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

Neurosurgery

PREOPERATIVE DIAGNOSIS: ,Gallstone pancreatitis.,POSTOPERATIVE DIAGNOSIS: , Gallstone pancreatitis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal and local injectable Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Gallbladder.,COMPLICATIONS: ,None.,OPERATIVE FINDINGS: , Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially. These dense adhesions were associated with chronic inflammatory edematous changes. The cystic duct was easily identifiable and seen entering into the gallbladder and clipped two proximally and one distally. The cystic artery was an anomalous branch that was anterior to the cystic duct and was identified, clipped with two clips proximally and one distally. The remainder of the evaluation of the abdomen revealed no evidence of nodularity or masses in the liver. There was no evidence of adhesions from the abdominal wall to the liver. The remainder of the abdomen was unremarkable.,BRIEF HISTORY: ,This is a 17-year-old African-American female who presented to ABCD General Hospital on 08/20/2003 with complaints of intractable right upper quadrant abdominal pain. She had been asked to follow up and scheduled for surgery previously. Her pain had now been intractable associated with anorexia. She was noted on physical examination to be afebrile; however, she was having severe right upper quadrant pain with examination as well as a Murphy's sign and voluntary guarding with examination. Her transaminases were markedly elevated. She also developed pancreatitis secondary to gallstones. Her common bile duct was dilated to 1 cm with no evidence of wall thickening, but evidence of cholelithiasis. She was seen by the gastroenterologist and underwent a sphincterotomy with balloon extraction of gallstones secondary to choledocholithiasis. Following this, she was scheduled for operative laparoscopic cholecystectomy. Her parents were explained the risks, benefits, and complications of the procedure. She gave us informed consent to proceed with surgery.,OPERATIVE PROCEDURE: ,The patient brought to the operative suite and placed in the supine position. Preoperatively, the patient received IV antibiotics of Ancef, sequential compression devices and subcutaneous heparin. The abdomen was prepped and draped in the normal sterile fashion with Betadine solution. Utilizing a #15 blade scalpel, a transverse infraumbilical incision was created. Utilizing a Veress needle with anterior traction on the anterior abdominal wall with a towel clamp, the Veress needle was inserted without difficulty. Hanging water drop test was performed with notable air aspiration through the Veress needle and the saline passed through the Veress needle without difficulty. The abdomen was then insufflated to 15 mmHg with carbon-dioxide. Once the abdomen was sufficiently insufflated, a #10 mm bladed trocar was inserted into the abdomen without difficulty. Video laparoscope was inserted and the above notable findings were identified in the operative findings. The patient to proceed with laparoscopic cholecystectomy was decided and a subxiphoid port was placed. A #15 bladed scalpel was used to make a transverse incision in the subxiphoid region within the midline. The trocar was then inserted into the abdomen under direct visualization with the video laparoscope and seen to go to the right of falciform ligament. Next, two 5 mm trocars were inserted under direct visualization, one in the midclavicular and one in the anterior midaxillary line. These were inserted without difficulty. The liver edge was lifted and revealed a markedly edematous gallbladder with severe omental adhesions encapsulating the gallbladder. Utilizing Endoshears scissor, a plane was created circumferentially to the dome of the gallbladder to allow assistance and dissection of these dense adhesions. Next, the omental adhesions adjacent to the infundibulum were taken down and allowed to expose the cystic duct. A small vessel was seen anterior to the cystic duct and this was clipped two proximally and one distally and noted to be an anomalous arterial branch. This was transected with Endoshears scissor and visualized the pulsatile branch with two clips securely in place. Next, the cystic duct was carefully dissected with Maryland dissectors and was visualized clearly both anterior and posteriorly. Endoclips were placed two proximally and one distally and then the cystic duct was transected with Endoshears scissor.,Once the clips were noted to be in place, utilizing electrocautery another Dorsey dissector was used to carefully dissect the gallbladder off the liver bed wall. The gallbladder was removed and the bleeding from the gallbladder wall was easily controlled with electrocautery. The abdomen was then irrigated with copious amounts of normal saline. The gallbladder was grasped with a gallbladder grasper and removed from the subxiphoid port. There was noted to be gallstones within the gallbladder. Once the abdomen was re-insufflated after removing the gallbladder and copious irrigation was performed, all ports were then removed under direct visualization with no evidence of bleeding from the anterior abdominal wall. Utilizing #0 Vicryl suture, a figure-of-eight was placed to the subxiphoid and infraumbilical fascia and this was approximated without difficulty. The subxiphoid port was irrigated with copious amounts of normal saline prior to closure of the fascia. A #4-0 Vicryl suture was used to approximate all incisions. The incisions were then injected with local injectable 0.25% Marcaine. All ports were then cleaned dry. Steri-Strips were placed across and sterile pressure dressings were placed on top of this. The patient tolerated the entire procedure well. She was transferred to the Postanesthesia Care Unit in stable condition. She will be followed closely in the postoperative course in General Medical Floor.

Surgery

IMPRESSION:, Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right. Clinical correlation is suggested.

Neurology

PROCEDURE:, Placement of Scott cannula, right lateral ventricle.,DESCRIPTION OF THE OPERATION:, The right side of the head was shaved and the area was then prepped using Betadine prep. Following an injection with Xylocaine with epinephrine, a small 1.5 cm linear incision was made paralleling the midline, lateral to the midline, at the region of the coronal suture. A twist drill was made with the hand drill through the dura. A Scott cannula was placed on the first pass into the right lateral ventricle with egress initially of bloody and the clear CSF. The Scott cannula was secured to the skin using 3-0 silk sutures. This will be connected to external drainage set at 10 cm of water.

Surgery

PREOPERATIVE DIAGNOSES: ,1. Left back skin nevus 2 cm.,2. Right mid back skin nevus 1 cm.,3. Right shoulder skin nevus 2.5 cm.,4. Actinic keratosis left lateral nasal skin 2.5 cm.,POSTOPERATIVE DIAGNOSES: ,1. Left back skin nevus 2 cm.,2. Right mid back skin nevus 1 cm.,3. Right shoulder skin nevus 2.5 cm.,4. Actinic keratosis, left lateral nasal skin, 2.5 cm.,PATHOLOGY: ,Pending.,TITLE OF PROCEDURES: ,1. Excisional biopsy of left back skin nevus 2 cm, two layer plastic closure.,2. Excisional biopsy of mid back skin nevus 1 cm, one-layer plastic closure.,3. Excisional biopsy of right shoulder skin nevus 2.5 cm, one-layer plastic closure.,4. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 8 mL.,BLOOD LOSS: , Minimal.,COMPLICATIONS:, None.,PROCEDURE:, Consent was obtained. The areas were prepped and draped and localized in the usual manner. First attention was drawn to the left back. An elliptical incision was made with a 15-blade scalpel. The skin ellipse was then grasped with a Bishop forceps and curved Iris scissors were used to dissect the skin ellipse. After dissection, the skin was undermined. Radiofrequency cautery was used for hemostasis, and using a 5-0 undyed Vicryl skin was closed in the subcuticular plane and then skin was closed at the level of the skin with 4-0 nylon interrupted suture.,Next, attention was drawn to the mid back. The skin was incised with a vertical elliptical incision with a 15-blade scalpel and then the mass was grasped with a Bishop forceps and excised with curved Iris scissors. Afterwards, the skin was approximated using 4-0 nylon interrupted sutures. Next, attention was drawn to the shoulder lesion. It was previously marked and a 15-blade scalpel was used to make an elliptical incision into the skin.,Next, the skin was grasped with a small Bishop forceps and curved Iris scissors were used to dissect the skin ellipse and removed the skin. The skin was undermined with the curved Iris scissors and then radio frequency treatment was used for hemostasis.,Next, subcuticular plain was closed with 5-0 undyed Vicryl interrupted suture. Skin was closed with 4-0 nylon suture, interrupted. Lastly, trichloroacetic acid chemical peel treatment to the left lateral nasal skin was performed. Please refer to separate operative report for details. The patient tolerated this procedure very well and we will follow up next week for postoperative re-evaluation or sooner if there are any problems.

Surgery

ADMISSION DIAGNOSES:,1. Pyelonephritis.,2. History of uterine cancer and ileal conduit urinary diversion.,3. Hypertension.,4. Renal insufficiency.,5. Anemia.,DISCHARGE DIAGNOSES:,1. Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit.,2. Hypertension.,3. Mild renal insufficiency.,4. Anemia, which has been present chronically over the past year.,HOSPITAL COURSE:, The patient was admitted with suspected pyelonephritis. Renal was consulted. It was thought that there was a thick mucous plug in the Foley in the ileal conduit that was irrigated by Dr. X. Her symptoms responded to IV antibiotics and she remained clinically stable. Klebsiella was isolated in this urine, which was sensitive to Bactrim and she was discharged on p.o. Bactrim. She was scheduled on 08/07/2007 for further surgery. She is to follow up with Dr. Y in 7-10 days. She also complained of right knee pain and the right knee showed no sign of effusion. She was exquisitely tender to touch of the patellar tendon. It was thought that this did not represent intraarticular process. She was advised to use ibuprofen over-the-counter two to three tabs t.i.d.

Discharge Summary

PROCEDURES PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,3. Left ventriculogram was not performed.,INDICATION: , Non-ST elevation MI.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery. Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin. The pressure was held. The needle was removed over the guidewire. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the left main coronary artery was engaged. Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views. Once an adequate study had been performed, the catheter was removed from the ostium of the left main coronary artery and a steel guidewire was inserted through the catheter. The catheter was then removed over the guidewire.,Next, a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to manifold and flushed. The catheter did slip into the left ventricle. During the rotation, the LVEDP was then measured. The ostium of the right coronary artery was then engaged. Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was then removed. The sheath was lastly flushed for the final time.,FINDINGS:,LEFT MAIN CORONARY ARTERY: , The left main coronary artery is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a moderate caliber vessel, which is subtotaled in its mid portion for approximately 1.5 cm to 1 cm with subsequent TIMI-I flow distally. The distal portion was diffusely diseased. The proximal portion otherwise shows minor luminal irregularities. The first diagonal branch demonstrated minor luminal irregularities throughout.,CIRCUMFLEX ARTERY: ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove. There is a 60% proximal lesion and a 90% mid lesion prior to the takeoff of the first obtuse marginal branch. The first obtuse marginal branch demonstrates minor luminal irregularities throughout.,RIGHT CORONARY ARTERY: , The RCA is a moderate caliber vessel, which demonstrates a 90% mid stenotic lesion. The dominant coronary artery gives off the posterior descending artery and posterolateral artery. The left ventricular end-diastolic pressure was approximately 22 mmHg. It should be noted that during injection of the contrast agent that there was ST elevation in the inferior leads, which resolved after the injection was complete.,IMPRESSION:,1. Three-vessel coronary artery disease involving a subtotaled left anterior descending artery with TIMI-I flow distally and 90% circumflex lesion and 90% right coronary artery lesion.,2. Mildly elevated left-sided filling pressures.,PLAN:,1. The patient will be transferred to Providence Hospital today for likely PCI of the mid LAD lesion with a surgical evaluation for a coronary artery bypass grafting. These findings and plan were discussed in detail with the patient and the patient's family. The patient is agreeable.,2. The patient will be continued on aggressive medical therapy including beta-blocker, aspirin, ACE inhibitor, and statin therapy. The patient will not be placed on Plavix secondary to the possibility for coronary bypass grafting. In light of the patient's history of cranial aneurysmal bleed, the patient will be held off of Lovenox and Integrilin.

Cardiovascular / Pulmonary

PREOPERATIVE DIAGNOSES: , Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,POSTOPERATIVE DIAGNOSES:, Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,PROCEDURES:, C5-C6 and C6-C7 anterior cervical discectomy (two levels) C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:, None.,INDICATION FOR THE PROCEDURE: , This lady presented with history of cervical pain associated with cervical radiculopathy with cervical and left arm pain, numbness, weakness, with MRI showing significant disk protrusions with the associate complexes at C5-C6 and C6-C7 with associated cervical radiculopathy. After failure of conservative treatment, this patient elected to undergo surgery.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the OR and after adequate general endotracheal anesthesia, she was placed supine on the OR table with the head of the bed about 10 degrees. A shoulder roll was placed and the head supported on a donut support. The cervical region was prepped and draped in the standard fashion. A transverse cervical incision was made from the midline, which was lateral to the medial edge of the sternocleidomastoid two fingerbreadths above the right clavicle. In a transverse fashion, the incision was taken down through the skin and subcutaneous tissue and through the platysmata and a subplatysmal dissection done. Then, the dissection continued medial to the sternocleidomastoid muscle and then medial to the carotid artery to the prevertebral fascia, which was gently dissected and released superiorly and inferiorly. Spinal needles were placed into the displaced C5-C6 and C6-C7 to confirm these disk levels using lateral fluoroscopy. Following this, monopolar coagulation was used to dissect the medial edge of the longus colli muscles off the adjacent vertebrae between C5-C7 and then the Trimline retractors were placed to retract the longus colli muscles laterally and blunt retractors were placed superiorly and inferiorly. A #15 scalpel was used to do a discectomy at C5-C6 from endplate-to-endplate and uncovertebral joint. On the uncovertebral joint, a pituitary rongeur was used to empty out any disk material ____________ to further remove the disk material down to the posterior aspect. This was done under the microscope. A high-speed drill under the microscope was used to drill down the endplates to the posterior aspect of the annulus. A blunt trocar was passed underneath the posterior longitudinal ligament and it was gently released using the #15 scalpel and then Kerrison punches 1-mm and then 2-mm were used to decompress further disk calcified material at the C5-C6 level. This was done bilaterally to allow good decompression of the thecal sac and adjacent neuroforamen. Then, at the C6-C7 level, in a similar fashion, #15 blade was used to do a discectomy from uncovertebral joint to uncovertebral joint and from endplate-to-endplate using a #15 scalpel to enter the disk space and then the curette was then used to remove the disk calcified material in the endplate, and then high-speed drill under the microscope was used to drill down the disk space down to the posterior aspect of the annulus where a blunt trocar was passed underneath the posterior longitudinal ligament which was gently released. Then using the Kerrison punches, we used 1-mm and 2-mm, to remove disk calcified material, which was extending more posteriorly to the left and the right. This was gently removed and decompressed to allow good decompression of the thecal sac and adjacent nerve roots. With this done, the wound was irrigated. Hemostasis was ensured with bipolar coagulation. Vertebral body distraction pins were then placed to the vertebral body of C5 and C7 for vertebral distraction and then a 6-mm allograft performed grafts were taken and packed in either aspect with demineralized bone matrix and this was tapped in flush with the vertebral bodies above and below C5-C6 and C6-C7 discectomy sites. Then, the vertebral body distraction pins were gently removed to allow for graft seating and compression and then the anterior cervical plate (Danek windows titanium plates) was then taken and sized and placed. A temporary pin was initially used to align the plate and then keeping the position and then two screw holes were drilled in the vertebral body of C5, two in the vertebral body of C6, and two in the vertebral body of C7. The holes were then drilled and after this self-tapping screws were placed into the vertebral body of C5, C6, and C7 across the plate to allow the plate to fit and stay flush with the vertebral body between C5, C6, and C7. With this done, operative fluoroscopy was used to check good alignment of the graft, screw, and plate, and then the wound was irrigated. Hemostasis was ensured with bipolar coagulation and then the locking screws were tightened down. A #10 round Jackson-Pratt drain was placed into the prevertebral space and brought out from a separate stab wound skin incision site. Then, the platysma was approximated using 2-0 Vicryl inverted interrupted stitches and the skin closed with 4-0 Vicryl running subcuticular stitch. Steri-Strips and sterile dressings were applied. The patient remained hemodynamically stable throughout the procedure. Throughout the procedure, the microscope had been used for the disk decompression and high-speed drilling. In addition, intraoperative SSEP, EMG monitoring, and motor-evoked potentials remained stable throughout the procedure. The patient remained stable throughout the procedure.

Surgery

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

Gastroenterology

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.

Office Notes

PROCEDURE: , Flexible sigmoidoscopy.,PREOPERATIVE DIAGNOSIS:, Rectal bleeding.,POSTOPERATIVE DIAGNOSIS: ,Diverticulosis.,MEDICATIONS: , None.,DESCRIPTION OF PROCEDURE: ,The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm, reaching the proximal descending colon. At this point, stool occupied the lumen, preventing further passage. The colon distal to this was well cleaned out and easily visualized. The mucosa was normal throughout the regions examined. Numerous diverticula were seen. There was no blood or old blood or active bleeding. A retroflexed view of the anorectal junction showed no hemorrhoids. He tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Sigmoid and left colon diverticulosis.,2. Otherwise normal flexible sigmoidoscopy to the proximal descending colon.,3. The bleeding was most likely from a diverticulum, given the self limited but moderately severe quantity that he described.,RECOMMENDATIONS:,1. Follow up with Dr. X as needed.,2. If there is further bleeding, a full colonoscopy is recommended.

Gastroenterology

PREOPERATIVE DIAGNOSES:,1. Hematochezia.,2. Refractory dyspepsia.,POSTOPERATIVE DIAGNOSES:,1. Colonic polyps at 35 cm and 15 cm.,2. Diverticulosis coli.,2. Acute and chronic gastritis.,PROCEDURE PERFORMED:,1. Colonoscopy to cecum with snare polypectomy.,2. Esophagogastroduodenoscopy with biopsies.,INDICATIONS FOR PROCEDURES: ,This is a 43-year-old white male who presents as an outpatient to the General Surgery Service with hematochezia with no explainable source at the anal verge. He also had refractory dyspepsia despite b.i.d., Nexium therapy. The patient does use alcohol and tobacco. The patient gave informed consent for the procedure.,GROSS FINDINGS: , At the time of colonoscopy, the entire length of colon was visualized. The patient was found to have a sigmoid diverticulosis. He also was found to have some colonic polyps at 35 cm and 15 cm. The polyps were large enough to be treated with snare cautery technique. The polyps were achieved and submitted to pathology. EGD did confirm acute and chronic gastritis. The biopsies were performed for H&E and CLO testing. The patient had no evidence of distal esophagitis or ulcers. No mass lesions were seen.,PROCEDURE: ,The patient was taken to the Endoscopy Suite with the heart and lungs examination unremarkable. The vital signs were monitored and found to be stable throughout the procedure. The patient was placed in the left lateral position where intravenous Demerol and Versed were given in a titrated fashion.,The video Olympus colonoscope was advanced per anus and without difficulty to the level of cecum. Photographic documentation of the diverticulosis and polyps were obtained. The patient's polyps were removed in a similar fashion, each removed with snare cautery. The polyps were encircled at their stalk. Increasing the tension and cautery was applied as coagulation and cutting blunt mode, 15/15 was utilized. Good blanching was seen. The polyp was retrieved with the suction port of the scope. The patient was re-scoped to the polyp levels to confirm that there was no evidence of perforation or bleeding at the polypectomy site. Diverticulosis coli was also noted. With colonoscopy completed, the patient was then turned for EGD. The oropharynx was previously anesthetized with Cetacaine spray and a biteblock was placed. Video Olympus GIF gastroscope model was inserted per os and advanced without difficulty through the hypopharynx. The esophagus revealed a GE junction at 39 cm. The GE junction was grossly within normal limits. The stomach was entered and distended with air. Acute and chronic gastritis features as stated were appreciated. The pylorus was traversed with normal duodenum. The stomach was again reentered. Retroflex maneuver of the scope confirmed that there was no evidence of hiatal hernia. There were no ulcers or mass lesions seen. The patient had biopsy performed of the antrum for H&E and CLO testing. There was no evidence of untoward bleeding at biopsy sites. Insufflated air was removed with withdrawal of the scope. The patient will be placed on a reflux diet, given instruction and information on Nexium usage. Additional recommendations will follow pending biopsy results. He is to also abstain from alcohol and tobacco. He will require follow-up colonoscopy again in three years for polyp disease.

Gastroenterology

PROCEDURE:, Total hip replacement.,PROCEDURE DESCRIPTION:, The patient was bought to the operating room and placed in the supine position. After induction of anesthesia, the patient was turned on the side and secured in the hip table. An incision was made, centered over the greater trochanter. Dissection was sharply carried down through the subcutaneous tissues. The gluteus maximus was incised and split proximally. The piriformis and external rotators were identified. These were removed from their insertions on the greater trochanter as a sleeve with the hip capsule. The hip was dislocated. A femoral neck cut was made using the guidance of preoperative templating. The femoral head was removed. Extensive degenerative disease was found on the femoral head as well as in the acetabulum.,Baseline leg-length measurements were taken. The femur was retracted anteriorly and a complete labrectomy was performed. Reaming of the acetabulum was then performed until adequate bleeding subchondral bone was identified in the key areas. The trial shell was placed and found to have an excellent fit. The real shell was opened and impacted into position in the appropriate amount of anteversion and abduction. Screws were placed by drilling into the pelvis, measuring, and placing the appropriate length screw. Excellent purchase was obtained. The trial liner was placed.,The femur was then flexed and internally rotated. The extra trochanteric bone was removed, as was any leftover lateral soft tissue at the piriformis insertion. An intramedullary hole was drilled into the femur to define the canal. Reaming was performed until the appropriate size was reached. The broaches were then used to prepare the femur with the appropriate amount of version. Once the appropriate size broach was reached, it was used as a trial with head and neck placement. Hip range-of-motion was checked in all planes, including flexion-internal rotation, the position of sleep, and extension-external rotation. The hip was found to have excellent stability with the final chosen head-neck combination. Leg length measurements were taken and found to be within acceptable range, given the necessity for stability.,The real stem was opened and impacted into position. The real head was impacted atop the stem. If cement was used, the canal was thoroughly washed and dried and plugged with a restrictor, and then the cement was injected and pressurized and the stem was implanted in the appropriate version. Excess cement was removed from the edges of the component. Range of motion and stability were once again checked and found to be excellent. Adequate hemostasis was obtained. Vigorous power irrigation was used to remove all debris from the joint prior to final reduction.,The arthrotomy and rotators were closed using #1 Ethibond through drill holes in the bone, recreating the posterior hip structural anatomy. The gluteus maximus was repaired using 0 Ethibond and 0 Vicryl. The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures. The skin was closed with nylon. Xeroform and a sterile dressing were applied followed by a cold pack and Ace wrap. The patient was transferred to the recovery room in stable condition, having tolerated the procedure well.

Orthopedic

HISTORY OF PRESENT ILLNESS: , This is a 48-year-old black male with stage IV chronic kidney disease, likely secondary to HIV nephropathy who presents to clinic for followup having missed prior clinic appointments. He was last seen in this clinic on 05/29/2007 by Dr. X. This is the first time that I have met the patient. The patient's history of renal insufficiency dates back to 06/2006 when he was hospitalized for an HIV-associated complication. He is unclear of the exact reason for his hospitalization at that time, but he was diagnosed with renal insufficiency and was followed in our Renal Clinic for approximately one year. He had a baseline creatinine during that time of between 3.2 to 3.3. When he was initially diagnosed with renal insufficiency, he had been noncompliant with his HAART regimen. Since that time, he has been very compliant with treatment for his HIV and is seeing Dr. Y in our Infectious Disease Clinic. He is currently on three-drug antiretroviral therapy. His last CD4 count in 03/2008 was 350. He has had no HIV complications since he was last seen in our clinic. The patient is also followed by Dr. Z at the outpatient VA Clinic, here in ABCD, although he has not seen her in approximately one year. The patient has an AV fistula that was placed in late 2006. The latest blood work that I have is from 06/11/2008 and shows a serum creatinine of 3.8, which represents a GFR of 22 and a potassium of 5.9. These laboratories were drawn by his infectious disease doctor and the results prompted their recommendation for him to return to our clinic for further evaluation. The only complaint that the patient has at this time is some difficulty sleeping. He was given Ambien by his primary care doctor, but this has not helped significantly with his difficulty sleeping. He says that he has trouble getting to sleep. The Ambien will allow him to sleep for about two hours, and then he is awake again. He is tired during the day, but is not taking any daytime naps. He has no history of excessive snoring or apneic periods. He has no history of falling asleep at work or while driving. He has never had a formal sleep study. He does continue to work in sales at a local butcher shop.,REVIEW OF SYSTEMS: ,He denies any change in his appetite. He has actually gained some weight in recent months. He denies any nausea, vomiting, or abdominal discomfort. He denies any pruritus. He denies any lower extremity edema. All other systems are reviewed and negative.,PAST MEDICAL HISTORY:,1. Stage IV chronic kidney disease with most recent GFR of 22.,2. HIV diagnosed in 09/2006 with the most recent CD4 count of 350 in 03/2008.,3. Hyperlipidemia.,4. Hypertension.,5. Secondary hyperparathyroidism.,6. Status post right upper extremity AV fistula in the fall of 2006.,7. History of a right brachial plexus palsy.,8. Recent lower back pain, status post lumbar steroid injection.,ALLERGIES:, HE SAYS THAT VITAMIN D HAS CAUSED HEADACHES.,MEDICATIONS:,1. Kaletra daily.,2. Epivir one daily.,3. Ziagen two daily.,4. Lasix 20 mg b.i.d.,5. Valsartan 20 mg b.i.d.,6. Ambien 10 mg q.h.s.,SOCIAL HISTORY: , He lives here in ABCD. He is employed at the sales counter of a local butcher shop. He continues to smoke one pack of cigarettes daily, as he has for the past 28 years. He denies any alcohol or illicit substances.,FAMILY HISTORY:, His mother is deceased. He said that she had some type of paralysis before she died. His father is deceased at age 64 of a head and neck cancer. He has a 56-year-old brother with type-two diabetes and blindness secondary to diabetic retinopathy. He has a 41-year-old brother who has hypertension. He has a sister who has thyroid disease.,PHYSICAL EXAMINATION:,VITAL SIGNS: Weight is 191 pounds. His temperature is 97.1. Pulse is 94. Blood pressure by automatic cuff 173/97, by manual cuff 180/90.,HEENT: His oropharynx is clear without thrush or ulceration.,NECK: Supple without lymphadenopathy or thyromegaly.,HEART: Regular with normal S1 and S2. There are no murmurs, rubs, or gallops. He has no JVD.,LUNGS: Clear to auscultation bilaterally without wheezes, rhonchi, or crackles.,ABDOMEN: Soft, nontender, nondistended, without abdominal bruit or organomegaly.,MUSCULOSKELETAL: He has difficulty with abduction of his right shoulder.,ACCESS: He has a right forearm AV fistula with an audible bruit and a palpable thrill. There is no sign of stenosis. The vascular access looks like it is ready to use.,EXTREMITIES: No peripheral edema.,SKIN: No bruises, petechiae, or rash.,LABS: ,Sodium was 140, potassium 5.9, chloride 114, bicarbonate 18. BUN is 49, creatinine 4.3. GFR is 19. Albumin 3.2. Protein 7. AST 17, ALT 16, alkaline phosphatase 106. Total bilirubin 0.4. Calcium 9.1., phosphorus 4.7, PTH of 448. The corrected calcium was 9.7. WBC is 8.9, hemoglobin 13.4, platelet 226. Total cholesterol 234, triglycerides 140, LDL 159, HDL 47. His ferritin is 258, iron is 55, and percent sat is 24.,IMPRESSION: ,This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.,RECOMMENDATIONS:,1. Renal. His serum creatinine is progressively worsening. His creatinine was 3.2 the last time we saw him in 05/2007 and today is 4.3. This represents a GFR of 19. This is stage IV chronic kidney disease. He does have vascular access and this appears to be ready to use. He is having some difficulty sleeping and it is possible that this represents some early signs of uremia. Otherwise, he has no signs or symptoms of uremia at this time. I am going to touch base with the dialysis educator and try to get The patient in to the dialysis teaching classes. He has already received some literature for the dialysis teaching, but has not yet enrolled in the classes. I have encouraged him to continue to exercise his right forearm. I am also going to contact the transplant coordinator and see if he can be evaluated for possible transplant. Given his progression of his chronic kidney disease, I will anticipate that he will need to start dialysis soon.,2. Hypertension. I have added labetolol 100 mg b.i.d. to his antihypertensive regimen. He shows no signs at this point of volume overload, although if he does demonstrate this in the future, his Lasix could be increased. Goal blood pressure would be less than 130/80.,3. Hyperkalemia. I am going to instruct him in a low-potassium diet and decrease his valsartan to 20 mg daily. I will have him return in one week to recheck his potassium. If his potassium continues to remain elevated, he may require initiation of dialysis for this.,4. Bone metabolism. His PTH is elevated and I am going to add PhosLo 800 mg t.i.d. with meals. His corrected calcium is 9.7, and I would like to avoid calcium-containing phosphate bonders in this situation.,5. Acid base. His bicarbonate is 18 and I will initiate the sodium bicarbonate 650 mg three tablets t.i.d.,6. Anemia. His hemoglobin is at goal for this stage of chronic kidney disease. His iron stores are adequate.

