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POSTOPERATIVE DIAGNOSIS: , Type 4 thoracoabdominal aneurysm.,OPERATION/PROCEDURE: , A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.,DESCRIPTION OF PROCEDURE IN DETAIL: , Patient was brought to the operating room and put in supine position, and general endotracheal anesthesia was induced through a double-lumen endotracheal tube. Patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30-degree angle. The left groin, abdominal and chest were prepped and draped in a sterile fashion. A thoracoabdominal incision was made. The 8th interspace was entered. The costal margin was divided. The retroperitoneal space was entered and bluntly dissected free to the psoas, bringing all the peritoneal contents to the midline, exposing the aorta. The inferior pulmonary ligament was then taken down so the aorta could be dissected free at the T10 level just above the diaphragm. It was dissected free circumferentially. The aortic bifurcation was dissected free, dissecting free both iliac arteries. The left inferior pulmonary vein was then dissected free, and a pursestring of 4-0 Prolene was placed on this. The patient was heparinized. Through a stab wound in the center of this, a right-angle venous cannula was then placed at the left atrium and secured to a Rumel tourniquet. This was hooked to a venous inflow of left heart bypass machine. A pursestring of 4-0 Prolene was placed on the aneurysm and through a stab wound in the center of this, an arterial cannula was placed and hooked to outflow. Bypass was instituted. The aneurysm was cross clamped just above T10 and also, cross clamped just below the diaphragm. The area was divided at this point. A 26-mm graft was then sutured in place with running 3-0 Prolene suture. The graft was brought into the diaphragm. Clamps were then placed on the iliacs, and the pump was shut off. The aorta was opened longitudinally, going posterior between the left and right renal arteries, and it was completely transected at its bifurcation. The SMA, celiac and right renal artery were then dissected free as a complete island, and the left renal was dissected free as a complete Carrell patch. The island was laid in the graft for the visceral liner, and it was sutured in place with running 4-0 Prolene suture with pledgetted 4-0 Prolene sutures around the circumference. The clamp was then moved below the visceral vessels, and the clamp on the chest was removed, re-establishing flow to the visceral vessels. The graft was cut to fit the bifurcation and sutured in place with running 3-0 Prolene suture. All clamps were removed, and flow was re-established. An 8-mm graft was sutured end-to-end to the Carrell patch and to the left renal. A partial-occlusion clamp was placed. An area of graft was removed. The end of the graft was cut to fit this and sutured in place with running Prolene suture. The partial-occlusion clamp was removed. Protamine was given. Good hemostasis was noted. The arterial cannula, of course, had been removed when that part of the aneurysm was removed. The venous cannula was removed and oversewn with a 4-0 Prolene suture. Good hemostasis was noted. A 36 French posterior and a 32 French anterior chest tube were placed. The ribs were closed with figure-of-eight #2 Vicryl. The fascial layer was closed with running #1 Prolene, subcu with running 2-0 Dexon and the skin with running 4-0 Dexon subcuticular stitch. Patient tolerated the procedure well.

HISTORY OF PRESENT ILLNESS: , I was kindly asked to see this patient for transesophageal echocardiogram performance by Dr. A and Neurology. Please see also my cardiovascular consultation dictated separately. But essentially, this is a pleasant 72-year-old woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. She has been recommended for a transesophageal echocardiogram for cardioembolic source of her CNS insult.,I discussed the procedure in detail with the patient as well as with her daughter, who was present at the patient's bedside with the patient's verbal consent. I then performed a risk/benefit/alternative analysis with benefits being more definitive exclusion of intracardiac thrombus as well as assessment for intracardiac shunts; alternatives being transthoracic echo imaging, which she had already had, with an inherent false negativity for this indication as well as empiric medical management, which the patient was not interested in; risks including, but not limited to, and the patient was aware this was not an all-inclusive list, of oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, risk of oropharyngeal, esophageal, oral, tracheal, pulmonary and/or gastric perforation, hemorrhage, or tear. The patient expressed understanding of this risk/benefit/alternative analysis, had the opportunity to ask questions, which I invited from her and her daughter, all of which were answered to their self-stated satisfaction. The patient then stated in a clear competent and coherent fashion that she wished to go forward with the transesophageal echocardiogram.,PROCEDURE: , The appropriate time-out procedure was performed as per Medical Center protocol under my direct supervision with appropriate identification of the patient, position, physician, procedure documentation; there were no safety issues identified by staff nor myself. She received 20 cc of viscous lidocaine for topical oral anesthetic effect. She received a total of 4 mg of Versed and 100 micrograms of fentanyl utilizing titrated conscious sedation with continuous hemodynamic and oximetric monitoring with reasonable effect. The multi-plane probe was passed using digital guidance for several passes, after an oral bite block had been put into place for protection of oral dentition. This was placed into the posterior oropharynx and advanced into the esophagus, then advanced into the stomach and then rotated and withdrawn and removed with adequate imaging obtained throughout. She was recovered as per the Medical Center conscious sedation protocol, and there were no apparent complications of the procedure.,FINDINGS: , Normal left ventricular size and systolic function. LVEF of 60%. Mild left atrial enlargement. Normal right atrial size. Normal right ventricular size and systolic function. No left ventricular wall motion abnormalities identified. The four pulmonary veins are identified. The left atrial appendage is interrogated, including with Doppler and color flow, and while there is good to-and-fro motion seen, echo smoke is seen, and in fact, an intracardiac thrombus is identified and circumscribed at 1.83 cm in circumference at the base of the left atrial appendage. No intracardiac vegetations nor endocarditis seen on any of the intracardiac valves. The mitral valve is seen. There is mild mitral regurgitation with two jets. No mitral stenosis. Four pulmonary veins were identified without reversible pulmonary venous flow. There are three cusps of the aortic valve seen. No aortic stenosis. There is trace aortic insufficiency. There is trace pulmonic insufficiency. The pulmonary artery is seen and is within normal limits. There is trace to mild tricuspid regurgitation. Unable to estimate PA systolic pressure accurately; however, on the recent transthoracic echocardiogram (which I would direct the reader to) on January 5, 2010, RVSP was calculated at 40 mmHg on that study. E wave velocity on average is 0.95 m/sec with a deceleration time of 232 milliseconds. The proximal aorta is within normal limits, annulus 1.19 cm, sinuses of Valsalva 2.54 cm, ascending aorta 2.61 cm. The intra-atrial septum is identified as are the SVC and IVC, and these are within normal limits. The intra-atrial septum is interrogated with color flow as well as agitated D5W and there is no evidence of intracardiac shunting, including no atrial septal defect nor patent foramen ovale. No pericardial effusion. There is mild nonmobile descending aortic atherosclerosis seen.,IMPRESSION:,1. Normal left ventricular size and systolic function. Left ventricular ejection fraction visually estimated at 60% without regional wall motion abnormalities.,2. Mild left atrial enlargement.,3. Intracardiac thrombus identified at the base of the left atrial appendage.,4. Mild mitral regurgitation with two jets.,5. Mild nonmobile descending aortic atherosclerosis.,Compared to the transthoracic echocardiogram done previously, other than identification of the intracardiac thrombus, other findings appear quite similar.,These results have been discussed with Dr. A of inpatient Internal Medicine service as well as the patient, who was recovering from conscious sedation, and her daughter with the patient's verbal consent.

EXAM: , CT abdomen without contrast and pelvis without contrast, reconstruction.,REASON FOR EXAM: , Right lower quadrant pain, rule out appendicitis.,TECHNIQUE: ,Noncontrast CT abdomen and pelvis. An intravenous line could not be obtained for the use of intravenous contrast material.,FINDINGS: , The appendix is normal. There is a moderate amount of stool throughout the colon. There is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process. Examination of the extreme lung bases appear clear, no pleural effusions. The visualized portions of the liver, spleen, adrenal glands, and pancreas appear normal given the lack of contrast. There is a small hiatal hernia. There is no intrarenal stone or evidence of obstruction bilaterally. There is a questionable vague region of low density in the left anterior mid pole region, this may indicate a tiny cyst, but it is not well seen given the lack of contrast. This can be correlated with a followup ultrasound if necessary. The gallbladder has been resected. There is no abdominal free fluid or pathologic adenopathy. There is abdominal atherosclerosis without evidence of an aneurysm.,Dedicated scans of the pelvis disclosed phleboliths, but no free fluid or adenopathy. There are surgical clips present. There is a tiny airdrop within the bladder. If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.,IMPRESSION:,1.Normal appendix.,2.Moderate stool throughout the colon.,3.No intrarenal stones.,4.Tiny airdrop within the bladder. If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection. The report was faxed upon dictation.

REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion. Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month. The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m. At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements. Her daughter called 911 and her symptoms seemed to improve. Then, she began vomiting. When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI. I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG. She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free. Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer. In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage. We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion. She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1. Amiodarone 200 mg once a day.,2. Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES: ,CODEINE. NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes. She uses alcohol. No use of illicit drugs. She is divorced and lives with her daughter. She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS: ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22. O2 saturation 100%. On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization. HEENT shows the cranium is normocephalic and atraumatic. She has dry mucosal membrane. She now has a right facial droop, which per her daughter is new. Neck veins are not distended. No carotid bruits visible. Skin: Warm, well perfused. Lungs are clear to auscultation anteriorly. No wheezes. Cardiac exam: S1, S2, regular rate. No significant murmurs. PMI is nondisplaced. Abdomen: Soft, nondistended. Extremities: Without edema, on limited exam. Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above. Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds. Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized. I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1. I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2. Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3. Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service. I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.

HISTORY: , Coronary artery disease.,TECHNIQUE AND FINDINGS: ,Calcium scoring and coronary artery CTA with cardiac function was performed on Siemens dual-source CT scanner with postprocessing on Vitrea workstation. Patient received oral Metoprolol 100 milligrams. 100 ml Ultravist 370 was utilized as the contrast agent. 0.4 milligrams of nitroglycerin was given.,Patient's calcium score 164, volume 205; this places the patient between the 75th and 90th percentile for age. There is at least moderate atherosclerotic plaque with mild coronary artery disease and significant narrowings possible.,Cardiac wall motion was within normal limits. Left ventricular ejection fraction calculated to be 82%. End-diastolic volume 98 mL, end-systolic volume calculated to be 18 mL.,There is normal coronary artery origins. There is codominance between the right coronary artery and the circumflex artery. There is mild to moderate stenosis of the proximal LAD with mixed plaque. Mild stenosis mid LAD with mixed plaque. No stenosis. Distal LAD with the distal vessel becoming diminutive in size. Right coronary artery shows mild stenosis proximally and in the midportion due to calcified focal plaque. Once again the distal vessel becomes diminutive in size. Circumflex shows mild stenosis due to focal calcified plaque proximally. No stenosis is seen involving the mid or distal circumflex. The distal circumflex also becomes diminutive in size. The left main shows small amount of focal calcified plaque without stenosis. Myocardium, pericardium and wall motion was unremarkable as seen.,IMPRESSION:,1. Atherosclerotic coronary artery disease with values as above. There are areas of stenosis most pronounced in the LAD with mild to moderate change and mild stenosis involving the circumflex and right coronary artery.,2. Consider cardiology consult and further evaluation if clinically indicated.,3. Full report was sent to the PACS. Report will be mailed to Dr. ABC.

HISTORY:, The patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves. Symptoms worsened considerable about a month ago. This normally occurs after being on her feet for any length of time. She was started on amitriptyline and this has significantly improved her symptoms. She is almost asymptomatic at present. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness.,On brief examination, straight leg raising is normal. The patient is obese. There is mild decreased vibration and light touch in distal lower extremities. Strength is full and symmetric. Deep tendon reflexes at the knees are 2+ and symmetric and absent at the ankles.,NERVE CONDUCTION STUDIES: , Bilateral sural sensory responses are absent. Bilateral superficial sensory responses are present, but mildly reduced. The right radial sensory response is normal. The right common peroneal and tibial motor responses are normal. Bilateral H-reflexes are absent.,NEEDLE EMG:, Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle. It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle. Lumbar paraspinals were attempted, but were too painful to get a good assessment.,IMPRESSION: ,This electrical study is abnormal. It reveals the following:,1. A very mild, purely sensory length-dependent peripheral neuropathy.,2. Mild bilateral L5 nerve root irritation. There is no evidence of active radiculopathy.,Based on the patient's history and exam, her new symptoms are consistent with mild bilateral L5 radiculopathies. Symptoms have almost completely resolved over the last month since starting Elavil. I would recommend MRI of the lumbosacral spine if symptoms return. With respect to the mild neuropathy, this is probably related to her mild glucose intolerance/early diabetes. However, I would recommend a workup for other causes to include the following: Fasting blood sugar, HbA1c, ESR, RPR, TSH, B12, serum protein electrophoresis and Lyme titer.

PROBLEM: ,Prescription evaluation for Crohn's disease., ,HISTORY: , This is a 46-year-old male who is here for a refill of Imuran. He is taking it at a dose of 100 mg per day. He is status post resection of the terminal ileum and has experienced intermittent obstructive symptoms for the past several years. In fact, he had an episode three weeks ago in which he was seen at the emergency room after experiencing sudden onset of abdominal pain and vomiting. An x-ray was performed, which showed no signs of obstruction per his report. He thinks that the inciting factor of this incident was too many grapes eaten the day before. He has had similar symptoms suggestive of obstruction when eating oranges or other high-residue fruits in the past. The patient's normal bowel pattern is loose stools and this is unchanged recently. He has not had any rectal bleeding. He asks today about a rope-like vein on his anterior right arm that has been a little tender and enlarged after he was in the emergency room and they had difficulty with IV insertion. He has not had any fever, red streaking up the arm, or enlargement of lymph nodes. The tenderness has now completely resolved. , ,He had a colonoscopy performed in August of 2003, by Dr. S. An anastomotic stricture was found at the terminal ileum/cecum junction. Dr. S recommended that if the patient experienced crampy abdominal pain or other symptoms of obstruction, that he may consider balloon dilation. No active Crohn's disease was found during the colonoscopy. , ,Earlier this year, he experienced a non-specific hepatitis with elevation of his liver function tests. At that time he was taking a lot of Tylenol for migraine-type headaches. Under Dr. S's recommendation, he stopped the Imuran for one month and reduced his dose of Tylenol. Since that time his liver enzymes have normalized and he has restarted the Imuran with no problems. , ,He also reports heartburn that is occurring on a slightly more frequent basis than it has in the past. It used to occur once a week only, but has now increased in frequency to twice a week. He takes over-the-counter H2 blockers as needed, as well as Tums. He associates the onset of his symptoms with eating spicy Mexican food., ,PAST MEDICAL HISTORY: , Reviewed and unchanged.,ALLERGIES: , No known allergies to medications.,OPERATIONS: , Unchanged.,ILLNESSES: , Crohn's disease, vitamin B12 deficiency.,MEDICATIONS:, Imuran, Nascobal, Vicodin p.r.n., ,REVIEW OF SYSTEMS: , Dated 08/04/04 is reviewed and noted. Please see pertinent GI issues as discussed above. Otherwise unremarkable., ,PHYSICAL EXAMINATION: , GENERAL: Pleasant male in no acute distress. Well nourished and well developed. SKIN: indurated, cord-like superficial vein on the right anterior forearm, approx. 3 cm in length. Non-tender to palpation. No erythema or red streaking. No edema. LYMPH: No epitrochlear or axillary lymph node enlargement or tenderness on the right side. , ,DATA REVIEWED: Labs from June 8th and July 19th reviewed. Liver function tests normal with AST 14 and ALT 44. WBCs were slightly low at 4.8. Hemoglobin dropped slightly from 14.1 on 6/8 to 12.9 on 7/19. Hematocrit dropped slightly as well from 43.2 on 6/804 to 40.0 on 7/19/04. These results were reviewed by Dr. S and lab results letter sent., ,IMPRESSION: ,1. Crohn's disease, status post terminal ileum resection, on Imuran. Intermittent symptoms of bowel obstruction. Last episode three weeks ago.,2. History of non-specific hepatitis while taking high doses of Tylenol. Now resolved. ,2. Increased frequency of reflux symptoms.,3. Superficial thrombophlebitis, resolving. ,4. Slightly low H&H., ,PLAN: ,1. We discussed Dr. S's recommendation that the patient undergo balloon dilation for recurrent bowel obstruction type symptoms. The patient emphatically states that he does not want to consider dilation at this time. The patient is strongly encouraged to call us when he does experience any obstructive symptoms, including abdominal pain, nausea, vomiting, or change in bowel habits. He states understanding of this. Advised to maintain low residue diet to avoid obstructions. ,2. Continue with liver panel and ABC every month per Dr. S's instructions.,3. Continue Imuran 100 mg per day.,4. Continue to minimize Tylenol use. The patient is wondering if he can take another type of medication for migraines that is not Tylenol or antiinflammatories or aspirin. Dr. S is consulted and agrees that Imitrex is an acceptable alternative for migraine headaches since he does not have advanced liver disease. The patient will make an appointment with his primary care provider to discuss this further. ,5. Reviewed the importance of prophylactic treatment of reflux-type symptoms. Encouraged the patient to take over-the-counter H2 blockers on a daily basis to prevent symptoms from occurring. The patient will try this and if he remains symptomatic, then he will call our office and a prescription for Zantac 150 mg per day will be provided. Reviewed the potential need for upper endoscopy should his symptoms continue or become more frequent. He does not want to undergo any type of procedure such as that at this time.,6.

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

PREOPERATIVE DIAGNOSIS: , Brain tumors, multiple.,POSTOPERATIVE DIAGNOSES:, Brain tumors multiple - adenocarcinoma and metastasis from breast.,PROCEDURE:, Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.,PROCEDURE:, The patient was placed in the prone position after general endotracheal anesthesia was administered. The scalp was prepped and draped in the usual fashion. The CUSA was brought in to supplement the use of operating microscope as well as the stealth, which was used to localize the tumor. Following this, we then made a transverse linear incision, the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor. The bone flap was elevated. The ultrasound was then used. The ultrasound showed the tumors directly I believe are in the interhemispheric fissure. We noticed that the dura was quite tense despite that the patient had slight hyperventilation. We gave 4 ounce of mannitol, the brain became more pulsatile. We then used the stealth to perform a ventriculostomy. Once this was done, the brain began to pulsate nicely. We then entered the interhemispheric space after we incised the dura in an inverted U fashion based on the superior side of the sinus. After having done this we then used operating microscope and slight self-retaining retraction was used. We obtained access to the tumor. We biopsied this and submitted it. This was returned as a malignant brain tumor - metastatic tumor, adenocarcinoma compatible with breast cancer.,Following this we then debulked this tumor using CUSA and then removed it in total. After gross total removal of this tumor, the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery. The next step was after removal of this tumor, closure of the wound, a large piece of Duragen was placed over the dural defect and the bone flap was reapproximated and held secured with Lorenz plates. The tumors self extend into the ventricle and after we had removed the tumor, we could see our ventricular catheter in the occipital horn of the ventricle. This being the case, we left this ventricular catheter in, brought it out through a separate incision and connected to sterile drainage. The next step was to close the wound after reapproximating the bone flap. The galea was closed with 2-0 Vicryl and the skin was closed with interrupted 3-0 nylon sutures inverted with mattress sutures. The sterile dressings were applied to the scalp. The patient returned to the recovery room in satisfactory condition. Hemodynamically remained stable throughout the operation.,Once again, we performed occipital craniotomy, total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy. The tumor was removed using the combination of CUSA, ultrasound, stealth guided-ventriculostomy and the patient will have a second operation today, we will perform a selective craniectomy to remove another large tumor in the posterior fossa.

CHIEF COMPLAINT: , Blood in urine.,HISTORY OF PRESENT ILLNESS: ,This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder. The patient has had problems with hematuria in the past, but the patient noted that this episode began yesterday, and today he has been passing principally blood with very little urine. The patient states that there is no change in his chronic lower back pain and denies any incontinence of urine or stool. The patient has not had any fever. There is no abdominal pain and the patient is still able to pass urine. The patient has not had any melena or hematochezia. There is no nausea or vomiting. The patient has already completed chemotherapy and is beyond treatment for his cancer at this time. The patient is receiving radiation therapy, but it is targeted to the bones and intended to give symptomatic relief of his skeletal pain and not intended to treat and cure the cancer. The patient is not enlisted in hospice, but the principle around the patient's current treatment management is focusing on comfort care measures.,REVIEW OF SYSTEMS: , CONSTITUTIONAL: No fever or chills. The patient does report generalized fatigue and weakness over the past several days. HEENT: No headache, no neck pain, no rhinorrhea, no sore throat. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath or cough, although the patient does get easily winded with exertion over these past few days. GASTROINTESTINAL: The patient denies any abdominal pain. No nausea or vomiting. No changes in the bowel movement. No melena or hematochezia. GENITOURINARY: A gross hematuria since yesterday as previously described. The patient is still able to pass urine without difficulty. The patient denies any groin pain. The patient denies any other changes to the genital region. MUSCULOSKELETAL: The chronic lower back pain which has not changed over these past few days. The patient does have multiple other joints, which cause him discomfort, but there have been no recent changes in these either. SKIN: No rashes or lesions. No easy bruising. NEUROLOGIC: No focal weakness or numbness. No incontinence of urine or stool. No saddle paresthesia. No dizziness, syncope or near-syncope. ENDOCRINE: No polyuria or polydipsia. No heat or cold intolerance. HEMATOLOGIC/LYMPHATIC: The patient does not have a history of easy bruising or bleeding, but the patient has had previous episodes of hematuria.,PAST MEDICAL HISTORY: , Prostate cancer with metastatic disease as previously described.,PAST SURGICAL HISTORY: , TURP.,CURRENT MEDICATIONS:, Morphine, Darvocet, Flomax, Avodart and ibuprofen.,ALLERGIES: , VICODIN.,SOCIAL HISTORY: , The patient is a nonsmoker. Denies any alcohol or illicit drug use. The patient does live with his family.,PHYSICAL EXAMINATION: , VITAL SIGNS: Temperature is 98.8 oral, blood pressure is 108/65, pulse is 109, respirations 16, oxygen saturation is 97% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished, well developed. The patient appears to be pale, but otherwise looks well. The patient is calm, comfortable. The patient is pleasant and cooperative. HEENT: Eyes normal with clear conjunctivae and corneas. Nose is normal without rhinorrhea or audible congestion. Mouth and oropharynx normal without any sign of infection. Mucous membranes are moist. NECK: Supple. Full range of motion. No JVD. CARDIOVASCULAR: Heart is mildly tachycardic with regular rhythm without murmur, rub or gallop. Peripheral pulses are +2. RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. No wheezes, rales or rhonchi. Good air movement bilaterally. GASTROINTESTINAL: Abdomen is soft, nontender, nondistended. No rebound or guarding. No hepatosplenomegaly. Normal bowel sounds. No bruit. No masses or pulsatile masses. GENITOURINARY: The patient has normal male genitalia, uncircumcised. There is no active bleeding from the penis at this time. There is no swelling of the testicles. There are no masses palpated to the testicles, scrotum or the penis. There are no lesions or rashes noted. There is no inguinal lymphadenopathy. Normal male exam. MUSCULOSKELETAL: Back is normal and nontender. There are no abnormalities noted to the arms or legs. The patient has normal use of the extremities. SKIN: The patient appears to be pale, but otherwise the skin is normal. There are no rashes or lesions. NEUROLOGIC: Motor and sensory are intact to the extremities. The patient has normal speech. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: There is no evidence of bruising noted to the body. No lymphadenitis is palpated.,EMERGENCY DEPARTMENT TESTING:, CBC was done, which had a hemoglobin of 7.7 and hematocrit of 22.6. Neutrophils were 81%. The RDW was 18.5, and the rest of the values were all within normal limits and unremarkable. Chemistry had a sodium of 134, a glucose of 132, calcium is 8.2, and rest of the values are unremarkable. Alkaline phosphatase was 770 and albumin was 2.4. Rest of the values all are within normal limits of the LFTs. Urinalysis was grossly bloody with a large amount of blood and greater than 50 rbc's. The patient also had greater than 300 of the protein reading, moderate leukocytes, 30-50 white blood cells, but no bacteria were seen. Coagulation profile study had a PT of 15.9, PTT of 43 and INR of 1.3.,EMERGENCY DEPARTMENT COURSE: , The patient was given normal saline 2 liters over 1 hour without any adverse effect. The patient was given multiple doses of morphine to maintain his comfort while here in the emergency room without any adverse effect. The patient was given Levaquin 500 mg by mouth as well as 2 doses of Phenergan over the course of his stay here in the emergency department. The patient did not have an adverse reaction to these medicines either. Phenergan resolved his nausea and morphine did relieve his pain and make him pain free. I spoke with Dr. X, the patient's urologist, about most appropriate step for the patient, and Dr. X said he would be happy to care for the patient in the hospital and do urologic scopes if necessary and surgery if necessary and blood transfusion. It was all a matter of what the patient wished to do given the advanced stage of his cancer. Dr. X was willing to assist in any way the patient wished him to. I spoke with the patient and his son about what he would like to do and what the options were from doing nothing from keeping him comfortable with pain medicines to admitting him to the hospital with the possibility of scopes and even surgery being done as well as the blood transfusion. The patient decided to choose a middle ground in which he would be transfused with 2 units of blood here in the emergency room and go home tonight. The patient's son felt comfortable with his father's choice. This was done. The patient was transfused 2 units of packed red blood cells after appropriately typed and match. The patient did not have any adverse reaction at any point with his transfusion. There was no fever, no shortness of breath, and at the time of disposition, the patient stated he felt a little better and felt like he had a little more strength. Over the course of the patient's several-hour stay in the emergency room, the patient did end up developing enough problems with clotted blood in his bladder that he had a urinary obstruction. Foley catheter was placed, which produced bloody urine and relieved the developing discomfort of a full bladder. The patient was given a leg bag and the Foley catheter was left in place.,DIAGNOSES,1. HEMATURIA.,2. PROSTATE CANCER WITH BONE AND BLADDER METASTATIC DISEASE.,3. SIGNIFICANT ANEMIA.,4. URINARY OBSTRUCTION.,CONDITION ON DISPOSITION: ,Fair, but improved.,DISPOSITION: , To home with his son.,PLAN: , We will have the patient follow up with Dr. X in his office in 2 days for reevaluation. The patient was given a prescription for Levaquin and Phenergan tablets to take home with him tonight. The patient was encouraged to drink extra water. The patient was given discharge instructions on hematuria and asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern.

PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE:, Stable, extubated, and transferred to the recovery room in stable condition.,INDICATIONS FOR PROCEDURE: ,The patient is a 10-month-old baby with a history of a bilateral cleft of the lip and palate. The patient has undergone cleft lip repair, and she is here today for her cleft palate operation. We have discussed with the mother the nature of the procedure, risks, and benefits; the risks included but not limited to the risk of bleeding, infection, dehiscence, scarring, the need for future revision surgeries. We will proceed with surgery.,DETAILS OF THE PROCEDURE:, The patient was taken into the operating room, placed in the supine position, and general anesthetic was administered. A prophylactic dose of antibiotics was given. The patient proceeded to have bilateral PE tube placement by Dr. X, from Ear, Nose, and Throat Surgery. After he was done with his procedure, the head of the bed was turned 90 degrees. The patient was positioned with a shoulder roll and doughnut. A Dingman retractor was placed. The operative area was infiltrated with lidocaine with epinephrine 1:200,000, a total of 3 mL, and then, I proceeded with the prepping and draping. The patient was prepped and draped. I proceeded to do the palate repair. The nature of the palate repair was done in the same way on the both sides. I will describe one side. The other side was done exactly in the same manner. The 2 hemiuvulas are placed, holding from a single hook and infiltrated with lidocaine with epinephrine 1:200,000, triangle in the nasal mucosa was previously marked. This triangle of nasal mucosa was removed and excised. This was done on both uvulas. Then, an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa. A 1-mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better. Once the incision was done up to the level of the hard palate, the muscle was dissected off the surrounding tissue, 2 mm from the nasal and the oral mucosa. Then, I proceeded to place an incision at the alveolopalatal junction with the help of 15-blade. The incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap. Then the flap was lifted up with the help of a freer, and then the remaining of the incision medially was completed. Hemostasis was achieved with help of electrocautery and Surgicel. The mucoperiosteal flap was retracted posteriorly with the help of a freer elevator. The greater auricular foramen was exposed, and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap. Then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle. The pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially. This procedure was done on both sides in the same manner, and then __________ dissection was done including dissection of the hard palate from the nasal mucosa, it was evident that the nasal mucosa would not reach medially to be placed together. At this point, the decision was made to proceed with vomer flaps. The flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book. The incision was done with a 15C blade. The vomer flaps were dissected, and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate. This was approximated on both sides with 5-0 chromic running and interrupted stitches, and I proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5-0 chromic and a 4-0 chromic. Then 2 stitches of 4-0 Vicryl were applied to the soft palate in the Delaire manner through the full thickness of the mucosa and muscle on one side, on the other side, and then coming back on the mucosa to evert the edges of the soft palate. The remaining part of the soft palate was placed together with 4-0 Vicryl and 4-0 chromic interrupted stitches. The throat pack was removed. The palate was cleaned. The Dingman retractor was removed, and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2-0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of Tegaderm. The patient tolerated the procedure without complications. BSS is applied to the eye after removing the Tegaderm. I was present and participated in all aspects of the procedure. The sponge, needle, and instrument count were completed at the end of the procedure. The patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition.

CHIEF COMPLAINT: , Testicular pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 4-year-old boy with a history of abrupt onset of left testicular pain at 11:30 this morning. He was unable to walk and would not stand upright, and had fairly significant discomfort, so the parents checked his panel because of it. Because of this, they took him to Emergency Department, at which time, he had no swelling noted initially, but very painful. He had no voiding or stooling problems. No nausea, vomiting or fever. Family denies trauma or dysuria. At that time, he was going to get an ultrasound done, but the mother said that all of sudden the patient stated the pain had resolved. He has had hot chocolate this morning at 10:30 in the morning and water around 2:30 in the morning. He has not had any pain since but states that he has had pain in the past, not as long and states there was a twisting sensation. He has no recent cold or flu, although he had rhinorrhea about 3 weeks ago. He is on no medications and he is here for evaluation.,PAST MEDICAL HISTORY:, The patient has no known allergies. He is term delivery via spontaneous vaginal delivery. He has had no problems or hospitalizations with circumcision.,PAST SURGICAL HISTORY: , He has had no previous surgeries.,REVIEW OF SYSTEMS:, All 14-point review of systems were negative except for the above left testicular pain and the history of possible upper respiratory infection about 2 to 3 weeks ago.,IMMUNIZATIONS: , Up-to-date.,FAMILY HISTORY: , The patient lives at home with both parents who are Spanish speaking. He is not in school.,MEDICATIONS:, He is on no medications.,PHYSICAL EXAMINATION:,VITAL SIGNS: On physical exam, weight is 15.9 kg.,GENERAL: The patient is a cooperative little boy.,HEENT: Normal head and neck exam. No oral or nasal discharge.,NECK: Without masses.,CHEST: Without masses.,LUNGS: Clear.,CARDIAC: Without murmurs or gallops.,ABDOMEN: Soft. No masses or tenderness. His scrotum did not have any swelling at the present time. There was only minimal discomfort with palpation at the left inguinal area, but no masses were noted. No palpable nodules such as appendix testis and no swelling was noted and he had mild epididymal swelling only. His left testis was slightly harder than the right, but this was not very significant.,EXTREMITIES: He had full range of motion in all 4 extremities.,SKIN: Warm, pink, and dry.,NEUROLOGIC: Grossly intact.,LABORATORY DATA: , Ultrasound was obtained today showing no blood flow or poor blood flow on the left except for increased blood flow to the epididymis on the study done at about 1330 hours, and second one done around 1630 hours was normal flow, possible increased flow on the left. This is personally reviewed by me. The right was normal. No masses were appreciated. There was some mild change in echotexture on the left on the initial study, which had apparently resolved on the second, but may be due to the technical aspects of the study.,ASSESSMENT/PLAN: , The patient has a possibly torsion detorsion versus other acute testicular problem. If the patient has indeed testicular torsion, there is an increased possibility that it may reoccur again, actually within the first 24 to 36 hours and as such is recommended doing a left scrotal exploration with possible detorsion of left testis, possible orchiectomy if the testis is markedly abnormal or nonviable, which probably is not the case, and bilateral testes fixation if the torsion is found. I discussed the pre and postsurgical care with the parents. Procedure itself with potential complications, risks, benefits, and alternatives of surgery including that the torsion could occur again, although it is less likely after the surgical fixation procedure. The parents understand and wished to proceed. We will schedule this later today emergently.

PREOPERATIVE DIAGNOSIS: , History of polyps.,POSTOPERATIVE DIAGNOSES:,1. Normal colonoscopy, left colonic diverticular disease.,2. 3+ benign prostatic hypertrophy.,PROCEDURE PERFORMED: , Total colonoscopy and photography.,GROSS FINDINGS: , This is a 74-year-old white male here for recheck colonoscopy for a history of polyps. After signed informed consent, blood pressure monitoring, EKG monitoring, and pulse oximetry monitoring, he was brought to the Endoscopic Suite. He was given 100 mg of Demerol, 3 mg of Versed IV push slowly. Digital examination revealed a large prostate for which he is following up with his urologist. No nodules. 3+ BPH. Anorectal canal was within normal limits. No stricture tumor or ulcer. The Olympus CF 20L video endoscope was inserted per anus. The anorectal canal was visualized, was normal. The sigmoid, descending, splenic, and transverse showed scattered diverticula. The hepatic, ascending, cecum, and ileocecal valve was visualized and was normal. The colonoscope was removed. The air was aspirated. The patient was discharged with high-fiber, diverticular diet. Recheck colonoscopy three years.

PREOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE PERFORMED: , Laparoscopic bilateral tubal occlusion with Hulka clips.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS: ,None.,FINDINGS: , On bimanual exam, the uterus was found to be anteverted at approximately six weeks in size. There were no adnexal masses appreciated. The vulva and perineum appeared normal. Laparoscopic findings revealed normal appearing uterus, fallopian tubes bilaterally as well as ovaries bilaterally. There was a functional cyst on the left ovary. There was filmy adhesion in the left pelvic sidewall. There were two clear lesions consistent with endometriosis, one was on the right fallopian tube and the other one was in the cul-de-sac. The uterosacrals and ovarian fossa as well as vesicouterine peritoneum were free of any endometriosis. The liver was visualized and appeared normal. The spleen was also visualized.,INDICATIONS: , This patient is a 34-year-old gravida 4, para-4-0-0-4 Caucasian female who desires permanent sterilization. She recently had a spontaneous vaginal delivery in June and her family planning is complete.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed under general anesthesia. She was then prepped and draped and placed in the dorsal lithotomy position. A bimanual exam was performed and the above findings were noted. Prior to beginning the procedure, her bladder was drained with a red Robinson catheter. A weighted speculum was placed in the patient's posterior vagina and the 12 o' clock position of the cervix was grasped with a single-toothed tenaculum. The cervix was dilated so that the uterine elevator could be placed. Gloves were exchanged and attention was then turned to the anterior abdominal wall where the skin at the umbilicus was everted and using the towel clips, a 1 cm infraumbilical skin incision was made. The Veress needle was then inserted and using sterile saline ______ the pelvic cavity. The abdomen was then insufflated with appropriate volume and flow of CO2. The #11 bladed trocar was then placed and intraabdominal placement was confirmed with the laparoscope. A second skin incision was made approximately 2 cm above the pubic symphysis and under direct visualization, a 7 mm bladed trocar was placed without difficulty. Using the Hulka clip applicator, the left fallopian tube was identified, followed out to its fimbriated end and the Hulka clip was then placed snugly against the uterus across the entire diameter of the fallopian tube. A second Hulka clip was then placed across the entire diameter just proximal to this. There was good hemostasis at the fallopian tube. The right fallopian tube was then identified and followed out to its fimbriated end and the Hulka clip was placed. snugly against the uterus across the entire portion of the fallopian tube in a 90 degree angle. A second Hulka clip was placed just distal to this again across the entire diameter. Good hemostasis was obtained. At this point, the abdomen was desufflated and after it was desufflated, the suprapubic port site was visualized and found to be hemostatic. The laparoscope and remaining trocars were then removed with good visualization of the peritoneum and fascia and the laparoscope was removed. The umbilical incision was then closed with two interrupted #4-0 undyed Vicryl. The suprapubic incision was then closed with Steri-Strips. The uterine elevator was removed and the single-toothed tenaculum site was found to be hemostatic. The patient tolerated that procedure well. The sponge, lap, and needle counts were correct x2. She will follow up postoperatively for followup care.

HISTORY OF PRESENT ILLNESS: , Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first emerged. He, since 10:17 p.m. on 01/17/10, noted recurrence of his atrial fibrillation, called our office this morning, that is despite being on flecainide, atenolol, and he is maintained on Coumadin.,The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred and we see that on his 12-lead EKG here. Otherwise, no chest pain.,PAST MEDICAL HISTORY: , Significant for atrial fibrillation/atrial flutter and again he had atrial fibrillation more persistently in 2006, but more recently it has been atrial flutter and that is despite use of antiarrhythmics including flecainide. He completed a stress test in my office within the past several weeks that was normal without evidence of ischemia. Other medical history is significant for hyperlipidemia.,MEDICATIONS:,As outpatient,,1. Atenolol 25 mg once a day.,2. Altace 2.5 mg once a day.,3. Zocor 20 mg once a day.,4. Flecainide 200 in the morning and 100 in the evening.,5. Coumadin as directed by our office.,ALLERGIES: , TO MEDICATIONS ARE NONE. HE DENIES SHRIMP, SEA FOOD OR DYE ALLERGY.,FAMILY HISTORY: , He has a nephew who was his sister's son who passed away at age 22 reportedly from an MI, but was reported to have hypertrophic cardiomyopathy as well. The patient has previously met with the electrophysiologist, Dr. X, at General Hospital and it sounds like he had a negative EP study.,SOCIAL HISTORY: , The patient does not smoke cigarettes, abuse alcohol nor drink any caffeine. No use of illicit drugs. He has been married for 22 years and he is actually accompanied throughout today's cardiology consultation by his wife. He is not participating in regular exercises now because he states since starting flecainide, he has gotten sluggish. He is employed as an attorney and while he states that overall his mental stress is better, he has noted more recent mental stress this past weekend when he was taking his daughter back to college.,REVIEW OF SYSTEMS: , He denies any history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi. There are some questions especially as his wife has told me that he may have obstructive sleep apnea and not had a formal sleep study.,PHYSICAL EXAM: , Blood pressure 156/93, pulse is 100, respiratory rate 18. On general exam, he is a pleasant overweight gentleman, in no acute distress. HEENT: Shows cranium is normocephalic and atraumatic. He has moist mucosal membranes. Neck veins are not distended. There are no carotid bruits. Visible skin warm and perfused. Affect appropriate. He is quite oriented and pleasant. No significant kyphoscoliosis on recumbent back exam. Lungs are clear to auscultation anteriorly. No wheezes. No egophony. Cardiac Exam: S1, S2. Regular rate, controlled. No significant murmurs, rubs or gallops. PMI is nondisplaced. Abdomen is soft, nondistended, appears benign. Extremities without significant edema. Pulses grossly intact.,DIAGNOSTIC STUDIES/LAB DATA:, Initial ECG shows atrial flutter.,IMPRESSION: , Mr. A is a 50-year-old gentleman with a history of paroxysmal atrial fibrillation in the past, more recently is having breakthrough atrial flutter despite flecainide and we had performed a transesophageal echocardiogram-guided cardioversion for him in late 12/20/09, who now has another recurrence within the past 41 hours or so. I have reviewed again with him in detail regarding risks, benefits, and alternatives of proceeding with cardioversion, which the patient is in favor of. After in depth explanation of the procedure with him that there would be more definitive resumption of normal sinus rhythm by using electrocardioversion with less long-term side effects, past the acute procedure, alternatives being continued atrial flutter with potential for electrophysiologic consultation for ablation and/or heart rate control with anticoagulation, which the patient was not interested nor was I primarily recommending as the next step, and risks including, but not limited to and the patient was aware and this was all done in the presence of his wife that this is not an all-inclusive list, but the risks include but not limited to oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, which would be less likely as I did confirm with the patient that he had been n.p.o. for greater than 15 hours, risk of induction of other arrhythmias including tachyarrhythmias requiring further management including cardioversion or risk of bradyarrhythmias, in the past when we had a cardioverter with 150 joules, he did have a 5.5-second pause especially while he is on antiarrhythmic therapy, statistically less significant risk of CVA, although we cannot really make that null. The patient expressed understanding of this risk, benefit, and alternative analysis. I invited questions from him and his wife and once their questions were answered to their self-stated satisfaction, we planned to go forward with the procedure.,PROCEDURE NOTE: ,The patient received a total of 7 mg of Versed and 50 micrograms of fentanyl utilizing titrate-down sedation with good effect and this was after the appropriate time-out procedure had been done as per the Medical Center universal protocol with appropriate identification of the patient, position, procedure documentation, procedure indication, and there were no questions. The patient did actively participate in this time-out procedure. After the universal protocol was done, he then received the cardioversion attempt with 50 joules using "lollipop posterior patch" with hands-driven paddle on the side, which was 50 joules of synchronized biphasic energy. There was successful resumption of normal sinus rhythm, in fact this time there was not a significant pause as compared to when he had this done previously in late 12/09 and this sinus rhythm was confirmed by a 12-lead EKG.,IMPRESSION: , Cardioversion shows successful resumption of normal sinus rhythm from atrial flutter and that is while the patient has been maintained on Coumadin and his INR is 3.22. We are going to watch him and discharge him from the Medical Center area on his current flecainide of 200 mg in the morning and 100 mg in the evening, atenolol 25 mg once a day, Coumadin _____ as currently being diagnosed. I had previously discussed with the patient and he was agreeable with meeting with his electrophysiologist again, Dr. X, at Electrophysiology Unit at General Hospital and I will be planning to place a call for Dr. X myself. Again, he has no ischemia on this most recent stress test and I suppose in the future it may be reasonable to get obstructive sleep apnea evaluation and that may be one issue promulgating his symptoms.,I had previously discussed the case with Dr. Y who is the patient's general cardiologist as well as updated his wife at the patient's bedside regarding our findings.

PROCEDURE: , Endotracheal intubation.,INDICATION: , Respiratory failure.,BRIEF HISTORY: , The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction. He has been on Coumadin for previous PE and currently on heparin drip. He became altered and subsequently deteriorated quite rapidly to the point where he is no longer breathing on his own and has minimal responsiveness. A code blue was called. On my arrival, the patient's vital signs are stable. His blood pressure is systolically in 140s and heart rate 80s. He however has 0 respiratory effort and is unresponsive to even painful stimuli. The patient was given etomidate 20 mg.,DESCRIPTION OF PROCEDURE: ,The patient positioned appropriate equipment at the bedside, given 20 mg of etomidate and 100 mg of succinylcholine. Mac-4 blade was used. A 7.5 ET tube placed to 24th teeth. There is good color change on the capnographer with bilateral breath sounds. Following intubation, the patient's blood pressure began to drop. He was given 2 L of bolus. I started him on dopamine drip at 10 mcg. Dr. X was at the bedside, who is the primary caregiver, he assumed the care of the patient, will be transferred to the ICU. Chest x-ray will be reviewed and Pulmonary will be consulted.

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.

CHIEF COMPLAINT:, Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions). One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake. His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion. He sleeps well, but has been more tired and has been fussy over the past 2 days. The parents noticed no improvement with albuterol treatments given in the ER. His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours. Mom denies any diarrhea. His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne. The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count. This tap was reported as clear, then turning bloody in nature. The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture. This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status. Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness. Mom's nipples are currently cracked and bleeding. Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area. He is status post a circumcision. Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section. Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family). GBS status was negative. Mom smoked up to the last 5 months of the pregnancy. Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions. Mom and baby were both discharged out of the hospital last 48 hours. This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:, Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, Tylenol.,IMMUNIZATIONS:, None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:, At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother. Both brothers at home are sick with cold symptoms including diarrhea and vomiting. The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription. A nephew of the mom with an ear infection. Mom also states that she herself was sick with the flu soon after delivery. There has been recent travel exposure to dad's family over the Christmas holidays. At this time, there is also exposure to indoor cats and dogs. This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker. There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION: ,VITALS: Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air. Weight was 4.1 kg.,GENERAL: Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT: Normocephalic, atraumatic head. Anterior fontanelle was soft, open, and flat. Bilateral red reflexes were positive. Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR: Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature. Capillary refill was less than 3 seconds.,LUNGS: Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN: Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly. Umbilical site was with scant dried yellow discharge.,GU: Tanner stage 1 male, circumcised. There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS: Negative Barlow or Ortolani maneuvers.,SKIN: Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes. The hemoglobin was 14.4, hematocrit was 40. The platelet count was elevated at 698,000. A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89. A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1. Rule out sepsis.,2. Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever. The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria. We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER. Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV. The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use. Also, there is negative apnea in this patient.,PLAN: ,1. We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2. We will follow up with his blood, urine, and CSF cultures.

PREOPERATIVE DIAGNOSIS:, Left supraorbital deep complex facial laceration measuring 6x2 cm.,POSTOPERATIVE DIAGNOSIS: , Left supraorbital deep complex facial laceration measuring 6x2 cm.,PROCEDURE PERFORMED: , Plastic closure of deep complex facial laceration measuring 6x2 cm.,ANESTHESIA: , Local anesthesia with 1% lidocaine with 1:100,000 epinephrine, total of 2 cc were used.,SPECIMENS: , None.,FINDINGS: , Deep complex left forehead laceration.,HISTORY: , The patient is a 23-year-old male who was intoxicated and hit with an unknown object to his forehead. The patient subjectively had loss of consciousness on the scene and minimal bleeding from the left supraorbital laceration site. He was brought to the Emergency Room, where a CAT scan of the head and facial bumps was performed, which were negative.,Prior to performing surgery informed consent was obtained from the patient who was well aware of the risks, benefits, alternatives and complications of the surgery to include infection, bleeding, cosmetic deformity, significant scarring, need for possible scar revision. The patient was allowed to ask all questions he wanted, and they were answered in a language he could understand. He wished to pursue surgery and signed the informed consent.,PROCEDURE: , The patient was placed in the supine position. The wound was copiously irrigated with normal saline on irrigating tip. After one liter of irrigation, the wound was prepped and draped in the usual sterile fashion. The incision was then localized with a solution of 1% lidocaine with 1:100,000 epinephrine, a total of less than 2 cc was used. We then reapproximated the wound in double-layered fashion with deep sutures of #5-0 Vicryl, two interrupted sutures were used, and then the skin was closed with interrupted sutures of #5-0 nylon. The wound came together very nicely. Tincture of Benzoin was placed. Steri-Strips were placed over the top and a small amount of bacitracin was placed over the Steri-Strips. The patient tolerated the procedure well with no complications.

ADMISSION DIAGNOSIS: , Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.,SECONDARY DIAGNOSIS:, Chronic pain syndrome.,PRINCIPAL PROCEDURE: , L5 Gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morphogenic protein, and pedicle fixation. This was performed by Dr. X on 01/08/08.,BRIEF HISTORY OF HOSPITAL COURSE: , The patient is a man with a history of longstanding back, buttock, and bilateral leg pain. He was evaluated and found to have bilateral pars defects at L5-S1 with spondylolysis and instability. He was admitted and underwent an uncomplicated surgical procedure as noted above. In the postoperative period, he was up and ambulatory. He was taking p.o. fluids and diet well. He was afebrile. His wounds were healing well. Subsequently, the patient was discharged home.,DISCHARGE MEDICATIONS: , Discharge medications included his usual preoperative pain medication as well as other medications.,FOLLOWUP: ,At this time, the patient will follow up with me in the office in six weeks' time. The patient understands discharge plans and is in agreement with the discharge plan. He will follow up as noted

PREOPERATIVE DIAGNOSES,1. EMG-proven left carpal tunnel syndrome.,2. Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3. Dupuytren's nodule in the palm.,POSTOPERATIVE DIAGNOSES,1. EMG-proven left carpal tunnel syndrome.,2. Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3. Dupuytren's nodule in the palm.,PROCEDURE: , Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.,ANESTHESIA: , Local plus IV sedation (MAC).,ESTIMATED BLOOD LOSS: ,Zero.,SPECIMENS: ,None.,DRAINS: , None.,PROCEDURE DETAIL: , Patient brought to the operating room. After induction of IV sedation the left hand was anesthetized suitable for carpal tunnel release; 10 cc of a mixture of 1% Xylocaine and 0.5% Marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery. Routine prep and drape was employed. Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet and tourniquet inflated to 250 mmHg pressure. Hand was positioned palm up in the lead hand-holder. A short curvilinear incision about the base of the thenar eminence was made. Skin was sharply incised. Sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin. Care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm. Proximally the antebrachial fascia was released for a distance of 2-3 cm proximal to the wrist crease to insure complete decompression of the median nerve. Retinacular flap was retracted radially to expose the contents of the carpal canal. Median nerve was identified, seen to be locally compressed with moderate erythema and mild narrowing. Locally adherent tenosynovium was present and this was carefully dissected free. Additional tenosynovium was dissected from the flexor tendons, individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal. Epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium. When this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5-0 nylon horizontal mattress sutures. A syringe with 3 cc of Kenalog-10 and 3 cc of 1% Xylocaine using a 25 gauge short needle was then selected; 1 cc of this mixture was injected into the third finger A1 and A2 pulley tendon sheaths using standard trigger finger injection technique; 1 cc was injected into the fourth finger A1/A2 pulley tendon sheath using standard tendon sheath injection technique; 1 cc was injected into the Dupuytren's nodule in the midpalm to relieve local discomfort. Routine postoperative hand dressing with well-padded, well-molded volar plaster splint and lightly compressive Ace wrap was applied. Tourniquet was deflated. Good vascular color and capillary refill were seen to return to the tips of all digits. Patient discharged to the ambulatory recovery area and from there discharged home. Discharge medication is Darvocet-N 100, 30 tablets, one to two PO q.4h. p.r.n. Patient asked to begin gentle active flexion, extension and passive nerve glide exercises beginning 24-48 hours after surgery. She was asked to keep the dressings clean, dry and intact and follow up in my office.

