how well she is doing at home. She lives alone and takes care of herself and does not communicate very much with her brother and sister. She also does not communicate very much with her son who lives in Santa Cruz or her grandchildren. She denied any sort of personality change, paranoid ideas or hallucinations. She does appear to have headaches that can be severe about four times a month and have primarily photophobia and some nausea and occasionally emesis associated with it. When these headaches are very severe, she goes to the emergency room to get a single shot. She is unclear if this is some sort of a migraine medication or just a primary pain medication. She takes Fiorinal for these headaches and she states that this helps greatly. She denies visual or migraine symptoms.,REVIEW OF SYSTEMS: , Negative for any sort of focal neurologic deficits such as weakness, numbness, visual changes, dysarthria, diplopia or dysphagia. She also denies any sort of movement disorders, tremors, rigidities or clonus. Her personal opinion is that some of her memory problems may be due to simply to her age and/or nervousness. She is unclear as if her memory is any worse than anyone else in her age group.,PAST MEDICAL HISTORY: , Significant for mesothelioma, which was diagnosed seemingly more than 20 to 25 years ago. The patient was not sure of exactly when it was diagnosed. This has been treated surgically by debulking operations for which she states that she has undergone about 10 operations. The mesothelioma is in her abdomen. She does not know of any history of having lung mesothelioma. She states that she has never gotten chemotherapy or radiation for her mesothelioma. Furthermore, she states that her last surgical debulking was more than 10 years ago and her disease has been fairly stable. She does have a history of three car accidents that she says were all rear-enders where she was hit while essentially in a stopped position. These have all occurred over the past five years. She also has a diagnosis of dementing illness, possibly Alzheimer disease from her previous neurology consultation. This diagnosis was given in March 2006.,MEDICATIONS:, Fiorinal, p.r.n. aspirin, unclear if baby or full sized, Premarin unclear of the dose.,ALLERGIES:, NONE.,SOCIAL HISTORY:, Significant for her being without a companion at this point. She was born in Munich, Germany. She immigrated to of America in 1957 after her family had to move to Eastern Germany, which was under Russian occupation at that time. She is divorced. She used to work as a secretary and later worked as a clerical worker at IBM. She stopped working more than 20 years ago due to complications from her mesothelioma. She denies any significant tobacco, alcohol or illicit drugs. She is bilingual speaking, German and English. She has known English from before her teens. She has the equivalent of a high school education in Germany. She has one brother and one sister, both of whom are healthy and she does not spend much time communicating with them. She has one son who lives in Santa Cruz. He has grandchildren. She is trying to contact with her grandchildren.,FAMILY HISTORY: , Significant for lung, liver, and prostate cancer. Her mother died in her 80s of "old age," but it appears that she may have had a mild dementing illness at that time. Whatever that dementing illness was, appears to have started mostly in her 80s per the patient. No one else appears to have Alzheimer disease including her brother and sister.,PHYSICAL EXAMINATION: , Her blood pressure is 152/92, pulse 80, and weight 80.7 kg. She is alert and well nourished in no apparent distress. She occasionally fumbles with questions of orientation, missing the day and the date. She also did not know the name of the hospital, she thought it was O'Connor and she thought she was in Orange County and also did not know the floor of the hospital that we are in. She lost three points for recall. Even with prompting, she could not remember the objects that she was given to remember. Her Mini Mental Score was 22/30. There were no naming problems or problems with repetition. There were also no signs of dysarthria. Her pupils were bilaterally reactive to light and accommodation. Her extraocular movements were intact. Her visual fields were full to confrontation. Her sensations of her face, arm, and leg were normal. There were no signs of neglect with double simultaneous stimulation. Tongue was midline. Her palate was symmetric. Her face was symmetric as well. Strength was approximately 5/5. She did have some right knee pain and she had a mildly antalgic gait due to her right knee pain. Her reflexes were symmetric and +2 except for her toes, which were +1 to trace. Her plantar reflexes were mute. Her sensation was normal for pain, temperature, and vibration. There were no signs of ataxia on finger-to-nose and there was no dysdiadochokinesia. Gait was narrow and she could toe walk briefly and heel walk without difficulty.,SUMMARY:, Ms. A is a pleasant 72-year-old right-handed woman with a history of mesothelioma that appears stable at this time and likely mild dementia, most likely Alzheimer type. We tactfully discussed the patient's diagnosis with her, and she felt reassured. We told her that this most likely was in the earlier stages of disease and she would benefit from trying Aricept. She stated that she did not have the prescription anymore from her outpatient neurology consult for the Aricept, so we wrote her another prescription for Aricept. The patient herself seemed very concerned about the stigma of the disease, but our lengthy discussion, expressed genuine understanding as to why her outpatient physician had reported her to DMV. It was explicitly told to not drive by her outpatient neurologist and we concur with this assessment. She will follow up with us in the next six months and will call us if she has any problems with the Aricept. She was written for Aricept to start at 5 mg for three weeks, and if she has no side effects which typically are GI side effects, then she can go up to 10 mg a day. We also reviewed with Ms. A the findings for outpatient MRI, which showed some mild atrophy per report and also that her metabolic workup, which included an RPR, TSH, and B12 were all within normal limits.,consult - history and phy., neurology consultation, dementing illness, alzheimer disease, dementia, alzheimer, mesothelioma, |
