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PREOPERATIVE DIAGNOSIS:, Right mesothelioma.,POSTOPERATIVE DIAGNOSIS: , Right lung mass invading diaphragm and liver.,FINDINGS: , Right lower lobe lung mass invading diaphragm and liver.,PROCEDURES:,1. Right thoracotomy.,2. Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,SPECIMENS: , Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,BLOOD LOSS: , 600 mL.,FLUIDS: , Crystalloid 2.7 L and 1 unit packed red blood cells.,ANESTHESIA: , Double-lumen endotracheal tube.,CONDITION:, Stable, extubated, to PACU.,PROCEDURE IN DETAIL:, Briefly, this is a gentleman who was diagnosed with a B-cell lymphoma and then subsequently on workup noted to have a right-sided mass seeming to arise from the right diaphragm. He was presented at Tumor Board where it was thought upon review that day that he had a right nodular malignant mesothelioma. Thus, he was offered a right thoracotomy and excision of mass with possible reconstruction of the diaphragm. He was explained the risks, benefits, and alternatives to this procedure. He wished to proceed, so he was brought to the operating room.,An epidural catheter was placed. He was put in a supine position where SCDs and Foley catheter were placed. He was put under general endotracheal anesthesia with a double-lumen endotracheal tube. He was given preoperative antibiotics, then he was placed in the left decubitus position, and the area was prepped and draped in the usual fashion.,A low thoracotomy in the 7th interspace was made using the skin knife and then Bovie cautery onto the middle of the rib and then with the Alexander instrument, the chest was entered. Upon entering the chest, the chest wall retractor was inserted and the cavity inspected. It appeared that the mass actually arose more from the right lower lobe and was involving the diaphragm. He also had some marked lymphadenopathy. With these findings, which were thought at that time to be more consistent with a bronchogenic carcinoma, we proceeded with the intent to perform a right lower lobectomy and en bloc diaphragmatic resection. Thus, we mobilized the inferior pulmonary ligament and made our way around the hilum anteriorly and posteriorly. We also worked to open the fissure and tried to identify the arteries going to the superior portion of the right lower lobe and basilar arteries as well as the artery going to the right middle lobe. The posterior portion of the fissure ultimately divided with the single firing of a GIA stapler with a blue load and with the final portion being divided between 2-0 ties. Once we had clearly delineated the arterial anatomy, we were able to pass a right angle around the artery going to the superior segment. This was ligated in continuity with an additional stick tie in the proximal portion of 3-0 silk. This was divided thus revealing a branched artery going to the basilar portion of the right lower lobe. This was also ligated in continuity and actually doubly ligated. Care was taken to preserve the artery to the right and middle lobe.,We then turned our attention once again to the hilum to dissect out the inferior pulmonary vein. The superior pulmonary vein was visualized as well. The right angle was passed around the inferior pulmonary vein, and this was ligated in continuity with 2-0 silk and a 3-0 stick tie. Upon division of this portion, the specimen site had some bleeding, which was eventually controlled using several 3-0 silk sutures. The bronchial anatomy was defined. Next, we identified the bronchus going to the right lower lobe as well as the right middle lobe. A TA-30 4.8 stapler was then closed. The lung insufflated. The right middle lobe and right upper lobe were noted to inflate well. The stapler was fired, and the bronchus was cut with a 10-blade.,We then turned our attention to the diaphragm. There was a small portion of the diaphragm of approximately 4 to 5 cm has involved with tumor, and we bovied around this with at least 1 cm margin. Upon going through the diaphragm, it became clear that the tumor was also involving the dome of the liver, so after going around the diaphragm in its entirety, we proceeded to wedge out the portion of liver that was involved. It seemed that it would be a mucoid shallow portion. The Bovie was set to high cautery. The capsule was entered, and then using Bovie cautery, we wedged out the remaining portion of the tumor with a margin of normal liver. It did leave quite a shallow defect in the liver. Hemostasis was achieved with Bovie cautery and gentle pressure. The specimen was then taken off the table and sent to Pathology for permanent. The area was inspected for hemostasis. A 10-flat JP was placed in the abdomen at the portion of the wedge resection, and 0 Prolene was used to close the diaphragmatic defect, which was under very little tension. A single 32 straight chest tube was also placed. The lung was seen to expand. We also noted that the incomplete fissure between the middle and upper lobes would prevent torsion of the right middle lobe. Hemostasis was observed at the end of the case. The chest tube was irrigated with sterile water, and there was no air leak observed from the bronchial stump. The chest was then closed with Vicryl at the level of the intercostal muscles, staying above the ribs. The 2-0 Vicryl was used for the latissimus dorsi layer and the subcutaneous layer, and 4-0 Monocryl was used to close the skin. The patient was then brought to supine position, extubated, and brought to the recovery room in stable condition.,Dr. X was present for the entirety of the procedure, which was a right thoracotomy, right lower lobectomy with en bloc resection of diaphragm and a portion of liver.

PREOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,POSTOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip.,ANESTHESIA: ,Spinal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Less than 100 cc.,HISTORY: ,The patient is an 86-year-old female who was seen and evaluated in ABCD General Hospital Emergency Department on 08/30/03 after sustaining a fall at her friend's house. The patient states that she was knocked over by her friend's dog. She sustained a subcapital left hip fracture. Prior to admission, she lived alone in Terrano, was ambulating with a walker. All risks, benefits, and potential complications of the procedure were then discussed with the patient and informed consent was obtained.,HARDWARE SPECIFICATIONS: , A 28 mm medium head was used, a small cemented femoral stem was used, and a 28 x 46 cup was used.,PROCEDURE: ,All risks, benefits, and potential complications of the procedure were discussed with the patient, informed consent was obtained. She was then transferred from the preoperative care unit to operating suite #1. Department of Anesthesia administered spinal anesthetic without complications.,After this, the patient was transferred to the operating table and positioned. All bony prominences were well padded. She was positioned on a beanbag in the right lateral decubitus position with the left hip facing upwards. The left lower extremity was then sterilely prepped and draped in the normal fashion. A skin maker was then used to mark all bony prominences. Skin incision was then carried out extending from the greater trochanter in a curvilinear fashion posteriorly across the buttocks. A #10 blade Bard-Parker scalpel was used to incise the skin through to the subcutaneous tissues. A second #10 blade was then used to incise through the subcutaneous tissue down to the fascia lata. This was then incised utilizing Metzenbaum scissors. This was taken down to the bursa, which was removed utilizing a rongeur. Utilizing a periosteal elevator as well as the sponge, the fat was then freed from the short external rotators of the left hip after these were placed and stretched. The sciatic nerve was then visualized and retracted utilizing a Richardson retractor. Bovie was used to remove the short external rotators from the greater trochanter, which revealed the joint capsule. The capsule was cleared and incised utilizing a T-shape incision. A fracture hematoma was noted upon entering the joint capsule as well as subcapital hip fracture. A cork screw was then used to remove the fractured femoral head, which was given to the scrub tech which was sized on the back table. All bony remnants were then removed from the acetabulum and surrounding soft tissue with a rongeur. Acetabulum was then inspected and found to be clear. Attention was then turned to the proximal femur where a cutting tunnel was used to mark the femur for the femoral neck cut. An oscillating saw was then used to make the femoral cut. Box osteotome was then used to remove the bone from proximal femur. A Charnley awl was then used to open the femoral canal, paying close attention to keep the awl in the lateral position. Next, attention was turned to broaching. Initially, a small broach was placed, first making efforts to lateralize the broach then the femoral canal. It was felt that the patient has less benefit from a cemented prosthesis and a small size was appropriate. Next, the trial components were inserted consisting of the above-mentioned component sizes. The hip was taken through range of motion and tested to adduction, internal and external rotations as well as with a shuck and a posterior directed force on a flexed tip. It was noted that these size were stable through the range of motion. Next, the trial components were removed and the femoral canal was copiously irrigated and suctioned dried utilizing Super sucker and __________ then inserted pressuring the femoral canal. The femoral component was then inserted and then held under pressure. Extruding cement was removed from the proximal femur. After the cement had fully hardened and dried, the head and cup were applied. The hip was subsequently reduced and taken again through range of motion, which was felt to be stable.,Next, the capsule was closed utilizing #1 Ethibond in figure-of-eight fashion. Next, the fascia lata was repaired utilizing a figure-of-eight Ethibond sutures. The most proximal region at the musculotendinous junction was repaired utilizing a running #1 Vicryl suture. The wound was then copiously irrigated again to suction dry. Next, the subcutaneous tissues were reapproximated using #2-0 Vicryl simple interrupted sutures. The skin was then reapproximated utilizing skin clips. Sterile dressing was applied consisting of Adaptic, 4x4s, ABDs as well as foam tape. The patient was then transferred from the operating table to the gurney. Leg lengths were checked, which were noted to be equal and abduction pillow was placed. The patient was then transferred to the Postoperative Care Unit in stable condition.

HISTORY OF PRESENT ILLNESS:, Patient is a 72-year-old white male complaining of a wooden splinter lodged beneath his left fifth fingernail, sustained at 4 p.m. yesterday. He attempted to remove it with tweezers at home, but was unsuccessful. He is requesting we attempt to remove this for him.,The patient believes it has been over 10 years since his last tetanus shot, but states he has been allergic to previous immunizations primarily with "horse serum." Consequently, he has declined to update his tetanus immunization.,MEDICATIONS: , He is currently on several medications, a list of which is attached to the chart, and was reviewed. He is not on any blood thinners.,ALLERGIES: , HE IS ALLERGIC ONLY TO TETANUS SERUM.,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife. ,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Temp and vital signs are all within normal limits.,GENERAL: The patient is a pleasant elderly white male who is sitting on the stretcher in no acute distress.,EXTREMITIES: Exam of the left fifth finger shows a 5- to 6-mm splinter lodged beneath the medial aspect of the nail plate. It does not protrude beyond the end of the nail plate. There is no active bleeding. There is no edema or erythema of the digit tip. Flexion and extension of the DIP joint is intact. The remainder of the hand is unremarkable.,TREATMENT: , I did attempt to grasp the end of the splinter with splinter forceps, but it is brittle and continues to break off. In order to better grasp the splinter, will require penetration beneath the nail plate, which the patient cannot tolerate due to pain. Consequently, the base of the digit tip was prepped with Betadine, and just distal to the DIP joint, a digital block was applied with 1% lidocaine with complete analgesia of the digit tip. I was able to grasp the splinter and remove this. No further foreign body was seen beneath the nail plate and the area was cleansed and dressed with bacitracin and bandage.,ASSESSMENT: , Foreign body of the left fifth fingernail (wooden splinter).,PLAN: , Patient was urged to clean the area b.i.d. with soap and water and to dress with bacitracin and a Band-Aid. If he notes increasing redness, pain, or swelling, he was urged to return for re-evaluation.

HISTORY: , Advanced maternal age and hypertension.,FINDINGS:, There is a single live intrauterine pregnancy with a vertex lie, posterior placenta, and adequate amniotic fluid. The amniotic fluid index is 23.2 cm. Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of delivery of 03/28/08. Based on fetal measurements obtained today, estimated fetal weight is 3249 plus or minus 396 g, 7 pounds 3 ounces plus or minus 14 ounces, which places the fetus in the 66th percentile for the estimated gestational age. Fetal heart motion at a rate of 156 beats per minute is documented. The cord Doppler ratio is normal at 2.2. The biophysical profile score, assessing fetal breathing movement, gross body movement, fetal tone, and qualitative amniotic fluid volume is 8/8.,IMPRESSION:,1. Single live intrauterine pregnancy in vertex presentation with an estimated gestational age of 36 weeks 4 days and established due date of 03/28/08.,2. Biophysical profile (BPP) score 8/8.

DESCRIPTION OF RECORD: ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system. Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical. During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 Hz alpha activity best seen posteriorly. The alpha activity attenuates with eye opening.,During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,There is no evidence of focal slowing or paroxysmal activity.,IMPRESSION: , Normal awake and drowsy (stage I sleep) EEG for patient's age.

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.

FINDINGS:,There is a well demarcated mass lesion of the deep lobe of the left parotid gland measuring approximately 2.4 X 3.9 X 3.0cm (AP X transverse X craniocaudal) in size. The lesion is well demarcated. There is a solid peripheral rim with a mean attenuation coefficient of 56.3. There is a central cystic appearing area with a mean attenuation coefficient of 28.1 HU, suggesting an area of central necrosis. There is the suggestion of mild peripheral rim enhancement. This large lesion within the deep lobe of the parotid gland abuts and effaces the facial nerve. Primary consideration is of a benign mixed tumor (pleomorphic adenoma), however, other solid mass lesions cannot be excluded, for which histologic evaluation would be necessary for definitive diagnosis. The right parotid gland is normal.,There is mild enlargement of the left jugulodigastric node, measuring 1.1cm in size, with normal morphology (image #33/68). There is mild enlargement of the right jugulodigastric node, measuring 1.2cm in size, with normal morphology (image #38/68).,There are demonstrated bilateral deep lateral cervical nodes at the midlevel, measuring 0.6cm on the right side and 0.9cm on the left side (image #29/68). There is a second midlevel deep lateral cervical node demonstrated on the left side (image #20/68), measuring 0.7cm in size. There are small bilateral low level nodes involving the deep lateral cervical nodal chain (image #15/68) measuring 0.5cm in size.,There is no demonstrated nodal enlargement of the spinal accessory or pretracheal nodal chains.,The right parotid gland is normal and there is no right parotid gland mass lesion.,Normal bilateral submandibular glands.,Normal parapharyngeal, retropharyngeal and perivertebral spaces.,Normal carotid spaces.,IMPRESSION:,Large, well demarcated mass lesion of the deep lobe of the left parotid gland, with probable involvement of the left facial nerve. See above for size, morphology and pattern enhancement. Primary consideration is of a benign mixed tumor (pleomorphic adenoma), however, other solid mass lesions cannot be excluded, for which histologic evaluation is necessary for specificity.,Multiple visualized nodes of the bilateral deep lateral cervical nodal chain, within normal size and morphology, most compatible with mild hyperplasia.

SUBJECTIVE: , This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma. She says her asthma has been worse over the last three months. She has been using her inhaler daily. Her allergies seem to be a little bit worse as well. Her husband has been hauling corn and this seems to aggravate things. She has not been taking Allegra daily but when she does take it, it seems to help somewhat. She has not been taking her Flonase which has helped her in the past. She also notes that in the past she was on Advair but she got some vaginal irritation with that.,She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle. She has been more impatient around that time. Says otherwise her mood is normal during the rest of the month. It usually is worse the week before her cycle and improves the day her menstrual cycle starts. Menses have been regular but somewhat shorter than in the past. Occasionally she will get some spotting after her cycles. She denies any hot flashes or night sweats with this. In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously. Her urine has not been rechecked. She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available.,REVIEW OF SYSTEMS: , As above. No fevers, no headaches, no shortness of breath currently. No chest pain or tightness. No abdominal pain, no heartburn, no constipation, diarrhea or dysuria. Occasional stress incontinence. No muscle or joint pain. No concerns about her skin. No polyphagia, polydipsia or polyuria.,PAST MEDICAL HISTORY: , Significant for asthma, allergic rhinitis and cervical dysplasia.,SOCIAL HISTORY: , She is married. She is a nonsmoker.,MEDICATIONS: , Proventil and Allegra.,ALLERGIES: , Sulfa.,OBJECTIVE:,Vital signs: Her weight is 151 pounds. Blood pressure is 110/60. Pulse is 72. Temperature is 97.1 degrees. Respirations are 20.,General: This is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress. Affect is appropriate and is pleasant.,HEENT: Normocephalic, atraumatic. Tympanic membranes are clear. Conjunctivae are clear. Pupils are equal, round and reactive to light. Nares without turbinate edema. Oropharynx is nonerythematous.,Neck: Supple without lymphadenopathy, thyromegaly, carotid bruit or JVD.,Chest: Clear to auscultation bilaterally.,Cardiovascular: Regular rate and rhythm without murmur.,Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds. No masses or organomegaly to palpation.,Extremities: Without cyanosis or edema.,Skin: Without abnormalities.,Breasts: Normal symmetrical breasts without dimpling or retraction. No nipple discharge. No masses or lesions to palpation. No axillary masses or lymphadenopathy.,Genitourinary: Normal external genitalia. The walls of the vaginal vault are visualized with normal pink rugae with no lesions noted. Cervix is visualized without lesion. She has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault. No cervical motion tenderness. No adnexal tenderness or fullness.,ASSESSMENT/PLAN:,1. Asthma. Seems to be worse than in the past. She is just using her Proventil inhaler but is using it daily. We will add Flovent 44 mcg two puffs p.o. b.i.d. May need to increase the dose. She did get some vaginal irritation with Advair in the past but she is willing to retry that if it is necessary. May also need to consider Singulair. She is to call me if she is not improving. If her shortness of breath worsens she is to call me or go into the emergency department. We will plan on following up for reevaluation in one month.,2. Allergic rhinitis. We will plan on restarting Allegra and Flonase daily for the time being.,3. Premenstrual dysphoric disorder. She may have some perimenopausal symptoms. We will start her on fluoxetine 20 mg one tablet p.o. q.d.,4. Hematuria. Likely this is secondary to urinary tract infection but we will repeat a UA to document clearing. She does have some frequent dysuria but is not having it currently.,5. Cervical dysplasia. Pap smear is taken. We will notify the patient of results. If normal we will go back to yearly Pap smear. She is scheduled for screening mammogram and instructed on monthly self-breast exam techniques. Recommend she get 1200 mg of calcium and 400 U of vitamin D a day.

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

CC:, Decreasing visual acuity.,HX: ,This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS, and is now blind in that eye. She denied any other symptomatology. Denied HA.,PMH:, 1) depression. 2) Blind OS,MEDS:, None.,SHX/FHX: ,unremarkable for cancer, CAD, aneurysm, MS, stroke. No h/o Tobacco or ETOH use.,EXAM:, T36.0, BP121/85, HR 94, RR16,MS: Alert and oriented to person, place and time. Speech fluent and unremarkable.,CN: Pale optic disks, OU. Visual acuity: 20/70 (OD) and able to detect only shadow of hand movement (OS). Pupils were pharmacologically dilated earlier. The rest of the CN exam was unremarkable.,MOTOR: 5/5 throughout with normal bulk and tone.,Sensory: no deficits to LT/PP/VIB/PROP.,Coord: FNF-RAM-HKS intact bilaterally.,Station: No pronator drift. Gait: ND,Reflexes: 3/3 BUE, 2/2 BLE. Plantar responses were flexor bilaterally.,Gen Exam: unremarkable. No carotid/cranial bruits.,COURSE:, CT Brain showed large, enhancing 4 x 4 x 3 cm suprasellar-sellar mass without surrounding edema. Differential dx: included craniopharyngioma, pituitary adenoma, and aneurysm. MRI Brain findings were consistent with an aneurysm. The patient underwent 3 vessel cerebral angiogram on 12/29/92. This clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery. Ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis. Emergent HCT showed no evidence of hemorrhage or sign of infarct. Emergent carotid duplex showed no significant stenosis or clot. The patient was left with an expressive aphasia and right hemiparesis. SPECT scans were obtained on 1/7/93 and 2/24/93. They revealed hypoperfusion in the distribution of the left MCA and decreased left basal-ganglia perfusion which may represent in part a mass effect from the LICA aneurysm. She was discharged home and returned and underwent placement of a Selverstone Clamp on 3/9/93. The clamp was gradually and finally closed by 3/14/93. She did well, and returned home. On 3/20/93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia. A HCT then showed SAH around her aneurysm, which had thrombosed. She was place on Nimodipine. Her clinical status improved; then on 3/25/93 she rapidly deteriorated over a 2 hour period to the point of lethargy, complete expressive aphasia, and right hemiplegia. An emergent HCT demonstrated a left ACA and left MCA infarction. She required intubation and worsened as cerebral edema developed. She was pronounced brain dead. Her organs were donated for transplant.

PREOPERATIVE DIAGNOSES:,1. Chronic cholecystitis.,2. Cholelithiasis.,POSTOPERATIVE DIAGNOSES:,1. Chronic cholecystitis.,2. Cholelithiasis.,3. Liver cyst.,PROCEDURES PERFORMED:,1. Laparoscopic cholecystectomy.,2. Excision of liver cyst.,ANESTHESIA: ,General endotracheal and injectable 0.25% Marcaine with 1% lidocaine.,SPECIMENS: , Include,1. Gallbladder.,2. Liver cyst.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,OPERATIVE FINDINGS:, Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder. Additionally, there was a notable liver cyst. The remainder of the abdomen remained free of any adhesions.,BRIEF HISTORY: , This is a 66-year-old Caucasian female who presented to ABCD General Hospital for an elective cholecystectomy. The patient complained of intractable nausea, vomiting, and abdominal bloating after eating fatty foods. She had had multiple attacks in the past of these complaints. She was discovered to have had right upper quadrant pain on examination. Additionally, she had an ultrasound performed on 08/04/2003, which revealed cholelithiasis. The patient was recommended to undergo laparoscopic cholecystectomy for her recurrent symptoms. She was explained the risks, benefits, and complications of the procedure and she gave informed consent to proceed.,OPERATIVE PROCEDURE: ,The patient was brought to the operative suite and placed in the supine position. The patient received preoperative antibiotics with Kefzol. The abdomen was prepped and draped in the normal sterile fashion with Betadine solution. The patient did undergo general endotracheal anesthesia. Once the adequate sedation was achieved, a supraumbilical transverse incision was created with a #10 blade scalpel. Utilizing a Veress needle, the Veress needle was inserted intra-abdominally and was hooked to the CO2 insufflation. The abdomen was insufflated to 15 mmHg. After adequate insufflation was achieved, the laparoscopic camera was inserted into the abdomen and to visualize a distended gallbladder as well as omental adhesion adjacent to the gallbladder. Decision to proceed with laparoscopic cystectomy was decided. A subxiphoid transverse incision was created with a #10 blade scalpel and utilizing a bladed 12 mm trocar, the trocar was inserted under direct visualization into the abdomen. Two 5 mm ports were placed, one at the midclavicular line 2 cm below the costal margin and a second at the axillary line, one hand length approximately below the costal margin. All ports were inserted with bladed 5 mm trocar then under direct visualization. After all trocars were inserted, the gallbladder was grasped at the fundus and retracted superiorly and towards the left shoulder. Adhesions adjacent were taken down with a Maryland dissector. Once this was performed, the infundibulum of the gallbladder was grasped and retracted laterally and anteriorly. This helped to better delineate the cystic duct as well as the cystic artery. Utilizing Maryland dissector, careful dissection of the cystic duct and cystic artery were created posteriorly behind each one. Utilizing Endoclips, clips were placed on the cystic duct and cystic artery, one proximal to the gallbladder and two distally. Utilizing endoscissors, the cystic duct and cystic artery were ligated. Next, utilizing electrocautery, the gallbladder was carefully dissected off the liver bed. Electrocautery was used to stop any bleeding encountered along the way. The gallbladder was punctured during dissection and cleared, biliary contents did drained into the abdomen. No evidence of stones were visualized. Once the gallbladder was completely excised from the liver bed, an EndoCatch was placed and the gallbladder was inserted into EndoCatch and removed from the subxiphoid port. This was sent off as an specimen, a gallstone was identified within the gallbladder. Next, utilizing copious amounts of irrigation, the abdomen was irrigated. A small liver cyst that have been identified upon initial aspiration was grasped with a grasper and utilizing electrocautery was completely excised off the left lobe of the liver. This was also taken and sent off as specimen. The abdomen was then copiously irrigated until clear irrigation was identified. All laparoscopic ports were removed under direct visualization. The abdomen was de-insufflated. Utilizing #0 Vicryl suture, the abdominal fascia was approximated with a figure-of-eight suture in the supraumbilical and subxiphoid region. All incisions were then closed with #4-0 undyed Vicryl. Two midline incisions were closed with a running subcuticular stitch and the lateral ports were closed with interrupted sutures. The areas were cleaned and dried. Steri-Strips were placed. On the incisions, sterile dressing was applied. The patient tolerated the procedure well. She was extubated following procedure. She is seen to tolerate the procedure well and she will follow up with Dr. X within one week for a follow-up evaluation.

ADMITTING DIAGNOSIS: , Cerebrovascular accident (CVA).,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old gentleman with a significant past medical history for nasopharyngeal cancer status post radiation therapy to his pharynx and neck in 1991 who presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. This occurred at 2:30 a.m. His wife said that he had trouble speaking as well, but gradually the symptoms resolved but he was still complaining of a headache and at that point, he was brought to the emergency room. He arrived at the emergency room here via private ambulance at 6:30 a.m. in the morning. Upon initial evaluation, he did have some left-sided weakness and was complaining of a headache. He underwent workup including a CT, which was negative and his symptoms slowly began to resolve. He was initially admitted, placed on Plavix and aspirin. However a few hours later, his symptoms returned and he had increasing weakness of his left arm and left leg as well as slurred speech. Repeat CT scan again done reportedly was negative and he was subsequently heparinized and admitted. He also underwent an echo, carotid ultrasound, and lab work in the emergency room. Wife is at the bedside and denies he had any other symptoms previous to this. He denied any chest pain or palpitations. She does report that he is on a Z-Pak, got a cortisone shot, and some decongestant from Dr. ABC on Saturday because of congestion and that had gotten better.,ALLERGIES: ,He has no known drug allergies.,CURRENT MEDICATIONS:,1. Multivitamin.,2. Ibuprofen p.r.n.,PAST MEDICAL HISTORY:,1. Nasopharyngeal cancer. Occurred in 1991. Status post XRT of the nasopharyngeal area and his neck because of spread to the lymph nodes.,2. Lumbar disk disease.,3. Status post diskectomy.,4. Chronic neck pain secondary to XRT.,5. History of thalassemia.,6. Chronic dizziness since his XRT in 1991.,PAST SURGICAL HISTORY: , Lumbar diskectomy, which is approximately 7 to 8 years ago, otherwise negative.,SOCIAL HISTORY: , He is a nonsmoker. He occasionally has a beer. He is married. He works as a flooring installer.,FAMILY HISTORY: ,Pertinent for father who died of an inoperable brain tumour. Mother is obese, but otherwise negative history.,REVIEW OF SYSTEMS: ,He reports he was in his usual state of health up until he awoke this morning. He does states that yesterday his son cleaned the walk area with some ether and since then he has not quite been feeling right. He is a right-handed male and normally wears glasses.,PHYSICAL EXAMINATION:,VITAL SIGNS: Stable. His blood pressure was 156/97 in the emergency room, pulse is 73, respiratory rate 20, and saturation is 99%.,GENERAL: He is alert, pleasant, and in no acute distress at this time. He answers questions appropriately.,HEENT: Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Sclerae are clear. TMs clear. Oropharynx is clear.,NECK: Supple with full range of motion. He does have some increased density to neck, I assume, secondary to XRT.,CARDIOVASCULAR: Regular rate and rhythm without murmur.,LUNGS: Clear bilaterally.,ABDOMEN: Soft, nontender, and nondistended.,EXTREMITIES: Show no clubbing, cyanosis or edema.,NEUROLOGIC: He does have a minimally slurred speech at present. He does have a slight facial droop. He has significant left upper extremity weakness approximately 3-4/5, left lower extremity weakness is approximately a 2-3/5 on the left. Handgrip is about 4/5 on the left, right side is 5/5.,LABORATORY DATA: ,His initial blood work, PT was 11 and PTT 27. CBC is within normal limits except for hemoglobin of 12.9 and hematocrit of 39.1. Chem panel is all normal.,EKG showed normal sinus rhythm, normal EKG. CT of his brain, initially his first CT, which was done this morning at approximately 7 a.m. showed a normal CT. Repeat CT done at approximately 3:30 p.m. this evening was reportedly also normal. He underwent an echocardiogram in the emergency room, which was essentially normal. He had a carotid ultrasound, which revealed total occlusion of the right internal carotid artery, 60% to 80% stenosis of the left internal carotid artery, and 60% stenosis of the left external carotid artery.,MPRESSION AND PLAN:,1. Cerebrovascular accident, in progress.

S:, ABC is in today for a followup of her atrial fibrillation. They have misplaced the Cardizem. She is not on this and her heart rate is up just a little bit today. She does complain of feeling dizziness, some vertigo, some lightheadedness, and has attributed this to the Coumadin therapy. She is very adamant that she wants to stop the Coumadin. She is tired of blood draws. We have had a difficult time getting her regulated. No chest pains. No shortness of breath. She is moving around a little bit better. Her arm does not hurt her. Her back pain is improving as well.,O:, Vital signs as per chart. Respirations 15. Exam: Nontoxic. No acute distress. Alert and oriented. HEENT: TMs are clear bilaterally without erythema or bulging. Clear external canals. Clear tympanic. Conjunctivae are clear. Clear nasal mucosa. Clear oropharynx with moist mucous membranes. NECK is soft and supple. LUNGS are clear to auscultation. HEART is irregularly irregular, mildly tachycardic. ABDOMEN is soft and nontender. EXTREMITIES: No cyanosis, no clubbing, no edema.,EKG shows atrial fibrillation with a heart rate of 104.,A:,1.

EXAM: , Three views of the right ankle.,INDICATIONS: ,Pain.,FINDINGS: , Three views of the right ankle are obtained. There is no evidence of fractures or dislocations. No significant degenerative changes or destructive osseous lesions of the ankle are noted. There is a small plantar calcaneal spur. There is no significant surrounding soft tissue swelling.,IMPRESSION: ,Negative right ankle.