Nephrology

PREOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,POSTOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,PROCEDURES: ,1. Anterior spine fusion from T11-L3.,2. Posterior spine fusion from T3-L5.,3. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.,ESTIMATED BLOOD LOSS: , 500 mL.,FINDINGS: , The patient was found to have a severe scoliosis. This was found to be moderately corrected. Hardware was found to be in good positions on AP and lateral projections using fluoroscopy.,INDICATIONS: , The patient has a history of severe neurogenic scoliosis. He was indicated for anterior and posterior spinal fusion to allow for correction of the curvature as well as prevention of further progression. Risks and benefits were discussed at length with the family over many visits. They wished to proceed.,PROCEDURE:, The patient was brought to the operating room and placed on the operating table in the supine position. General anesthesia was induced without incident. He was given a weight-adjusted dose of antibiotics. Appropriate lines were then placed. He had a neuromonitoring performed as well.,He was then initially placed in the lateral decubitus position with his left side down and right side up. An oblique incision was then made over the flank overlying the 10th rib. Underlying soft tissues were incised down at the skin incision. The rib was then identified and subperiosteal dissection was performed. The rib was then removed and used for autograft placement later.,The underlying pleura was then split longitudinally. This allowed for entry into the pleural space. The lung was then packed superiorly with wet lap. The diaphragm was then identified and this was split to allow for access to the thoracolumbar spine.,Once the spine was achieved, subperiosteal dissection was performed over the visualized vertebral bodies. This required cauterization of the segmental vessels. Once the subperiosteal dissection was performed to the posterior and anterior extents possible, the diskectomies were performed. These were performed from T11-L3. This was over 5 levels. Disks and endplates were then removed. Once this was performed, morcellized rib autograft was placed into the spaces. The table had been previously bent to allow for easier access of the spine. This was then straightened to allow for compression and some correction of the curvature.,The diaphragm was then repaired as was the pleura overlying the thoracic cavity. The ribs were held together with #1 Vicryl sutures. Muscle layers were then repaired using a running #2-0 PDS sutures and the skin was closed using running inverted #2-0 PDS suture as well. Skin was closed as needed with running #4-0 Monocryl. This was dressed with Xeroform dry sterile dressings and tape.,The patient was then rotated into a prone position. The spine was prepped and draped in a standard fashion.,Longitudinal incision was made from T2-L5. The underlying soft tissues were incised down at the skin incision. Electrocautery was then used to maintain hemostasis. The spinous processes were then identified and the overlying apophyses were split. This allowed for subperiosteal dissection over the spinous processes, lamina, facet joints, and transverse processes. Once this was completed, the C-arm was brought in, which allowed for easy placement of screws in the lumbar spine. These were placed at L4 and L5. The interspaces between the spinous processes were then cleared of soft tissue and ligamentum flavum. This was done using a rongeur as well as a Kerrison rongeur. Spinous processes were then harvested for morcellized autograft.,Once all the interspaces were prepared, Songer wires were then passed. These were placed from L3-T3.,Once the wires were placed, a unit rod was then positioned. This was secured initially at the screws distally on both the left and right side. The wires were then tightened in sequence from the superior extent to the inferior extent, first on the left-sided spine where I was operating and then on the right side spine. This allowed for excellent correction of the scoliotic curvature.,Decortication was then performed and placement of a morcellized autograft and allograft was then performed after thoroughly irrigating the wound with 4 liters of normal saline mixed with bacitracin. This was done using pulsed lavage.,The wound was then closed in layers. The deep fascia was closed using running #1 PDS suture, subcutaneous tissue was closed using running inverted #2-0 PDS suture, the skin was closed using #4-0 Monocryl as needed. The wound was then dressed with Steri-Strips, Xeroform dry sterile dressings, and tape. The patient was awakened from anesthesia and taken to the intensive care unit in stable condition. All instrument, sponge, and needle counts were correct at the end of the case.,The patient will be managed in the ICU and then on the floor as indicated.

Surgery

SUBJECTIVE: , The patient is a 60-year-old female, who complained of coughing during meals. Her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit, which was completed approximately 2 months ago. The patient had a history of hypertension and TIA/stroke. The patient denied history of heartburn and/or gastroesophageal reflux disorder. A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,OBJECTIVE: , Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. ABC. The patient was seated upright in a video imaging chair throughout this assessment. To evaluate the patient's swallowing function and safety, she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid (teaspoon x2, cup sip x2); nectar-thick liquid (teaspoon x2, cup sip x2); puree consistency (teaspoon x2); and solid food consistency (1/4 cracker x1).,ASSESSMENT,ORAL STAGE:, Premature spillage to the level of the valleculae and pyriform sinuses with thin liquid. Decreased tongue base retraction, which contributed to vallecular pooling after the swallow.,PHARYNGEAL STAGE: , No aspiration was observed during this evaluation. Penetration was noted with cup sips of thin liquid only. Trace residual on the valleculae and on tongue base with nectar-thick puree and solid consistencies. The patient's hyolaryngeal elevation and anterior movement are within functional limits. Epiglottic inversion is within functional limits.,CERVICAL ESOPHAGEAL STAGE: ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus. Radiologist noted reduced peristaltic action of the constricted muscles in the esophagus, which may be contributing to the patient's complaint of globus sensation.,DIAGNOSTIC IMPRESSION:, No aspiration was noted during this evaluation. Penetration with cup sips of thin liquid. The patient did cough during this evaluation, but that was noted related to aspiration or penetration.,PROGNOSTIC IMPRESSION: ,Based on this evaluation, the prognosis for swallowing and safety is good.,PLAN: , Based on this evaluation and following recommendations are being made:,1. The patient to take small bite and small sips to help decrease the risk of aspiration and penetration.,2. The patient should remain upright at a 90-degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation.,3. The patient should be referred to a gastroenterologist for further evaluation of her esophageal function.,The patient does not need any skilled speech therapy for her swallowing abilities at this time, and she is discharged from my services.

Speech - Language

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.

Neurosurgery

REASON FOR ADMISSION: , Rectal bleeding.,HISTORY OF PRESENT ILLNESS: ,The patient is a very pleasant 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks. He has had some physical therapy for his lower back secondary to pain after hernia repair. He states that the pain worsened after this. He has had previous history of rectal bleeding and a colonoscopy approximately 8 years ago that was normal. He denies any dysuria. He denies any hematemesis. He denies any pleuritic chest pain. He denies any hemoptysis.,PAST MEDICAL HISTORY:,1. History of bilateral hernia repair by Dr. X in 8/2008.,2. History of rectal bleeding.,ALLERGIES: , NONE.,MEDICATIONS:,1. Cipro.,2. Lomotil.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS: The patient is afebrile. Pulse 117, respirations 18, and blood pressure 117/55. Saturating 98% on room air.,GENERAL: The patient is alert and oriented x3.,HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is clear without exudates.,NECK: Supple. No thyromegaly. No jugular venous distention.,HEART: Tachycardic. Regular rhythm without murmurs, rubs or gallops.,LUNGS: Clear to auscultation bilaterally both anteriorly and posteriorly.,ABDOMEN: Positive bowel sounds. Soft and nontender with no guarding.,EXTREMITIES: No clubbing, cyanosis or edema in the upper or lower extremities.,NEUROLOGIC: Nonfocal.,LABORATORY STUDIES:, Sodium 131, potassium 3.9, chloride 94, CO2 25, BUN 15, creatinine 0.9, glucose 124, INR 1.2, troponin less than 0.04, white count 17.5, hemoglobin 12.3, and platelet count 278 with 91% neutrophils. EKG shows sinus tachycardia.,PROBLEM LIST:,1. Colitis.,2. Sepsis.,3. Rectal bleeding.,RECOMMENDATIONS:,1. GI consult with Dr. Y's group.,2. Continue Levaquin and Flagyl.,3. IV fluids.,4. Send for fecal WBCs, O&P, and C. diff.,5. CT of the abdomen and pelvis to rule out abdominal pathology.,6. PPI for PUD prophylaxis.

Gastroenterology

PREOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,POSTOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,OPERATION:, Open reduction, nasal fracture with nasal septoplasty.,ANESTHESIA: , General.,HISTORY: , This 16-year-old male fractured his nose playing basketball. He has a left nasal obstruction and depressed left nasal bone.,DESCRIPTION OF PROCEDURE: , The patient was given general endotracheal anesthesia and monitored with pulse oximetry, EKG, and CO2 monitors.,The face was prepped with Betadine soap and solution and draped in a sterile fashion. Nasal mucosa was decongested using Afrin pledgets as well as 1% Xylocaine, 1:100,000 epinephrine was injected into bilateral nasal septal mucoperichondrium and the nasal dorsum, lateral osteotomy sites.,Inspection revealed caudal portion of the cartilaginous septum lying crosswise across the nasal spine area and columella causing obstruction of the left nasal valve. Further up, the cartilaginous septum was displaced to the left of the maxillary crest. There was a large maxillary crest and supramaxillary crest had a large spur with the vomer bone touching the inferior turbinate.,There was a large deep groove horizontally on the right side corresponding to the left maxillary crest.,A left hemitransfixion incision was made. Mucoperichondrium was elevated from left side of the cartilaginous septum and mucoperiosteum was elevated from the ethmoid plate. Vomer and inferior tunnel was created at the floor of the left side of the nose to connect the anterior and inferior tunnels, which was rather difficult at the area of the vomerine spur, which was very sharp and touching the inferior turbinate.,The caudal cartilaginous septum, which was lying crosswise, was separated from the main cartilage leaving approximately 1 cm strut. The right side mucoperichondrium was released from the cartilaginous septum as well as ethmoid plate and the maxillary crest area.,The caudal cartilaginous strut was sutured to the columella with interrupted #4-0 chromic catgut suture to bring it into the midline.,Further back, the cartilaginous septum anterior to the ethmoid plate was deviated to the left side, so it was freed from the maxillary crest, nasal dorsum, from the ethmoid plate, and was sutured in the midline with a transfixion #4-0 plain catgut sutures.,Further posteriorly, the ethmoid plate was deviated to the left side and portion of it was removed with Jansen-Middleton punch forceps.,The main deviation was also caused by the vomerine crest and the maxillary crest and supramaxillary cartilaginous cartilage.,This area was freed from the perichondrium on both sides. The maxillary crest was removed with a gouge. Vomer was partially removed with a gouge and the rest of the vomer was displaced back into the midline.,Thus, the deviated septum was corrected. Left hemitransfixion incisions were closed with interrupted #4-0 chromic catgut sutures. The septum was also filtered with #4-0 plain catgut sutures.,By valve, septal splints were tied to the septum bilaterally with a transfixion #5-0 nylon suture.,Next, the nasal bone suture deviated to the left side were corrected. The right nasal bone was depressed and left nasal bone was wide. Therefore, the nasal bones were refractured back into the midline by compressing the left nasal bone and elevating the right nasal bone with the nasal bone elevator through the nasal cavities. The left intercartilaginous incision was made and the nasal bones were disimpacted subperiosteally and they were molded back into the midline.,Steri-Strips were applied to the nasal dorsal skin and a Denver type of splint was applied to the nasal dorsal to stabilize the nasal bones.,Nasal cavities were packed with Telfa gauze rolled on both sides with bacitracin ointment. Approximate blood loss was 10 to 20 mL.

ENT - Otolaryngology

PROCEDURE:, Esophagogastroduodenoscopy with biopsy and snare polypectomy.,INDICATION FOR THE PROCEDURE:, Iron-deficiency anemia.,MEDICATIONS:, MAC.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, and aspiration.,PROCEDURE:, After informed consent and appropriate sedation, the upper endoscope was inserted into the oropharynx down into the stomach and beyond the pylorus and the second portion of the duodenum. The duodenal mucosa was completely normal. The pylorus was normal. In the stomach, there was evidence of diffuse atrophic-appearing nodular gastritis. Multiple biopsies were obtained. There also was a 1.5-cm adenomatous appearing polyp along the greater curvature at the junction of the body and antrum. There was mild ulceration on the tip of this polyp. It was decided to remove the polyp via snare polypectomy. Retroflexion was performed, and this revealed a small hiatal hernia in the distal esophagus. The Z-line was identified and was unremarkable. The esophageal mucosa was normal.,FINDINGS:,1. Hiatal hernia.,2. Diffuse nodular and atrophic appearing gastritis, biopsies taken.,3. A 1.5-cm polyp with ulceration along the greater curvature, removed.,RECOMMENDATIONS:,1. Follow up biopsies.,2. Continue PPI.,3. Hold Lovenox for 5 days.,4. Place SCDs.

Gastroenterology

PREOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,POSTOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,OPERATION PROCEDURE: , Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,INDICATION FOR THE PROCEDURE: ,The patient was a 71-year-old female transferred from an outside facility with the left main, proximal left anterior descending, and proximal circumflex severe coronary occlusive disease, ejection fraction about 40%.,FINDINGS: , The LAD was 2-mm vessel and good, mammary was good, and obtuse marginal was 2-mm vessel and good, and the main was good.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring devices were placed. The chest, abdomen and legs were prepped and draped in the sterile fashion. The right greater saphenous vein was harvested and prepared by 2 interrupted skin incisions and by ligating all branches with 4-0 Surgilon and flushed with heparinized blood. Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.,Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The pericardium was opened. The pericardial cradle was created. The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted. A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet. An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene. Cardiopulmonary bypass was instituted and the ascending aorta was crossclamped. Antegrade cardioplegia was given at a total of 5 mL per kg through the aortic route. This was followed by something in the aortic route and retrograde cardioplegia through the coronary sinus at a total of 5 mL per kg. The obtuse marginal coronary was identified and opened.,End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length. Cold antegrade and retrograde potassium cardioplegia were given. The mammary artery was clipped distally, divided and spatulated for anastomosis. The anterior descending was identified and opened. End-to-side anastomosis was performed with running 8-0 Prolene suture and the warm blood potassium cardioplegia was given antegrade and retrograde and the aortic cross-clamp was removed. The partial occlusion clamp was placed. Aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. A partial occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Ventilation was commenced. The patient was fully warm and the patient was then wean from cardiopulmonary bypass. The patient was decannulated in routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire plus two 5-mm Mersiline tapes.,The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch. The patient tolerated the procedure well.

Surgery

CHIEF COMPLAINT: , Foot pain.,HISTORY OF PRESENT ILLNESS: , This is a 17-year-old high school athlete who swims for the swimming team. He was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet. He was barefoot at that time. He had been in the pool practicing an hour prior to this injury. Because of the contusions and abrasions to his feet, his athletic trainer brought in him to the urgent care. He is able to bear weight; however, complains of pain in his toes. The patient did have some avulsion of the skin across the second and third toes of the left foot with contusions across the second, third, and fourth toes and dorsum of the foot. According to the patient, he was at his baseline state of health prior to this acute event.,PAST MEDICAL HISTORY: , Significant for attention deficit hyperactivity disorder.,PAST SURGICAL HISTORY: ,Positive for wisdom tooth extraction.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: ,He does not use alcohol, tobacco or illicit drugs. He plays water polo for the school team.,IMMUNIZATION HISTORY: , All immunizations are up-to-date for age.,REVIEW OF SYSTEMS: , The pertinent review of systems is as noted above; the remaining review of systems was reviewed and is noted to be negative.,PRESENT MEDICATIONS: , Provigil, Accutane and Rozerem.,ALLERGIES: ,None.,PHYSICAL EXAMINATION:,GENERAL: This is a pleasant white male in no acute distress.,VITAL SIGNS: He is afebrile. Vitals are stable and within normal limits.,HEENT: Negative for acute evidence of trauma, injury or infection.,LUNGS: Clear.,HEART: Regular rate and rhythm with S1 and S2.,ABDOMEN: Soft.,EXTREMITIES: There are some abrasions across the dorsum of the right foot including the second, third and fourth toes. There is some mild tenderness to palpation. However, there are no clinical fractures. Distal pulses are intact. The left foot notes superficial avulsion lacerations to the third and fourth digit. There are no subungual hematomas. Range of motion is decreased secondary to pain. No obvious fractures identified.,BACK EXAM: Nontender.,NEUROLOGIC EXAM: He is alert, awake and appropriate without deficit.,RADIOLOGY: , AP, lateral, and oblique views of the feet were conducted per Radiology, which were negative for acute fractures and significant soft tissue swelling or bony injuries.,On reevaluation, the patient was resting comfortably. He was informed of the x-ray findings. The patient was discharged in the care of his mother with a preliminary diagnosis of bilateral foot contusions with superficial avulsion lacerations, not requiring surgical repair.,DISCHARGE MEDICATIONS: , Darvocet.,The patient's condition at discharge was stable. All medications, discharge instructions and follow-up appointments were reviewed with the patient/family prior to discharge. The patient/family understood the instructions and was discharged without further incident.

Podiatry

PREOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Chronic dyspepsia.,POSTOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Chronic dyspepsia.,3. Alkaline reflux gastritis.,4. Gastroparesis.,5. Probable Billroth II anastomosis.,6. Status post Whipple's pancreaticoduodenectomy.,PROCEDURE PERFORMED:, Esophagogastroduodenoscopy with biopsies.,INDICATIONS FOR PROCEDURE: , This is a 55-year-old African-American female who had undergone Whipple's procedure approximately five to six years ago for a benign pancreatic mass. The patient has pancreatic insufficiency and is already on replacement. She is currently using Nexium. She has continued postprandial dyspepsia and reflux symptoms. To evaluate this, the patient was boarded for EGD. The patient gave informed consent for the procedure.,GROSS FINDINGS: , At the time of EGD, the patient was found to have alkaline reflux gastritis. There was no evidence of distal esophagitis. Gastroparesis was seen as there was retained fluid in the small intestine. The patient had no evidence of anastomotic obstruction and appeared to have a Billroth II reconstruction by gastric jejunostomy. Biopsies were taken and further recommendations will follow.,PROCEDURE: ,The patient was taken to the Endoscopy Suite. The heart and lungs examination were unremarkable. The vital signs were monitored and found to be stable throughout the procedure. The patient's oropharynx was anesthetized with Cetacaine spray. She was placed in left lateral position. The patient had the video Olympus GIF gastroscope model inserted per os and was advanced without difficulty through the hypopharynx. GE junction was in normal position. There was no evidence of any hiatal hernia. There was no evidence of distal esophagitis. The gastric remnant was entered. It was noted to be inflamed with alkaline reflux gastritis. The anastomosis was open and patent. The small intestine was entered. There was retained fluid material in the stomach and small intestine and _______ gastroparesis. Biopsies were performed. Insufflated air was removed with withdrawal of the scope. The patient's diet will be adjusted to postgastrectomy-type diet. Biopsies performed. Diet will be reviewed. The patient will have an upper GI series performed to rule out more distal type obstruction explaining the retained fluid versus gastroparesis. Reglan will also be added. Further recommendations will follow.

Gastroenterology

EYES: , The conjunctivae are clear. The lids are normal appearing without evidence of chalazion or hordeolum. The pupils are round and reactive. The irides are without any obvious lesions noted. Funduscopic examination shows sharp disk margins. There are no exudates or hemorrhages noted. The vessels are normal appearing.,EARS, NOSE, MOUTH AND THROAT:, The nose is without any evidence of any deformity. The ears are with normal-appearing pinna. Examination of the canals is normal appearing bilaterally. There is no drainage or erythema noted. The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex. Hearing is grossly intact to finger rubbing and whisper. The nasal mucosa is moist. The septum is midline. There is no evidence of septal hematoma. The turbinates are without abnormality. No obvious abnormalities to the lips. The teeth are unremarkable. The gingivae are without any obvious evidence of infection. The oral mucosa is moist and pink. There are no obvious masses to the hard or soft palate. The uvula is midline. The salivary glands appear unremarkable. The tongue is midline. The posterior pharynx is without erythema or exudate. The tonsils are normal appearing.,NECK:, The neck is nontender and supple. The trachea is midline. The thyroid is without any evidence of thyromegaly. No obvious adenopathy is noted to the neck.,RESPIRATORY: , The patient has normal respiratory effort. There is normal lung excursion. Percussion of the chest is without any obvious dullness. There is no tactile fremitus or egophony noted. There is no tenderness to the chest wall or ribs. There are no obvious abnormalities. The lungs are clear to auscultation. There are no wheezes, rales or rhonchi heard. There are no obvious rubs noted.,CARDIOVASCULAR: , There is a normal PMI on palpation. I do not hear any obvious abnormal sounds. There are no obvious murmurs. There are no rubs or gallops noted. The carotid arteries are without bruit. No obvious thrill is palpated. There is no evidence of enlarged abdominal aorta to palpation. There is no abdominal mass to suggest enlargement of the aorta. Good strong femoral pulses are palpated. The pedal pulses are intact. There is no obvious edema noted to the extremities. There is no evidence of any varicosities or phlebitis noted.,GASTROINTESTINAL: , The abdomen is soft. Bowel sounds are present in all quadrants. There are no obvious masses. There is no organomegaly, and no liver or spleen is palpable. No obvious hernia is noted. The perineum and anus are normal in appearance. There is good sphincter tone and no obvious hemorrhoids are noted. There are no masses. On digital examination, there is no evidence of any tenderness to the rectal vault; no lesions are noted. Stool is brown and guaiac negative.,GENITOURINARY (FEMALE): , The external genitalia is normal appearing with no obvious lesions, no evidence of any unusual rash. The vagina is normal in appearance with normal-appearing mucosa. The urethra is without any obvious lesions or discharge. The cervix is normal in color with no obvious cervical discharge. There are no obvious cervical lesions noted. The uterus is nontender and small, and there is no evidence of any adnexal masses or tenderness. The bladder is nontender to palpation. It is not enlarged.,GENITOURINARY (MALE): , Normal scrotal contents are noted. The testes are descended and nontender. There are no masses and no swelling to the epididymis noted. The penis is without any lesions. There is no urethral discharge. Digital examination of the prostate reveals a nontender, non-nodular prostate.,BREASTS:, The breasts are normal in appearance. There is no puckering noted. There is no evidence of any nipple discharge. There are no obvious masses palpable. There is no axillary adenopathy. The skin is normal appearing over the breasts.,LYMPHATICS: , There is no evidence of any adenopathy to the anterior cervical chain. There is no evidence of submandibular nodes noted. There are no supraclavicular nodes palpable. The axillae are without any abnormal nodes. No inguinal adenopathy is palpable. No obvious epitrochlear nodes are noted.,MUSCULOSKELETAL/EXTREMITIES: , The patient has normal gait and station. The patient has normal muscle strength and tone to all extremities. There is no obvious evidence of any muscle atrophy. The joints are all stable. There is no evidence of any subluxation or laxity to any of the joints. There is no evidence of any dislocation. There is good range of motion of all extremities without any pain or tenderness to the joints or extremities. There is no evidence of any contractures or crepitus. There is no evidence of any joint effusions. No obvious evidence of erythema overlying any of the joints is noted. There is good range of motion at all joints. There are normal-appearing digits. There are no obvious lesions to any of the nails or nail beds.,SKIN:, There is no obvious evidence of any rash. There are no petechiae, pallor or cyanosis noted. There are no unusual nodules or masses palpable.,NEUROLOGIC: , The cranial nerves II XII are tested and are intact. Deep tendon reflexes are symmetrical bilaterally. The toes are downgoing with normal Babinskis. Sensation to light touch is intact and symmetrical. Cerebellar testing reveals normal finger nose, heel shin. Normal gait. No ataxia.,PSYCHIATRIC: ,The patient is oriented to person, place and time. The patient is also oriented to situation. Mood and affect are appropriate for the present situation. The patient can remember 3 objects after 3 minutes without any difficulties. Remote memory appears to be intact. The patient seems to have normal judgment and insight into the situation.

Office Notes

INDICATIONS:, Atrial fibrillation, coronary disease.,STRESS TECHNIQUE:, The patient was infused with dobutamine to a maximum heart rate of 142. ECG exhibits atrial fibrillation.,IMAGE TECHNIQUE:, The patient was injected with 5.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT system.,IMAGE ANALYSIS:, It should be noted that the images are limited slightly by the patient's obesity with a weight of 263 pounds. There is normal LV myocardial perfusion. The LV systolic ejection fraction is normal at 65%. There is normal global and regional wall motion.,CONCLUSIONS:,1. Basic rhythm of atrial fibrillation with no change during dobutamine stress, maximum heart rate of 142.,2. Normal LV myocardial perfusion.,3. Normal LV systolic ejection fraction of 65%.,4. Normal global and regional wall motion.