| 89 | 1 | Total Thyroid Lumpectomy | PREOPERATIVE DIAGNOSIS:, Left thyroid mass.,POSTOPERATIVE DIAGNOSIS:, Left thyroid mass.,PROCEDURE PERFORMED:, Left total thyroid lumpectomy.,ANESTHESIA,: General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:, None.,INDICATIONS FOR PROCEDURE:, The patient is a 76-year-old Caucasian female with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole. The patient was then discussed the risks, complications, and consequences of a surgical procedure and a written consent was obtained.,PROCEDURE: ,The patient is brought to the operative suite by Anesthesia. The patient was placed on the operative table in supine position. After this, the patient was placed under general endotracheal intubation anesthesia and the patient was then placed upon a shoulder roll. After this, the skin incision was marked approximately two fingerbreadths above the sternal notch. It was then localized with 1% lidocaine with epinephrine 1:1000 approximately 7 cc total.,After this, the patient was then prepped and draped in the usual sterile fashion and a #10 blade was then utilized to make a skin incision. The subcutaneous tissue was then bluntly dissected utilizing a Ray-Tec sponge and a bear claw was then utilized to retract the upper incisional skin with counter retraction performed to allow a subplatysmal plane of skin flaps to be performed in superior and inferolateral directions. After this, the midline was then identified and grasped on either side with a DeBakey forceps. The raphe was noted and Bovie cauterization was utilized to cut down into this region. The fine stats were utilized to further open this area with exposure and bisection of the sternothyroid muscle. It was separated on the left side from the patient's sternothyroid muscle. After this, the sternothyroid muscle was identified, grasped with the DeBakey forceps and infiltrated initially through its fascial plane with the Metzenbaum scissors. Blunt dissection was then utilized to free the sternothyroid muscle from the thyroid gland in superior and inferior directions and laterally with the help of Kitners. After this, the plane was rotated more anteriorly with the superior and inferior parathyroid glands identified. The fat cap was noted to be attached on the superior parathyroid to the posterior aspect of the thyroid itself. It was freed from the thyroid gland and reflected laterally and posteriorly. The inferior parathyroid gland actually appeared to be attached also to the inferior aspect of the thyroid itself and was reflected laterally. After this, the patient's thyroid gland was palpated noting a thyroid nodule in the posterior inferior aspect along with the calcification laterally. The nodule appeared to be sort of rubbery in consistency and approximately 1 cm diameter. As the gland was rotated more anteriorly, the recurrent laryngeal nerve on the left side was identified and further dissection along Berry's ligament on the medial aspect was performed. The middle thyroid vein and inferior thyroid artery were both cauterized with a bipolar cautery and bisected. After this, the gland was easily rotated anteriorly with further dissection carried up to the superior pole. The superior pole was exposed with the help of a Richardson and Army-Navy retractors with cross-clamping and tying of the superior laryngeal artery and vein. Further, the small bleeding vessels were identified and bipolared, and cut with the Metzenbaum scissors. The superior pole was finally freed and the gland was rotated more anteriorly onto the anterior aspect of the trachea. Berry's ligament was finally freed and the gland was cross-clamped on the opposing thyroid isthmus with a mosquito. After this, the gland was cut with a Metzenbaum scissors and tied with a #3-0 undyed Vicryl tie. The defect on the neck now was thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization. Surgicel was then cut in small strips and three replaced in the lateral part of the neck.,The opposing side of the thyroid gland on the right was palpated with no noticeable nodules or masses. The strap muscles were then reapproximated with #3-0 Vicryl on a SH, followed by reapproximation of the subcutaneous tissue with #4-0 Vicryl, followed by reapproximation of the skin by running subcuticular #5-0 Prolene and a #6-0 fast absorbing gut. Mastisol, Steri-Strips, and bacitracin were placed followed by a sterile 4 x 4 dressing. The patient was then turned back to Anesthesia, extubated in the operating room, and transferred to Recovery in stable condition. The patient tolerated the procedure well and will be admitted to hospital for 23-hour observation and will be followed up in one week afterwards.surgery, thyroid lumpectomy, thyroid uptake scan, thyroid mass nodule, total thyroid lumpectomy, parathyroid glands, berry's ligament, metzenbaum scissors, thyroid gland, thyroid mass, gland, thyroid, total, |
| 90 | 3 | Bronchoscopy | PREOPERATIVE DIAGNOSIS: , Atelectasis.,POSTOPERATIVE DIAGNOSIS: , Mucous plugging.,PROCEDURE PERFORMED: , Bronchoscopy.,ANESTHESIA: , Lidocaine topical 2%, Versed 3 mg IV. Conscious sedation.,PROCEDURE: , At bedside, a bronchoscope was passed down the tracheostomy tube under monitoring. The main carina was visualized. The trachea was free of any secretions. The right upper lobe, middle and lower lobes appeared to have some mucoid secretions but minimal and with some erythema. Left mainstem appeared patent. Left lower lobe had slight plugging in the left base, but much better that previous bronchoscopy findings. The area was lavaged with some saline and cleared. The patient tolerated the procedure well.cardiovascular / pulmonary, |