DISCHARGE DIAGNOSES:,1. Acute respiratory failure, resolved.,2. Severe bronchitis leading to acute respiratory failure, improving.,3. Acute on chronic renal failure, improved.,4. Severe hypertension, improved.,5. Diastolic dysfunction.,X-ray on discharge did not show any congestion and pro-BNP is normal.,SECONDARY DIAGNOSES:,1. Hyperlipidemia.,2. Recent evaluation and treatment, including cardiac catheterization, which did not show any coronary artery disease.,3. Remote history of carcinoma of the breast.,4. Remote history of right nephrectomy.,5. Allergic rhinitis.,HOSPITAL COURSE:, This 83-year-old patient had some cold symptoms, was treated as bronchitis with antibiotics. Not long after the patient returned from Mexico, the patient started having progressive shortness of breath, came to the emergency room with severe bilateral wheezing and crepitations. X-rays however did not show any congestion or infiltrates and pro-BNP was within normal limits. The patient however was hypoxic and required 4L nasal cannula. She was admitted to the Intensive Care Unit. The patient improved remarkably over the night on IV steroids and empirical IV Lasix. Initial swab was positive for MRSA colonization., ,Discussed with infectious disease, Dr. X and it was decided no treatment was required for de-colonization. The patient's breathing has improved. There is no wheezing or crepitations and O2 saturation is 91% on room air. The patient is yet to go for exercise oximetry. Her main complaint is nasal congestion and she is now on steroid nasal spray. The patient was seen by Cardiology, Dr. Z, who advised continuation of beta blockers for diastolic dysfunction. The patient has been weaned off IV steroids and is currently on oral steroids, which she will be on for seven days.,DISPOSITION: , The patient has been discharged home.,DISCHARGE MEDICATIONS:,1. Metoprolol 25 mg p.o. b.i.d.,2. Simvastatin 20 mg p.o. daily.,NEW MEDICATIONS:,1. Prednisone 20 mg p.o. daily for seven days.,2. Flonase nasal spray daily for 30 days.,Results for oximetry pending to evaluate the patient for need for home oxygen.,FOLLOW UP:, The patient will follow up with Pulmonology, Dr. Y in one week's time and with cardiologist, Dr. X in two to three weeks' time.

HISTORY OF PRESENT ILLNESS: , This is the case of a 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. The patient had a positive hCG with a negative sonogram and hCG titer of about 18,000.,HOSPITAL COURSE:, The patient was admitted to the hospital with the diagnosis of a possible incomplete abortion, to rule out ectopic pregnancy or rupture of corpus luteal cyst. The patient was kept in observation for 24 hours. The sonogram stated there was no gestational sac, but there was a small mass within the uterus that could represent a gestational sac. The patient was admitted to the hospital. A repeat hCG titer done on the same day came back as 15,000, but then the following day, it came back as 18,000. The diagnosis of a possible ruptured ectopic pregnancy was established. The patient was taken to surgery and a laparotomy was performed with findings of a right ruptured ectopic pregnancy. The right salpingectomy was performed with no complications. The patient received 2 units of red packed cells. On admission, her hemoglobin was 12.9, then in the afternoon it dropped to 8.1, and the following morning, it was 7.9. Again, based on these findings, the severe abdominal pain, we made the diagnosis of ectopic and it was proved or confirmed at surgery. The hospital course was uneventful. There was no fever reported. The abdomen was soft. She had a normal bowel movement. The patient was dismissed on 09/09/2007 to be followed in my office in 4 days.,FINAL DIAGNOSES:,1. Right ruptured ectopic pregnancy with hemoperitoneum.,2. Anemia secondary to blood loss.,PLAN: , The patient will be dismissed on pain medication and iron therapy.

PREOPERATIVE DIAGNOSES:, 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,POSTOPERATIVE DIAGNOSES: , 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,PROCEDURES PERFORMED:,1. Lateral escharotomy of right upper arm burn eschar.,2. Medial escharotomy of left upper extremity burns and eschar.,ANESTHESIA:, Propofol and Versed.,INDICATIONS FOR PROCEDURE: , The patient is a 72-year-old gentleman who was involved in a propane explosion where he sustained significant burns to his bilateral upper extremities, neck, and thorax. The patient was transferred from outside facility and was found to have significant burns with impending compartment syndrome of the right upper extremity. The patient had a _____ between his left and right upper extremity and very tight compartment of his right upper extremity. It is felt the patient would need an escharotomy of his right upper extremity to maintain perfusion to his right arm and hand.,DESCRIPTION OF PROCEDURE:, After appropriate time out was performed indicating the correct procedure, correct patient, and all parties involved, the patient's right upper extremity was placed in anatomical position. An electrocautery device was readied and used to incise making make an incision on the lateral aspect of the patient's right upper extremity. Starting just below the right humeral head, an incision was made through the burn eschar down to underlying subcutaneous tissue. The incision was carried from the right humeral head down to just below the antecubital fossa on the right upper extremity. All dermal bridging was taken down and was opened without any excessive bleeding. Next, a medial incision was made starting at the axilla down to just below the medial epicondyle of the right upper extremity. Again, the incision was carried through the entire of the eschar down to underlying subcutaneous tissue. All bleeding was made hemostatic with electrocautery and all dermal abrasions were taken down. At the completion of the procedure, the patient had improved right distal radial pulse and his compartment was much softer. Silvadene cream was placed within the escharotomy incision and wrapped in Kerlix. The patient tolerated the procedure well, and there were no adverse events during or after the procedure.

EXAMINATION: , Cardiac catheterization.,PROCEDURE PERFORMED: , Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.,INDICATION: , Syncope with severe aortic stenosis.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained from the patient, the patient was brought to the cardiac catheterization laboratory in a post observed state. The right groin was prepped and draped in the usual sterile fashion. After adequate conscious sedation and local anesthesia was obtained, a 6-French sheath was placed in the right common femoral artery and a 8-French sheath was placed in the right common femoral vein. Following this, a 7.5-French Swan-Ganz catheter was advanced into the right atrium where the right atrial pressure was 10/7 mmHg. The catheter was then manipulated into the right ventricle where the right ventricular pressure was 37/10/4 mmHg. The catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmHg. The pulmonary arterial pressures were noted to be 31/14/21 mmHg. Following this, the catheter was removed, the sheath was flushed and a 6-French JL4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views. Following this, the catheter was exchanged over the guidewire for 6-French JR4 diagnostic catheter. We were unable to cannulate the right coronary artery. Therefore, we exchanged for a Williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views. Following this, this catheter was exchanged over a guidewire for a 6-French Langston pigtail catheter and the left ventricle was entered and left ventriculography was performed. Following this, the catheters were removed. Sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6-French Angio-Seal device. The patient tolerated the procedure well. There were no complications.,DESCRIPTION OF FINDINGS: , The left main coronary artery is a large vessel, which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions. The left circumflex artery is a short vessel, which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions. The left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches. There is a 70% ostial lesion in the first diagonal branch and the second diagonal branch has mild-to-moderate luminal irregularities. The right coronary artery is a very large dominant vessel with a 60% to 70% lesion in its descending mid-portion. The remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions. The left ventricle appears to be normal sized. The aortic valve is heavily calcified. The estimated ejection fraction is approximately 60%. There was 4+ mitral regurgitation noted. The mean gradient across the aortic valve was noted to be 33 mmHg yielding an aortic valve area of 0.89 cm2.,CONCLUSION:,1. Moderate-to-severe coronary artery disease with a high-grade lesion seen at the ostium of the first diagonal artery as well as a 60% to 70% lesion seen at the mid portion of the right coronary artery.,2. Moderate-to-severe aortic stenosis with an aortic valve area of 0.89 cm2.,3. 4+ mitral regurgitation.,PLAN: , The patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to Dr Kenneth Fang for possible aortic valve replacement as well as mitral valve repair/replacement and possible surgical revascularization.

CHIEF COMPLAINT: , The patient is here for followup visit and chemotherapy.,DIAGNOSES:,1. Posttransplant lymphoproliferative disorder.,2. Chronic renal insufficiency.,3. Squamous cell carcinoma of the skin.,4. Anemia secondary to chronic renal insufficiency and chemotherapy.,5. Hypertension.,HISTORY OF PRESENT ILLNESS: , A 51-year-old white male diagnosed with PTLD in latter half of 2007. He presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia. He did not seek medical attention immediately. He was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin, which showed diagnosis of large cell lymphoma. He was discussed at the hematopathology conference. Chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started. First cycle of chemotherapy was complicated by sepsis despite growth factor support. He also appeared to have become disoriented either secondary to sepsis or steroid therapy.,The patient has received 5 cycles of chemotherapy to date. He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well. His therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection.,The patient is here for the sixth and final cycle of chemotherapy. He states he feels well. He denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue. He denies any tingling or numbness in his fingers. Review of systems is otherwise entirely negative.,Performance status on the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS: He is afebrile. Blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit. There is mild pallor noted. There is no icterus, adenopathy or petechiae noted. CHEST: Clear to auscultation. CARDIOVASCULAR: S1 and S2 normal with regular rate and rhythm. Systolic flow murmur is best heard in the pulmonary area. ABDOMEN: Soft and nontender with no organomegaly. Renal transplant is noted in the right lower quadrant with a scar present. EXTREMITIES: Reveal no edema.,LABORATORY DATA: , CBC from today shows white count of 9.6 with a normal differential, ANC of 7400, hemoglobin 8.9, hematocrit 26.5 with an MCV of 109, and platelet count of 220,000.,ASSESSMENT AND PLAN:,1. Diffuse large B-cell lymphoma following transplantation. The patient is to receive his sixth and final cycle of chemotherapy today. PET scan has been ordered to be done within 2 weeks. He will see me back for the visit in 3 weeks with CBC, CMP, and LDH.,2. Chronic renal insufficiency.,3. Anemia secondary to chronic renal failure and chemotherapy. He is to continue on his regimen of growth factor support.,4. Hypertension. This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled. His CMP is pending from today.,5. Squamous cell carcinoma of the skin. The scalp is well healed. He still has an open wound on the right posterior aspect of his trunk. This has no active drainage, but it is yet to heal. This probably will heal by secondary intention once chemotherapy is finished. Prescription for prednisone as part of his chemotherapy has been given to him.

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

PREOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,POSTOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,PROCEDURE:, Exam under anesthesia. Removal of intrauterine clots.,ANESTHESIA: , Conscious sedation.,ESTIMATED BLOOD LOSS:, Approximately 200 mL during the procedure, but at least 500 mL prior to that and probably more like 1500 mL prior to that.,COMPLICATIONS: , None.,INDICATIONS AND CONCERNS: , This is a 19-year-old G1, P1 female, status post vaginal delivery, who was being evaluated by the nurse on labor and delivery approximately four hours after her delivery. I was called for persistent bleeding and passing large clots. I examined the patient and found her to have at least 500 mL of clots in her uterus. She was unable to tolerate exam any further than that because of concerns of the amount of bleeding that she had already had and inability to adequately evaluate her. I did advise her that I would recommend they came under anesthesia and dilation and curettage. Risks and benefits of this procedure were discussed with Misty, all of her questions were adequately answered and informed consent was obtained.,PROCEDURE: , The patient was taken to the operating room where satisfactory conscious sedation was performed. She was placed in the dorsal lithotomy position, prepped and draped in the usual fashion. Bimanual exam revealed moderate amount of clot in the uterus. I was able to remove most of the clots with my hands and an attempt at short curettage was performed, but because of contraction of the uterus this was unable to be adequately performed. I was able to thoroughly examine the uterine cavity with my hand and no remaining clots or placental tissue or membranes were found. At this point, the procedure was terminated. Bleeding at this time was minimal. Preop H&H were 8.3 and 24.2. The patient tolerated the procedure well and was taken to the recovery room in good condition.

ADENOIDECTOMY,PROCEDURE:, The patient was brought into the operating room suite, anesthesia administered via endotracheal tube. Following this the patient was draped in standard fashion. The Crowe-Davis mouth gag was inserted in the oral cavity. The palate and tonsils were inspected, the palate was suspended with a red rubber catheter passed through the right nostril. Following this, the mirror was used to visualize the adenoid pad and an adenoid curet was seated against the vomer. The adenoid pad was removed without difficulty. The nasopharynx was packed. Following this, the nasopharynx was unpacked, several discrete bleeding sites were gently coagulated with electrocautery and the nasopharynx and oral cavity were irrigated. The Crowe-Davis was released.,The patient tolerated the procedure without difficulty and was in stable condition on transfer to recovery.

HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old Caucasian female with a history of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia and left lower extremity cellulitis. She was brought in by the EMS service to Erlanger emergency department with pulseless electrical activity. Her husband states that he was at home with his wife, when she presented to him complaining of fever and chills. She became acutely unresponsive. She was noted to have worsening of her breathing. She took several of her MDIs and then was placed on her CPAP. He went to notify EMS and when he returned, she was found to not be breathing. He stated that she was noted to have no breathing in excess of 10 minutes. He states that the EMS system arrived at the home and she was found not breathing. The patient was intubated at the scene and upon arrival to Erlanger Medical Center, she was found to have pupils fixed and dilated. She was seen by me in the emergency department and was on Neo-Synephrine, dopamine with a blood pressure of 97/22 with a rapid heart rate and again, in an unresponsive state.,REVIEW OF SYSTEMS:, Review of systems was not obtainable.,PAST MEDICAL HISTORY:, Diabetes, osteoarthritis, hypertension, asthma, atrial fibrillation, diabetic foot ulcer and anemia.,PAST SURGICAL HISTORY:, Noncontributory to above.,FAMILY HISTORY:, Mother with history of coronary artery disease.,SOCIAL HISTORY:, The patient is married. She uses no ethanol, no tobacco and no illicits. She has a very support family unit.,MEDICATIONS:, Augmentin; Detrol LA; lisinopril.,IMMUNIZATIONS:, Immunizations were up to date for influenza, negative for Pneumovax.,ALLERGIES:, PENICILLIN.,LABORATORY AT PRESENTATION:, White blood cell count 11, hemoglobin 10.5, hematocrit 32.2, platelets 175,000. Sodium 148, potassium 5.2, BUN 30, creatinine 2.2 and glucose 216. PT was 22.4.,RADIOLOGIC DATA:, Chest x-ray revealed a diffuse pulmonary edema.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 97/52, pulse of 79, respirations 16, O2 sat 100%.,HEENT: The patient's pupils were again, fixed and dilated and intubated on the monitor.,CHEST: Poor air movement bilateral with bilateral rales.,CARDIOVASCULAR: Regular rate and rhythm.,ABDOMEN: The abdomen was obese, nondistended and nontender.,EXTREMITIES: Left diabetic foot had oozing pus drainage from the foot.,GU: Foley catheter was in place.,IMPRESSION AND PLAN:,1. Acute cardiac arrest with pulseless electrical activity with hypotensive shock and respiratory failure: Will continue ventilator support. Will rule out pulmonary embolus, rule out myocardial infarction. Continue pressors. The patient is currently on dopamine, Neo-Synephrine and Levophed.,2. Acute respiratory distress syndrome: Will continue ventilatory support.,3. Questionable sepsis: Will obtain blood cultures, intravenous vancomycin and Rocephin given.,4. Hypotensive shock: Will continue pressors. Will check random cortisol. Hydrocortisone was added.,Further inpatient management for this patient will be provided by Dr. R. The patient's status was discussed with her daughter and her husband. The husband states that his wife has been very ill in the past with multiple admissions, but he had never seen her as severely ill as with this event. He states that she completely was not breathing at all and he is aware of the severity of her illness and the gravity of her current prognosis. Will obtain the assistance with cardiology with this admission and will continue pressors and supportive therapy. The family will make an assessment and final decision concerning her long-term management after a 24 hour period.

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

REASON FOR CONSULTATION: , Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years.,HISTORY OF PRESENT ILLNESS:, A 23-year-old female who is approximately 5 months' pregnant, who has had recurrent abscesses in the above-mentioned areas. She would usually have pustular type of lesion that would eventually break and would be quite painful. The drainage would be malodorous. It would initially not be infected as far as she knows, but then could eventually become infected. She stated that this first started after she had her first born about 2 years ago. She had recurrences of these abscesses and had pain, actually hospitalized at Hospital approximately a year and a half ago for about 1-1/2 months. She was treated with multiple courses of antibiotics. She had biopsies done. She was seen by Dr. X. Reportedly, she had a HIV test done that was negative. She had been seen by a dermatologist who said that she had a problem with her sweat glands. She has been on multiple courses of antibiotics. She never had any fevers. She has pain, drainage, and reportedly there was some bleeding in the area of the perineum/vaginal area.,PAST MEDICAL HISTORY:,1. History of recurrent abscesses in the perineum, upper medial thigh, and the vulva area for about 2 years. Per her report, a dermatologist had told her that she had an overactive sweat gland, and I believe she probably has hidradenitis suppurativa. Probably, she has had Staphylococcus infection associated with it as well.,2. Reported history of asthma.,GYNECOLOGIC HISTORY: , G3, P1. She is currently 5 months' pregnant.,ALLERGIES: , None.,MEDICATIONS: , Her medication had been Augmentin.,SOCIAL HISTORY: , She is followed by a gynecologist in Bartow. She is not an alcohol or tobacco user. She is not married. She has a 2-year-old child.,FAMILY HISTORY: ,Noncontributory.,REVIEW OF SYSTEMS: , The patient has been complaining of diarrhea about 5 or 6 times a day for several weeks now.,PHYSICAL EXAMINATION,GENERAL:

PREOPERATIVE DIAGNOSES:,1. Fullness in right base of the tongue.,2. Chronic right ear otalgia.,POSTOPERATIVE DIAGNOSIS: , Pending pathology.,PROCEDURE PERFORMED: , Microsuspension direct laryngoscopy with biopsy.,ANESTHESIA: , General.,INDICATION:, This is a 50-year-old female who presents to the office with a chief complaint of ear pain on the right side. Exact etiology of her ear pain had not been identified. A fiberoptic examination had been performed in the office. Upon examination, she was noted to have fullness in the right base of her tongue. She was counseled on the risks, benefits, and alternatives to surgery and consented to such.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Operative Suite where she was placed in supine position. General endotracheal tube intubation was delivered by the Department of Anesthesia. The patient was rotated 90 degrees away where a shoulder roll was placed. A tooth guard was then placed to protect the upper dentition. The Dedo laryngoscope was then inserted into the oral cavity. It was advanced on the right lateral pharyngeal wall until the epiglottis was brought into view. At this point, it was advanced underneath the epiglottis until the vocal cords were seen. At this point, it was suspended via the Lewy suspension arm from the Mayo stand. At this point, the Zeiss microscope with a 400 mm lens was brought into the surgical field. Inspection of the vocal cords underneath the microscope revealed them to be white and glistening without any mucosal abnormalities. It should be mentioned that the right vocal cord did appear to be slightly more hyperemic, however, there were no mucosal abnormalities identified. This was confirmed with a laryngeal probe as well as use of mirror evaluated in the subglottic portion as well as the ventricle. At this point, the scope was desuspended and the microscope was removed. The scope was withdrawn through the vallecular region. Inspection of the vallecula revealed a fullness on the right side with a papillomatous type growth that appeared very friable. Biopsies were obtained with straight-biting cup forceps. Once hemostasis was achieved, the scope was advanced into the piriform sinuses. Again in the right piriform sinus, there was noted to be studding along the right lateral wall of the piriform sinus. Again, biopsies were performed and once hemostasis was achieved, the scope was further withdrawn down the lateral pharyngeal wall. There were no mucosal abnormalities identified within the oropharynx. The scope was then completely removed and a bimanual examination was performed. No neck masses were identified. At this point, the procedure was complete. The mouth guard was removed and the patient was returned to Anesthesia for awakening and taken to the recovery room without incident.

HISTORY: ,The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch. As an infant, he was initially palliated with the right and modified Blalock-Taussig shunt in October of 2002 and underwent atrioventricular septal defect and repair of pulmonary artery unifocalization and homograft placement between the right ventricle and unifocalized pulmonary arteries. He developed a significant branch of pulmonary artery stenosis for which on 07/20/2004, he underwent a bilateral balloon pulmonary arterioplasty and stent implantation at the San Diego at Children's Hospital. This was followed on 09/13/2007 with replacement of pulmonary valve utilizing a 16-mm Contegra valve. A recent echocardiogram demonstrated a significant branch of pulmonary artery stenosis with the predicted gradient of 41 to 55 mmHg and a well-functioning Contegra valve. The lung perfusion scan from 11/14/2007 demonstrated 47% flow to the left lung and 53% flow to the right lung. The patient underwent a repeat catheterization in consideration for further balloon angioplasty of the branch pulmonary arteries.,PROCEDURE: , After sedation, the patient was placed under general endotracheal anesthesia breathing 50% oxygen throughout the case. The patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures,Using a 7-French sheath, 6-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch pulmonary arteries. This catheter was exchanged over wire. A 5-French marker pigtail catheter was directed into the main pulmonary artery. A second site of venous access was achieved in and the left femoral vein with the placement of 5-French sheath.,Using a 4-French sheath, a 4-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta and left ventricle. Angiogram with injection in the main pulmonary artery demonstrated stable stent configuration of the proximal branch pulmonary arteries with intimal ingrowth in the region of the proximal stents. The distal right pulmonary measured approximately 10 mm in diameter with a mid stent section measuring 9.4 mm and the proximal stent near the origin of the right pulmonary artery of 5.80 mm. The distal left pulmonary measured approximately 10 mm in diameter with a mid stent measuring 10.3 mm and the proximal stent near the origin of the left pulmonary artery is 6.8 mm diameter. The left femoral venous sheath was exchanged over wire for a 7-French sheath. Guidewires were then advanced through the respective venous sheath into the branch pulmonary arteries and simultaneous balloon pulmonary arterioplasty was performed using the two Z-Med 12 x 4 cm balloon catheter was advanced into the branch of pulmonary arteries and inflated maximally to 9 hemispheres of pressure on 5 occasions near complete disappearance of proximal waist. The balloon catheter was then exchanged for a 5-French Mistique catheter for pressure pull-back and measurement in the angiogram. The catheter's wires were then removed and final hemodynamic assessment was made with the wedge catheter.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with angiograph injection in the main pulmonary artery.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.,DISCUSSION: ,Oxygen consumption was assumed to be in normal. Mixed venous saturation that was not normal with no evidence of intracardiac shunt. Left side of the heart was mildly desaturated following a part to parenchymal lung disease with the partial pressure of oxygen of only 82 mmHg. Aphasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure. Left ventricular systolic pressure was moderately elevated at 70% of systemic level and there was no obstruction into the proximal main pulmonary artery. There was a 20 mmHg of peak systolic gradient across the branch pulmonary artery stents to the distal artery. Right and left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the mildly elevated left ventricular end-diastolic pressure of 13 mmHg. Left ventricular systolic pressure was systemic. No outflow constriction to the ascending aorta. Phasic ascending and descending pressures were similar and normal. The calculated systemic and pulmonary flows were equal and normal. Vascular resistances were normal. Angiogram with injection in the main pulmonary artery showed catheter induced pulmonary insufficiency, well functioning Contegra valve with no appreciable calcification. The proximal narrowing of the distal main pulmonary artery was appreciated. Neointimal ingrowth within the proximal stents were appreciated. There is good distal growth of the pulmonary arteries. Arborization appeared normal. Levophase contrast returned to the heart appeared normal with a well-functioning left ventricle and the right aortic arch. Following the branch pulmonary artery angioplasty that was increased in the mixed venous saturation, as well as an increase in the systemic arterial saturation. Right ventricular systolic pressure felt slightly to 40 mmHg with an increase in systemic arterial pressure with a systolic pressure ratio of 54%. The main pulmonary pressures remained similar. There was 10 mmHg systolic gradient into the branch of pulmonary arteries. There is an increase in distal branch of pulmonary arteries with the mean pressure increased from 16 mmHg to 21 mmHg. Final angiogram with injection in the main pulmonary artery showed a competent Contegra valve. A brisk flow through the proximal branch stents with the improved caliber of the branch pulmonary artery lumens. There was no evidence of intimal disruption.,DIAGNOSES: ,1. Atrioventricular septal defect.,2. Tetralogy of Fallot with the pulmonary atresia.,3. Bilateral superior vena cava. The left cava draining to the coronary sinus.,4. The right aortic arch.,5. Discontinuous pulmonary arteries.,6. Down syndrome.,PRIOR SURGERIES AND INTERVENTIONS: ,1. Right modified Blalock-Taussig shunt.,2. Repair of tetralogy of Fallot with external conduit.,3. The atrioventricular septal defect repair.,4. Unifocalization of branch pulmonary arteries.,5. Bilateral balloon pulmonary angioplasty and stent implantation.,6. Pulmonary valve replacement with 16-mm Contegra valve.,CURRENT DIAGNOSES: ,1. Mild-to-moderate proximal branch pulmonary stenosis.,2. Well-functioning Contegra valve and current intervention. A balloon dilation of the right pulmonary artery.,3. Balloon dilation of left pulmonary artery.,MANAGEMENT: , The case will be discussed at Combined Cardiology and Cardiothoracic Surgery Case Conference and conservative outpatient management will be pursued. Further cardiologic care be directed by Dr. X.

PREOPERATIVE DIAGNOSES:,1. Trimalleolar ankle fracture.,2. Dislocation right ankle.,POSTOPERATIVE DIAGNOSES:,1. Trimalleolar ankle fracture.,2. Dislocation right ankle.,PROCEDURE PERFORMED: , Closed open reduction and internal fixation of right ankle.,ANESTHESIA: ,Spinal with sedation.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: ,Minimal.,TOTAL TOURNIQUET TIME: ,75 minutes at 325 mmHg.,COMPONENTS: , Synthes small fragment set was used including a 2.5 mm drill bed. A six hole one-third tibial plate, one 12 mm 3.5 mm cortical screw fully threaded and two 16 mm 3.5 mm cortical fully-threaded screws. There were two 20 mm 4.0 cancellous screws and one 18 mm 4.0 cancellous screw placed. There were two 4.0 cancellous partially-threaded screws placed.,GROSS FINDINGS: ,Include a comminuted fracture involving the lateral malleolus as well as a medial and posterior malleolus fracture as well.,HISTORY OF PRESENT ILLNESS: , The patient is an 87-year-old Caucasian female who presented to ABCD General Hospital Emergency Room complaining of right ankle pain status post a trip and fall. The patient noted while walking with a walker, apparently tripped and fell. The patient had significant comorbidities, seen and evaluated by the Emergency Room Department as well as Department of Orthopedics while in the Emergency Room. At that time, a closed reduction was performed and she was placed in a Robert-Jones splint. After complete medical workup and clearance, we elected to take her to the operating room for definitive care.,PROCEDURE: ,After all potential complications and risks as well as risks and benefits of the above-mentioned procedure was discussed at length with the patient and family, informed consent was obtained. The upper extremity was then confirmed with the operating surgeon, the patient, the nursing staff and Department of Anesthesia. The patient was then transferred to preoperative area in the Operative Suite #3 and placed on the operating room table in supine position. At this time, the Department of Anesthesia administered spinal anesthetic to the patient as well as sedation. All bony prominences were well padded at this time. A nonsterile tourniquet was placed on the right upper thigh of the patient. This was then removed and the right lower extremity was sterilely prepped and draped in the usual sterile fashion. The right lower extremity was then elevated and exsanguinated using Esmarch and tourniquet was then placed to 325 mmHg and kept up to a total of 75 minutes. Next, after all bony and soft tissue landmarks were identified, a 6 cm longitudinal incision was made directly over this vestibule on the right ankle. A sharp dissection was carefully taken down to the level of bone taking care to protect the neurovascular structures. Once the bone was reached, the fractured site was identified. The bony ends were then opened and divided of all hematoma as well as excess periosteum within the fracture site. The wound was copiously irrigated and dried. Next, the fracture was then reduced in anatomic position. There was noted to be quite a bit of comminution as well as soft overall status of the bone. It was held in place with reduction forceps. A six hole one-third tubular Synthes plate was then selected for instrumentation. It was contoured using ________ and placed on the lateral aspect of the distal fibula. Next, the three most proximal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged and then a 3.5 mm fully threaded cortical screw was placed in each. The most proximal was a 12 mm and the next two were 16 mm in length. Next, the three most distal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged, and a 4.0 cancellous screw was placed in each hole. The most distal with a 20 mm and two most proximal were 18 mm in length. Next the Xi-scan was used to visualize the hardware placement as well as the fracture reduction appeared to be in good anatomic position, all hardware was in good position. There was no lateralization of the joints. Attention was then directed towards the medial aspect of the ankle. Again, after all bony and soft tissue landmarks were identified, a 4 cm longitudinal incision was made directly over the medial malleolus. Again, the dissection was carefully taken down the level of the fracture site. The retractors were then placed to protect all neurovascular structures. Once the fracture site was identified, it was dried of all hematoma as well as excess periosteum. The fracture site was then displaced and the ankle joint was visualized including the dome of the talus. There appeared to be some minor degenerative changes of the talus, but no loose bodies. Next, the wound was copiously irrigated and suctioned dry. The medial malleolus was placed in reduced position and held in place with a 1.25 mm K-wire. Next, the 2.5 mm drill bed was then used to sequentially drill holes to full depth and 4.0 cancellous screws were placed in each, each with a 45 mm in length. These appeared to hold the fracture site securely in an anatomic position. Again, Xi-scan was brought in to confirm placement of the screws. They were in good overall position and there was no lateralization of the joint. At this time, each wound was copiously irrigated and suctioned dry. The wounds were then closed using #2-0 Vicryl suture in subcutaneous fashion followed by staples on the skin. A sterile dressing was applied consistent with Adaptic, 4x4s, Kerlix, and Webril. A Robert-Jones style splint was then placed on the right lower extremity. This was covered by a 4-inch Depuy dressing. At this time, the Department of Anesthesia reversed the sedation. The patient was transferred back to the hospital gurney and to the Postanesthetic Care Unit. The patient tolerated the procedure well. There were no complications.

PREOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,POSTOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,OPERATION:, Right subclavian triple lumen central line placement.,ANESTHESIA: , Local Xylocaine.,INDICATIONS FOR OPERATION: ,This 50-year-old gentleman with severe respiratory failure is mechanically ventilated. He is currently requiring multiple intravenous drips, and Dr. X has kindly requested central line placement.,INFORMED CONSENT: ,The patient was unable to provide his own consent, secondary to mechanical ventilation and sedation. No available family to provide conservator ship was located either.,PROCEDURE: ,With the patient in his Intensive Care Unit bed, mechanically ventilated in the Trendelenburg position. The right neck was prepped and draped with Betadine in a sterile fashion. Single needle stick aspiration of the right subclavian vein was accomplished without difficulty, and the guide wire was advanced. The dilator was advanced over the wire. The triple lumen catheter was cannulated over the wire, and the wire then removed. No PVCs were encountered during the procedure. All three ports to the catheter aspirated and flushed blood easily, and they were all flushed with normal saline. The catheter was anchored to the chest wall with butterfly phalange using 3-0 silk suture. Betadine ointment and a sterile Op-Site dressing were applied. Stat upright chest x-ray was obtained at the completion of the procedure, and final results are pending.,FINDINGS/SPECIMENS REMOVED:, None,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Nil.

PROCEDURE: , Placement of left ventriculostomy via twist drill.,PREOPERATIVE DIAGNOSIS:, Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,POSTOPERATIVE DIAGNOSIS: , Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,INDICATIONS FOR PROCEDURE: ,The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage. His condition is felt to be critical. In a desperate attempt to relieve increased intracranial pressure, we have proposed placing a ventriculostomy. I have discussed this with patient's wife who agrees and asked that we proceed emergently.,After a sterile prep, drape, and shaving of the hair over the left frontal area, this area is infiltrated with local anesthetic. Subsequently a 1 cm incision was made over Kocher's point. Hemostasis was obtained. Then a twist drill was made over this area. Bones strips were irrigated away. The dura was perforated with a spinal needle.,A Camino monitor was connected and zeroed. This was then passed into the left lateral ventricle on the first pass. Excellent aggressive very bloody CSF under pressure was noted. This stopped, slowed, and some clots were noted. This was irrigated and then CSF continued. Initial opening pressures were 30, but soon arose to 80 or a 100.,The patient tolerated the procedure well. The wound was stitched shut and the ventricular drain was then connected to a drainage bag.,Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding.

PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS: ,Chronic cholecystitis.,PROCEDURE PERFORMED: ,Laparoscopic cholecystectomy.,BLOOD LOSS: , Minimal.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS: , None.,DISPOSITION: ,To recovery room and to home.,FLUIDS: ,Crystalloid.,FINDINGS: , Consistent with chronic cholecystitis. Final pathology is pending.,INDICATIONS FOR THE PROCEDURE: ,Briefly, the patient is a 38-year-old male referred with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge. He presented now after informed consent for the above procedure.,PROCEDURE IN DETAIL: ,The patient was identified in the preanesthesia area, then taken to the operating room, placed in the supine position on the operating table, and induced under general endotracheal anesthesia. The patient was correctly positioned, padded at all pressure points, had antiembolic TED hose and Flowtrons in the lower extremities. The anterior abdomen was then prepared and draped in a sterile fashion. Preemptive local anesthetic was infiltrated with 1% lidocaine and 0.5% ropivacaine. The initial incision was made sharply at the umbilicus with a #15-scalpel blade and carried down through deeper tissues with Bovie cautery, down to the midline fascia with a #15 scalpel blade. The blunt-tipped Hasson introducer cannula was placed into the abdominal cavity under direct vision where it was insufflated using carbon dioxide gas to a pressure of 15 mmHg. The epigastric and right subcostal trocars were placed under direct vision. The right upper quadrant was well visualized. The gallbladder was noted to be significantly distended with surrounding dense adhesions. The fundus of the gallbladder was grasped and retracted anteriorly and superiorly, and the surrounding adhesions were then taken down off the gallbladder using a combination of the bullet-nose Bovie dissector and the blunt Kittner peanut dissector. Further dissection allowed identification of the infundibulum and cystic duct junction where the cystic duct was identified and dissected out further using a right-angle clamp. The cystic duct was clipped x3 and then divided. The cystic artery was dissected out in like fashion, clipped x3, and then divided. The gallbladder was then taken off the liver bed in a retrograde fashion using the hook-tip Bovie cautery with good hemostasis. Prior to removal of the gallbladder, all irrigation fluid was clear. No active bleeding or oozing was seen. All clips were noted to be secured and intact and in place. The gallbladder was placed in a specimen pouch after placing the camera in the epigastric port. The gallbladder was retrieved through the umbilical fascial defect and submitted to Pathology. The camera was placed back once again into the abdominal cavity through the umbilical port, and all areas remained clean and dry and the trocar was removed under direct visualization. The insufflation was allowed to escape. The umbilical fascia was closed using interrupted #1 Vicryl sutures. Finally, the skin was closed in a layered subcuticular fashion with interrupted 3-0 and 4-0 Monocryl. Sterile dressings were applied. The patient tolerated the procedure well.,

INDICATIONS FOR PROCEDURE:, This is a 61-year-old, white male with onset of chest pain at 04: 30 this morning, with history of on and off chest discomfort over the past several days. CPK is already over 1000. There is ST elevation in leads II and aVF, as well as a Q wave. The chest pain is now gone, mild residual shortness of breath, no orthopnea. Cardiac monitor shows resolution of ST elevation lead III.,DESCRIPTION OF PROCEDURE:, Following sterile prep and drape of the right groin, installation of 1% Xylocaine anesthesia, the right common femoral artery was percutaneously entered and 6-French sheath inserted. ACT approximately 165 seconds on heparin. Borderline hypotension 250 mL fluid bolus given and nitroglycerin patch removed. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricular pressures and left ventriculography. Left pullback pressure. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. He tolerated the procedure well and was transported to the Cardiac Step-Down Unit in stable condition.,HEMODYNAMIC DATA:, Left ventricular end diastolic pressure elevated post A-wave at 25 mm of Mercury with no aortic valve systolic gradient on pullback.,ANGIOGRAPHIC FINDINGS:,I. Left coronary artery: The left main coronary artery is unremarkable. The left anterior descending has 30 to 40% narrowing with tortuosity in its proximal portion, patent first septal perforator branch. The first diagonal branch is a 2 mm vessel with a 90% ostial stenosis. The second diagonal branch is unremarkable, as are the tiny distal diagonal branches. The intermediate branch is a small, normal vessel. The ostial non-dominant circumflex has some contrast thinning, but no stenosis, normal obtuse marginal branch, and small AV sulcus circumflex branch.,II. Right coronary artery: The right coronary artery is a large, dominant vessel which gives off large posterior descending and posterolateral left ventricular branches. There are luminal irregularities, less than 25%, within the proximal to mid vessel. Some contrast thinning is present in the distal RCA just before the bifurcation into posterior descending and posterolateral branches. A 25%, smooth narrowing at the origin of the posterior descending branch. Posterolateral branch is unremarkable and quite large, with secondary and tertiary branches.,III. Left ventriculogram: The left ventricle is normal in size. Ejection fraction estimated at 40 to 45%. No mitral regurgitation. Severe hypokinesis to akinesis is present in the posterobasal and posteromedial segments with normal anteroapical wall motion.,DISCUSSION:, Recent inferior myocardial infarction with only minor contrast thinning distal RCA remaining on coronary angiography with resolution of chest pain and ST segment elevation. Left coronary system has one hemodynamically significant stenosis (a 90% ostial stenosis at the first diagonal branch, which is a 2 mm vessel). Left ventricular function is reduced with ejection fraction 40 to 45% with inferior wall motion abnormality.,PLAN:, Medical treatment, including Plavix and nitrates, in addition to beta blocker, aspirin, and aggressive lipid reduction.

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

PREOPERATIVE DIAGNOSES:,1. Hallux valgus, right foot.,2. Hallux interphalangeus, right foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux valgus, right foot.,2. Hallux interphalangeus, right foot.,PROCEDURES PERFORMED:,1. Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2. Akin bunionectomy, right toe with internal wire fixation.,ANESTHESIA: , TIVA/local.,HISTORY: ,This 51-year-old female presents to ABCD preoperative holding area after keeping herself NPO since mid night for a surgery on her painful bunion through her right foot. The patient has a history of gradual onset of a painful bunion over the past several years. She has tried conservative methods such as wide shoes, accommodative padding on an outpatient basis with Dr. X all of which have provided inadequate relief. At this time, she desires attempted surgical correction. The risks versus benefits of the procedure have been discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operative table in supine position and a safety strap was placed across her waist for her protection. Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was placed over the Webril.,After adequate IV sedation was administered by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 0.5% Marcaine plain and 1% Lidocaine plain was injected into the foot in a standard Mayo block fashion. The foot was elevated off the table. Esmarch bandages were used to exsanguinate the right foot. The pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered in the operative field and the sterile stockinet was reflected. A sterile Betadine was wiped away with a wet and dry sponge and one toothpick was used to test anesthesia, which was found to be adequate. Attention was directed to the first metatarsophalangeal joint, which was found to be contracted, laterally deviated, and had decreased range of motion. A #10 blade was used to make a 4 cm dorsolinear incision. A #15 blade was used to deepen the incision through the subcutaneous layer. All superficial subcutaneous vessels were ligated with electrocautery. Next, a linear capsular incision was made down the bone with a #15 blade. The capsule was elevated medially and laterally off the metatarsal head and the metatarsal head was delivered into the wound. A hypertrophic medial eminence was resected with a sagittal saw taking care not to strike the head. The medial plantar aspect of the metatarsal head had some erosive changes and eburnation. Next, a 0.45 inch Kirschner wire was placed with some access guide slightly plantar flexing the metatarsal taking care not to shorten it. A sagittal saw was used to make a long-arm Austin osteotomy in the usual fashion. Standard lateral release was also performed as well as a lateral capsulotomy freeing the fibular sesamoid complex.,The capital head was shifted laterally and impacted on the residual metatarsal head. Nice correction was achieved and excellent bone to bone contact was achieved. The bone stock was slightly decreased, but adequate. Next, a 0.45 inch Kirschner wire was used to temporarily fixate the metatarsal capital fragment. A 2.7 x 18 mm Synthes cortical screw was thrown using standard AO technique. Excellent rigid fixation was achieved. A second 2.0 x 80 mm Synthes fully threaded cortical screw was also thrown using standard AO technique at the proximal aspect of the metatarsal head. Again, an excellent rigid fixation was obtained and the screws were tight. The temporary fixation was removed. A medial overhanging bone was resected with a sagittal saw. The foot was loaded and the hallux was found to have an interphalangeus deformity present.,A sagittal saw was used to make a proximal cut in approximately 1 cm dorsal to the base of the proximal phalanx, leaving a lateral intact cortical hinge. A distal cut parallel with the nail base was performed and a standard proximal Akin osteotomy was done.,After the wedge bone was removed, the saw blade was reinserted and used to tether the osteotomy with counter-pressure used to close down the osteotomy. A #15 drill blade was used to drill two converging holes on the medial aspect of the bone. A #28 gauge monofilament wire was inserted loop to loop and pulled through the bone. The monofilament wire was twisted down and tapped into the distal drill hole. The foot was loaded again and the toe had an excellent cosmetic straight appearance and the range of motion of the first metatarsophalangeal joint was then improved. Next, reciprocating rasps were used to smooth all bony surfaces. Copious amounts of sterile saline was used to flush the joint. Next, a #3-0 Vicryl was used to reapproximate the capsular periosteal tissue layer. Next, #4-0 Vicryl was used to close the subcutaneous layer. #5-0 Vicryl was used to the close the subcuticular layer in a running fashion. Next, 1 cc of dexamethasone phosphate was then instilled in the joint. The Steri-Strips were applied followed by standard postoperative dressing consisting of Owen silk, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits. The patient tolerated the above anesthesia and procedure without complications. She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot. She is to be partial weightbearing with crutches. She is to follow with Dr. X. She was given emergency contact numbers and instructions to call if problems arise. She was given prescription for Vicodin ES #25 one p.o. q.4-6h. p.r.n. pain and Naprosyn one p.o. b.i.d. 500 mg. She was discharged in stable condition.

REASON FOR CONSULTATION: , Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.,HISTORY OF PRESENT ILLNESS:, This is a 66-year-old Native American gentleman, a patient of Dr. X, my associate, who has a past medical history of coronary artery disease, status post stent placement, admitted with chest pressure around 4 o'clock last night. He took some nitroglycerin tablets at home with no relief. He came to the ER. He is going to have a coronary angiogram done today by Dr. Y. I have seen this patient first time in the morning, approximately around the 4 o'clock. This is a late entry dictation. Presently lying in bed, but he feels fine. Denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea. Denies hematuria, dysuria, or bright red blood per rectum.,PAST MEDICAL HISTORY:,1. Coronary artery disease, status post stent placement two years ago.,2. Diabetes mellitus for the last 12 years.,3. Hypertension.,4. End-stage renal disease.,5. History of TIA in the past.,PAST SURGICAL HISTORY:,1. As mentioned above.,2. Cholecystectomy.,3. Appendectomy.,4. Right IJ PermaCath placement.,5. AV fistula graft in the right wrist.,PERSONAL AND SOCIAL HISTORY:, He smoked 2 to 3 packets per day for at least last 10 years. He quit smoking roughly about 20 years ago. Occasional alcohol use.,FAMILY HISTORY: , Noncontributory.,ALLERGIES: ,No known drug allergies.,MEDICATIONS AT HOME: , Metoprolol, Plavix, Rocaltrol, Lasix, Norvasc, Zocor, hydralazine, calcium carbonate, and loratadine.,PHYSICAL EXAMINATION,GENERAL: He is alert, seems to be in no apparent distress.,VITAL SIGNS: Temperature 98.2, pulse 61, respiratory 20, and blood pressure 139/63.,HEENT: Atraumatic and normocephalic.,NECK: No JVD, no thyromegaly, supra and infraclavicular lymphadenopathy.,LUNGS: Clear to auscultation. Air entry bilateral equal.,HEART: S1 and S2. No pericardial rub.,ABDOMEN: Soft and nontender. Normal bowel sounds.,EXTREMITIES: No edema.,NEUROLOGIC: The patient is alert without focal deficit.,LABORATORY DATA:, Laboratory data shows hemoglobin 13, hematocrit 38.4, sodium 130, potassium 4.2, chloride 96.5, carbonate 30, BUN 26, creatinine 6.03, and glucose 162.,IMPRESSION:,1. End-stage renal disease, plan for dialysis today.,2. Diabetes mellitus.,3. Chest pain for coronary angiogram today.,4. Hypertension, blood pressure stable.,PLAN: , Currently follow the patient. Dr. Z is going to assume the care.

REASON FOR CONSULTATION: , Syncope.,HISTORY OF PRESENT ILLNESS: ,The patient is a 69-year-old gentleman, a good historian, who relates that he was brought in the Emergency Room following an episode of syncope. The patient relates that he may have had a seizure activity prior to that. Prior to the episode, he denies having any symptoms of chest pain or shortness of breath. No palpitation. Presently, he is comfortable, lying in the bed. As per the patient, no prior cardiac history.,CORONARY RISK FACTORS: , History of hypertension. No history of diabetes mellitus. Nonsmoker. Cholesterol status is borderline elevated. No history of established coronary artery disease. Family history noncontributory.,PAST MEDICAL HISTORY: ,Hypertension, hyperlipidemia, recently diagnosed with Parkinson's, as a Parkinson's tremor, admitted for syncopal evaluation.,PAST SURGICAL HISTORY: ,Back surgery, shoulder surgery, and appendicectomy.,FAMILY HISTORY: , Nonsignificant.,MEDICATIONS:,1. Pain medications.,2. Thyroid supplementation.,3. Lovastatin 20 mg daily.,4. Propranolol 20 b.i.d.,5. Protonix.,6. Flomax.,ALLERGIES:, None.,PERSONAL HISTORY:, He is married. Nonsmoker. Does not consume alcohol. No history of recreational drug use.,REVIEW OF SYSTEMS,CONSTITUTIONAL: No weakness, fatigue, or tiredness.,HEENT: No history of cataract or glaucoma.,CARDIOVASCULAR: No congestive heart failure. No arrhythmias.,RESPIRATORY: No history of pneumonia or valley fever.,GASTROINTESTINAL: No nausea, vomiting, hematemesis, or melena.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: Arthritis and muscle weakness.,SKIN: Nonsignificant.,NEUROLOGIC: No TIA or CVA. No seizure disorder.,ENDOCRINE/HEMATOLOGIC: Nonsignificant.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 93, blood pressure of 158/93, afebrile, and respiratory rate 16 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Neck veins are flat. No significant carotid bruits.,LUNGS: Air entry is bilaterally decreased.,HEART: PMI is displaced. S1 and S2 are regular.,ABDOMEN: Soft and nontender. Bowel sounds are present.,EXTREMITIES: No edema. Pulses are palpable. No clubbing or cyanosis. The patient is moving all extremities; however, the patient has tremors.,RADIOLOGICAL DATA: , EKG reveals normal sinus rhythm with underlying nonspecific ST-T changes secondary to tremors.,LABORATORY DATA: , H&H stable. White count of 14. BUN and creatinine are within normal limits. Cardiac enzyme profile is negative. Ammonia level is elevated at 69. CT angiogram of the chest, no evidence of pulmonary embolism. Chest x-ray is negative for acute changes. CT of the head, unremarkable, chronic skin changes. Liver enzymes are within normal limits.,IMPRESSION:,1. The patient is a 69-year-old gentleman, admitted with syncopal episode and possible seizure disorder.

CHIEF COMPLAINT: , Burn, right arm.,HISTORY OF PRESENT ILLNESS: , This is a Workers' Compensation injury. This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. He has had it cooled, and presents with his friend to the Emergency Department for care.,PAST MEDICAL HISTORY: ,Noncontributory.,MEDICATIONS: ,None.,ALLERGIES: ,None.,PHYSICAL EXAMINATION: , GENERAL: Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative. His only injury is to the right upper extremity. There are first and second degree burns on the right forearm, ranging from the elbow to the wrist. Second degree areas with blistering are scattered through the medial aspect of the forearm. There is no circumferential burn, and I see no areas of deeper burn. The patient moves his hands well. Pulses are good. Circulation to the hand is fine.,FINAL DIAGNOSIS:,1. First-degree and second-degree burns, right arm secondary to hot oil spill.,2. Workers' Compensation industrial injury.,TREATMENT: , The wound is cooled and cleansed with soaking in antiseptic solution. The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication. A burn dressing is applied with Neosporin ointment. The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain. He is to return tomorrow for a dressing change. Tetanus immunization is up to date. Preprinted instructions are given. Workers' Compensation first report and work status report are completed.,DISPOSITION: , Home.

HISTORY: ,This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema. No confirmed prior history of heart attack, myocardial infarction, heart failure. History dates back to about six months of intermittent shortness of breath, intermittent very slight edema with shortness of breath. The blood pressure was up transiently last summer when this seemed to start and she was asked not to take Claritin-D, which she was taking for what she presumed was allergies. She never had treated hypertension. She said the blood pressure came down. She is obviously very hypertensive this evening. She has some mid scapular chest discomfort. She has not had chest pain, however, during any of the other previous symptoms and spells.,CARDIAC RISKS:, Does not smoke, lipids unknown. Again, no blood pressure elevation, and she is not diabetic.,FAMILY HISTORY:, Negative for coronary disease. Dad died of lung cancer.,DRUG SENSITIVITIES:, Penicillin.,CURRENT MEDICATIONS: , None.,SURGICAL HISTORY:, Cholecystectomy and mastectomy for breast cancer in 1992, no recurrence.,SYSTEMS REVIEW: , Did not get headaches or blurred vision. Did not suffer from asthma, bronchitis, wheeze, cough but short of breath as described above. No reflux, abdominal distress. No other types of indigestion, GI bleed. GU: Negative. She is unaware of any kidney disease. Did not have arthritis or gout. No back pain or surgical joint treatment. Did not have claudication, carotid disease, TIA. All other systems are negative.,PHYSICAL FINDINGS,VITAL SIGNS: Presenting blood pressure was 170/120 and her pulse at that time was 137. Temperature was normal at 97, and she was obviously in major respiratory distress and hypoxemic. Saturation of 86%. Currently, blood pressure 120/70, heart rate is down to 100.,EYES: No icterus or arcus.,DENTAL: Good repair.,NECK: Neck veins, cannot see JVD, at this point, carotids, no bruits, carotid pulse brisk.,LUNGS: Fine and coarse rales, lower two thirds of chest.,HEART: Diffuse cardiomegaly without a sustained lift, first and second heart sounds present, second is split. There is loud third heart sound. No murmur.,ABDOMEN: Overweight, guess you would say obese, nontender, no liver enlargement, no bruits.,SKELETAL: No acute joints.,EXTREMITIES: Good pulses. No edema.,NEUROLOGICALLY: No focal weakness.,MENTAL STATUS: Clear.,DIAGNOSTIC DATA: , 12-lead ECG, left bundle-branch block.,LABORATORY DATA:, All pending.,RADIOGRAPHIC DATA: , Chest x-ray, pulmonary edema, cardiomegaly.,IMPRESSION,1. Acute pulmonary edema.,2. Physical findings of dilated left ventricle.,3. Left bundle-branch block.,4. Breast cancer in 1992.,PLAN: ,Admit. Aggressive heart failure management. Get echo. Start ACE and Coreg. Diuresis of course underway.

PROCEDURE NOTE:, The patient was brought to the transesophageal echo laboratory after informed consent was obtained. The patient was seen by Anesthesia for MAC anesthesia. The patient's posterior pharynx was anesthetized with local Cetacaine spray. The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.,FINDINGS: ,1. Left ventricle is normal in size and function; ejection fraction approximately 60%.,2. Right ventricle is normal in size and function.,3. Left atrium and right atrium are normal in size.,4. Mitral valve, aortic valve, tricuspid valve, and pulmonic valve with no evidence of vegetation. Aortic valve is only minimally thickened.,5. Mild mitral regurgitation and mild tricuspid regurgitation.,6. No left ventricular thrombus.,7. No pericardial effusion.,8. There is evidence of patent foramen ovale by contrast study.,The patient tolerated the procedure well and is sent to recovery in stable condition. He should be n.p.o. x4 hours, then liquid, then increase as tolerated. Once his infection is cleared, he should follow up with us with regard to followup of patent foramen ovale.

ADMISSION DIAGNOSES:,1. Seizure.,2. Hypoglycemia.,3. Anemia.,4. Hypotension.,5. Dyspnea.,6. Edema.,DISCHARGE DIAGNOSES:,1. Colon cancer, status post right hemicolectomy.,2. Anemia.,3. Hospital-acquired pneumonia.,4. Hypertension.,5. Congestive heart failure.,6. Seizure disorder.,PROCEDURES PERFORMED:,1. Colonoscopy.,2. Right hemicolectomy.,HOSPITAL COURSE: , The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD, bipolar disorder, and anemia. She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia. Regarding the seizure disorder, Neurology was consulted. Noncontrast CT of the head was negative. Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d. Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour. Her insulin pump had a basal rate of roughly three at night during the feedings. While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times. She seemed to tolerate the insulin pump rate well throughout her hospital course. There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course.,At discharge, her endocrinologist was contacted. It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m., from 0.8 units per hour from 6 a.m. until 8 a.m., and then at 0.2 units per hour from 8 a.m. until 6 p.m. The insulin was to be NovoLog. Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools. A colonoscopy was performed, which found a mass at the right hepatic flexure. General Surgery was then consulted and a right hemicolectomy was performed on the patient. The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour. Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer. CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis. Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia. She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well. Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness. The patient was seen by the Infectious Disease specialist. The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site. At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours. The Bactrim was used to cover the MRSA at the J-tube site. It was found that MRSA was sensitive to Bactrim. Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable. She also received Lipitor for her high cholesterol. Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night. The dosage increases can begin on an outpatient basis.,DISCHARGE INSTRUCTIONS/MEDICATIONS: , The patient was discharged to home. She was told to shy away from strenuous activity. Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night. The discharge medications were as follows:,1. Coreg 12.5 mg p.o. b.i.d.,2. Lipitor 10 mg p.o. at bedtime.,3. Nitro-Dur patch 0.3 mg per hour one patch daily.,4. Phenergan syrup 6.25 mg p.o. q.4h. p.r.n.,5. Synthroid 0.175 mg p.o. daily.,6. Zyrtec 10 mg p.o. daily.,7. Lamictal 100 mg p.o. daily.,8. Lamictal 150 mg p.o. at bedtime.,9. Ferrous sulfate drops 325 mg, PEG tube b.i.d.,10. Nexium 40 mg p.o. at breakfast.,11. Neurontin 400 mg p.o. t.i.d.,12. Lasix 40 mg p.o. b.i.d.,13. Fentanyl 50 mcg patch transdermal q.72h.,14. Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d.,15. Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days.,16. Levaquin 750 mg one tablet p.o. x3 days.,The medications listed above, one listed as p.o. are to be administered via the J-tube.,FOLLOWUP: ,The patient was instructed to see Dr. X in approximately five to seven days. She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X. She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer. She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes. We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment. She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.,CONDITION ON DISCHARGE: , Stable.

REFERRING DIAGNOSIS: , Motor neuron disease.,PERTINENT HISTORY AND EXAMINATION:, Briefly, the patient is an 83-year-old woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.,SUMMARY: ,The right median sensory response showed a borderline normal amplitude for age with mild slowing of conduction velocity. The right ulnar sensory amplitude was reduced with slowing of the conduction velocity. The right radial sensory amplitude was reduced with slowing of the conduction velocity. The right sural and left sural sensory responses were absent. The right median motor response showed a prolonged distal latency across the wrist, with proximal slowing. The distal amplitude was very reduced, and there was a reduction with proximal stimulation. The right ulnar motor amplitude was borderline normal, with slowing of the conduction velocity across the elbow. The right common peroneal motor response showed a decreased amplitude when recorded from the EDB, with mild slowing of the proximal conduction velocity across the knee. The right tibial motor response showed a reduced amplitude with prolongation of the distal latency. The left common peroneal response recorded from the EDB showed a decreased amplitude with mild distal slowing. The left tibial motor response showed a decreased amplitude with a borderline normal distal latency. The minimum F-wave latencies were normal with the exception of a mild prolongation of the ulnar F-wave latency, and the tibial F-wave latency as indicated above. With repetitive nerve stimulation, there was no significant decrement noted in either the right nasalis or the right trapezius muscles. Concentric needle EMG studies were performed in the right lower extremity, right upper extremity, thoracic paraspinals, and in the tongue. There was evidence of increased insertional activity in the right tibialis anterior muscle, with evidence of fasciculations noted in several lower and upper extremity muscles and in the tongue. In addition, there was evidence of increased amplitude, long duration and polyphasic motor units with a decreased recruitment noted in most muscles tested as indicated in the table above.,INTERPRETATION: , Abnormal electrodiagnostic study. There is electrodiagnostic evidence of a disorder of the anterior motor neurons affecting at least four segments. There is also evidence of a more generalized neuropathy that seems to be present in both the upper and lower extremities. There is also evidence of a right median mononeuropathy at the wrist and a right ulnar neuropathy at the elbow. Even despite the patient's age, the decrease in sensory responses is concerning, and makes it difficult to be certain about the diagnosis of motor neuron disease. However, the overall changes on the needle EMG would be consistent with a diagnosis of motor neuron disease. The patient will return for further evaluation.

CC:, Progressive visual loss.,HX:, 76 y/o male suddenly became anosmic following shoulder surgery 13 years prior to this presentation. He continues to be anosmic, but has also recently noted decreased vision OD. He denies any headaches, weakness, numbness, weight loss, or nasal discharge.,MEDS:, none.,PMH:, 1) Diabetes Mellitus dx 1 year ago. 2) Benign Prostatic Hypertrophy, s/p TURP. 3) Right shoulder surgery (?DJD).,FHX:, noncontributory.,SHX:, Denies history of Tobacco/ETOH/illicit drug use.,EXAM:, BP132/66 HR78 RR16 36.0C,MS: A&O to person, place, and time. No other specifics given in Neurosurgery/Otolaryngology/Neuro-ophthalmology notes.,CN: Visual acuity has declined from 20/40 to 20/400, OD; 20/30, OS. No RAPD. EOM was full and smooth and without nystagmus. Goldmann visual fields revealed a central scotoma and enlarged blind spot OD and OS (OD worse) with a normal periphery. Intraocular pressures were 15/14 (OD/OS). There was moderate pallor of the disc, OD. Facial sensation was decreased on the right side (V1 distribution).,Motor/Sensory/Coord/Station/Gait: were all unremarkable.,Reflexes: 2/2 and symmetric throughout. Plantars were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, MRI Brain, 10/7/92, revealed: a large 6x5x6cm slightly heterogeneous, mostly isointense lesion on both T1 and T2 weighted images arising from the planum sphenoidale and olfactory groove. The mass extends approximately 3.6cm superior to the planum into both frontal regions with edema in both frontal lobes. The mass extends 2.5cm inferiorly involving the ethmoid sinuses with resultant obstruction of the sphenoid and frontal sinuses.,It also extends into the superomedial aspect of the right maxillary sinus. There is probable partial encasement of both internal carotid arteries just above the siphon. The optic nerves are difficult to visualize but there is also probable encasement of these structures as well. The mass enhances significantly with gadolinium contrast. These finds are consistent with Meningioma.,The patient underwent excision of this tumor by simultaneous bifrontal craniotomy and lateral rhinotomy following an intrasinus biopsy which confirmed the meningioma. Postoperatively, he lost visual acuity, OS, but this gradually returned to baseline. His 9/6/96 neuro-ophthalmology evaluation revealed visual acuity of 20/25-3 (OD) and 20/80-2 (OS). His visual fields continued to abnormal, but improved and stable when compared to 10/92. His anosmia never resolved.