EXAM: , MRI of the brain without contrast.,HISTORY: , Daily headaches for 6 months in a 57-year-old.,TECHNIQUE: ,Noncontrast axial and sagittal images were acquired through the brain in varying degrees of fat and water weighting.,FINDINGS: , The brain is normal in signal intensity and morphology for age. There are no extraaxial fluid collections. There is no hydrocephalus/midline shift. Posterior fossa, 7th and 8th nerve complexes and intraorbital contents are within normal limits. The normal vascular flow volumes are maintained. The paranasal sinuses are clear.,Diffusion images demonstrate no area of abnormally restricted diffusion that suggests acute infarct.,IMPRESSION: , Normal MRI brain. Specifically, no findings to explain the patient's headaches are identified.

PROCEDURE PERFORMED: , Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification.,ANESTHESIA:, Peribulbar.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine drops. A Honan balloon was placed over the eye for a period of 20 minutes at 10 mmHg. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine. The Honan balloon was then re-placed over the eye for an additional 10 minutes at 20 mmHg. The eye was prepped with a Betadine solution and draped in the usual sterile fashion. A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade, followed by instillation of 0.1 cc of preservative-free lidocaine 1% into the anterior chamber, followed by viscoelastic. A 2.8-mm keratome was used to create a self-sealing temporal corneal incision and then a bent capsulotomy needle was used to create an anterior capsular flap. The Utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula. Phacoemulsification in a quartering-and-cracking technique was used to remove the nucleus and then the residual cortex was removed with the irrigation and aspiration unit. Gentle vacuuming of the central posterior capsule was performed. The capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size with an additional keratome to allow insertion of the intraocular lens.,The intraocular lens was folded, inserted into the capsular bag and then un-folded. The trailing haptic was tucked underneath the anterior capsular rim. The lens was shown to center very well. Therefore, the viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction. The wound was shown to be watertight. Therefore, TobraDex ointment was applied to the eye, an eye pad loosely applied and a Fox shield taped firmly in place.,The patient tolerated the procedure well and left the operating room in good condition.

PREOPERATIVE DIAGNOSIS:, Bilateral upper eyelid dermatochalasis.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE: , Bilateral upper lid blepharoplasty, (CPT 15822).,ANESTHESIA: , Lidocaine with 1:100,000 epinephrine.,DESCRIPTION OF PROCEDURE: , This 65-year-old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction. The procedure, alternatives, risks and limitations in this individual case have been very carefully discussed with the patient. All questions have been thoroughly answered, and the patient understands the surgery indicated. She has requested this corrective repair be undertaken, and a consent was signed.,The patient was brought into the operating room and placed in the supine position on the operating table. An intravenous line was started, and sedation and sedation anesthesia was administered IV after preoperative p.o. sedation. The patient was monitored for cardiac rate, blood pressure, and oxygen saturation continuously. The excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured, and the incisions were marked for fusiform excision with a marking pen. The surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally.,The upper eyelid areas were bilaterally injected with 1% Lidocaine with 1:100,000 Epinephrine for anesthesia and vasoconstriction. The plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally.,The face was prepped and draped in the usual sterile manner.,After waiting a period of approximately ten minutes for adequate vasoconstriction, the previously outlined excessive skin of the right upper eyelid was excised with blunt dissection. Hemostasis was obtained with a bipolar cautery. A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right. The defect in the orbital septum was identified, and herniated orbital fat was exposed. The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit. A similar procedure was performed exposing herniated portion of the nasal pocket. Great care was taken to obtain perfect hemostasis with this maneuver. A similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion. Careful hemostasis had been obtained on the upper lid areas. The lateral aspects of the upper eyelid incisions were closed with a couple of interrupted 7-0 blue Prolene sutures.,At the end of the operation the patient's vision and extraocular muscle movements were checked and found to be intact. There was no diplopia, no ptosis, no ectropion. Wounds were reexamined for hemostasis, and no hematomas were noted. Cooled saline compresses were placed over the upper and lower eyelid regions bilaterally.,The procedures were completed without complication and tolerated well. The patient left the operating room in satisfactory condition. A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to return home in satisfactory condition.

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.

CHIEF COMPLAINT:,1. Stage IIIC endometrial cancer.,2. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. In March 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus. CT scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis. On 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy. The pathology was positive for grade III endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion. Four of 30 lymph nodes were positive for disease. The left ovary was positive for metastatic disease. Postsurgical PET/CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease. The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup. Of note, we had sent off genetic testing which was denied back in June. I have been trying to get this testing completed.,CURRENT MEDICATIONS: , Synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., Ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.,ALLERGIES:

PREOPERATIVE DIAGNOSES: ,1. Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2. Cervical spondylosis.,3. Cervical stenosis, C5-C6 secondary to above (723.0).,POSTOPERATIVE DIAGNOSES: ,1. Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2. Cervical spondylosis.,3. Cervical stenosis, C5-C6 secondary to above (723.0), with surgical findings confirmed.,PROCEDURES: , ,1. Anterior cervical discectomy at C5-C6 with spinal cord and spinal canal decompression (63075).,2. Anterior interbody fusion at C5-C6, (22554) utilizing Bengal cage (22851).,3. Anterior instrumentation for stabilization by Uniplate construction, C5-C6, (22845); with intraoperative x-ray times two.,ANESTHESIA: , General.,SERVICE: , Neurosurgery.,OPERATION: ,The patient was brought into the operating room, placed in a supine position where general anesthesia was administered. Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion. A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected only in a subplatysmal manner bluntly, and with only blunt dissection at the prevertebral space where a localizing intraoperative x-ray was obtained, once self-retaining retractors were placed along the mesial edge of a cauterized longus colli muscle, to protect surrounding tissues throughout the remainder of the case. A prominent anterior osteophyte at C5-C6 was then localized, compared to preoperative studies in the usual fashion intraoperatively, and the osteophyte was excised with a rongeur and bony fragments saved. This allowed for an annulotomy, which was carried out with a #11 blade and discectomy, removed with straight disc forceps portions of the disc, which were sent to Pathology for a permanent section. Residual osteophytes and disc fragments were removed with 1 and 2-mm micro Kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well. A hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace, a sign of a decompressed status. At no time during the case was evidence of CSF leakage, and hemostasis was readily achieved with pledgets of Gelfoam subsequently removed with copious amounts of antibiotic irrigation. Once the decompression was inspected with a double ball dissector and all found to be completely decompressed, and the dura bulged at the interspace, and pulsated, then a Bengal cage was filled with the patient's own bone elements and fusion putty and countersunk into position, and was quite tightly applied. Further stability was added nonetheless with an appropriate size Uniplate, which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner. The wound was inspected, and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was Steri-Stripped for reinforcement, and a sterile dressing was applied, incorporating a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner. Once the sterile dressing was applied, the patient was taken from the operating room to the recovery area having left in stable condition.,At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.

XYZ, M.D.,RE: ABC,DOB: MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC. The patient is being referred for evaluation of diabetic retinopathy. The patient was just diagnosed with diabetes; however, he does not have any serious visual complaints at this time.,On examination, the patient is seeing 20/40 OD pinholing to 20/20. The vision in the left eye is 20/20 uncorrected. Applanation pressures are normal at 17 mmHg bilaterally. Visual fields are full to count fingers OU and there is no relative afferent pupillary defect. Slit lamp examination was within normal limits, other than trace to 1+ nuclear sclerosis OU. On dilated examination, the patient shows a normal cup-to-disc ratio that is symmetric bilaterally. The macula, vessels, and periphery are also within normal limits.,In conclusion, Mr. ABC does not show any evidence of diabetic retinopathy at this time. We recommended him to have his eyes dilated once a year. I have advised him to follow up with you for his regular check-ups. Again, thank you for your kind referral of Mr. ABC and we should check on him once a year at this time.,Sincerely,,

DIAGNOSIS AT ADMISSION: , Congestive heart failure (CHF) with left pleural effusion.,DIAGNOSES AT DISCHARGE,1. Congestive heart failure (CHF) with pleural effusion.,2. Hypertension.,3. Prostate cancer.,4. Leukocytosis.,5. Anemia of chronic disease.,HOSPITAL COURSE: ,The patient was admitted to the emergency room by Dr. X. He has diuresed with IV Lasix. He was placed on Prinivil, aspirin, oxybutynin, docusate, and Klor-Con. Chest x-rays were followed. He did have free flowing fluid in his left chest. Radiology consultation was obtained for thoracentesis. The patient was seen by Dr. Y. An echocardiogram was done. This revealed an ejection fraction of 60% with diastolic dysfunction and periaortic stenosis with an opening of 1 cm3. An adenosine sestamibi was done in March 2000, with a small fixed apical defect, but no ischemia. Cardiac enzymes were negative. Dr. Y recommended a beta-blocker with an ACE inhibitor; therefore, the lisinopril was discontinued. The patient felt much better after the thoracentesis. I do not have the details of this, i.e., the volumes. No fluid was sent for routine studies.,LABORATORY AT DISCHARGE: , Sodium 134, potassium 4.2, chloride 99, CO2 26, glucose 182, BUN 17, and creatinine 1.0. Glucose was elevated because of several doses of Solu-Medrol given to him because of bronchospams. Magnesium was 1.8, calcium was 8.1. Liver enzymes were unremarkable. Cardiac enzymes were normal as mentioned. PT/INR is 1.02, PTT 31.3, white blood cell count 15, 000 with a left shift. This was presumed due to the corticosteroids. H&H was 32.3/11.3 and platelets 352,000, and MCV was 99. The patient's O2 saturations on room air were normal.,Vital signs were stable.,DISCHARGE MEDICATIONS: , He is being discharged home on Lasix 40 mg daily, potassium chloride 10 mEq daily, atenolol 25 mg daily, aspirin 5 grains daily, Ditropan 5 mg b.i.d., and Colace 100 mg b.i.d.,FOLLOWUP: , He will be followed in my office in 1 week. He is to notify if recurrent fever or chills.,PROGNOSIS: ,Guarded.

CHIEF COMPLAINT:, Dental pain.,HISTORY OF PRESENT ILLNESS:, This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and pain to the left lower mandible area today. Presents now for evaluation.,PAST MEDICAL HISTORY: , Remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease. She has chronic pain in general and is followed by Dr. X.,REVIEW OF SYSTEMS: , Otherwise, unremarkable. Has not noted any fever or chills. However she, as mentioned, does note the dental discomfort with increasing swelling and pain. Otherwise, unremarkable except as noted.,CURRENT MEDICATIONS: , Please see list.,ALLERGIES: , IODINE, FISH OIL, FLEXERIL, BETADINE.,PHYSICAL EXAMINATION: , VITAL SIGNS: The patient was afebrile, has stable and normal vital signs. The patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain. HEENT: Unremarkable. I do not see any obvious facial swelling, but she is definitely tender all in the left mandible region. There is no neck adenopathy. Oral mucosa is moist and well hydrated. Dentition looks to be in reasonable condition. However, she definitely is tender to percussion on the left lower first premolar. I do not see any huge cavity or anything like that. No real significant gingival swelling and there is no drainage noted. None of the teeth are tender to percussion.,PROCEDURE:, Dental nerve block. Using 0.5% Marcaine with epinephrine, I performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia. I have then written a prescription for penicillin and Vicodin for pain.,IMPRESSION: , ACUTE DENTAL ABSCESS.,ASSESSMENT AND PLAN: ,The patient needs to follow up with the dentist for definitive treatment and care. She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics. However, outpatient followup should be adequate. She is discharged in stable condition.

PREOPERATIVE DIAGNOSIS:, Open calcaneus fracture on the right.,POSTOPERATIVE DIAGNOSIS:, Open calcaneus fracture on the right.,PROCEDURES:, ,1. Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture.,2. Placement of antibiotic-impregnated beads.,ANESTHESIA:, General.,BLOOD LOSS:, Minimal.,COMPLICATIONS:, None.,FINDINGS:, Healing skin with no gross purulence identified, some fibrinous material around the beads.,SUMMARY:, After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table. After uneventful general anesthesia was obtained, her right leg was sterilely prepped and draped in a normal fashion. The tourniquet was inflated and the previous wound was opened. Dr. X came in to look at the wound and the beads were removed, all 25 beads were extracted, and pulsatile lavage, and curette, etc., were used to debride the wound. The wound margins were healthy with the exception of very central triangular incision area. The edges were debrided and then 19 antibiotic-impregnated beads with gentamicin and tobramycin were inserted and the wound was further closed today.,The skin edges were approximated under minimal tension. The soft dressing was placed. An Ace was placed. She was awakened from the anesthesia and taken to recovery room in a stable condition. Final needle, instrument, and sponge counts were correct.

CHIEF COMPLAINT:, Not gaining weight.,HISTORY OF PRESENT ILLNESS:, The patient is a 1-month-26-day-old African-American female in her normal state of health until today when she was taken to her primary care physician's office to establish care and to follow up on her feeds. The patient appeared to have failure-to-thrive. was only at her birth weight but when eating one may be possibly gaining 2 ounces every 3-4 hours, and was noted to have a murmur. At this point, the Hospitalist Service was contacted for admission. The patient was directly admitted to Children's Hospital Explore Ward.,In the explore ward, she was noted to be in mild respiratory distress and has some signs and symptoms of heart failure and had a prominent murmur, so an echo was done at bedside, which did show a moderately-sized patent ductus arteriosus and very small VSD and some mild signs and symptoms of congestive heart failure. The patient was also seen by Dr. X of Cardiology Service and a plan was then obtained.,PAST MEDICAL/BIRTH HISTORY: , The patient was born at term repeat C-section to a 27-year-old G3, P2 African-American female. Pregnancy was not complicated by hypertension, diabetes, drugs, alcohol abuse or smoking. Birthweight was 7 pounds 4 ounces at Community Hospital. The mother did have a repeat C-section. There is no rupture of membranes or group B strep status. The prenatal care began in the second month of pregnancy and was otherwise uncomplicated. Mother denies any sexual transmitted diseases or other significant illness. The patient was discharged home on day of life #3 without any complications.,ALLERGIES:, No known drug allergies.,DIET: , The patient only takes Enfamil 20 calories, 1-3 ounces per history every 3-4 hours.,ELIMINATION: , The patient urinates 3-4 times a day and has a bowel movement 3-4 times a day.,FAMILY HISTORY/SOCIAL HISTORY: , The patient lives with the mother. She has 2 older male siblings. All were reported good health. Family history is negative for any congenital heart disease, syndromes, hypertension, sickle cell anemia or sickle cell trait and no significant positive PPD contacts and history of second-hand smoke exposures.,REVIEW OF SYSTEMS: ,GENERAL: The patient has been reported to have normal activity and normal cry with no significant weight loss per mom's report, but conversely no significant weight gain. Mother does not report that she sweats whenever she eats or has any episodes of cyanosis. ,HEENT: Denies any significant nasal congestion or cough. ,RESPIRATORY: Denies any difficulty breathing or wheezing. ,CARDIOVASCULAR: As per above. GI: No history of any persistent vomiting or diarrhea. ,GU: Denies any decreased urinary output. ,MUSCULOSKELETAL: Negative. ,NEUROLOGICAL: Negative. ,SKIN: Negative.,All other systems reviewed are negative.,PHYSICAL EXAMINATION:,GENERAL: The patient is examined in her room, our next floor. She is crying very vigorously, especially when I examined but she is consolable.,VITAL SIGNS: Temperature currently is 96.3, heart rate 137, respirations 36, blood pressure 105/61 while crying.,HEENT: Normocephalic. The patient has a possible right temporoparietal bossing noted and slightly irregular shaped trapezoidal-shaped head. The anterior fontanelle is soft and flat. Pupils are equal, reactive to light and accommodation, but there is some mild hypertelorism. There is also some mild posterior rotation of the ears. Oropharynx, mucous membranes are pink and moist. There is a slightly high arched palate.,NECK: Significant for possible mild reddening of the neck.,LUNGS: Significant for perihilar crackles. Mild tachypnea is noted. O2 saturations are currently 97% on room air. There is mild intercostal retraction.,CARDIOVASCULAR: Heart has regular rate and rhythm. Peripheral pulses are only 1+. Capillary refills less than 3-4 seconds.,EXTREMITIES: Slightly cool to touch. There is 2-3/6 systolic murmur along the left sternal border. Does radiate to the axilla and to the back.,ABDOMEN: Soft, slightly distended, but nontender. The liver edge is palpable 4 cm below right costal margin. The spleen tip is also palpable.,GU: Normal female external genitalia is noted.,MUSCULOSKELETAL: The patient has poor fat deposits in her extremities. Strength is only 2/4. She had normal number of fingers and toes.,SKIN: Significant for slight mottling. There are very poor subcutaneous fat deposits in her skin.,LABORATORY DATA: , The i-STAT only shows sodium 135, potassium on a heel stick was 6.3, hemoglobin and hematocrit are 14 and 41, and white count was 1.4. CBG on i-STAT showed the pH of 7.34 with CO2 of 55, O2 sat of 51, CO2 of 29 with the base excess of 4. Chest x-ray shows bilateral infiltrates and significant cardiomegaly consistent with congenital heart disease and mild congestive heart failure.,ASSESSMENT: , This is an almost 2-month-old presents with:,1. Failure-to-thrive.,2. Significant murmur and patent ductus arteriosus.,3. Congestive heart failure.,PLAN: ,At present, we are going to admit and monitor closely tonight. We will get a chest x-ray and start Lasix at 1 mg/kg twice daily. We will also get a CBC and check a blood culture and further workup as necessary.

PREOPERATIVE DIAGNOSIS:, Left nasolabial fold scar deformity with effacement of alar crease.,POSTOPERATIVE DIAGNOSIS:, Left nasolabial fold scar deformity with effacement of alar crease.,PROCEDURES PERFORMED:,1. Left midface elevation with nasolabial fold elevation.,2. Left nasolabial fold z-plasty and right symmetrization midface elevation.,ANESTHESIA: , General endotracheal intubation.,ESTIMATED BLOOD LOSS: , Less than 25 mL.,FLUIDS: , Crystalloid,CULTURES TAKEN: , None.,PATIENT'S CONDITION: , Stable.,IMPLANTS: , Coapt Endotine Midface B 4.5 bioabsorbable implants, reference #CFD0200197, lot #01447 used on the right and used on the left side.,IDENTIFICATION: , This patient is well known to the Stanford Plastic Surgery Service. The patient is status post resection of the dorsal nasal sidewall skin cancer with nasolabial flap reconstruction with subsequent deformity. In particular, the patient has had effacement of his alar crease with deepening of his nasolabial fold and notable asymmetry. The patient was seen in consultation and felt to be a surgical candidate for improvement. Risks and benefits of the operation were described to the patient in detail including, but not limited to bleeding, infection, scarring, possible damage to surrounding structures including neurovascular structures, need for revision of surgery, continued asymmetry, and anesthetic complication. The patient understood these risks and benefits and consented to the operation.,PROCEDURE IN DETAIL: , The patient was taken to OR and placed supine on the operating table. Dose of antibiotics was given to the patient. Compression devices were placed on the lower extremities to prevent the knee embolic events. The patient was turned to 180 degrees. The ETT tube was secured and the area was then prepped and draped in usual sterile fashion. A head wrap was then placed on the position and we then began our local. Of note, the patient had previous incisions just lateral to his lateral canthus bilaterally and that were used for access. Local consisting a 50:50 mix of 0.25% Marcaine with epinephrine and 1% lidocaine with epinephrine was then injected into the subperiosteal plane taking care to prevent injury to the infraorbital nerves. This was done bilaterally. We then marked the nasolabial fold and began with the elevation of the left midface.,We began with a lateral canthal-type incision extending out over his previous incision down to subcutaneous tissue. We continued down to the lateral orbital rim until we identified periosteum. We then pulled in a periosteal elevator and elevated the midface down over the zygoma elevating some lateral mesenteric attachments down over the buccal region until we felt we had reached pass the nasolabial folds medially. Care was taken to preserve the infraorbital nerve and that was visualized after elevation. We then released the periosteum distally and retracted up on the periosteum and noted improved contour of the nasolabial fold with increased bulk over the midface region over the zygoma.,We then used our Endotine Coapt device to engage the periosteum at the desired location and then elevated the midface and secured into position using the Coapt bioabsorbable screw. After this was then carried out, we then clipped and cut as well as the end of the screw. Satisfied with this, we then elevated the periosteum and secured it to reinforce our midface elevation to the lateral orbital rim and this was done using 3-0 Monocryl. Several sutures were then used to anchor the orbicularis and deeper tissue to create additional symmetry. Excess skin along the incision was then removed as well the skin from just lateral to the canthus. Care was taken to leave the orbicularis muscle down. We then continued closing our incision using absorbable plain gut 5-0 sutures for the subciliary-type incision and then continuing with interrupted 6-0 Prolenes lateral to the canthus.,We then turned our attention to performing the z-plasty portion of the case. A z-plasty was designed along the previous scar where it was padding to the notable scar deformity and effacement of crease and the z-plasty was then designed to lengthen along the scar to improve the contour. This was carried out using a 15 blade down to subcutaneous tissue. The flaps were debulked slightly to reduce the amount of fullness and then transposed and sutured into place using chromic suture. At this point, we then noted that he had improvement of the nasal fold but continued asymmetry with regards to improved bulk on the left side and less bulk on the right and it was felt that a symmetrization procedure was required to make more symmetry with the midface bilaterally and nasolabial folds bilaterally. As such, we then carried out the dissection after injecting local as noted and we used a 15 blade scalpel to create our incision along the lateral canthus along its preexisting incision. We carried this down to the lateral orbital rim again elevating the periosteum taking care to preserve infraorbital nerve.,At this point, we then released the periosteum distally just at the level of the nasolabial fold and placed our Endotine midface implant into the desired area and then elevated slightly just for symmetry only. This was then secured in place using the bioabsorbable screw and then resected a very marginal amount of tissue just for removal of the dog ear deformity and closed the deeper layers of tissue using 3-0 PDS and then closing the extension to the subciliary area using 5-0 plain gut and then 6-0 Prolene lateral to the canthus.,At this point, we felt that we had achieved improved contour, improved symmetry, and decreased effacement of the nasolabial fold and alar crease. Satisfied with our procedures, we then placed cool compresses on to the eyes.,The patient was then extubated and brought to the PACU in stable condition.,Dr. X was present and scrubbed for the entire case and actively participated during all key elements. Dr. Y was available and participated in the portions of the case as well.

HISTORY OF PRESENT ILLNESS: This is a 91-year-old female who was brought in by family. Apparently, she was complaining that she felt she might have been poisoned at her care facility. The daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated and she thinks that is the biggest problem with the patient right now. The patient apparently had a little bit of dry heaves, but no actual vomiting. She had just finished eating dinner. No one else in the facility has been ill.,PAST MEDICAL HISTORY: Remarkable for previous abdominal surgeries. She has a pacemaker. She has a history of recent collarbone fracture.,REVIEW OF SYSTEMS: Very difficult to get from the patient herself. She seems to deny any significant pain or discomfort, but really seems not particularly intent on letting me know what is bothering her. She initially stated that everything was wrong, but could not specify any specific complaints. Denies chest pain, back pain, or abdominal pain. Denies any extremity symptoms or complaints.,SOCIAL HISTORY: The patient is a nonsmoker. She is accompanied here with daughter who brought her over here. They were visiting the patient when this episode occurred.,MEDICATIONS: Please see list.,ALLERGIES: NONE.,PHYSICAL EXAMINATION: VITAL SIGNS: The patient is afebrile, actually has a very normal vital signs including normal pulse oximetry at 99% on room air. GENERAL: The patient is an elderly frail looking little lady lying on the gurney. She is awake, alert, and not really wanted to answer most of the questions I asked her. She does have a tremor with her mouth, which the daughter states has been there for "many years". HEENT: Eye exam is unremarkable. Oral mucosa is still moist and well hydrated. Posterior pharynx is clear. NECK: Supple. LUNGS: Actually clear with good breath sounds. There are no wheezes, no rales, or rhonchi. Good air movement. CARDIAC: Without murmur. ABDOMEN: Soft. I do not elicit any tenderness. There is no abdominal distention. Bowel sounds are present in all quadrants. SKIN: Skin is without rash or petechiae. There is no cyanosis. EXTREMITIES: No evidence of any trauma to the extremities.,EMERGENCY DEPARTMENT COURSE: I had a long discussion with the family and they would like the patient receive something for agitation, so she was given 0.5 mg of Ativan intramuscularly. After about half an hour, I came back to talk to the patient and the family, the patient states that she feels better. Family states she seems more calm. They do not want to pursue any further workup at this time.,IMPRESSION: ACUTE EPISODE OF AGITATION.,PLAN: At this time, I had reviewed the patient's records and it is not particularly enlightening as to what could have triggered off this episode. The patient herself has good vital signs. She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given, a small quantity was given to the patient. Family and daughter specifically did not want to pursue any workup at this point, which at this point I think is reasonable and we will have her follow up with ABC. She is discharged in stable condition.