Cardiovascular / Pulmonary

CHIEF COMPLAINT (1/1):, This 62 year old female presents today for evaluation of angina.,Associated signs and symptoms: Associated signs and symptoms include chest pain, nausea, pain radiating to the arm and pain radiating to the jaw.,Context: The patient has had no previous treatments for this condition.,Duration: Condition has existed for 5 hours.,Quality: Quality of the pain is described by the patient as crushing.,Severity: Severity of condition is severe and unchanged.,Timing (onset/frequency): Onset was sudden and with exercise. Patient has the following coronary risk factors: smoking 1 packs/day for 40 years and elevated cholesterol for 5 years. Patient's elevated cholesterol is not being treated with medication. Menopause occurred at age 53.,ALLERGIES:, No known medical allergies.,MEDICATION HISTORY:, Patient is currently taking Estraderm 0.05 mg/day transdermal patch.,PMH:, Past medical history unremarkable.,PSH:, No previous surgeries.,SOCIAL HISTORY:, Patient admits tobacco use She relates a smoking history of 40 pack years.,FAMILY HISTORY:, Patient admits a family history of heart attack associated with father (deceased).,ROS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAMINATION:,General: Patient is a 62 year old female who appears pleasant, her given age, well developed,,oriented, well nourished, alert and moderately overweight.,Vital Signs: BP Sitting: 174/92 Resp: 28 HR: 88 Temp: 98.6 Height: 5 ft. 2 in. Weight: 150 lbs.,HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck masses. Ocular motility exam reveals muscles are intact. Pupil exam reveals round and equally reactive to light and accommodation. There is no conjunctival inflammation nor icterus. Inspection of nose reveals no abnormalities. Inspection of oral mucosa and tongue reveals no pallor or cyanosis. Inspection of the tongue reveals normal color, good motility and midline position. Examination of oropharynx reveals the uvula rises in the midline. Inspection of lips, teeth, gums, and palate reveals healthy teeth, healthy gums, no gingival,hypertrophy, no pyorrhea and no abnormalities.,Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.,Thyroid examination reveals smooth and symmetric gland with no enlargement, tenderness or masses noted.,Carotid pulses are palpated bilaterally, are symmetric and no bruits auscultated over the carotid and vertebral arteries. Jugular veins examination reveals no distention or abnormal waves were noted. Neck lymph nodes are not noted.,Back: Examination of the back reveals no vertebral or costovertebral angle tenderness and no kyphosis or scoliosis noted.,Chest: Chest inspection reveals intercostal interspaces are not widened, no splinting, chest contours are normal and normal expansion. Chest palpation reveals no abnormal tactile fremitus.,Lungs: Chest percussion reveals resonance. Assessment of respiratory effort reveals even respirations without use of accessory muscles and diaphragmatic movement normal. Auscultation of lungs reveal diminished breath sounds bibasilar.,Heart: The apical impulse on heart palpation is located in the left border of cardiac dullness in the midclavicular line, in the left fourth intercostal space in the midclavicular line and no thrill noted. Heart auscultation reveals rhythm is regular, normal S1 and S2, no murmurs, gallop, rubs or clicks and no abnormal splitting of the second heart sound which moves normally with respiration. Right leg and left leg shows evidence of edema +6.,Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities with respect to size, tenderness or masses. Palpation of spleen reveals no abnormalities with respect to size, tenderness or masses. Examination of abdominal aorta shows normal size without presence of systolic bruit.,Extremities: Right thumb and left thumb reveals clubbing.,Pulses: The femoral, popliteal, dorsalis, pedis and posterior tibial pulses in the lower extremities are equal and normal. The brachial, radial and ulnar pulses in the upper extremities are equal and normal. Examination of peripheral vascular system reveals varicosities absent, extremities warm to touch, edema present - pitting and pulses are full to palpation. Femoral pulses are 2 /4, bilateral. Pedal pulses are 2 /4, bilateral.,Neurological: Testing of cranial nerves reveals nerves intact. Oriented to person, place and time. Mood and affect normal and appropriate to situation.Deep tendon reflexes normal. Touch, pin, vibratory and proprioception sensations are normal. Babinski reflex is absent. Coordination is normal. Speech is not aphasic. Musculoskeletal: Muscle strength is 5/5 for all groups tested. Gait and station examination reveals midposition without abnormalities.,Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Skin is warm and dry with normal turgor and there is no icterus.,Lymphatics: No lymphadenopathy noted.,IMPRESSION:, Angina pectoris, other and unspecified.,PLAN:, ,DIAGNOSTIC & LAB ORDERS:, Ordered serum creatine kinase isoenzymes (CK isoenzymes). Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report. The following cardiac risk factor modifications are recommended: quit smoking and reduce LDL cholesterol to below 120 mg/dl.,PATIENT INSTRUCTIONS:

Cardiovascular / Pulmonary

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,TITLE OF OPERATION: ,Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Retrobulbar block.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room where retrobulbar anesthesia was induced. The patient was then prepped and draped using standard procedure. A wire lid speculum was inserted to keep the eye open and the eye rotated downward with a 0.12. The anterior chamber was entered by making a small superior limbal incision with a crescent blade and then entering the anterior chamber with a keratome. The chamber was then filled with viscoelastic and a continuous-tear capsulorrhexis performed. The phacoemulsification was then instilled in the eye and a linear incision made in the lens. The lens was then cracked with a McPherson forceps, and the remaining lens material removed with the phacoemulsification tip. The remaining cortex was removed with an I&A. The capsular bag was then inflated with viscoelastic and the wound extended slightly with the keratome. The folding posterior chamber lens was then inserted in the capsular bag and rotated into position. The remaining viscoelastic was removed from the eye with the I&A. The wound was checked for watertightness and found to be watertight. Tobramycin drops were instilled in the eye and a shield placed over it. The patient tolerated the procedure well.

Surgery

PREOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,POSTOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,PROCEDURE PERFORMED:, Release of first dorsal extensor compartment.,ASSISTANT: , None.,ANESTHESIA: , Bier block.,TOURNIQUET TIME: , 30 minutes.,COMPLICATIONS: , None.,INDICATIONS: ,The above patient is a 47-year-old right hand dominant black female who has signs and symptomology of de Quervain's stenosing tenosynovitis. She was treated conservatively with steroid injections, splinting, and nonsteroidal anti-inflammatory agents without relief. She is presenting today for release of the first dorsal extensor compartment. She is aware of the risks, benefits, alternatives and has consented to this operation.,PROCEDURE: , The patient was given intravenous prophylactic antibiotics. She was taken to the operating suite under the auspices of Anesthesiology. She was given a left upper extremity bier block. Her left upper extremity was then prepped and draped in the normal fashion with Betadine solution. Afterwards, a transverse incision was made over the extensor retinaculum of the first dorsal extensor compartment. Dissection was carried down through the dermis into the subcutaneous tissue. The dorsal radial sensory branches were kept out of harm's way. They were retracted gently to the ulnar side of the wrist. The retinaculum was incised with a #15 scalpel blade in the longitudinal fashion and the retinaculum was released completely both proximally and distally. Both the extensor pollices brevis and abductor pollices longus tendons were identified. There was no pathology noted within the first dorsal extensor compartment. The wound was irrigated. Hemostasis was obtained with bipolar cautery. The wound was infiltrated with _0.25% Marcaine solution and then closure performed with #6-0 nylon suture utilizing a horizontal mattress stitch. Sterile occlusive dressing was applied along with the thumb spica splint. The tourniquet was released and the patient was transported to the recovery area in stable and satisfactory condition.

Orthopedic

PREOPERATIVE DIAGNOSES: ,1. Nasolabial mesiolabial fold.,2. Mid glabellar fold.,POSTOPERATIVE DIAGNOSES: ,1. Nasolabial mesiolabial fold.,2. Mid glabellar fold.,TITLE OF PROCEDURES: ,1. Perlane injection for the nasolabial fold.,2. Restylane injection for the glabellar fold.,ANESTHESIA: ,Topical with Lasercaine.,COMPLICATIONS: , None.,PROCEDURE: , The patient was evaluated preop and noted to be in stable condition. Chart and informed consent were all reviewed preop. All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient. This includes risk of bleeding, infection, scarring, need for further procedure, etc. The patient did sign the informed consent form regarding the Perlane and Restylane. She is aware of the potential risk of bruising. The patient has had Cosmederm in the past and had had a minimal response with this. Please note Lasercaine had to be applied 30 minutes prior to the procedure. The excess Lasercaine was removed with a sterile alcohol swab.,Using the linear threading technique, I injected the deep nasolabial fold. We used 2 mL of the Perlane for injection of the nasolabial mesiolabial fold. They were carefully massaged into good position at the end of the procedure. She did have some mild erythema noted.,I then used approximately 0.4 mL of the Restylane for injection of the mid glabellar site. She has a resting line of the mid glabella that did not respond with previous Botox injection. Once this was filled, the Restylane was massaged into the proper tissue plane. Cold compressors were applied afterwards. She is scheduled for a recheck in the next one to two weeks, and we will make further recommendations at that time. Post Restylane and Perlane precautions have been reviewed with the patient as well.

Surgery

REASON FOR VISIT: ,The patient is a 76-year-old man referred for neurological consultation by Dr. X. The patient is companied to clinic today by his wife and daughter. He provides a small portion of his history; however, his family provides virtually all of it.,HISTORY OF PRESENT ILLNESS: , He has trouble with walking and balance, with bladder control, and with thinking and memory. When I asked him to provide me detail, he could not tell me much more than the fact that he has trouble with his walking and that he has trouble with his bladder. He is vaguely aware that he has trouble with his memory.,According to his family, he has had difficulty with his gait for at least three or four years. At first, they thought it was weakness and because of he was on the ground (for example, gardening) he was not able to get up by himself. They did try stopping the statin that he was taking at that time, but because there was no improvement over two weeks, they resumed the statin. As time progressed, he developed more and more difficulty. He started to shuffle. He started using a cane about two and a half years ago and has used a walker with wheels in the front since July of 2006. At this point, he frequently if not always has trouble getting in or out of the seat. He frequently tends to lean backwards or sideways when sitting. He frequently if not always has trouble getting in or out a car, always shuffles or scuffs his feet, always has trouble turning or changing direction, always has trouble with uneven surfaces or curbs, and always has to hold on to someone or something when walking. He has not fallen in the last month. He did fall earlier, but there seemed to be fewer opportunities for him to fall. His family has recently purchased a lightweight wheelchair to use if he is traveling long distances. He has no stairs in his home, however, his family indicates that he would not be able to take stairs. His handwriting has become smaller and shakier.,In regard to the bladder, he states, "I wet the bed." In talking with his family, it seems as if he has no warning that he needs to empty his bladder. He was diagnosed with a small bladder tumor in 2005. This was treated by Dr. Y. Dr. X does not think that the bladder tumor has anything to do with the patient's urinary incontinence. The patient has worn a pad or undergarment for at least one to one and a half years. His wife states that they go through two or three of them per day. He has been placed on medications; however, they have not helped.,He has no headaches or sensation of head fullness.,In regard to the thinking and memory, at first he seemed forgetful and had trouble with dates. Now he seems less spontaneous and his family states he seems to have trouble expressing himself. His wife took over his medications about two years ago. She stopped his driving about three years ago. She discovered that his license had been expired for about a year and she was concerned enough at that time that she told him he could drive no more. Apparently, he did not object. At this point, he frequently has trouble with memory, orientation, and everyday problems solving at home. He needs coaching for his daily activities such as reminders to brush his teeth, put on his clothes, and so forth. He is a retired office machine repairman. He is currently up and active about 12 hours a day and sleeping or lying down about 12 hours per day.,He has not had PT or OT and has not been treated with medications for Parkinson's disease or Alzheimer's disease. He has been treated for the bladder. He has not had lumbar puncture.,Past medical history and review of all 14 systems from the form they completed for this visit that I reviewed with them is negative with the exception that he has had hypertension since 1985, hypercholesterolemia since 1997, and diabetes since 1998. The bladder tumor was discovered in 2005 and was treated noninvasively. He has lost weight from about 200 pounds to 180 pounds over the last two or three years. He had a period of depression in 1999 and was on Prozac for a while, but this was then stopped. He used to drink a significant amount of alcohol. This was problematic enough that his wife was concerned. She states he stopped when she retired and she was at home all day.,SOCIAL HISTORY: ,He quit smoking in 1968. His current weight is 183 pounds. His tallest height is 5 feet 10 inches.,FAMILY HISTORY: ,His grandfather had arthritis. His father had Parkinson's disease. His mother had heart disease and a sister has diabetes.,He does not have a Living Will and indicates he would wish his wife to make decisions for him if he could not make them for himself.,REVIEW OF HYDROCEPHALUS RISK FACTORS: , None.,ALLERGIES: , None.,MEDICATIONS: , Metformin 500 mg three times a day, Lipitor 10 mg per day, lisinopril 20 mg per day, metoprolol 50 mg per day, Uroxatral 10 mg per day, Detrol LA 4 mg per day, and aspirin 81 mg per day.,PHYSICAL EXAM: , On examination today, this is a pleasant 76-year-old man who is guided back from the clinic waiting area walking with his walker. He is well developed, well nourished, and kempt.,Vital Signs: His weight is 180 pounds.,Head: The head is normocephalic and atraumatic. The head circumference is 59 cm, which is the ,75-90th percentile for an adult man whose height is 178 cm.,Spine: The spine is straight and not tender. I can easily palpate the spinous processes. There is no scoliosis.,Skin: No neurocutaneous stigmata.,Cardiovascular Examination: No carotid or vertebral bruits.,Mental Status: Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge. The Mini-Mental State Exam score was 17/30. He did not know the year, season, or day of the week nor did he know the building or specialty or the floor. There was a tendency for perseveration during the evaluation. He could not copy the diagram of intersecting pentagons.,Cranial Nerve Exam: No evidence of papilledema. The pupillary light reflex is intact as are extraocular movements without nystagmus, facial expression and sensation, hearing, head turning, tongue, and palate movement.,Motor Exam: Normal bulk and strength, but the tone is marked by significant paratonia. There is no atrophy, fasciculations, or drift. There is tremulousness of the outstretched hands.,Sensory Exam: Is difficult to interpret. Either he does not understand the test or he is mostly guessing.,Cerebellar Exam: Is intact for finger-to-nose, heel-to-knee, and rapid alternating movement tests. There is no dysarthria.,Reflexes: Trace in the arms, 2+ at the knees, and 0 at the ankles. It is not certain whether there is a Babinski sign or simply withdrawal.,Gait: Assessed using the Tinetti assessment tool that shows a balance score of 7-10/16 and a gait score of 2-5/12 for a total score of 9-15/28, which is significantly impaired.,REVIEW OF X-RAYS: , I personally reviewed the MRI scan of the brain from December 11, 2007 at Advanced Radiology. It shows the ventricles are enlarged with a frontal horn span of 5.0 cm. The 3rd ventricle contour is flat. The span is enlarged at 12 mm. The sylvian aqueduct is patent. There is a pulsation artifact. The corpus callosum is effaced. There are extensive T2 signal abnormalities that are confluent in the corona radiata. There are also scattered T2 abnormalities in the basal ganglia. There is a suggestion of hippocampal atrophy. There is also a suggestion of vermian atrophy.,ASSESSMENT: , The patient has a clinical syndrome that raises the question of idiopathic normal pressure hydrocephalus. His examination today is notable for moderate-to-severe dementia and moderate-to-severe gait impairment. His MRI scan raises the question of hydrocephalus, however, is also consistent with cerebral small vessel disease.,PROBLEMS/DIAGNOSES:,1. Possible idiopathic normal pressure hydrocephalus (331.5).,2. Probable cerebral small-vessel disease (290.40 & 438).,3. Gait impairment (781.2).,4. Urinary urgency and incontinence (788.33).,5. Dementia.,6. Hypertension.,7. Hypercholesterolemia.

Neurology

CLINICAL HISTORY: , Patient is a 37-year-old female with a history of colectomy for adenoma. During her preop evaluation it was noted that she had a lesion on her chest x-ray. CT scan of the chest confirmed a left lower mass.,SPECIMEN: , Lung, left lower lobe resection.,IMMUNOHISTOCHEMICAL STUDIES:, Tumor cells show no reactivity with cytokeratin AE1/AE3. No significant reactivity with CAM5.2 and no reactivity with cytokeratin-20 are seen. Tumor cells show partial reactivity with cytokeratin-7. PAS with diastase demonstrates no convincing intracytoplasmic mucin. No neuroendocrine differentiation is demonstrated with synaptophysin and chromogranin stains. Tumor cells show cytoplasmic and nuclear reactivity with S100 antibody. No significant reactivity is demonstrated with melanoma marker HMB-45 or Melan-A. Tumor cell nuclei (spindle cell and pleomorphic/giant cell carcinoma components) show nuclear reactivity with thyroid transcription factor marker (TTF-1). The immunohistochemical studies are consistent with primary lung sarcomatoid carcinoma with pleomorphic/giant cell carcinoma and spindle cell carcinoma components.,FINAL DIAGNOSIS:,Histologic Tumor Type: Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.,Tumor Size: 2.7 x 2.0 x 1.4 cm.,Visceral Pleura Involvement: The tumor closely approaches the pleural surface but does not invade the pleura.,Vascular Invasion: Present.,Margins: Bronchial resection margins and vascular margins are free of tumor.,Lymph Nodes: Metastatic sarcomatoid carcinoma into one of four hilar lymph nodes.,Pathologic Stage: pT1N1MX.

Cardiovascular / Pulmonary

HISTORY OF PRESENT ILLNESS: , This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis. He is also taking digoxin, aspirin, warfarin, and furosemide. Mother reports that he does have problems with 2-3 loose stools per day since September, but tolerates this relatively well. This has not increased in frequency recently.,Mark recently underwent surgery at Children's Hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of Gore-Tex membrane pericardial substitute. He tolerated this procedure well. He has been doing well at home since that time.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm.,GENERAL APPEARANCE: Well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress.,HEENT: Remarkable for the badly degenerated left lower molar. Funduscopic exam is unremarkable.,NECK: Supple without adenopathy.,CHEST: Clear including the sternal wound.,CARDIOVASCULAR: A 3/6 systolic murmur heard best over the upper left sternal border.,ABDOMEN: Soft. He does have an enlarged spleen, however, given his obesity, I cannot accurately measure its size.,GU: Deferred.,EXTREMITIES: Examination of extremities reveals no embolic phenomenon.,SKIN: Free of lesions.,NEUROLOGIC: Grossly within normal limits.,LABORATORY DATA: , Doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5. Hydroxychloroquine level obtained at that time was undetectable. Of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/mL. Q-fever serology obtained on 10/05/2007 was positive for phase I antibodies in 1/2/6 and phase II antibodies at 1/128, which is an improvement over previous elevated titers. Studies on the pulmonary valve tissue removed at surgery are pending.,IMPRESSION: , Q-fever endocarditis.,PLAN: ,1. Continue doxycycline and hydroxychloroquine. I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications. She assures me that he is compliant with his medications. We will however repeat his hydroxychloroquine and doxycycline levels.,2. Repeat Q-fever serology.,3. Comprehensive metabolic panel and CBC.,4. Return to clinic in 4 weeks.,5. Clotting times are being followed by Dr. X.

Cardiovascular / Pulmonary

PREOPERATIVE DIAGNOSIS:, Completely bony impacted teeth #1, #16, #17, and #32.,POSTOPERATIVE DIAGNOSIS: , Completely bony impacted teeth #1, #16, #17, and #32.,PROCEDURE: , Surgical removal of completely bony impacted teeth #1, #16, #17, and #32.,ANESTHESIA: , General nasotracheal.,COMPLICATIONS: , None.,CONDITION: ,Stable to PACU.,DESCRIPTION OF PROCEDURE: , Patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure. A gauze throat pack was placed and local anesthetic was administered in all four quadrants, a total of 7.2 mL of lidocaine 2% with 1:100,000 epinephrine, and 3.6 mL of bupivacaine 0.5% with 1:200,000 epinephrine. Beginning on the upper right tooth #1, incision was made with a #15 blade. Envelope flap was raised with the periosteal elevator, and bone was removed on the buccal aspect with straight elevator. Potts elevator was then used to luxate the tooth from the socket. Remnants of the follicle were then removed with hemostat. The area was irrigated and then closed with 3-0 gut suture. On the lower right tooth #32, incision was made with a #15 blade. Envelope flap was raised with the periosteal elevator, and bone was removed on the buccal and distal aspect with a high-speed drill with a round bur. Tooth was then sectioned with the bur and removed in several pieces. Remnants of the follicle were removed with a curved hemostat. The area was irrigated with normal saline solution and closed with 3-0 gut sutures. Moving to #16 on the upper left, incision was made with a #15 blade. Envelope flap was raised with the periosteal elevator, and bone was removed on the buccal aspect with straight elevator. Potts elevator was then used to luxate the tooth from the socket. Remnants of the follicle were removed with a curved hemostat. The area was irrigated with normal saline solution and closed with 3-0 gut sutures. Moving to the lower left #17, incision was made with a #15 blade. Envelope flap was raised with the periosteal elevator, and bone was removed on the buccal and distal aspect with high-speed drill with a round bur. Then the bur was used to section the tooth vertically. Tooth was removed in several pieces followed by the removal of the remnants of the follicle. The area was irrigated with normal saline solution and closed with 3-0 gut sutures. Upon completion of the procedure, the throat pack was removed and the pharynx was suctioned. An NG tube was then inserted and small amount of gastric contents were suctioned. Patient was then awakened, extubated, and taken to the PACU in stable condition.

Dentistry

PREOPERATIVE DIAGNOSIS: , Acute abdominal pain, rule out appendicitis versus other.,POSTOPERATIVE DIAGNOSIS:, Acute pelvic inflammatory disease and periappendicitis.,PROCEDURE PERFORMED: , Diagnostic laparoscopy.,COMPLICATIONS:, None.,CULTURES:, Intra-abdominally are done.,HISTORY: ,The patient is a 31-year-old African-American female patient who complains of sudden onset of pain and has seen in the Emergency Room. The pain has started in the umbilical area and radiated to McBurney's point. The patient appears to have a significant pain requiring surgical evaluation. It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix. The patient was seen by Dr. Y at my request in the ER with me in attendance. We went over the case. He decided that she should go to the operating room for evaluation and to have appendix evaluated and probably removed. The patient on ultrasound had a 0.9 cm ovarian cyst on the right side. The patient's cyst was not completely simple and they are concerns over the possibility of an abnormality. The patient states that she has had chlamydia in the past, but it was not a pelvic infection more vaginal infection. The patient has had hospitalization for this. The patient therefore signed informed in layman's terms with her understanding that perceivable risks and complications, the alternative treatment, the procedure itself and recovery. All questions were answered. ,PROCEDURE: ,The patient was seen in the Emergency Room. In the Emergency Room, there is really no apparent vaginal discharge. No odor or cervical motion tenderness. Negative bladder sweep. Adnexa were without abnormalities. In the OR, we were able to perform pelvic examination showing a slightly enlarged fibroid uterus about 9 to 10-week size. The patient had no adnexal fullness. The patient then underwent an insertion of a uterine manipulator and Dr. X was in the case at that time and he started the laparoscopic process i.e., inserting the laparoscope. We then observed under direct laparoscopic visualization with the aid of a camera that there was pus in and around the uterus. The both fallopian tubes were seen. There did not appear to be hydrosalpinx. The ovaries were seen. The left showed some adhesions into the ovarian fossa. The cul-de-sac had a banded adhesions. The patient on the right adnexa had a hemorrhagic ovarian cyst, where the cyst was only about a centimeter enlarged. The ovary did not appear to have pus in it, but there was pus over the area of the bladder flap. The patient's bowel was otherwise unremarkable. The liver contained evidence of Fitz-Hugh-Curtis syndrome and prior PID. The appendix was somewhat adherent into the retrocecal area and to the mid-quadrant abdominal sidewall on the right. The case was then turned over to Dr. Y who was in the room at that time and Dr. X had left. The patient's case was turned over to him. Dr. Y was performed an appendectomy following which cultures and copious irrigation. Dr. Y was then closed the case. The patient was placed on antibiotics. We await the results of the cultures and as well further ______ therapy.,PRIMARY DIAGNOSES:,1. Periappendicitis.,2. Pelvic inflammatory disease.,3. Chronic adhesive disease.

Obstetrics / Gynecology

PREOPERATIVE DIAGNOSIS:, Residual stone, status post right percutaneous nephrolithotomy.,POSTOPERATIVE DIAGNOSES: , Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.,ANESTHESIA:, General via endotracheal tube.,BLOOD LOSS:, Minimal.,DRAINS: , 16-French Foley, 6-French variable length double-J stent.,INTRAOPERATIVE COMPLICATIONS: , Unable to re-access the collecting system.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room and laid supine. General anesthesia was accomplished. A 16-French Foley was placed using aseptic technique. The patient was then placed on the operating table prone. His right flank was prepped and draped in a sterile fashion. At this point, contrast was injected through his existing nephrostomy tube and there was no continuity with the collecting system and it was removed. The 5-French Pollack catheter was used to pass a 0.38 super-stiff Amplatz wire. The wire would not go down the ureter. Multiple attempts were made using Pollack catheters and Cobra catheters and attempts were made to dilate the track, both with rigid dilator and the balloon dilator and access could not be obtained. After multiple attempts, access was lost. At this point, the tubes were left out of the kidney and sterile dressings were applied. The patient was then placed on another operating table supine. His genitalia were prepped and draped after removing his Foley catheter. Flexible cystoscopy was performed and the right orifice identified, which was edematous and erythematous. The wire was passed up to kidney and a 5-French Pollack catheter was then passed over to after the removing the scope. The wire was removed. Contrast injection with good placement in the collecting system. The wire was replaced. The Pollack catheter removed and 6-French variable length double-J stent was inserted using fluoroscopic guidance. The wire was removed leaving the double-J stent in good position. _______ 16-French Foley was reinserted and connected to close drains.,Procedure was terminated at this point and had been well tolerated. The patient was awakened and taken to recovery room in satisfactory condition having tolerated the procedure well.

Surgery

PREOPERATIVE DIAGNOSIS:, Left thyroid mass.,POSTOPERATIVE DIAGNOSIS:, Left thyroid mass.,PROCEDURE PERFORMED:, Left total thyroid lumpectomy.,ANESTHESIA,: General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:, None.,INDICATIONS FOR PROCEDURE:, The patient is a 76-year-old Caucasian female with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole. The patient was then discussed the risks, complications, and consequences of a surgical procedure and a written consent was obtained.,PROCEDURE: ,The patient is brought to the operative suite by Anesthesia. The patient was placed on the operative table in supine position. After this, the patient was placed under general endotracheal intubation anesthesia and the patient was then placed upon a shoulder roll. After this, the skin incision was marked approximately two fingerbreadths above the sternal notch. It was then localized with 1% lidocaine with epinephrine 1:1000 approximately 7 cc total.,After this, the patient was then prepped and draped in the usual sterile fashion and a #10 blade was then utilized to make a skin incision. The subcutaneous tissue was then bluntly dissected utilizing a Ray-Tec sponge and a bear claw was then utilized to retract the upper incisional skin with counter retraction performed to allow a subplatysmal plane of skin flaps to be performed in superior and inferolateral directions. After this, the midline was then identified and grasped on either side with a DeBakey forceps. The raphe was noted and Bovie cauterization was utilized to cut down into this region. The fine stats were utilized to further open this area with exposure and bisection of the sternothyroid muscle. It was separated on the left side from the patient's sternothyroid muscle. After this, the sternothyroid muscle was identified, grasped with the DeBakey forceps and infiltrated initially through its fascial plane with the Metzenbaum scissors. Blunt dissection was then utilized to free the sternothyroid muscle from the thyroid gland in superior and inferior directions and laterally with the help of Kitners. After this, the plane was rotated more anteriorly with the superior and inferior parathyroid glands identified. The fat cap was noted to be attached on the superior parathyroid to the posterior aspect of the thyroid itself. It was freed from the thyroid gland and reflected laterally and posteriorly. The inferior parathyroid gland actually appeared to be attached also to the inferior aspect of the thyroid itself and was reflected laterally. After this, the patient's thyroid gland was palpated noting a thyroid nodule in the posterior inferior aspect along with the calcification laterally. The nodule appeared to be sort of rubbery in consistency and approximately 1 cm diameter. As the gland was rotated more anteriorly, the recurrent laryngeal nerve on the left side was identified and further dissection along Berry's ligament on the medial aspect was performed. The middle thyroid vein and inferior thyroid artery were both cauterized with a bipolar cautery and bisected. After this, the gland was easily rotated anteriorly with further dissection carried up to the superior pole. The superior pole was exposed with the help of a Richardson and Army-Navy retractors with cross-clamping and tying of the superior laryngeal artery and vein. Further, the small bleeding vessels were identified and bipolared, and cut with the Metzenbaum scissors. The superior pole was finally freed and the gland was rotated more anteriorly onto the anterior aspect of the trachea. Berry's ligament was finally freed and the gland was cross-clamped on the opposing thyroid isthmus with a mosquito. After this, the gland was cut with a Metzenbaum scissors and tied with a #3-0 undyed Vicryl tie. The defect on the neck now was thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization. Surgicel was then cut in small strips and three replaced in the lateral part of the neck.,The opposing side of the thyroid gland on the right was palpated with no noticeable nodules or masses. The strap muscles were then reapproximated with #3-0 Vicryl on a SH, followed by reapproximation of the subcutaneous tissue with #4-0 Vicryl, followed by reapproximation of the skin by running subcuticular #5-0 Prolene and a #6-0 fast absorbing gut. Mastisol, Steri-Strips, and bacitracin were placed followed by a sterile 4 x 4 dressing. The patient was then turned back to Anesthesia, extubated in the operating room, and transferred to Recovery in stable condition. The patient tolerated the procedure well and will be admitted to hospital for 23-hour observation and will be followed up in one week afterwards.