ALLOWED CONDITION: , Right shoulder sprain and right rotator cuff tear (partial).,CONTESTED CONDITION:, AC joint arthrosis right aggravation.,DISALLOWED CONDITION: ,

ADMITTING DIAGNOSIS: , Kawasaki disease.,DISCHARGE DIAGNOSIS:, Kawasaki disease, resolving.,HOSPITAL COURSE:, This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR. When he was sent to the hospital, he had a fever of 102. Subsequently, the patient was evaluated and based on the criteria, he was started on high dose of aspirin and IVIG. Echocardiogram was also done, which was negative. IVIG was done x1, and between 12 hours of IVIG, he spiked fever again; it was repeated twice, and then after second IVIG, he did not spike any more fever. Today, his fever and his rash have completely resolved. He does not have any conjunctivitis and no redness of mucous membranes. He is more calm and quite and taking good p.o.; so with a very close followup and a cardiac followup, he will be sent home.,DISCHARGE ACTIVITIES:, Ad-lib.,DISCHARGE DIET: , PO ad-lib.,DISCHARGE MEDICATIONS: , Aspirin high dose 340 mg q.6h. for 1 day and then aspirin low dose 40 mg q.d. for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p.o. once a day. He will be followed by his primary doctor in 2 to 3 days. Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG, all the live virus vaccine, and if he gets any rashes, any fevers, should go to primary care doctor as soon as possible.

HISTORY:, Smoking history zero.,INDICATION: , Dyspnea with walking less than 100 yards.,PROCEDURE:, FVC was 59%. FEV1 was 61%. FEV1/FVC ratio was 72%. The predicted was 70%. The FEF 25/75% was 45%, improved from 1.41 to 2.04 with bronchodilator, which represents a 45% improvement. SVC was 69%. Inspiratory capacity was 71%. Expiratory residual volume was 61%. The TGV was 94%. Residual volume was 113% of its predicted. Total lung capacity was 83%. Diffusion capacity was diminished.,IMPRESSION:,1. Moderate restrictive lung disease.,2. Some reversible small airway obstruction with improvement with bronchodilator.,3. Diffusion capacity is diminished, which might indicate extrapulmonary restrictive lung disease.,4. Flow volume loop was consistent with the above and no upper airway obstruction.,

REASON FOR VISIT:, Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,HISTORY OF PRESENT ILLNESS: , The patient is now approximately week status post removal of Ex-Fix from the right knee with an MUA following open reduction internal fixation of right tibial plateau fracture. The patient states that this pain is well controlled. He has had no fevers, chills or night sweats. He has had some mild drainage from his pin sites. He just started doing range of motion type exercises for his right knee. He has had no numbness or tingling.,FINDINGS: , On exam, his pin sites had no erythema. There is some mild drainage but they have been dressing with bacitracin, it looks like there may be part of the fluid noted. The patient had 3/5 strength in the EHL, FHL. He has intact sensation to light touch in a DP, SP, and tibial nerve distribution.,X-rays taken include three views of the right knee. It demonstrate status post open reduction internal fixation of the right tibial plateau with excellent hardware placement and alignment.,ASSESSMENT: , Status post open reduction and internal fixation of right tibial plateau fracture with removal ex fix.,PLANS: , I gave the patient a prescription for aggressive range of motion of the right knee. I would like to really work on this as he has not had much up to this time. He should remain nonweightbearing. I would like to have him return in 2 weeks' time to assess his knee range of motion. He should not need x-rays at that time.

REASON FOR CONSULTATION: , Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.,HISTORY OF PRESENT ILLNESS:, This is a 66-year-old Native American gentleman, a patient of Dr. X, my associate, who has a past medical history of coronary artery disease, status post stent placement, admitted with chest pressure around 4 o'clock last night. He took some nitroglycerin tablets at home with no relief. He came to the ER. He is going to have a coronary angiogram done today by Dr. Y. I have seen this patient first time in the morning, approximately around the 4 o'clock. This is a late entry dictation. Presently lying in bed, but he feels fine. Denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea. Denies hematuria, dysuria, or bright red blood per rectum.,PAST MEDICAL HISTORY:,1. Coronary artery disease, status post stent placement two years ago.,2. Diabetes mellitus for the last 12 years.,3. Hypertension.,4. End-stage renal disease.,5. History of TIA in the past.,PAST SURGICAL HISTORY:,1. As mentioned above.,2. Cholecystectomy.,3. Appendectomy.,4. Right IJ PermaCath placement.,5. AV fistula graft in the right wrist.,PERSONAL AND SOCIAL HISTORY:, He smoked 2 to 3 packets per day for at least last 10 years. He quit smoking roughly about 20 years ago. Occasional alcohol use.,FAMILY HISTORY: , Noncontributory.,ALLERGIES: ,No known drug allergies.,MEDICATIONS AT HOME: , Metoprolol, Plavix, Rocaltrol, Lasix, Norvasc, Zocor, hydralazine, calcium carbonate, and loratadine.,PHYSICAL EXAMINATION,GENERAL: He is alert, seems to be in no apparent distress.,VITAL SIGNS: Temperature 98.2, pulse 61, respiratory 20, and blood pressure 139/63.,HEENT: Atraumatic and normocephalic.,NECK: No JVD, no thyromegaly, supra and infraclavicular lymphadenopathy.,LUNGS: Clear to auscultation. Air entry bilateral equal.,HEART: S1 and S2. No pericardial rub.,ABDOMEN: Soft and nontender. Normal bowel sounds.,EXTREMITIES: No edema.,NEUROLOGIC: The patient is alert without focal deficit.,LABORATORY DATA:, Laboratory data shows hemoglobin 13, hematocrit 38.4, sodium 130, potassium 4.2, chloride 96.5, carbonate 30, BUN 26, creatinine 6.03, and glucose 162.,IMPRESSION:,1. End-stage renal disease, plan for dialysis today.,2. Diabetes mellitus.,3. Chest pain for coronary angiogram today.,4. Hypertension, blood pressure stable.,PLAN: , Currently follow the patient. Dr. Z is going to assume the care.

DIAGNOSIS: , Status post brain tumor with removal.,SUBJECTIVE: ,The patient is a 64-year-old female with previous medical history of breast cancer that has metastasized to her lung, liver, spleen, and brain, status post radiation therapy. The patient stated that on 10/24/08 she had a brain tumor removed with subsequent left-sided weakness. The patient was readmitted to ABC Hospital on 12/05/08 and was found to have massive swelling in the brain and a second surgery was performed to reduce the swelling. The patient remained at the acute rehab at ABC until she was discharged home on 01/05/09. The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function. The patient also complains of difficulty with word retrieval and slurring of speech. The patient denies any difficulty with swallowing at this time.,OBJECTIVE: ,Portions of the cognitive linguistic quick test was administered. An oral mechanism exam was performed. A motor speech protocol was completed.,The cognitive linguistic subtests of recalling personal facts, symbol cancellation, confrontational naming, clock drawing, story retelling, generative naming, design and memory, and completion of mazes was administered.,The patient was 100% accurate with recalling personal facts, completion of the symbol cancellation tasks, and with confrontational naming. She had no difficulty with the clock drawing task; however, she has considerable hand tremors, which makes writing difficult. In the storytelling task, she scored within normal limits. She was also within normal limits for generative naming. She did have difficulty with the design, memory, and mazes subtests. She was unable to complete the second maze during the allotted time. The design generation subtest was also completed. She was able to draw four unique designs, and toward the end of the tasks was no longer able to recall the stated direction.,ORAL MECHANISM EXAMINATION:, The patient has mild left facial droop with decreased nasolabial fold. Tongue is at midline, and lingual range of motion and strength are within functional limit. The patient does complain of biting her tongue on occasion, but denied biting the inside of her cheeks. Her AMRs are judged to be within functional limit. Her rate of speech is decreased with a monotonous vocal quality. The decreased rate may be a compensation for decreased word retrieval ability. The patient's speech is judged to be 100% intelligible without background noise.,DIAGNOSTIC IMPRESSION: ,The patient has mild cognitive linguistic deficits in the areas of higher level cognitive function seen in mental flexibility, memory, and executive function.,PLAN OF CARE:, Outpatient skilled speech therapy two times a week for four weeks to include cognitive linguistic treatment.,SHORT-TERM GOALS (THREE WEEKS):,1. The patient will complete deductive reasoning and mental flexibility tasks with greater than 90% accuracy, independently.,2. The patient will complete perspective memory test with 100% accuracy using compensatory strategy.,3. The patient will complete visual perceptual activities, which focus on scanning, flexibility, and problem solving with greater than 90% accuracy with minimal cueing.,4. The patient will listen to and/or read a lengthy narrative and be able to recall at least 6 details after a 15-minute delay, independently.,PATIENT'S GOAL: ,To improve functional independence and cognitive abilities.,LONG-TERM GOAL (FOUR WEEKS): ,Functional cognitive linguistic abilities to improve safety and independence at home and to decrease burden of care on caregiver.,

PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS: , A 1-year-10-month-old with a history of dysphagia to solids. The procedure was done to rule out organic disease.,POSTOPERATIVE DIAGNOSES: , Loose lower esophageal sphincter and duodenal ulcers.,CONSENT: , The consent is signed.,MEDICATIONS: ,The procedure was done under general anesthesia given by Dr. Marino Fernandez.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL:, A history and physical examination were performed, and the procedure, indications, potential complications including bleeding, perforation, the need for surgery, infection, adverse medical reaction, risks, benefits, and alternatives available were explained to the parents, who stated good understanding and consented to go ahead with the procedure. The opportunity for questions was provided, and informed consent was obtained. Once the consent was obtained, the patient was sedated with IV medications and intubated by Dr. Fernandez and placed in the supine position. Then, the tip of the XP-160 videoscope was introduced into the oropharynx, and under direct visualization, we could advance the endoscope into the upper, mid, and lower esophagus. We did not find any strictures in the upper esophagus, but the patient had the lower esophageal sphincter totally loose. Then the tip of the endoscope was advanced down into the stomach and guided into the pylorus, and then into the first portion of the duodenum. We noticed that the patient had several ulcers in the first portion of the duodenum. Then the tip of the endoscope was advanced down into the second portion of the duodenum, one biopsy was taken there, and then, the tip of the endoscope was brought back to the first portion, and two biopsies were taken there. Then, the tip of the endoscope was brought back to the antrum, where two biopsies were taken, and one biopsy for CLOtest. By retroflexed view, at the level of the body of the stomach, I could see that the patient had the lower esophageal sphincter loose. Finally, the endoscope was unflexed and was brought back to the lower esophagus, where two biopsies were taken. At the end, air was suctioned from the stomach, and the endoscope was removed out of the patient's mouth. The patient tolerated the procedure well with no complications.,FINAL IMPRESSION: ,1. Duodenal ulcers.,2. Loose lower esophageal sphincter.,PLAN:,1. To start omeprazole 20 mg a day.,2. To review the biopsies.,3. To return the patient back to clinic in 1 to 2 weeks.

PREOPERATIVE DIAGNOSIS:, Subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: , Subglottic stenosis.,OPERATIVE PROCEDURES: , Direct laryngoscopy and bronchoscopy.,ANESTHESIA:, General inhalation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operative table. General inhalational anesthesia was administered through the patient's tracheotomy tube. The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway. There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds. The stoma showed some suprastomal fibroma. The remaining tracheobronchial passages were clear. The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties. Bleeding was negligible. There were no untoward complications. The patient tolerated the procedure well and was transferred to recovery room in stable condition.

REASON FOR REFERRAL: , Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,HISTORY:, This is a 77-year-old white female patient whom I have known for the last about a year or so who has underlying multiple medical problems including hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post aortocoronary bypass surgery about eight years ago at Halifax Medical Center where she had triple vessel bypass surgery with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the left circumflex and right coronary arteries. Since then, she has generally done well. She used to be seeing another cardiologist and apparently she had a stress test in September 2008 and she was otherwise cardiac catheterization and coronary angiography, but the patient declined to have one done and since then she has been on medical therapy.,The patient had been on medical therapy at home and generally doing well. Recently, she had no leg swelling, undue exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea. She denies any rest or exertional chest discomfort. Yesterday evening, she had her dinner and she was sitting around and she felt discomfort in the chest at about 7:00 p.m. The discomfort was a crampy pain in the left lower quadrant area, which seemed to radiating to the center of the abdomen and to the right side and it was off and on lasting for a few minutes at a time and then subsiding. Later on she was nauseous, but she did not have any vomiting. She denied any diarrhea. No history of fever or chills. Since the pain seemed to persist, the patient came to the hospital emergency room at 11:35 p.m. where she was seen and admitted for the same. She was given morphine, Zofran, Demerol, another Zofran, and Reglan as well as Demerol again and she was given intravenous fluids. Subsequently, her pain finally went away and she does not have any pain since about 7:00 a.m. this morning. The patient was admitted however for further workup and treatment. At the time of my examination this afternoon, the patient is sitting, lying in bed and comfortable and has no abdominal pain of any kind. She has not been fed any food, however. The patient also had had pelvis and abdominal CT scan performed, which has been described to be partial small bowel obstruction, internal hernia, volvulus or adhesion most likely in the left flank area. The patient has had left nephrectomy and splenectomy, which has been described. A 1.5-mm solid mass is described to be in the lower pole of the kidney. The patient also has been described to have diverticulosis without diverticulitis on this finding.,Currently however, the patient has no clinical symptoms according to her.,PAST MEDICAL HISTORY:, She has had hypertension and hyperlipidemia for the last 15 years, diabetes mellitus for the last eight years, and coronary artery disease for last about eight years or so. She had a chest and back pain about eight years ago for about two weeks and then subsequently she was reported to be evaluated. She has a small myocardial infarction and then she was under the care of Dr. A and she had aortocoronary bypass surgery at Halifax Medical Center by Dr. B, which was a three-vessel bypass surgery with left internal mammary artery to the left descending artery and saphenous vein graft to the left circumflex and distal right coronary artery respectively.,She had had nuclear stress test with Dr. C on September 3, 2008, which was described to be abnormal with ischemic defects, but I do not think the patient had any further cardiac catheterization and coronary angiography after that. She has been treated medically.,This patient also had an admission to this hospital in May 2008 also for partial small bowel obstruction and cholelithiasis and sigmoid diverticulosis. She was described to have had a hemorrhagic cyst of the right kidney. She has mild arthritis for the last 10 or 15 years. She has a history of GERD for the last 20 years, and she also has a history of peptic ulcer disease in the duodenum, but never had any bleeding. She has a history of diverticulosis as mentioned. No history of TIA or CVA. She has one kidney. She was in a car accident in 1978 and afterwards she had to have left nephrectomy as well as splenectomy because of rupture. The patient has a history of pulmonary embolism once about eight years ago after her aortocoronary bypass surgery. She describes this to be a clot on left lung. I am not sure if she had any long-term treatment, however.,In the past, the patient had aortocoronary bypass surgery in 2003 and incisional hernia surgery in 1979 as well as hysterectomy in 1979 and she had splenectomy and nephrectomy as described in 1978.,FAMILY HISTORY: , Her father died at age of 65 of massive heart attack and mother died at age of 62 of cancer. She had a one brother who died of massive heart attack in his 50s, a brother died at the age of 47 of cancer, and another brother died in his 60s of possible rupture of appendix.,SOCIAL HISTORY: , The patient is a widow. She lives alone. She does have three daughters, two of them live in Georgia and one lives in Tennessee. She did smoke in the past up to one to one and a half packs of cigarettes per day for about 10 years, but she quit long time ago. She never drank any alcohol. She likes to drink one or two cups of tea in a day.,ALLERGIES: , PAXIL.,MEDICATIONS:, Her home medications prior to coming in include some of the following medications, although the exact list is not available in the chart at this stage, but they have been on glyburide, Januvia, lisinopril, metformin, metoprolol, simvastatin, ranitidine, meloxicam, and furosemide.,REVIEW OF SYSTEMS:, Appetite is good. She sleeps good at night. She has no headaches and she has mild joint pains from arthritis.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 90 per minute and regular, blood pressure 140/90 mmHg, respirations 18, and temperature of 98.5 degree Fahrenheit. Moderate obesity is present.,CARDIAC: Carotid upstroke is slightly diminished, but no clear bruit heard.,LUNGS: Slightly decreased air entry at both bases. No rales or rhonchi heard.,CARDIOVASCULAR: PMI in the left fifth intercostal space in the midclavicular line. Regular heart rhythm. S1 and S2 normal. S4 is present. No S3 heard. Short ejection systolic murmur grade I/VI is present at the left lower sternal border of the apex, peaking in LV systole, no diastolic murmur heard.,ABDOMEN: Soft, obese, no tenderness, no masses felt. Bowel sounds are present.,EXTREMITIES: Bilateral trace edema. The extremities are heavy. There is no pitting at this stage. No clubbing or cyanosis. Distal pulses are fair.,CENTRAL NERVOUS SYSTEM: Without any obvious focal deficits.,LABORATORY DATA: , Includes an electrocardiogram, which shows normal sinus rhythm, left atrial enlargement, and right bundle branch block. This is overall unchanged compared to previous electrocardiogram, which also has the same present. Nuclear stress test from 2008 was described to show ejection fraction of 49% and inferior and posterolateral ischemia. Otherwise, laboratory data includes on this patient at this stage WBC 18.3, hemoglobin 15.5, hematocrit is 47.1, and platelet count is 326,000. Electrolytes, sodium 137, potassium 5.2, chloride 101, CO2 27, BUN 34, creatinine 1.2, calcium 9.5, and magnesium 1.7. AST and ALT are normal. Albumin is 4.1. Lipase and amylase are normal. INR is 0.92. Urinalysis is relatively unremarkable except for trace protein. Chest x-ray has been described to show elevated left hemidiaphragm and median sternotomy sutures. No infiltrates seen. Abdomen and pelvis CAT scan findings are as described before with suggestion of partial small bowel obstruction and internal hernia. Volvulus or adhesions have been considered. Left nephrectomy and splenectomy demonstrated right kidney has a 1.5 cm solid mass at the lower pole suspicious for neoplasm according to the radiologist's description and there is diverticulosis.,IMPRESSION:,1. Coronary artery disease and prior aortocoronary bypass surgery, currently clinically the patient without any angina.,2. Possible small old myocardial infarction.,3. Hypertension with hypertensive cardiovascular disease.,4. Non-insulin-dependent diabetes mellitus.,5. Moderate obesity.,6. Hyperlipidemia.,7. Chronic non-pitting leg edema.,8. Arthritis.,9. GERD and positive history of peptic ulcer disease.,CONCLUSION:,1. Past left nephrectomy and splenectomy after an accident and injury and rupture of the spleen.,2. Abnormal nuclear stress test in September 2008, but no further cardiac studies performed, such as cardiac catheterization.,3. Lower left quadrant pain, which could be due to diverticulosis.,4. Diverticulosis and partial bowel obstruction.,RECOMMENDATION:,1. At this stage, the patient's cardiac medication should be continued if the patient is allowed p.o. intake.

PREOPERATIVE DIAGNOSIS:, Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Pelvic endometriosis.,3. Pelvic adhesions.,PROCEDURE PERFORMED:,1. Laparoscopy.,2. Harmonic scalpel ablation of endometriosis.,3. Lysis of adhesions.,4. Cervical dilation.,ANESTHESIA: ,General.,SPECIMEN: ,Peritoneal biopsy.,ESTIMATED BLOOD LOSS:, Scant.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small, anteverted, and freely mobile uterus with no adnexal masses. Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa. There are adhesions involving the right ovary to the anterior abdominal wall and the bowel. There are also adhesions from the omentum to the anterior abdominal wall near the liver. The uterus and ovaries appear within normal limits other than the adhesions. The left fallopian tube grossly appeared within normal limits. The right fallopian tube was not well visualized but appeared grossly scarred and no tubal end was visualized. There was a large area of endometriosis, approximately 1 cm wide in the left ovarian fossa and there was a small spot of endometriosis in the posterior cul-de-sac. There was also vesicular appearing endometriosis lesion in the posterior cul-de-sac.,PROCEDURE: ,The patient was taken in the operating room and generalized anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. After exam under anesthetic, weighted speculum was placed in the vagina. The anterior lip of the cervix was grasped with vulsellum tenaculum. The uterus was sounded and then was serially dilated with Hank dilators to a size 10 Hank, then the uterine manipulator was inserted and attached to the anterior lip of the cervix. At this point, the vulsellum tenaculum was removed along with the weighted speculum and attention was turned towards the abdomen. An approximately 2 cm incision was made immediately inferior to the umbilicus with the skin knife. The superior aspect of the umbilicus was grasped with a towel clamp. The abdomen was tented up and a Veress needle inserted through this incision. When the Veress needle was felt to be in place, deep position was checked by placing saline in the needle. This was seen to freely drop in the abdomen so it was connected to CO2 gas. Again, this was started at the lowest setting, was seen to flow freely, so it was advanced to the high setting. The abdomen was then insufflated to an adequate distention. Once an adequate distention was reached, the CO2 gas was disconnected. The Veress needle was removed and a size #11 step trocar was placed. Next, the laparoscope was inserted through this port. The medial port was connected to CO2 gas. Next, a 1 cm incision was made in the midline approximately 2 fingerbreadths above the pubic symphysis. Through this, a Veress needle was inserted followed by size #5 step trocar and this procedure was repeated under direct visualization on the right upper quadrant lateral to the umbilicus and a size #5 trocar was also placed. Next, a grasper was placed through the suprapubic port. This was used to grasp the bowel that was adhesed to the right ovary and the Harmonic scalpel was then used to lyse these adhesions. Bowel was carefully examined afterwards and no injuries or bleeding were seen. Next, the adhesions touching the right ovary and anterior abdominal wall were lysed with the Harmonic scalpel and this was done without difficulty. There was a small amount of bleeding from the anterior abdominal wall peritoneum. This was ablated with the Harmonic scalpel. The Harmonic scalpel was used to lyse and ablate the endometriosis in the left ovarian fossa and the posterior cul-de-sac. Both of these areas were seen to be hemostatic. Next, a grasper was placed and was used to bluntly remove the vesicular lesion from the posterior cul-de-sac. This was sent to pathology. Next, the pelvis was copiously irrigated with the Nezhat dorsi suction irrigator and the irrigator was removed. It was seen to be completely hemostatic. Next, the two size #5 ports were removed under direct visualization. The camera was removed. The abdomen was desufflated. The size #11 introducer was replaced and the #11 port was removed.,Next, all the ports were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion. The incisions were dressed with Steri-Strips and bandaged appropriately and the patient was taken to recovery in stable condition and she will be discharged home today with Darvocet for pain and she will follow-up in one week in the clinic for pathology results and to have a postoperative check.

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

CHIEF COMPLAINT:, Sinus problems.,SINUSITIS HISTORY:, The problem began 2 weeks ago and is constant. Symptoms include postnasal drainage, sore throat, facial pain, coughing, headaches and congestion. Additional symptoms include snoring, nasal burning and teeth pain. The symptoms are characterized as moderate to severe. Symptoms are worse in the evening and morning.,REVIEW OF SYSTEMS:,ROS General: General health is good.,ROS ENT: As noted in history of present Illness listed above.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any nausea, vomiting, abdominal pain, dysphagia or any altered bowel movements.,ROS Respiratory: Complaints include coughing.,ROS Neurological: Patient complains of headaches. All other systems are negative.,PAST SURGICAL HISTORY:, Gallbladder 7/82. Hernia 5/79,PAST MEDICAL HISTORY:, Negative.,PAST SOCIAL HISTORY:, Marital Status: Married. Denies the use of alcohol. Patient has a history of smoking 1 pack of cigarettes per day and for the past 15 years. There are no animals inside the home.,FAMILY MEDICAL HISTORY:, Family history of allergies and hypertension.,CURRENT MEDICATIONS:, Claritin. Dilantin.,PREVIOUS MEDICATIONS UTILIZED:, Rhinocort Nasal Spray.,EXAM:,Exam Ear: Auricles/external auditory canals reveal no significant abnormalities bilaterally. TMs intact with no middle ear effusion and are mobile to insufflation.,Exam Nose: Intranasal exam reveals moderate congestion and purulent mucus.,Exam Oropharynx: Examination of the teeth/alveolar ridges reveals missing molar (s). Examination of the posterior pharynx reveals a prominent uvula and purulent postnasal drainage. The palatine tonsils are 2+ and cryptic.,Exam Neck: Palpation of anterior neck reveals no tenderness. Examination of the posterior neck reveals mild tenderness to palpation of the suboccipital muscles.,Exam Facial: There is bilateral maxillary sinus tenderness to palpation.,X-RAY / LAB FINDINGS:, Water's view x-ray reveals bilateral maxillary mucosal thickening.,IMPRESSION:, Acute maxillary sinusitis (461.0). Snoring (786.09).,MEDICATION:, Augmentin. 875 mg bid. MucoFen 800 mg bid.,PLAN:,

HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend. The patient has a long history of psychological disorders. As per the patient, she also has a history of supraventricular tachycardia and coronary artery disease, for which the patient has had workup done in ABC Medical Center. The patient was evaluated in the emergency room. The initial cardiac workup was negative. The patient was admitted to telemetry unit for further evaluation. In the emergency room, the patient was also noted to have a strongly positive drug screen including methadone and morphine. The patient's EKG in the emergency room was normal and the patient had some relief from her chest pain after she got some nitroglycerin.,PAST MEDICAL HISTORY: , As mentioned above is significant for history of seizure disorder, migraine headaches, coronary artery disease, CHF, apparently coronary stenting done, mitral valve prolapse, supraventricular tachycardia, pacemaker placement, colon cancer, and breast cancer. None of the details of these are available.,PAST SURGICAL HISTORY: , Significant for history of lumpectomy on the left breast, breast augmentation surgery, cholecystectomy, cardiac ablation x3, left knee surgery as well as removal of half the pancreas.,CURRENT MEDICATIONS AT HOME: , Included Dilantin 400 mg daily, Klonopin 2 mg 3 times a day, Elavil 300 mg at night, nitroglycerin sublingual p.r.n., Thorazine 300 mg 3 times a day, Neurontin 800 mg 4 times a day, and Phenergan 25 mg as tolerated.,OB HISTORY: , Her last menstrual period was 6/3/2009. The patient is admitting to having a recent abortion done. She is not too sure whether the abortion was completed or not, has not had a followup with her OB/GYN.,FAMILY HISTORY: ,Noncontributory.,SOCIAL HISTORY: ,She lives with her boyfriend. The patient has history of tobacco abuse as well as multiple illicit drug abuse.,REVIEW OF SYSTEMS: As mentioned above.,PHYSICAL EXAMINATION:,GENERAL: She is alert, awake, and oriented.,VITAL SIGNS: Her blood pressure is about 132/72, heart rate of about 87 per minute, respiratory rate of 16.,HEENT: Shows head is atraumatic. Pupils are round and reactive to light. Extraocular muscles are intact. No oropharyngeal lesions noted.,NECK: Supple, no JV distention, no carotid bruits, and no lymphadenopathy.,LUNGS: Clear to auscultation bilaterally.,CARDIAC: Reveals regular rate and rhythm.,ABDOMEN: Soft, nontender, nondistended. Bowel sounds are normally present.,LOWER EXTREMITIES: Shows no edema. Distal pulses are 2+.,NEUROLOGICAL: Grossly nonfocal.,LABORATORY DATA: , The database that is available at this point of time, WBC count is normal, hemoglobin and hematocrit are normal. Sodium, potassium, chloride, glucose, bicarbonate, BUN and creatinine, and liver function tests are normal. The patient's 3 sets of cardiac enzymes including troponin-I, CPK-MB, and myoglobulin have been normal. EKG is normal, sinus rhythm without any acute ST-T wave changes. As mentioned before, the patient's toxicology screen was positive for morphine, methadone, and marijuana. The patient also had a head CT done in the emergency room, which was fairly unremarkable. The patient's beta-hCG level was marginally elevated at about 48.,ASSESSMENT AND EVALUATION:,1. Chest pains, appear to be completely noncardiac. The patient does seem to have a psychosomatic component to her chest pain. There is no evidence of acute coronary syndrome or unstable angina at this point of time.,2. Possible early pregnancy. The patient's case was discussed with OB/GYN on-call over the phone. Some of the medications have to be held secondary to potential danger. The patient will follow up on an outpatient basis with her primary OB/GYN as well as PCP for the workup of her pregnancy as well as continuation of the pregnancy and prenatal visits.,3. Migraine headaches for which the patient has been using her routine medications and the headaches seem to be under control. Again, this is an outpatient diagnosis. The patient will follow up with her PCP for control of migraine headache.,Overall prognosis is too soon to predict.,The plan is to discharge the patient home secondary to no evidence of acute coronary syndrome.

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

HISTORY OF PRESENT ILLNESS: , The patient is a 22-year-old male who sustained a mandible fracture and was seen in the emergency department at Hospital. He was seen in my office today and scheduled for surgery today for closed reduction of the mandible fractures.,PREOPERATIVE DIAGNOSES: , Left angle and right body mandible fractures.,POSTOPERATIVE DIAGNOSES: , Left angle and right body mandible fractures.,PROCEDURE: , Closed reduction of mandible fractures with Erich arch bars and elastic fixation.,ANESTHESIA:, General nasotracheal.,COMPLICATIONS:, None.,CONDITION:, Stable to PACU.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, the patient was prepped and draped in the usual fashion for placement of arch bars. Gauze throat pack was placed and upper and lower arch bars were placed on the maxillary and mandibular dentition with a 25-gauge circumdental wires. After the placement of the arch bars, the occlusion was checked and found to be satisfactory and stable. The throat pack was then removed. An NG tube was then passed and approximately 50 cc of stomach contents were suctioned out.,The elastic fixation was then placed on the arch bars holding the patient in maxillomandibular fixation and at this point, the procedure was terminated and the patient was then awakened, extubated, and taken to the PACU in stable condition.