PREOPERATIVE DIAGNOSES:,1. Entropion, left upper lid.,2. Entropion and some blepharon, right lower lid.,TITLE OF OPERATION:,1. Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy.,2. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room and prepped and draped in the usual fashion. The left upper lid and right lower lid were all infiltrated with 2% Xylocaine with Epinephrine.,The lid was then everted with special clips and the mucotome was then used to cut a large mucous membrane graft from the lower lid measuring 0.5 mm in thickness. The graft was placed in saline and a 4 x 4 was placed over the lower lid.,Attention was then drawn to the left upper lid and the operating microscope was found to place. An incision was made in the gray line nasally in the area of trichiasis and entropion, and the dissection was carried anterior to the tarsal plate and an elliptical piece of the anterior lamella was excised. Bleeding was controlled with the wet-field cautery and the cryoprobe was then used with a temperature of -8 degree centigrade in the freeze-thaw-refreeze technique to treat the bed of the excised area.,Attention was then drawn to the right lower lid with the operating microscope and a large elliptical area of the internal aspect of the lid margin was excised with a super blade. Some of the blepharon were dissected from the globe and bleeding was controlled with the wet-field cautery. An elliptical piece of mucous membrane was then fashioned and placed into the defect in the lower lid and sutured with a running 6-0 chromic catgut suture anteriorly and posteriorly.,The graft was in good position and everything was satisfactory at the end of procedure. Some antibiotic steroidal ointment was instilled in the right eye and a light pressure dressing was applied. No patch was applied to the left eye. The patient tolerated the procedure well and was sent to recovery room in good condition.

REASON FOR VISIT:, Six-month follow-up visit for paroxysmal atrial fibrillation (PAF).,She reports that she is getting occasional chest pains with activity. Sometimes she feels that at night when she is lying in bed and it concerns her.,She is frustrated by her inability to lose weight even though she is hyperthyroid.,MEDICATIONS: , Tapazole 10 mg b.i.d., atenolol/chlorthalidone 50/25 mg b.i.d., Micro-K 10 mEq q.d., Lanoxin 0.125 mg q.d., spironolactone 25 mg q.d., Crestor 10 mg q.h.s., famotidine 20 mg, Bayer Aspirin 81 mg q.d., Vicodin p.r.n., and Nexium 40 mg-given samples of this today.,REVIEW OF SYSTEMS:, No palpitations. No lightheadedness or presyncope. She is having mild pedal edema, but she drinks a lot of fluid.,PEX: , BP: 112/74. PR: 70. WT: 223 pounds (up three pounds). Cardiac: Regular rate and rhythm with a 1/6 murmur at the upper sternal border. Chest: Nontender. Lungs: Clear. Abdomen: Moderately overweight. Extremities: Trace edema.,EKG: , Sinus bradycardia at 58 beats per minute, mild inferolateral ST abnormalities.,IMPRESSION:,1. Chest pain-Mild. Her EKG is mildly abnormal. Her last stress echo was in 2001. I am going to have her return for one just to make sure it is nothing serious. I suspect; however, that is more likely due to her weight and acid reflux. I gave her samples of Nexium.,2. Mild pedal edema-Has to cut down on fluid intake, weight loss will help as well, continue with the chlorthalidone.,3. PAF-Due to hypertension, hyperthyroidism and hypokalemia. Staying in sinus rhythm.,4. Hyperthyroidism-Last TSH was mildly suppressed, she had been out of her Tapazole for a while, now back on it.,5. Dyslipidemia-Samples of Crestor given.,6. LVH.,7. Menometrorrhagia.,PLAN:,1. Return for stress echo.,2. Reduce the fluid intake to help with pedal edema.,3. Nexium trial.

PREOPERATIVE DIAGNOSIS: , Bilateral inguinal hernias.,POSTOPERATIVE DIAGNOSIS:, Bilateral inguinal hernias.,OPERATION PERFORMED: ,Bilateral inguinal herniorrhaphy.,ANESTHESIA: , General.,INDICATIONS: , This 3-1/2-year-old presents with bilateral scrotal swellings, which both reduce and are consistent with bilateral inguinal hernias. He comes to the operating room today for the repair.,OPERATIVE PROCEDURE: ,After the induction of general anesthetic, the abdomen and perineum were prepped and draped in usual manner. Transverse right lower quadrant skin fold incision was made and carried down through skin and subcutaneous tissue with sharp dissection. The external oblique fascia identified upon course of its fibers. The hernia sac was identified and brought into the operative field. Hernia sac was grasped with hemostat and the cord structures were carefully stripped away from it until the entire circumference of the sac could be identified. The sac clamped and divided. The distal sac was then dissected down to where the large hydrocele with the testicle would be brought up and the sac opened, the fluid drained, and a portion of the sac removed. The testicle was returned to the scrotum. The proximal sac was then dissected free of the cord up to the peritoneal reflection at the internal ring where it was ligated with a #3-0 Vicryl stick tie and a #3-0 Vicryl free tie. The excess removed. The cord returned to the inguinal canal and external oblique fascia closed with interrupted sutures of #3-0 Vicryl and subcutaneous tissue with the same, skin closed with #5-0 subcuticular Monocryl. Sterile dressing applied. Attention was then turned to the left side where an identical procedure was carried out for his left hernia, although the only difference being with the sac was somewhat smaller and did not have the large hydrocele around the testicle. Otherwise the procedure was carried down in identical manner. Sterile dressings were then applied to both sides. The child awakened and taken to the recovery room in satisfactory condition.

TITLE OF OPERATION:, Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.,INDICATION FOR SURGERY: , She is a 3-year-old girl who is known to have a head injury and CT in 2005 was normal, presented with headache. All endocrine labs were normal. Surgery was recommended.,PREOP DIAGNOSIS: , Cystic suprasellar tumor.,POSTOP DIAGNOSIS:, Cystic suprasellar tumor.,PROCEDURE DETAIL: , The patient was brought to operating room, underwent smooth induction of general endotracheal anesthesia, head was placed in the horseshoe head rest and positioned supine with head turned slightly towards left and slightly extended. The patient was then prepped and draped in the usual sterile fashion. With the assistance of fluoro and mapping the localization, the right nostril was infiltrated. Dr. X will dictate the procedure of the approach. Once the dura was visualized, there was a complex procedure secondary to the small nasal naris as well as the bony drilling that would necessitate significant drilling. Once the operating microscope was in the field, at this point, the drilling was completed. The dura was opened in cruciate fashion revealing normal pituitary, which was displaced and the cystic tumor. This was then opened and using microsurgical technique with the curette suctioned and the pituitary calcifications were removed, several Valsalva maneuvers were performed without any evidence of CSF leak and trying to pull the tumor further down. Once this was completed, there was no evidence of any bleeding. The endoscope was then used to remove any residual fragments __________ with the arachnoid. Once this was completely ensured, small piece of Duragel was placed and the closure will be dictated by Dr. X. She was reversed, extubated, and transported to the ICU in stable condition. Blood loss, minimal. All sponge, needle counts were correct.

PREOPERATIVE DIAGNOSIS: ,1. Left carpal tunnel syndrome.,2. de Quervain's tenosynovitis.,POSTOPERATIVE DIAGNOSIS:, ,1. Left carpal tunnel syndrome.,2. de Quervain's tenosynovitis.,OPERATIONS PERFORMED: ,1. Endoscopic carpal tunnel release.,2. de Quervain's release.,ANESTHESIA:, I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:, Zero.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: ,ENDOSCOPIC CARPAL TUNNEL RELEASE:, With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated at 290 mm/Hg. Construction lines were made on the left palm to identify the ring ray. A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin. Blunt dissection exposed the antebrachial fascia. Hemostasis was obtained with bipolar cautery. A distal-based window in the antebrachial fascia was then fashioned. Care was taken to protect the underlying contents. A proximal forearm fasciotomy was performed under direct vision. A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface. Hamate sounds were then used to palpate the hook of hamate. The endoscopic instrument was then inserted into the proximal incision. The transverse carpal ligament was easily visualized through the portal. Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window. The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision. After complete division o the transverse carpal ligament, the instrument was reinserted. Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch. Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips. The tourniquet was deflated. The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.,DE QUERVAIN'S RELEASE: , With the patient under adequate regional anesthesia applied by surgeon using 1% plain Xylocaine, the upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated to 290 mm/Hg. A transverse incision was then made over the radial aspect of the wrist overlying the first dorsal tunnel. Using blunt dissection, the radial sensory nerve branches were dissected and retracted out of the operative field. The first dorsal tunnel was then identified. The first dorsal tunnel was incised along the dorsal ulnar border, completely freeing the stenosing tenosynovitis (de Quervain's release). EPB and APL tendons were inspected and found to be completely free. The radial sensory nerve was inspected and found to be without damage.,The skin was closed with a running 3-0 Prolene subcuticular stitch and Steri-Strips were applied and, over the Steri-Strips, a sterile dressing, and, over the sterile dressing, a volar splint with the hand in safe position. The tourniquet was deflated. The patient was returned to the holding area in satisfactory condition, having tolerated the procedure well.

PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,OPERATIVE PROCEDURE:, Laparoscopic appendectomy.,INTRAOPERATIVE FINDINGS: , Include inflamed, non-perforated appendix.,OPERATIVE NOTE: ,The patient was seen by me in the preoperative holding area. The risks of the procedure were explained. She was taken to the operating room and given perioperative antibiotics prior to coming to the surgery. General anesthesia was carried out without difficulty and a Foley catheter was inserted. The left arm was tucked and the abdomen was prepped with Betadine and draped in sterile fashion. A 5-mm blunt port was inserted infra-umbilically at the level of the umbilicus under direct vision of a 5-mm 0-degree laparoscope. Once we were inside the abdominal cavity, CO2 was instilled to attain an adequate pneumoperitoneum. A left lower quadrant 5-mm port was placed under direct vision and a 12-mm port in the suprapubic region. The 5-mm scope was introduced at the umbilical port and the appendix was easily visualized. The base of the cecum was acutely inflamed but not perforated. I then was easily able to grasp the mesoappendix and create a window between the base of the mesoappendix and the base of the appendix. The window is big enough to get an Endo GIA blue cartridge through it and fired across the base of the mesoappendix without difficulty. I reloaded with a red vascular cartridge, came across the mesoappendix without difficulty. I then placed the appendix in an Endobag and brought out through the suprapubic port without difficulty. I reinserted the suprapubic port and irrigated out the right lower quadrant until dry. One final inspection revealed no bleeding from the staple line. We then removed all ports under direct vision, and there was no bleeding from the abdominal trocar sites. The pneumoperitoneum was then deflated and the suprapubic fascial defect was closed with 0-Vicryl suture. The skin incision was injected with 0.25% Marcaine and closed with 4-0 Monocryl suture. Steri-strips and sterile dressings were applied. No complications. Minimal blood loss. Specimen is the appendix. Brought to the recovery room in stable condition.

ADMITTING DIAGNOSES:,1. Leiomyosarcoma.,2. History of pulmonary embolism.,3. History of subdural hematoma.,4. Pancytopenia.,5. History of pneumonia.,PROCEDURES DURING HOSPITALIZATION:,1. Cycle six of CIVI-CAD (Cytoxan, Adriamycin, and DTIC) from 07/22/2008 to 07/29/2008.,2. CTA, chest PE study showing no evidence for pulmonary embolism.,3. Head CT showing no evidence of acute intracranial abnormalities.,4. Sinus CT, normal mini-CT of the paranasal sinuses.,HISTORY OF PRESENT ILLNESS: ,Ms. ABC is a pleasant 66-year-old Caucasian female who first palpated a mass in the left posterior arm in spring of 2007. The mass increased in size and she was seen by her primary care physician and referred to orthopedic surgeon. MRI showed inflammation and was thought to be secondary to rheumatoid arthritis. The mass increased in size. She eventually underwent a partial resection found to have pathologic grade 2 leiomyosarcoma, margins were impossible to assess, but were likely positive. She was evaluated by Dr. X and Dr. Y and a decision was made to proceed with preoperative chemotherapy. She began treatment with CIVI-CAD in December 2007. Her course was complicated by pulmonary embolus, pneumonia, and subdural hematoma while on anticoagulation. She eventually underwent surgical resection on May 1, 2008 with small area of residual disease, but otherwise clear margins.,HOSPITAL COURSE:,1. Leiomyosarcoma, the patient was admitted to Hem/Onco B Service under attending Dr. XYZ for cycle six of continuous IV infusion Cytoxan, Adriamycin, and DTIC, which she tolerated well.,2. History of pulmonary embolism. Upon admission, the patient reported an approximate two-week history of dyspnea on exertion and some mild chest pain. She underwent a CTA, which showed no evidence of pulmonary embolism and the patient was started on prophylactic doses of Lovenox at 40 mg a day. She had no further complaints throughout the hospitalization with any shortness of breath or chest pain.,3. History of subdural hematoma, also on admission the patient noted some mild intermittent headaches that were fleeting in nature, several a day that would resolve on their own. Her headaches were not responding to pain medication and so on 07/24/2008, we obtained a head CT that showed no evidence of acute intracranial abnormalities. The patient also had a history of sinusitis and so a sinus CT scan was obtained, which was normal.,4. Pancytopenia. On admission, the patient's white blood count was 3.4, hemoglobin 11.3, platelet count 82, and ANC of 2400. The patient's counts were followed throughout admission. She did not require transfusion of red blood cells or platelets; however, on 07/26/2008 her ANC did dip to 900 and she was placed on neutropenic diet. At discharge her ANC is back up to 1100 and she is taken off neutropenic diet. Her white blood cell count at discharge was 1.4 and her hemoglobin was 11.2 with a platelet count of 140.,5. History of pneumonia. During admission, the patient did not exhibit any signs or symptoms of pneumonia.,DISPOSITION: , Home in stable condition.,DIET: , Regular and less neutropenic.,ACTIVITY: , Resume same activity.,FOLLOWUP: ,The patient will have lab work at Dr. XYZ on 08/05/2008 and she will also return to the cancer center on 08/12/2008 at 10:20 a.m. The patient is also advised to monitor for any fevers greater than 100.5 and should she have any further problems in the meantime to please call in to be seen sooner.

PREOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,POSTOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,PROCEDURE: , Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.,ANESTHESIA: , Surgery performed under general anesthesia. The patient received 6 mL of 0.25% Marcaine local anesthetic on each side.,TOURNIQUET TIME: ,Tourniquet time was 53 minutes on the left and 45 minutes on the right.,COMPLICATIONS: , There were no intraoperative complications.,DRAINS:, None.,SPECIMENS: , None.,HARDWARE USED: , Staple 7/8 inch x1 on each side.,HISTORY AND PHYSICAL: ,The patient is a 5-year-4-month-old male who presents for evaluation of feet. He has been having significant feet pain with significant planovalgus deformity. The patient was noted to have flexible vertical talus. It was decided that the patient would benefit by subtalar arthrodesis, possible autograft, and Achilles lengthening. This was explained to the mother in detail. This is going to be a stabilizing measure and the patient will probably need additional surgery at a later day when his foot is more mature. Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time. All questions were answered and the mother agreed to the above plan.,PROCEDURE NOTE: , The patient was taken to the operating room, placed supine on the operating room, general anesthesia was administered. The patient received Ancef preoperatively. Bilateral nonsterile tourniquets were placed on each thigh. A bump was placed underneath the left buttock. Both the extremities were then prepped and draped in standard surgical fashion. Attention was first turned towards the left side. Intended incision was marked on the skin. The ankle was taken through a range of motion with noted improvement in the reduction of the talocalcaneal alignment with the foot in plantar flexion on the lateral view. The foot was wrapped in Esmarch prior to inflation of tourniquet to 200 mmHg. Incision was then made over the left lateral aspect of the hind foot to expose the talocalcaneal joint. The sinus tarsi was then identified using a U-shaped flap to tack muscles, and periosteum was retracted distally. Once the foot was reduced a Steinman pin was used to hold it in position. This position was first checked on the fluoroscopy. The 7/8th inch staple was then placed across the sinus tarsi to maintain the reduction. This was also checked with fluoroscopy. The incision was then extended posteriorly to allow for visualization of the Achilles, which was Z-lengthened with the release of the lateral distal half. This was sutured using 2-0 Ethibond and that was also oversewn. The wound was irrigated with normal saline. The periosteal flap was sutured over the staple using 2-0 Vicryl. Skin was closed using 2-0 Vicryl interrupted and then with 4-0 Monocryl. The area was injected with 6 mL of 0.25% Marcaine local anesthetic. The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, and 4 x 4s and Webril. Tourniquet was released after 53 minutes. The exact same procedure was repeated on the right side with no changes or complications. Tourniquet time on the right side was 45 minutes. The patient tolerated the procedure well. Bilateral long-leg casts were then placed with the foot in neutral with some moulding of his medial plantar arch. The patient was subsequently was taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for pain as per parents' request. The patient is to be strict nonweightbearing for at least 6 weeks. He is to follow up in the next 10 days for a check. We will plan of changing to short-leg casts in about 4 weeks postop.

An orbital block was done. An infraorbital block was also performed with a 25 gauge needle. A skin muscle flap was elevated by sharp dissection down to the orbital rim area. The herniated periorbital fat was removed by opening the orbital septum with sharp dissection using a 15 blade, teasing the periorbital fat out, cross clamping the fat and removing the fat with a scissor over the clamp. The clamp was cauterized with needle cautery and then the clamp was scarped with a 15 blade.,The remaining fat was left to fall back into the orbit. This was done in three compartments, the middle, medial and lateral compartments. Fat was removed from all three compartments. Then with the mouth open and the eyes in upward gaze, the lower skin muscle flap was redraped on the eyelids and tailored to fit exactly into place and then sutured into place with multiple 6-0 silk sutures.,Bleeding was minimal. The patient tolerated the procedure well.

DIAGNOSIS: , Left knee osteoarthritis.,HISTORY: , The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. Prior to this incident, the patient was ambulating independently with a pickup walker throughout her home. Since that time, the patient has only been performing transverse and has been unable to ambulate. The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.,PAST MEDICAL HISTORY: , High blood pressure, obesity, right patellar fracture with pin in 1990, and history of blood clots.,MEDICATIONS: ,Naproxen, Plavix, and stool softener.,MEDICAL DIAGNOSTICS: , The patient states that she had an x-ray of the knee in 2007 and was diagnosed with osteoarthritis.,SUBJECTIVE:, The patient reports that when seated and at rest, her knee pain is 0/10. The patient states that with active motion of the left knee, the pain in the anterior portion increases to 5/10.,PATIENT'S GOAL: , To transfer better and walk 5 feet from her bed to the couch.,INSPECTION: , The right knee has a large 8-inch long and very wide tight scar with adhesions to the underlying connective tissue due to her patellar fracture and surgery following an MVA in 1990, bilateral knees are very large due to obesity. There are no scars, bruising or increased temperature noted in the left knee.,RANGE OF MOTION: , Active and passive range of motion of the right knee is 0 to 90 degrees and the left knee, 0 to 85 degrees. Pain is elicited during active range of motion of the left knee.,PALPATION: , Palpation to the left knee elicits pain around the patellar tendon and to each side of this area.,FUNCTIONAL MOBILITY: ,The patient reports that she transfers with standby to contact-guard assist in the home from her bed to her wheelchair and return. The patient is able to stand modified independent from wheelchair level and tolerates at least 15 seconds of standing prior to needing to sit down due to the left knee pain.,ASSESSMENT: ,The patient is a 58-year-old female with left knee osteoarthritis. Examination indicates deficits in pain, muscle endurance, and functional mobility. The patient would benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: ,The patient will be seen two times per week for an initial 4 weeks with re-assessment at that time for an additional 4 weeks if needed.,INTERVENTIONS INCLUDE:,1. Modalities including electrical stimulation, ultrasound, heat, and ice.,2. Therapeutic exercise.,3. Functional mobility training.,4. Gait training.,LONG-TERM GOALS TO BE ACHIEVED IN 4 WEEKS:,1. The patient is to have increased endurance in bilateral lower extremities as demonstrated by being able to perform 20 repetitions of all lower extremity exercises in seated and supine positions with minimum 2-pound weight.,2. The patient is to perform standby assist transfer using a pickup walker.,3. The patient is to demonstrate 4 steps of ambulation using forward and backward using a pickup walker or front-wheeled walker.,4. The patient is to report maximum 3/10 pain with weightbearing of 2 minutes in the left knee.,LONG-TERM GOALS TO BE ACHIEVED IN 8 WEEKS:,1. The patient is to be independent with the home exercise program.,2. The patient is to tolerate 20 reps of standing exercises with pain maximum of 3/10.,3. The patient is to ambulate 20 feet with the most appropriate assistive device.,PROGNOSIS TO THE ABOVE-STATED GOALS:, Fair to good.,The above treatment plan has been discussed with the patient. She is in agreement.

SUBJECTIVE:, This is a 6-year-old male who comes in rechecking his ADHD medicines. We placed him on Adderall, first time he has been on a stimulant medication last month. Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine. She has two concerns. It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in. It wears off about 2 and they have problems in the evening with him. He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off. His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible. The patient even commented that he thought he needed his medication.,PAST HISTORY:, Reviewed from appointment on 08/16/2004.,CURRENT MEDICATIONS:, He is on Adderall XR 10 mg once daily.,ALLERGIES: , To medicines are none.,FAMILY AND SOCIAL HISTORY:, Reviewed from appointment on 08/16/2004.,REVIEW OF SYSTEMS:, He has been having problems as mentioned in the morning and later in the afternoon but he has been eating well, sleeping okay. Review of systems is otherwise negative.,OBJECTIVE:, Weight is 46.5 pounds, which is down just a little bit from his appointment last month. He was 49 pounds, but otherwise, fairly well controlled, not all that active in the exam room. Physical exam itself was deferred today because he has otherwise been very healthy.,ASSESSMENT:, At this point is attention deficit hyperactivity disorder, doing fairly well with the Adderall.,PLAN:, Discussed with mother two options. Switch him to the Ritalin LA, which I think has better release of the medicine early in the morning or to increase his Adderall dose. As far as the afternoon, if she really wanted him to be on the medication, we will do a small dose of the Adderall, which she would prefer. So I have decided at this point to increase him to the Adderall XR 15 mg in the morning and then Adderall 5 mg in the afternoon. Mother is to watch his diet. We would like to recheck his weight if he is doing very well, in two months. But if there are any problems, especially in the morning then we would do the Ritalin LA. Mother understands and will call if there are problems. Approximately 25 minutes spent with patient, all in discussion.

PREOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS:, None.,SUMMARY: ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details). Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle. After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle. These needles were removed and the patient was discharged in stable condition.

She is stable at this time and does not require any intervention at today's visit. I have asked her to return in six months' for a followup dilated examination, but would be happy to see her sooner should you or she notice any changes in her vision.

Informed written consent has been obtained from the patient. I explained the procedure to her prior to initiation of such. The appropriate time-out procedure as per Medical Center protocol was performed prior to the procedure being begun while the patient was actively participating with appropriate identification of the patient, procedure, physician, documentation, position. There were no safety concerns noted by staff nor myself.,REST ECHO:, EF 60%. No wall motion abnormalities. EKG shows normal sinus rhythm with mild ST depressions. The patient exercised for 7 minutes 30 seconds on a standard Bruce protocol, exceeding target heart rate; no angina nor significant ECG changes seen. Peak stress echo imaging shows EF of 75%, no regional wall motion abnormalities. There was resting hypertension noted, systolic of approximately 152 mmHg with appropriate response of blood pressure to exercise. No dysrhythmias noted.,IMPRESSION:,1. Negative exercise ECG/echocardiogram stress evaluation for inducible ischemia in excess of target heart rate.,2. Resting hypertension with appropriate response of blood pressure to exercise.,These results have been discussed with the patient. Other management as per the hospital-based internal medicine service.,To be clear, there were no complications of this procedure.