Surgery

SUBJECTIVE: , This patient presents to the office today with his mom for checkup. He used to live in the city. He used to go to college down in the city. He got addicted to drugs. He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom. He has a history of doing heroin. He was injecting into his vein. He was seeing a physician in the city. They were prescribing methadone for some time. He says that did help. He was on 10 mg of methadone. He was on it for three to four months. He tried to wean down on the methadone a couple of different times, but failed. He has been intermittently using heroin. He says one of the big problems is that he lives in a household full of drug users and he could not get away from it. All that changed now that he is living with his mom. The last time he did heroin was about seven to eight days ago. He has not had any methadone in about a week either. He is coming in today specifically requesting methadone. He also admits to being depressed. He is sad a lot and down. He does not have much energy. He does not have the enthusiasm. He denies any suicidal or homicidal ideations at the present time. I questioned him on the symptoms of bipolar disorder and he does not seem to have those symptoms. His past medical history is significant for no medical problems. Surgical history, he voluntarily donated his left kidney. Family and social history were reviewed per the nursing notes. His allergies are no known drug allergies. Medications, he takes no medications regularly.,OBJECTIVE: , His weight is 164 pounds, blood pressure 108/60, pulse 88, respirations 16, and temperature was not taken. General: He is nontoxic and in no acute distress. Psychiatric: Alert and oriented times 3. Skin: I examined his upper extremities. He showed me his injection sites. I can see marks, but they seem to be healing up nicely. I do not see any evidence of cellulitis. There is no evidence of necrotizing fasciitis.,ASSESSMENT: , Substance abuse.,PLAN: , I had a long talk with the patient and his mom. I am not prescribing him any narcotics or controlled substances. I am not in the practice of trading one addiction for another. It has been one week without any sort of drugs at all. I do not think he needs weaning. I think right now it is mostly psychological, although there still could be some residual physical addiction. However, once again I do not believe it to be necessary to prescribe him any sort of controlled substance at the present time. I do believe that his depression needs to be treated. I gave him fluoxetine 20 mg one tablet daily. I discussed the side effects in detail. I did also warn him that all antidepressant medications carry an increased risk of suicide. If he should start to feel any of these symptoms, he should call #911 or go to the emergency room immediately. If he has any problems or side effects, he was also directed to call me here at the office. After-hours, he can go to the emergency room or call #911. I am going to see him back in three weeks for the depression. I gave him the name and phone number of Behavioral Health and I told him to call so that he can get into rehabilitation program or at least a support group. We are unable to make a referral for him to do that. He has to call on his own. He has no insurance. However, I think fluoxetine is very affordable. He can get it for $4 per month at Wal-Mart. His mom is going to keep an eye on him as well. He is going to be staying there. It sounds like he is looking for a job.

General Medicine

PROCEDURE: , Skin biopsy, scalp mole.,INDICATION: ,A 66-year-old female with pulmonary pneumonia, effusion, rule out metastatic melanoma to lung.,PROCEDURE NOTE: , The patient's scalp hair was removed with:,1. K-Y jelly.,2. Betadine prep locally.,3. A 1% lidocaine with epinephrine local instilled.,4. A 3 mm punch biopsy used to obtain biopsy specimen, which was sent to the lab. To control bleeding, two 4-0 P3 nylon sutures were applied, antibiotic ointment on the wound. Hemostasis was controlled. The patient tolerated the procedure.,IMPRESSION:, Darkened mole status post punch biopsy, scalp lesion, rule out malignant melanoma with pulmonary metastasis.,PLAN: , The patient will have sutures removed in 10 days.

Surgery

PREOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,POSTOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,PROCEDURE:,1. Emergent subxiphoid pericardial window.,2. Transesophageal echocardiogram.,ANESTHESIA:, General endotracheal.,FINDINGS:, The patient was noted to have 600 mL of dark bloody fluid around the pericardium. We could see the effusion resolve on echocardiogram. The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. There was no evidence of endocarditis. The mitral valve leaflets moved normally with some mild mitral insufficiency.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room emergently. After adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. A small incision was made at the bottom of the previous sternotomy incision. The subcutaneous sutures were removed. The dissection was carried down into the pericardial space. Blood was evacuated without any difficulty. Pericardial Blake drain was then placed. The fascia was then reclosed with interrupted Vicryl sutures. The subcutaneous tissues were closed with a running Monocryl suture. A subdermal PDS followed by a subcuticular Monocryl suture were all performed. The wound was closed with Dermabond dressing. The procedure was terminated at this point. The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition.

Cardiovascular / Pulmonary

EXAM: , Bilateral renal ultrasound.,CLINICAL INDICATION: , UTI.,TECHNIQUE: , Transverse and longitudinal sonograms of the kidneys were obtained.,FINDINGS: ,The right kidney is of normal size and echotexture and measures 5.7 x 2.2 x 3.8 cm. The left kidney is of normal size and echotexture and measures 6.2 x 2.8 x 3.0 cm. There is no evidence for ,HYDRONEPHROSIS, or ,PERINEPHRIC ,fluid collections. The bladder is of normal size and contour. The bladder contains approximately 13 mL of urine after recent voiding. This is a small postvoid residual.,IMPRESSION: , Normal renal ultrasound. Small postvoid residual.

Radiology

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.

Neurosurgery

MEDICAL DIAGNOSIS:, Strokes.,SPEECH AND LANGUAGE THERAPY DIAGNOSIS: ,Global aphasia.,SUBJECTIVE: ,The patient is a 44-year-old female who is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke. The patient's sister-in-law was present throughout this assessment and provided all the patient's previous medical history. Based on the sister-in-law's report, the patient had a stroke on 09/19/08. The patient spent 6 weeks at XY Medical Center, where she was subsequently transferred to XYZ for therapy for approximately 3 weeks. ABCD brought the patient to home the Monday before Thanksgiving, because they were not satisfied with the care the patient was receiving at a skilled nursing facility in Tucson. The patient's previous medical history includes a long history of illegal drug use to include cocaine, crystal methamphetamine, and marijuana. In March of 2008, the patient had some type of potassium issue and she was hospitalized at that time. Prior to the stroke, the patient was not working and ABCD reported that she believes the patient completed the ninth grade, but she did not graduate from high school. During the case history, I did pose several questions to the patient, but her response was often "no." She was very emotional during this evaluation and crying occurred multiple times.,OBJECTIVE: ,To evaluate the patient's overall communication ability, a Western Aphasia Battery was completed. Also tests were not done due to time constraint and the patient's severe difficulty and emotional state. Speech automatic tests were also completed to determine if the patient had any functional speech.,ASSESSMENT:, Based on the results of the Weston aphasia battery, the patient's deficits most closely resemble global aphasia. On the spontaneous speech subtest, the patient responded "no" to all questions asked except for how are you today where she gave a thumbs-up. She provided no responses to picture description task and it is unclear if the patient was unable to follow the direction or if she was unable to see the picture clearly. The patient's sister-in-law did state that the patient wore glasses, but she currently does not have them and she did not know the extent the patient's visual deficit.,On the auditory verbal comprehension portion of the Western Aphasia Battery, the patient answered "no" to all "yes/no" questions. The auditory word recognition subtest, the patient had 5 out of 60 responses correct. With the sequential command, she had 10 out of 80 corrects. She was able to shut her eyes, point to the window, and point to the pen after directions. With repetition subtest, she repeated bed correctly, but no other stimuli. At this time, the patient became very emotional and repeatedly stated "I can't". During the naming subtest of the Western Aphasia Battery, the patient's responses contained numerous paraphasias and her speech was often unintelligible due to jargon. The word fluency test was not administered and the patient scored 2 out of 10 on the sentence completion task and 0 out of 10 on the responsive speech. In regards to speech automatics, the patient is able to count from 1 to 9 accurately; however, stated 7 instead of 10 at the end of the task. She is not able to state the days of the week or months in the year or her name at this time. She cannot identify the day on calendar and was unable to verbally state the date or month.,DIAGNOSTIC IMPRESSION: ,The patient's communication deficits most closely resemble global aphasia where she has difficulty with both receptive as well as expressive communication. She does perseverate and is very emotional due to probable frustration. Outpatient skilled speech therapy is recommended to improve the patient's functional communication skills.,PATIENT GOAL: , Her sister-in-law stated that they would like to improve upon the patient's speech to allow her to communicate more easily at home.,PLAN OF CARE: , Outpatient skilled speech therapy two times a week for the next 12 weeks. Therapy to include aphasia treatment and home activities.,SHORT-TERM GOALS (8 WEEKS):,1. The patient will answer simple "yes/no" questions with greater than 90% accuracy with minimal cueing.,2. The patient will be able to complete speech automatic tasks with greater than 80% accuracy without models or cueing.,3. The patient will be able to complete simple sentence completion and/or phrase completion with greater than 80% accuracy with minimal cueing.,4. The patient will be able to follow simple one-step commands with greater than 80% accuracy with minimal cueing.,5. The patient will be able to name 10 basic everyday objects with greater than 80% accuracy with minimal cueing.,SHORT-TERM GOALS (12 WEEKS):, Functional communication abilities to allow the patient to express her basic wants and needs.

Speech - Language

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:

Hematology - Oncology

CC:, Orthostatic lightheadedness.,HX:, This 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. The dizziness worsened when moving into upright positions. In addition, he complained of intermittent throbbing holocranial headaches, which did not worsen with positional change, for the past several weeks. He had lost 40 pounds over the past year and denied any recent fever, SOB, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes.,He had a 100+ pack-year history of tobacco use and continued to smoke 1 to 2 packs per day. He has a history of sinusitis.,EXAM:, BP 98/80 mmHg and pulse 64 BPM (supine); BP 70/palpable mmHG and pulse 84BPM (standing). RR 12, Afebrile. Appeared fatigued.,CN: unremarkable.,Motor and Sensory exam: unremarkable.,Coord: Slowed but otherwise unremarkable movements.,Reflexes: 2/2 and symmetric throughout all 4 extremities. Plantar responses were flexor, bilaterally.,The rest of the neurologic and general physical exam was unremarkable.,LAB:, Na 121 meq/L, K 4.2 meq/L, Cl 90 meq/L, CO2 20meq/L, BUN 12mg/DL, CR 1.0mg/DL, Glucose 99mg/DL, ESR 30mm/hr, CBC WNL with nl WBC differential, Urinalysis: SG 1.016 and otherwise WNL, TSH 2.8 IU/ML, FT4 0.9ng/DL, Urine Osmolality 246 MOSM/Kg (low), Urine Na 35 meq/L,,COURSE:, The patient was initially hydrated with IV normal saline and his orthostatic hypotension resolved, but returned within 24-48hrs. Further laboratory studies revealed: Aldosterone (serum)<2ng/DL (low), 30 minute Cortrosyn Stimulation test: pre 6.9ug/DL (borderline low), post 18.5ug/DL (normal stimulation rise), Prolactin 15.5ng/ML (no baseline given), FSH and LH were within normal limits for males. Testosterone 33ng/DL (wnl). Sinus XR series (done for history of headache) showed an abnormal sellar region with enlarged sella tursica and destruction of the posterior clinoids. There was also an abnormal calcification seen in the middle of the sellar region. A left maxillary sinus opacity with air-fluid level was seen. Goldman visual field testing was unremarkable. Brain CT and MRI revealed suprasellar mass most consistent with pituitary adenoma. He was treated with Fludrocortisone 0.05 mg BID and within 24hrs, despite discontinuation of IV fluids, remained hemodynamically stable and free of symptoms of orthostatic hypotension. His presumed pituitary adenoma continues to be managed with Fludrocortisone as of this writing (1/1997), though he has developed dementia felt secondary to cerebrovascular disease (stroke/TIA).

Radiology

CC: ,Vertigo.,HX: ,This 61y/o RHF experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. In 11/92, while eating breakfast, she suddenly experienced vertigo. This was immediately followed by nausea and several episodes of vomiting. The vertigo lasted 2-3minutes. She retired to her room for a 2 hour nap after vomiting. When she awoke, the symptoms had resolved. On 1/13/93 she had an episode of right arm numbness lasting 4-5hours. There was no associated weakness, HA, dysarthria, dysphagia, visual change, vertigo or lightheadedness.,OUTSIDE RECORDS:, 12/16/92 Carotid Doppler (RICA 30-40%, LICA 10-20%). 12/4/92, brain MRI revealed a right cerebellar hypodensity consistent with infarct.,MEDS:, Zantac 150mg bid, Proventil MDI bid, Azmacort MDI bid, Doxycycline 100mg bid, Premarin 0.625mg qd, Provera 2.5mg qd. ASA 325mg qd.,PMH:, 1)MDD off antidepressants since 6/92. 2)asthma. 3)allergic rhinitis. 4)chronic sinusitis. 5)s/p Caldwell-Luc 1978, and nasal polypectomy. 6) GERD. 7)h/o elevated TSH. 8)hypercholesterolemia 287 on 11/20/93. 9)h/o heme positive stool: BE 11/24/92 and UGI 11/25/92 negative.,FHX: ,Father died of a thoracic aortic aneurysm, age 71. Mother died of stroke, age 81.,SHX:, Married. One son deceased. Salesperson. Denied tobacco/ETOH/illicit drug use.,EXAM,: BP (RUE)132/72 LUE (136/76). HR67 RR16 Afebrile. 59.2kg.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Thought lucid.,CN: unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits appreciated.,Coord: unremarkable.,Station: no pronator drift, truncal ataxia, or Romberg sign.,Gait: not done.,Reflexes: 2/2 throughout BUE and at patellae. 1/1 at Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese.,COURSE: ,CBC, GS, PT/PTT, UA were unremarkable. The patient was admitted with a working diagnosis of posterior circulation TIA and history of cerebellar stroke. She was placed on Ticlid 250mg bid. HCT,1/15/93: low density focus in the right medial and posterior cerebellar hemisphere. MRI and MRA, 1/18/93, revealed a well circumscribed lesion within the posterior aspect of the right cerebellar hemisphere suggestive of vascular malformation (e.g. cavernous angioma. An abnormal vascular blush was seen on the MRA. This area appeared to be supplied by one of the external carotid arteries (which one is was not specified). this finding maybe suggestive of a vascular malformation. 1/20/93 Cerebral Angiogram: The right cerebellar hemisphere lesion seen on MRI as a possible cavernous angioma was not seen on angiography. Upon review of the MRI and HCT the lesion was felt to probably represent an old infarction with hemosiderin deposition. The "vascular blush" seen on MRA was no visualized on angiography. The patient was discharged home on 1/25/93.

Consult - History and Phy.

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.

SOAP / Chart / Progress Notes

INDICATIONS FOR PROCEDURES: , Impending open-heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure.,The patient was already under general anesthesia in the operating room. Antibiotic prophylaxis with cephazolin and gentamicin were already given. A strict aseptic technique was used including use of gowns, mask, and gloves, etc. The skin was cleansed with alcohol and then prepped with ChloraPrep solution.,PROCEDURE #1:, Insertion of central venous line.,DESCRIPTION OF PROCEDURE #1: , Attention was directed to the right groin. A Cook 4-French double-lumen 12-cm long central venous heparin-coated catheter kit was opened. Using the 21-gauge needle that comes with this kit, the needle was inserted approximately 2 cm below the right inguinal ligament just medial to the pulsations of the femoral artery. There was good venous blood return on the first try. Using the Seldinger technique, the soft J-end of the wire was inserted through the needle without resistance approximately 15 cm. It was then exchanged for a 5-French dilator followed by the 4-French double-lumen catheter and the wire was removed intact. There was good blood return from both lumens, which were flushed with heparinized saline. The catheter was sutured to the skin at three points with #4-0 silk for stabilization.,PROCEDURE #2:, Insertion of arterial line.,DESCRIPTION OF PROCEDURE #2:, Attention was directed to the left wrist, which was placed on wrist rest. The Allen test was normal. A Cook 2.5-French 5 cm long arterial catheter kit was opened. A 22-gauge IV cannula was used to enter the artery, which was done on the first try with good pulsatile blood return. Using the Seldinger technique, the catheter was exchanged for a 2.5-French catheter and the wire was removed intact. There was pulsatile blood return and the catheter was flushed with heparinized saline solution. It was sutured to the skin with #4-0 silk at three points for stabilization.,Both catheters functioned well throughout the procedure. The distal circulation of the leg and the hand was intact immediately after insertion, approximately 20 minutes later, and at the end of the procedure. There were no complications.,PROCEDURE #3: , Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #3: , The probe was inserted under direct vision because initially there was some resistance to insertion. Under direct vision, using the #2 Miller blade, the upper esophageal opening was visualized and the probe was passed easily without resistance. There was good visualization of the heart. The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography. The probe was removed at the end. There was no trauma and there was no blood tingeing.,

Cardiovascular / Pulmonary

HISTORY: , The patient is a 61-year-old male patient. I was asked to evaluate this patient because of the elevated blood urea and creatinine. The patient has ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, history of congestive heart failure status post AICD. The patient has a history of exposure to asbestos in the past, history of diabetes mellitus of 15 years duration, hypertension, and peripheral vascular disease. The patient came in with a history of abdominal distention of about one to two months with bruises on the right flank about two days status post fall. The patient has been having increasing distention of the abdomen and frequent nosebleeds.,PAST MEDICAL HISTORY:, As above.,PAST SURGICAL HISTORY: , The patient had a pacemaker placed.,ALLERGIES: , NKDA.,REVIEW OF SYSTEMS: , Showed no history of fever, no chills, no weight loss. No history of sore throat. No history of any ascites. No history of nausea, vomiting, or diarrhea. No black stools. No history of any rash. No back pain. No leg pain. No neuropsychiatric problems.,FAMILY HISTORY: , History of hypertension, diabetes present.,SOCIAL HISTORY:, He is a nonsmoker, nonalcoholic, and not a drug user.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure is 124/66, heart rate around 68 per minute, and temperature 96.4.,HEENT: The patient is atraumatic and normocephalic. Pupils are equal and reactive to light. Extraocular muscles are intact.,NECK: Supple. No JVD and no thyromegaly.,HEART: S1 and S2 heard. No murmurs or extra sounds.,ABDOMEN: Distention of the abdomen present.,EXTREMITIES: No pedal edema.,LABORATORY: , His lab investigation showed WBC of 6.2, H&H is 11 and 34. PT, PTT, and INR is normal. Urinalysis showed 2+ protein and 3+ blood, and 5 to 10 rbc's. Potassium is 5.3, BUN of 39, and creatinine of 1.9. Liver function test, ALT was 12, AST 15, albumin 3, TSH of 4.8, and T3 of 1.33.,IMPRESSION AND PLAN: ,The patient is admitted with a diagnosis of acute on chronic renal insufficiency, rule out hepatorenal insufficiency could be secondary to congestive heart failure, cardiac cirrhosis, rule out possibility of ascites secondary to mesothelioma because the patient has got history of exposure to asbestos and has got pulmonary nodule, rule out diabetic nephropathy could be secondary to hypertensive nephrosclerosis. The patient has hematuria could be secondary to benign prostatic hypertrophy, rule out malignancy. We will do urine for cytology. We will do a renal ultrasound, and 24-hour urine collection for protein/creatinine, creatinine clearance, immunofixation, serum electrophoresis, serum uric acid, serum iron, TIBC, and serum ferritin levels. We will send a PSA level and if needed may be a urology consult.

Nephrology

PREOPERATIVE DIAGNOSIS: , Left lateral malleolus fracture.,POSTOPERATIVE DIAGNOSIS:, Left lateral malleolus fracture.,PROCEDURE PERFORMED: , Open reduction and internal fixation of left lateral malleolus.,ANESTHESIA: ,General.,TOURNIQUET TIME: , 59 minutes.,COMPLICATIONS: , None.,BLOOD LOSS: , Negligible.,CLOSURE: , 2-0 Vicryl and staples.,INDICATIONS FOR SURGERY:, This is a young gentleman with soccer injury to his left ankle and an x-ray showed displaced lateral malleolus fracture with widening of the mortise now for ORIF. The risks and perceivable complications of the surgeries were discussed with the patient via a translator as well as nonsurgical treatment options and this was scheduled emergently.,OPERATIVE PROCEDURE: , The patient was taken to the operative room where general anesthesia was successfully introduced. The right ankle was prepped and draped in standard fashion. The tourniquet was applied about the right upper thigh. An Esmarch tourniquet was used to exsanguinate the ankle. The tourniquet was insufflated to a pressure 325 mm for approximately 59 minutes. An approximately 6 inch longitudinal incision was made just over the lateral malleolus. Care was taken to spare overlying nerves and vessels. An elevator was used to expose the fracture. The fracture was freed of old hematoma and reduced with a reducing clamp. An interfragmentary cortical screw was placed of 28 mm with excellent purchase. The intraoperative image showed excellent reduction. A 5-hole semitubular plate was then contoured to the lateral malleolus and fixed with 3 cortical screws proximally and 2 cancellous screws distally. Excellent stability of fracture was achieved. Final fluoroscopy showed a reduction to be anatomic in 2 planes. The wound was irrigated with copious amounts of normal saline. Deep tissue was closed with 2-0 Vicryl. The skin was approximated with 2-0 Vicryl and closed with staples. Dry sterile dressing was applied.,The patient tolerated the procedure, was awakened and taken to the recovery room in stable condition.

Surgery

PROCEDURES PERFORMED: , Endoscopy.,INDICATIONS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:, Esophageal ring and active reflux esophagitis.,PROCEDURE: , Informed consent was obtained prior to the procedure from the parents and patient. The oral cavity is sprayed with lidocaine spray. A bite block is placed. Versed IV 5 mg and 100 mcg of IV fentanyl was given in cautious increments. The GIF-160 diagnostic gastroscope used. The patient was alert during the procedure. The esophagus was intubated under direct visualization. The scope was advanced toward the GE junction with active reflux esophagitis involving the distal one-third of the esophagus noted. The stomach was unremarkable. Retroflexed exam unremarkable. Duodenum not intubated in order to minimize the time spent during the procedure. The patient was alert although not combative. A balloon was then inserted across the GE junction, 15 mm to 18 mm, and inflated to 3, 4.7, and 7 ATM, and left inflated at 18 mm for 45 seconds. The balloon was then deflated. The patient became uncomfortable and a good-size adequate distal esophageal tear was noted. The scope and balloon were then withdrawn. The patient left in good condition.,IMPRESSION: , Successful dilation of distal esophageal fracture in the setting of active reflux esophagitis albeit mild.,PLAN: , I will recommend that the patient be on lifelong proton pump inhibition and have repeat endoscopy performed as needed. This has been discussed with the parents. He was sent home with a prescription for omeprazole.

Surgery

CHIEF COMPLAINT:, The patient is here for two-month followup.,HISTORY OF PRESENT ILLNESS:, The patient is a 55-year-old Caucasian female. She has hypertension. She has had no difficulties with chest pain. She has some shortness of breath only at walking up the stairs. She has occasional lightheadedness only if she bends over then stands up quickly. She has had no nausea, vomiting, or diarrhea. She does have severe osteoarthritis of the left knee and is likely going to undergo total knee replacement with Dr. XYZ in January of this coming year. The patient is wanting to lose weight before her surgery. She is concerned about possible coronary disease or stroke risk. She has not had any symptoms of cardiac disease other than some shortness of breath with exertion, which she states has been fairly stable. She has had fairly normal lipid panel, last being checked on 11/26/2003. Cholesterol was 194, triglycerides 118, HDL 41, and LDL 129. The patient is a nonsmoker. Her fasting glucose in November 2003 was within normal limits at 94. Her fasting insulin level was normal. Repeat nonfasting glucose was 109 on 06/22/2004. She does not have history of diabetes. She does not exercise regularly and is not able to because of knee pain. She also has had difficulties with low back pain. X-ray of the low back did show a mild compression fracture of L1. She has had no falls that would contribute to a compression fracture. She has had a normal DEXA scan on 11/07/2003 that does not really correlate with having a compression fracture of the lumbar spine; however, it is possible that arthritis could contribute to falsely high bone density reading on DEXA scan. She is wanting to consider treatment for prevention of further compression fractures and possible osteoporosis.,CURRENT MEDICATIONS:, Hydrochlorothiazide 12.5 mg a day, Prozac 20 mg a day, Vioxx 25 mg a day, vitamin C 250 mg daily, vitamin E three to four tablets daily, calcium with D 1500 mg daily, multivitamin daily, aspirin 81 mg daily, Monopril 40 mg daily, Celexa p.r.n.,ALLERGIES: ,Bactrim, which causes nausea and vomiting, and adhesive tape.,PAST MEDICAL HISTORY:,1. Hypertension.,2. Depression.,3. Myofascitis of the feet.,4. Severe osteoarthritis of the knee.,5. Removal of the melanoma from the right thigh in 1984.,6. Breast biopsy in January of 1997, which was benign.,7. History of Holter monitor showing ectopic beat. Echocardiogram was normal. These were in 1998.,8. Compression fracture of L1, unknown cause. She had had no injury. Interestingly, DEXA scan was normal 11/07/2003, which is somewhat conflicting.,SOCIAL HISTORY:, The patient is married. She is a nonsmoker and nondrinker.,REVIEW OF SYSTEMS:, As per the HPI.,PHYSICAL EXAMINATION:,General: This is a well-developed, well-nourished, pleasant Caucasian female, who is overweight.,Vital signs: Weight: Refused. Blood pressure: 148/82, on recheck by myself with a large cuff, it was 125/60. Pulse: 64. Respirations: 20. Temperature: 96.3.,Neck: Supple. Carotids are silent.,Chest: Clear to auscultation.,Cardiovascular: Revealed a regular rate and rhythm without murmur, S3, or S4.,Extremities: Revealed no edema.,Neurologic: Grossly intact.,RADIOLOGY: EKG revealed normal sinus rhythm, rate 61, borderline first degree AV block, and poor R-wave progression in the anterior leads.,ASSESSMENT:,1. Hypertension, well controlled.,2. Family history of cerebrovascular accident.,3. Compression fracture of L1, mild.,4. Osteoarthritis of the knee.,5. Mildly abnormal chest x-ray.,PLAN:,1. We will get a C-reactive protein cardiac.,2. We discussed weight loss options. I would recommend Weight Watchers or possibly having her see a dietician. She will think about these options. She is not able to exercise regularly right now because of knee pain.,3. We would recommend a screening colonoscopy. She states that we discussed this in the past and she canceled her appointment to have that done. She will go ahead and make an appointment to see Dr. XYZ for screening colonoscopy.,4. We will start Fosamax 70 mg once weekly. She is to take this in the morning on an empty stomach with full glass of water. She is not to eat, lie down, or take other medications for at least 30 minutes after taking Fosamax.,5. I would like to see her back in one to two months. At that time, we can do preoperative evaluation and we will probably send her to a cardiologist because of mildly abnormal EKG for preoperative cardiac testing. One would also consider preoperative beta-blocker for cardiac protection.