| 91 | 3 | Subxiphoid Pericardial Window | PREOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,POSTOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,PROCEDURE:,1. Emergent subxiphoid pericardial window.,2. Transesophageal echocardiogram.,ANESTHESIA:, General endotracheal.,FINDINGS:, The patient was noted to have 600 mL of dark bloody fluid around the pericardium. We could see the effusion resolve on echocardiogram. The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. There was no evidence of endocarditis. The mitral valve leaflets moved normally with some mild mitral insufficiency.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room emergently. After adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. A small incision was made at the bottom of the previous sternotomy incision. The subcutaneous sutures were removed. The dissection was carried down into the pericardial space. Blood was evacuated without any difficulty. Pericardial Blake drain was then placed. The fascia was then reclosed with interrupted Vicryl sutures. The subcutaneous tissues were closed with a running Monocryl suture. A subdermal PDS followed by a subcuticular Monocryl suture were all performed. The wound was closed with Dermabond dressing. The procedure was terminated at this point. The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition.cardiovascular / pulmonary, endocarditis, valve replacement, st. jude, echocardiogram, transesophageal, pericardium, blake drain, st jude mechanical valve, subxiphoid pericardial window, pericardial window, aortic valve, tamponade, subxiphoid, valve, pericardial, aortic |
| 92 | 4 | Intracranial aneurysm - ER Visit | CHIEF COMPLAINT:, Headache.,HPI: , This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan. He was discharged home with a follow up to neurosurgery on the 14th. Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery. He has had headaches since the 13th and complains now of some worsening of his pain. He denies photophobia, fever, vomiting, and weakness of the arms or legs.,PMH: , As above.,MEDS:, Vicodin.,ALLERGIES:, None.,PHYSICAL EXAM: ,BP 180/110 Pulse 65 RR 18 Temp 97.5.,Mr. P is awake and alert, in no apparent distress.,HEENT: Pupils equal, round, reactive to light, oropharynx moist, sclera clear. ,Neck: Supple, no meningismus.,Lungs: Clear.,Heart: Regular rate and rhythm, no murmur, gallop, or rub. ,Abdomen: Benign.,Neuro: Awake and alert, motor strength normal, no numbness, normal gait, DTRs normal. Cranial nerves normal. ,COURSE IN THE ED: ,Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus. I recommended an LP but he prefers not to have this done. He received morphine for pain and his headache improved. I've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram. He left the ED against my advice. ,IMPRESSION: , Headache, improved. Intracranial aneurysm.,PLAN: , The patient will return tomorrow am for his angiogram.neurology, angiogram, mass, ct scan, intracranial aneurysm, headache, aneurysm, intracranial, |
| 93 | 3 | Chronic Kidney Disease Followup | HISTORY OF PRESENT ILLNESS: , This is a followup for this 69-year-old African American gentleman with stage IV chronic kidney disease secondary to polycystic kidney disease. His creatinine has ranged between 4 and 4.5 over the past 6 months, since I have been following him. I have been trying to get him educated about end-stage kidney disease and we have been unsuccessful in getting him into classes. On his last visit, I really stressed the importance of him taking his medications adequately and not missing some of the doses, and he returns today with much better blood pressure control. He has also brought a machine at home, and states his blood pressure readings have been better. He has not gone to the transplant orientation class yet and has not been to dialysis education yet, and both of these I have discussed with him in the past. He also needs followup for his elevated PSA in the past, which has not been done for over 2 years and will likely need cardiac clearance if we ever are able to evaluate him for transplant.,REVIEW OF SYSTEMS: , Really negative. He continues to feel well. He denies any problems with shortness of breath, chest pain, swelling in his legs, nausea or vomiting, and his appetite remains good.,CURRENT MEDICATIONS:,1. Vytorin 10/40 mg one a day.,2. Rocaltrol 0.25 micrograms a day.,3. Carvedilol 12.5 mg twice a day.,4. Cozaar 50 mg twice a day.,5. Lasix 40 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS: On exam, his blood pressure is 140/57, pulse 58, current weight is 67.1 kg, and again his blood pressure is markedly improved over his previous readings. GENERAL: He is a thin African American gentleman in no distress. LUNGS: Clear. CARDIOVASCULAR: Regular rate and rhythm. Normal S1 and S2. I did not appreciate a murmur. ABDOMEN: Soft. He has a very soft systolic murmur at the left lower sternal border. No rubs or gallops. EXTREMITIES: No significant edema.,LABORATORY DATA: , Today indicates that his creatinine is 4.5 and stable, ionized calcium 8.5, intact PTH 458, and hemoglobin stable at 10.9. He is not on EPO yet. His UA has been negative.,IMPRESSION:,1. Chronic kidney disease, stage IV, secondary to polycystic kidney disease. His estimated GFR is 16 mL per minute. He has no uremic symptoms.,2. Hypertension, which is finally better controlled.,3. Metabolic bone disease.,4. Anemia.,RECOMMENDATION:, He needs a number of things done in terms of followup and education. I gave him more information again about dialysis education and transplant, and instructed him he needs to go to these classes. I also gave him websites that he can get on to find out more information. I have not made any changes in his medications. He is getting blood work done prior to his next visit with me. I will check a PSA on him but he needs to get back into see urology, as his last PSA that I see was 37 and this was from 02/05. He will see me back in about 4 to 6 weeks.nephrology, metabolic bone disease, anemia, polycystic kidney disease, chronic kidney disease, blood pressure, transplant, metabolic, kidney |