PREOPERATIVE DIAGNOSES:,1. Left diabetic foot abscess and infection.,2. Left calcaneus fracture with infection.,3. Right first ray amputation.,POSTOP DIAGNOSES:,1. Left diabetic foot abscess and infection.,2. Left calcaneus fracture with infection.,3. Right first ray amputation.,OPERATION AND PROCEDURE:,1. Left below-the-knee amputation.,2. Dressing change, right foot.,ANESTHESIA: , General.,BLOOD LOSS: , Less than 100 mL.,TOURNIQUET TIME:, 24 minutes on the left, 300 mmHg.,COMPLICATIONS:, None.,DRAINS: , A one-eighth-inch Hemovac.,INDICATIONS FOR SURGERY: , The patient is a 62 years of age with diabetes. He developed left heel abscess. He had previous debridements, developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads. After re-inspecting the wound last week, the plan was for possible debridement and he desired below-the-knee amputation. We are going to change the dressing on the right side also. The risks, benefits, and alternatives of surgery were discussed. The risks of bleeding, infection, damage to nerves and blood vessels, persistent wound healing problems, and the need for future surgery. He understood all the risks and desired operative treatment.,OPERATIVE PROCEDURE IN DETAIL: , After appropriate informed consent obtained, the patient was taken to the operating room and placed in the supine position. General anesthesia induced. Once adequate anesthesia had been achieved, cast padding placed on the left proximal thigh and tourniquet was applied. The right leg was redressed. I took the dressing down. There was a small bit of central drainage, but it was healing nicely. Adaptic and new sterile dressings were applied.,The left lower extremity was then prepped and draped in usual sterile fashion.,A transverse incision made about the mid shaft of the tibia. A long posterior flap was created. It was taken to the subcutaneous tissues with electrocautery. Please note that tourniquet had been inflated after exsanguination of the limb. Superficial peroneal nerve identified, clamped, and cut. Anterior compartment was divided. The anterior neurovascular bundle identified, clamped, and cut. The plane was taken between the deep and superficial compartments. The superficial compartment was reflected posteriorly. Tibial nerve identified, clamped, and cut. Tibial vessels identified, clamped, and cut.,Periosteum of the tibia elevated proximally along with the fibula. The tibia was then cut with Gigli saw. It was beveled anteriorly and smoothed down with a rasp. The fibula was cut about a cm and a half proximal to this using a large bone cutter. The remaining posterior compartment was divided. The peroneal bundle identified, clamped, and cut. The leg was then passed off of the field. Each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie. The nerves were each pulled at length, injected with 0.25% Marcaine with epinephrine, cut, and later retracted proximally. The tourniquet was released. Good bleeding from the tissues and hemostasis obtained with electrocautery. Copious irrigation performed using antibiotic-impregnated solution. A one-eighth-inch Hemovac drain placed in the depth of wound adhering on the medial side. A gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with #1 Vicryl in an interrupted fashion. The remaining fascia was closed with #1 Vicryl. Subcutaneous tissues were then closed with 2-0 PDS suture using 2-0 Monocryl suture in interrupted fashion. Skin closed with skin staples. Xeroform gauze, 4 x 4, and a padded soft dressing applied. He was placed in a well-padded anterior and posterior slab splint with the knee in extension. He was then awakened, extubated, and taken to recovery in stable condition. There were no immediate operative complications, and he tolerated the procedure well.

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

PREOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,PROCEDURE: , Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein.,ANESTHESIA: , Endotracheal.,DESCRIPTION OF OPERATIVE PROCEDURE: , General endotracheal anesthesia was initiated without difficulty. The right arm, axilla, and chest wall were prepped and draped in sterile fashion. Longitudinal skin incision was made from the lower axilla distally down the medial aspect of the arm and the basilic vein was not apparent. The draining veins are the deep brachial veins. The primary vein was carefully dissected out and small tributaries clamped, divided, and ligated with #3-0 Vicryl suture. A nice length of vein was obtained to the distal one third of the arm. This appeared to be of adequate length to transpose the vein through the subcutaneous tissue to an old occluded fistula vein, which remains patent through a small collateral vein. A transverse skin incision was made over the superior aspect of the old fistula vein. This vein was carefully dissected out and encircled with vascular tapes. The brachial vein was then tunneled in a gentle curve above the bicep to the level of the cephalic vein fistula. The patient was sensible, was then systemically heparinized. The existing fistula vein was clamped proximally and distally, incised longitudinally for about a centimeter. The brachial vein end was spatulated. Subsequently, a branchial vein to arterialized fistula vein anastomosis was then constructed using running #6-0 Prolene suture in routine fashion. After the completion of the anastomosis, the fistula vein was forebled and the branchial vein backbled. The anastomosis was completed. A nice thrill could be palpated over the outflow brachial vein. Hemostasis was noted. A 8 mm Blake drain was placed in the wound and brought out through inferior skin stab incision and ___ the skin with #3-0 nylon suture. The wounds were then closed using interrupted #4-0 Vicryl and deep subcutaneous tissue ___ staples closed the skin. Sterile dressings were applied. The patient was then x-ray'd and taken to Recovery in satisfactory condition. Estimated blood loss 50 mL, drains 8 mm Blake. Operative complication none apparent, final sponge, needle, and instrument counts reported as correct.

CHIEF COMPLAINT:, Bright red blood per rectum ,HISTORY OF PRESENT ILLNESS: ,This 73-year-old woman had a recent medical history significant for renal and bladder cancer, deep venous thrombosis of the right lower extremity, and anticoagulation therapy complicated by lower gastrointestinal bleeding. Colonoscopy during that admission showed internal hemorrhoids and diverticulosis, but a bleeding site was not identified. Five days after discharge to a nursing home, she again experienced bloody bowel movements and returned to the emergency department for evaluation. ,REVIEW OF SYMPTOMS: ,No chest pain, palpitations, abdominal pain or cramping, nausea, vomiting, or lightheadedness. Positive for generalized weakness and diarrhea the day of admission. ,PRIOR MEDICAL HISTORY:, Long-standing hypertension, intermittent atrial fibrillation, and hypercholesterolemia. Renal cell carcinoma and transitional cell bladder cancer status post left nephrectomy, radical cystectomy, and ileal loop diversion 6 weeks prior to presentation, postoperative course complicated by pneumonia, urinary tract infection, and retroperitoneal bleed. Deep venous thrombosis 2 weeks prior to presentation, management complicated by lower gastrointestinal bleeding, status post inferior vena cava filter placement. ,MEDICATIONS: ,Diltiazem 30 mg tid, pantoprazole 40 mg qd, epoetin alfa 40,000 units weekly, iron 325 mg bid, cholestyramine. Warfarin discontinued approximately 10 days earlier. ,ALLERGIES: ,Celecoxib (rash).,SOCIAL HISTORY:, Resided at nursing home. Denied alcohol, tobacco, and drug use. ,FAMILY HISTORY:, Non-contributory.,PHYSICAL EXAM: ,Temp = 38.3C BP =146/52 HR= 113 RR = 18 SaO2 = 98% room air ,General: Pale, ill-appearing elderly female. ,HEENT: Pale conjunctivae, oral mucous membranes moist. ,CVS: Irregularly irregular, tachycardia. ,Lungs: Decreased breath sounds at the bases. ,Abdomen: Positive bowel sounds, soft, nontender, nondistended, gross blood on rectal exam. ,Extremities: No cyanosis, clubbing, or edema. ,Skin: Warm, normal turgor. ,Neuro: Alert and oriented. Nonfocal. ,LABS: ,CBC: ,WBC count: 6,500 per mL ,Hemoglobin: 10.3 g/dL ,Hematocrit:31.8% ,Platelet count: 248 per mL ,Mean corpuscular volume: 86.5 fL ,RDW: 18% ,CHEM 7: ,Sodium: 131 mmol/L ,Potassium: 3.5 mmol/L ,Chloride: 98 mmol/L ,Bicarbonate: 23 mmol/L ,BUN: 11 mg/dL ,Creatinine: 1.1 mg/dL ,Glucose: 105 mg/dL ,COAGULATION STUDIES: ,PT 15.7 sec ,INR 1.6 ,PTT 29.5 sec ,HOSPITAL COURSE: ,The patient received 1 liter normal saline and diltiazem (a total of 20 mg intravenously and 30 mg orally) in the emergency department. Emergency department personnel made several attempts to place a nasogastric tube for gastric lavage, but were unsuccessful. During her evaluation, the patient was noted to desaturate to 80% on room air, with an increase in her respiratory rate to 34 breaths per minute. She was administered 50% oxygen by nonrebreadier mask, with improvement in her oxygen saturation to 89%. Computed tomographic angiography was negative for pulmonary embolism.

PREOPERATIVE DIAGNOSIS:, Bunion, right foot.,POSTOPERATIVE DIAGNOSIS:, Bunion, right foot.,PROCEDURE PERFORMED:, Austin/akin bunionectomy, right foot.,HISTORY: , This 77-year-old African-American female presents to ABCD General Hospital with the above chief complaint. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful. The patient has attempted conservative treatment without long-term relief of symptoms and desires surgical treatment.,PROCEDURE DETAILS:, An IV was instituted by Department of Anesthesia in the preop holding area. The patient was transported to the operating room and placed on the operating table in the supine position with a safety strap across her lap. Copious amounts of Webril were placed around the right ankle followed by blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected in a Mayo block type fashion. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated to the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was inflated to 250 mmHg. The foot was lowered to the operating field and the stockinet was reflected. The foot was cleansed with wet and dry sponge.,Attention was directed to the bunion deformity on the right foot. An approximately 6 cm dorsal medial incision was created over the first metatarsophalangeal joint. The incision was then deepened with a #15 blade. All vessels encountered were ligated with hemostasis. The skin and subcutaneous tissue were then undermined off of the capsule medially. A dorsal linear capsular incision was then created over the first metatarsophalangeal joint. The periosteum and capsule were then reflected off of the first metatarsal. There was noted to be a prominent medial eminence. The articular cartilage was healthy for patient's age and race. Attention was then directed to the first interspace where a lateral release was performed.. A combination of sharp and blunt dissection was carried out until the adductor tendon insertions were identified. The adductor tendons were transected as well as a lateral capsulotomy was performed. The extensor digitorum brevis tendon was identified and transected. Care was taken to preserve the extensor hallucis longus to make sure that tendon that was transected was the extensor hallucis brevis at the _______ digitorum. Extensor hallucis brevis tendon was transected and care was taken to preserve the extensor halucis longus tendon. Attention was then directed to medial eminence, which was resected with a sagittal saw. Sagittal was then used to create a long dorsal arm outside the Austin type osteotomy and the first metatarsal. The head of the first metatarsal was then translocated laterally until correction of the intermetatarsal angle was noted. The head was intact. A 0.45 K-wire was inserted through subcutaneously from proximal medial to distal lateral. A second K-wire was then inserted from distal lateral to proximal plantar medial. Adequate fixation was noted at the osteotomy site. The K-wires were bent, cut, and pin caps were placed. Attention was then directed to the proximal phalanx of the hallux. The capsular periostem was reflected off of the base of the proximal phalanx. A sagittal was then used to create an akin osteotomy closing wedge. The apex was lateral and the base of the wedge was medial. The wedge was removed in the total and the osteotomy site was then feathered until closure was achieved without compression. Two 0.45 K-wires were then inserted, one from distal medial to proximal lateral and the second from distal lateral to proximal medial across the osteotomy site. Adequate fixation was noted at the osteotomy site and the osteotomy was closed. The toe was noted to be in a markedly more rectus position. Sagittal saw was then used to resect the remaining prominent medial eminence. The area was then smoothed with a reciprocating rasp. There was noted to be a small osteophytic formation laterally over first metatarsal head that was removed with a rongeur and smoothed with a reciprocating rasp. The area was then inspected for any remaining short bony edges, none were noted.,Copious amounts of sterile saline was then used to flush the surgical site. The capsule was closed with #3-0 Vicryl. Subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular #5-0 Vicryl. Steri-Strips were applied and 1 cc of dexamethasone phosphate was injected into the surgical site.,Dressings consisted of #0-1 silk, copious Betadine, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the right foot. A _______ cast was then applied postoperatively. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported from the operating room to the PACU with vital signs stable and vascular status intact to the right foot. The patient was given postoperative pain prescription for Tylenol #3 and instructed to take one q4-6h. p.o. p.r.n. for pain. The patient is to follow up with Dr. X in his office as directed.

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

PHYSICAL EXAMINATION,GENERAL: , The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative. No dysarthria is noted. No discomfort on presentation is noted. ,HEAD: , Atraumatic, normocephalic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Sclerae are white without injection or icterus. Fundi are without papilledema, hemorrhages or exudates with normal vessels. ,EARS: , The ear canals are patent without edema, exudate or drainage. Tympanic membranes are intact with a normal cone of light. No bulging or erythema to indicate infection is present. There is no hemotympanum. Hearing is grossly intact. ,NOSE:, Without deformity, bleeding or discharge. No septal hematoma is noted. ,ORAL CAVITY:, No swelling or abnormality to the lip or teeth. Oral mucosa is pink and moist. No swelling to the palate or pharynx. Uvula is midline. The pharynx is without exudate or erythema. No edema is seen of the tonsils. The airway is completely patent. The voice is normal. No stridor is heard. ,NECK: , No signs of meningismus. No Brudzinski or Kernig sign is present. No adenopathy is noted. No JVD is seen. No bruits are auscultated. Trachea is midline. ,CHEST: , Symmetrical with equal breath sounds. Equal excursion. No hyperresonance or dullness to percussion is noted. There is no tenderness on palpation of the chest. ,LUNGS: ,Clear to auscultation bilaterally. No rales, rhonchi or wheezes are appreciated. Good air movement is auscultated in all 4 lung fields. ,HEART:, Regular rate and rhythm. No murmur. No S3, S4 or rub is auscultated. Point of maximal impulse is strong and in normal position. Abdominal aorta is not palpable. The carotid upstroke is normal. ,ABDOMEN: ,Soft, nontender and nondistended. Normal bowel sounds are auscultated. No organomegaly is appreciated. No masses are palpated. No tympany is noted on percussion. No guarding, rigidity or rebound tenderness is seen on exam. Murphy and McBurney sign is negative. There is no Rovsing, obturator or psoas sign present. No hepatosplenomegaly and no hernias are noted. ,RECTAL:, Normal tone. No masses. Soft, brown stool in the vault. Guaiac negative. ,GENITOURINARY:, Penis is normal without lesion or urethral discharge. Scrotum is without edema. The testes are descended bilaterally. No masses are palpated. There is no tenderness. ,EXTREMITIES: , No clubbing, cyanosis or edema. Pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal. No deformity or signs of trauma. All joints are stable without laxity. There is good range of motion of all joints without tenderness or discomfort. Homan sign is negative. No atrophy or contractures are noted. ,SKIN: , No rashes. No jaundice. Pink and warm with good turgor. Good color. No erythema or nodules noted. No petechia, bulla or ecchymosis. ,NEUROLOGIC: , Cranial nerves II through XII are grossly intact. Muscle strength is graded 5/5 in the upper and lower extremities bilaterally. Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally. Babinski is downgoing bilaterally. Sensation is intact to light touch and vibration. Gait is normal. Romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal. There is no ataxia seen on gait testing. Tone is normal. No pronator drift is seen. ,PSYCHIATRIC: ,The patient is oriented x4. Mood and affect are appropriate. Memory is intact with good short- and long-term memory recall. No dysarthria is noted. Remote memory is intact. Judgment and insight appear normal.,

CC: ,Sensory loss.,HX: ,25y/o RHF began experiencing pruritus in the RUE, above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt "asleep" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, weight loss.,MEDS:, None.,PMH:, Unremarkable.,FHX: ,GF with CAD, otherwise unremarkable.,SHX:, Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any h/o Tobacco/ETOH/illicit drug use.,EXAM:, BP121/66 HR77 RR14 36.5C,MS: A&O to person, place and time. Speech normal with logical lucid thought process.,CN: mild optic disk pallor OS. No RAPD. EOM full and smooth. No INO. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout all extremities except for 5/4+ hip extensors. Normal muscle tone and bulk.,Sensory: Decreased PP/LT below T4-5 on the left side down to the feet. Decreased PP/LT/VIB in BLE (left worse than right). Allodynic in RUE.,Coord: Intact FNF, HKS and RAM, bilaterally.,Station: No pronator drift. Romberg's test not documented.,Gait: Unsteady wide-based. Able to TT and HW. Poor TW.,Reflexes: 3/3 BUE. Hoffman's signs were present bilaterally. 4/4 patellae. 3+/3+ Achilles with 3-4 beat nonsustained clonus. Plantar responses were extensor on the right and flexor on the left.,Gen. Exam: Unremarkable.,COURSE:, CBC, GS, PT, PTT, ESR, FT4, TSH, ANA, Vit B12, Folate, VDRL and Urinalysis were normal. MRI T-spine, 10/27/92, was unremarkable. MRI Brain, 10/28/92, revealed multiple areas of abnormally increased signal on T2 weighted images in the white matter regions of the right corpus callosum, periventricular region, brachium pontis and right pons. The appearance of the lesions was felt to be strongly suggestive of multiple sclerosis. 10/28/92, Lumbar puncture revealed the following CSF results: RBC 1, WBC 9 (8 lymphocytes, 1 histiocyte), Glucose 55mg/dl, Protein 46mg/dl (normal 15-45), CSF IgG 7.5mg/dl (normal 0.0-6.2), CSF IgG index 1.3 (normal 0.0-0.7), agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample. Beta-2 microglobulin was unremarkable. An abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing. Visual and Brainstem Auditory evoked potentials were normal. HTLV-1 titers were negative. CSF cultures and cytology were negative. She was not treated with medications as her symptoms were primarily sensory and non-debilitating, and she was discharged home.,She returned on 11/7/92 as her symptoms of RUE dysesthesia, lower extremity paresthesia and weakness, all worsened. On 11/6/92, she developed slow slurred speech and had marked difficulty expressing her thoughts. She also began having difficulty emptying her bladder. Her 11/7/92 exam was notable for normal vital signs, lying motionless with eyes open and nodding and rhythmically blinking every few minutes. She was oriented to place and time of day, but not to season, day of the week and she did not know who she was. She had a leftward gaze preference and right lower facial weakness. Her RLE was spastic with sustained ankle clonus. There was dysesthetic sensory perception in the RUE. Jaw jerk and glabellar sign were present.,MRI brain, 11/7/92, revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale. The right peritrigonal region is more prominent than on prior study. The left centrum semiovale lesion has less enhancement than previously. Multiple other white matter lesions are demonstrated on the right side, in the posterior limb of the internal capsule, the anterior periventricular white matter, optic radiations and cerebellum. The peritrigonal lesions on both sides have increased in size since the 10/92 MRI. The findings were felt more consistent with demyelinating disease and less likely glioma. Post-viral encephalitis, Rapidly progressive demyelinating disease and tumor were in the differential diagnosis. Lumbar Puncture, 11/8/92, revealed: RBC 2, WBC 12 (12 lymphocytes), Glucose 57, Protein 51 (elevated), cytology and cultures were negative. HIV 1 titer was negative. Urine drug screen, negative. A stereotactic brain biopsy of the right parieto-occipital region was consistent with demyelinating disease. She was treated with Decadron 6mg IV qhours and Cytoxan 0.75gm/m2 (1.25gm). On 12/3/92, she has a focal motor seizure with rhythmic jerking of the LUE, loss of consciousness and rightward eye deviation. EEG revealed diffuse slowing with frequent right-sided sharp discharges. She was placed on Dilantin. She became depressed.

PREOPERATIVE DIAGNOSES:,1. Cervical intraepithelial neoplasia grade-III status post conization with poor margins.,2. Recurrent dysplasia.,3. Unable to follow in office.,4. Uterine procidentia grade II-III.,POSTOPERATIVE DIAGNOSES:,1. Cervical intraepithelial neoplasia grade-III postconization.,2. Poor margins.,3. Recurrent dysplasia.,4. Uterine procidentia grade II-III.,5. Mild vaginal vault prolapse.,PROCEDURES PERFORMED:,1. Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy.,2. Uterosacral ligament vault suspension.,ANESTHESIA: , General and spinal with Astramorph for postoperative pain.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,FLUIDS: ,2400 cc.,URINE: , 200 cc of clear urine output.,INDICATIONS: ,This patient is a 57-year-old nulliparous female who desires definitive hysterectomy for history of cervical intraepithelial neoplasia after conization and found to have poor margins.,FINDINGS: ,On bimanual examination, the uterus was found to be small. There were no adnexal masses appreciated. Intraabdominal findings revealed a small uterus approximately 2 cm in size. The ovaries were atrophic consistent with menopause. The liver margins and stomach were palpated and found to be normal.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the operating suite and administered a spinal anesthesia for postoperative pain control. She was then placed in the dorsal lithotomy position and administered general anesthesia. She was then prepped and draped in the sterile fashion and an indwelling Foley catheter was placed in her bladder. At this point, the patient was evaluated for a possible vaginal hysterectomy. She was nulliparous and the pelvis was narrow. After the anesthesia was administered, the patient was repeatedly stooling and therefore because of these two reasons, the decision was made to do an abdominal hysterectomy. After the patient was prepped and draped, a Pfannenstiel skin incision was made approximately 2 cm above the pubic symphysis. The second scalpel was used to dissect out to the underlying layer of fascia. The fascia was incised in the midline and extended laterally using the Mayo scissors. The superior aspect of the rectus fascia was grasped with Ochsners, tented up and underlying layer of rectus muscle was dissected off bluntly as well as with Mayo scissors. In a similar fashion, the inferior portion of the rectus fascia was tented up, dissected off bluntly as well as with Mayo scissors. The rectus muscle was then separated bluntly in the midline and the peritoneum was identified and entered with the Metzenbaum. The peritoneal incision was extended superiorly and inferiorly with good visualization of the bladder. At this point, the above findings were noted and the GYN Balfour retractor was placed. Moist laparotomy sponges were used to pack the bowel out of the operative field. The bladder blade and the extension for the retractor were then placed. An Allis was used on the uterus for retraction. The round ligaments were then identified, clamped with two hemostats and transected and then suture ligated. The anterior portion of the broad ligament was dissected along vesicouterine resection. The bladder was then dissected off the anterior cervix and vagina without difficulty. The infundibulopelvic ligaments on both sides were then doubly clamped using hemostats, transected and suture ligated with #0 Vicryl suture. The uterine vessels on both sides were skeletonized and clamped with two hemostats and transected and suture ligated with #0 Vicryl. Good hemostasis was assured. The cardinal ligaments on both sides were clamped using a curved hemostat, transected and suture ligated with #0 Vicryl. Good hemostasis was obtained. Two hemostats were then placed just under the cervix meeting in the midline. The uterus and cervix were then _______ off using a scalpel. This was handed and sent to Pathology for evaluation. Using #0 Vicryl suture, the right vaginal cuff angle was closed and affixed to the ipsilateral cardinal ligament. A baseball stitch was then used to close the cuff to the midline. The same was done to the left vaginal cuff angle, which was affixed to the ipsilateral and cardinal ligaments. The baseball stitch was used to close the cuff to the midline. The hemostats were removed and the cuff was closed and good hemostasis was noted. The uterosacral ligaments were also transfixed to the cuff and brought out for good support by using a #0 Vicryl suture through each uterosacral ligament and incorporating this into the vaginal cuff. The pelvis was then copiously irrigated with warm normal saline. Good support and hemostasis was noted. The bowel packing was then removed and the GYN Balfour retractor was moved. The peritoneum was then repaired with #0 Vicryl in a running fashion. The fascia was then closed using #0 Vicryl in a running fashion, marking the first stitch and first last stitch in a lateral to medial fashion. The skin was then closed with #4-0 undyed Vicryl in a subcuticular closure and an Op-Site was placed over this. The patient was then brought out of general anesthesia and extubated. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2. She will follow up postoperatively as an inpatient.

PREOPERATIVE DIAGNOSIS:, Right hallux abductovalgus deformity.,POSTOPERATIVE DIAGNOSIS:, Right hallux abductovalgus deformity.,PROCEDURES PERFORMED:,1. Right McBride bunionectomy.,2. Right basilar wedge osteotomy with OrthoPro screw fixation.,ANESTHESIA: , Local with IV sedation.,HEMOSTASIS: , With pneumatic ankle cuff.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in a supine position. The right foot was prepared and draped in usual sterile manner. Anesthesia was achieved utilizing a 50:50 mixture of 2% lidocaine plain with 0.5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint. Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg. At this time, attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made. The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary. The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary. The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure. The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection. Using a microsagittal saw, the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp. At this time, attention was directed to the first inner space using sharp and blunt dissection. Dissection was carried down to the underling level of the adductor hallucis tendon, which was isolated and freed from its phalangeal, sesamoidal, and metatarsal attachments. The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0.5 cm to help prevent any re-fibrous attachment. At this time, the lateral release was stressed and was found to be complete. The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0.5-cm resection. The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw. The area was again copiously flushed and inspected for any abnormalities and/or prominences and none were noted. At this time, attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length. The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary. The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption. At this time, there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint. At this time, 0.5 cm was measured distal to that lateral measurement and using microsagittal saw, a wedge osteotomy was taken from the base with the apex of the osteotomy being medial, taking care to keep the medial cortex intact as a hinge. The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3.0 x 22 mm. The screw was placed following proper technique. The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing. A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy. The packing of the cancellous bone was held in place with bone wax. The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed. At this time, a deep closure was achieved utilizing #2-0 Vicryl suture, subcuticular closure was achieved using #4-0 Vicryl suture, and skin repair was achieved at both surgical sites with #5-0 nylon suture in a running interlocking fashion. The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site. At this time, the surgical site was postoperatively injected with 0.5 Marcaine plain as well as dexamethasone 4 mg primarily. The surgical sites were then dressed with sterile Xeroform, sterile 4x4s, cascading, and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion. The tourniquet was dropped and color and temperature of all digits returned to normal. The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition.,The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions, problems, or concerns at any time with the numbers provided. The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot.,

EXAM: , Carotid and cerebral arteriograms.,INDICATION: , Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,IMPRESSION:,1. Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.,2. Mild stenosis of the right internal carotid artery measured at 20%.,3. Patent bilateral vertebral arteries.,4. No significant disease was identified of the anterior cerebral vessels.,DISCUSSION: ,Carotid and cerebral arteriograms were performed on Month DD, YYYY, previous studies are not available for comparison.,The right groin was sterilely cleansed and draped. Lidocaine 1% buffered with sodium bicarbonate was used as local anesthetic. A 19-French needle was then advanced into the common femoral artery and a wire was advanced. Over the wire, a sheath was placed. A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire. Flushed arteriogram was performed. Arteriogram demonstrated no significant disease of the great vessels at their origins. There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin. The vertebral arteries were widely patent. Following this, the flushed catheter was exchanged for ***** catheter and selective catheterization of the common carotid artery on the right was performed. Carotid and cerebral arteriograms were performed. The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable. The external carotid artery on the right is quite tortuous in its appearance. The internal carotid artery demonstrates a mild plaque creating stenosis, which is measured approximately 20%. Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal. No significant stenosis identified. There is complete cross-filling into the left brain via the right. No significant stenosis was appreciated.,Following this, the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion.,The patient tolerated the procedure well. No complications occurred during or immediately after the procedure. Stasis was achieved of the puncture site using a VasoSeal. The patient will be observed for at least 2-1/2 hours prior to being discharged to home.

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

REASON FOR CONSULTATION:, Atrial fibrillation.,HISTORY OF PRESENT ILLNESS:, The patient is a 78-year-old, Hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia. Apparently, the patient is a resident of Lake Harris Port Square long-term facility after her stroke. She was found to have confusion while in her facility. She then came to the emergency room and found to have a right sided acute stroke. 12-lead EKG performed on August 10, 2009, found to have atrial fibrillation. Telemetry also revealed atrial fibrillation with rapid ventricular response. Currently, the telemetry is normal sinus rhythm. Because of the finding of atrial fibrillation, cardiology was consulted.,The patient is a poor historian. She did not recall why she is in the hospital, she said she had a stroke. She reported no chest discomfort, no shortness of breath, no palpitations.,The following information was obtained from the patient's chart:,PAST MEDICAL HISTORY:,1. Coronary artery disease status post bypass grafting surgery. Unable to obtain the place, location, anatomy, and the year it was performed.,2. Carotid artery stenosis status post right carotid artery stenting. Again, the time was unknown.,3. Diabetes.,4. Hypertension.,5. Hyperlipidemia.,6. History of stroke with left side hemiplegia.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:, The patient is a resident of Lake Harris Port Square. She has no history of alcohol use.,CURRENT MEDICATIONS: , Please see attached list including hydralazine, Celebrex, Colace, metformin, aspirin, potassium, Lasix, Levaquin, Norvasc, insulin, Plavix, lisinopril, and Zocor.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 133/44, pulse 98, O2 saturation is 98% on room air. Temperature 99, respiratory rate 16.,GENERAL: The patient is sitting in the chair at bedside. Appears comfortable. Left facial droop. Left side hemiplegia.,HEAD AND NECK: No JVP seen. Right side carotid bruit heard.,CHEST: Clear to auscultation bilaterally.,CARDIOVASCULAR: PMI not displaced, regular rhythm. Normal S1 and S2. Positive S4. There is a 2/6 systolic murmur best heard at the left lower sternal border.,ABDOMEN: Soft.,EXTREMITIES: Not edematous.,DATA:, A 12-lead EKG performed on August 9, 2009, revealed atrial fibrillation with a ventricular rate of 96 beats per minute, nonspecific ST wave abnormality.,Review of telemetry done the last few days, currently the patient is in normal sinus rhythm at the rate of 60 beats per minute. Atrial fibrillation was noted on admission noted August 8 and August 10; however, there was normal sinus rhythm on August 10.,LABORATORY DATA: , WBC 7.2, hemoglobin 11.7. The patient's hemoglobin was 8.2 a few days ago before blood transfusion. Chemistry-7 within normal limits. Lipid profile: Triglycerides 64, total cholesterol 106, HDL 26, LDL 17. Liver function tests are within normal limits. INR was 1.1.,A 2D echo was performed on August 11, 2009, and revealed left ventricle normal in size with EF of 50%. Mild apical hypokinesis. Mild dilated left atrium. Mild aortic regurgitation, mitral regurgitation, and tricuspid regurgitation. No intracardiac masses or thrombus were noted. The aortic root was normal in size.,ASSESSMENT AND RECOMMENDATIONS:,1. Paroxysmal atrial fibrillation. It is unknown if this is a new onset versus a paroxysmal atrial fibrillation. Given the patient has a recurrent stroke, anticoagulation with Coumadin to prevent further stroke is indicated. However, given the patient's current neurologic status, the safety of falling is unclear. We need to further discuss with the patient's primary care physician, probably rehab physician. If the patient's risk of falling is low, then Coumadin is indicated. However, if the patient's risk for falling is high, then a course using aspirin and Plavix will be recommended. Transesophageal echocardiogram probably will delineate possible intracardiac thrombus better, however will not change our current management. Therefore, I will not recommend transesophageal echocardiogram at this point. Currently, the patient's heart rate is well controlled, antiarrhythmic agent is not recommended at this point.,2. Carotid artery stenosis. The patient underwent a carotid Doppler ultrasound on this admission and found to have a high-grade increased velocity of the right internal carotid artery. It is difficult to assess the severity of the stenosis given the history of possible right carotid stenting. If clinically indicated, CT angio of the carotid will be indicated to assess for stent patency. However, given the patient's current acute stroke, revascularization is not indicated at this time.,3. Coronary artery disease. Clinically stable. No further test is indicated at this time.