PROCEDURES PERFORMED: , C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.,ESTIMATED BLOOD LOSS: , 10 mL.,CLINICAL NOTE: , This is a 57-year-old gentleman with refractory neck pain with single-level degeneration of the cervical spine and there was also some arm pain. We decided go ahead with anterior cervical discectomy at C5-C6 and fusion. The risks of lack of pain relief, paralysis, hoarse voice, nerve injuries, and infection were explained and the patient agreed to proceed.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room where a general endotracheal anesthesia was induced without complication. The patient was placed in the slightly extended position with the neck and the head was restrained in a doughnut and the occiput was restrained by the doughnut. He had tape placed over the shoulders during intraoperative x-rays and his elbows were well padded. The tape was placed and his arms were well padded. He was prepped and draped in a sterile fashion. A linear incision was fashioned at the cricothyroid level from near the midline to over the sternocleidomastoid muscle. We separated the platysma from the subcutaneous tissue and then opened the platysma along the medial border of the sternocleidomastoid muscle. We then dissected sharply medial to carotid artery, which we palpated to the prevertebral region. We placed Caspar retractors for medial and lateral exposure over the C5-C6 disc space, which we confirmed with the lateral cervical spine x-ray including 18-gauge needle in the disc space. We then marked the disc space. We then drilled off ventral osteophyte as well as osteophyte creating concavity within the disc space. We then under magnification removed all the disc material, we could possibly see down to bleeding bone and both the endplates. We took down posterior longitudinal ligament as well. We incised the 6-mm cornerstone bone. We placed a 6-mm parallel medium bone nicely into the disc space. We then sized a 23-mm plate. We inserted the screws nicely above and below. We tightened down the lock-nuts. We irrigated the wound. We assured hemostasis using bone wax prior to placing the plate. We then assured hemostasis once again. We reapproximated the platysma using 3-0 Vicryl in a simple interrupted fashion. The subcutaneous level was closed using 3-0 Vicryl in a simple buried fashion. The skin was closed with 3-0 Monocryl in a running subcuticular stitch. Steri-Strips were applied. Dry sterile dressing with Telfa was applied over this. We obtained an intraoperative x-ray to confirm the proper level and good position of both plates and screw construct on the lateral x-ray and the patient was transferred to the recovery room, moving all four extremities with stable vital signs. I was present as a primary surgeon throughout the entire case.

PREOPERATIVE DIAGNOSIS:, Acute appendicitis with perforation.,POSTOPERATIVE DIAGNOSIS: ,Acute appendicitis with perforation.,ANESTHESIA:, General.,PROCEDURE: , Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE: , The patient is a 4-year-old little boy, who has been sick for several days and was seen in our Emergency Department yesterday where a diagnosis of possible constipation was made, but he was sent home with a prescription for polyethylene glycol but became more acutely ill and returned today with tachycardia, high fever and signs of peritonitis. A CT scan of his abdomen showed evidence of appendicitis with perforation. He was evaluated in the Emergency Department and placed on the appendicitis critical pathway for this acute appendicitis process. He required several boluses of fluid for tachycardia and evidence of dehydration.,I met with Carlos' parents and talked to them about the diagnosis of appendicis and surgical risks, benefits, and alternative treatment options. All their questions have been answered and they agree with the surgical plan.,OPERATIVE FINDINGS: , The patient had acute perforated appendicitis with diffuse suppurative peritonitis including multiple intraloop abscesses and purulent debris in all quadrants of the abdomen including the perihepatic and subphrenic recesses as well.,DESCRIPTION OF PROCEDURE: , The patient came to the operating room and had an uneventful induction of general anesthesia. A Foley catheter was placed for decompression, and his abdomen was prepared and draped in a standard fashion. A 0.25% Marcaine was infiltrated in the soft tissues around his umbilicus and in the suprapubic and left lower quadrant locations chosen for trocar insertion. We conducted our surgical timeout and reiterated all of Carlos' unique and important identifying information and confirmed the diagnosis of appendicitis and planned laparoscopic appendectomy as the procedure. A 1-cm vertical infraumbilical incision was made and an open technique was used to place a 12-mm Step trocar through the umbilical fascia. CO2 was insufflated to a pressure of 15 mmHg and then two additional 5-mm working ports were placed in areas that had been previously anesthetized.,There was a lot of diffuse purulent debris and adhesions between the omentum and adjacent surfaces of the bowel and the parietal peritoneum. After these were gently separated, we began to identify the appendix. In the __________ due to the large amount of small bowel dilatation and distension, I used the hook cautery with the lowest intraperitoneal __________ profile to coagulate the mesoappendix. The base of the appendix was then ligated with 2-0 PDS Endoloops, and the appendix was amputated and withdrawn through the umbilical port. I spent the next 10 minutes irrigating purulent fluid and debris from the peritoneal cavity using 2 L of sterile crystalloid solution and a suction power irrigation system. When this was complete, the CO2 was released one final time and as much of the fluid was drained from the peritoneal cavity as possible. The umbilical fascia was closed with figure-of-eight suture of 0 Monocryl and the skin incisions were closed with subcuticular 5-0 Monocryl and Steri-Strips. The patient tolerated the operation well. He was awakened and taken to the recovery room in satisfactory condition. His blood loss was less than 10 mL, and he received only crystalloid fluid during the procedure.

PREOPERATIVE DIAGNOSIS: ,Lateral epicondylitis.

CHIEF COMPLAINT:, Detox from heroin.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine. The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.,PAST MEDICAL HISTORY: , Remarkable for chronic pain. He has had multiple stab wounds, gunshot wounds, and a variety of other injuries that resulted him having chronic pain and he states that is what triggers of him getting on heroin to try to get out of pain. He has previously been followed by ABC but has not seen him for several years.,REVIEW OF SYSTEMS: ,The patient states that he did use heroin as well as cocaine earlier today and feels under the influence. Denies any headache or visual complaints. No hallucinations. No chest pain, shortness of breath, abdominal pain or back pain. Denies any abscesses.,SOCIAL HISTORY: , The patient is a smoker. Admits to heroin use, alcohol abuse as well. Also admits today using cocaine.,FAMILY HISTORY:, Noncontributory.,MEDICATIONS: , He has previously been on analgesics and pain medications chronically. Apparently, he just recently got out of prison. He has previously also been on Klonopin and lithium. He was previously on codeine for this pain.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS: The patient is afebrile. He is markedly hypertensive, 175/104 and pulse 117 probably due to the cocaine onboard. His respiratory rate is normal at 18. GENERAL: The patient is a little jittery but lucid, alert, and oriented to person, place, time, and situation. HEENT: Unremarkable. Pupils are actually moderately dilated about 4 to 5 mm, but reactive. Extraoculars are intact. His oropharynx is clear. NECK: Supple. His trachea is midline. LUNGS: Clear. He has good breath sounds and no wheezing. No rales or rhonchi. Good air movement and no cough. CARDIAC: Without murmur. ABDOMEN: Soft and nontender. He has multiple track marks, multiple tattoos, but no abscesses. NEUROLOGIC: Nonfocal.,IMPRESSION: , MEDICAL EXAMINATION FOR THE PATIENT WHO WILL BE DETOXING FROM HEROIN.,ASSESSMENT AND PLAN: ,At this time, I think the patient can be followed up at XYZ. I have written a prescription of clonidine and Phenergan for symptomatic relief and this has been faxed to the pharmacy. I do not think he needs any further workup at this time. He is discharged otherwise in stable condition.

PREOPERATIVE DIAGNOSIS: , Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS:, Left indirect inguinal hernia.,PROCEDURE PERFORMED:, Repair of left inguinal hernia indirect.,ANESTHESIA: , Spinal with local.,COMPLICATIONS:, None.,DISPOSITION,: The patient tolerated the procedure well, was transferred to recovery in stable condition.,SPECIMEN: , Hernia sac.,BRIEF HISTORY: , The patient is a 60-year-old female that presented to Dr. X's office with complaints of a bulge in the left groin. The patient states that she noticed there this bulge and pain for approximately six days prior to arrival. Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have a left indirect inguinal hernia.,PROCEDURE: , After informed consent was obtained, risks and benefits of the procedure were explained to the patient. The patient was brought to the operating suite. After spinal anesthesia and sedation given, the patient was prepped and draped in normal sterile fashion. In the area of the left inguinal region just superior to the left inguinal ligament tract, the skin was anesthetized with 0.25% Marcaine. Next, a skin incision was made with a #10 blade scalpel. Using Bovie electrocautery, dissection was carried down to Scarpa's fascia until the external oblique was noted. Along the side of the external oblique in the direction of the external ring, incision was made on both sides of the external oblique and then grasped with a hemostat. Next, the hernia and hernia sac was circumferentially grasped and elevated along with the round ligament. Attention was next made to ligating the hernia sac at its base for removal. The hernia sac was opened prior grasping with hemostats. It was a sliding indirect hernia. The bowel contents were returned to abdomen using a #0 Vicryl stick tie pursestring suture at its base. The hernia sac was ligated and then cut above with the Metzenbaum scissors returning it to the abdomen. This was then sutured at the apex of the repair down to the conjoint tendon. Next, attention was made to completely removing the round ligament hernia sac which was again ligated at its base with an #0 Vicryl suture and removed as specimen. Attention was next made to reapproximate it at floor with a modified ______ repair. Using a #2-0 Ethibond suture in simple interrupted fashion, the conjoint tendon was approximated to the ilioinguinal ligament capturing a little bit of the floor of the transversalis fascia. Once this was done, the external oblique was closed over, reapproximated again with a #2-0 Ethibond suture catching each hump in between each repair from the prior floor repair. This was done in simple interrupted fashion as well. Next Scarpa's fascia was reapproximated with #3-0 Vicryl suture. The skin was closed with running subcuticular #4-0 undyed Vicryl suture. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure very well and he was transferred to Recovery in stable condition. The patient had an abnormal chest x-ray in preop and is going for a CT of the chest in Recovery.

DIAGNOSES,1. Term pregnancy.,2. Possible rupture of membranes, prolonged.,PROCEDURE:, Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:, The patient is a 20-year-old female, gravida 4, para 0, who presented to the office. She had small amount of leaking since last night. On exam, she was positive Nitrazine, no ferning was noted. On ultrasound, her AFI was about 4.7 cm. Because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,She was brought to the hospital and begun on Pitocin. Once she was in her regular pattern, we ruptured her bag of water; fluid was clear. She went rapidly to completion over the next hour and a half. She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation. Upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications. The baby was vigorous, moving all extremities. The cord was clamped and cut. The baby was handed off to mom with nurse present. Apgars were 8 and 9. Placenta was delivered spontaneously, intact. Three-vessel cord with no retained placenta. Estimated blood loss was about 150 mL. There were no tears.

REASON FOR CONSULT:, Evaluation of alcohol withdrawal and dependance as well as evaluation of anxiety.,HISTORY OF PRESENT ILLNESS: , This is a 50-year-old male who was transferred from Sugar Land ER to ABCD Hospital for admission to the MICU for acute alcohol withdrawal. The patient had been on a drinking binge for the past 12 days prior to admission and had not been eating. He reported that he called 911 secondary to noticing bilious vomiting and dry heave. The patient has been drinking for the past 25 years and has noted it to be a problem for at least the past 3 years. He has been away from work secondary to alcohol cravings and drinking. He has also experienced marital and family conflict as a result of his drinking habit. On average, the patient drinks 5 to 8 glasses or cups of vodka or rum per day, and on the weekend, he tends to drink more heavily. He reports a history of withdrawal symptoms, but denied history of withdrawal seizures. His longest period of sobriety was one year, and this was due to the assistance of attending AA meetings. The patient reports problems with severe insomnia, more so late insomnia and low self esteem as a result of feeling guilty about what he has done to his family due to his drinking habit. He reports anxiety that is mostly related to concern about his wife's illness and fear of his wife leaving him secondary to his drinking habits. He denies depressive symptoms. He denies any psychotic symptoms or perceptual disturbances. There are no active symptoms of withdrawal at this time.,PAST PSYCHIATRIC HISTORY: , There are no previous psychiatric hospitalizations or evaluations. The patient denies any history of suicidal attempts. There is no history of inpatient rehabilitation programs. He has attended AA for periodic moments throughout the past few years. He has been treated with Antabuse before.,PAST MEDICAL HISTORY:, The patient has esophagitis, hypertension, and fatty liver (recently diagnosed).,MEDICATIONS: , His outpatient medications include Lotrel 30 mg p.o. q.a.m. and Restoril 30 mg p.o. q.h.s.,Inpatient medications are Vitamin supplements, potassium chloride, Lovenox 40 mg subcutaneously daily, Lactulose 30 mL q.8h., Nexium 40 mg IV daily, Ativan 1 mg IV p.r.n. q.6-8h.,ALLERGIES:, No known drug allergies.,FAMILY HISTORY: , Distant relatives with alcohol dependance. No other psychiatric illnesses in the family.,SOCIAL HISTORY:, The patient has been divorced twice. He has two daughters one from each marriage, ages 15 and 22. He works as a geologist at Petrogas. He has limited contact with his children. He reports that his children's mothers have turned them against him. He and his wife have experienced marital discord secondary to his alcohol use. His wife is concerned that he may loose his job because he has skipped work before without reporting to his boss. There are no other illicit drugs except alcohol that the patient reports.,PHYSICAL EXAMINATION:, VITAL SIGNS: Temperature 98, pulse 89, and respiratory rate 20, and blood pressure is 129/83.,MENTAL STATUS EXAMINATION:, This is a well-groomed male. He appears his stated age. He is lying comfortably in bed. There are no signs of emotional distress. He is pleasant and engaging. There are no psychomotor abnormalities. No signs of tremulousness. His speech is with normal rate, volume, and inflection. Mood is reportedly okay. Affect euthymic. Thought content, no suicidal or homicidal ideations. No delusions. Thought perception, there are no auditory or visual hallucinations. Thought process, Logical and goal directed. Insight and judgment are fair. The patient knows he needs to stop drinking and knows the hazardous effects that drinking will have on his body.,LABORATORY DATA:, CBC: WBC 5.77, H&H 14 and 39.4 respectively, and platelets 102,000. BMP: Sodium 140, potassium 3, chloride 104, bicarbonate 26, BUN 13, creatinine 0.9, glucose 117, calcium 9.5, magnesium 2.1, phosphorus 2.9, PT 13.4, and INR 1.0. LFTs: ALT 64, AST 69, direct bilirubin 0.5, total bilirubin 1.3, protein 5.8, and albumin 4.2. PFTs within normal limits.,IMAGING:, CAT scan of the abdomen and pelvis reveals esophagitis and fatty liver. No splenomegaly.,ASSESSMENT:, This is a 50-year-old male with longstanding history of alcohol dependence admitted secondary to alcohol withdrawal found to have derangement in liver function tests and a fatty liver. The patient currently has no signs of withdrawal. The patient's anxiety is likely secondary to situation surrounding his wife and their marital discord and the effect of chronic alcohol use. The patient had severe insomnia that is likely secondary to alcohol use. Currently, there are no signs of primary anxiety disorder in this patient.,DIAGNOSES:, Axis I: Alcohol dependence.,Axis II: Deferred.,Axis III: Fatty liver, esophagitis, and hypertension.,Axis IV: Marital discord, estranged from children.,Axis V: Global assessment of functioning equals 55.,RECOMMENDATIONS:,1. Continue to taper off p.r.n. Ativan and discontinue all Ativan prior to discharge, benzodiazepine use, also on the same receptor as alcohol and prolonged use can cause relapse in the patient. Discontinue outpatient Restoril. The patient has been informed of the hazards of using benzodiazepines along with alcohol.,2. Continue Alcoholics Anonymous meetings to maintain abstinence.,3. Recommend starting Campral 666 mg p.o. t.i.d. to reduce alcohol craving.,4. Supplement with multivitamin, thiamine, and folate upon discharge and before. Marital counseling strongly advised as well as individual therapy for patient once sobriety is reached. Referral has been given to the patient and his wife for the sets of counseling #713-263-0829.,5. Alcohol education and counseling provided during consultation.,6. Trazodone 50 mg p.o. q.h.s. for insomnia.,7. Follow up with PCP in 1 to 2 weeks.

PREOPERATIVE DIAGNOSIS:, Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Left inguinal hernia.,ANESTHESIA:, General; 0.25% Marcaine at trocar sites.,NAME OF OPERATION:, Laparoscopic left inguinal hernia repair.,PROCEDURE: , A skin incision was placed at the umbilicus where the left rectus fascia was incised anteriorly. The rectus muscle was retracted laterally. Balloon dissector was passed below the muscle and above the peritoneum. Insufflation and deinsufflation were done with the balloon removed. The structural balloon was placed in the preperitoneal space and insufflated to 10 mmHg carbon dioxide. The other trocars were placed in the lower midline times two. The hernia sac was easily identified and was well defined. It was dissected off the cord anteromedially. It was an indirect sac. It was taken back down and reduced into the peritoneal cavity. Mesh was then tailored and placed overlying the defect, covering the femoral, indirect, and direct spaces, tacked into place. After this was completed, there was good hemostasis. The cord, structures, and vas were left intact. The trocars were removed. The wounds were closed with 0 Vicryl for the fascia, 4-0 for the skin. Steri-Strips were applied. The patient was awakened and carried to the recovery room in good condition, having tolerated the procedure well.

PREPROCEDURE DIAGNOSIS: , History of colon polyps and partial colon resection, right colon.,POSTPROCEDURE DIAGNOSES: ,1. Normal operative site. ,2. Mild diverticulosis of the sigmoid colon. ,3. Hemorrhoids.,PROCEDURE: ,Total colonoscopy.,PROCEDURE IN DETAIL: ,The patient is a 60-year-old of Dr. ABC's being evaluated for the above. The patient also apparently had an x-ray done at the Hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed. She was prepped the night before and on the morning of the test with oral Fleet's, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push. Digital rectal exam was done, unremarkable. At that point, the Pentax video colonoscope was inserted. The rectal vault appeared normal. The sigmoid showed diverticula throughout, mild to moderate in nature. The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized. The scope was passed a short distance up the ileum, which appeared normal. The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area. The scope was then retroflexed, and anal verge visualized showed some hemorrhoids. The scope was then removed. The patient tolerated the procedure well.,RECOMMENDATIONS: ,Repeat colonoscopy in three years.

CHIEF COMPLAINT:, Status epilepticus.,HISTORY OF PRESENT ILLNESS: ,The patient is a 6-year-old male who is a former 27-week premature infant who suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis. At baseline, he can put about 2 to 4 words together in brief sentences. His speech is not always easily understood; however, he is in a special education classroom in kindergarten. He ambulates independently, but falls often. He has difficulty with his left side compared to the right, and prefers to use the right upper extremity more than the left. Mother reports he postures the left upper extremity when running. He is being followed by Medical Therapy Unit and has also been seen in the past by Dr. X. He has not received Botox or any other interventions with regard to his cerebral palsy.,The patient did require one shunt revision, but since then his shunt has done well.,The patient developed seizures about 2 years ago. These occurred periodically, but they are always in the same and with the involvement of the left side more than right and he had an eye deviation forcefully to the left side. His events, however, always tend to be prolonged. He has had seizures as long as an hour and a half. He tends to require multiple medications to stop them. He has been followed by Dr. Y and was started on Trileptal. At one point, The patient was taken off his medication for presumed failure to prevent his seizures. He was more recently placed on Topamax since March 2007. His last seizures were in March and May respectively. He is worked up to a dose of 25 mg capsules, 2 capsules twice a day or about 5 mg/kg/day at this point.,The patient was in his usual state of health until early this morning and was noted to be in seizure. His seizure this morning was similar to the previous seizures with forced deviation of his head and eyes to the left side and convulsion more on the left side than the right. Family administered Diastat 7.5 mg x1 dose. They did not know they could repeat this dose. EMS was called and he received lorazepam 2 mg and then in the emergency department, 15 mg/kg of fosphenytoin. His seizures stopped thereafter, since that time, he had gradually become more alert and is eating, and is nearly back to baseline. He is a bit off balance and tends to be a bit weaker on the left side compared to baseline postictally.,REVIEW OF SYSTEMS: , At this time, he is positive for a low-grade fever, he has had no signs of illness otherwise. He does have some fevers after his prolonged seizures. He denies any respiratory or cardiovascular complaints. There is no numbness or loss of skills. He has no rashes, arthritis or arthralgias. He has no oropharyngeal complaints. Visual or auditory complaints.,PAST MEDICAL HISTORY: , Also positive for some mild scoliosis.,SOCIAL HISTORY: , The patient lives at home with mother, father, and 2 other siblings. There are no ill contacts.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL: The patient is a well-nourished, well-hydrated male, in no acute distress.,VITAL SIGNS: His vital signs are stable and he is currently afebrile.,HEENT: Atraumatic and normocephalic. Oropharynx shows no lesions.,NECK: Supple without adenopathy.,CHEST: Clear to auscultation.,CARDIOVASCULAR: Regular rate and rhythm, no murmurs.,ABDOMEN: Benign without organomegaly.,EXTREMITIES: No clubbing, cyanosis or edema.,NEUROLOGIC: The patient is alert and will follow instructions. His speech is very dysarthric and he tends to run his words together. He is about 50% understandable at best. He does put words and sentences together. His cranial nerves reveal his pupils are equal, round, and reactive to light. His extraocular movements are intact. His visual fields are full. Disks are sharp bilaterally. His face shows left facial weakness postictally. His palate elevates midline. Vision is intact bilaterally. Tongue protrudes midline.,Motor exam reveals clearly decreased strength on the left side at baseline. His left thigh is abducted at the hip at rest with the right thigh and leg straight. He has difficulty using the left arm and while reaching for objects, shows exaggerated tremor/dysmetria. Right upper extremity is much more on target. His sensations are intact to light touch bilaterally. Deep tendon reflexes are 2+ and symmetric. When sitting up, he shows some truncal instability and tendency towards decreased truncal tone and kyphosis. He also shows some scoliotic curve of the spine, which is mild at this point. Gait was not tested today.,IMPRESSION: , This is a 6-year-old male with recurrent status epilepticus, left hemiparesis, history of prematurity, and intraventricular hemorrhage. He is on Topamax, which is at a moderate dose of 5 mg/kg a day or 50 mg twice a day. At this point, it is not clear whether this medication will protect him or not, but the dose is clearly not at maximum, and he is tolerating the dose currently. The plan will be to increase him up to 50 mg in the morning, and 75 mg at night for 2 weeks, and then 75 mg twice daily. Reviewed the possible side effects of higher doses of Topamax, they will monitor him for language issues, cognitive problems or excessive somnolence. I also discussed his imaging studies, which showed significant destruction of the cerebellum compared to other areas and despite this, the patient at baseline has a reasonable balance. The plan from CT standpoint is to continue stretching program, continue with medical therapy unit. He may benefit from Botox.,In addition, I reviewed the Diastat protocol with parents and given the patient tends to go into status epilepticus each time, they can administer Diastat immediately and not wait the standard 2 minutes or even 5 minutes that they were waiting before. They are going to repeat the dose within 10 minutes and they can call EMS at any point during that time. Hopefully at home, they need to start to abort these seizures or the higher dose of Topamax will prevent them. Other medication options would include Keppra, Zonegran or Lamictal.,FOLLOWUP: , Followup has already been scheduled with Dr. Y in February and they will continue to keep that date for followup.

PREOPERATIVE DIAGNOSIS: , Ovarian cancer.,POSTOPERATIVE DIAGNOSIS:, Ovarian cancer.,OPERATION PERFORMED:, Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance.,DETAILED OPERATIVE NOTE:, The patient was placed on the operating table and placed under LMA general anesthesia in preparation for insertion of a Port-A-Catheter. The chest was prepped and draped in the routine fashion for insertion of a Port-A-Catheter. The left subclavian vein was punctured with a single stick and a guidewire threaded through the needle into the superior vena cava under fluoroscopic guidance. The needle was removed. An incision was made over the guidewire for entrance of the dilator with sheath. A second counter incision was made transversally on the chest wall about an inch and half below the puncture site with a #15 blade. Hemostasis was effective to electrocautery, and a pocket was fashioned subcutaneously for positioning of the reservoir. The Port-A-Catheter reservoir tubing was attached to the reservoir in the routine fashion. The reservoir was placed in the pocket and sutured to the anterior chest wall muscle with three interrupted 4-0 Prolene sutures for stability. Next, a catheter passer was passed from the pocket exiting through the skin at the puncture site, previously placed for the guidewire, and the Port-A-Catheter was pulled from the reservoir exiting on the skin. It was placed on the chest, measured, and cut to the appropriate length. This having been done, the dilator with sheath attached was passed over the guidewire into the superior vena cava under fluoroscopic guidance. The guidewire and dilator were removed, and the Port-A-Catheter was threaded through the sheath into the superior vena cava, and the sheath removed under fluoroscopic guidance. Fluoroscopy revealed the Port-A-Catheter to be in excellent position. The Port-A-Catheter was accessed with a butterfly 90-degree needle percutaneously that drew blood well and flushed easily. It was flushed with heparinized saline connected in cath. This having been done, the puncture site was closed with a circumferential subcutaneous 3-0 Vicryl suture, and the skin was closed with a percutaneous circumferential subcuticular suture. This having been done, attention was applied to the reservoir incision. It was closed with two layers of continuous 3-0 Vicryl suture, and the skin was closed with a continuous 3-0 Monocryl subcuticular stitch. A dry sterile dressing was applied, and the patient having tolerated the procedure was transferred to the recovery room for postoperative care.