General Medicine

CHIEF COMPLAINT: , Anxiety, alcohol abuse, and chest pain.,HISTORY OF PRESENT ILLNESS:, This is a pleasant 40-year-old male with multiple medical problems, basically came to the hospital yesterday complaining of chest pain. The patient states that he complained of this chest pain, which is reproducible, pleuritic in both chest radiating to the left back and the jaw, complaining of some cough, nausea, questionable shortness of breath. The patient describes the pain as aching, sharp and alleviated with pain medications, not alleviated with any nitrates. Aggravated by breathing, coughing, and palpation over the area. The pain was 9/10 in the emergency room and he was given some pain medications in the ER and was basically admitted. Labs were drawn, which were essentially, potassium was about 5.7 and digoxin level was drawn, which was about greater than 5. The patient said that he missed 3 doses of digoxin in the last 3 days after being discharged from Anaheim Memorial and then took 3 tablets together. The patient has a history prior digoxin overdose of the same nature.,MEDICATIONS:, Digoxin 0.25 mg, metoprolol 50 mg, Naprosyn 500 mg, metformin 500 mg, lovastatin 40 mg, Klor-Con 20 mEq, Advair Diskus, questionable Coreg.,PAST MEDICAL HISTORY: , MI in the past and atrial fibrillation, he said that he has had one stent put in, but he is not sure. The last cardiologist he saw was Dr. X and his primary doctor is Dr. Y.,SOCIAL HISTORY:, History of alcohol use in the past.,He is basically requesting for more and more pain medications. He states that he likes Dilaudid and would like to get the morphine changed to Dilaudid. His pain is tolerable.,PHYSICAL EXAMINATION:,VITAL SIGNS: Stable.,GENERAL: Alert and oriented x3, no apparent distress.,HEENT: Extraocular muscles are intact.,CVS: S1, S2 heard.,CHEST: Clear to auscultation bilaterally.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema or clubbing.,NEURO: Grossly intact. Tender to palpate over the left chest, no obvious erythema or redness, or abnormal exam is found.,EKG basically shows atrial fibrillation, rate controlled, nonspecific ST changes.,ASSESSMENT AND PLAN:,1. This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse. Now, he has had significant block with EKG changes as stated. Continue to follow the patient clinically at this time. The patient has been admitted to ICU and will be changed to DOU.,2. Chronic chest pain with a history of myocardial infarction in the past, has been ruled out with negative cardiac enzymes. The patient likely has opioid dependence and requesting more and more pain medications. He is also bargaining for pain medications with me. The patient was advised that he will develop more opioid dependence and I will stop the pain medications for now and give him only oral pain medications in the anticipation of the discharge in the next 1 or 2 days. The patient was likely advised to also be seen by a pain specialist as an outpatient after being referred. We will try to verify his pain medications from his primary doctor and his pharmacy. The patient said that he has been on Dilaudid and Vicodin ES and Norco and all these medications in the past.

Consult - History and Phy.

DIAGNOSES: , Traumatic brain injury, cervical musculoskeletal strain.,DISCHARGE SUMMARY: , The patient was seen for evaluation on 12/11/06 followed by 2 treatment sessions. Treatment consisted of neuromuscular reeducation including therapeutic exercise to improve range of motion, strength, and coordination; functional mobility training; self-care training; cognitive retraining; caregiver instruction; and home exercise program. Goals were not achieved, as the patient was admitted to inpatient rehabilitation center.,RECOMMENDATIONS: , Discharged from OT this date, as the patient has been admitted to Inpatient Rehabilitation Center.,Thank you for this referral.

Physical Medicine - Rehab

CHIEF COMPLAINT:, Patient AF is a 50-year-old hepatitis C positive African-American man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting.,HISTORY OF PRESENT ILLNESS: , AF's symptoms began 2 days ago, and he has not passed gas or had any bowel movements. He has not eaten anything, and has vomited 8 times. AF reports 10/10 pain in the LLQ.,PAST MEDICAL HISTORY:, AF's past medical history is significant for an abdominal injury during the Vietnam War which required surgery, and multiple episodes of small bowel obstruction and abdominal pain. Other elements of his history include alcoholism, cocaine abuse, alcoholic hepatitis, hepatitis C positive, acute pancreatitis, chronic pancreatitis, appendicitis, liver hematoma/contusion, Hodgkin's Disease, constipation, diarrhea, paralytic ileus, anemia, multiple blood transfusions, chorioretinitis, pneumonia, and "crack chest pain" ,PAST SURGICAL HISTORY: , AF has had multiple abdominal surgeries, including Bill Roth Procedure Type 1 (partial gastrectomy) during Vietnam War, at least 2 exploratory laparotomies and enterolysis procedures (1993; 2000), and appendectomy,MEDICATIONS:, None.,ALLERGIES:, Iodine, IV contrast (anaphylaxis), and seafood/shellfish.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY:, AF was born and raised in San Francisco. His father was an alcoholic. He currently lives with his sister, and does not work; he collects a pension.,HEALTH-RELATED BEHAVIORS:, AF reports that he smokes 1 to 2 cigarettes per day, and drinks 40 ounces of beer per day.,REVIEW OF SYSTEMS: , Noncontributory, except that patient reports a 6 pound weight loss since his symptoms began, and reports multiple transfusions for anemia.,PHYSICAL EXAM:,Vital Signs: T: 37.1

Consult - History and Phy.

EXAM:, Magnified airway.,CLINICAL HISTORY: , An 11-month-old female with episodes of difficulty in breathing, cough.,TECHNIQUE: , Multiple fluoroscopic spot images of the pharyngeal airway, trachea, and mainstem bronchi were performed in various phases of respiration.,FINDINGS:, The airway is patent throughout its course. Specifically, the trachea and both mainstem bronchi do not demonstrate evidence of dynamic collapse greater than 50%.,No filling defects are identified.,The vocal cords demonstrate normal opening and closing.,IMPRESSION: , Normal magnified airway examination.

Radiology

BILATERAL SCROTAL ORCHECTOMY,PROCEDURE:,: The patient is placed in the supine position, prepped and draped in the usual manner. Under satisfactory general anesthesia, the scrotum was approached and through a transverse mid scrotal incision, the right testicle was delivered through the incision. Hemostasis was obtained with the Bovie and the spermatic cord was identified. It was clamped, suture ligated with 0 chromic catgut and the cord above was infiltrated with 0.25% Marcaine for postoperative pain relief. The left testicle was delivered through the same incision. The spermatic cord was identified, clamped, suture ligated and that cord was also injected with 0.25% percent Marcaine. The incision was injected with the same material and then closed in two layers using 4-0 chromic catgut continuous for the dartos and interrupted for the skin. A dry sterile dressing fluff and scrotal support applied over that. The patient was sent to the Recovery Room in stable condition.

Surgery

PREOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,POSTOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,PROCEDURES: ,1. Anterior spine fusion from T11-L3.,2. Posterior spine fusion from T3-L5.,3. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.,ESTIMATED BLOOD LOSS: , 500 mL.,FINDINGS: , The patient was found to have a severe scoliosis. This was found to be moderately corrected. Hardware was found to be in good positions on AP and lateral projections using fluoroscopy.,INDICATIONS: , The patient has a history of severe neurogenic scoliosis. He was indicated for anterior and posterior spinal fusion to allow for correction of the curvature as well as prevention of further progression. Risks and benefits were discussed at length with the family over many visits. They wished to proceed.,PROCEDURE:, The patient was brought to the operating room and placed on the operating table in the supine position. General anesthesia was induced without incident. He was given a weight-adjusted dose of antibiotics. Appropriate lines were then placed. He had a neuromonitoring performed as well.,He was then initially placed in the lateral decubitus position with his left side down and right side up. An oblique incision was then made over the flank overlying the 10th rib. Underlying soft tissues were incised down at the skin incision. The rib was then identified and subperiosteal dissection was performed. The rib was then removed and used for autograft placement later.,The underlying pleura was then split longitudinally. This allowed for entry into the pleural space. The lung was then packed superiorly with wet lap. The diaphragm was then identified and this was split to allow for access to the thoracolumbar spine.,Once the spine was achieved, subperiosteal dissection was performed over the visualized vertebral bodies. This required cauterization of the segmental vessels. Once the subperiosteal dissection was performed to the posterior and anterior extents possible, the diskectomies were performed. These were performed from T11-L3. This was over 5 levels. Disks and endplates were then removed. Once this was performed, morcellized rib autograft was placed into the spaces. The table had been previously bent to allow for easier access of the spine. This was then straightened to allow for compression and some correction of the curvature.,The diaphragm was then repaired as was the pleura overlying the thoracic cavity. The ribs were held together with #1 Vicryl sutures. Muscle layers were then repaired using a running #2-0 PDS sutures and the skin was closed using running inverted #2-0 PDS suture as well. Skin was closed as needed with running #4-0 Monocryl. This was dressed with Xeroform dry sterile dressings and tape.,The patient was then rotated into a prone position. The spine was prepped and draped in a standard fashion.,Longitudinal incision was made from T2-L5. The underlying soft tissues were incised down at the skin incision. Electrocautery was then used to maintain hemostasis. The spinous processes were then identified and the overlying apophyses were split. This allowed for subperiosteal dissection over the spinous processes, lamina, facet joints, and transverse processes. Once this was completed, the C-arm was brought in, which allowed for easy placement of screws in the lumbar spine. These were placed at L4 and L5. The interspaces between the spinous processes were then cleared of soft tissue and ligamentum flavum. This was done using a rongeur as well as a Kerrison rongeur. Spinous processes were then harvested for morcellized autograft.,Once all the interspaces were prepared, Songer wires were then passed. These were placed from L3-T3.,Once the wires were placed, a unit rod was then positioned. This was secured initially at the screws distally on both the left and right side. The wires were then tightened in sequence from the superior extent to the inferior extent, first on the left-sided spine where I was operating and then on the right side spine. This allowed for excellent correction of the scoliotic curvature.,Decortication was then performed and placement of a morcellized autograft and allograft was then performed after thoroughly irrigating the wound with 4 liters of normal saline mixed with bacitracin. This was done using pulsed lavage.,The wound was then closed in layers. The deep fascia was closed using running #1 PDS suture, subcutaneous tissue was closed using running inverted #2-0 PDS suture, the skin was closed using #4-0 Monocryl as needed. The wound was then dressed with Steri-Strips, Xeroform dry sterile dressings, and tape. The patient was awakened from anesthesia and taken to the intensive care unit in stable condition. All instrument, sponge, and needle counts were correct at the end of the case.,The patient will be managed in the ICU and then on the floor as indicated.

Neurosurgery

CHIEF COMPLAINT:, Colostomy failure. ,HISTORY OF PRESENT ILLNESS:, This patient had a colostomy placed 9 days ago after resection of colonic carcinoma. Earlier today, he felt nauseated and stated that his colostomy stopped filling. He also had a sensation of "heartburn." He denies vomiting but has been nauseated. He denies diarrhea. He denies hematochezia, hematemesis, or melena. He denies frank abdominal pain or fever. ,PAST MEDICAL HISTORY:, As above. Also, hypertension. ,ALLERGIES:, "Fleet enema." ,MEDICATIONS:, Accupril and vitamins. ,REVIEW OF SYSTEMS:,SYSTEMIC: The patient denies fever or chills.,HEENT: The patient denies blurred vision, headache, or change in hearing.,NECK: The patient denies dysphagia, dysphonia, or neck pain.,RESPIRATORY: The patient denies shortness of breath, cough, or hemoptysis.,CARDIAC: The patient denies history of arrhythmia, swelling of the extremities, palpitations, or chest pain.,GASTROINTESTINAL: See above.,MUSCULOSKELETAL: The patient denies arthritis, arthralgias, or joint swelling.,NEUROLOGIC: The patient denies difficulty with balance, numbness, or paralysis.,GENITOURINARY: The patient denies dysuria, flank pain, or hematuria.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 183/108, pulse 76, respirations 16, temperature 98.7. ,HEENT: Cranial nerves are grossly intact. There is no scleral icterus. ,NECK: No jugular venous distention. ,CHEST: Clear to auscultation bilaterally. ,CARDIAC: Regular rate and rhythm. No murmurs. ,ABDOMEN: Soft, nontender, nondistended. Bowel sounds are decreased and high-pitched. There is a large midline laparotomy scar with staples still in place. There is no evidence of wound infection. Examination of the colostomy port reveals no obvious fecal impaction or site of obstruction. There is no evidence of infection. The mucosa appears normal. There is a small amount of nonbloody stool in the colostomy bag. There are no masses or bruits noted. ,EXTREMITIES: There is no cyanosis, clubbing, or edema. Pulses are 2+ and equal bilaterally. ,NEUROLOGIC: The patient is alert and awake with no focal motor or sensory deficit noted. ,MEDICAL DECISION MAKING:, Failure of colostomy to function may repre- sent an impaction; however, I did not appreciate this on physical examination. There may also be an adhesion or proximal impaction which I cannot reach, which may cause a bowel obstruction, failure of the shunt, nausea, and ultimately vomiting. ,An abdominal series was obtained, which confirmed this possibility by demonstrating air-fluid levels and dilated bowel. ,The CBC showed WBC of 9.4 with normal differential. Hematocrit is 42.6. I interpret this as normal. Amylase is currently pending. ,I have discussed this case with Dr. S, the patient's surgeon, who agrees that there is a possibility of bowel obstruction and the patient should be admitted to observation. Because of the patient's insurance status, the patient will actually be admitted to Dr. D on observation. I have discussed the case with Dr. P, who is the doctor on call for Dr. D. Both Dr. S and Dr. P have been informed of the patient's condition and are aware of his situation. ,FINAL IMPRESSION:, Bowel obstruction, status post colostomy. ,DISPOSITION:, Admission to observation. The patient's condition is good. He is hemodynamically stable.

Gastroenterology

CHIEF COMPLAINT:, A 2-month-old female with 1-week history of congestion and fever x2 days.,HISTORY OF PRESENT ILLNESS:, The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week. The mother has also reported irregular breathing, which she describes as being rapid breathing associated with retractions. The mother states that the cough is at times paroxysmal and associated with posttussive emesis. The patient has had short respiratory pauses following the coughing events. The patient's temperature has ranged between 102 and 104. She has had a decreased oral intake and decreased wet diapers. The brother is also sick with URI symptoms, and the patient has had no diarrhea. The mother reports that she has begun to regurgitate after her feedings. She did not do this previously.,MEDICATIONS: , None.,SMOKING EXPOSURE: , None.,IMMUNIZATIONS: , None.,DIET: ,Similac 4 ounces every 2 to 3 hours.,ALLERGIES:, No known drug allergies.,PAST MEDICAL HISTORY: ,The patient delivered at term. Birth weight was 6 pounds 1 ounce. Postnatal complications: Neonatal Jaundice. The patient remained in the hospital for 3 days. The in utero ultrasounds were reported to be normal.,PRIOR HOSPITALIZATIONS: , None.,FAMILY/SOCIAL HISTORY: , Family history is positive for asthma and diabetes. There is also positive family history of renal disease on the father's side of the family.,DEVELOPMENT: , Normal. The patient tests normal on the newborn hearing screen.,REVIEW OF SYSTEMS: GENERAL: , The patient has had fever, there have been no chills. SKIN: No rashes. HEENT: Mild congestion x1 week. Cough, at times paroxysmal, no cyanosis. The patient turns red in the face during coughing episodes, posttussive emesis. CARDIOVASCULAR: No cyanosis. GI: Posttussive emesis, decreased oral intake. GU: Decreased urinary output. ORTHO: No current issues. NEUROLOGIC: No change in mental status. ENDOCRINE: There is no history of weight loss. DEVELOPMENT: No loss of developmental milestones.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Weight is 4.8 kg, temperature 100.4, heart rate is 140, respiratory rate 30, and saturations 100%.,GENERAL: This is a well-appearing infant in no acute distress.,HEENT: Shows anterior fontanelle to be open and flat. Pupils are equal and reactive to light with red reflex. Nares are patent. Oral mucosa is moist. Posterior pharynx is clear. Hard palate is intact. Normal gingiva.,HEART: Regular rate and rhythm without murmur.,LUNGS: A few faint rales. No retractions. No stridor. No wheezing on examination. Mild tachypnea.,EXTREMITIES: Warm, good perfusion. No hip clicks.,NEUROLOGIC: The patient is alert. Normal tone throughout. Deep tendon reflexes are 2+/4. No clonus.,SKIN: Normal.,LABORATORY DATA:, CBC shows a white count of 12.4, hemoglobin 10.1, platelet count 611,000; 38 segs 3 bands, 42 lymphocytes, and 10 monocytes. Electrolytes were within normal limits. C-reactive protein 0.3. Chest x-ray shows no acute disease with the exception of a small density located in the retrocardiac area on the posterior view. UA shows 10 to 25 bacteria.,ASSESSMENT/PLAN: ,This is a 2-month-old, who presents with fever, paroxysmal cough and episodes of respiratory distress. The patient is currently stable in the emergency room. We will admit the patient to the pediatric floor. We will send out pertussis PCR. We will also follow results of urine culture and that the urine dip shows 10 to 25 bacteria. The patient will be followed up for signs of sepsis, apnea, urinary tract infection, and pneumonia. We will wait for a radiology reading on the chest x-ray to determine if the density seen on the lateral film is a normal variant or represents pathology.

Pediatrics - Neonatal

PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:, Acute suppurative appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and Marcaine 0.25% local.,INDICATIONS:, This 29-year-old female presents to ABCD General Hospital Emergency Department on 08/30/2003 with history of acute abdominal pain. On evaluation, it was noted that the patient has clinical findings consistent with acute appendicitis. However, the patient with additional history of loose stools for several days prior to event. Therefore, a CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis. There was no evidence of colitis on the CAT scan. With this in mind and the patient's continued pain at present, the patient was explained the risks and benefits of appendectomy. She agreed to procedure and informed consent was obtained.,GROSS FINDINGS: , The appendix was removed without difficulty with laparoscopic approach. The appendix itself noted to have a significant inflammation about it. There was no evidence of perforation of the appendix.,PROCEDURE DETAILS:, The patient was placed in supine position. After appropriate anesthesia was obtained and sterile prep and drape completed, a #10 blade scalpel was used to make a curvilinear infraumbilical incision. Through this incision, a Veress needle was utilized to create a CO2 pneumoperitoneum of 15 mmHg. The Veress needle was then removed. A 10 mm trocar was then introduced through this incision into the abdomen. A video laparoscope was then inserted and the above noted gross findings were appreciated upon evaluation. Initially, bilateral ovarian cysts were appreciated, however, there was no evidence of acute disease on evaluation. Photodocumentation was obtained.,A 5 mm port was then placed in the right upper quadrant. This was done under direct visualization and a blunt grasper was utilized to mobilize the appendix. Next, a 12 mm port was placed in the left lower quadrant lateral to the rectus musculature under direct visualization. Through this port, the dissector was utilized to create a small window in the mesoappendix. Next, an EndoGIA with GI staples was utilized to fire across the base of the appendix, which was done noting it to be at the base of the appendix. Next, staples were changed to vascular staples and the mesoappendix was then cut and vessels were then ligated with vascular staples. Two 6 X-loupe wires with EndoGIA were utilized in this prior portion of the procedure. Next, an EndoCatch was placed through the 12 mm port and the appendix was placed within it. The appendix was then removed from the 12 mm port site and taken off the surgical site. The 12 mm port was then placed back into the abdomen and CO2 pneumoperitoneum was recreated. The base of the appendix was reevaluated and noted to be hemostatic. Aspiration of warm saline irrigant then done and noted to be clear. There was a small adhesion appreciated in the region of the surgical site. This was taken down with blunt dissection without difficulty. There was no evidence of other areas of disease. Upon re-exploration with a video laparoscope in the abdomen and after this noting the appendix base to be hemostatic and intact. The instruments were removed from the patient and the port sites were then taken off under direct visualization. The CO2 pneumoperitoneum was released into the air and the fascia was approximated in the 10 mm and 12 mm port sites with #0 Vicryl ligature x2. Marcaine 0.25% was then utilized in all three incision sites and #4-0 Vicryl suture was used to approximate the skin and all three incision sites. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and taken to Postoperative Care Unit in stable condition and monitored under General Medical Floor on IV antibiotics, pain medications, and return to diet.

Surgery

INDICATIONS FOR PROCEDURE:, A 51-year-old, obese, white female with positive family history of coronary disease and history of chest radiation for Hodgkin disease 20 years ago with no other identifiable risk factors who presents with an acute myocardial infarction with elevated enzymes. The chest pain occurred early Tuesday morning. She was treated with Plavix, Lovenox, etc., and transferred for coronary angiography and possible PCI. The plan was discussed with the patient and all questions answered.,PROCEDURE NOTE:, Following sterile prep and drape, the right groin and instillation of 1% Xylocaine anesthesia, the right femoral artery was percutaneously entered with a single wall puncture. A 6-French sheath inserted. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricle pressures, and a left ventriculography. The left pullback pressure. The catheters withdrawn. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. She tolerated the procedure well.,Left ventricular end-diastolic pressure equals 25 mmHg post A wave. No aortic valve or systolic gradient on pullback.,ANGIOGRAPHIC FINDINGS:,I. Left coronary artery: The left main coronary artery is,normal. The left anterior descending extends to the apex and has only minor luminal irregularities within the midportion of the vessel. Normal diagonal branches. Normal septal perforator branches. The left circumflex is a nondominant vessel with only minor irregularities with normal obtuse marginal branches.,II. Right coronary artery: The proximal right coronary artery has a focal calcification. There is minor plaque with luminal irregularity in the proximal and midportion of the vessel with no narrowing greater than 10 to 20% at most. The right coronary artery is a dominant system which gives off normal posterior,descending and posterior lateral branches. TIMI 3 flow is present.,III. Left ventriculogram: The left ventricle is slightly enlarged with normal contraction of the base, but, with wall motion abnormality involving the anteroapical and inferoapical left ventricle with hypokinesis within the apical portion. Ejection fraction estimated 40%, 1+ mitral regurgitation (echocardiogram ordered).,DISCUSSION:, Recent inferoapical mild myocardial infarction by left ventriculography and cardiac enzymes with elevated left ventricular end-diastolic pressure post A wave, but, only minor residual coronary artery plaque with calcification proximal right coronary artery.,PLAN:, Medical treatment is contemplated, including ACE inhibitor, a beta blocker, aspirin, Plavix, nitrates. An echocardiogram is ordered to exclude apical left ventricular thrombus and to further assess ejection fraction.