PROCEDURE PERFORMED: , Inguinal herniorrhaphy.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner.,A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated. The external oblique was then incised with a scalpel, and this incision was carried out to the external ring using Metzenbaum scissors. Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was placed around the cord structures at the level of the pubic tubercle. This Penrose drain was then used to retract the cord structures as needed. Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures. The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery. Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature. The sac was excised and went to Pathology. The ends of the suture were then cut and the stump retracted back into the abdomen.,The Penrose drain was removed. The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery. The incision in the external oblique was approximated using a 3-0 Vicryl in a running fashion, thus reforming the external ring. The skin incision was approximated with 4-0 Vicryl in a subcuticular fashion. The skin was prepped and draped with benzoin, and Steri-Strips were applied. A dressing consisting of a 2 x 2 and OpSite was then applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.

REASON FOR REFERRAL:, The patient was referred to me by Dr. X of the Clinic due to concerns regarding behavioral acting out as well as encopresis. This is a 90-minute initial intake completed on 10/03/2007. I met with the patient's mother individually for the entire session. I reviewed with her the treatment, consent form, as well as the boundaries of confidentiality, and she stated that she understood these concepts.,PRESENTING PROBLEMS: , Mother reported that her primary concern in regard to the patient had to do with his oppositionality. She was more ambivalent regarding addressing the encopresis. In regards to his oppositionality, she reported that the onset of his oppositionality was approximately at 4 years of age, that before that he had been a very compliant and happy child, and that he has slowly worsened over time. She noted that the oppositionality occurred approximately after his brother, who has multiple medical problems, was born. At that time, mother had spent 2 months back East with the brother due to his feeding issues and will have to go again next year. She reported that in terms of the behaviors that he loses his temper frequently, he argues with her that he defies her authority that she has to ask him many times to do things, that she has to repeat instructions, that he ignores her, that he whines, and this is when he is told to do something that he does not want to do. She reported that he deliberately annoys other people, that he can be angry and resentful. She reported that he does not display these behaviors with the father nor does he display them at home, but they are specific to her. She reported that her response to him typically is that she repeats what she wants him to do many, many times, that eventually she gets upset. She yells at him, talks with him, and tries to make him go and do what she wants him to do. Mother also noted that she probably ignores some his misbehaviors. She stated that the father tends to be more firm and more direct with him, and that, the father sometimes thinks that the mother is too easy on him. In regards to symptoms of depression, she denied symptoms of depression, noting that he tends to only become unhappy when he has to do something that he does not want to do, such as go to school or follow through on a command. She denied any suicidal ideation. She denied all symptoms of anxiety. PTSD was denied. ADHD symptoms were denied, as were all other symptoms of psychopathology.,In regards to the encopresis, she reported that he has always soiled, he does so 2 to 3 times a day. She reported that he is concerned about this issue. He currently wears underwear and had a pull-up. She reported that he was seen at the Gastroenterology Department here several years ago, and has more recently been seen at the Diseases Center, seen by Dr. Y, reported that the last visit was several months ago, that he is on MiraLax. He does sit on the toilet may be 2 times a day, although that is not consistent. Mother believes that he is probably constipated or impacted again. He refuses to eat any fiber. In regards to what happens when he soils, mother basically takes full responsibility. She cleans and changes his underwear, thinks of things that she has tried, she mostly gets frustrated, makes negative comments, even though she knows that he really cannot help it. She has never provided him with any sort of rewards, because she feels that this is something he just needs to learn to do. In regards to other issues, she noted that he becomes frustrated quite easily, especially around homework, that when mother has to correct him, or when he has had difficulty doing something that he becomes upset, that he will cry, and he will get angry. Mother's response to him is that either she gets agitated and raises her voice, tells him to stop etc. Mother reported it is not only with homework, but also with other tasks, such as if he is trying to build with his LEGOs and things do not go well.,DEVELOPMENTAL BACKGROUND: , The patient was reported to be the 8 pound 12 ounce product of a planned and noncomplicated pregnancy and emergency cesarean delivery. The patient presented in a breech position. Mother denied the use of drugs, alcohol, or tobacco during the pregnancy. No sleeping or eating issues were present in the perinatal period. Temperament was described as easy. He was described as a cuddly baby. No concerns expressed regarding his developmental milestones. No serious injuries reported. No hospitalizations or surgeries. No allergies. The patient has been encopretic for all of his life. He currently is taking MiraLax.,FAMILY BACKGROUND: , The patient lives with his mother who is age 37, and is primarily a homemaker, but does work approximately 48 hours a month as a beautician; with his father, age 35, who is a police officer; and also, with his younger brother who is age 3, and has significant medical problems as will be noted in a moment. Mother and father have been together since 1997, married in 1999. The maternal grandmother and grandfather are living and are together, and live in the Central California Coast Area. There is one maternal aunt, age 33, and then, two adopted maternal aunt and uncle, age 18 and age 13. In regards to the father's side of the family, the paternal grandparents are divorced. Grandfather was in Arkansas, grandmother lives in Dos Palos. The patient does not see his grandfather. Mother stated that her relationship with her child was as described, that he very much stresses her out, that she wishes that he was not so defiant, that she finds him to be a very stressful child to deal with. In regards to the relationship with the father, it was reported that the father tends to leave most of the parenting over to the mother, unless she specifically asks him to do something, and then, he will follow through and do it. He will step in and back mother up in terms of parenting, tell the child not to speak to his mother that way etc. Mother reported that he does spend some time with the children, but not as much as mother would like him to, but occasionally, he will go outside and do things with them. The mother reported that sometimes she has a problem in interfering with his parenting, that she steps in and defends The patient. It was reported that mother stated that she tries the parenting technique, primarily of yelling and tried time-out, although her description suggests that she is not doing time-out correctly, as he simply gets up from his time-out, and she does not follow through. Mother reported that she and the patient are very much alike in temperament, and this has made things more difficult. Mother tends to be stubborn and gets angry easily also. Mother reported becoming fatigued in her parenting, that she lets him get away with things sometimes because she does not want to punish him all day long, sometimes ignores problems that she probably should not ignore. There was reported to be jealousy between The patient and his brother, B. B evidently has some heart problems and feeding issues, and because of that, tends to get more attention in terms of his medical needs, and that the patient is very jealous of that attention and feels that B is favored and that he get things that The patient does not get, and that there is some tension between the brothers. They do play well together; however, The patient does tend to be somewhat intrusive, gets in his space, and then, B will hit him. Mother reported that she graduated from high school, went to Community College, and was an average student. No learning problems. Mother has a history of depression. She has currently been taking 100 mg of Zoloft administered by her primary medical doctor. She is not receiving counseling. She has been on the medications for the last 5 years. Her dosage has not been changed in a year. She feels that she is getting more irritable and more angry. I encouraged her to see a primary medical doctor. Mother has no drug or alcohol history. Father graduated from high school, went to the Police Academy, average student. No learning problems, no psychological problems, no drug or alcohol problems are reported. In terms of extended family, maternal grandmother as well as maternal great grandfather have a history of depression. Other psychiatric symptoms were denied in the family.,Mother reported that the marriage is generally okay, that there is some arguing. She reported that it was in the normal range.,ACADEMIC BACKGROUND: , The patient attends the Roosevelt Elementary School, where he is in a regular first grade classroom with Mrs. The patient. This is in the Kingsburg Unified School District. No behavior problems, academic problems were reported. He does not receive special education services.,SOCIAL HISTORY: , The patient was described as being able to make and keep friends, but at this point in time, there has been no teasing regarding smell from the encopresis. He does have kids over to play at the house.,PREVIOUS COUNSELING:, Denied.,DIAGNOSTIC SUMMARY AND IMPRESSION: , My impression is that the patient has a long history of constipation and impaction, which has been treated medically, but it would appear that the mother has not followed through consistently with the behavioral component of toilet sitting, increased fiber, regular medication, so that the problem has likely continued. She also has not used any sort of rewards as a way to encourage him, in the encopresis. The patient clearly qualifies for a diagnosis of disruptive behavior disorder, not otherwise specified, and possibly oppositional defiant disorder. It would appear that mother needs help in her parenting, and that she tends to mostly use yelling and anger as a way, and tends to repeat herself a lot, and does not have a strategy for how to follow through and to deal with defiant behavior. Also, mother and father, may not be on the same page in terms of parenting.,PLAN:, In terms of my plan, I will meet with the child in the next couple of weeks. I also asked the mother to bring the father in, so he could be involved in the treatment also, and I gave the mother a behavioral checklist to be completed by herself and the father as well as the teacher.,DSM IV DIAGNOSES: ,AXIS I: Adjustment disorder with disturbance of conduct (309.3). Encopresis, without constipation, overflow incontinence (307.7),AXIS II: No diagnoses (V71.09).,AXIS III: No diagnoses.,AXIS IV: Problems with primary support group.,AXIS V: Global assessment of functioning equals 65.

CHIEF REASON FOR CONSULTATION:, Evaluate recurrent episodes of uncomfortable feeling in the left upper arm at rest, as well as during exertion for the last one month.,HISTORY OF PRESENT ILLNESS:, This 57-year-old black female complains of having pain and discomfort in the left upper arm, especially when she walks and after heavy meals. This lasts anywhere from a few hours and is not associated with shortness of breath, palpitations, dizziness, or syncope. Patient does not get any chest pain or choking in the neck or pain in the back. Patient denies history of hypertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive of previous myocardial infarction, or acute rheumatic polyarthritis during childhood. Her exercise tolerance is one to two blocks for shortness of breath and easy fatigability.,MEDICATIONS:, Patient does not take any specific medications.,PAST HISTORY:, The patient underwent hysterectomy in 1986.,FAMILY HISTORY:, The patient is married, has four children who are doing fine. Family history is positive for hypertension, congestive heart failure, obesity, cancer, and cerebrovascular accident.,SOCIAL HISTORY:, The patient smokes one pack of cigarettes per day and takes drinks on social occasions.

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: ,Cataract, right eye.,PROCEDURE PERFORMED: ,Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used, * diopters, #*.,ANESTHESIA: ,Topical 4% lidocaine with 1% nonpreserved intracameral lidocaine.,COMPLICATIONS:, None.,PROCEDURE: , Prior to surgery, the patient was counseled as to the risks, benefits and alternatives of the procedure with risks including, but not limited to, bleeding, infection, loss of vision, loss of the eye, need for a second surgery, retinal detachment and retinal swelling. The patient understood the risks clearly and wished to proceed.,The patient was brought into the operating suite after being given dilating drops. Topical 4% lidocaine drops were used. The patient was prepped and draped in the normal sterile fashion. A lid speculum was placed into the right eye. Paracentesis was made at the infratemporal quadrant. This was followed by 1% nonpreservative lidocaine into the anterior chamber, roughly 250 microliters. This was exchanged for Viscoat solution. Next, a crescent blade was used to create a partial-thickness linear groove at the temporal limbus. This was followed by a clear corneal bevel incision with a 3 mm metal keratome blade. Circular capsulorrhexis was initiated with a cystitome and completed with Utrata forceps. Balanced salt solution was used to hydrodissect the nucleus. Nuclear material was removed via phacoemulsification with divide-and-conquer technique. The residual cortex was removed via irrigation and aspiration. The capsular bag was then filled with Provisc solution. The wound was slightly enlarged. The lens was folded and inserted into the capsular bag.,Residual Provisc solution was irrigated out of the eye. The wound was stromally hydrated and noted to be completely self-sealing.,At the end of the case, the posterior capsule was intact. The lens was well centered in the capsular bag. The anterior chamber was deep. The wound was self sealed and subconjunctival injections of Ancef, dexamethasone and lidocaine were given inferiorly. Maxitrol ointment was placed into the eye. The eye was patched with a shield.,The patient was transported to the recovery room in stable condition to follow up the following morning.

CHIEF COMPLAINT:, Abdominal pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was "normal." She was given oral antibiotics of Cipro and Flagyl. She has had no nausea and vomiting, but has had persistent associated anorexia. She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago. She denies any bright red blood per rectum and no history of recent melena. Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice. The patient denies any significant recent weight loss.,PAST MEDICAL HISTORY: ,Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.,PAST SURGICAL HISTORY: , Significant for cholecystectomy, appendectomy, and hysterectomy. She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.,ALLERGIES: , SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.,SOCIAL HISTORY: , She does not drink or smoke.,REVIEW OF SYSTEMS: , Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.,PHYSICAL EXAMINATION:,GENERAL: The patient is an elderly thin white female, very pleasant, in no acute distress.,VITAL SIGNS: Her temperature is 98.8 and vital signs are all stable, within normal limits.,HEENT: Head is grossly atraumatic and normocephalic. Sclerae are anicteric. The conjunctivae are non-injected.,NECK: Supple.,CHEST: Clear.,HEART: Regular rate and rhythm.,ABDOMEN: Generally nondistended and soft. She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness. There is no CVA or flank tenderness, although some very minimal left flank tenderness.,PELVIC: Currently deferred, but has history of grade 4 urinary bladder prolapse.,EXTREMITIES: Grossly and neurovascularly intact.,LABORATORY VALUES: ,White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal. Alkaline phosphatase elevated at 184. Liver function tests otherwise normal. Electrolytes normal. Glucose 134, BUN 4, and creatinine 0.7.,DIAGNOSTIC STUDIES:, EKG shows normal sinus rhythm.,IMPRESSION AND PLAN: , A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant. Currently is a nonacute abdomen. The working diagnosis would be sigmoid diverticulitis. She does have a history in the distant past of sigmoid diverticulitis. I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth. The patient was seen 5 years ago by Dr. Y in Colorectal Surgery. We will consult her also for evaluation. The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically. The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.

EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 26 year old with a history of instability. Examination was preformed on 12/20/2005.,FINDINGS:,There is supraspinatus tendinosis without a full-thickness tear, gap or fiber retraction and there is no muscular atrophy (series #105 images #4-6).,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is medial subluxation of the tendon under the transverse humeral ligament, and there is tendinosis of the intracapsular portion of the tendon with partial tearing, but there is no complete tear or discontinuity. Biceps anchor is intact (series #105 images #4-7; series #102 images #10-22).,There is a very large Hill-Sachs fracture, involving almost the entire posterior half of the humeral head (series #102 images #13-19). This is associated with a large inferior bony Bankart lesion that measures approximately 15 x 18mm in AP and craniocaudal dimension with impaction and fragmentation (series #104 images #10-14; series #102 images #18-28). There is medial and inferior displacement of the fragment. There are multiple interarticular bodies, some of which may be osteochondromatous and some may be osseous measuring up to 8mm in diameter. (These are too numerous to count.) There is marked stretching, attenuation and areas of thickening of the inferior and middle glenohumeral ligaments, compatible with a chronic tear with scarring but there is no discontinuity or demonstrated HAGL lesion (series #105 images #5-10).,Normal superior glenohumeral ligament.,There is no SLAP tear.,Normal acromioclavicular joint without narrowing of the subacromial space.,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There is fluid in the glenohumeral joint and biceps tendon sheath.,IMPRESSION:,There is a very large Hill-Sachs fracture involving most of the posterior half of the humeral head with an associated large and inferior and medial displaced osseous Bankart lesion.,There are multiple intraarticular bodies, and there is a partial tear of the inferior and middle glenohumeral ligaments.,There is medial subluxation of the long biceps tendon under the transverse humeral ligament with partial tearing of the intracapsular portion.,

PREOPERATIVE DIAGNOSIS:, Infected sebaceous cyst, right neck.,POSTOPERATIVE DIAGNOSIS:, Infected sebaceous cyst, right neck.,PROCEDURE: , The patient was electively taken to the operating room after obtaining an informed consent. With a combination of intravenous sedation and local infiltration anesthesia, a time-out process was followed and then the patient was prepped and draped in the usual fashion. The elliptical incision was performed around the draining tract. Immediately we fell in to an abscess cavity with a lot of pus and necrotic tissue. All the necrotic tissue was excised together with an ellipse of skin. Hemostasis was achieved with a cautery. The cavity was irrigated with normal saline. At the end of procedure, there was a good size around cavity that was packed with iodoform gauze. One skin suture was grazed for approximation.,A bulky dressing was applied.,The patient tolerated the procedure well. Estimated blood loss was negligible and the patient was sent to Same Day Surgery for recovery.

HISTORY OF PRESENT ILLNESS: ,This is a 55-year-old female with a history of stroke, who presents today for followup of frequency and urgency with urge incontinence. This has been progressively worsening, and previously on VESIcare with no improvement. She continues to take Enablex 50 mg and has not noted any improvement of her symptoms. The nursing home did not do a voiding diary. She is accompanied by her power of attorney. No dysuria, gross hematuria, fever or chills. No bowel issues and does use several Depends a day.,Recent urodynamics in April 2008, here in the office, revealed significant detrusor instability with involuntary urinary incontinence and low bladder volumes, and cystoscopy was unremarkable.,IMPRESSION: ,Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke. This has not improved on VESIcare as well as Enablex. Options are discussed.,We discussed other options of pelvic floor rehabilitation, InterStim by Dr. X, as well as more invasive procedure. The patient and the power of attorney would like him to proceed with meeting Dr. X to discuss InterStim, which was briefly reviewed here today and brochure for this is provided today. Prior to discussion, the nursing home will do an extensive voiding diary for one week, while she is on Enablex, and if this reveals no improvement, the patient will be started on Ventura twice daily and prescription is provided. They will see Dr. X with a prior voiding diary, which is again discussed. All questions answered.,PLAN:, As above, the patient will be scheduled to meet with Dr. X to discuss option of InterStim, and will be accompanied by her power of attorney. In the meantime, Sanctura prescription is provided, and voiding diaries are provided. All questions answered.

PREOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy.,2. Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy.,2. Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet arthropathy with scar tissue.,3. No evidence of instability.,OPERATIVE PROCEDURE PERFORMED,1. Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty.,2. Total laminectomy C3, C4, C5, and C6.,3. Excision of scar tissue.,4. Repair of dural tear with Prolene 6-0 and Tisseel.,FLUIDS:, 1500 cc of crystalloid.,URINE OUTPUT: , 200 cc.,DRAINS: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA:, General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:, Less than 250 cc.,INDICATIONS FOR THE OPERATION: ,This is the case of a very pleasant 41 year-old Caucasian male well known to me from previous anterior cervical discectomy and posterior decompression. Last surgery consisted of four-level decompression on 08/28/06. The patient continued to complain of posterior neck pain radiating to both trapezius. Review of his MRI revealed the presence of what still appeared to be residual lateral recess stenosis. It also raised the possibility of instability and based on this I recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial. Based on this, I did total decompression by removing the lamina of C3 through C6 and doing bilateral medial facetectomy and foraminotomy at C3-C4, C4-C5, C5-C6, and C6-C7 with no spinal instrumentation. Operation and expected outcome risks and benefits were discussed with him prior to the surgery. Risks include but not exclusive of bleeding and infection. Infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection. There is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord. This may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma. There is also the risk of a dural tear with its attendant problems of CSF leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis. This too may require return to the operating room for evacuation of said pseudomeningocele and repair. The patient understood the risk of the surgery. I told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress. After smooth induction and intubation, a Foley catheter was inserted. Monitoring leads were also placed by Premier Neurodiagnostics for both SSEP and EMG monitoring. The SSEPs were normal, and the EMGs were silent during the entire case. After completion of the placement of the monitoring leads, the patient was then positioned prone on a Wilson frame with the head supported on a foam facial support. Shave was then carried out over the occipital and suboccipital region. All pressure points were padded. I proceeded to mark the hypertrophic scar for excision. This was initially cleaned with alcohol and prepped with DuraPrep.,After sterile drapes were laid out, incision was made using a scalpel blade #10. Wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar. Dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of C2 was then identified. There was absence of the spinous process of C3, C4, C5, and C6, but partial laminectomy was noted; removal of only 15% of the lamina. With this completed, we proceeded to do a total laminectomy at C3, C4, C5, and C6, which was technically difficult due to the previous surgery. There was also a dural tear on the right C3-C4 space that was exposed and repaired with Prolene 6-0 and later with Tisseel. By careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at C3-C4, C4-C5, C5-C6, and C6-C7. There was significant epidural bleeding, which was carefully coagulated. At two points, I had to pack this with small pieces of Gelfoam. After repair of the dural tear, Valsalva maneuver showed no evidence of any CSF leakage. Area was irrigated with saline and bacitracin and then lined with Tisseel. The wound was then closed in layers with Vicryl 0 simple interrupted sutures to the fascia; Vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch. The patient was extubated and transferred to recovery.

PROCEDURE: , Elective male sterilization via bilateral vasectomy.,PREOPERATIVE DIAGNOSIS: ,Fertile male with completed family.,POSTOPERATIVE DIAGNOSIS:, Fertile male with completed family.,MEDICATIONS: ,Anesthesia is local with conscious sedation.,COMPLICATIONS: , None.,BLOOD LOSS: , Minimal.,INDICATIONS: ,This 34-year-old gentleman has come to the office requesting sterilization via bilateral vasectomy. I discussed the indications and the need for procedure with the patient in detail, and he has given consent to proceed. He has been given prophylactic antibiotics.,PROCEDURE NOTE: , Once satisfactory sedation have been obtained, the patient was placed in the supine position on the operating table. Genitalia was shaved and then prepped with Betadine scrub and paint solution and were draped sterilely. The procedure itself was started by grasping the right vas deferens in the scrotum, and bringing it up to the level of the skin. The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath. The vas was brought out of the incision carefully. A 2-inch segment was isolated, and 1-inch segment was removed. The free ends were cauterized and were tied with 2-0 silk sutures in such a fashion that the ends double back on themselves. After securing hemostasis with a cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Attention was now turned to the left side. The vas was grasped and brought up to the level of the skin. The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath. The vas was brought out of the incision carefully. A 2-inch segment was isolated, and 1-inch segment was removed. The free ends were cauterized and tied with 2-0 silk sutures in such a fashion that the ends double back on themselves. After securing hemostasis with the cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Bacitracin ointment was applied as well as dry sterile dressing. The patient was awakened and was returned to Recovery in satisfactory condition.

SUBJECTIVE:, The patient is keeping a food journal that she brought in. She is counting calorie points, which ranged 26 to 30 per day. She is exercising pretty regularly. She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia. The patient requests information on diabetic exchanges. She said she is feeling better since she has lost weight.,OBJECTIVE:,Vital Signs: The patient's weight today is 209 pounds, which is down 22 pounds since I last saw her on 06/07/2004. I praised her weight loss and her regular exercising. I looked at her food journal. I praised her record keeping. I gave her a list of the diabetic exchanges and explained them. I also gave her a food dairy sheet so that she could record exchanges. I encouraged her to continue.,ASSESSMENT:, The patient seems happy with her progress and she seems to be doing well. She needs to continue.,PLAN:, Followup is on a p.r.n. basis. She is always welcome to call or return.

DESCRIPTION:, The patient was placed in the supine position and was prepped and draped in the usual manner. The left vas was grasped in between the fingers. The skin and vas were anesthetized with local anesthesia. The vas was grasped with an Allis clamp. Skin was incised and the vas deferens was regrasped with another Allis clamp. The sheath was incised with a scalpel and elevated using the iris scissors and clamps were used to ligate the vas deferens. The portion in between the clamps was excised and the ends of the vas were clamped using hemoclips, two in the testicular side and one on the proximal side. The incision was then inspected for hemostasis and closed with 3-0 chromic catgut interrupted fashion.,A similar procedure was carried out on the right side. Dry sterile dressings were applied and the patient put on a scrotal supporter. The procedure was then terminated.

NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented. There is no evidence of cognitive or language dysfunction. Cranial nerves: Visual fields are full. Funduscopic examination is normal. Extraocular movements full. Pupils equal, round, react to light. There is no evidence of nystagmus noted. Fifth nerve function is normal. There is no facial asymmetry noted. Lower cranial nerves are normal. ,Manual motor testing reveals good tone and bulk throughout. There is no evidence of pronator drift or decreased fine finger movements. Muscle strength is 5/5 throughout. Deep tendon reflexes are 2+ throughout with downgoing toes. Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk. Finger-to-nose and heel-to-shin moves are normal. Romberg sign negative. I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection.

HISTORY:, The patient was in the intensive care unit setting; he was intubated and sedated. The patient is a 55-year-old patient, who was admitted secondary to a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory as well as renal failure and found to be intubated. He has been significantly hypotensive during his stay in the intensive care unit and has had minimal urine output. His creatinine has gone from 2.1 to 4.2 overnight and the patient also developed florid acidosis and hypokalemia. Nephrology input has been requested for management of acute renal failure and acidosis.,PAST MEDICAL HISTORY:,1. Pancreatitis.,2. Poison ivy. The patient has recently been on oral steroids.,3. Hypertension.,MEDICATIONS: , Include Ambien, prednisone, and blood pressure medication, which is not documented in the record at the moment.,INPATIENT MEDICATIONS: , Include Protonix IV, half-normal saline at 125 mL an hour, D5W with 3 ounces of bicarbonate at 150 mL an hour. The patient was initially on dopamine, which has now been discontinued. The patient remains on Levophed and Invanz 1 g IV q.24 h.,PHYSICAL EXAMINATION:, Vitals, emergency room presentation, the blood pressure was 82/45. His blood pressure in the ICU had dipped down into the 60s systolic, most recent blood pressure is 108/67 and he has been maintained on 100% FiO2. The patient has had minimal urine output since admission. HEENT, the patient is intubated at the moment. Neck examination, no overt lymph node enlargement. No jugular venous distention. Lungs examination is benign in terms of crackles. The patient has some harsh breath sounds secondary to being intubated. CVS, S1 and S2 are fairly regular at the moment. There is no pericardial rub. Abdominal examination, obese, but benign. Extremity examination reveals no lower extremity edema. CNS, the patient is intubated and sedated.,LABORATORY DATA: , Blood work, sodium 152, potassium 2.7, bicarbonate 13, BUN 36, and creatinine 4.2. The patient's BUN and creatinine yesterday were 23 and 2.1 respectively. H&H of 17.7 and 51.6, white cell count of 8.4 from earlier on this morning. The patient's liver function tests are all out of whack and his alkaline phosphatase is 226, ALT is 539, CK 1103, INR 1.66, and ammonia level of 55. Latest ABGs show a pH of 7.04, bicarbonate of 10.7, pCO2 of 40.3, and pO2 of 120.7.,ASSESSMENT:,1. Acute renal failure, which in all probability is secondary to acute tubular necrosis and sepsis and significant hypotension, but the patient is at the moment on 100% FiO2. He has been given intravenous fluid at a high rate to replete intravascular volume and to hopefully address his acidosis. The patient also has significant acidosis and his creatinine has increased from 2.1 to 4.2 overnight. Given the fact that he would need dialytic support for his electrolyte derangements and for volume control, I would suggest continuous venovenous hemodiafiltration as opposed to conventional hemodialysis as the patient will not be able to tolerate conventional hemodialysis given his hemodynamic instability.,2. Hypotension, which is significant and is related to his sepsis. Now the patient has been maintained on Levophed and high rate of intravenous fluid at the moment.,3. Acidosis, which is again secondary to his renal failure. The patient was administered intravenous bicarbonate as mentioned above. Dialytic support in the form of continuous venovenous hemodiafiltration was highly recommended for possible correction of his electrolyte derangements.,4. Pancreatitis, which has been managed by his gastroenterologist.,5. Sepsis, the patient is on broad-spectrum antibiotic therapy.,6. Hypercalcemia. The patient has been given calcium chloride. We will need to watch for rebound hypercalcemia.,7. Hypoalbuminemia.,8. Hypokalemia, which has been repleted.,RECOMMENDATIONS: , Again include continuation of IV fluid and bicarbonate infusion as well as transfer to the Piedmont Hospital for continuous venovenous hemodiafiltration.