| 94 | 4 | Phenol Neurolysis & Botulinum Toxin Injection - 1 | 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.neurology, 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 |
| 95 | 1 | Circumcision - 2 | CIRCUMCISION - NEONATAL,PROCEDURE:,: The procedure, risks and benefits were explained to the patient's mom, and a consent form was signed. She is aware of the risk of bleeding, infection, meatal stenosis, excess or too little foreskin removed and the possible need for revision in the future. The infant was placed on the papoose board. The external genitalia were prepped with Betadine. A penile block was performed with a 30-gauge needle and 1.5 mL of Nesacaine without epinephrine.,Next, the foreskin was clamped at the 12 o'clock position back to the appropriate proximal extent of the circumcision on the dorsum of the penis. The incision was made. Next, all the adhesions of the inner preputial skin were broken down. The appropriate size bell was obtained and placed over the glans penis. The Gomco clamp was then configured, and the foreskin was pulled through the opening of the Gomco. The bell was then placed and tightened down. Prior to do this, the penis was viewed circumferentially, and there was no excess of skin gathered, particularly in the area of the ventrum. A blade was used to incise circumferentially around the bell. The bell was removed. There was no significant bleeding, and a good cosmetic result was evident with the appropriate amount of skin removed.,Vaseline gauze was then placed. The little boy was given back to his mom.,PLAN:, They have a new baby checkup in the near future with their primary care physician. I will see them back on a p.r.n. basis if there are any problems with the circumcision.urology, neonatal, circumcision, gomco, gomco clamp, external genitalia, foreskin, glans, glans penis, infant, meatal stenosis, penile block, penis, preputial skin, circumferentially, infection, bell, |
| 96 | 4 | Psych Consult - Assaultive Behavior | IDENTIFYING DATA: ,The patient is a 40-year-old white male. He is married, on medical leave from his job as a tree cutter, and lives with his wife and five children.,CHIEF COMPLAINT AND REACTION TO HOSPITALIZATION: ,The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.,HISTORY OF PRESENT ILLNESS: ,The patient was very sleepy this morning, only minimally cooperative with interview. Additional information taken from the emergency room records that accompanied him from Hospital yesterday as well as from his wife, who I contacted by telephone. The patient was apparently at his stable baseline when discharged from the Hospital on 01/21/10, status post back surgery following a work-related injury. The patient returned to Emergency Room on the evening prior to admission complaining of severe back pain. His ER course is notable for yelling, spitting, and striking multiple staff members. The patient was originally to be admitted for pain control, but when he threatened to leave, he was referred to MHPs, who subsequently detained him for 72 hours for dangerousness to others. On interview, the patient reports only hazy memories of these incidences and states this behavior was secondary to his pain and his medications. He was contrite about the violence. When his wife was contacted by telephone, she agreed with this assessment and reports that he has a history of domestic violence usually in the setting of alcohol and illicit substance intoxication, but denies any events in the last 3 years.,His wife reports that after discharge from the hospital, on 01/21/10, he was prescribed Percocet, Soma, hydroxyzine, and Valium. He essentially exhausted his approximately 10 days' supply of these agents on the morning of 01/23/10, and as above believes that this was responsible for his presentation yesterday. She reports that she has been in contact with him since his arrival in our facility and reports that he is "back to normal." She denies feeling that he currently represents a threat to her or her five children. She was unaware of his mental health history, but denies that he has received care for any condition since they were married three years ago.,PAST PSYCHIATRIC HISTORY: , The patient has a history of Involuntary Treatment Act of 72 hours in our facility in 2004 or 2005 for assaultive behaviors; however, these records are not currently available for review. The patient denies any outpatient mental health treatment before or since this hospitalization. He describes his mental health diagnosis of bipolar affective disorder; however, he denies a history of dramatic mood swings in the absence of illicit substances or alcohol intoxication.,PAST MEDICAL HISTORY:, Notable for status post back surgery, discharged from Hospital on 01/21/10.,MEDICATIONS:, From discharge from Hospital on 01/21/10, include Percocet, Valium, Soma, and Vistaril, doses and frequency are not currently known. His wife reports that he was discharged with approximately 10 days' supply of these agents.,SOCIAL AND DEVELOPMENTAL HISTORY: ,The patient is employed as a tree cutter, currently on medical leave for the last 2 months following a back injury. He lives with his wife and children. He has a history of domestic violence, but not recently. Other details of occupational, educational history not currently known.,SUBSTANCE AND ALCOHOL HISTORY:, Records indicate a previous history of methamphetamine and alcohol abuse/dependence. The wife states that he has not consumed either since 12/07. Of note, urine tox screen at Hospital was positive for marijuana.,LEGAL HISTORY: ,The patient has been charged with domestic violence in the past, but his wife denies any repeat instances since in the last 3 years. It is not known whether the patient is currently on probation.