Surgery

TITLE OF OPERATION: ,1. Arthrotomy, removal humeral head implant, right shoulder.,2. Repair of torn subscapularis tendon (rotator cuff tendon) acute tear.,3. Debridement glenohumeral joint.,4. Biopsy and culturing the right shoulder.,INDICATION FOR SURGERY: , The patient had done well after a previous total shoulder arthroplasty performed by Dr. X. However, the patient was lifted with subsequent significant pain and apparent tearing of his subscapularis. Risks and benefits of the procedure had been discussed with the patient at length including, but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, continued instability, retearing of the tendon, need for revision of his arthroplasty, permanent nerve or artery damage, etc. The patient understood and wished to proceed.,PREOP DIAGNOSIS: ,1. Torn subscapularis tendon, right shoulder.,2. Right total shoulder arthroplasty (Biomet system).,POSTOP DIAGNOSIS: ,1. Torn subscapularis tendon, right shoulder.,2. Right total shoulder arthroplasty (Biomet system).,3. Diffuse synovitis, right shoulder.,PROCEDURE: , The patient was anesthetized in the supine position. A Foley catheter was placed in his bladder. He was then placed in a beach chair position. He was brought to the side of the table and the torso secured with towels and tape. His head was then placed in the neutral position with no lateral bending or extension. It was secured with paper tape over his forehead. Care was taken to stay off his auricular cartilages and his orbits. Right upper extremity was then prepped and draped in the usual sterile fashion. The patient was given antibiotics well before the beginning of the procedure to decrease any risk of infection. Once he had been prepped and draped with the standard prep, he was prepped a second time with a chlorhexidine-type skin prep. This was allowed to dry and the skin was then covered with Ioban bandages also to decrease his risk of infection.,Also, preoperatively, the patient had his pacemaker defibrillator function turned off as a result during this case. Bipolar type cautery had to be used as opposed to monopolar cautery.,The patient's deltopectoral incision was then opened and extended proximally and distally. The patient had significant amount of scar already in this interval. Once we got down to the deltoid and pectoralis muscle, there was no apparent cephalic vein present, as a result the rotator cuff interval had to be developed through an area of scar. This created a significant amount of bleeding. As a result a very slow and meticulous dissection was performed to isolate his coracoid and then his proximal humerus. Care was taken to stay above the pectoralis minor and the conjoint tendon. The deltoid had already started to scar down the proximal humerus as a result a very significant amount of dissection had to be performed to release the deltoid from proximal humerus. Similarly, the deltoid insertion had to be released approximately 50% of its width to allow us enough mobility of the proximal humerus to be able to visualize the joint or the component. It was clear that the patient had an avulsion of the subscapularis tendon as the tissue on the anterior aspect of the shoulder was very thin. The muscle component of the subscapularis could be located approximately 1 cm off the glenoid rim and approximately 3 cm off the lesser tuberosity. The soft tissue in this area was significantly scarred down to the conjoint tendon, which had to be very meticulously released. The brachial plexus was identified as was the axillary nerve. Once this was completed, an arthrotomy was then made leaving some tissue attached to the lesser tuberosity in case it was needed for closure later. This revealed sanguineous fluid inside the joint. We did not feel it was infected based upon the fluid that came from the joint. The sutures for the subscapularis repair were still located in the proximal humerus with no tearing through the bone, which was fortunate because in that we could use the bone later for securing the sutures. The remaining sutures were seen to be retracted medially to an area of the subscapularis as mentioned previously. Some more capsule had to be released off the inferior neck in order for us to gain exposure during the scarring. This was done also very meticulously. The upper one half of the latissimus dorsi tendon was also released. Once this was completed, the humerus could be subluxed enough laterally that we could remove the head. This was done with no difficulty. Fortunately, the humeral component stayed intact. There were some exudates beneath the humeral head, which were somewhat mucinous. However, these do not really appear to be infected, however, we sent them to pathology for a frozen section. This frozen section later returned as possible purulent material. I discussed this personally with the pathologist at that point. We told him that the procedure is only 3 weeks old, but he was concerned that there might be more white blood cells in the tissue than he would expect. As a result, all the mucinous exudates were carefully removed. We also performed a fairly extensive synovectomy of the joint primarily to gain vision of the components, but also we irrigated the joint throughout the case with antibiotic impregnated irrigation. At that point, we also had sent portions of this mucinous material to pathology for a stat Gram stain. This came back as no organisms seen. We also sent portions for culture and sensitivity both aerobic and anaerobic.,Once this was completed, attention was then directed to the glenoid. The patient had significant amount of scar already. The subscapularis itself was significantly scarred down to the anterior rim. As a result, the adhesions along the anterior edge were released using a knife. Also adhesions in the subcoracoid space area were released very carefully and meticulously to prevent any injury to the brachial plexus. Two long retractors were placed medially to protect the brachial plexus during all portions of suturing of the subscapularis. The subscapularis was then tagged with multiple number 2 Tycron sutures. Adhesions were released circumferentially and it was found that with the arm in internal rotation about neutral degrees, the subscapularis could reach the calcar region without tension. As a result, seven number 2 Tycron sutures were placed from the bicipital groove all the way down to the inferior calcar region of the humerus. These all had excellent security in bone. Once the joint had been debrided and irrigated, the real humeral head was then placed back on the proximal humerus. Care was taken to remove fluid off the Morse taper. The head was then impacted. It should be noted that we tried multiple head sizes to see if a smaller or larger head size might be more appropriate for this patient. Unfortunately, any of the larger head sizes would overstep the joint and any smaller sizes would not give good coverage to the proximal humerus. As a result, it was felt to place the offset head back on the humerus, we did insert a new component as opposed to using the old component. The old component was given to the family postoperatively.,With the arm in internal rotation, the Tycron sutures were then placed through the subscapularis tendon in the usual horizontal mattress fashion. Also, it should be noted that the rotator cuff interval had to be released as part of the exposure. We started the repair by closing the rotator cuff interval. Anterior and posterior translation was then performed and was found to be very stable. The remaining sutures were then secured through the subscapularis tendon taking care to make sure that very substantial bites were obtained. This was then reinforced with the more flimsy tissue laterally being sewn into the tissue around the bicipital tuberosity essentially provided us with a two-layer repair of the subscapularis tendon. After the tendon had been repaired, there was no tension on repair until 0 degrees external rotation was reached with the arm to the side. Similarly with the arm abducted 90 degrees, tension was on repair at 0 degrees of external rotation. It should be noted that the wound was thoroughly irrigated throughout with antibiotic impregnated irrigation. The rotator cuff interval was closed with multiple number 2 Tycron sutures. It was reinforced with 0 Vicryl sutures. Two Hemovac drains were then placed inferiorly at the deltoid. The deltopectoral interval was then closed with 0 Vicryl sutures. A third drain was placed in the subcutaneous tissues to prevent any infections or any fluid collections. This was sewn into place with the drain pulled out superiorly. Once all the sutures have been secured and the drain visualized throughout this part of the closure, the drain was pulled distally until it was completely covered. There were no signs that it had been tagged or hung up by any sutures.,The superficial subcutaneous tissues were closed with interrupted with 2-0 Vicryl sutures. Skin was closed with staples. A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer. The patient was sent to the intensive care unit in stable and satisfactory condition.,Due to the significant amount of scar and bleeding in this patient, a 22 modifier is being requested for this case. This was a very difficult revision case and was significantly increased in technical challenges and challenges in the dissection and exposure of this implant compared to a standard shoulder replacement. Similarly, the repair of the subscapularis tendon presented significantly more challenges than that of a standard rotator cuff repair because of the implant. This was being dictated for insurance purposes only and reflects no inherent difficulties with this case. The complexity and the time involved in this case was approximately 30% greater than that of a standard shoulder replacement or of a rotator cuff repair. This is being dictated to indicate this was a revision case with significant amount of scar and bleeding due to the patient's situation with his pacemaker. This patient also had multiple medical concerns, which increased the complexity of this case including the necessity to place him in intensive care unit postoperatively for observation.

Orthopedic

CHIEF COMPLAINT:, A 74-year-old female patient admitted here with altered mental status.,HISTORY OF PRESENT ILLNESS:, The patient started the last 3-4 days to do poorly. She was more confused, had garbled speech, significantly worse from her baseline. She has also had decreased level of consciousness since yesterday. She has had aphasia which is baseline but her aphasia has gotten significantly worse. She eventually became unresponsive and paramedics were called. Her blood sugar was found to be 40 because of poor p.o. intake. She was given some D50 but that did not improve her mental status, and she was brought to the emergency department. By the time she came to the emergency department, she started having some garbled speech. She was able to express her husband's name and also recognize some family members, but she continued to be more somnolent when she was in the emergency department. When seen on the floor, she is more awake, alert.,PAST MEDICAL HISTORY: , Significant for recurrent UTIs as she was recently to the hospital about 3 weeks ago for urinary tract infection. She has chronic incontinence and bladder atony, for which eventually it was decided for the care of the patient to put a Foley catheter and leave it in place. She has had right-sided CVA. She has had atrial fibrillation status post pacemaker. She is a type 2 diabetic with significant neuropathy. She has also had significant pain on the right side from her stroke. She has a history of hypothyroidism. Past surgical history is significant for cholecystectomy, colon cancer surgery in 1998. She has had a pacemaker placement. ,REVIEW OF SYSTEMS:,GENERAL: No recent fever, chills. No recent weight loss.,PULMONARY: No cough, chest congestion.,CARDIAC: No chest pain, shortness of breath.,GI: No abdominal pain, nausea, vomiting. No constipation. No bleeding per rectum or melena.,GENITOURINARY: She has had frequent urinary tract infection but does not have any symptoms with it. ENDOCRINE: Unable to assess because of patient's bed-bound status.,MEDICATIONS: ,Percocet 2 tablets 4 times a day, Neurontin 1 tablet b.i.d. 600 mg, Cipro recently started 500 b.i.d., Humulin N 30 units twice a day. The patient had recently reduced that to 24 units. MiraLax 1 scoop nightly, Avandia 4 mg b.i.d., Flexeril 1 tablet t.i.d., Synthroid 125 mcg daily, Coumadin 5 mg. On the medical records, it shows she is also on ibuprofen, Lasix 40 mg b.i.d., Lipitor 20 mg nightly, Reglan t.i.d. 5 mg, Nystatin powder. She is on oxygen chronically.,SOCIAL/FAMILY HISTORY: , She is married, lives with her husband, has 2 children that passed away and 4 surviving children. No history of tobacco use. No history of alcohol use. Family history is noncontributory.,PHYSICAL EXAMINATION:,GENERAL: She is awake, alert, appears to be comfortable.,VITAL SIGNS: Blood pressure 111/43, pulse 60 per minute, temperature 37.2. Weight is 98 kg. Urine output is so far 1000 mL. Her intake has been fairly similar. Blood sugars are 99 fasting this morning. ,HEENT: Moist mucous membranes. No pallor,NECK: Supple. She has a rash on her neck. ,HEART: Regular rhythm, pacemaker could be palpated.,CHEST: Clear to auscultation.,ABDOMEN: Soft, obese, nontender.,EXTREMITIES: Bilateral lower extremities edema present. She is able to move the left side more efficiently than the right. The power is about 5 x 5 on the left and about 3-4 x 5 on the right. She has some mild aphasia.,DIAGNOSTIC STUDIES: , BUN 48, creatinine 2.8. LFTs normal. She is anemic with a hemoglobin of 9.6, hematocrit 29. INR 1.1, pro time 14. Urine done in the emergency department showed 20 white cells. It was initially cloudy but on the floor it has cleared up. Cultures from the one done today are pending. The last culture done on August 20 showed guaiac negative status and prior to that she has had mixed cultures. There is a question of her being allergic to Septra that was used for her last UTI.,IMPRESSION/PLAN:,1. Cerebrovascular accident as evidenced by change in mental status and speech. She seems to have recovered at this point. We will continue Coumadin. The patient's family is reluctant in discontinuing Coumadin but they do express the patient since has overall poor quality of life and had progressively declined over the last 6 years, the family has expressed the need for her to be on hospice and just continue comfort care at home.,2. Recurrent urinary tract infection. Will await culture at this time, continue Cipro.,3. Diabetes with episode of hypoglycemia. Monitor blood sugar closely, decrease the dose of Humulin N to 15 units twice a day since intake is poor. At this point, there is no clear evidence of any benefit from Avandia but will continue that for now.,4. Neuropathy, continue Neurontin 600 mg b.i.d., for pain continue the Percocet that she has been on.,5. Hypothyroidism, continue Synthroid.,6. Hyperlipidemia, continue Lipitor.,7. The patient is not to be resuscitated. Further management based on the hospital course.

Consult - History and Phy.

PRINCIPAL DIAGNOSES:,1. A 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with BEAM regimen in 04/02 followed by relapse.,2. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,3. Graft versus host disease involving GI tracts, skin, and liver presently off immunosuppression.,4. Diabetes.,5. Bipolar disorder.,6. Chronic muscle aches.,7. Chronic lower extremity edema.,8. ECOG performance status 1.,INTERIM HISTORY: , The patient comes to the clinic today for followup. I am seeing him once every 4 to 8 weeks. He is off of all immunosuppression. He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant.,He has multiple complaints. He has had hematochezia. I referred him to gastroenterology. They did an upper and lower endoscopy. No evidence of ulcers or any abnormality was found. Some polyps were removed. They were benign. He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity.,CURRENT MEDICATIONS:,1. Paxil 40 mg once daily.,2. Cozaar.,3. Xanax 1 mg four times a day.,4. Prozac 20 mg a day.,5. Lasix 40 mg a day.,6. Potassium 10 mEq a day.,7. Mirapex two tablets every night.,8. Allegra 60 mg twice a day.,9. Avandamet 4/1000 mg daily.,10. Nexium 20 mg a day.,11. NovoLog 25/50.,REVIEW OF SYSTEMS:, Fatigue, occasional rectal bleeding, and obesity. Other systems were reviewed and were found to be unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS: Today revealed that temperature 35.8, blood pressure 120/49, pulse 85, and respirations 18. HEENT: Oral cavity, no mucositis. NECK: No nodes. AXILLA: No nodes. LUNGS: Clear. CARDIAC: Regular rate and rhythm without murmurs. ABDOMEN: No palpable masses. Morbid obesity. EXTREMITIES: Mild lower extremity edema. SKIN: Mild dryness. CNS: Grossly intact.,LABORATORY DATA:, White count 4.4, hemoglobin 10.1, platelet count 132,000, sodium 135, potassium 3.9, chloride 105, bicarbonate 24, BUN 15, and creatinine 0.9. Normal alkaline phosphatase 203, AST 58, and ALT 31.,ASSESSMENT AND PLAN:,1. The patient with mantle cell lymphoma who is 4-1/2 years post allotransplant. He is without evidence of disease at the present time. Since he is 4-1/2 years posttransplant, I do not plan to scan him or obtain chimerisms unless there is reason to.,2. He is slightly anemic, may be iron deficient. He has had recurrent rectal bleeding. I told him to take multivitamin with iron and see how that helps the anemia.,3. Regarding the hematochezia, he had an endoscopy. I reviewed the results from the previous endoscopy. It appears that he has polyps, but there is no evidence of graft versus host disease.,4. Regarding the fatigue, I just reassured him that he should increase his activity level, but I am not sure how realistic that is going to be.,5. He is followed for his diabetes by his internist.,6. If he should have any fever or anything suggestive of infection, I advised him to call me. I will see him back in about 2 months from now.

SOAP / Chart / Progress Notes

TITLE OF OPERATION:,1. Repair of total anomalous pulmonary venous connection.,2. Ligation of patent ductus arteriosus.,3. Repair secundum type atrial septal defect (autologous pericardial patch).,4. Subtotal thymectomy.,5. Insertion of peritoneal dialysis catheter.,INDICATION FOR SURGERY: , This neonatal was diagnosed postnatally with total anomalous pulmonary venous connection. Following initial stabilization, she was transferred to the Hospital for complete correction.,PREOP DIAGNOSIS: ,1. Total anomalous pulmonary venous connection.,2. Atrial septal defect.,3. Patent ductus arteriosus.,4. Operative weight less than 4 kilograms (3.2 kilograms).,COMPLICATIONS: , None.,CROSS-CLAMP TIME: , 63 minutes.,CARDIOPULMONARY BYPASS TIME MONITOR:, 35 minutes, profound hypothermic circulatory arrest time (4 plus 19) equals 23 minutes. Low flow perfusion 32 minutes.,FINDINGS:, Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left-sided veins. Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence. Nonobstructed ascending vein ligated. Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin. At completion of the procedure, right ventricular pressure approximating one-half of systemic, normal sinus rhythm, good biventricular function by visual inspection.,PROCEDURE: , After the informed consent, the patient was brought to the operating room and placed on the operating room table in supine position. Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines. The patient was prepped and draped in the usual sterile fashion from chin to groins. A median sternotomy incision was performed. Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw. A subtotal thymectomy was performed. Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle. A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure. Pursestrings were deployed on the ascending aorta on the right. Atrial appendage. The aorta was then cannulated with an 8-French aorta cannula and the right atrium with an 18-French Polystan right-angle cannula. With an ACT greater than 400, greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2-0 silk tie. Systemic cooling was started and the head was packed and iced and systemic steroids were administered. During cooling, traction suture was placed in the apex of the left ventricle. After 25 minutes of cooling, the aorta was cross-clamped and the heart arrested by administration of 30 cubic centimeter/kilogram of cold-blood cardioplegia delivered directly within the aortic root following the aorta cross-clamping. Following successful cardioplegic arrest, a period of low flow perfusion was started and a 10-French catheter was inserted into the right atrial appendage substituting the 18-French Polystan venous cannula. The heart was then rotated to the right side and the venous confluence was exposed. It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed. The two openings were then anastomosed in an end-to-side fashion with several interlocking sutures to avoid pursestring effect with a running 7-0 PDS suture. Following completion of the anastomosis, the heart was returned into the chest and the patient's blood volume was drained into the reservoir. A right atriotomy was then performed during the period of circulatory arrest. The atrial septal defect was very difficult to expose, but it was sealed with an autologous pericardial patch was secured in place with a running 6-0 Prolene suture. The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6-0 Prolene sutures. The venous cannula was reinserted. Cardiopulmonary bypass restarted and the aorta cross-clamp was released. The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which, following a prolonged period of rewarming, allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm. Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15-French Blake drains. Venous decannulation was followed by aortic decannulation and administration of protamine sulfate. All cannulation sites were oversewn with 6-0 Prolene sutures and the anastomotic sites noticed to be hemostatic. With good hemodynamics and hemostasis, the sternum was then smeared with vancomycin, placing closure with stainless steel wires. The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was transferred in very stable condition to the pediatric intensive care unit .,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case. Given the magnitude of the operation, the unavailability of an appropriate level, cardiac surgical resident, Mrs. X (attending pediatric cardiac surgery at the Hospital) participated during the cross-clamp time of the procedure in quality of first assistant.

Cardiovascular / Pulmonary

PROCEDURES PERFORMED: , Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.,PROCEDURE CODES: , 64640 times one, 64614 times two, 95873 times two.,PREOPERATIVE DIAGNOSIS: , Spastic right hemiparetic cerebral palsy, 343.1.,POSTOPERATIVE DIAGNOSIS:, Spastic right hemiparetic cerebral palsy, 343.1.,ANESTHESIA:, MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient. She was brought to the minor procedure area and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine. The right obturator nerve was identified using active EMG stimulation lateral to the adductor longus tendon origin and below the femoral pulse. Approximately 6 mL of 5% phenol was injected in this location. At all sites of phenol injections, injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation. Approximately 100 units was injected in the right pectoralis major and 100 units in the right rectus femoris and vastus intermedius muscles. Total amount of botulinum toxin injected was 200 units diluted 25 units to 1 mL. The patient tolerated the procedure well and no complications were encountered.

Surgery

PREOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.,POSTOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion, and potentially unstable cervical spine.,OPERATIVE PROCEDURE: ,Application of PMT large halo crown and vest.,ESTIMATED BLOOD LOSS: , None.,ANESTHESIA: ,Local, conscious sedation with Morphine and Versed.,COMPLICATIONS: , None. Post-fixation x-rays, nonalignment, no new changes. Post-fixation neurologic examination normal.,CLINICAL HISTORY: ,The patient is a 41-year-old female who presented to me with severe cervical spondylosis and myelopathy. She was referred to me by Dr. X. The patient underwent a complicated anterior cervical discectomy, 2-level corpectomy, spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate. Surgery had gone well, and the patient has done well in the last 2 days. She is neurologically improved and is moving all four extremities. No airway issues. It was felt that the patient was now a candidate for a halo vest placement given that chance of going to the OR were much smaller. She was consented for the procedure, and I sought the help of ABC and felt that a PMT halo would be preferable to a Bremer halo vest. The patient had this procedure done at the bedside, in the SICU room #1. I used a combination of some morphine 1 mg and Versed 2 mg for this procedure. I also used local anesthetic, with 1% Xylocaine and epinephrine a total of 15 to 20 cc.,PROCEDURE DETAILS:, The patient's head was positioned on some towels, the retroauricular region was shaved, and the forehead and the posterolateral periauricular regions were prepped with Betadine. A large PMT crown was brought in and fixed to the skull with pins under local anesthetic. Excellent fixation achieved. It was lateral to the supraorbital nerves and 1 fingerbreadth above the brows and the ear pinnae.,I then put the vest on, by sitting the patient up, stabilizing her neck. The vest was brought in from the front as well and connected. Head was tilted appropriately, slightly extended, and in the midline. All connections were secured and pins were torqued and tightened.,During the procedure, the patient did fine with no significant pain.,Post-procedure, she is neurologically intact and she remained intact throughout. X-rays of the cervical spine AP, lateral, and swimmer views showed excellent alignment of the hardware construct in the graft with no new changes.,The patient will be subjected to a CT scan to further define the alignment, and barring any problems, she will be ambulating with the halo on.,The patient will undergo pin site care as per protocol, and likely she will go in the next 2 to 3 days. Her prognosis indeed is excellent, and she is already about 90% or so better from her surgery. She is also on a short course of Decadron, which we will wean off in due course.,The matter was discussed with the patient and the patient's family.

Orthopedic

PREOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,POSTOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,PROCEDURE: , Left axillary lymph node excisional biopsy.,ANESTHESIA:, LMA.,INDICATIONS: , Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only. Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast. Patient has been following with Dr. Diener and Dr. Wilmot. I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both. She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion. I recommended that she have this lymph node removed. The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution, draped in a sterile fashion. An incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia. I was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures. The lymph node was excised in its entirety. The wound was irrigated. The lymph node sent to pathology. The wound was then closed. Hemostasis was assured and the patient was taken to recovery room in stable condition.

Hematology - Oncology

CHIEF COMPLAINT:, This 61-year-old male presents today with recent finding of abnormal serum PSA of 16 ng/ml. Associated signs and symptoms: Associated signs and symptoms include dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and urine stream is slow. Timing (onset/frequency): Onset was 6 months ago. Patient denies fever and chills and denies flank pain.,ALLERGIES: ,Patient admits allergies to adhesive tape resulting in severe rash. Patient denies an allergy to anesthesia.,MEDICATION HISTORY:, Patient is not currently taking any medications.,PAST MEDICAL HISTORY:, Childhood Illnesses: (+) asthma, Cardiovascular Hx: (-) angina, Renal / Urinary Hx: (-) kidney problems.,PAST SURGICAL HISTORY:, Patient admits past surgical history of appendectomy in 1992.,SOCIAL HISTORY:, Patient admits alcohol use, Drinking is described as heavy, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:, Patient admits a family history of gout attacks associated with father.,REVIEW OF SYSTEMS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAM: ,BP Sitting: 120/80 Resp: 20 HR: 72 Temp: 98.6,The patient is a pleasant, 61-year-old male in no apparent distress who looks his given age, is well-developed and nourished with good attention to hygiene and body habitus.,Neck: Neck is normal and symmetrical, without swelling or tenderness. Thyroid is smooth and symmetric with no enlargement, tenderness or masses noted.,Respiratory: Respirations are even without use of accessory muscles and no intercostal retractions noted. Breathing is not labored, diaphragmatic, or abdominal. Lungs clear to auscultation with no rales, rhonchi, wheezes, or rubs noted.,Cardiovascular: Normal S1 and S2 without murmurs, gallop, rubs or clicks. Peripheral pulses full to palpation, no varicosities, extremities warm with no edema or tenderness.,Gastrointestinal: Abdominal organs, bladder, kidney: No abnormalities, without masses, tenderness, or rigidity. Hernia: absent; no inguinal, femoral, or ventral hernias noted. Liver and/or Spleen: no abnormalities, tenderness, or masses noted. Stool specimen not indicated.,Genitourinary: Anus and perineum: no abnormalities. No fissures, edema, dimples, or tenderness noted.,Scrotum: no abnormalities. No lesions, rash, or sebaceous cyst noted.,Epididymides: no abnormalities, masses, or spermatocele, without enlargement, induration, or tenderness.,Testes: symmetrical; no abnormalities, tenderness, hydrocele, or masses noted.,Urethral Meatus: no abnormalities; no hypospadias, lesions, polyps, or discharge noted.,Penis: no abnormalities; circumcised; no phimosis, Peyronie's, condylomata, or lumps noted.,Prostate: size 60 gr, RT>LT and firm.,Seminal Vesicles: no abnormalities; symmetrical; no tenderness, induration, or nodules noted.,Sphincter tone: no abnormalities; good tone; without hemorrhoids or masses.,Skin/Extremities: Skin is warm and dry with normal turgor and there is no icterus. No skin rash, subcutaneous nodules, lesions or ulcers observed.,Neurological/Psychiatric: Oriented to person, place and time. Mood and affect normal, appropriate to situation, without depression, anxiety, or agitation.,TEST RESULTS:, No tests to report at this time.,IMPRESSION: ,Elevated prostate specific antigen (PSA).,PLAN:, Cystoscopy in the office.,DIAGNOSTIC & LAB ORDERS:, Ordered serum creatinine. Urinalysis and C & S ordered using clean-catch specimen. Ordered free prostate specific antigen (PSA). Ordered ultrasound of prostate.,I have discussed the findings of this follow-up evaluation with the patient. The discussion included a complete verbal explanation of any changes in the examination results, diagnosis and current treatment plan. Discussed the possibility of a TURP surgical procedure; risks, complications, benefits, and alternative measures discussed. There are no activity restrictions . Instructed Ben to avoid caffeinated or alcoholic beverages and excessively spiced foods. Questions answered. If any questions should arise after returning home I have encouraged the patient to feel free to call the office at 327-8850.,PRESCRIPTIONS: , Proscar Dosage: 5 mg tablet Sig: once daily Dispense: 30 Refills: 0 Allow Generic: No,PATIENT INSTRUCTIONS:, Patient completed benign prostatic hypertrophy questionnaire.

Consult - History and Phy.

EXAM: ,CT maxillofacial for trauma.,FINDINGS: , CT examination of the maxillofacial bones was performed without contrast. Coronal reconstructions were obtained for better anatomical localization.,There is normal appearance to the orbital rims. The ethmoid, sphenoid, and frontal sinuses are clear. There is polypoid mucosal thickening involving the floor of the maxillary sinuses bilaterally. There is soft tissue or fluid opacification of the ostiomeatal complexes bilaterally. The nasal bones appear intact. The zygomatic arches are intact. The temporomandibular joints are intact and demonstrate no dislocations or significant degenerative changes. The mandible and maxilla are intact. There is soft tissue swelling seen involving the right cheek.,IMPRESSION:,1. Mucosal thickening versus mucous retention cyst involving the maxillary sinuses bilaterally. There is also soft tissue or fluid opacification of the ostiomeatal complexes bilaterally.,2. Mild soft tissue swelling about the right cheek.

ENT - Otolaryngology

PREOPERATIVE DIAGNOSIS:, Low Back Syndrome - Low back pain with left greater than right lower extremity radiculopathy.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE:,1. Nerve root decompression at L45 on the left side.,2. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.,3. Interpretation of radiograph.,ANESTHESIA: , IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,INDICATION FOR PROCEDURE: , Severe and excruciating pain in the lumbar spine and lower extremity. MRI shows disc pathology as well as facet arthrosis.,SUMMARY OF PROCEDURE: , The patient was admitted to the operating room, consent was obtained and signed. The patient was taken to the Operating room and was placed in the prone position. Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring. After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral region was prepped and draped in sterile fashion with Betadine and four sterile towels. After the towels were places then sterile drapes were placed on top of that.,After which time the Epimed catheter was then placed, this was done by first repositioning the C-Arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at L5, verifying the sacral hiatus. The skin over the sacral hiatus was then injected with 1% Lidocaine and an #18-gauge needle was used for skin puncture. The #18-gauge needle was inserted off of midline. A #16-gauge RK needle was then placed into the skin puncture and using the paramedian approach and loss-of-resistance technique the needle was placed. Negative aspiration was carefully performed. Omnipaque 240 dye was then injected through the #16-gauge RK needle. The classical run off was noted. A filling defect was noted @ L45 nerve root on the left side. After which time 10 cc of 0.25% Marcaine/Triamcinolone (9/1 mixture) was then infused through the 16 R-K Needle. Some additional lyses of adhesions were visualized as the local anesthetic displaced the Omnipaque 240 dye using this barbotage technique.,An Epimed Tun-L catheter was then inserted through the #16-gauage R-K needle and threaded up to the L45 interspace under continuous fluoroscopic guidance. As the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized. The tip of the catheter was noted to be @ L45 level on the left side. After this the #16-gauge RK needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the L45 nerve root region on the left side. After this was successfully done, the catheter was then secured in place; this was done with Neosporin ointment, a Split 2x2, Op site and Hypofix tape. The catheter was then checked with negative aspiration and the Omnipaque 240 dye was then injected. The classical run off was noted in the lumbar region. Some lyses of adhesions were also visualized at this time with barbotage technique. Good dye spread was noted to extend one level above and one level below the L45 nerve root and bilateral spread was noted. Nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect. After which time negative aspiration was again performed through the Epimed® Tun-L catheter and then 10 cc of solution was then infused through the catheter, this was done over a 10-minute period with initial 3 cc test dose. Approximately 3 minutes elapsed and then the remaining 7 cc were infused (Solution consisting of 8 cc of 0.25% Marcaine, 2 cc of Triamcinolone and 1 cc of Wydase.) The catheter was then capped with a bacterial filter. The patient was noted to have tolerated the procedure well without any complications.,Interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed. A filling defect was seen at the L45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure. This verified positive nerve root decompression. The tip of the Epimed Tun L catheter was noted to be at L45 level on the left side. Positive myelogram without dural puncture was noted during this procedure; no sub-dural spread of Omnipaque 240 dye was noted. This patient did not report any problems and reported pain reduction.