HISTORY OF PRESENT ILLNESS:, Patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today. He did not note any immediate reaction. Since that time, he has noted some increasing redness and swelling to his left hand, but he denies any generalized symptoms such as itching, hives, or shortness of breath. He denies any sensation of tongue swelling or difficulty swallowing.,The patient states he was stung approximately one month ago without any serious reaction. He did windup taking Benadryl at that time. He has not taken anything today for his symptoms, but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day.,ALLERGIES: , HE DOES HAVE MEDICATION INTOLERANCES TO SULFA DRUGS (HEADACHE), MORPHINE (NAUSEA AND VOMITING), AND TORADOL (ULCER).,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife, who is here with him.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Temp and vital signs are all within normal limits.,GENERAL: In general, the patient is an elderly white male who is sitting on the stretcher in no acute distress.,HEENT: Head is normocephalic and atraumatic. The face shows no edema. The tongue is not swollen and the airway is widely patent.,NECK: No stridor.,HEART: Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS: Clear without rales, rhonchi, or wheezes.,EXTREMITIES: Upper extremities, there is some edema and erythema to the dorsum of the left hand in the region of the distal third to fifth metacarpals. There was some slight edema of the fourth digit, on which he still is wearing his wedding band. The right hand shows no reaction. The right knee is not swollen either.,The left fourth digit was wrapped in a rubber tourniquet to express the edema and using some Surgilube, I was able to remove his wedding band without any difficulty. Patient was given Claritin 10 mg orally for what appears to be a simple local reaction to an insect sting. I did explain to him that his swelling and redness may progress over the next few days.,ASSESSMENT: , Local reaction secondary to insect sting.,PLAN: , The patient was reassured that this is not a serious reaction to an insect sting and he should not progress to such a reaction. I did urge him to use Claritin 10 mg once daily until the redness and swelling has gone. I did explain that the swelling may worsen over the next two to three days, it may produce a large local reaction, but that anti-histamines were still the mainstay of therapy for such a reaction. If he is not improved in the next four days, follow up with his PCP for a re-exam.

PREOPERATIVE DIAGNOSIS:, Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS: ,Rule out temporal arteritis.,PROCEDURE:, Bilateral temporal artery biopsy.,ANESTHESIA:, Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:, I was consulted by Dr. X for this patient with bilateral temporal headaches to rule out temporal arteritis. I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way. After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery. The temporal artery was identified and was grossly normal on both sides. Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult. The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm. They were sent as separate specimens, right and left labeled. The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond. She tolerated the procedure well.

DIAGNOSIS: , Cognitive linguistic impairment secondary to stroke.,NUMBER OF SESSIONS COMPLETED:, 5,HOSPITAL COURSE: ,The patient is a 73-year-old female who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits. Based on the initial evaluation completed 12/29/08, the patient had mild difficulty with generative naming and auditory comprehension and recall. The patient's skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities. At this time, the patient has accomplished all 5 of her short-term therapy goals. She is able to complete functional mass tasks with 100% accuracy independently. She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently.,She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently. She is able to state 15 items in a broad category within a minute and a half independently. The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100% accuracy independently. The patient also met her long-term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home. The patient is no longer in need of skilled speech therapy and is discharged from my services. She did quite well in therapy and also agreed with this discharge.

PREOPERATIVE DIAGNOSIS:, Right both bone forearm refracture.,POSTOPERATIVE DIAGNOSIS: , Right both bone forearm refracture.,PROCEDURE:, Closed reduction and pinning of the right ulna with placement of a long-arm cast.,ANESTHESIA: , Surgery performed under general anesthesia. Local anesthetic was 10 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HARDWARE: ,Hardware was 0.79 K-wire.,HISTORY AND PHYSICAL: , The patient is a 5-year-old male who sustained refracture of his right forearm on 12/05/2007. The patient was seen in the emergency room. The patient had a complete fracture of both bones with shortening bayonet apposition. Treatment options were offered to the family including casting versus closed reduction and pinning. The parents opted for the latter. Risks and benefits of surgery were discussed. Risks of surgery included risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, cast tightness. All questions were answered, and the parents agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was then administered. The patient received Ancef preoperatively. The right upper extremity was then prepped and draped in standard surgical fashion. A small incision was made at the tip of the olecranon. Initially, a 1.11 guidewire was placed, but this was noted to be too wide for this canal. This was changed for a 0.79 K-wire. This was driven up to the fracture site. The fracture was manually reduced and then the K-wire passed through the distal segment. This demonstrated adequate fixation and reduction of both bones. The pin was then cut short. The fracture site and pin site was infiltrated with 0.25% Marcaine. The incision was closed using 4-0 Monocryl. The wounds were cleaned and dried. Dressed with Xeroform, 4 x 4. The patient was then placed in a well-moulded long-arm cast. He tolerated the procedure well. He was subsequently taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be maintain current pin, and long-arm cast for 4 weeks at which time he will return for cast removal. X-rays of the right forearm will be taken. The patient may need additional mobilization time. Once the fracture has healed, we will take the pin out, usually at the earliest 3 to 4 months. Intraoperative findings were relayed to the parents. All questions were answered.

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.,

PREOPERATIVE DIAGNOSIS:, Benign prostatic hyperplasia.,POSTOPERATIVE DIAGNOSIS:, Benign prostatic hyperplasia.,OPERATION PERFORMED: , Transurethral electrosurgical resection of the prostate.,ANESTHESIA: , General.,COMPLICATIONS:, None.,INDICATIONS FOR THE SURGERY:, This is a 77-year-old man with severe benign prostatic hyperplasia. He has had problem with urinary retention and bladder stones in the past. He will need to have transurethral resection of prostate to alleviate the above-mentioned problems. Potential complications include, but are not limited to:,1. Infection.,2. Bleeding.,3. Incontinence.,4. Impotence.,5. Formation of urethral strictures.,PROCEDURE IN DETAIL: , The patient was identified, after which he was taken into the operating room. General LMA anesthesia was then administered. The patient was given prophylactic antibiotic in the preoperative holding area. The patient was then positioned, prepped and draped. Cystoscopy was then performed by using a #26-French continuous flow resectoscopic sheath and a visual obturator. The prostatic urethra appeared to be moderately hypertrophied due to the lateral lobes and a large median lobe. The anterior urethra was normal without strictures or lesions. The bladder was severely trabeculated with multiple bladder diverticula. There is a very bladder diverticula located in the right posterior bladder wall just proximal to the trigone. Using the ***** resection apparatus and a right angle resection loop, the prostate was resected initially at the area of the median lobe. Once the median lobe has completely resected, the left lateral lobe and then the right lateral lobes were taken down. Once an adequate channel had been achieved, the prostatic specimen was retrieved from the bladder by using an Ellik evacuator. A 3-mm bar electrode was then introduced into the prostate to achieve perfect hemostasis. The sheath was then removed under direct vision and a #24-French Foley catheter was then inserted atraumatically with pinkish irrigation fluid obtained. The patient tolerated the operation well.

PREOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,POSTOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,PROCEDURE PERFORMED:, Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.,ANESTHESIA: ,Scalene block with general anesthesia.,ESTIMATED BLOOD LOSS: , 30 cc.,COMPLICATIONS: , None.,DISPOSITION: ,The patient went to the PACU stable.,GROSS OPERATIVE FINDINGS: , There was no overt pathology of the biceps tendon. There was some softening and loss of the articular cartilage over the glenoid. The labrum was ________ attached permanently to the glenoid. The biceps tendon was nonsubluxable. Upon ranging of the shoulder in internal and external rotation showed no evidence of rotator cuff tear on the articular side. Subacromial space did show excessive soft tissue causing some overstuffing of the subacromial space. There was reconstitution of the bursa noted as well.,HISTORY OF PRESENT ILLNESS:, This is a 51-year-old female had left shoulder pain of chronic nature who has had undergone prior rotator cuff debridement in May with partial pain relief and has had continued pain in the left shoulder. MRI shows partial rotator cuff tear.,PROCEDURE: , The patient was taken to the operating room and placed in a beachchair position. After all bony prominences were adequately padded, the head was placed in the headholder with no excessive extension in the neck on flexion. The left extremity was prepped and draped in usual fashion. The #18 gauge needles were inserted into the left shoulder to locate the AC joint, the lateral aspect of the acromion as well as the pass of the first trocar to enter the shoulder joint from the posterior aspect. We took an #11 blade scalpel and made a small 1-cm skin incision posteriorly approximately 4-cm inferior and medial to the lateral port of the acromion. A blunt trocar was used to bluntly cannulate the joint and we put the camera into the shoulder at that point of the joint and instilled sterile saline to distend the capsule and begin our arthroscopic assessment of the shoulder. A second port was established superior to the biceps tendon anteriorly under direct arthroscopic visualization using #11 blade on the skin and inserted bluntly the trocar and the cannula. The operative findings found intra-articularly were as described previously gross operative findings. We did not see any evidence of acute pathology. We then removed all the arthroscopic instruments as well as the trocars and tunneled subcutaneously into the subacromial space and reestablished the portal and camera and inflow with saline. The subacromial space was examined and found to have excessive soft tissue and bursa that was in the subacromial space that we debrided using arthroscopic shaver after establishing a lateral portal. All this was done and hemostasis was achieved. The rotator cuff was examined from the bursal side and showed no evidence of tears. There was some fraying out laterally near its attachment over the greater tuberosity, which was debrided with the arthroscopic shaver. We removed all of our instruments and suctioned the subacromial space dry. A #4-0 nylon was used on the three arthroscopic portal and on the skin we placed sterile dressing and the arm was placed in an arm sling. She was placed back on the gurney, extubated and taken to the PACU in stable condition.

PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:, Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:, This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot. His family physician attempted to remove the wire, but it only became deeper in the foot. The wound eventually healed, but a scar tissue was formed. The patient has had constant pain with ambulation intermittently since the incident occurred. He desires attempted surgical removal of the wire. The risks and benefits of the procedure have been explained to the patient in detail by Dr. X. The consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection.,A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient's protection. After adequate IV sedation was administered by the Department of Anesthesia, a total of 12 cc of 0.5% Marcaine plain was used to administer an ankle block. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered into the operative field and the sterile stockinet was reflected. Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized. This was the origin and entry point of the previous puncture wound from the wire. This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area. Next, the Xi-scan was draped and brought into the operating room. A #25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire. Next, a #10 blade was used to make approximately a 3 cm curvilinear "S"-shaped incision. Next, the #15 blade was used to carry the incision through the subcutaneous tissue. The medial and lateral margins of the incision were undermined. Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot, the wires seemed to serve no benefit other then helping with the incision planning. Therefore, they were removed. Once the wound was opened, a hemostat was used to locate the wire very quickly and the wire was clamped. A second hemostat was used to clamp the wire. A #15 blade was used to carefully transect the fatty tissue around the tip of the hemostats, which were visualized in the base of the wound. The wire quickly came into visualization. It measured approximately 4 mm in length and was approximately 1 mm in diameter. The wire was green colored and metallic in nature. It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification. The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament. Next, copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected. Next, a #3-0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space. Next, #4-0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique. The standard postoperative dressing consisting of saline-soaked Owen silk, 4x4s, Kling, Kerlix, and Coban were applied. The pneumatic ankle tourniquet was released. There was immediate hyperemic flush to the digits noted. The patient's anesthesia was reversed. He tolerated the above anesthesia and procedure without complications. The patient was transported via cart to the Postanesthesia Care Unit.,Vital signs were stable and vascular status was intact to the right foot. He was given OrthoWedge shoe. Ice was applied behind the knee and his right lower extremity was elevated on to pillows. He was given standard postoperative instructions consisting of rest, ice and elevation to the right lower extremity. He is to be non-weightbearing for three weeks, at which time, the wound will be evaluated and sutures will be removed. He is to follow up with Dr. X on 08/22/2003 and was given emergency contact number to call if problems arise. He was given a prescription for Tylenol #4, #30 one p.o. q.4-6h. p.r.n., pain as well as Celebrex 200 mg #30 take two p.o. q.d. p.c., with 200 mg 12 hours later as a rescue dose. He was given crutches. He was discharged in stable condition.

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

CHIEF COMPLAINT:, Left knee pain.,SUBJECTIVE: , This is a 36-year-old white female who presents to the office today with a complaint of left knee pain. She is approximately five days after a third Synvisc injection. She states that the knee is 35% to 40 % better, but continues to have a constant pinching pain when she full weight bears, cannot handle having her knee in flexion, has decreased range of motion with extension. Rates her pain in her knee as a 10/10. She does alternate ice and heat. She is using Tylenol No. 3 p.r.n. and ibuprofen OTC p.r.n. with minimal relief.,ALLERGIES,1. PENICILLIN.,2. KEFLEX.,3. BACTRIM.,4. SULFA.,5. ACE BANDAGES.,MEDICATIONS,1. Toprol.,2. Xanax.,3. Advair.,4. Ventolin.,5. Tylenol No. 3.,6. Advil.,REVIEW OF SYSTEMS:, Will be starting the Medifast diet, has discussed this with her PCP, who encouraged her to have gastric bypass, but the patient would like to try this Medifast diet first. Other than this, denies any further problems with her eyes, ears, nose, throat, heart, lungs, GI, GU, musculoskeletal, nervous system, except what is noted above and below.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse 72, blood pressure 130/88, respirations 16, height 5 feet 6.5 inches.,GENERAL: This is a 36-year-old white female who is A&O x3, in no apparent distress with a pleasant affect. She is well developed, well nourished, appears her stated age.,EXTREMITIES: Orthopedic evaluation of the left knee reveals there to be well-healed portholes. She does have some medial joint line swelling. Negative ballottement. She has significant pain to palpation of the medial joint line, none of the lateral joint line. She has no pain to palpation on the popliteal fossa. Range of motion is approximately -5 degrees to 95 degrees of flexion. It should be noted that she has extreme hyperextension on the right with 95+ degrees of flexion on the right. She has a click with McMurray. Negative anterior-posterior drawer. No varus or valgus instability noted. Positive patellar grind test. Calf is soft and nontender. Gait is stable and antalgic on the left.,ASSESSMENT,1. Osteochondral defect, torn meniscus, left knee.,2. Obesity.,PLAN: , I have encouraged the patient to work on weight reduction, as this will only benefit her knee. I did discuss treatment options at length with the patient, but I think the best plan for her would be to work on weight reduction. She questions whether she needs a total knee; I don't believe she needs total knee replacement. She may, however, at some point need an arthroscopy. I have encouraged her to start formal physical therapy and a home exercise program. Will use ice or heat p.r.n. I have given her refills on Tylenol No. 3, Flector patch, and Relafen not to be taken with any other anti-inflammatory. She does have some abdominal discomfort with the anti-inflammatories, was started on Nexium 20 mg one p.o. daily. She will follow up in our office in four weeks. If she has not gotten any relief with formal physical therapy and the above-noted treatments, we will discuss with Dr. X whether she would benefit from another knee arthroscopy. The patient shows a good understanding of this treatment plan and agrees.

HEENT:, No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.,GASTROINTESTINAL:, No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems.,GENITOURINARY: , No dysuria, hematuria, frequency, incontinence or colic.,NERVOUS SYSTEM: , No gait problems, strokes, numbness or muscle weakness.,PSYCHIATRIC: , No history of emotional lability, depression or sleep disturbances.,ONCOLOGIC:, No history of any cancer, change in moles or rashes. No history of weight loss. The patient has a good energy level.,ALLERGIC/LYMPH: , No history of systemic allergy, abnormal lymph nodes or swelling.,MUSCULOSKELETAL: , No fractures, motor weakness, arthritis or other joint pains.

PREOPERATIVE DIAGNOSIS:, Right middle lobe lung cancer.,POSTOPERATIVE DIAGNOSIS: , Right middle lobe lung cancer.,PROCEDURES PERFORMED:,1. VATS right middle lobectomy.,2. Fiberoptic bronchoscopy thus before and after the procedure.,3. Mediastinal lymph node sampling including levels 4R and 7.,4. Tube thoracostomy x2 including a 19-French Blake and a 32-French chest tube.,5. Multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.,ANESTHESIA: ,General endotracheal anesthesia with double-lumen endotracheal tube.,DISPOSITION OF SPECIMENS: , To pathology both for frozen and permanent analysis.,FINDINGS:, The right middle lobe tumor was adherent to the anterior chest wall. The adhesion was taken down, and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis. The final frozen pathology on this entire area returned as negative for tumor. Additional chest wall abnormalities were biopsied and sent for pathologic analysis, and these all returned separately as negative for tumor and only fibrotic tissue. Several other biopsies were taken and sent for permanent analysis of the chest wall. All of the biopsy sites were additionally marked with Hemoclips. The right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE:, This patient is well known to our service. He was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control. The patient was subsequently taken to the operating room on April 4, 2007, was given general anesthesia and was endotracheally intubated without incident. Although, he had markedly difficult airway, the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi. No abnormalities were noted in the entire tracheobronchial tree, and based on this, the decision was made to proceed with the surgery. The patient was kept in the supine position, and the single-lumen endotracheal tube was removed and a double-lumen tube was placed. Following this, the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded. Sterile DuraPrep preparation on the right chest was placed. A sterile drape around that was also placed. The table was flexed to open up the intercostal spaces. A second bronchoscopy was performed to confirm placement of the double-lumen endotracheal tube. Marcaine was infused into all incision areas prior to making an incision. The incisions for the VATS right middle lobectomy included a small 1-cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula. The camera port was in the posterior axillary line in the eighth intercostal space through which a 5-mm 30-degree scope was used. Third incision was an anterior port, which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space, and the third incision was a utility port, which was a 4 cm long incision, which was approximately one rib space below the superior pulmonary vein. All of these incisions were eventually created during the procedure. The initial incision was the camera port through which, under direct visualization, an additional small 5-mm port was created just inferior to the anterior port. These two ports were used to identify the chest wall lesions, which were initially thought to be metastatic lesions. Multiple biopsies of the chest wall lesions were taken, and the decision was made to also insert the auscultatory incision port. Through these three incisions, the initial working of the diagnostic portion of the chest wall lesion was performed. Multiple biopsies were taken of the entire chest wall offers and specimens came back as negative. The right middle lobe was noted to be adherent to the anterior chest wall. This area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis. This also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue, but no tumor cells. Based on this, the decision was made to not proceed with chest wall resection and continue with right middle lobectomy. Following this, the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed. The middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45-mm EndoGIA stapler. Following division of the right superior pulmonary vein, the right middle lobe bronchus was easily identified. Initially, this was thought to be the main right middle lobe bronchus, but in fact it was the medial branch of the right middle lobe bronchus. This was encircled and divided with a blue load stapler with a 45-mm EndoGIA. Following division of this, the pulmonary artery was easily identified. Two branches of the pulmonary artery were noted to be going into the right middle lobe. These were individually divided with a vascular load after encircling with a right angle clamp. The vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk, and following this, an additional branch of the bronchus was noted to be going to the right middle lobe. A fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus. This was divided with a blue load stapler 45 mm EndoGIA. Following division of this, the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe. Following complete division of the fissure, the lobe was put into an EndoGIA bag and taken out through the utility port. Following removal of the right middle lobe, a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4R area as well as the 7 lymph node package. Node station 8 or 9 nodes were easily identified, therefore none were taken. The patient was allowed to ventilate under water on the right lung with no obvious air leaking noted. A 19-French Blake was placed into the posterior apical position and a 32-French chest tube was placed in the anteroapical position. Following this, the patient's lung was allowed to reexpand fully, and the patient was checked for air leaking once again. Following this, all the ports were closed with 2-0 Vicryl suture used for the deeper tissue, and 3-0 Vicryl suture was used to reapproximate the subcutaneous tissue and 4-0 Monocryl suture was used to close the skin in a running subcuticular fashion. The patient tolerated the procedure well, was extubated in the operating room and taken to the recovery room in stable condition.

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.

PREOPERATIVE DIAGNOSIS:, Posterior mediastinal mass with possible neural foraminal involvement.,POSTOPERATIVE DIAGNOSIS: , Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).,OPERATION PERFORMED:, Left thoracotomy with resection of posterior mediastinal mass.,INDICATIONS FOR PROCEDURE: ,The patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina. For this reason, Dr. X and I agreed to operate on this patient together. Please note that two surgeons were required for this case due to the complexity of it. The indications and risks of the procedure were explained and the patient gave her informed consent.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating suite and placed in the supine position. General endotracheal anesthesia was given with a double lumen tube. The patient was positioned for a left thoracotomy. All pressure points were carefully padded. The patient was prepped and draped in usual sterile fashion. A muscle sparing incision was created several centimeters anterior to the tip of the scapula. The serratus and latissimus muscles were retracted. The intercostal space was opened. We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization. Through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass. This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta. The lung was deflated and allowed to retract anteriorly. With a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass. We began by opening the tumor and taking a very wide large biopsy. This was sent for frozen section, which revealed a benign nerve sheath tumor. Then, using the occluder device Dr. X was able to _____ the inferior portions of the mass. This left the external surface of the mass much more malleable and easier to retract. Using a bipolar cautery and endoscopic scissors we were then able to completely resect it. Once the tumor was resected, it was then sent for permanent sections. The entire hemithorax was copiously irrigated and hemostasis was complete. In order to prevent any lymph leak, we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space. A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace. The wounds were then closed in multiple layers. A #2 Vicryl was used to approximate the ribs. The muscles of the chest wall were allowed to return to their normal anatomic position. A 19 Blake was placed in the subcutaneous tissues. Subcutaneous tissues and skin were closed with running absorbable sutures. The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition.

HISTORY: , The patient is a 52-year-old right-handed female with longstanding bilateral arm pain, which is predominantly in the medial aspect of her arms and hands as well as left hand numbness, worse at night and after doing repetitive work with her left hand. She denies any weakness. No significant neck pain, change in bowel or bladder symptoms, change in gait, or similar symptoms in the past. She is on Lyrica for the pain, which has been somewhat successful.,Examination reveals positive Phalen's test on the left. Remainder of her neurological examination is normal.,NERVE CONDUCTION STUDIES: ,The left median motor distal latency is prolonged with normal evoked response amplitude and conduction velocity. The left median sensory distal latency is prolonged with an attenuated evoked response amplitude. The right median sensory distal latency is mildly prolonged with a mildly attenuated evoked response amplitude. The right median motor distal latency and evoked response amplitude is normal. Left ulnar motor and sensory and left radial sensory responses are normal. Left median F-wave is normal.,NEEDLE EMG:, Needle EMG was performed on the left arm, right first dorsal interosseous muscle, and bilateral cervical paraspinal muscles. It revealed spontaneous activity in the left abductor pollicis brevis muscle. There is increased insertional activity in the right first dorsal interosseous muscle. Both interosseous muscles showed signs of reinnervation. Left extensor digitorum communis muscle showed evidence of reduced recruitment. Cervical paraspinal muscles were normal.,IMPRESSION: , This electrical study is abnormal. It reveals the following: A left median neuropathy at the wrist consistent with carpal tunnel syndrome. Electrical abnormalities are moderate-to-mild bilateral C8 radiculopathies. This may be an incidental finding.,I have recommended MRI of the spine without contrast and report will be sent to Dr. XYZ. She will follow up with Dr. XYZ with respect to treatment of the above conditions.

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.