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAMINATION:,Attitude: The patient is only minimally cooperative with interview secondary to being sleepy, and after repeated attempts to ask questions, he rolled over and went to bed.,Appearance: He is unkempt and there are multiple visible tattoos on his biceps.,Psychomotor: There is no obvious psychomotor agitation or retardation. There are no obvious extrapyramidal symptoms of tardive dyskinesia.,Affect: His affect is notably restricted probably due to the fact that he is sleepy.,Mood: Describes his mood as "okay.",Speech: Speech is normal rate, volume, and tone.,Thought Processes: His thought processes appear to be linear.,Thought Content: His thought content is notable for his expressions of contrition about violence at Hospital last night. He denies suicidal or homicidal ideation.,Cognitive Assessment: Cognitively, he is alert and oriented to person, place, and date but not situation. Attributes this to not really remembering the events at Hospital that resulted in this hospitalization.,Judgment and Insight: His insight and judgment are both appear to be improving.,Assets: Include his supportive wife and the fact he has been able to remain alcohol and methamphetamine sobriety for the last 3 years.,Limitations: Include his back injury and possible need for improvement of health treatment engagement.,FORMULATION: ,This is a 40-year-old white male, who was admitted for an acute agitation in the setting of misuse of prescribed opiates, Soma, hydroxyzine, and Valium. He appears much improved from his condition at Hospital last night and I suspect that his behavior is most likely attributed to delirium and this since resolved. He reports historical diagnosis of bipolar affective disorder, however, the details of this diagnosis are not currently available for review.,DIAGNOSES:,AXIS I: Delirium, resolved (recent mental status changes likely secondary to misuse of prescribed opiates, Soma, Valium, and hydroxyzine.) Rule out bipolar affective disorder.,AXIS II: Deferred.,AXIS III: Chronic pain status post back surgery.,AXIS IV: Appears to be moderate. He is currently on medical leave from his job.,AXIS V: Global Assessment of Functioning is currently 50 (his GAF was 20 approximately 24 hours ago).,ESTIMATED LENGTH OF STAY:, Three days.,PLAN:, I will hold psychiatric medications for now given the patient's fairly rapid improvement as he cleared from the condition, I suspect is likely due to misuse of prescribed medications. The patient will be placed on CIWA protocol given that one of the medications he overused was Valium. Of note, he does not currently appear to be withdrawing and I anticipate that his CIWA will be discontinued prior to discharge. I would like to increase the database regarding the details of his historical diagnosis of bipolar affective disorder before pursuing referrals for outpatient mental health care. The internal medicine service will evaluate for treatment for any underlying medical problems specifically to provide recommendations regarding pain management.nan |
| 97 | 3 | Breast Calcifications - Preop Consult | REASON FOR HOSPITALIZATION: ,Suspicious calcifications upper outer quadrant, left breast.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old woman who had undergone routine screening mammography on 06/04/08. That study disclosed the presence of punctate calcifications that were felt to be in a cluster distribution in the left breast mound at the 2 o'clock position. Additional imaging studies confirmed the suspicious nature of these calcifications. The patient underwent a stereotactic core needle biopsy of the left breast 2 o'clock position on 06/17/08. The final histologic diagnosis of the tissue removed during that procedure revealed focal fibrosis. No calcifications could be identified in examination of the biopsy material including radiograph taken of the preserved tissue.,Two days post stereotactic core needle biopsy, however, the patient returned to the breast center with severe swelling and pain and mass in the left breast. She underwent sonographic evaluation and was found to have a development of false aneurysm formation at the site of stereotactic core needle biopsy. I was called to see the patient in the emergency consultation in the breast center. At the same time, Dr. Y was consulted in Interventional Radiology. Dr. Z and Dr. Y were able to identify the neck of the false aneurysm in the left breast mound and this was injected with ultrasound guidance with thrombin material. This resulted in immediate occlusion of the false aneurysm. The patient was seen in my office for followup appointment on 06/24/08. At that time, the patient continued to have signs of a large hematoma and extensive ecchymosis, which resulted from the stereotactic core needle biopsy. There was, however, no evidence of reforming of the false aneurysm. There was no evidence of any pulsatile mass in the left breast mound or on the left chest wall.,I discussed the issues with the patient and her husband. The underlying problem is that the suspicious calcifications, which had been identified on mammography had not been adequately sampled with the stereotactic core needle biopsy; therefore, the histologic diagnosis is not explanatory of the imaging findings. For this reason, the patient was advised to have an excisional biopsy of this area with guidewire localization. Since the breast mound was significantly disturbed from the stereotactic core needle biopsy, the decision was to postpone any surgical intervention for at least three to four months. The patient now returns to undergo the excision of the left breast tissue with preoperative guidewire localization to identify the location of suspicious calcifications.,The patient has a history