Radiology

REASON FOR CONSULTATION:, Newly diagnosed head and neck cancer.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old gentleman who was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa. He was also noted to have palpable level 2 cervical lymph nodes. His staging is T3 N2c M0 Stage IV invasive squamous cell carcinoma of the head and neck. The patient comes in to the clinic today after radiation Oncology consultation. His Otolaryngologist performed a direct laryngoscopy with biopsy on July 29, 2010. The patient reports that in December-January timeframe, he had noted some difficulty swallowing and ear pain. He had a work up by his local physician that was relatively negative, and he was treated for gastroesophageal reflux disease. His symptoms continued to progress, and he developed difficulty with his speech, dysphagia, otalgia and odynophagia. He was then referred to Dr. X and examination revealed a mass at the right base of the tongue that extended across the midline to include the left base of the tongue as well as posterior extension involved in the right tonsillar fossa. He was noted to have bilateral neck nodes. His biopsy was positive for squamous cell carcinoma.,PAST MEDICAL HISTORY:, Significant for mild hypertension. He has had cataract surgery, gastroesophageal reflux disease and a history of biceps tendon tear.,ALLERGIES: , Penicillin.,CURRENT MEDICATIONS: , Lisinopril/hydrochlorothiazide 20/25 mg q.d., alprazolam 0.5 mg q.d., omeprazole 20 mg b.i.d., Lortab 7.5/500 mg q 4h p.r.n.,FAMILY HISTORY: , Significant for father who has stroke and grandfather with lung cancer.,SOCIAL HISTORY: , The patient is married but has been separated from his wife for many years, they remain close, and they have two adult sons. He is retired from the Air Force, currently works for Lockheed Martin. He was born and raised in New York. He does have a smoking history, about a 20 pack-year history and he reports quitting on July 27. He does drink alcohol socially. No use of illicit drugs.,REVIEW OF SYSTEMS: ,The patient's chief complaint is fatigue. He has difficulty swallowing and dysphagia. He is responding well to Lortab and Tylenol for pain control. He denies any chest pain, shortness of breath, fevers, chills and night sweats. The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:

Hematology - Oncology

PROCEDURE:, Upper endoscopy with foreign body removal.,PREOPERATIVE DIAGNOSIS (ES):, Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS (ES):, Penny in proximal esophagus.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,After informed consent was obtained, the patient was taken to the pediatric endoscopy suite. After appropriate sedation by the anesthesia staff and intubation, an upper endoscope was inserted into the mouth, over the tongue, into the esophagus, at which time the foreign body was encountered. It was grasped with a coin removal forcep and removed with an endoscope. At that time, the endoscope was reinserted, advanced to the level of the stomach and stomach was evaluated and was normal. The esophagus was normal with the exception of some mild erythema, where the coin had been sitting. There were no erosions. The stomach was decompressed of air and fluid. The scope was removed without difficulty.,SUMMARY:, The patient underwent endoscopic removal of esophageal foreign body.,PLAN:, To discharge home, follow up as needed.

Gastroenterology

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:

SOAP / Chart / Progress Notes

Thereafter, he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated. On December 5, 2008, Mr. XXXX did undergo a total knee replacement arthroplasty performed by Dr. X.,Thereafter, he did an extensive course of physical therapy, work hardening, and a work conditioning type program.,At the present time, he does complain of significant pain and swelling as related to the right knee. He is unable to crawl and/or kneel. He does state he is able to walk a city block and in fact, he is able to do 20 minutes of a treadmill. Stairs are a significant problem. His pain is a 5 to 6 on a scale of 1 to 10.,He is better when he is resting, sitting, propped up, and utilizing his ice. He is much worse when he is doing any type of physical activity.,He has denied having any previous history of similar problems.,CURRENT MEDICATIONS: ,Over-the-counter pain medication.,ALLERGIES: , NKA.,SURGERIES: , Numerous surgeries as related to the right lower extremity.,SOCIAL HISTORY: , He does admit to one half pack of cigarette consumption per day. He denies any alcohol consumption.,PHYSICAL EXAMINATION: ,On examination today, he is 28-year-old male who is 6 feet 1, weighs 250 pounds. He does not appear to be in distress at this time. One could appreciate 1-2/4 intraarticular effusion. The range of motion is 0 to a 110 degrees of flexion. I could not appreciate any evidence of instability medial, lateral, anterior or posterior. Crepitus is noted with regards to range of motion testing. His strength is 4 to 5 as related to the quadriceps and hamstring.,There is atrophy as related to the right thigh. The patient is able to stand from a seated position and sit from a standing position without difficulty.,RECORDS REVIEW:,1. First report of injury.,2. July 17, 2002, x-rays of the right knee were negative.,3. Notes of the Medina General Hospital Occupational Health, Steven Rodgers, M.D.,4. August 5, 2002, an MRI scan of the right knee which demonstrated peripheral tear of the posterior horn of the medial

Consult - History and Phy.

EXAM: , Left Heart Catheterization,REASON FOR EXAM:, Chest pain, coronary artery disease, prior bypass surgery.,INTERPRETATION: , The procedure and complications were explained to the patient in detail and formal consent was obtained. The patient was brought to the cath lab. The right groin was draped in the usual sterile manner. Using modified Seldinger technique, a 6-French arterial sheath was introduced in the right common femoral artery. A JL4 catheter was used to cannulate the left coronary arteries. A JR4 catheter was used to cannulate the right coronary artery and also bypass grafts. The same catheter was used to cannulate the vein graft and also LIMA. I tried to attempt to cannulate other graft with Williams posterior catheter and also bypass catheter was unsuccessful. A 6-French pigtail catheter was used to perform left ventriculography and pullback was done. No gradient was noted. Arterial sheath was removed. Hemostasis was obtained with manual compression. The patient tolerated the procedure very well without any complications.,FINDINGS:,1. Native coronary arteries. The left main is patent. The left anterior descending artery is not clearly visualized. The circumflex artery appears to be patent. The proximal segment gives rise to small caliber obtuse marginal vessel.,2. Right coronary artery is patent with mild distal and mid segment. No evidence of focal stenosis or dominant system.,3. Bypass graft LIMA to the left anterior descending artery patent throughout the body as well the anastomotic site. There appears to be possible _______ graft to the diagonal 1 vessel. The distal LAD wraps around the apex. No stenosis following the anastomotic site noted.,4. Vein graft to what appears to be obtuse marginal vessel was patent with a small caliber obtuse marginal 1 vessel.,5. No other bypass grafts are noted by left ventriculography and also aortic root shot.,6. Left ventriculography with an ejection fraction of 60%.,IMPRESSION:,1. Left coronary artery disease native.,2. Patent vein graft with obtuse marginal vessel and also LIMA to LAD. _______ graft to the diagonal 1 vessel.,3. Native right coronary artery is patent, mild disease.,RECOMMENDATIONS: , Medical treatment.

Surgery

DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1. Glucosamine complex.,2. Toprol XL.,3. Alprazolam,4. Hydrochlorothiazide.,5. Dyazide.,6. Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck. She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area. As such, I feel that we could safely re-treat the lower neck. Her weight has increased to 189.5 from 185.2. She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK: On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area. No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY: Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected. No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN: Normal bowel sounds, no hepatomegaly. No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress. Thank you for having allowed me to participate in her care.

SOAP / Chart / Progress Notes

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

Orthopedic

HISTORY OF PRESENT ILLNESS:, The patient is an 85-year-old gentleman who follows as an outpatient with Dr. A. He is known to us from his last admission. At that time, he was admitted with a difficulty voiding and constipation. His urine cultures ended up being negative. He was seen by Dr. B and discharged home on Levaquin for five days.,He presents to the ER today with hematuria that began while he was sleeping last night. He denies any pain, nausea, vomiting or diarrhea. In the ER, a Foley catheter was placed and was irrigated with saline. White count was 7.6, H and H are 10.8 and 38.7, and BUN and creatinine are of 27 and 1.9. Urine culture is pending. Chest x-ray is pending. His UA did show lots of red cells. The patient currently is comfortable. CBI is running. His urine is clear.,PAST MEDICAL HISTORY:,1. Hypertension.,2. High cholesterol.,3. Bladder cancer.,4. Bilateral total knee replacements.,5. Cataracts.,6. Enlarged prostate.,ALLERGIES:, SULFA.,MEDICATIONS AT HOME:,1. Atenolol.,2. Cardura.,3. Zegerid.,4. Flomax.,5. Levaquin.,6. Proscar.,7. Vicodin.,8. Morphine.,9. Phenergan.,10. Ativan.,11. Zocor.,12. Prinivil.,13. Hydrochlorothiazide.,14. Folic acid.,15. Digoxin.,16. Vitamin B12.,17. Multivitamin.,SOCIAL HISTORY: , The patient lives at home with his daughter. He does not smoke, occasionally drinks alcohol. He is independent with his activities of daily living.,REVIEW OF SYSTEMS:, Not additionally rewarding.,PHYSICAL EXAMINATION:,GENERAL: An awake and alert 85-year-old gentleman who is afebrile.,VITAL SIGNS: BP of 162/60 and pulse oximetry of 98% on room air.,HEENT: Pink conjunctivae. Anicteric sclerae. Oral mucosa is moist.,NECK: Supple.,CHEST: Clear to auscultation.,HEART: Regular S1 and S2.,ABDOMEN: Soft and nontender to palpation.,EXTREMITIES: Without edema.,He has a Foley catheter in place. His urine is clear.,LABORATORY DATA:, Reviewed.,IMPRESSION:,1. Hematuria.

Consult - History and Phy.

HISTORY: , The patient is a 4-day-old being transferred here because of hyperbilirubinemia and some hypoxia. Mother states that she took the child to the clinic this morning since the child looked yellow and was noted to have a bilirubin of 23 mg%. The patient was then sent to Hospital where she had some labs drawn and was noted to be hypoxic, but her oxygen came up with minimal supplemental oxygen. She was also noted to have periodic breathing. The patient is breast and bottle-fed and has been feeding well. There has been no diarrhea or vomiting. Voiding well. Bowels have been regular.,According to the report from referring facility, because the patient had periodic breathing and was hypoxic, it was thought the patient was septic and she was given a dose of IM ampicillin.,The patient was born at 37 weeks' gestation to gravida 3, para 3 female by repeat C-section. Birth weight was 8 pounds 6 ounces and the mother's antenatal other than was normal except for placenta previa. The patient's mother apparently went into labor and then underwent a cesarean section.,FAMILY HISTORY: , Positive for asthma and diabetes and there is no exposure to second-hand smoke.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: The patient has a temperature of 36.8 rectally, pulse of 148 per minute, respirations 50 per minute, oxygen saturation is 96 on room air, but did go down to 90 and the patient was given 1 liter by nasal cannula.,GENERAL: The patient is icteric, well hydrated. Does have periodic breathing. Color is pink and also icterus is noted, scleral and skin.,HEENT: Normal.,NECK: Supple.,CHEST: Clear.,HEART: Regular with a soft 3/6 murmur. Femorals are well palpable. Cap refill is immediate,ABDOMEN: Soft, small, umbilical hernia is noted, which is reducible.,EXTERNAL GENITALIA: Those of a female child.,SKIN: Color icteric. Nonspecific rash on the body, which is sparse. The patient does have a cephalhematoma hematoma about 6 cm over the left occipitoparietal area.,EXTREMITIES: The patient moves all extremities well. Has a normal tone and a good suck.,EMERGENCY DEPARTMENT COURSE: , It was indicated to the parents that I would be repeating labs and also catheterize urine specimen. Parents were made aware of the fact that child did have a murmur. I spoke to Dr. X, who suggested doing an EKG, which was normal and since the patient will be admitted for hyperbilirubinemia, an echo could be done in the morning. The case was discussed with Dr. Y and he will be admitting this child for hyperbilirubinemia.,CBC done showed a white count of 15,700, hemoglobin 18 gm%, hematocrit 50.6%, platelets 245,000, 10 bands, 44 segs, 34 lymphs, and 8 monos. Chemistries done showed sodium of 142 mEq/L, potassium 4.5 mEq/L, chloride 104 mEq/L, CO2 28 mmol/L, glucose 75 mg%, BUN 8 mg%, creatinine 0.7 mg%, and calcium 8.0 mg%. Total bilirubin was 25.4 mg, all of which was unconjugated. CRP was 0.3 mg%. Blood culture was drawn. Catheterized urine specimen was normal. Parents were kept abreast of what was going on all the time and the need for admission. Phototherapy was instituted in the ER almost after the baby got to the emergency room.,IMPRESSION:, Hyperbilirubinemia and heart murmur.,DIFFERENTIAL DIAGNOSES: , Considered breast milk, jaundice, ABO incompatibility, galactosemia, and ventricular septal defect.

Emergency Room Reports

REASON FOR VISIT: , Followup circumcision.,HISTORY OF PRESENT ILLNESS: , The patient had his circumcision performed on 09/16/2007 here at Children's Hospital. The patient had a pretty significant phimosis and his operative course was smooth. He did have a little bit of bleeding when he woke in recovery room, which required placement of some additional sutures, but after that, his recovery has been complete. His mom did note that she had to him a couple of days of oral analgesics, but he seems to be back to normal and pain free now. He is having no difficulty urinating, and his bowel function remains normal.,PHYSICAL EXAMINATION: ,Today, The patient looks healthy and happy. We examined his circumcision site. His Monocryl sutures are still in place. The healing is excellent, and there is only a mild amount of residual postoperative swelling. There was one area where he had some recurrent adhesions at the coronal sulcus, and I gently lysed this today and applied antibiotic ointment showing this to mom had to especially lubricate this area until the healing is completed.,IMPRESSION: , Satisfactory course after circumcision for severe phimosis with no perioperative complications.,PLAN: ,The patient came in followup for his routine care with Dr. X, but should not need any further routine surgical followup unless he develops any type of difficulty with this surgical wound. If that does occur, we will be happy to see him back at any time.,

Urology

EXAM: , Bilateral renal ultrasound.,CLINICAL INDICATION: , UTI.,TECHNIQUE: , Transverse and longitudinal sonograms of the kidneys were obtained.,FINDINGS: ,The right kidney is of normal size and echotexture and measures 5.7 x 2.2 x 3.8 cm. The left kidney is of normal size and echotexture and measures 6.2 x 2.8 x 3.0 cm. There is no evidence for ,HYDRONEPHROSIS, or ,PERINEPHRIC ,fluid collections. The bladder is of normal size and contour. The bladder contains approximately 13 mL of urine after recent voiding. This is a small postvoid residual.,IMPRESSION: , Normal renal ultrasound. Small postvoid residual.

Nephrology

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

Obstetrics / Gynecology

PREOPERATIVE DIAGNOSES:,1. Acute pain.,2. Fever postoperatively.,POSTOPERATIVE DIAGNOSIS:,1. Acute pain.,2. Fever postoperatively.,3. Hemostatic uterine perforation.,4. No bowel or vascular trauma.,PROCEDURE PERFORMED:,1. Diagnostic laparoscopy.,2. Rigid sigmoidoscopy by Dr. X.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Scant.,SPECIMEN:, None.,INDICATIONS: ,This is a 17-year-old African-American female, gravida-1, para-1, and had a hysteroscopy and dilation curettage on 09/05/03. The patient presented later that evening after having increasing abdominal pain, fever and chills at home with a temperature up to 101.2. The patient denied any nausea, vomiting or diarrhea. She does complain of some frequent urination. Her vaginal bleeding is minimal.,FINDINGS: , On bimanual exam, the uterus is approximately 6-week size, anteverted, and freely mobile with no adnexal masses appreciated. On laparoscopic exam, there is a small hemostatic perforation noted on the left posterior aspect of the uterus. There is approximately 40 cc of serosanguineous fluid in the posterior cul-de-sac. The bilateral tubes and ovaries appeared normal. There is no evidence of endometriosis in the posterior cul-de-sac or along the bladder flap. There is no evidence of injury to the bowel or pelvic sidewall. The liver margin, gallbladder and remainder of the bowel including the appendix appeared normal.,PROCEDURE: , After consent was obtained, the patient was taken to the Operating Room where general anesthetic was administered. The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. A sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum. The uterine manipulator was then placed into the patient's cervix and the vulsellum tenaculum and sterile speculum were removed. Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made. Veress needle was placed through this incision and the gas turned on. When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate. A 11 mm trocar was then placed through this incision. The camera was placed with the above findings noted. A 5 mm step trocar was placed 2 cm superior to the pubic bone and along the midline. A blunt probe was placed through this trocar to help for visualization of the pelvic and abdominal organs. The serosanguineous fluid of the cul-de-sac was aspirated and the pelvis was copiously irrigated with sterile saline. At this point, Dr. X was consulted. He performed a rigid sigmoidoscopy, please see his dictation for further details. There does not appear to be any evidence of colonic injury. The saline in the pelvis was then suctioned out using Nezhat-Dorsey. All instruments were removed. The 5 mm trocar was removed under direct visualization with excellent hemostasis noted. The camera was removed and the abdomen was allowed to desufflate. The 11 mm trocar introducer was replaced and the trocar removed. The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion. Approximately 10 cc of 0.25% Marcaine was injected into the incision sites for postoperative pain relief. Steri-Strips were then placed across the incision. The uterine manipulator was then removed from the patient's cervix with excellent hemostasis noted. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct at the end of the procedure. The patient was taken to the recovery room in satisfactory condition.,She will be followed immediately postoperatively within the hospital and started on IV antibiotics.

Surgery

PREOPERATIVE DIAGNOSIS: , Biliary colic.

Surgery

CHIEF COMPLAINT: , Worsening seizures.,HISTORY OF PRESENT ILLNESS: ,A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity. The patient stated she was in her normal state of well being when she was experiencing having frequent seizures. She lives in assisted living. She has been falling more frequently. The patient was driving a scooter and apparently was hitting into the wall with unresponsiveness in association with this. There was no head trauma, but apparently she was doing that many times and there was no responsiveness. The patient has no memory of the event. She is now back to her baseline. She states her seizures are worse in the setting of stress, but it is not clear to her why this has occurred. She is on Carbatrol 300 mg b.i.d. and she has been very compliant and without any problems. The patient is admitted for EMU monitoring for the characterization of these episodes and for the possibility of complex partial epilepsy syndrome or better characterization of this current syndrome.,PAST MEDICAL HISTORY: ,Include dyslipidemia and hypertension.,FAMILY HISTORY: ,Positive for stroke and sleep apnea.,SOCIAL HISTORY: , No smoking or drinking. No drugs.,MEDICATIONS AT HOME: , Include, Avapro, lisinopril, and dyslipidemia medication, she does not remember.,REVIEW OF SYSTEMS:, The patient does complain of gasping for air, witnessed apneas, and dry mouth in the morning. The patient also has excessive daytime sleepiness with EDS of 16.,PHYSICAL EXAMINATION:,VITAL SIGNS: Last blood pressure 130/85, respirations 20, and pulse 70.,GENERAL: Normal.,NEUROLOGICAL: As follows. Right-handed female, normal orientation, normal recollection to 3 objects. The patient has underlying MR. Speech, no aphasia, no dysarthria. Cranial nerves, funduscopic intact without papilledema. Pupils are equal, round, and reactive to light. Extraocular movements intact. No nystagmus. Her mood is intact. Symmetric face sensation. Symmetric smile and forehead. Intact hearing. Symmetric palate elevation. Symmetric shoulder shrug and tongue midline. Motor 5/5 proximal and distal. The patient does have limp on the right lower extremity. Her Babinski is hyperactive on the left lower extremity, upgoing toes on the left. Sensory, the patient does have sharp, soft touch, vibration intact and symmetric. The patient has trouble with ambulation. She does have ataxia and uses a walker to ambulate. There is no bradykinesia. Romberg is positive to the left. Cerebellar, finger-nose-finger is intact. Rapid alternating movements are intact. Upper airway examination, the patient has a Friedman tongue position with 4 oropharyngeal crowding. Neck more than 16 to 17 inches, BMI elevated above 33. Head and neck circumference very high.,IMPRESSION:,1. Cerebral palsy, worsening seizures.,2. Hypertension.,3. Dyslipidemia.,4. Obstructive sleep apnea.,5. Obesity.,RECOMMENDATIONS:,1. Admission to the EMU, drop her Carbatrol 200 b.i.d., monitor for any epileptiform activity. Initial time of admission is 3 nights and 3 days.,2. Outpatient polysomnogram to evaluate for obstructive sleep apnea followed by depression if clinically indicated. Continue her other medications.,3. Consult Dr. X for hypertension, internal medicine management.,4. I will follow this patient per EMU protocol.

Neurology

EXAM: , Five views of the right knee.,HISTORY: , Pain. The patient is status-post surgery, he could not straighten his leg, pain in the back of the knee.,TECHNIQUE:, Five views of the right knee were evaluated. There are no priors for comparison.,FINDINGS: , Five views of the right knee were evaluated and they reveal there is no evidence of any displaced fractures, dislocations, or subluxations. There are multiple areas of growth arrest lines seen in the distal aspect of the femur and proximal aspect of the tibia. There is also appearance of a high-riding patella suggestive of patella alta.,IMPRESSION:,1. No evidence of any displaced fractures, dislocations, or subluxations.,2. Growth arrest lines seen in the distal femur and proximal tibia.,3. Questionable appearance of a slightly high-riding patella, possibly suggesting patella alta.

Radiology

PREOPERATIVE DIAGNOSES:,1. Right carpal tunnel syndrome.,2. Right index finger and middle fingers tenosynovitis.,POSTOPERATIVE DIAGNOSES:,1. Right carpal tunnel syndrome.,2. Right index finger and middle fingers tenosynovitis.,PROCEDURES PERFORMED:,1. Right carpal tunnel release.,2. Right index and middle fingers release A1 pulley.,TOURNIQUET TIME: ,70 minutes.,BLOOD LOSS: , Minimal.,GROSS INTRAOPERATIVE FINDINGS:,1. A compressed median nerve at the carpal tunnel, which was flattened.,2. A stenosing tenosynovitis of the A1 pulley of the right index as well as middle fingers. After the A1 pulley was released, there was evidence of some synovitis as well as some fraying of the flexor digitorum profundus as well as flexor digitorum superficialis tendons.,HISTORY: ,This is a 78-year-old male who is complaining of right hand pain and numbness with decreased range of the middle index finger and right middle finger complaining of catching and locking. The patient was diagnosed with carpal tunnel syndrome on bilateral hands the right being worse than the left. He had positive EMG findings as well as clinical findings. The patient did undergo an injection, which only provided him with temporary relief and is for this reason, he has consented to undergo the above-named procedure.,All risks as well as complications were discussed with the patient and consent was obtained.,PROCEDURE: ,The patient was wheeled back to the operating room #1 at ABCD General Hospital on 08/29/03. He was placed supine on the operating room table. Next, a non-sterile tourniquet was placed on the right forearm, but not inflated. At this time, 8 cc of 0.25% Marcaine with epinephrine was instilled into the carpal tunnel region of the volar aspect of the wrist for anesthesia. In addition, an additional 2 cc were used on the superficial skin of the volar palm over the A1 pulley of the right index and right middle fingers. At this time, the extremity was then prepped and draped in usual sterile fashion for this procedure. First, we went for release of the carpal tunnel. Approximately 2.5 cm incision was made over the volar aspect of the wrist over the carpal tunnel region. First, dissection through the skin in the superficial fascia was performed with a self-retractor placed in addition to Ragnells retracting proximally and distally. The palmaris brevis muscle was then identified and sharply transected. At this time, we identified the transverse carpal tunnel ligament and a #15 blade was used to sharply and carefully release that fascia. Once the fascia of the transverse carpal ligament was transected, the identification of the median nerve was visualized. The resection of the ligament was taken both proximally and distally to assure complete release and it was checked thoroughly. At this time, a neurolysis was performed and no evidence of space-occupying lesions were identified within the carpal tunnel. At this time, copious irrigation was used to irrigate the wound. The wound was suctioned dry. At this time, we proceeded to the release of the A1 pulleys. Approximately, a 1.5 cm incision was made over the A1 pulley in the volar aspect of the palm of the right index and right middle fingers. First, we went for the index finger. Once the skin incision was made, Metzenbaum scissor was used to longitudinally dissect the subcutaneous tissue and with Ragnell retractors we identified the A1 pulley. A #15 blade was used to make a longitudinal slit along with A1 pulley and the Littler scissors were used to release the A1 pulley proximally as well as distally. Once this was performed, a tendon hook was then used to wrap the tendon and release the tendons both proximally and distally and they were removed from the wound in order to check their integrity. There was some evidence of synovitis in addition to some fraying of the both the profundus as well as superficialis tendons. Once a thorough release was performed, copious irrigation was used to irrigate that wound. In the similar fashion, a 1.5 cm incision was made over the volar aspect of the A1 pulley of the right middle finger. A Littler scissor was used to bluntly dissect in the longitudinal fashion. With the Ragnell retractors, we identified the A1 pulley of the right middle finger.,Using a #15 blade, the A1 pulley was scored with the #15 blade and the Litter scissor was used to complete the release of the A1 pulley distally and proximally. We again placed the tendon hook around both the superficialis and the profundus tendons and they were extruded from the wound to check their integrity. Again, there was evidence of some synovitis as well as fraying of both tendons. The girth of both tendons and both wounds were within normal limits. At this time, copious irrigation was used to irrigate the wound. The patient was then asked to intraoperatively flex and extend his fingers and he was able to fully flex his fingers to make a close fit which he was not able to do preoperatively. In addition, he was able to abduct his thumb indicating that the recurrent branch of the median nerve was intact. At this time, #5-0 nylon was used to approximate in a vertical mattress type fashion both the carpal tunnel incision as well as the both A1 pulley incisions of the right middle finger and right index finger. The wound closure took place after the tourniquet was released and hemostasis was obtained with Bovie cautery. At this time, a short-arm splint was placed on the volar aspect of the wrist after it was wrapped in a sterile dressing consisting of Adaptic and Kerlix roll. The patient was then carefully taken off of the operating room table to Recovery in stable condition.