GENERAL EVALUATION:,Fetal Cardiac Activity: Normal with a heart rate of 135BPM,Fetal Presentation: Cephalic.,Placenta: Anterior,Placentral grade: II,Previa: ? None.,Amniotic Fluid: 1.5 + 2.5 + 0.0 + 0.0 = 4cm compatible with oligohydramnios.,BIOMETRY:,BPD: 9.0cm consistent with 36weeks, 4days gestation,HC: 34.6cm which equals 40weeks and 1day gestational age.,FL: 6.9cm which equals 35weeks and 3days gestational age.,AC: 34.6cm which equals 38weeks and 4days gestational age.,CI (BPD/OFD): (70-86) 73,FL/BPD: (71-87) 77,FL/HC: (20.8-22.6) 19.9,FL/AC (20-24) 20,HC/AC: (0.92-1.05) 1.00,GESTATIONAL AGE BY CURRENT ULTRASOUND: 37weeks 4days.,FETAL WEIGHT BY CURRENT ULTRASOUND: 3289grams (7pounds 4ounces).,ESTIMATED FETAL WEIGHT PERCENTILE: 24%.,EDD BY CURRENT ULTRASOUND: 06/04/07.,GESTATIONAL AGE BY DATES: 40weeks 0days.,L M P: Unknown.,EDD BY DATES: 05/18/07.,DATE OF PREVIOUS ULTRASOUND: 03/05/07.,EDD BY PREVIOUS ULTRASOUND: 05/24/07.,FETAL ANATOMY:,Fetal Ventricles: Normal,Fetal Cerebellum: Normal,Fetal Cranium: Normal,Fetal Face: Normal Nose and Mouth,Fetal Heart (4 Chamber View): Normal,Fetal Diaphragm: Normal,Fetal Stomach: Normal,Fetal Cord: Normal three-vessel cord,Fetal Abdominal Wall: Normal,Fetal Spine: Normal,Fetal Kidneys: Normal,Fetal Bladder: Normal,Fetal Limbs: Normal,IMPRESSION:,Active intrauterine pregnancy with a sonographic gestational age of 37weeks and 4days.,AFI=4cm compatible with mild oligohydramnios.,Fetal weight equals 3289grams (7pounds 4ounces). EFW percentile is 24%.,Placental grade is II.,No evidence of gross anatomical abnormality, with a biophysical profile total equal to 8 out of 8.,

XYZ, O.D.,RE: ABC,DOB: MM/DD/YYYY,Dear XYZ:,Thank you very much for your kind referral of Mrs. ABC who you referred to me for narrow angles and possible associated glaucoma. I examined Mrs. ABC initially on MM/DD/YYYY. At that time, she expressed a chief concern of occasional pain around her eye, but denied any flashing lights, floaters, halos, or true brow ache. She reports a family history of glaucoma in her mother, but is unsure of the specific kind. Her past ocular history has been fairly unremarkable. As you know, she has a history of non-insulin dependent diabetes. She is unaware of her last hemoglobin A1c levels, but reports a blood sugar of 158 taken on the morning of her appointment with me. She is followed by Dr. X here locally.,Upon examination, her visual acuity measured 20/20-1 in either eye with her glasses. Presenting intraocular pressures were14 mmHg in either eye at 2:03 p.m. Pupillary reactions, confrontational visual fields, and ocular motility were normal. The slit lamp exam revealed narrow anterior chambers and on gonioscopy only the buried anterior trabecular meshwork was visible in either eye, but the angle deepened with gonio-compression suggesting appositional and not synechial closure. I deferred the dilated portion of the exam on that day.,We proceeded with peripheral iridectomies and following this upon her most recent visit on MM/DD/YYYY, I was able to safely dilate her eyes as her chambers had deepened and the PIs were patent. I note that she has an increased CD ratio measuring 0.65 in the right eye and 0.7 in the left and although her FDT visual fields and GDX testing were normal at your office, she does have an enlarged blind spot in either eye on Humphrey visual fields and retinal tomography also shows some suspicious changes. Therefore, I feel she has sustained some optic nerve damage perhaps from intermittent angle closure in the past.,In summary, Mrs. ABC has a history of narrow angles not successfully treated with laser PIs. Her intraocular pressures have remained stable. I will continue to monitor her closely.,Thank you very much once again for allowing me to have shared in her care. If I can provide any additional information or be of further service, do let me know.,Sincerely,,

SUBJECTIVE:, The patient's assistant brings in her food diary sheets. The patient says she stays active by walking at the mall.,OBJECTIVE:, Weight today is 201 pounds, which is down 3 pounds in the past month. She has lost a total of 24 pounds. I praised this and encouraged her to continue. I went over her food diary. I praised her three-meal pattern and all of her positive food choices, especially the use of sugar-free Kool-Aid, sugar-free Jell-O, sugar-free lemonade, diet pop, as well as the variety of foods she is using in her three-meal pattern. I encouraged her to continue all of this.,ASSESSMENT:, The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity. She needs to continue all this.,PLAN:, Followup is set for 06/13/05 to check the patient's weight, her food diary, and answer any questions.

ADMISSION DIAGNOSES:,1. Pneumonia, failed outpatient treatment.,2. Hypoxia.,3. Rheumatoid arthritis.,DISCHARGE DIAGNOSES:,1. Atypical pneumonia, suspected viral.,2. Hypoxia.,3. Rheumatoid arthritis.,4. Suspected mild stress-induced adrenal insufficiency.,HOSPITAL COURSE: , This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission. She was seen on multiple occasions at Urgent Care and in her physician's office. Initial x-ray showed some mild diffuse patchy infiltrates. She was first started on Avelox, but had a reaction, switched to Augmentin, which caused loose stools, and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin. Her O2 saturations drifted downward. They were less than 88% when active; at rest, varied between 88% and 92%. Decision was made because of failed outpatient treatment of pneumonia. Her medical history is significant for rheumatoid arthritis. She is on 20 mg of methotrexate every week as well as Remicade every eight weeks. Her last dose of Remicade was in the month of June. Hospital course was relatively unremarkable. CT scan was performed and no specific focal pathology was seen. Dr. X, pulmonologist was consulted. He also was uncertain as to the exact etiology, but viral etiology was most highly suspected. Because of her loose stools, C. difficile toxin was ordered, although that is pending at the time of discharge. She was continued on Rocephin IV and azithromycin. Her fever broke 18 hours prior to discharge, and O2 saturations improved, as did her overall strength and clinical status. She was instructed to finish azithromycin. She has two pills left at home. She is to follow up with Dr. X in two to three days. Because she is on chronic prednisone therapy, it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia. She is to continue the increased dose of prednisone at 20 mg (up from 5 mg per day). We will consult her rheumatologist as to whether to continue her methotrexate, which we held this past Friday. Methotrexate is known on some occasions to cause pneumonitis.

CURRENT HISTORY:, A 94-year-old female from the nursing home with several days of lethargy and anorexia. She was found to have evidence of UTI. She also has renal insufficiency and digitalis toxicity. She is admitted for further treatment.,Past medical history, social history, family history, physical examination can be seen on the admission H&P.,LABORATORIES ON ADMISSION: , White count 11,700, hemoglobin 12.8, hematocrit 37.2, BUN 91, creatinine 2.2, sodium 131, potassium 5.1. Digoxin level of 4.1.,HOSPITAL COURSE: , The patient was admitted and intravenous fluids and antibiotics were administered. Blood cultures were negative. Urine cultures were nondiagnostic. Renal function improved with creatinine down to 1 at the time of discharge. Digoxin was restarted at a lower dose. Her condition improved and she is stabilized and transferred back to assisted living in good condition.,PRIMARY DIAGNOSES:,1. Urinary tract infection.,2. Volume depletion.,3. Renal insufficiency.,4. Digitalis toxicity.,SECONDARY DIAGNOSES:,1. Aortic valve stenosis.,2. Congestive heart failure.,3. Hypertension.,4. Chronic anemia.,5. Degenerative joint disease.,6. Gastroesophageal reflux disease.,PROCEDURES:, None.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Improved and stable.,DISCHARGE PLAN: ,Physical activity: With assistance. ,Diet: No restriction. ,Medications: Lasix 40 mg daily, lisinopril 5 mg daily, digoxin 0.125 mg daily, Augmentin 875 mg 1 tablet twice a day for 1 week, Nexium 40 mg daily, Elavil 10 mg at bedtime, Detrol 2 mg twice a day, potassium 10 mEq daily and diclofenac 50 mg twice a day. ,Follow up: She will see Dr. X in the office as scheduled.

PAST MEDICAL CONDITION:, None.,ALLERGIES:, None.,CURRENT MEDICATION:, Zyrtec and hydrocodone 7.5 mg one every 4 to 6 hours p.r.n. for pain.,CHIEF COMPLAINT: , Back injury with RLE radicular symptoms.,HISTORY OF PRESENT ILLNESS:, The patient is a 52-year-old male who is here for independent medical evaluation. The patient states that he works for ABC ABC as a temporary worker. He worked for ABCD too. The patient's main job was loading and unloading furniture and appliances for the home. The patient was approximately there for about two and a half weeks. Date of injury occurred back in October. The patient stating that he had history of previous back problems ongoing; however, he states that on this particular day back in October, he was unloading an 18-wheeler at ABC and he was bending down picking up boxes to unload and load. Unfortunately at this particular event, the patient had sharp pain in his lower back. Soon afterwards, he had radiating symptoms down his right buttock all the way down to the lateral part of his leg crossing his knee. This became progressively worse. He also states that some of his radiating pain went down to his left leg as well. He noticed increase in buttock spasm and also noticed spasm in his buttocks. He initially saw Dr. Z and was provided with some muscle relaxer and was given some pain patches or Lidoderm patch, I believe. The patient states that after this treatment, his symptoms still persisted. At this point, the patient later on was referred to Dr. XYZ through the workmen's comp and he was initially evaluated back in April. After the evaluation, the patient was sent for MRI, was provided with pain medications such as short-acting opioids. He was put on restricted duty. The MRI essentially came back negative, but the patient continued to have radiating symptoms down to his lower extremity and subsequently the patient was essentially released by Dr. XYZ in June with maximum medical improvement.,Unfortunately, the patient continued to have persistence of back pain and radiating symptoms down to his leg and went back to see Dr. XYZ again, and at this point, the patient was provided with further medication management and sent for Pain Clinic referral. The patient also was recommended for nerve block at this point and the patient received epidural steroid injection by Dr. ABC without any significant relief. The patient also was sent for EMG and nerve conduction study, which was performed by Dr. ABCD and the MRI, EMG, and nerve conduction study came back essentially negative for radiculopathy, which was performed by Dr. ABCD. The patient states that he continues to have pain with extended sitting, he has radiating symptoms down to his lower extremity on the right side of his leg, increase in pain with stooping. He has difficulty sleeping at nighttime because of increase in pain. Ultimately, the patient was returned back to work in June, and deemed with maximum medical improvement back in June. The patient unfortunately still has significant degree of back pain with activities such as stooping and radicular symptoms down his right leg, worse than the left side. The patient also went to see Dr. X who is a chiropractic specialist and received eight or nine visits of chiropractic care without long-term relief in his overall radicular symptoms.,PHYSICAL EXAMINATION:, The patient was examined with the gown on. Lumbar flexion was moderately decreased. Extension was normal. Side bending to the right was decreased. Side bending to the left was within normal limits. Rotation and extension to the right side was causing increasing pain. Extension and side bending to the left was within normal limits without significant pain on the left side. While seated, straight leg was negative on the LLE at 90° and also negative on the RLE at 90°. There was no true root tension sign or radicular symptoms upon straight leg raising in the seated position. In supine position, straight leg was negative in the LLE and also negative on the RLE. Sensory exam shows there was a decrease in sensation to the S1 dermatomal distribution on the right side to light touch and at all other dermatomal distribution was within normal limits. Deep tendon reflex at the patella was 2+/4 bilaterally, but there was a decrease in reflex in the Achilles tendon 1+/4 on the right side and essentially 2+/4 on the left side. Medial hamstring reflex was 2+/4 on both hamstrings as well. On prone position, there was tightness in the paraspinals and erector spinae muscle as well as tightness on the right side of the quadratus lumborum area, right side was worse than the left side. Increase in pain at deep palpatory examination in midline of the L5 and S1 level.,MEDICAL RECORD REVIEW:, I had the opportunity to review Dr. XYZ's medical records. Also reviewed Dr. ABC procedural note, which was the epidural steroid injection block that was performed in December. Also, reviewed Dr. X's medical record notes and an EMG and nerve study that was performed by Dr. ABCD, which was essentially normal. The MRI of the lumbar spine that was performed back in April, which showed no evidence of herniated disc.,DIAGNOSIS: , Residual from low back injury with right lumbar radicular symptomatology.,EVALUATION/RECOMMENDATION:, The patient has an impairment based on AMA Guides Fifth Edition and it is permanent. The patient appears to have re-aggravation of the low back injury back in October related to his work at ABC when he was working unloading and loading an 18-wheel truck. Essentially, there was a clear aggravation of his symptoms with ongoing radicular symptom down to his lower extremity mainly on the right side more so than the left. The patient also has increase in back pain with lumbar flexion and rotational movement to the right side. With these ongoing symptoms, the patient has also decrease in activities of daily living such as mobility as well as decrease in sleep pattern and general decrease in overall function. Therefore, the patient is assigned 8% impairment of the whole person. We are able to assign this utilizing the Fifth Edition on spine section on the AMA guide. Using page 384, table 15-3, the patient does fall under DRE Lumbar Category II under criteria for rating impairment due to lumbar spine injury. In this particular section, it states that the patient's clinical history and examination findings are compatible with specific injury; and finding may include significant muscle guarding or spasm observed at the time of examination, a symmetric loss of range of motion, or non-verifiable radicular complaints define his complaints of radicular pain without objective findings; no alteration of the structural integrity and no significant radiculopathy. The patient also has decrease in activities of daily living; therefore, the patient is assigned at the higher impairment rating of 8% WPI. In the future, the patient should avoid prolonged walking, standing, stooping, squatting, hip bending, climbing, excessive flexion, extension, and rotation of his back. His one time weight limit should be determined by work trial, although the patient should continue to be closely monitored and managed for his pain control by the specific specialist for management of his overall pain. The patient although has a clear low back pain with certain movements such as stooping and extended sitting and does have a clear radicular symptomatology, the patient also should be monitored closely for specific dependency to short-acting opioids in the near future by specialist who could monitor and closely follow his overall pain management. The patient also should be treated with appropriate modalities and appropriate rehabilitation in the near future.,

PROCEDURE PERFORMED:, Laparoscopic cholecystectomy with attempted intraoperative cholangiogram.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner.,A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp. A 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident. Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening. Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg.,The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar. A total of 3 other trocars were placed. The first was a 10/11 mm trocar in the upper midline position. The second was a 5 mm trocar placed in the anterior axillary line approximately 3 cm above the anterior superior iliac spine. The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars. All of the trocars were placed without difficulty.,The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left. The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder. A laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of Calot were meticulously dissected free.,A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct close to the gallbladder. The gallbladder was then grasped through the upper midline cannula and a fine-tipped scissors introduced through the third cannula and used to make a small ductotomy in the cystic duct near the clips. Several attempts at passing the cholangiocatheter into the ductotomy were made. Despite numerous attempts at several angles, the cholangiocatheter could not be inserted into the cystic duct. After several such attempts, and due to the fact that the anatomy was clear, we aborted any further attempts at cholangiography. The distal cystic duct was doubly clipped. The duct was divided between the clips. The clips were carefully placed to avoid occluding the juncture with the common bile duct. The port sites were injected with 0.5% Marcaine.,The cystic artery was found medially and slightly posteriorly to the cystic duct. It was carefully dissected free from its surrounding tissues. A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally. The artery was divided between the clips. The port sites were injected with 0.5% Marcaine.,After the cystic duct and artery were transected, the gallbladder was dissected from the liver bed using Bovie electrocautery. Prior to complete dissection of the gallbladder from the liver, the peritoneal cavity was copiously irrigated with saline and the operative field was examined for persistent blood or bile leaks of which there were none.,After the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula. The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula. As the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen. The neck of the gallbladder was then secured with a Kocher clamp, and the gallbladder was removed from the abdomen.,Following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,Both midline fascial defects were then approximated using 0 Vicryl suture. All skin incisions were approximated with 4-0 Vicryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. Dressings were applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.

COMPARISON STUDIES:, None.,MEDICATION: , Lopressor 5 mg IV.,HEART RATE AFTER MEDICATION:, 64bpm,EXAM:,TECHNIQUE: Tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc’s of Isovue 370 was injected in the right arm.,TECHNICAL QUALITY:,Examination is limited secondary to extensive artifact from defibrillator wires.,There is good demonstration of the coronary arteries and there is good bolus timing.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,The left main coronary artery is a moderate-sized vessel with a normal ostium. There is no calcific or non-calcific plaque. The vessel bifurcates into a left anterior descending artery and a left circumflex artery.,LEFT ANTERIOR DESCENDING ARTERY:,The left anterior descending artery is a moderate-sized vessel, with a small first diagonal branch and a large second diagonal branch. The vessel continues as a small vessel, tapering at the apex of the left ventricle. There is calcific plaque within the mid vessel, with dense calcific plaque at the bifurcation of the second diagonal branch. This limits evaluation of the vessel lumen, and although a flow-limiting lesion cannot be excluded, there is no evidence of a high-grade stenosis. There is ostial calcification within the second diagonal branch as well. The LAD distal to the second diagonal branch is small relative to the more proximal vessel, and this is worrisome for a proximal flow-limiting lesion.,In addition, there is marked tapering of the D2 branch distal to the proximal and ostial calcific plaque. This is worrisome for either occlusion or a high-grade stenosis. There is only minimal contrast that is identified in the distal vessel.,LEFT CIRCUMFLEX ARTERY:,The left circumflex artery is a moderate-sized vessel with a patent ostium. There is calcific plaque within the proximal vessel. There is dense calcific plaque at the bifurcation of the OM1, and the AV groove branch. The AV groove branch tapers as a small vessel at the base of the heart. The dense calcific plaque within the bifurcation of the OM1 and the AV groove branch limits evaluation of the vessel lumen. There is no demonstrated high-grade stenosis, but a flow-limiting lesion cannot be excluded here.,RIGHT CORONARY ARTERY:,The right coronary artery is a moderate-sized vessel with a patent ostium. There is proximal mixed calcific and non-calcific plaque, but there is no flow-limiting lesion. The vessel continues as a moderate-sized vessel to the crux of the heart, supplying a small posterior descending artery and moderate to large posterolateral ventricular branches.,There is scattered calcific plaque within the mid vessel and there is also calcific plaque within the distal vessel at the origin of the posterior descending artery. There is no flow-limited lesion demonstrated.,The right coronary artery is dominant.,NONCORONARY CARDIAC STRUCTURE:,CARDIAC CHAMBERS:, There is diffuse myocardial thinning within the left ventricle, particularly within the apex where there is subendocardial calcification, consistent with chronic infarction. There is ventricular enlargement. There is no demonstrated aneurysm or pseudoaneurysm.,CARDIAC VALVES: ,There is calcification within the left aortic valve cusp. The aortic valve is tri-leaflet. Normal mitral valve.,PERICARDIUM:, Normal.,GREAT VESSELS: ,There are atherosclerotic changes within the aorta.,VISUALIZED LUNG PARENCHYMA, MEDIASTINUM AND CHEST WALL: ,Normal.,IMPRESSION:,Limited examination secondary to extensive artifact from the pacemaker wires.,There is extensive calcific plaque within the left anterior descending artery as well as within the proximal second diagonal branch. There is marked tapering of the LAD distal to the bifurcation of the D1 and this is worrisome for a flow-limiting lesion, but there is no evidence of occlusion.,There is marked tapering of the D1 branch distal to the calcific plaque and occlusion cannot be excluded.,There is dense calcific plaque within the left circumflex artery, and although a flow-limiting lesion cannot be excluded here, there is no evidence of an occlusion or high-grade stenosis.,There is mixed soft and calcific plaque within the proximal RCA, but there is no flow limiting lesion demonstrated.,There is diffuse thinning of the left ventricular wall, most focal at the apex where there is also dense calcification, consistent with chronic infarction. There is no demonstrated aneurysm or pseudoaneurysm.

CHIEF COMPLAINT (1/1):, This 59 year old female presents today complaining that her toenails are discolored, thickened, and painful. Duration: Condition has existed for 6 months. Severity: Severity of condition is worsening.,ALLERGIES: ,Patient admits allergies to dairy products, penicillin.,MEDICATION HISTORY:, None.,PAST MEDICAL HISTORY:, Past medical history is unremarkable.,PAST SURGICAL HISTORY:, Patient admits past surgical history of eye surgery in 1999.,SOCIAL HISTORY:, Patient denies alcohol use, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:, Unremarkable.,REVIEW OF SYSTEMS:, Psychiatric: (+) poor sleep pattern, Respiratory: (+) breathing difficulties, respiratory symptoms.,PHYSICAL EXAM:, Patient is a 59 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. Toenails 1-5 bilateral appear crumbly, discolored - yellow, friable and thickened.,Cardiovascular: DP pulses palpable bilateral. PT pulses palpable bilateral. CFT immediate. No edema observed. Varicosities are not observed.,Skin: Skin temperature of the lower extremities is warm to cool, proximal to distal. No skin rash, subcutaneous nodules, lesions or ulcers observed.,Neurological: Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.,Musculoskeletal: Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:, No tests to report at this time.,IMPRESSION:, Onychomycosis.,PLAN:, Debrided 10 nails.,PRESCRIPTIONS:, Penlac Dosage: 8% Topical Solution Sig:

HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. She has had a dry cough and a fever as high as 100, but this has not been since the first day. She denies any vomiting or diarrhea. She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe, but she does not think that this has helped.,FAMILY HISTORY: , The patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,REVIEW OF SYSTEMS:, The patient does note some pressure in her sinuses. She denies any skin rash.,SOCIAL HISTORY:, Patient lives with her mother, who is here with her.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits. Room air oximetry is 100%.,GENERAL: Patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,HEENT: Head is normocephalic, atraumatic. Pharynx shows no erythema, tonsillar edema, or exudate. Both TMs are easily visualized and are clear with good light reflex and no erythema. Sinuses do show some mild tenderness to percussion.,NECK: No meningismus or enlarged anterior/posterior cervical lymph nodes.,HEART: Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS: Clear without rales, rhonchi, or wheezes.,SKIN: No rash.,ASSESSMENT:, Viral upper respiratory infection (URI) with sinus and eustachian congestion.,PLAN:, I did educate the patient about her problem and urged her to switch to Advil Cold & Sinus for the next three to five days for better control of her sinus and eustachian discomfort. I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses. If she is unimproved in five days, follow up with her PCP for re-exam.

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,PROCEDURE:, Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap. Operating microscope was used for both illumination and magnification.,FIRST ASSISTANT: , Nurse practitioner.,PROCEDURE IN DETAIL: , The patient was placed in supine position. The neck was prepped and draped in the usual fashion for anterior discectomy and fusion. An incision was made midline to the anterior body of the sternocleidomastoid at C5-C6 level. The skin, subcutaneous tissue, and platysma muscle was divided exposing the carotid sheath, which was retracted laterally. Trachea and esophagus were retracted medially. After placing the self-retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at C5 and C6 and confirming our position with intraoperative x-rays, we then proceeded with the discectomy.,We then cleaned out the disc at C5-C6 after incising the annulus fibrosis. We cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes, and the next step was to clean out the disc space totally. With this having been done, we then turned our attention with the operating microscope to the osteophytes. We drilled off the vertebral osteophytes at C5-C6, as well as the uncovertebral osteophytes. This was removed along with the posterior longitudinal ligament. After we had done this, the dural sac was opposed very nicely and both C6 nerve roots were thoroughly decompressed. The next step after the decompression of the thecal sac and both C6 nerve roots was the fusion. We observed that there was a ____________ in the posterior longitudinal ligament. There was a free fragment disc, which had broken through the posterior longitudinal ligament just to the right of midline.,The next step was to obtain the bone from the back bone, using cortical cancellous graft 10 mm in size after we had estimated the size. That was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor.,After we had tapped in the bone plug, we then removed the distraction and the bone plug was fitting nicely.,We then use the Aesculap cervical titanium instrumentation with the 16-mm screws. After securing the C5-C6 disc with four screws and titanium plate, x-rays showed good alignment of the spine, good placement of the bone graft, and after x-rays showed excellent position of the bone graft and instrumentation, we then placed in a Jackson-Pratt drain in the prevertebral space brought out through a separate incision. The wound was closed with 2-0 Vicryl for subcutaneous tissues and skin was closed with Steri-Strips. Blood loss during the operation was less than 10 mL. No complications of the surgery. Needle count, sponge count, and cottonoid count were correct.,

PREOPERATIVE DIAGNOSIS:, Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,PROCEDURE DONE: , Open radical retropubic prostatectomy with bilateral lymph node dissection.,INDICATIONS:, This is a 66-year-old gentleman who had an elevated PSA of 5. His previous PSAs were in the 1 range. TRUS biopsy revealed 4+3 Gleason score prostate cancer with a large tumor burden. After extensive counseling, the patient elected for retropubic radical prostatectomy. Given his disease burden, it was advised that an open prostatectomy is probably the standard of care to ensure entire excision. The patient consented and agreed to proceed forward.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room here. Time out was taken to properly identify the patient and procedure going to be done. General anesthesia was induced. The patient was placed in the supine position. The bed was flexed distant to the pubic area. The patient's lower abdominal area, pubic area, and penile and scrotal area were clipped, and then scrubbed with Hibiclens soap for three minutes. The patient was then prepped and draped in normal sterile fashion. Foley catheter was inserted sterilely in the field. Preoperative antibiotics were given within 30 minutes of skin incision. A 10 cm lower abdominal incision was made from the symphysis pubis towards the umbilicus. Dissection was taken down through Scarpa's fascia to the level of the anterior rectus sheath. The rectus sheath was then incised and the muscle was split in the middle. Space of rectus sheath was then entered. The Bookwalter ring was then applied to the belly, and the bladder was then retracted to the right side, thus exposing the left obturator area. The lymph node packet on the left side was then dissected. This was done in a split and roll fashion with the flimsy tissue, and the left external iliac vein was incised, and the tissues were then rolled over the left external iliac vein. Dissection was carried down from the left external iliac vein to the obturator nerve and up to the level of the pelvic sidewall. The proximal extent of dissection was the left hypogastric artery to the level of the node of Cloquet distally. Care was taken to avoid injury to the nerves. An accessory obturator vein was noted and was ligated. The same procedure was done on the right side with dissection of the right obturator lymph node packet, which was sent for pathologic evaluation. The bladder subsequently was retracted cephalad. The prostate was then defatted up to the level of the endopelvic fascia. The endopelvic fascia was then incised bilaterally, and the incision was then taken to the level of the puboprostatic ligaments. Vicryl stitch was then applied at the level of the bladder neck in order to control the bladder back bleeders. A Babcock was then applied around the dorsal venous complex over the urethra and the K-wire was then passed between the dorsal vein complex and the urethra by passing by the aid of a right angle. A 0-Vicryl stitch was then applied over the dorsal venous complex, which was then tied down and cinched to the symphysis pubis. Using a knife on a long handle, the dorsal venous complex was then incised using the K-wire as a guide. Following the incision of the dorsal venous complex, the anterior urethra was then incised, thus exposing the Foley catheter. The 3-0 Monocryl sutures were then applied going outside in on the anterior aspect of the urethra. The lateral edges of the urethra were also then incised, and two lateral stitches were also applied going outside end. The catheter was then drawn back at the level of membranous urethra, and a final posterior stitch was applied going outside end. The urethra was subsequently divided in its entirety. A Foley catheter was then taken out and was inserted directly into the bladder through the prostatic apex. The prostate was then entered cephalad, and the prostatic pedicles were then systematically taken down with the right angle clips and cut. Please note that throughout the case, the patient was noted to have significant oozing and bleeding partially from the dorsal venous complex, pelvic veins, and extensive vascularity that was noted in the patient's pelvic fatty tissue. Throughout the case, the bleeding was controlled with the aid of a clips, Vicryl sutures, silk sutures, and ties, direct pressure packing, and FloSeal. Following the excision of the prostatic pedicles, the posterior dissection at this point was almost complete. Please note that the dissection was relatively technically challenging due to extensive adhesions between the prostate and Denonvilliers' fascia. The seminal vesicle on the left side was dissected in its entirety; however, the seminal vesicle on the right side was adherently stuck to the Denonvilliers' fascia, which prompted the excision of most of the right seminal vesicle with the exception of the tip. Care was taken throughout the posterior dissection to preserve the integrity of the ureters. The anterior bladder neck was then cut anteriorly, and the bladder neck was separated from the prostate. Following the dissection, the 5-French feeding tubes were inserted bilaterally into the ureters thus insuring their integrity. Following the dissection of the bladder from the prostate, the prostate at this point was mobile and was sent for pathological evaluation. The bladder neck was then repaired using Vicryl in a tennis racquet fashion. The rest of the mucosa was then everted. The ureteral orifices and ureters were protected throughout the procedure. At this point, the initial sutures that were applied into the urethra were then applied into the corresponding position on the bladder neck, and the bladder neck was then cinched down and tied down after a new Foley catheter was inserted through the penile meatus and into the bladder pulling the bladder in position. Hemostasis was then adequately obtained. FloSeal was applied to the pelvis. The bladder was then irrigated. It was draining pink urine. The wound was copiously irrigated. The fascia was then closed using a #1 looped PDS. The skin wound was then irrigated, and the skin was closed with a 4-0 Monocryl in subcuticular fashion. At this point, the procedure was terminated with no complications. The patient was then extubated in the operating room and taken in stable condition to the PACU. Please note that during the case about 3600 mL of blood was noted. This was due to the persistent continuous oozing from vascular fatty tissue and pelvic veins as previously noted in the dictation.