of prior stereotactic core needle biopsy of the left breast, which was performed on 01/27/04. This revealed benign histologic findings. The family history is positive involving a daughter who was diagnosed with breast cancer at the age of 40. Other than her age, the patient has no other risk factors for development of breast cancer. She is not receiving any hormone replacement therapy. She has had five children with the first pregnancy occurring at the age of 24. Other than her daughter, there are no other family members with breast cancer. There are no family members with a history of ovarian cancer.,PAST MEDICAL HISTORY: , Other hospitalizations have occurred for issues with asthma and pneumonia.,PAST SURGICAL HISTORY: , Colon resection in 1990 and sinus surgeries in 1987, 1990 and 2005.,CURRENT MEDICATIONS:,1. Plavix.,2. Arava.,3. Nexium.,4. Fosamax.,5. Advair.,6. Singulair.,7. Spiriva.,8. Lexapro.,DRUG ALLERGIES:, ASPIRIN, PENICILLIN, IODINE AND CODEINE.,FAMILY HISTORY:, Positive for heart disease, hypertension and cerebrovascular accidents. Family history is positive for colon cancer affecting her father and a brother. The patient has a daughter who was diagnosed with breast cancer at age 40.,SOCIAL HISTORY: , The patient does not smoke. She does have an occasional alcoholic beverage.,REVIEW OF SYSTEMS: ,The patient has multiple medical problems, for which she is under the care of Dr. X. She has a history of chronic obstructive lung disease and a history of gastroesophageal reflux disease. There is a history of anemia and there is a history of sciatica, which has been caused by arthritis. The patient has had skin cancers, which have been treated with local excision.,PHYSICAL EXAMINATION:,GENERAL: The patient is an elderly aged female who is alert and in no distress.,HEENT: Head, normocephalic. Eyes, PERRL. Sclerae are clear. Mouth, no oral lesions.,NECK: Supple without adenopathy.,HEART: Regular sinus rhythm.,CHEST: Fair air entry bilaterally. No wheezes are noted on examination.,BREASTS: Normal topography bilaterally. There are no palpable abnormalities in either breast mound. Nipple areolar complexes are normal. Specifically, the left breast upper outer quadrant near the 2 o'clock position has no palpable masses. The previous tissue changes from the stereotactic core needle biopsy have resolved. Axillary examination normal bilaterally without suspicious lymphadenopathy or masses.,ABDOMEN: Obese. No masses. Normal bowel sounds are present.,BACK: No CVA tenderness.,EXTREMITIES: No clubbing, cyanosis or edema.,ASSESSMENT:,1. Left breast mound clustered calcifications, suspicious by imaging located in the upper outer quadrant at the 2 o'clock position.,2. Prior stereotactic core needle biopsy of the left breast did not resolve the nature of the calcifications, this now requires excision of the tissue with preoperative guidewire localization.,3. History of chronic obstructive lung disease and asthma, controlled with medications.,4. History of gastroesophageal reflux disease, controlled with medications.,5. History of transient ischemic attack managed with medications.,6. History of osteopenia and osteoporosis, controlled with medications.,7. History of anxiety controlled with medications.,PLAN: , Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography. This will be performed on an outpatient basis.nan |
| 98 | 1 | EGD & PEG Tube Placement | PREOPERATIVE DIAGNOSES:,1. protein-calorie malnutrition.,2. Intractable nausea, vomiting, and dysphagia.,POSTOPERATIVE DIAGNOSES:,1. Protein-calorie malnutrition.,2. Intractable nausea, vomiting, and dysphagia.,3. Enterogastritis.,PROCEDURE PERFORMED: , EGD with PEG tube placement using Russell technique.,ANESTHESIA: , IV sedation with 1% lidocaine for local.,ESTIMATED BLOOD LOSS: ,None.,COMPLICATIONS: ,None.,BRIEF HISTORY: , This is a 44-year-old African-American female who is well known to this service. She has been hospitalized multiple times for intractable nausea and vomiting and dehydration. She states that her decreased p.o. intake has been progressively worsening. She was admitted to the service of Dr. Lang and was evaluated by Dr. Wickless as well all of whom agreed that the best option for supplemental nutrition for this patient was placement of a PEG tube.,PROCEDURE: , After risks, complications, and benefits were explained to the patient and informed consent was obtained, the patient was taken to the operating room. She was placed in the supine position. The area was prepped and draped in the sterile fashion. After adequate IV sedation was obtained by anesthesia, esophagogastroduodenoscopy was performed. The esophagus, stomach, and duodenum were visualized without difficulty. There was no gross evidence of any malignancy. There was some enterogastritis which was noted upon exam. The appropriate location was noted on the anterior wall of the stomach. This area was localized externally with 1% lidocaine. Large gauge needle was used to enter the lumen of the stomach under visualization. A guide wire was then passed again under visualization and the needle was subsequently removed. A scalpel was used to make a small incision, next to the guidewire and ensuring that the underlying fascia was nicked as well. A dilator with break-away sheath was then inserted over the guidewire and under direct visualization was seen to enter the lumen of the stomach without difficulty. The guidewire and dilator were then removed again under visualization and the PEG tube was placed through the break-away sheath and visualized within the lumen of the stomach. The balloon was then insufflated and the break-away sheath was then pulled away. Proper placement of the tube was ensured through visualization with a scope. The tube was then sutured into place using nylon suture. Appropriate sterile dressing was applied.,DISPOSITION: ,The patient was transferred to the recovery in a stable condition. She was subsequently returned to her room on the General Medical Floor. Previous orders will be resumed. We will instruct the Nursing that the PEG tube can be used at 5 p.m. this evening for medications if necessary and bolus feedings.surgery, protein-calorie malnutrition, nausea, vomiting, peg tube placement, russell technique, peg tube, egd, protein, dysphagia, malnutrition, enterogastritis |