Surgery

ADMISSION DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Severe anemia.,3. Symptomatic fibroid uterus.,DISCHARGE DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Severe anemia.,3. Symptomatic fibroid uterus.,4. Extensive adenomyosis by pathological report.,OPERATION PERFORMED: , On 6/10/2009 total abdominal hysterectomy (TAH).,COMPLICATIONS:, None.,BLOOD TRANSFUSIONS: , None.,INFECTIONS: , None.,SIGNIFICANT LAB AND X-RAY: , On admission hemoglobin and hematocrit was 10.5 and 32.8 respectively. On discharge, hemoglobin and hematocrit 7.9 and 25.2.,HOSPITAL COURSE AND TREATMENT: ,The patient was admitted to the surgical suite and taken to the operating room on 6/10/2009 where a total abdominal hysterectomy (TAH) with low intraoperative complication was performed. The patient tolerated all procedures well. On the 1st postoperative day, the patient was afebrile and all vital signs were stable. On the 3rd postoperative day, the patient was ambulating with difficulty and tolerating clear liquid diet. On the 4th postoperative day, the patient was complaining of pain in her back and abdomen as well as incisional wound tenderness. On the 5th postoperative day, the patient was afebrile. Vital signs were stable. The patient was tolerating a diet and ambulating without difficulty. The patient was desirous of going home. The patient denied any abdominal pain or flank pain. The patient had minimal incisional wound tenderness. The patient was desirous of going home and was discharged home.,DISCHARGE CONDITION: , Stable.,DISCHARGE INSTRUCTIONS:, Regular diet, bedrest x1 week with slow return to normal activity over the ensuing 4 to 6 weeks, pelvic rest for 6 weeks. Motrin 600 mg tablets 1 tablet p.o. q.8h. p.r.n. pain, Colace 100 mg tablets 1 tablet p.o. daily p.r.n. constipation and ferrous sulfate 60 mg tablets 1 tablet p.o. daily, and multiple vitamin 1 tablet p.o. daily. The patient is to return on Wednesday 6/17/2009 for removal of staples. The patient was given a full explanation of her clinical condition. The patient was given full and complete postoperative and discharge instructions. All her questions were answered.

Discharge Summary

HISTORY OF PRESENT ILLNESS:, The patient is a two-and-a-half-month-old male who has been sick for the past three to four days. His mother has described congested sounds with cough and decreased appetite. He has had no fever. He has had no rhinorrhea. Nobody else at home is currently ill. He has no cigarette smoke exposure. She brought him to the emergency room this morning after a bad coughing spell. He did not have any apnea during this episode.,PAST MEDICAL HISTORY:, Unremarkable. He has had his two-month immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 99.1, oxygen saturations 98%, respirations by the nurse at 64, however, at my examination was much slower and regular in the 40s.,GENERAL: Sleeping, easily aroused, smiling, and in no distress.,HEENT: Soft anterior fontanelle. TMs are normal. Moist mucous membranes.,LUNGS: Equal and clear.,CHEST: Without retraction.,HEART: Regular in rate and rhythm without murmur.,ABDOMEN: Benign.,DIAGNOSTIC STUDIES:, Chest x-ray ordered by ER physician is unremarkable, but to me also.,ASSESSMENT:, Upper respiratory infection.,TREATMENT: , Use the bulb syringe and saline nose drops if there is any mucus in the anterior nares. Smaller but more frequent feeds. Discuss proper sleeping position. Recheck if there is any fever or if he is no better in the next three days.

Emergency Room Reports

VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE:, Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT: , Eyes: EOMI. PERRLA. Sclerae nonicteric. No lesions of lids, lashes, brows, or conjunctivae noted. Funduscopic examination unremarkable. Ears: Normal set, shape, TMs, canals and hearing. Nose and Sinuses: Negative. Mouth, Tongue, Teeth, and Throat: Negative except for dental work.,NECK: , Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:, Lungs are bilaterally clear to auscultation and percussion.,HEART: , S1 and S2. Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop. PMI nondisplaced. Chest wall unremarkable to inspection and palpation. No axillary or supraclavicular adenopathy detected.,BREASTS:, In the seated and supine position unremarkable.,ABDOMEN: , No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding. No widening of the aortic impulse and no intraabdominal bruit auscultated.,EXTERNAL GENITALIA: , Normal for age.,RECTAL: , Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis. Nails of the hands and feet, and creases of the palms and soles are unremarkable. Good active and passive range of motion of all major joints.,BACK:, Normal to inspection and percussion. Negative for spinous process tenderness or CVA tenderness. Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC:, Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function. Affect is normal. Speech is clear and fluent. Thought process is lucid and rational. Gait and station are unremarkable.,SKIN: , Unremarkable for any premalignant or malignant condition with normal changes for age.

Consult - History and Phy.

P.O. Box 12345,City, State ,RE: EXAMINEE : Abc,CLAIM NUMBER : 12345-67890,DATE OF INJURY : April 20, 2003,DATE OF EXAMINATION : August 26, 2003,EXAMINING PHYSICIANS : Y Z, DC,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,CHIEF COMPLAINTS: , Improved focal lower back pain.,HISTORY: , Abc is a 26-year-old man who immigrated to this country approximately six years ago. He speaks "un poquito" English and an interpreter is provided. He has worked for the last four years at Floragon Forest Products, where he normally functions as a "stacker." He indicates that another worker was on vacation, and because of this he was put on another job in which he separated logs using a picaroon. He was doing this on April 20, 2003, and was pulling on the picaroon when it gave way, and he fell backwards landing on a metal step, which was approximately 1 foot off of the ground. He demonstrates that he came down square on the step and did not fall backwards or hyperextend over it. He did not hit his upper back or neck or shoulders, and only sat down on the step as described. He had "a little" pain in his back at that time, but was able to get up and continue working. He completed his shift that day and returned to work the following day. He had the next two days off. He says that his symptoms persisted and increased, and on April 25, 2003, he went to the First Choice Physicians Chiropractic and Rehab Clinic, where he came under the care of Dr. Abcd, DC. The file contains an entrance form completed by Mr. Abc which indicates at the bottom under "previous occurrence of the same pain" a notation of "Yes, but it was not really the same, it was just a little and tolerable." There is an additional note on the side which states "no pain prior to this injury or on that day, occasional (but low back)." Saw this notation, he says today that he did not state this and that the form was done by "Edna" at Dr. Abcd's office.,Mr. Abc was initially treated three times a week and states that this has now been reduced to twice per week. He does not know how long the chiropractic treatment is to continue. Initially, he has been seen by Dr. Xyz on three occasions, the last being on August 15, 2003. Dr. Xyz has basically referred him back to Dr. Abcd for continued chiropractic management.,Mr. Abc has now returned to his normal job as a stacker and is able to do that with no significant increased pain. He does mention, however, that bending over, picking up anything particularly heavy is bothersome; however, he does not normally have to do that. He denies any new accident or injury that would be contributory either as a result of his work or outside activities or any motor vehicle accident. He does not participate physically in any sports or hobbies that would be a factor.,PRESENT COMPLAINTS: , Mr. Abc indicates at this time that he is overall better in that initially he had difficulty "moving." He grades his current overall level of pain as a 2 to 4 on a scale from 0 to 10, stating that the worst he had was at 6-7. He now has "good and bad days" which depends on his activity level noting that he is better over the weekend. He localizes his pain to the midline lumbosacral region. He states that initially he did experience some diffuse radiation into both lower extremities, but that this has now resolved. He occasionally will notice some tightness behind both knees, but again no radicular type of distribution. He denies any focal muscular weakness or sphincter disturbance. His quality of the pain at this time is a "tightness" which bothers him, again, primarily with bending at the waist and lifting. He is able to do his normal activities of life, including his work without any significant problem, noting again only increased pain with bending and lifting.,PAST HISTORY: , Mr. Abc denies any prior similar complaints or treatments. He denies any previous specific lower back injury. He has enjoyed essentially good lifetime health and denies any concurrent medical conditions or problems. He has seasonal allergies only with no known drug hypersensitivities. He has not been hospitalized overnight and has had no surgeries in his life. He currently takes OTC Advil and Tylenol for lower back pain, but no prescriptive medication. He does not smoke, drink, or use street drugs of any type. Review of systems and family history are generally noncontributory.,SOCIO-ECONOMIC HISTORY: , Mr. Abc, as indicated, was born and reared in Mexico and immigrated into this country six years ago.,Education: He has our equivalent of a high school education in Mexico with no additional formal education in United States.,Military History: He has no military experience in his life.,Work History: He currently is doing his normal work activities as a stacker without arbitrary restrictions or limitations. He is not receiving any Workers Compensation or other benefits at this time.,PHYSICAL EXAMINATION: , Abc presents as a cooperative and straightforward 26-year-old Hispanic male. He has a very thin body habitus with a reported height of 5 feet 7 inches and weight of 125 pounds. He is right hand dominant. He is noted to sit comfortably throughout the history taking process conversant with the interpreter and myself without observable guarding or postural conversation or motion. He did stand readily to full upright with equal weightbearing and exhibits normal spinal posture with double hips and shoulders. Lumbar lordosis is normal. He ambulates without a limp or lift, and is able to walk on heels and toes and perform a full squat and rise and hop without difficulty with some expression of increased lower back pain. Waddell's testing is negative on compression and traction with some slight increased lower back pain on passive rotation.,Kemp's maneuver of posterolateral bending has some increased localized lumbosacral pain, but no radiation distally into the buttocks or lower extremities.,Active lumbar ranges of motion with double inclinometer are:,Flexion 70 degrees.,Extension 20 degrees.,Side bending symmetric at 28 degrees.,He complains of lower back pain at the extremes of flexion only. Motion palpation reveals full mobility without any detectable intrasegmental fixation with normal symmetry and alignment.,Tendon reflexes are 2+ and symmetric at the knees and ankles without sensory loss to pinprick. Babinski's are neutral, and there is no clonus.,Manual muscle testing reveals 5/5 strength at the hips, knees, and ankles without give-way or complaint.,Supine passive straight leg raising is limited by hamstring tightness to 66 degrees bilaterally, but causes no expression of lower back pain or radiation. Cross leg with rotation hip joint motion is full on either side without reported hip or back pain. Hip flexion is symmetric at 130 degrees, again without complaint. Leg lengths appeared visually symmetric. Mid calf girth is 11-1/2 inches bilaterally. Five inches above the knees measured 13 inches right and left. The seated SLR is done to 90 degrees, and he brings his fingertips 2 inches from his toes, showing good flexibility at the waist despite the hamstring tightness noted in the supine straight leg raising test.,In the prone position, he has good gluteal strength on either side with Yeoman's test causing some increased lumbosacral pain but no focal sacroiliac involvement. No sacroiliac fixation is identified. Hibbs test is negative on either side.,On palpation, he reports midline tenderness at L5-S1 without additional areas of tenderness noted even to very firm palpatory pressure in the entirety of the lumbar spine over the pelvis. He indicates no focal or sacroiliac, sciatic notch, or trochanteric tenderness on either side. No definitive muscular spasm is noted in the lumbar paraspinal musculature.,Mr. Abc tolerated the examination process without apparent or expressed ill effect. ,IMAGING STUDIES:, AP and lateral lumbar/pelvic views dated May 15, 2003 are reviewed. The films are negative for recent fracture or pathology. There appears to be a transitional lumbosacral area with a spatulated transverse process of L1 and slight narrowing of the lumbosacral disc space. No additional abnormalities are identified. The hip and sacroiliac articulations appear well preserved. Disc spacing in the rest of the lumbar spine appears normal, and no significant degenerative changes are identified. Soft tissue appeared normal without paraspinal mass or abnormality.,DIAGNOSIS: , Lumbosacral contusion/strain relative to the April 20, 2003 industrial accident - objectively resolved.,SUMMARY: , Discussion and recommendations in response to questions posed in your August 15, 2003 letter:,1. What is your diagnosis of the worker's condition as a result of the injury? Please provide objective medical findings that support your diagnosis. Please indicate if the objective findings are reproducible, measurable, or observable, and how.,The diagnosis of the workers condition secondary to the described April 20, 2003 fall is by history a lumbosacral contusion/strain. This impression is primarily made based on his history noting that at this time, he has no abnormal objective findings.,2. In your opinion, is the work injury a contributing cause of the diagnosis? If so, is the work injury the material contributing cause of the diagnosis? Please provide an explanation for your opinion.,It would appear that the work injury was the major contributing cause of the diagnosis.,3. Are there any off work factors that may have caused or contributed to the worker's current complaints or condition? (Such as idiopathic causes, predisposition, congenital abnormalities, off work injuries, etc.).

Letters

PREOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.,POSTOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion; finding of volar radial wrist mass of bulging inflammatory tenosynovitis from the volar radial wrist joint rather than a true ganglion cyst; synovitis was debrided and removed.,PROCEDURE: , Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist.,ANESTHESIA:, Axillary block plus IV sedation.,ESTIMATED BLOOD LOSS:, Zero.,SPECIMENS,1. Inflammatory synovitis from the volar radial wrist area.,2. Inflammatory synovitis from the dorsal wrist area.,DRAINS:, None.,PROCEDURE DETAIL: , Patient brought to the operating room. After induction of IV sedation a right upper extremity axillary block anesthetic was performed by anesthesia staff. Routine prep and drape was employed. Patient received 1 gm of IV Ancef preoperatively. Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet. Tourniquet inflated to 250 mmHg pressure. Hand positioned palm up in a lead hand-holder. A longitudinal zigzag incision over the volar radial wrist mass was made. Skin was sharply incised. Careful blunt dissection was used in the subcutaneous tissue. Antebrachial fascia was bluntly dissected and incised to reveal the radial artery. Radial artery was mobilized preserving its dorsal and palmar branches. Small transverse concomitant vein branches were divided to facilitate mobilization of the radial artery. Wrist mass was exposed by blunt dissection. This appeared to be an inflammatory arthritic mass from the volar radial wrist capsule. This was debrided down to the wrist capsule with visualization of the joint through a small capsular window. After complete volar synovectomy the capsular window was closed with 4-0 Mersilene figure-of-eight suture. Subcutaneous tissue was closed with 4-0 PDS and the skin was closed with a running subcuticular 4-0 Prolene. Forearm was pronated and C-arm image intensifier was used to confirm localization of the radial styloid for marking of the skin incision. An oblique incision overlying the radial styloid centered on the second extensor compartment was made. Skin was sharply incised. Blunt dissection was used in the subcutaneous tissue. Care was taken to identify and protect the superficial radial nerve. Blunt dissection was carried out in the extensor retinaculum. This was incised longitudinally over the second extensor compartment. EPL tendon was identified, mobilized and released to facilitate retraction and prevent injury. The interval between the ECRL and the ECRB was developed down to bone. Dorsal capsulotomy was made and local synovitis was identified. This was debrided and sent as second pathologic specimen. Articular surface of the scaphoid was identified and seen to be completely devoid of articular cartilage with hard, eburnated subchondral bone consistent with a SLAC pattern arthritis. Radial styloid had extensive spurring and was exposed subperiosteally and osteotomized in a dorsal oblique fashion preserving the volar cortex as the attachment point of the deep volar carpal ligament layer. Dorsally the styloidectomy was beveled smooth and contoured with a rongeur. Final x-rays documenting the styloidectomy were obtained. Local synovitis beneath the joint capsule was debrided. Remnants of the scapholunate interosseous which was completely deteriorated were debrided. The joint capsule was closed anatomically with 4-0 PDS and extensor retinaculum was closed with 4-0 PDS. Subcutaneous tissues closed with 4-0 Vicryl. Skin was closed with running subcuticular 4-0 Prolene. Steri-Strips were applied to wound edge closure; 10 cc of 0.5% plain Marcaine was infiltrated into the areas of the surgical incisions and radial styloidectomy for postoperative analgesia. A bulky gently compressive wrist and forearm bandage incorporating an EBI cooling pad were 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 PRESCRIPTIONS:,1. Keflex 500 mg tablets, #20, one PO q.6h. x 5 days.,2. Vicodin, 40 tablets, one to two PO q.4h. p.r.n.,3. Percocet, #20 tablets, one to two PO q.3-4h. p.r.n. severe pain.

Surgery

CHIEF COMPLAINT:,1. Chronic lymphocytic leukemia (CLL).,2. Autoimmune hemolytic anemia.,3. Oral ulcer.,HISTORY OF PRESENT ILLNESS: , The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008. He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis. He has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day. He comes in to clinic today for follow-up and complete blood count. At his last office visit we discontinued this prophylactic antivirals and antibacterial.,CURRENT MEDICATIONS:, Prilosec 20 mg b.i.d., levothyroxine 50 mcg q.d., Lopressor 75 mg q.d., vitamin C 500 mg q.d., multivitamin q.d., simvastatin 20 mg q.d., and prednisone 5 mg q.o.d.,ALLERGIES: ,Vicodin.,REVIEW OF SYSTEMS: ,The patient reports ulcer on his tongue and his lip. He has been off of Valtrex for five days. He is having some difficulty with his night vision with his left eye. He has a known cataract. He denies any fevers, chills, or night sweats. He continues to have headaches. The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:

SOAP / Chart / Progress Notes

PREOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Status post spontaneous vaginal delivery.,POSTOPERATIVE DIAGNOSES:,1. Abnormal uterine bleeding.,2. Status post spontaneous vaginal delivery.,PROCEDURE PERFORMED:,1. Dilation and curettage (D&C).,2. Hysteroscopy.,ANESTHESIA: , IV sedation with paracervical block.,ESTIMATED BLOOD LOSS:, Less than 10 cc.,INDICATIONS: ,This is a 17-year-old African-American female that presents 7 months status post spontaneous vaginal delivery without complications at that time. The patient has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.,PROCEDURE:, The patient was consented and seen in the preoperative suite. She was taken to the operative suite, placed in a dorsal lithotomy position, and placed under IV sedation. She was prepped and draped in the normal sterile fashion. Her bladder was drained with the red Robinson catheter which produced approximately 100 cc of clear yellow urine. A bimanual exam was done, was performed by Dr. X and Dr. Z. The uterus was found to be anteverted, mobile, fully involuted to a pre-pregnancy stage. The cervix and vagina were grossly normal with no obvious masses or deformities. A weighted speculum was placed in the posterior aspect of the vagina and the anterior lip of the cervix was grasped with the vulsellum tenaculum.,The uterus was sounded to 8 cm. The cervix was sterilely dilated with Hank dilator and then Hagar dilator. At the time of blunt dilation, it was noticed that the dilator passed posteriorly with greater ease than it had previously. The dilation was discontinued at that time because it was complete and the hysteroscope was placed into the uterus. Under direct visualization, the ostia were within normal limits. The endometrial lining was hyperplastic, however, there was no evidence of retained products or endometrial polyps. The hyperplastic tissue did not appear to have calcification or other abnormalities. There was a small area of the lower uterine segment posteriorly that was suspicious for endometrial perforation, however this area was hemostatic, no evidence of bowel involvement and was approximately 1 x 1 cm in nature. The hysteroscope was removed and a sharp curette was placed intrauterine very carefully using a anterior wall for guidance. Endometrial curettings were obtained and the posterior aspect suspicious for perforation was gently probed and seemed to have clamped down since the endometrial curetting. The endometrial sampling was placed on Telfa pad and sent to Pathology for evaluation. A rectal exam was performed at the end of the procedure which showed no hematoma formation in the posterior cul-de-sac. There was a normal consistency of the cervix and the normal step-off. The uterine curette was removed as well as the vulsellum tenaculum and the weighted speculum. The cervix was found to be hemostatic. The patient was taken off the dorsal lithotomy position and recovered from her IV sedation in the recovery room. The patient will be sent home once stable from anesthesia. She will be instructed to followup in the office in two weeks for discussion of the pathologic report of the endometrial curettings. The patient is sent home on Tylenol #3 prescription as she is allergic to Motrin. The patient is instructed to refrain from intercourse douching or using tampons for the next two weeks. The patient is also instructed to contact us if she has any problems with further bleeding, fevers, or difficulty with urination.

Obstetrics / Gynecology

PREOPERATIVE DIAGNOSIS:, Brain tumor left temporal lobe.,POSTOPERATIVE DIAGNOSIS:, Brain tumor left temporal lobe - glioblastoma multiforme.,OPERATIVE PROCEDURE:,1. Left temporal craniotomy.,2. Removal of brain tumor.,OPERATING MICROSCOPE: , Stealth.,PROCEDURE: , The patient was placed in the supine position, shoulder roll, and the head was turned to the right side. The entire left scalp was prepped and draped in the usual fashion after having being placed in 2-point skeletal fixation. Next, we made an inverted-U fashion base over the asterion over temporoparietal area of the skull. A free flap was elevated after the scalp that was reflected using the burr hole and craniotome. The bone flap was placed aside and soaked in the bacitracin solution.,The dura was then opened in an inverted-U fashion. Using the Stealth, we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle. We head through the vein of Labbe, and we made great care to preserve this. We saw where the tumor almost made to the surface. Here we made a small corticectomy using the Stealth for guidance. We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid. This was submitted to pathology. We biopsied this very abnormal tissue and submitted it to pathology. They gave us a frozen section diagnosis of glioblastoma multiforme. With the operating microscope and Greenwood bipolar forceps, we then systematically debulked this tumor. It was very vascular and we really continued to remove this tumor until all visible tumors was removed. We appeared to get two gliotic planes circumferentially. We could see it through the ventricle. After removing all visible tumor grossly, we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4-0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal. The bone flap was then replaced and sutured with the Lorenz titanium plate system. The muscle fascia galea was closed with interrupted 2-0 Vicryl sutures. Skin staples were used for skin closure. The blood loss of the operation was about 200 cc. There were no complications of the surgery per se. The needle count, sponge count, and the cottonoid count were correct.,COMMENT: ,Operating microscope was quite helpful in this; as we could use the light as well as the magnification to help us delineate the brain tumor - gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic-looking tumor of the brain.

Neurology

Surgery

CC:, Memory difficulty.,HX: ,This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the Neurology clinic on his own referral.,MEDS:, None.,PMH: ,1)appendectomy, 2)tonsillectomy, 3)childhood pneumonia, 4)allergy to sulfa drugs.,FHX:, Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his family.,SHX:, Catholic priest. Denied Tobacco/ETOH/illicit drug use.,EXAM:, BP131/74, HR78, RR12, 36.9C, Wt. 77kg, Ht. 178cm.,MS: A&O to person, place and time. 29/30 on MMSE; 2/3 recall at 5 minutes. 2/10 word recall at 10 minutes. Unable to remember the name of the President (Clinton). 23words/60 sec on Category fluency testing (normal). Mild visual constructive deficit.,The rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted.,COURSE:, TSH 5.1, T4 7.9, RPR non-reactive. Neuropsychological evaluation, 3/6/95, revealed: 1)well preserved intellectual functioning and orientation, 2) significant deficits in verbal and visual memory, proper naming, category fluency and working memory, 3)performances which were below expectations on tests of speed of reading, visual scanning, visual construction and clock drawing, 4)limited insight into the scope and magnitude of cognitive dysfunction. The findings indicated multiple areas of cerebral dysfunction. With the exception of the patient's report of minimal occupational dysfunction ( which may reflect poor insight), the clinical picture is consistent with a progressive dementia syndrome such as Alzheimer's disease. MRI brain, 3/6/95, showed mild generalized atrophy, more severe in the occipital-parietal regions.,In 4/96, his performance on repeat neuropsychological evaluation was relatively stable. His verbal learning and delayed recognition were within normal limits, whereas delayed recall was "moderately severely" impaired. Immediate and delayed visual memory were slightly below expectations. Temporal orientation and expressive language skills were below expectation, especially in word retrieval. These findings were suggestive of particular, but not exclusive, involvement of the temporal lobes.,On 9/30/96, he was evaluated for a 5 minute spell of visual loss, OU. The episode occurred on Friday, 9/27/96, in the morning while sitting at his desk doing paperwork. He suddenly felt that his gaze was pulled toward a pile of letters; then a "curtain" came down over both visual fields, like "everything was in the shade." During the episode he felt fully alert and aware of his surroundings. He concurrently heard a "grating sound" in his head. After the episode, he made several phone calls, during which he reportedly sounded confused, and perseverated about opening a bank account. He then drove to visit his sister in Muscatine, Iowa, without accident. He was reportedly "normal" when he reached her house. He was able to perform Mass over the weekend without any difficulty. Neurologic examination, 9/30/96, was notable for: 1)category fluency score of 18items/60 sec. 2)VFFTC and EOM were intact. There was no RAPD, INO, loss of visual acuity. Glucose 178 (elevated), ESR ,Lipid profile, GS, CBC with differential, Carotid duplex scan, EKG, and EEG were all normal. MRI brain, 9/30/96, was unchanged from previous, 3/6/95.,On 1/3/97, he had a 30 second spell of lightheadedness without vertigo, but with balance difficulty, after picking up a box of books. The episode was felt due to orthostatic changes.,1/8/97 neuropsychological evaluation was stable and his MMSE score was 25/30 (with deficits in visual construction, orientation, and 2/3 recall at 1 minute). Category fluency score 23 items/60 sec. Neurologic exam was notable for graphesthesia in the left hand.,In 2/97, he had episodes of anxiety, marked fluctuations in job performance and resigned his pastoral position. His neurologic exam was unchanged. An FDG-PET scan on 2/14/97 revealed decreased uptake in the right posterior temporal-parietal and lateral occipital regions.

Radiology

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

Orthopedic

PROCEDURES:,1. Esophagogastroduodenoscopy.,2. Colonoscopy with polypectomy.,PREOPERATIVE DIAGNOSES:,1. History of esophageal cancer.,2. History of colonic polyps.,POSTOPERATIVE FINDINGS:,1. Intact surgical intervention for a history of esophageal cancer.,2. Melanosis coli.,3. Transverse colon polyps in the setting of surgical changes related to partial and transverse colectomy.,MEDICATIONS:, Fentanyl 250 mcg and 9 mg of Versed.,INDICATIONS:, The patient is a 55-year-old dentist presenting for surveillance upper endoscopy in the setting of a history of esophageal cancer with staging at T2N0M0.,He also has a history of adenomatous polyps and presents for surveillance of this process.,Informed consent was obtained after explanation of the procedures, as well as risk factors of bleeding, perforation, and adverse medication reaction.,ESOPHAGOGASTRODUODENOSCOPY:, The patient was placed in the left lateral decubitus position and medicated with the above medications to achieve and maintain a conscious sedation. Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation. The Olympus single-channel endoscope was passed under direct visualization, through the oral cavity, and advanced to the second portion of the duodenum.,FINDINGS:,1. ESOPHAGUS: Anatomy consistent with esophagectomy with colonic transposition.,2. STOMACH: Revealed colonic transposition with normal mucosa.,3. DUODENUM: Normal.,IMPRESSION: , Intact surgical intervention with esophagectomy colonic transposition.,COLONOSCOPY: , The patient was then turned and a colonic 140-series colonoscope was passed under direct visualization through the anal verge and advanced to the cecum as identified by the appendiceal orifice. Circumferential visualization the colonic mucosa revealed the following:,1. Cecum revealed melanosis coli.,2. Ascending, melanosis coli.,3. Transverse revealed two diminutive sessile polyps, excised by cold forceps technique and submitted to histology as specimen #1 with surgical changes consistent with partial colectomy related to the colonic transposition.,4. Descending, melanosis coli.,5. Sigmoid, melanosis coli.,6. Rectum, melanosis coli.,IMPRESSION: , Diffuse melanosis coli with incidental finding of transverse colon polyps.,RECOMMENDATION: , Follow-up histology. Continue fiber with avoidance of stimulant laxatives.

Gastroenterology