CHIEF COMPLAINT: , Cough and abdominal pain for two days.,HISTORY OF PRESENT ILLNESS: , This is a 76-year-old female who has a history of previous pneumonia, also hypertension and macular degeneration, who presents with generalized body aches, cough, nausea, and right-sided abdominal pain for two days. The patient stated that the abdominal pain was only associated with coughing. The patient reported that the cough is dry in nature and the patient had subjective fevers and chills at home.,PAST MEDICAL HISTORY: ,Significant for pneumonia in the past, pleurisy, macular degeneration, hypertension, and phlebitis.,PAST SURGICAL HISTORY: ,The patient had bilateral cataract extractions in 2007, appendectomy as a child, and three D&Cs in the past secondary to miscarriages.,MEDICATIONS: , On presentation included hydrochlorothiazide 12.5 mg p.o. daily, aspirin 81 mg p.o. daily, and propranolol 40 mg p.o. daily. The patient also takes multivitamin and Lutein over-the-counter for macular degeneration.,ALLERGIES: , THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,FAMILY HISTORY:, Mother died at the age of 59 due to stomach cancer and father died at the age of 91 years old.,SOCIAL HISTORY:, The patient quit smoking 17 years ago; prior to that had smoked one pack per day for 44 years. Denies any alcohol use. Denies any IV drug use.,PHYSICAL EXAMINATION: ,GENERAL: This is a 76-year-old female, well nourished. VITAL SIGNS: On presentation included a temperature of 100.1, pulse of 144 with a blood pressure of 126/77, the patient is saturating at 95% on room air, and has respiratory rate of 20. HEENT: Anicteric sclerae. Conjunctivae pink. Throat was clear. Mucosal membranes were dry. CHEST: Coarse breath sounds bilaterally at the bases. CARDIAC: S1 and S2. No murmurs, rubs or gallops. No evidence of carotid bruits. ABDOMEN: Positive bowel sounds, presence of soreness on examination in the abdomen on palpation. There is no rebound or guarding. EXTREMITIES: No clubbing, cyanosis or edema.,HOSPITAL COURSE: , The patient had a chest x-ray, which showed increased markings present bilaterally likely consistent with chronic lung changes. There is no evidence of effusion or consolidation. Degenerative changes were seen in the shoulder. The patient also had an abdominal x-ray, which showed nonspecific bowel gas pattern. Urinalysis showed no evidence of infection as well as her influenza A&B were negative. Preliminary blood cultures have been with no growth to date status post 48 hours. The patient was started on cefepime 1 g IV q.12h. and given IV hydration. She has also been on Xopenex nebs q.8h. round the clock and in regards to her hypertension, she was continued on her hydrochlorothiazide and propranolol. In terms of prophylactic measures, she received Lovenox subcutaneously for DVT prophylaxis. Currently today, she feels much improved with still only a mild cough. The patient has been afebrile for two days, saturating at 97% on room air with a respiratory rate of 18. Her white count on presentation was 13.6 and yesterday's white count was 10.3.,FINAL DIAGNOSIS:, Bronchitis.,DISPOSITION: , The patient will be going home.,MEDICATIONS: , Hydrochlorothiazide 12.5 mg p.o. daily, propranolol 40 mg p.o. daily. Also, Avelox 400 mg p.o. daily x10 days, guaifenesin 10 cc p.o. q.6h. p.r.n. for cough, and aspirin 81 mg p.o. daily.,DIET:, To follow a low-salt diet.,ACTIVITY:, As tolerated.,FOLLOWUP: ,To follow up with Dr. ABC in two weeks.

EXAM: , CT scan of the abdomen and pelvis without and with intravenous contrast.,CLINICAL INDICATION: , Left lower quadrant abdominal pain.,COMPARISON: , None.,FINDINGS: , CT scan of the abdomen and pelvis was performed without and with intravenous contrast. Total of 100 mL of Isovue was administered intravenously. Oral contrast was also administered.,The lung bases are clear. The liver is enlarged and decreased in attenuation. There are no focal liver masses.,There is no intra or extrahepatic ductal dilatation.,The gallbladder is slightly distended.,The adrenal glands, pancreas, spleen, and left kidney are normal.,A 12-mm simple cyst is present in the inferior pole of the right kidney. There is no hydronephrosis or hydroureter.,The appendix is normal.,There are multiple diverticula in the rectosigmoid. There is evidence of focal wall thickening in the sigmoid colon (image #69) with adjacent fat stranding in association with a diverticulum. These findings are consistent with diverticulitis. No pneumoperitoneum is identified. There is no ascites or focal fluid collection.,The aorta is normal in contour and caliber.,There is no adenopathy.,Degenerative changes are present in the lumbar spine.,IMPRESSION: , Findings consistent with diverticulitis. Please see report above.

DIAGNOSIS AT ADMISSION: , Hypothermia.,DIAGNOSES ON DISCHARGE,1. Hypothermia.,2. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.,3. Organic brain syndrome.,4. Seizure disorder.,5. Adrenal insufficiency.,6. Hypothyroidism.,7. Anemia of chronic disease.,HOSPITAL COURSE: ,The patient was admitted through the emergency room. He was admitted to the Intensive Care Unit. He was rewarmed and had blood, sputum, and urine cultures done. He was placed on IV Rocephin. His usual medications of Dilantin and Depakene were given. The patient's hypertension was treated with fluid boluses. The patient was empirically placed on Synthroid and hydrocortisone by Dr. X. Blood work consisted of a chemistry panel that was unremarkable, except for decreased proteins. H&H was stable at 33.3/10.9 and platelets of 80,000. White blood cell counts were normal, differential was normal. TSH was 3.41. Free T4 was 0.9. Dr. X felt this was consistent with secondary hypothyroidism and recommended Synthroid replacement. A cortisol level was obtained prior to administration of hydrocortisone. This was 10.9 and that was not a fasting level. Dr. X felt because of his hypothyroidism and his hypothermia that he had secondary adrenal insufficiency and recommended hydrocortisone and Florinef. The patient was eventually changed to prednisone 2.5 mg b.i.d. in addition to his Florinef 0.1 mg on Monday, Wednesday, and Friday. The patient was started back on his tube feeds. He tolerated these poorly with residuals. Reglan was increased to 10 mg q.6 h. and erythromycin is being added. The patient's temperature has been stable in the 94 to 95 range. Other vital signs have been stable. His urine output has been diminished. An external jugular line was placed in the Intensive Care Unit. The patient's legal guardian, Janet Sanchez in Albuquerque has requested he be transported there. As per several physicians in Albuquerque and Dr. Y, an internist, we will accept him once we have a nursing home available to him. He is being transported back to the nursing home today and discharge planners are working on getting him a nursing home in Albuquerque. His prognosis is poor.

PREOPERATIVE DIAGNOSIS:, Ovarian cyst, persistent.,POSTOPERATIVE DIAGNOSIS: , Ovarian cyst.,ANESTHESIA:, General,NAME OF OPERATION:, Diagnostic laparoscopy and drainage of cyst.,PROCEDURE:, The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced. An infraumbilical incision was made, and Veress needle placed without difficulty. Gas was entered into the abdomen at two liters. The laparoscope was entered, and the abdomen was visualized. The second puncture site was made, and the second trocar placed without difficulty. The cyst was noted on the left, a 3-cm, ovarian cyst. This was needled, and a hole cut in it with the scissors. Hemostasis was intact. Instruments were removed. The patient was awakened and taken to the recovery room in good condition.

PREOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,POSTOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,OPERATION: , Removal of an ingrown part of the left big toenail with excision of the nail matrix.,DESCRIPTION OF PROCEDURE: ,After obtaining informed consent, the patient was taken to the minor OR room and intravenous sedation with morphine and Versed was performed and the toe was blocked with 1% Xylocaine after having been prepped and draped in the usual fashion. The ingrown part of the toenail was freed from its bed and removed, then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail. The matrix was excised down to the bone and then the skin flap was placed over it. Hemostasis had been achieved with a cautery. A tubular dressing was performed to provide a bulky dressing.,The patient tolerated the procedure well. Estimated blood loss was negligible. The patient was sent back to Same Day Surgery for recovery.

CLINICAL HISTORY:, Gravida 1, para 0 at 33 weeks 5 days by early dating. The patient is developing gestational diabetes.,Transabdominal ultrasound examination demonstrated a single fetus and uterus in vertex presentation. The placenta was posterior in position. There was normal fetal breathing movement, gross body movement, and fetal tone, and the qualitative amniotic fluid volume was normal with an amniotic fluid index of 18.2 cm.,The following measurements were obtained: Biparietal diameter 8.54 cm, head circumference 30.96 cm, abdominal circumference 29.17 cm, and femoral length 6.58 cm. These values predict a fetal weight of 4 pounds 15 ounces plus or minus 12 ounces or at the 42nd percentile based on gestation.,CONCLUSION:, Normal biophysical profile (BPP) with a score of 8 out of possible 8. The fetus is size appropriate for gestation.

CYSTOSCOPY & VISUAL URETHROTOMY,OPERATIVE NOTE:, The patient was placed in the dorsal lithotomy position and prepped and draped in the usual manner under satisfactory general anesthesia. A Storz urethrotome sheath was inserted into the urethra under direct vision. Visualization revealed a stricture in the bulbous urethra. This was intubated with a 0.038 Teflon-coated guidewire, and using the straight cold urethrotomy knife, it was incised to 12:00 to allow free passage of the scope into the bladder. Visualization revealed no other lesions in the bulbous or membranous urethra. Prostatic urethra was normal for age. No foreign bodies, tumors or stones were seen within the bladder. Over the guidewire, a #16-French Foley catheter with a hole cut in the tip with a Cook cutter was threaded over the guidewire and inserted into the bladder and inflated with 10 mL of sterile water.,He was sent to the recovery room in stable condition.

REASON FOR EXAM: , Dynamic ST-T changes with angina.,PROCEDURE:,1. Selective coronary angiography.,2. Left heart catheterization with hemodynamics.,3. LV gram with power injection.,4. Right femoral artery angiogram.,5. Closure of the right femoral artery using 6-French AngioSeal.,Procedure explained to the patient, with risks and benefits. The patient agreed and signed the consent form.,The patient received a total of 2 mg of Versed and 25 mcg of fentanyl for conscious sedation. The patient was draped and dressed in the usual sterile fashion. The right groin area infiltrated with lidocaine solution. Access to the right femoral artery was successful, okayed with one attempt with anterior wall stick. Over a J-wire, 6-French sheath was introduced using modified Seldinger technique.,Over the J-wire, a JL4 catheter was passed over the aortic arch. The wire was removed. Catheter was engaged into the left main. Multiple pictures with RAO caudal, AP cranial, LAO cranial, shallow RAO, and LAO caudal views were all obtained. Catheter disengaged and exchanged over J-wire into a JR4 catheter, the wire was removed. Catheter with counter-clock was rotating to the RCA one shot with LAO, position was obtained. The cath disengaged and exchanged over J-wire into a pigtail catheter. Pigtail catheter across the aortic valve. Hemodynamics obtained. LV gram with power injection of 36 mL of contrast was obtained.,The LV gram assessed followed by pullback hemodynamics.,The catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6-French AngioSeal with no hematoma. The patient tolerated the procedure well with no immediate postprocedure complication.,HEMODYNAMICS: ,The aortic pressure was 117/61 with a mean pressure of 83. The left ventricular pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmHg. The pullback across the aortic valve reveals zero gradient.,ANATOMY: ,The left main showed minimal calcification as well as the proximal LAD. No stenosis in the left main seen, the left main bifurcates in to the LAD and left circumflex.,The LAD was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was TIMI 3 flow in the LAD. The LAD gave off two early diagonal branches. The second was the largest of the two and showed minimal lumen irregularities, but no focal stenosis.,Left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the PDA. The left circumflex was large and patent, 6.0 mm in diameter. All three obtuse marginal branches appeared to be with no significant stenosis.,The obtuse marginal branch, the third OM3 showed at the origin about 30 to 40% minimal narrowing, but no significant stenosis. The PDA was wide, patent, with no focal stenosis.,The RCA was a small nondominant system with no focal stenosis and supplying the RV marginal.,LV gram showed that the LV EF is preserved with EF of 60%. No mitral regurgitation identified.,IMPRESSION:,1. Patent coronary arteries with normal left anterior descending, left circumflex, and dominant left circumflex system.,2. Nondominant right, which is free of atheromatous plaque.,3. Minimal plaque in the diagonal branch II, and the obtuse,marginal branch III, with no focal stenosis.,4. Normal left ventricular function.,5. Evaluation for noncardiac chest pain would be recommended.

REASON FOR NEUROLOGICAL CONSULTATION: , Cervical spondylosis and kyphotic deformity. The patient was seen in conjunction with medical resident Dr. X. I personally obtained the history, performed examination, and generated the impression and plan.,HISTORY OF PRESENT ILLNESS: ,The patient is a 45-year-old African-American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain. This has subsequently resolved. She started vigorous workouts in November 2005. In March of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician. By her report, she had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe. Symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe. She then started getting sensory sensations in the left hand and arm. She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg. Symptoms have been mildly progressive. She is unaware of any trigger other than the vigorous workouts as mentioned above. She has no associated bowel or bladder symptoms. No particular position relieves her symptoms.,Workup has included two MRIs of the C-spine, which were personally reviewed and are discussed below. She saw you for consultation and the possibility of surgical decompression was raised. At this time, she is somewhat reluctant to go through any surgical procedure.,PAST MEDICAL HISTORY:,1. Ocular migraines.,2. Myomectomy.,3. Infertility.,4. Hyperglycemia.,5. Asthma.,6. Hypercholesterolemia.,MEDICATIONS: , Lipitor, Pulmicort, Allegra, Xopenex, Patanol, Duac topical gel, Loprox cream, and Rhinocort.,ALLERGIES: , Penicillin and aspirin.,Family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet. Of note, she does not drink or smoke. She is married with two adopted children. She is a paralegal specialist. She used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,REVIEW OF SYSTEMS: , She does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,PHYSICAL EXAMINATION: , On examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds. Pain scale is 0. A full general and neurological examination was personally performed and is documented on the chart. Of note, she has a normal general examination. Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk. She has mild postural tremor in both arms. She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities. Motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis. She has hyperreflexia in her lower extremities, worse on the left. Babinski's are downgoing.,PERTINENT DATA: ,MRI of the brain from 05/02/06 and MRI of the C-spine from 05/02/06 and 07/25/06 were personally reviewed. MRI of the brain is broadly within normal limits. MRI of the C-spine reveals large central disc herniation at C6-C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema. There is also a fairly large disc at C3-C4 with cord deformity and partial effacement of the subarachnoid space. I do not appreciate any cord edema at this level.,IMPRESSION AND PLAN: ,The patient is a 45-year-old female with cervical spondylosis with a large C6-C7 herniated disc with mild cord compression and signal change at that level. She has a small disc at C3-C4 with less severe and only subtle cord compression. History and examination are consistent with signs of a myelopathy.,Results were discussed with the patient and her mother. I am concerned about progressive symptoms. Although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis. If she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis. I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation. I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem. I have recommended that she wear a hard collar while driving. The results of my consultation were discussed with you telephonically.

OPERATIVE PROCEDURES: , Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy.,PREOPERATIVE DIAGNOSES:,1. Colon cancer screening.,2. Family history of colon polyps.,POSTOPERATIVE DIAGNOSES:,1. Multiple colon polyps (5).,2. Diverticulosis, sigmoid colon.,3. Internal hemorrhoids.,ENDOSCOPE USED: , EC3870LK.,BIOPSIES: ,Biopsies taken from all polyps. Hot biopsy got applied to one. Epinephrine sclerotherapy and snare polypectomy applied to four polyps.,ANESTHESIA: , Fentanyl 75 mcg, Versed 6 mg, and glucagon 1.5 units IV push in divided doses. Also given epinephrine 1:20,000 total of 3 mL.,The patient tolerated the procedure well.,PROCEDURE: ,The patient was placed in left lateral decubitus after appropriate sedation. Digital rectal examination was done, which was normal. Endoscope was introduced and passed through a rather spastic tortuous sigmoid colon with multiple diverticula seen all the way through transverse colon where about 1 cm x 1 cm sessile polyp was seen. It was biopsied and then in piecemeal fashion removed using snare polypectomy after base was infiltrated with epinephrine. Pedunculated polyp next to it was hard to see and there was a lot of peristalsis. The scope then was advanced through rest of the transverse colon to ascending colon and cecum. Terminal ileum was briefly reviewed, appeared normal and so did cecum after copious amount of fecal material was irrigated out. Ascending colon was unremarkable. At hepatic flexure may be proximal transverse colon, there was a sessile polyp about 1.2 cm x 1 cm that was removed in the same manner with a biopsy taken, base infiltrated with epinephrine and at least two passes of snare polypectomy and subsequent hot biopsy cautery removed to hold polypoid tissue, which could be seen. In transverse colon on withdrawal and relaxation with epinephrine, an additional 1 mm to 2 mm sessile polyp was removed by hot biopsy. Then in the transverse colon, additional larger polyp about 1.3 cm x 1.2 cm was removed in piecemeal fashion again with epinephrine, sclerotherapy, and snare polypectomy. Subsequently pedunculated polyp in distal transverse colon near splenic flexure was removed with snare polypectomy. The rest of the splenic flexure and descending colon were unremarkable. Diverticulosis was again seen with almost constant spasm despite of glucagon. Sigmoid colon did somewhat hinder the inspection of that area. Rectum, retroflexion posterior anal canal showed internal hemorrhoids moderate to large. Excess of air insufflated was removed. The endoscope was withdrawn.,PLAN: , Await biopsy report. Pending biopsy report, recommendation will be made when the next colonoscopy should be done at least three years perhaps sooner besides and due to multitude of the patient's polyps.

HISTORY OF PRESENT ILLNESS:, This 66-year-old white male was seen in my office on Month DD, YYYY. Patient was recently discharged from Doctors Hospital at Parkway after he was treated for pneumonia. Patient continues to have severe orthopnea, paroxysmal nocturnal dyspnea, cough with greenish expectoration. His exercise tolerance is about two to three yards for shortness of breath. The patient stopped taking Coumadin for reasons not very clear to him. He was documented to have recent atrial fibrillation. Patient has longstanding history of ischemic heart disease, end-stage LV systolic dysfunction, and is status post ICD implantation. Fasting blood sugar this morning is 130.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: Blood pressure is 120/60. Respirations 18 per minute. Heart rate 75-85 beats per minute, irregular. Weight 207 pounds.,HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good. ,NECK: Supple. JVP is flat. Carotid upstroke is good. ,LUNGS: Severe inspiratory and expiratory wheezing heard throughout the lung fields. Fine crepitations heard at the base of the lungs on both sides. ,CARDIOVASCULAR: PMI felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex.,ABDOMEN: Soft. There is no hepatosplenomegaly.,EXTREMITIES: Patient has 1+ pedal edema.,MEDICATIONS: , ,1. Ambien 10 mg at bedtime p.r.n.,2. Coumadin 7.5 mg daily.,3. Diovan 320 mg daily.,4. Lantus insulin 50 units in the morning.,5. Lasix 80 mg daily.,6. Novolin R p.r.n.,7. Toprol XL 100 mg daily.,8. Flovent 100 mcg twice a day.,DIAGNOSES:,1. Atherosclerotic coronary vascular disease with old myocardial infarction.,2. Moderate to severe LV systolic dysfunction.,3. Diabetes mellitus.,4. Diabetic nephropathy and renal failure.,5. Status post ICD implantation.,6. New onset of atrial fibrillation.,7. Chronic Coumadin therapy.,PLAN:,1. Continue present therapy.,2. Patient will be seen again in my office in four weeks.

PROCEDURE PERFORMED: , Endotracheal intubation.,INDICATION FOR PROCEDURE: ,The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters.,NARRATIVE OF PROCEDURE: , The patient was given a total of 5 mg of Versed, 20 mg of etomidate, and 10 mg of vecuronium. He was intubated in a single attempt. Cords were well visualized, and a #8 endotracheal tube was passed using a curved blade. Fiberoptically, a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap A lavage with 100 mL of normal sterile saline for cytology, AFB, and fungal smear and culture. A separate trap B was then lavaged for bacterial C&S and Gram stain and was sent for those purposes. The patient tolerated the procedure well.

PREOPERATIVE DIAGNOSIS: , Colon polyps.,POSTOPERATIVE DIAGNOSES:,1. Universal diverticulosis.,2. Nonsurgical internal hemorrhoids.,PROCEDURE PERFORMED:, Total colonoscopy with photos.,ANESTHESIA:, Demerol 100 mg IV with Versed 3 mg IV.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: ,The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.,PROCEDURE:, Informed consent was obtained. All risks and benefits of the procedure were explained and all questions were answered. The patient was brought back to the Endoscopy Suite where he was connected to cardiopulmonary monitoring. Demerol 100 mg IV and Versed 3 mg IV was given in a titrated fashion until appropriate anesthesia was obtained. Upon appropriate anesthesia, a digital rectal exam was performed, which showed no masses. The colonoscope was then placed into the anus and the air was insufflated. The scope was then advanced under direct vision into the rectum, rectosigmoid colon, descending colon, transverse colon, ascending colon until it reached the cecum. Upon entering the sigmoid colon and throughout the rest of the colon, there was noted diverticulosis. After reaching the cecum, the scope was fully withdrawn visualizing all walls again noting universal diverticulosis.,Upon reaching the rectum, the scope was then retroflexed upon itself and there was noted to be nonsurgical internal hemorrhoids. The scope was then subsequently removed. The patient tolerated the procedure well and there were no complications.