ANATOMICAL SUMMARY,1. Sharp force wound of neck, left side, with transection of left internal jugular vein.,2. Multiple stab wounds of chest, abdomen, and left thigh: Penetrating stab wounds of chest and abdomen with right hemothorax and hemoperitoneum.,3. Multiple incised wounds of scalp, face, neck, chest and left hand (defense wound).,4. Multiple abrasions upper extremities and hands (defense wounds).,NOTES AND PROCEDURES,1. The body is described in the Standard Anatomical Position. Reference is to this position only.,2. Where necessary, injuries are numbered for reference. This is arbitrary and does not correspond to any order in which they may have been incurred. All the injuries are antemortem, unless otherwise specified.,3. The term "anatomic" is used as a specification to indicate correspondence with the description as set forth in the textbooks of Gross Anatomy. It denotes freedom from significant, visible or morbid alteration.,EXTERNAL EXAMINATION:, The body is that of a well developed, well nourished Caucasian male stated to be 25 years old. The body weighs 171 pounds, measuring 69 inches from crown to sole. The hair on the scalp is brown and straight. The irides appear hazel with the pupils fixed and dilated. The sclerae and conjunctive are unremarkable, with no evidence of petechial hemorrhages on either. Both upper and lower teeth are natural, and there are no injuries of the gums, cheeks, or lips.,There is a picture-type tattoo on the lateral aspect of the left upper arm. There are no deformities, old surgical scars or amputations.,Rigor mortis is fixed.,The body appears to the Examiner as stated above. Identification is by toe tag and the autopsy is not material to identification. The body is not embalmed.,The head is normocephalic, and there is extensive evidence of external traumatic injury, to be described below. Otherwise, the eyes, nose and mouth are not remarkable. The neck shows sharp force injuries to be described below. The front of the chest and abdomen likewise show injuries to be described below. The genitalia are that of an adult male, with the penis circumcised, and no evidence of injury.,Examination of the posterior surface of the trunk reveals no antemortem traumatic injuries.,Refer to available photographs and diagrams and to the specific documentation of the autopsy protocol.,CLOTHING:, The clothes were examined both before and after removal from the body.,The decedent was wearing a long-sleeved type of shirt/sweater; it was extensively bloodstained.,On the front, lower right side, there was a 1 1/2 inch long slit-like tear. Also on the lower right sleeve there was a 1 inch slit-like tear. On the back there was a 1/2 inch slit-like tear on the right lower side.,Decedent was wearing a pair of Levi jeans bloodstained. On the outside of the left hip region there was a 1-1/2 inch long slit-like tear. The decedent also was wearing 2 canvas type boots and 2 sweat socks.,EVIDENCE OF THERAPEUTIC INTERVENTION:, None.,EVIDENCE OF INJURY,SHARP FORCE INJURIES OF NECK,1. Sharp force injury of neck, left side, transecting left internal jugular vein. This sharp force injury is complex, and appears to be a combination of a stabbing and cutting wound. It begins on the left side of the neck, at the level of the midlarynx, over the left sternocleidomastoid muscle; it is gaping, measuring 3 inches in length with smooth edges. It tapers superiorly to 1 inch in length cut skin. Dissection discloses that the wound path is through the skin, the subcutaneous tissue, and the sternocleidomastoid muscle with hemorrhage along the wound path and transection of the left internal jugular vein, with dark red-purple hemorrhage in the adjacent subcutaneous tissue and fascia. The direction of the pathway is upward and slightly front to back for a distance of approximately 4 inches where it exits, post-auricular, in a 2 inch in length gaping stab/incised wound which has undulating or wavy borders, but not serrated. Intersecting the wound at right angle superior inferior is a 2 inch in length interrupted superficial, linear incised wound involving only the skin. Also, intervening between the 2 gaping stab-incised wounds is a horizontally oriented 3-1/2 inch in length interrupted superficial, linear incised wound of the skin only. In addition, there is a 1/2 inch long, linear-triangular in size wound of the inferior portion of the left earlobe. The direction of the sharp force injury is upward (rostral), and slightly front to back with no significant angulation or deviation. The total length of the wound path is approximately 4 inches. However, there is a 3/4 inch in length, linear, cutting or incised wound of the top or superior aspect of the pinna of the left ear; a straight metallic probe placed through the major sharp force injury shows that the injury of the superior part of the ear can be aligned with the straight metallic rod, suggesting that the 3 injuries are related; in this instance the total length of the wound path is approximately 6 inches. Also, in the left postauricular region, transversely oriented, extending from the auricular attachment laterally to the scalp is a 1-1/8 inch in length linear superficial incised skin wound.,OPINION: , This sharp force injury of the neck is fatal, associated with transection of the left internal jugular vein.,2. Sharp force wound of the right side of neck. This is a complex injury, appearing to be a combination stabbing and cutting wound. The initial wound is present on the right side of the neck, over the sternocleidomastoid muscle, 3 inches directly below the right external auditory canal. It is diagonally oriented, and after approximation of the edges measures 5/8 inch in length; there is a pointed or tapered end inferiorly and a split or forked end superiorly approximately 1/16 inch in maximal width. Subsequent autopsy shows that the wound path is through the skin and subcutaneous tissue, without penetration of injury of a major,artery or vein; the direction is front to back and upward for a total wound path length of 2 inches and the wound exits on the right side of the back of the neck, posterior to the right sternocleidomastoid muscle where a 2 inch long gaping incised/stab wound is evident on the skin; both ends are tapered; superiorly there is a 1 inch long superficial incised wounds extension on the skin to the back of the head; inferiorly there is a 2 inch long incised superficial skin extension, extending inferiorly towards the back of the neck. There is fresh hemorrhage and bruising along the wound path; the direction, as stated, is upward and slightly front to back.,OPINION: ,This is a nonfatal sharp force injury, with no injury or major artery or vein.,3. At the level of the superior border of the larynx there is a transversely oriented, superficial incised wound of the neck, extending from 3 inches to the left of the anterior midline; it is 3 inches in length and involves the skin only; a small amount of cutaneous hemorrhage is evident.,OPINION:, This is a nonfatal superficial incised wound.,4. ImmediateLY inferior and adjacent to incised wound #3 is a transversely oriented, superficial incised wound involving the skin and subcutaneous tissue; there is a small amount of dermal hemorrhage.,OPINION:, This is a nonfatal superficial incised wound.,SHARP FORCE INJURIES OF FACE,1. There is a stab wound, involving the right earlobe; it is vertically oriented, and after approximation of the edges measures 1 inch in length with forked or split ends superiorly and inferiorly approximately 1/16 inch in total width both superior and inferior. Subsequent dissection discloses that the wound path is from right to left, in the horizontal plane for approximately 1-1/4 inches; there is fresh hemorrhage along the wound path; the wound path terminates in the left temporal bone and does not penetrate the cranial cavity.,OPINION:, This is a nonfatal stab wound.,2. There is a group of 5 superficial incised or cutting wounds on the right side of the face, involving the right cheek and the right side of the jaw. They are varied in orientation both diagonal and horizontal; the smallest is 1/4 inch in length; the largest 5/8 inch in length. They are superficial, involving the skin only, associated with a small amount of cutaneous hemorrhage.,3. On the back of the neck, right side, posterior to the ear and posterior border of the right sternocleidomastoid muscle there is vertically oriented superficial incised skin wound, measuring 3/4 inch in length.,4. There are numerous superficial incised wounds or cuts, varied in orientation, involving the skin of the right cheek, intersection and mingled with the various superficial incised wounds described above. The longest is a 3 inch long diagonally oriented superficial incised wound extending from the right side of the forehead to the cheek; various other superficial wound vary from 1/2 to 1 inch.,5. On the right side of the cheek, adjacent to the ramus of the mandible, right, there is a 1-1/2 x 3/4 inch superficial nonpatterned red-brown abrasion with irregular border, extending superiorly towards the angle of the jaw where there are poorly defined and circumscribed abrasions adjacent to the superficial cuts or abrasions described above. It should be noted that the 5th superficial incised wound of the right side of the mandible which measures 5/8 inch in length is tapered on the posterior aspect and forked on the anterior aspect where it has a width of 1/32 inch.,6. On the left ear, there is a superficial incised wound measuring 1/4 inch, adjacent to the posterior border of the pinna. Just below this on the inferior pinna, extending to the earlobe, there is an interrupted superficial linear abrasion measuring 1 inch in length.

PREOPERATIVE DIAGNOSIS: , T12 compression fracture with cauda equina syndrome and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:, T12 compression fracture with cauda equina syndrome and spinal cord compression.,OPERATION PERFORMED: , Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click'X System using 6.5 mm diameter x 40 mm length T11 screws and L1 screws, 7 mm diameter x 45 mm length.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:, 400 mL, replaced 2 units of packed cells.,Preoperative hemoglobin was less than 10.,DRAINS:, None.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: , With the patient prepped and draped in a routine fashion in the prone position on laminae support, an x-ray was taken and demonstrated a needle at the T12-L1 interspace. An incision was made over the posterior spinous process of T10, T11, T12, L1, and L2. A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10, T11, T12, L1, and L2. An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator. The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent. Initially, on the patient's left side, pedicle screws were placed in T11 and L1. The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle. Placement confirmed with biplanar coaxial fluoroscopy. The awl was in appropriate location and using a pedicle finder under fluoroscopic control, the pedicle was probed to the mid portion of the body of T11. A 40-mm Click'X screw, 6.5 mm diameter with rod holder was then threaded into the T11 vertebral body.,Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra-articular process was located using an AM-8 dissecting tool, AM attachment to the Midas Rex instrumentation. The area was decorticated, an awl was placed, and under fluoroscopic biplanar imaging noted to be at the pedicle in L1. Using a pedicle probe, the pedicle was then probed to the mid body of L1 and a 7-mm diameter 45-mm in length Click'X Synthes screw with rod holder was placed in the L1 vertebral body.,At this point, an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient's ventral canal on the right side. Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point, the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis. The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur. It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12.,At this point, a laminectomy was performed using 45-degree Kerrison rongeur, both 2 mm and 4 mm, and Leksell rongeur. There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11-T12 interlaminar space. Additionally, there was marked instability of the facets bilaterally at T12 and L1. These facets were removed with 45-degree Kerrison rongeur and Leksell rongeur. Bony compression both superiorly and laterally from fractured bony elements was removed with 45-degree Kerrison rongeur until the thecal sac was completely decompressed. The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors, and these nerve roots were noted to be completely free. Hemostasis was controlled with bipolar coagulation.,At this point, a Frazier dissector could be passed superiorly, inferiorly, medially, and laterally to the T11-T12 nerve roots bilaterally, and the thecal sac was noted to be decompressed both superiorly and inferiorly, and noted to be quite pulsatile. A #4 Penfield was then used to probe the floor of the spinal canal, and no significant ventral compression remained on the thecal sac. Copious antibiotic irrigation was used and at this point on the patient's right side, pedicle screws were placed at T11 and L1 using the technique described for a left-sided pedicle screw placement. The anatomic landmarks being the transverse process at T11, the inferior articulating facet, and the lateral aspect of the superior articular facet for T11 and at L1, the transverse process, the junction of the intra-articular process and the facet joint.,With the screws placed on the left side, the elongated rod was removed from the patient's right side along with the locking caps, which had been placed. It was felt that distraction was not necessary. A 75-mm rod could be placed on the patient's left side with reattachment of the locking screw heads with the rod cap locker in place; however, it was necessary to cut a longer rod for the patient's right side with the screws slightly greater distance apart ultimately settling on a 90-mm rod. The locking caps were placed on the right side and after all 4 locking caps were placed, the locking cap screws were tied to the cold weld. Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11-T12 or T12-L1 with excellent positioning of the rods and screws. A crosslink approximately 60 mm in width was then placed between the right and left rods, and all 4 screws were tightened.,It should be noted that prior to the placement of the rods, the patient's autologous bone, which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11, T12, and L1 with AM-8 dissecting tool, AM attachment as well as the lateral aspects of the facet joints. This was done bilaterally prior to placement of the rods.,Following placement of the rods as noted above, allograft bone chips were packed in addition on top of the patient's own allograft in these posterolateral gutters. Gelfoam was used to cover the thecal sac and at this point, the wound was closed by approximating the deep muscle with 0 Vicryl suture. The fascia was closed with interrupted 0 Vicryl suture, subcutaneous layer was closed with 2-0 Vicryl suture, subcuticular layer was closed with 2-0 inverted interrupted Vicryl suture, and the skin approximated with staples. The patient appeared to tolerate the procedure well without complications.

PREOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,POSTOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,OPERATION,Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.,ANESTHESIA,General endotracheal anesthesia.,PROCEDURE,The patient was placed in the supine position. Under effects of general endotracheal anesthesia, markings were made preoperatively for the mastopexy. An eccentric circle was drawn around the nipple and a wedge drawn from the inferior border of the areola to the inframammary fold. A stab incision was made bilaterally and tumescent infiltration of anesthesia, lactated ringers with 1 cc of epinephrine to 1000 cc of lactated ringers was infused with a tumescent blunt needle. 200 cc was infiltrated on each side. This was followed by power-assisted liposuction and manual liposuction with removal of 350 cc of supernatant fat from both sides utilizing a radial tunneling technique with a 4-mm cannula. This was followed by the epithelialization of skin between the inner circle corresponding to the diameter of the areola 4 cm diameter and the outer eccentric circle with a tangent at the 6 o'clock position. This would result in an elevation of the nipple-areolar complex with transposition. The epithelialization of the wedge inferiorly equalized the circumference distance between the inner circle and the outer circle. Hemostasis was achieved with electrocautery. After the epithelialization was performed on both sides, nipple-areolar complex was transposed to new nipple position and the wedge was closed with transposition of the nipple-areolar complex beneath the transposed nipple. Closure was performed with interrupted 3-0 PDS suture on deep subcutaneous tissue and dermal skin closure with running subcuticular 4-0 Monocryl suture. Dermabond was applied followed by Adaptic and Kerlix in the suturing spaces supportive mildly compressive dressing. The patient tolerated the procedure well. The patient was returned to recovery room in satisfactory condition.

ADMITTING DIAGNOSIS: , Right C5-C6 herniated nucleus pulposus.,PRIMARY OPERATIVE PROCEDURE: , Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.,SUMMARY:, This is a pleasant, 43-year-old woman, who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including ESIs. She underwent another MRI and significant degenerative disease at C5-6 with a central and right-sided herniation was noted. Risks and benefits of the surgery were discussed with her and she wished to proceed with surgery. She was interested in participating in the artificial disk replacement study and was entered into that study. She was randomly picked for the artificial disk and underwent the above named procedure on 08/27/2007. She has done well postoperatively with a sensation of right arm pain and numbness in her fingers. She will have x-rays AP and lateral this morning which will be reviewed and she will be discharged home today if she is doing well. She will follow up with Dr. X in 2 weeks in the clinic as per the study protocol with cervical AP and lateral x-rays with ring prior to the appointment. She will contact our office prior to her appointment if she has problems. Prescriptions were written for Flexeril 10 mg 1 p.o. t.i.d. p.r.n. #50 with 1 refill and Lortab 7.5/500 mg 1 to 2 q.6 h. p.r.n. #60 with 1 refill.

PREOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,POSTOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,PROCEDURES:,1. Open septorhinoplasty with placement of bilateral spreader grafts.,2. Placement of a radiated rib tip graft.,3. Placement of a morcellized autogenous cartilage dorsal onlay graft.,4. Placement of endogen, radiated collagen dorsal onlay graft.,5. Placement of autogenous cartilage columellar strut graft.,6. Bilateral lateral osteotomies.,7. Takedown of the dorsal hump with repair of the bony and cartilaginous open roof deformities.,8. Fracture of right upper lateral cartilage.,ANESTHESIA: ,General endotracheal tube anesthesia.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,100 mL.,URINE OUTPUT:, Not recorded.,SPECIMENS:, None.,DRAINS: , None.,FINDINGS: ,1. The patient had a marked dorsal hump, which was both bony and cartilaginous in nature.,2. The patient had marked hypertrophy of his nasalis muscle bilaterally contributing to the soft tissue dorsal hump.,3. The patient had a C-shaped deformity to the left before he had tip ptosis.,INDICATIONS FOR PROCEDURE: , The patient is a 22-year-old Hispanic male who is status post blunt trauma to the nose approximately 9 months with the second episode 2 weeks following and suffered a marked dorsal deformity. The patient was evaluated, but did not complain of nasal obstruction, and his main complaint was his cosmetic deformity. He was found to have a C-shaped deformity to the left as well as some tip ptosis. The patient was recommended to undergo an open septorhinoplasty to repair of this cosmetic defect.,OPERATION IN DETAIL: , After obtaining a full consent from the patient, identified the patient, prepped with Betadine, brought to the operating room and placed in the supine position on the operating table. The appropriate Esmarch was placed; and after adequate sedation, the patient was subsequently intubated without difficulty. The endotracheal tube was then secured, and the table was then turned clockwise to 90 degrees. Three Afrin-soaked cottonoids were then placed in nasal cavity bilaterally. The septum was then injected with 3 mL of 1% lidocaine with 1:100,000 epinephrine in the subperichondrial plane bilaterally. Then, 50 additional mL of 1% lidocaine with 1:100,000 epinephrine was then injected into the nose in preparation for an open rhinoplasty.,Procedure was begun by first marking a columellar incision. This incision was made using a #15 blade. A lateral transfixion incision was then made bilaterally using a #15 blade, and then, the columellar incision was completed using iris scissors with care not to injure the medial crura. However, there was a dissection injury to the left medial crura. Dissection was then taken in the subperichondrial plane over the lower lateral cartilages and then on to the upper lateral cartilage. Once we reached the nasal bone, a Freer was used to elevate the tissue overlying the nasal bone in a subperiosteal fashion. Once we had completed exposure of the bony cartilaginous structures, we appreciated a very large dorsal hump, which was made up of both a cartilaginous and bony portions. There was also an obvious fracture of the right upper lateral cartilage. There was also marked hypertrophy what appeared to be in the nasalis muscle in the area of the dorsal hump. The skin was contributing to the patient's cosmetic deformity. In addition, we noted what appeared to be a small mucocele coming from the area of the fractured cartilage on the right upper lateral cartilage. This mucocele was attempted to be dissected free, most of which was removed via dissection. We then proceeded to remove takedown of the dorsal hump using a Rubin osteotome. The dorsal hump was taken down and passed off the table. Examination of the specimen revealed the marking amount of scar tissue at the junction of the bone and cartilage. This was passed off to use later for possible onlay grafts. There was now a marked open roof deformity of the cartilage and bony sprue. A septoplasty was then performed throughout and a Kelly incision on the right side. Subperichondrial planes were elevated on the right side, and then, a cartilage was incised using a caudal and subperichondrial plane elevated on the left side. A 2 x 3-cm piece of the cardinal cartilage was then removed with care to leave at least 1 cm dorsal and caudal septal strut. This cartilage was passed down the table and then 2 columellar strut grafts measuring approximately 15 mm in length were then used and placed to close the bony and cartilaginous open roof deformities. The spreader grafts were sewn in place using three interrupted 5-0 PDS sutures placed in the horizontal fashion bilaterally. Once these were placed, we then proceeded to work on the bony open roof. Lateral osteotomies were made with 2-mm osteotomes bilaterally. The nasal bones were then fashioned medially to close the open roof deformity, and this reduced the width of the bony nasal dorsum. We then proceeded to the tip. A cartilaginous strut was then fashioned from the cartilaginous septum. It was approximately 15 mm long. This was placed, and a pocket was just formed between the medial crura. This pocket was taken down to the nasal spine, and then, the strut graft was placed. The intradermal sutures were then placed using interrupted 5-0 PDS suture to help to provide more tip projection and definition. The intradermal sutures were then placed to help to align the nasal tip. The cartilage strut was then sutured in place to the medial crura after elevating the vestibular skin off the medial crura in the area of the plane suturing. Prior to the intradermal suturing, the vestibular skin was also taken off in the area of the dome.,The columellar strut was then sutured in place using interrupted 5-0 PDS suture placed in a horizontal mattress fashion with care to help repair the left medial crural foot. The patient had good tip support after this maneuver. We then proceeded to repair the septal deformity created by taking down the dorsal hump with the Rubin osteotome. This was done by crushing the remaining cartilage in the morcellizer and then wrapping this crushed cartilage in endogen, which is a radiated collagen. The autogenous cartilage was wrapped in endogen in a sandwich fashion, and then, a 4-0 chromic suture was placed through this to help with placement of the dorsal onlay graft.,The dorsal onlay was then sewn into position, and then, the 4-0 chromic suture was brought out through this externally to help the superior placement of the dorsal onlay graft. Once we were happy with the position of the dorsal onlay graft, the graft was then sutured in place using two interrupted 4-0 fast-absorbing sutures inferiorly just above the superior edge of the lower lateral cartilages. Once we were happy with the placement of this, we did need to take down some of the bony dorsal hump laterally, and this was done using a #6 and then followed with a #3 push grafts. This wrapping was performed prior to placement of the dorsal onlay graft.,I went through content with the dorsal onlay graft and the closure of the roof deformities as well as placement of the columellar strut, we then felt the patient could use a bit more tip projection; and therefore, we fashioned a radiated rib into a small octagon; and this was sutured in place over the tip using two interrupted 5-0 PDS sutures.,At this point, we were happy with the test results, although the patient did have significant amount of fullness in the dorsal hump area due to soft tissue thick and fullness. There do not appear to be any other pathology causing the patient dorsal hump and therefore, we felt we have achieved the best cosmetic result at this point. The septum was reapproximated using a fast-absorbing 4-0 suture and a Keith needle placed in the mattress fashion. The Kelly incision was closed using two interrupted 4-0 fast-absorbing gut suture. Doyle splints were then placed within the nasal cavity and secured to the inferior septum using a 3-0 monofilament suture. The columellar skin was reapproximated using interrupted 6-0 nylon sutures, and the marginal incision of the vestibular skin was closed using interrupted 4-0 chromic sutures.,At the end of the procedure, all sponge, needle, and instrument counts were correct. A Denver external splint was then applied. The patient was awakened, extubated, and transported to Anesthesia Care Unit in good condition.

REASON FOR CONSULTATION: , Questionable need for antibiotic therapy for possible lower extremity cellulitis.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Caucasian female with past medical history of morbid obesity and chronic lower extremity lymphedema. She follows up at the wound care center at Hospital. Her lower extremity edema is being managed there. She has had multiple episodes of cellulitis of the lower extremities for which she has received treatment with oral Bactrim and ciprofloxacin in the past according to her. As her lymphedema was not improving on therapy at that facility, she was referred for admission to Long-Term Acute Care Facility for lymphedema management. She at present has a stage II ulcer on the lower part of the medial aspect of left leg without any drainage and has slight erythema of bilateral lower calf and shin areas. Her measurements for lymphedema wraps have been taken and in my opinion, it is going to be started in a day or two.,I have been consulted to rule out the possibility of lower extremity cellulitis that may require antibiotic therapy.,PAST MEDICAL HISTORY:, Positive for morbid obesity, chronic lymphedema of the lower extremities, at least for the last three years, spastic colon, knee arthritis, recurrent cellulitis of the lower extremities. She has had a hysterectomy and a cholecystectomy in the remote past.,SOCIAL HISTORY: , The patient lives by herself and has three pet cats. She is an ex-smoker, quit smoking about five years ago. She occasionally drinks a glass of wine. She denies any other recreational drugs use. She recently retired from State of Pennsylvania as a psychiatric aide after 32 years of service.,FAMILY HISTORY: , Positive for mother passing away at the age of 38 from heart problems and alcoholism, dad passed away at the age of 75 from leukemia. One of her uncles was diagnosed with leukemia.,ALLERGIES: , ADHESIVE TAPE ALLERGIES.,REVIEW OF SYSTEMS:, At present, the patient is admitted with a nonresolving bilateral lower extremity lymphedema, which is a little bit more marked on the right lower extremity compared to the left. She denies any nausea, vomiting or diarrhea. She denies any pain, tenderness, increased warmth or drainage from the lower extremities. Denies chest pain, cough or phlegm production. All other systems reviewed were negative.,PHYSICAL EXAMINATION:,General: A 51-year-old morbidly obese Caucasian female who is not in any acute hemodynamic distress at present.,Vital signs: Her maximum recorded temperature since admission today is 96.8, pulse is 65 per minute, respiratory rate is 18 to 20 per minute, blood pressure is 150/54, I do not see a recorded weight at present.,HEENT: Pupils are equal, round, and reactive to light. Extraocular movements intact. Head is normocephalic and external ear exam is normal.,Neck: Supple. There is no palpable lymphadenopathy.,Cardiovascular system: Regular rate and rhythm of the heart without any appreciable murmur, rub or gallop. Heart sounds are little distant secondary to thick chest wall.,Lungs: Clear to auscultation and percussion bilaterally.,Abdomen: Morbidly obese, soft, nontender, nondistended, there is no percussible organomegaly, there is no evidence of lymphedema on the abdominal pannus. There is no evidence of cutaneous candidiasis in the inguinal folds. There is no palpable lymphadenopathy in the inguinal and femoral areas.,Extremities: Bilateral lower extremities with evidence of extensive lymphedema, there is slight pinkish discoloration of the lower part of calf and shin areas, most likely secondary to stasis dermatosis. There is no increased warmth or tenderness, there is no skin breakdown except a stage II chronic ulcer on the lower medial aspect of the right calf area. It has minimal serosanguineous drainage and there is no surrounding erythema. Therefore, in my opinion, there is no current evidence of cellulitis or wound infection. There is no cyanosis or clubbing. There is no peripheral stigmata of endocarditis.,Central nervous system: The patient is alert and oriented x3, cranial nerves II through XII are intact, and there is no focal deficit appreciated.,LABORATORY DATA: , White cell count is 7.4, hemoglobin 12.9, hematocrit 39, platelet count of 313,000, differential is normal with 51% neutrophils, 37% lymphocytes, 9% monocytes and 3% eosinophils. The basic electrolyte panel is within normal limits and the renal function is normal with BUN of 17 and creatinine of 0.5. Liver function tests are also within normal limits.,The nasal screen for MRSA is negative. Urine culture is negative so far from admission. Urinalysis was negative for pyuria, leucocyte esterase, and nitrites.,IMPRESSION AND PLAN:, A 51-year-old Caucasian female with multiple medical problems mentioned above including history of morbid obesity and chronic lower extremity lymphedema. Admitted for inpatient management of bilateral lower extremity lymphedema. I have been consulted to rule out possibility of active cellulitis and wound infection.,At present, I do not find evidence of active cellulitis that needs antibiotic therapy. In my opinion, lymphedema wraps could be initiated. We will continue to monitor her legs with lymphedema wraps changes 2 to 3 times a week. If she develops any cellulitis, then appropriate antibiotic therapy will be initiated. ,Her stage II ulcer on the right leg does not look infected. I would recommend continuation of wound care along with lymphedema wraps.,Other medical problems will continue to be followed and treated by Dr. X's group during this hospitalization. Dr. Y from Plastic Surgery and Lymphedema Management Clinic is following.,I appreciate the opportunity of participating in this patient's care. If you have any questions, please feel free to call me at any time. I will continue to follow the patient along with you 2-3 times per week during this hospitalization at the Long-Term Acute Care Facility.