| 99 | 1 | Cardiac Catheterization - 4 | PROCEDURES PERFORMED:,1. Left heart catheterization with coronary angiography and left ventricular pressure measurement.,2. Left ventricular angiography was not performed.,3. Right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting.,4. Right femoral artery angiography.,5. Perclose to seal the right femoral arteriotomy.,INDICATIONS FOR PROCEDURE:, Patient presenting with a history of coronary artery disease in the past with coronary angiography in the early 1990s. The patient presented with what appeared to be a COPD exacerbation and had mildly positive cardiac enzyme markers suggestive of a non-ST elevation myocardial infarction. He was subsequently dispositioned to the cardiac catheterization lab for further evaluation.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, the patient was taken to the cardiac catheterization lab, where his procedure was performed. The patient was appropriately prepped and prepared on the table, after which his right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery. Over a standard 0.035 guidewire, coronary angiography and left ventricular pressure measurements were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery, a 6-French JR4 diagnostic catheter to image the right coronary artery, a 6-French angled pigtail catheter to measure left ventricular pressure. At the conclusion of the diagnostic study, the case was progressed to percutaneous coronary intervention, which will be described below. Subsequently, right femoral artery angiography was performed which showed right femoral artery which was free of significant atherosclerotic plaque, and an arteriotomy that was suitable for a closure device. Then, a Perclose was used to seal the right femoral arteriotomy.,HEMODYNAMIC DATA:, The opening aortic pressure was 91/63. The left ventricular pressure was 94/13 with an end-diastolic pressure of 24. Left ventricular ejection fraction was not assessed, as ventriculogram was not performed. The patient did have some elevated creatinine earlier in this hospital course which warranted limitation of contrast where possible.,CORONARY ANGIOGRAM:, The left main coronary artery was angiographically okay. The LAD had mild diffuse disease. There appeared to be distal tapering of the LAD. The left circumflex had mild diffuse disease. In the very distal aspect of the circumflex after OM-3 and OM-4 type branch, there was a long, severely diseased segment that appeared to be chronic and subtotal in one area. The runoff from this area appeared to be a very small PLOM type branch and continuation of a circ which did not appear to supply much territory, and there was not much to salvage by approaching this lesion. The right coronary artery had mild diffuse disease. The PLV branch was 100% occluded at its ostium at the crux. The PDA at the ostium had an 80% stenosis. The PDA was a fairly sizeable vessel with a long course. The right coronary is dominant.,CONCLUSION:, Mild diffuse coronary artery disease with severe distal left circumflex lesion with not much runoff beyond this lesion. This circumflex appears to be chronically diseased and has areas that appear to be subtotal. There is a 100% PLV branch which is also chronic and reported in his angiogram in the 1990s. There is an ostial 80% right PDA lesion. The plan is to proceed with percutaneous intervention to the right PDA.,The case was then progressed to percutaneous intervention of the right PDA. A 6-French JR4 guide catheter with side holes was selected and used to engage the right coronary artery ostium. The lesion was crossed with a long BMW 0.014 guidewire. Then, we ballooned the lesion with a 2.5 x 9 mm Maverick balloon. Subsequently, we stented the lesion with a 2.5 x 16 mm Taxus drug-eluting stent with a nice angiographic result. The patient tolerated the procedure very well, without complications.,ANGIOPLASTY CONCLUSION:, Successful percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.,RECOMMENDATIONS:, Aspirin indefinitely, and Plavix 75 mg p.o. daily for no less than six months. The patient will be dispositioned back to telemetry for further monitoring.,TOTAL MEDICATIONS DURING PROCEDURE:, Versed 1 mg and fentanyl 25 mcg for conscious sedation. Heparin 8400 units IV was given for anticoagulation. Ancef 1 g IV was given for closure device prophylaxis.,CONTRAST ADMINISTERED:, 200 mL.,FLUOROSCOPY TIME:, 12.4 minutes.surgery, coronary angiography, ventricular pressure, coronary angioplasty, french, pda, drug-eluting stent, coronary artery disease, cardiac catheterization lab, plv branch, cardiac catheterization, femoral artery, coronary artery, artery, coronary, angioplasty, angiogram, angiographically, arteriotomy, angiography, cardiac, circumflex, ostium, ventricular, femoral, percutaneous, catheterization, |
| 100 | 4 | Neuropsychological Evaluation | REASON FOR REFERRAL: , Ms. A is a 60-year-old African-American female with 12 years of education who was referred for neuropsychological evaluation by Dr. X after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in July. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION:, Historical information was obtained from a review of available medical records and clinical interview with Ms. A. A summary of pertinent information is presented below. Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:, Ms. A presented to the ABC Hospital emergency department on 07/26/2009 reporting that after she had woken up that morning she noticed numbness and weakness in her left hand, slurred speech, and left facial droop. Neurological evaluation with Dr. X confirmed left hemiparesis. Brain CT showed no evidence of intracranial hemorrhage or mass effect and that she received TPA and had moderate improvement in left-sided weakness. These symptoms were thought to be due to a right middle cerebral artery stroke. She was transferred to the ICU for monitoring. Ultrasound of the carotids showed 20% to 30% stenosis of the right ICA and 0% to 19% stenosis of the left ICA. On 07/29/2009, she was admitted for acute inpatient rehabilitation for the treatment of residual functional deficits of her acute ischemic right MCA/CVA. At discharge on 08/06/2009, she was mainly on supervision for all ADLs and walking with a rolling walker, but tolerating increased ambulation with a cane. She was discharged home with recommendations for outpatient physical therapy. She returned to the Sinai ER on 08/2009/2009 due to reported left arm pain, numbness, and weakness, which lasted 10 to 15 minutes and she reported that it felt "just like the stroke." Brain CT on 08/2009/2009 was read as showing "mild chronic microvascular ischemic change of deep white matter," but no acute or significant interval change compared to her previous scan. Neurological examination with Dr. Y was within normal limits, but she was admitted for a more extensive workup. Due to left arm pain an ultrasound was completed on her left upper extremity, but it did not show deep vein thrombosis.,Followup CT on 08/10/2009 showed no significant interval change. MRI could not be completed due to the patient's weight. She was discharged on 08/11/2009 in stable condition after it was determined that this event was not neurological in origin; however, note that Ms. A referred to this as a second stroke.,Ms. A presented for a followup outpatient neurological evaluation with Dr. X on 09/22/2009, at which time a brief neuropsychological screening was also conducted. She demonstrated significant impairments in confrontation naming, abstract verbal reasoning, and visual and verbal memory and thus a more comprehensive evaluation was suggested due to her intent to return to her full-time work duty. During the current interview, Ms. A reported that she noticed mild memory problems including some difficultly remembering conversations, events, and at times forgetting to take her medications. She also reported mild difficulty finding words in conversation, solving novel problems and tasks (e.g. difficulty learning to use her camcorder), but overall denied significant cognitive deficits in attention, concentration, language or other areas of cognitive functioning. When asked about her return to work, she said that she was still on light duty due to limited physical activity because of residual left leg weakness. She reported that no one had indicated to her that she appeared less capable of performing her job duties, but said that she was also receiving fewer files to process and enter data into the computer at the Social Security Agency that she works at. Note also that she had some difficulty explaining exactly what her job involved. She also reported having problems falling asleep at work and that she is working full-time although on light duty.,OTHER MEDICAL HISTORY: ,As mentioned, Ms. A continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly. She was diagnosed with sleep apnea approximately two years ago and was recently counseled by Dr. X on the need to use her CPAP because she indicated she never used it at night. She reported that since her appointment with Dr. X, she has been using it "every other night." When asked about daytime fatigue, Ms. A initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen. She reported at times "snoring" and forgetting where she is at and said that a supervisor offered to give her coffee at one point. She receives approximately two to five hours of sleep per night. Other current untreated risk factors include obesity and hypercholesterolemia. Her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke).,CURRENT MEDICATIONS: , Aspirin 81 mg daily, Colace 100 mg b.i.d., Lipitor 80 mg daily, and albuterol MDI p.r.n.,SUBSTANCE USE:, Ms. A denied drinking alcohol or using illicit drugs. She used to smoke a pack of cigarettes per day, but quit five to six years ago.,FAMILY MEDICAL HISTORY: , Ms. A had difficulty providing information on familial medical history. She reported that her mother died three to four years ago from lung cancer. Her father has gout and blood clots. Siblings have reportedly been treated for asthma and GI tumors. She was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc.,SOCIAL HISTORY: , Ms. A completed high school degree. She reported that she primarily obtained B's and C's in school. She received some tutoring for algebra in middle school, but denied ever having been held back a grade failing any classes or having any problems with attention or hyperactivity.,She currently works for the Social Security Administration in data processing. As mentioned, she has returned to full-time work, but continues to perform only light duties due to her physical condition. She is now living on her own. She has never driven. She reported that she continues to perform ADLs independently such as cooking and cleaning. She lost her husband in 2005 and has three adult daughters. She previously reported some concerns that her children wanted her to move into assisted living, but she did not discuss that during this current evaluation. She also reported number of other family members who had recently passed away. She has returned to activities she enjoys such as quire, knitting, and cooking and plans to go on a cruise to the Bahamas at the end of October.,PSYCHIATRIC HISTORY: , Ms. A did not report a history of psychological or psychiatric treatment. She reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events. She reported that this only "comes and goes.",TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Testnan |