PRESENT COMPLAINTS: , The patient is reporting ongoing, chronic right-sided back pain, pain that radiates down her right leg intermittently. She is having difficulty with bending and stooping maneuvers. She cannot lift heavy objects. She states she continues to have pain in her right neck and pain in her right upper extremity. She has difficulty with pushing and pulling and lifting with her right arm. She describes an intermittent tingling sensation in the volar aspect of her right hand. She states she has diminished grip strength in her right hand because of wrist pain complaints. She states that the Wellbutrin samples I had given her previously for depression seem to be helping. Her affect appears appropriate. She reports no suicidal ideation. She states she continues to use Naprosyn as an anti-inflammatory, Biofreeze ointment over her neck and shoulder and back areas of complaints. She also takes Imitrex occasionally for headache complaints related to her neck pain. She also takes Flexeril occasionally for back spasms and Darvocet for pain. She is asking for a refill on some of her medications today. She is relating a VAS pain score regarding her lower back at a 6-7/10 and regarding her neck about 3/10, and regarding her right upper extremity about a 4/10., ,PHYSICAL EXAMINATION: , She is afebrile. Blood pressure is 106/68, pulse of 64, respirations of 20. Her physical exam is unchanged from 03/21/05. Her orthopedic exam reveals full range of motion of the cervical spine. Cervical compression test is negative. Valsalva's maneuver is negative. Hoffmann's sign is negative. DTRs are +1 at the biceps, brachioradialis and trapezius bilaterally. Her sensation is grossly intact to the upper extremity dermatomes. Motor strength appears 5/5 strength in the upper extremity muscle groups tested.,Phalen's and Tinel's signs are negative at both wrists. Passive range of motion of the right wrist is painful for her. Passive range of motion of the left wrist is non painful. Active range of motion of both wrists and hands are full. She is right hand dominant. Circumferential measurements were taken in her upper extremities. She is 11" in the right biceps, 10 1/2" in the left biceps. She is 9 3/4" in both right and left forearms. Circumferential measurements were also taken of the lower extremities. She is 21" at both the right and left thighs, 15" in both the right and left calves. Jamar dynamometry was assessed on three tries in this right-hand-dominant individual. She is 42/40/40 pounds on the right hand with good effort, and on the left is 60/62/60 pounds, suggesting a loss of at least 20% to 25% pre-injury grip strength in the right dominant hand. , ,Examination of her lumbar trunk reveals decreased range of motion, flexion allowing her fingertips about 12" from touching the floor. Lumbar extension is to 30 degrees. The right SLR is limited to about 80 degrees, provoking back pain, with a positive Bragard's maneuver, causing pain to radiate to the back of the thigh. The left SLR is to 90 degrees without back pain. DTRs are +1 at the knees and ankles. Toes are downgoing to plantar reflexes bilaterally. Sensation is grossly intact in the lower extremity dermatomes. Motor strength appears 5/5 strength in the lower extremity muscle groups tested., ,IMPRESSION: , (1) Sprain/strain injury to the lumbosacral spine with lumbar disc herniation at L5-S1, with radicular symptoms in the right leg. (2) Cervical sprain/strain with myofascial dysfunction. (3) Thoracic sprain/strain with myofascial dysfunction. (4) Probable chronic tendonitis of the right wrist. She has negative nerve conduction studies of the right upper extremity. (5) Intermittent headaches, possibly migraine component, possibly cervical tension cephalalgia-type headaches or cervicogenic headaches., ,TREATMENT / PROCEDURE: , I reviewed some neck and back exercises. , ,RX:, I dispensed Naprosyn 500 mg b.i.d. as an anti-inflammatory. I refilled Darvocet N-100, one tablet q.4-6 hours prn pain, #60 tablets, and Flexeril 10 mg t.i.d. prn spasms, #90 tablets, and dispensed some Wellbutrin XL tablets, 150-mg XL tablet q.a.m., #30 tablets., ,PLAN / RECOMMENDATIONS:, I told the patient to continue her medication course per above. It seems to be helping with some of her pain complaints. I told her I will pursue trying to get a lumbar epidural steroid injection authorized for her back and right leg symptoms. I told her in my opinion I would declare her Permanent and Stationary as of today, on 04/18/05 with regards to her industrial injuries of 05/16/03 and 02/10/04. , ,I understand her industrial injury of 05/16/03 is related to an injury at Home Depot where she worked as a credit manager. She had a stack of screen doors fall, hitting her on the head, weighing about 60 pounds, knocking her to the ground. She had onset of headaches and neck pain, and pain complaints about her right upper extremity. She also has a second injury, dated 02/10/04, when apparently a co-worker was goofing around and apparently kicked her in the back accidentally, causing severe onset of back pain. , ,FACTORS FOR DISABILITY:,OBJECTIVE: ,1. She exhibits decreased range of motion in the lumbar trunk.,2. She has an abnormal MRI revealing a disc herniation at L5-S1.,3. She exhibits diminished grip strength in the right arm and upper extremity., ,SUBJECTIVE: ,1. Based on her headache complaints alone, would be considered occasional and minimal to slight at best. ,2. With regards to her neck pain complaints, these would be considered occasional and slight at best. ,3. Regarding her lower back pain complaints, would be considered frequent and slight at rest, with an increase to a moderate level of pain with repetitive bending and stooping and heavy lifting, and prolonged standing. ,4. Regarding her right upper extremity and wrist pain complaints, these would be considered occasional and slight at rest, but increasing to slight to moderate with repetitive gripping, grasping, and torquing maneuvers of her right upper extremity. ,LOSS OF PRE-INJURY CAPACITY: , The patient advises that prior to her industrial dates of injury she was capable of repetitively bending and stooping and lifting at least 60 pounds. She states she now has difficulty lifting more than 10 or 15 pounds without exacerbating back pain. She has trouble trying to repetitively push or pull, torque, twist and lift with the right upper extremity, due to wrist pain, which she did not have prior to her industrial injury dates. She also relates headaches, which she did not have prior to her industrial injury. , ,WORK RESTRICTIONS AND DISABILITY: , I would find it reasonable to place some permanent restrictions on this patient. It is my opinion she has a disability precluding heavy work, which contemplates the individual has lost approximately half of her pre-injury capacity for performing such activities as bending, stooping, lifting, pushing, pulling and climbing or other activities involving comparable physical effort. The patient should probably no lift more than 15 to 20 pounds maximally. She should probably not repetitively bend or stoop. She should avoid repetitive pushing, pulling or torquing maneuvers, as well as gripping and grasping maneuvers of the right hand. She should probably not lift more than 10 pounds repetitively with the right upper extremity. I suspect that prior to her industrial she could lift repetitively and push, pull, torque and twist at least 20 to 25 pounds with the right upper extremity. , ,CAUSATION AND APPORTIONMENT:, With regards to issues of causation, they appear appropriate to her industrial injuries and histories given per the 05/16/03 and the 02/10/04 injuries., ,With regards issues of apportionment, it is my opinion that 100% of her pain complaints are industrially related to her industrial injuries of 05/16/03 and 02/10/04. There does not appear to be any apportionable issues here.

HISTORY: , The patient is a 71-year-old female, who was referred for an outpatient modified barium swallow study to objectively evaluate her swallowing function and safety. The patient complained of globus sensation high in her throat particularly with solid foods and with pills. She denied history of coughing and chocking with meals. The patient's complete medical history is unknown to me at this time. The patient was cooperative and compliant throughout this evaluation.,STUDY:, Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. X. The patient was seated upright at a 90-degree angle in a video imaging chair. To evaluate her swallowing function and safety, she was administered graduated amounts of food and liquid mixed with barium in the form of thin liquids (teaspoon x3. cup sip x4); thickened liquid (cup sip x3); puree consistency (teaspoon x3); and solid consistency (1/4 cracker x1). The patient was given 2 additional cup sips of thin liquid following the puree and solid food presentation.,ORAL STAGE: ,The patient had no difficulty with bolus control and transport. No spillage out lips. The patient appears to have pocketing __________ particularly with puree and solid food between her right faucial pillars. The patient did state that she had her tonsil taken out as a child and appears to be a diverticulum located in this state. Further evaluation by an ENT is highly recommended based on the residual and pooling that occurred during this evaluation. We were not able to clear out the residual with alternating cup sips and thin liquid.,PHARYNGEAL STAGE: ,No aspiration or penetration occurred during this evaluation. The patient's hyolaryngeal elevation and anterior movements are within the functional limits. Epiglottic inversion is within functional limits. She had no residual or pooling in the pharynx after the swallow.,CERVICAL ESOPHAGEAL STAGE: ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION: ,The patient had no aspiration or penetration occurred during this evaluation. She does appear to have a diverticulum in the area between her right faucial pillars. Additional evaluation is needed by an ENT physician.,PLAN: ,Based on this evaluation, the following is recommended:,1. The patient's diet should consist regular consistency food with thin liquids. She needs to take small bites and small sips to help decrease her risk of aspiration and penetration as well as reflux.,2. The patient should be referred to an otolaryngologist for further evaluation of her oral cavity particularly the area between her faucial pillars.,The above recommendations and results of the evaluation were discussed with the patient as well as her daughter and both responded appropriately.,Thank you for the opportunity to be required the patient's medical care. She is not in need of skilled speech therapy and is discharged from my services.

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,PROCEDURE: ,Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.,ANESTHESIA: ,Topical.,COMPLICATIONS: ,None.,PROCEDURE IN DETAIL: ,The patient was identified. The operative eye was treated with tetracaine 1% topically in the preoperative holding area. The patient was taken to the operating room and prepped and draped in the usual sterile fashion for ophthalmic surgery.,Attention was turned to the left/right eye. The lashes were tapped using Steri-Strips to prevent blinking. A lid speculum was placed to prevent lid closure. Anesthesia was verified. Then, a 3.5-mm groove was created with a diamond blade temporarily. This was beveled with a crescent blade, and the anterior chamber was entered with a 3.2-mm keratome in the iris plane. A 1% nonpreserved lidocaine was injected intracamerally and followed with Viscoat. A paracentesis was made. A round capsulorrhexis was performed. The anterior capsular flap was removed. Hydrodelineation and dissection were followed by phacoemulsification of the cataract using a chop technique. The irrigating-aspirating machine was used to clear residual cortex. The Provisc was instilled. An SN60WS diopter intraocular lens was inserted into the capsular bag, and the position was verified. The viscoelastic was removed. Intraocular lens remained well centered. The incision was hydrated, and the anterior chamber pressure was checked with tactile pressure and found to be normal. The anterior chamber remained deep, and there was no wound leak. The patient tolerated the procedure well. The eye was dressed with Maxitrol ointment. A tight patch and Fox shield were placed. The patient returned to the recovery room in excellent condition with stable vital signs and no eye pain.

NAME OF PROCEDURE,1. Selective coronary angiography.,2. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.,3. Abdominal aortography.,INDICATIONS: ,The patient is a 65-year-old gentleman with a history of exertional dyspnea and a cramping-like chest pain. Thallium scan has been negative. He is undergoing angiography to determine if his symptoms are due to coronary artery disease.,NARRATIVE: ,The right groin was sterilely prepped and draped in the usual fashion and the area of the right coronary artery anesthetized with 2% lidocaine. Constant sedation was obtained using Versed 1 mg and fentanyl 50 mcg. Received additional Versed and fentanyl during the procedure. Please refer to the nurses' notes for dosages and timing.,The right femoral artery was entered and a 4-French sheath was placed. Advancement of the guidewire demonstrated some obstruction at the level of abdominal aorta. Via the right Judkins catheter, the guidewire was easily infiltrated to the thoracic aorta and over aortic arch. The right Judkins catheter was advanced to the origin of the right coronary artery where selective angiograms were performed. This revealed a very high-grade lesion at the proximal right coronary artery. This catheter was exchanged for a left #4 Judkins catheter which was advanced to the ostium of the left main coronary artery where selective angiograms were performed.,The patient was found to have the above mentioned high-grade lesion in the right coronary artery and a coronary intervention was performed. A 6-French sheath and a right Judkins guide was placed. The patient was started on bivalarudin. A BMW wire was easily placed across the lesion and into the distal right coronary artery. A 3.0 x 15 mm Voyager balloon was placed and deployed at 10 atmospheres. The intermediate result was improved with TIMI-3 flow to the terminus of the vessel. Following this, a 3.0 x 18 mm Xience stent was placed across the lesion and deployed at 17 atmospheres. This revealed excellent result however at the very distal of the stent there was an area of haziness but no definite dissection. This was stented with a 3.0 x 8 mm Xience stent deployed again at 17 atmospheres. Final angiograms revealed excellent result with TIMI-3 flow at the terminus of the right coronary artery and approximately 10% residual stenosis at the worst point of the narrowing. The guiding catheter was withdrawn over wire and a pigtail was placed. This was advanced to the abdominal aorta at the area of obstruction and small injection of contrast was given demonstrating that there was a small aneurysm versus a small retrograde dissection in that area with some dye hang up after injection. The catheter was removed. The bivalarudin was stopped at the termination of procedure. A small injection of contrast given through arterial sheath and Angio-Seal was placed without incident.,It should also be noted that an 8-French sheath was placed in the right femoral vein. This was placed initially as the patient was going to have a right heart catheterization as well because of the dyspnea.,Total contrast media, 205 mL, total fluoroscopy time was 7.5 minutes, X-ray dose, 2666 milligray.,HEMODYNAMICS: , Rhythm was sinus throughout the procedure. Aortic pressure was 170/81 mmHg.,The right coronary artery is a dominant vessel. This vessel gives rise to conus branch and two small RV free wall branches and PDA and a small left ventricular branch. It should be noted that there was competitive flow in the posterior left ventricular branch and that the distal right coronary artery fills via left sided collaterals. In the proximal right coronary artery, there is a large ulcerative plaque followed immediately by a severe stenosis that is subtotal in severity. After intervention, there is TIMI-3 flow to the terminus of the right coronary with better fill into the distal right coronary artery and loss of competitive flow. There was approximately 10% residual stenosis at the worst part of the previous stenosis.,The left main is without disease and trifurcates into a moderate-sized ramus intermedius, the LAD and the circumflex. The ramus intermedius is free of disease. The LAD terminates at the LV apex and has elongated area of mild stenosis at its mid segment. This measures 25% to 30% at its worst point. The circumflex is a large caliber vessel. There is a proximal 15% to 20% stenosis and an area of ectasia in the proximal circumflex. Distally, this circumflex gives rise to a large bifurcating marginal artery and beyond that point, the circumflex is a small vessel within the AV groove.,The aortogram demonstrates eccentric aneurysm formation. This may represent a small retrograde dissection as well. There was some dye hang up in the wall.,IMPRESSION,1. Successful stenting of subtotal stenosis of the proximal coronary artery.,2. Non-obstructive coronary artery disease in the mid left anterior descending as described above and ectasia of the proximal circumflex coronary artery.,3. Left to right collateral filling noted prior to coronary intervention.,4. Small area of eccentric aneurysm formation in the abdominal aorta.

PREOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,POSTOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,PROCEDURE: , Hypospadias repair (urethroplasty plate incision with tissue flap relocation and chordee release).,ANESTHESIA: , General inhalation anesthetic with a 0.25% Marcaine dorsal block and ring block per surgeon, 7 mL given.,TUBES AND DRAINS: , An 8-French Zaontz catheter.,ESTIMATED BLOOD LOSS: ,10 mL.,FLUIDS RECEIVED:, 300 mL.,INDICATIONS FOR OPERATION: , The patient is a 6-month-old boy with the history of coronal hypospadias with chordee. Plan is for repair.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room with surgical consent, operative site, and the patient identification were verified. Once he was anesthetized, IV antibiotics were given. The dorsal hood was retracted and cleansed. He was then sterilely prepped and draped. Stay suture of #4-0 Prolene was then placed in the glans. His urethra was calibrated to 10-French bougie-a-boule. We then marked the coronal cuff and the penile shaft skin, as well as the periurethral meatal area on the ventrum. Byers flaps were also marked. Once this was done, the skin was then incised around the coronal cuff with 15-blade knife and further extended with the curved tenotomy scissors to deglove the penis. On the ventrum, the chordee tissue was removed and dissected up towards the urethral plate to use as secondary tissue flap coverage. Once this was done, an electrocautery was used for hemostasis were then used. A vessel loop tourniquet and IV grade saline was used for achieve artificial erection and chordee. We then incised Buck fascia at the area of chordee in the ventrum and then used the #5-0 Prolene as a Heinecke-Mikulicz advancement suture. Sutures were placed burying the knot and then artificial erection was again performed showing the penis was straight. We then left the tourniquet in place, although loosened it slightly and then marked out the transurethral incision plate with demarcation for the glans and the ventral midline of the plate. We then incised it with the ophthalmic micro lancet blade in the midline and along the __________ to elevate the glanular wings. Using the curved iris scissors, we then elevated the wings even further. Again, electrocautery was used for hemostasis. An 8-French Zaontz catheter was then placed into the urethral plate and then interrupted suture of #7-0 Vicryl was used to mark the distal most extent of the urethral meatus and then the urethral plate was rolled using a subcutaneous closure using the #7-0 Vicryl suture. There were two areas of coverage with the tissue flap relocation from the glanular wings. The tissue flap that was rolled with the Byers flap was used to cover this, as well as the chordee tissue with interrupted sutures of #7-0 Vicryl. Once this was completed, the glans itself had been rolled using two deep sutures of #5-0 Vicryl. Interrupted sutures of #7-0 Vicryl were used to create the neomeatus and then horizontal mattress sutures of #7-0 Vicryl used to roll the glans in the midline. The extra dorsal hood tissue of preputial skin was then excised. An interrupted sutures of #6-0 chromic were then used to approximate penile shaft skin to the coronal cuff and on the ventrum around the midline. The patient's scrotum was slightly asymmetric; however, this was due to the tissue configuration of the scrotum itself. At the end of the procedure, stay suture of #4-0 Prolene was used to tack the drain into place and a Dermabond and Surgicel were used for dressing. Telfa and the surgical eye tape was then used for the final dressing. IV Toradol was given. The patient tolerated the procedure well and was in stable condition upon transfer to recovery room.

CC: ,Delayed motor development.,HX:, This 21 month old male presented for delayed motor development, "jaw quivering" and "lazy eye." He was an 8 pound 10 ounce product of a full term, uncomplicated pregnancy-labor-spontaneous vaginal delivery to a G3P3 married white female mother. There had been no known toxic intrauterine exposures. He had no serious illnesses or hospitalizations since birth. He sat independently at 7 months, stood at 11 months, crawled at 16 months, but did not cruise until 18 months.,He currently cannot walk and easily falls. His gait is reportedly marked by left "intoeing." His upper extremity strength and coordination reportedly appear quite normal and he is able to feed himself, throw and transfer objects easily. He knows greater than 20 words and speaks two-word phrases.,No seizures or unusual behavior were reported except for "quivering" movement of his jaw. This has occurred since birth. In addition the parents have noted transient left exotropia.,PMH: ,As above.,FHX:, Many family members with "lazy eye." No other neurologic diseases declared.,9 and 5 year old sisters who are healthy.,SHX:, lives with parents and sisters.,EXAM:, BP83/67 HR122 36.4C Head circumference 48.0cm Weight 12.68kg (70%) Height 86.0cm (70%),MS: fairly cooperative.,CN: Minimal transient esotropia OS. Tremulous quivering of jaw--increased with crying. No obvious papilledema, though difficult to evaluate due to patient movement.,Motor: sat independently with normal posture and no truncal ataxia. symmetric and normal strength and muscle bulk throughout.,Sensory: withdrew to vibration.,Coordination: unremarkable in BUE.,Station: no truncal ataxia.,Gait: On attempting to walk, his right foot rotated laterally at almost 70degrees. Both lower extremities could rotate outward to 90degrees. There was marked passive eversion at the ankles as well.,Reflexes: 2+/2+ throughout.,Musculoskeletal: pes planovalgus bilaterally.,COURSE: ,CK normal. The parents decided to forego an MRI in 8/90. The patient returned 12/11/92 at age 4 years. He was ambulatory and able to run awkwardly. His general health had been good, but he showed signs developmental delay. Formal evaluation had tested his IQ at 87 at age 3.5 years. He was weakest on tasks requiring visual/motor integration and fine motor and visual discrimination skills. He was 6 months delayed in cognitive development at that time. On exam, age 4 years, he displayed mild right ankle laxity on eversion and inversion, but normal gait. The rest of the neurological exam was normal. Head circumference was 49.5cm (50%) and height and weight were in the 90th percentile. Fragile X analysis and karyotyping were unremarkable.

PREOPERATIVE DIAGNOSES,1. Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2. Cervical radiculopathy involving the left arm.,3. Disc degeneration at C3-C4 and C6-C7.,POSTOPERATIVE DIAGNOSES,1. Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2. Cervical radiculopathy involving the left arm.,3. Disc degeneration at C3-C4 and C6-C7.,OPERATIVE PROCEDURES,1. Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy.,2. Posterior cervical fusion C4-C5.,3. Songer wire.,4. Right iliac bone graft.,TECHNIQUE: ,The patient was brought to the operating room. Preoperative evaluations included previous cervical spine surgery. The patient initially had some relief; however, his left arm pain did recur and gradually got worse. Repeat studies including myelogram and postspinal CTs revealed some blunting of the nerve root at C4-C5 and C5-C6. There was also noted to be some annular bulges at C3-C4, and C6-C7. The CT scan in March revealed that the fusion was not fully solid. X-rays were done in November including flexion and extension views, it appeared that the fusion was solid.,The patient had been on pain medication. The patient had undergone several nonoperative treatments. He was given the option of surgical intervention. We discussed Botox, I discussed with the patient and posterior cervical decompression. I explained to the patient this will leave a larger scar on his neck, and that no guarantee would help, there would be more bleeding and more pain from the posterior surgery than it was from the anterior surgery. If at the time of surgery there was some motion of the C4-C5 level, I would recommend a fusion. The patient was a smoker and had been advised to quit smoking but has not quit smoking. I have therefore recommended that he use iliac bone graft. I explained to the patient that this would give him a scar over the back of the right pelvis and could be a source of chronic pain for the patient for the rest of his life. Even if this type of bone graft was used, there was no guarantee that it will fuse and he should stop smoking completely.,The patient also was advised that if I did a fusion, I would also use post instrumentation, which was a wire. The wire would be left permanently.,Even with all these procedures, there was no guarantee that his symptoms would improve. His numbness, tingling, and weakness could get worse rather than better, his neck pain and arm pain could persist. He still had some residual bursitis in his left shoulder and this would not be cured by this procedure. Other procedures may be necessary later. There is still with a danger of becoming quadriplegic or losing total control of bowel or bladder function. He could lose total control of his arms or legs and end up in the bed for the rest of his life. He could develop chronic regional pain syndromes. He could get difficulty swallowing or eating. He could have substantial weakness in the arm. He was advised that he should not undergo the surgery unless the pain is persistent, severe, and unremitting.,He was also offered his records if he would like any other pain medications or seek other treatments, he was advised that Dr. X would continue to prescribe pain medication if he did not wish to proceed with surgery.,He stated he understood all the risks. He did not wish to get any other treatments. He said the pain has reached the point that he wished to proceed with surgery.,PROCEDURE IN DETAIL: , In the operating room, he was given general endotracheal anesthesia.,I then carefully rolled the patient on thoracic rolls. His head was controlled by a horseshoe holder. The anesthesiologist checked the eye positions to make sure there was no pressure on the orbits and the anesthesiologist continued to check them every 15 minutes. The arms, the right hip, and the neck was then prepped and draped. Care was taken to position both arms and both legs. Pulses were checked.,A midline incision was made through the skin and subcutaneous tissue on the cervical spine. A loupe magnification and headlamp illumination was used. Bleeding vessels were cauterized. Meticulous hemostasis was carried out throughout the procedure. Gradually and carefully I exposed the spinous process of the C6, C5, and C4. A lateral view was done after an instrument in place. This revealed the C6-C7 level. I therefore did a small laminotomy opening at C4-C5. I placed an instrument and x-rays confirmed C4-C5 level.,I stripped the muscles from the lamina and then moved them laterally and held with a self-retaining retractor.,Once I identified the level, I then used a bur to thin the lamina of C5. I used a 1-mm, followed by a 2-mm Kerrison rongeur to carefully remove the lamina off C5 on the left. I removed some of the superior lamina of C6 and some of the inferior lamina of C4. This allowed me to visualize the dura and the nerve roots and gradually do neural foraminotomies for both the C5 and C6 nerve roots. There was some bleeding from the epidural veins and a bipolar cautery was used. Absolutely no retractors were ever placed in the canal. There was no retraction. I was able to place a small probe underneath the nerve root and check the disc spaces to make sure there was no fragments of disc or herniation disc and none were found.,At the end of the procedure, the neuroforamen were widely patent. The nerve roots had been fully decompressed.,I then checked stability. There was micromotion at the C4-C5 level. I therefore elected to proceed with a fusion.,I debrided the interspinous ligament between C4 and C5. I used a bur to roughen up the surface of the superior portion of the spinous process of C5 and the inferior portion of C4. Using a small drill, I opened the facet at C4-C5. I then used a very small curette to clean up the articular cartilage. I used a bur then to roughen up the lamina at C4-C5.,Attention was turned to the right and left hip, which was also prepped. An incision made over the iliac crest. Bleeding vessels were cauterized. I exposed just the posterior aspect of the crest. I removed some of the bone and then used the curette to remove cancellous bone.,I placed the Songer wire through the base of the spinous process of C4 and C5. Drill holes made with a clip. I then packed cancellous bone between the decorticated spinous process. I then tightened the Songer wire to the appropriate tension and then cut off the excess wire.,Prior to tightening the wire, I also packed cancellous bone with facet at C4-C5. I then laid bone upon the decorticated lamina of C4 and C5.,The hip wound was irrigated with bacitracin and Kantrex. Deep structures were closed with #1 Vicryl, subcutaneous suture and subcuticular tissue was closed.,No drain was placed in the hip.,A drain was left in the posterior cervical spine. The deep tissues were closed with 0 Vicryl, subcutaneous tissue and skin were then closed. The patient was taken to the recovery room in good condition.

PREOPERATIVE DIAGNOSIS:, Prostate cancer.,POSTOPERATIVE DIAGNOSIS: , Prostate cancer.,OPERATIVE PROCEDURE: , Radical retropubic prostatectomy with pelvic lymph node dissection.,ANESTHESIA: ,General epidural,ESTIMATED BLOOD LOSS: , 800 cc.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY: , This is a 64-year-old man with adenocarcinoma of the prostate confirmed by needle biopsies. He has elected to undergo radical retropubic prostatectomy with pelvic lymph node dissection. Potential complications include, but are not limited to:,1. Infection.,2. Bleeding.,3. Incontinence.,4. Impotence.,5. Deep venous thrombosis.,6. Recurrence of the cancer.,PROCEDURE IN DETAIL: , Epidural anesthesia was administered by the anesthesiologist in the holding area. Preoperative antibiotic was also given in the preoperative holding area. The patient was then taken into the operating room after which general LMA anesthesia was administered. The patient was shaved and then prepped using Betadine solution. A sterile 16-French Foley catheter was inserted into the bladder with clear urine drain. A midline infraumbilical incision was performed. The rectus fascia was opened sharply. The perivesical space and the retropubic space were developed bluntly. Bookwalter retractor was then placed. Bilateral obturator pelvic lymphadenectomy was performed. The obturator nerve was identified and was untouched. The margin for the resection of the lymph node bilaterally were the Cooper's ligament, the medial edge of the external iliac artery, the bifurcation of the common iliac vein, the obturator nerve, and the bladder. Both hemostasis and lymphostasis was achieved by using silk ties and Hemo clips. The lymph nodes were palpably normal and were set for permanent section. The Bookwalter retractor was then repositioned and the endopelvic fascia was opened bilaterally using Metzenbaum scissors. The puboprostatic ligament was taken down sharply. The superficial dorsal vein complex over the prostate was bunched up by using the Allis clamp and then tied by using 2-0 silk sutures. The deep dorsal vein complex was then bunched up by using the Allis over the membranous urethral area. The dorsal vein complex was ligated by using 0 Vicryl suture on a CT-1 needle. The Allis clamp was removed and the dorsal vein complex was transected by using Metzenbaum scissors. The urethra was then identified and was dissected out. The urethral opening was made just distal to the apex of the prostate by using Metzenbaum scissors. This was extended circumferentially until the Foley catheter could be seen clearly. 2-0 Monocryl sutures were then placed on the urethral stump evenly spaced out for the anastomosis to be performed later. The Foley catheter was removed and the posteriormost aspect of urethra and rectourethralis muscle was transected. The lateral pelvic fascia was opened bilaterally to sweep the neurovascular bundles laterally on both sides. The plane between Denonvilliers' fascia and the perirectal fat was developed sharply. No tension was placed on the neurovascular bundle at any point in time. The prostate dissected off the rectal wall easily. Once the seminal vesicles were identified, the fascia covering over them were opened transversely. The seminal vesicles were dissected out and the small bleeding vessels leading to them were clipped by using medium clips and then transected. The bladder neck was then dissected out carefully to spare most of the bladder neck muscles. Once all of the prostate had been dissected off the bladder neck circumferentially the mucosa lining the bladder neck was transected releasing the entire specimen. The specimen was inspected and appeared to be completely intact. It was sent for permanent section. The bladder neck mucosa was then everted by using 4-0 chromic sutures. Inspection at the prostatic bed revealed no bleeding vessels. The sutures, which were placed previously onto the urethral stump, were then placed onto the bladder neck. Once the posterior sutures had been placed, the Foley was placed into the urethra and into the bladder neck. A 20-French Foley Catheter was used. The anterior sutures were then placed. The Foley was then inflated. The bed was straightened and the sutures were tied down sequentially from anteriorly to posteriorly. Mild traction of the Foley catheter was placed to assure the anastomosis was tight. Two #19-French Blake drains were placed in the perivesical spaces. These were anchored to the skin by using 2-0 silk sutures. The instrument counts, lab counts, and sponge counts were verified to be correct, the patient was closed. The fascia was closed in running fashion using #1 PDS. Subcutaneous tissue was closed by using 2-0 Vicryl suture. Skin was approximated by using metallic clips. The patient tolerated the operation well.

HOSPITAL COURSE:, The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections. Baby was born at 5:57 on 07/30/2006. Mother received ampicillin 2 g 4 hours prior to delivery. Mother came with preterm contractions, with progressive active labor in spite of the terbutaline and magnesium sulfate. Baby was born with Apgar scores of 8 and 9 at delivery. Fluid was cleared. Nuchal cord x1. Prenatal was at ABC Valley. Prenatal labs were O positive, antibody negative, rubella immune, RPR nonreactive. Baby was suctioned on perineum with good support. The baby was admitted to the NICU for prematurity and to rule out sepsis. Baby's cry was good. Color, tone, and __________ mild retractions. CBC, CRP, blood cultures were done. IV fluids of D10 at a rate of 6 mL an hour. Ampicillin and gentamicin were started via protocol. At the time of admission, the patient was stable on room air and has feeding issues. Baby was fed EBM 22 and NeoSure per os. Ampicillin and gentamicin were started per protocol but were discontinue when blood cultures came out negative after 48 hours. The patient continues on feeding issues, will not suck properly, was kept in the NICU, and put on OG tube for a couple of days after which p.o. feeds were advanced. Also, the baby was able to suck properly and was tolerating feeds. The baby was fed EBM 22 and NeoSure was added a day before discharge. At the time of discharge, baby was stable on room air, baby was tolerated p.o. foods and was sucking properly, was taking ad lib feeds and gaining weight.,ADMISSION DIAGNOSES:, Respiratory distress, rule out sepsis and prematurity.,DISCHARGE DIAGNOSES:, Stable, ex-34-week preemie.,Pediatrician after discharge will be Dr. X.,DISCHARGE INSTRUCTIONS: , To follow up with Dr. X in 2 to 3 days, an appointment was made for 08/14/2006. CPR teaching was completed on 08/11/2006 to parents. Formula feeding schedule with breast and NeoSure 2 to 3 ounces per feed. Ad lib feeding on demand.

DIAGNOSIS ON ADMISSION: , Gastrointestinal bleed.,DIAGNOSES ON DISCHARGE,1. Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.,2. Atherosclerotic cardiovascular disease.,3. Hypothyroidism.,PROCEDURE:, Colonoscopy.,FINDINGS:, Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.,HOSPITAL COURSE: ,The patient was admitted to the emergency room by Dr. X. He apparently had an NG tube placed in the emergency room with gastric aspirate revealing no blood. Dr. Y Miller saw him in consultation and recommended a colonoscopy. A bowel prep was done. H&Hs were stable. His most recent H&H was 38.6/13.2 that was this morning. His H&H at admission was 41/14.3. The patient had the bowel prep that revealed no significant bleeding. His vital signs are stable. He is continuing on his usual medications of Imdur, metoprolol, and Synthroid. His Plavix is discontinued. He is given IV Protonix. I am hesitant to use Prilosec or Protonix because of his history of pancreatitis associated with Prilosec.,The patient's PT/INR was 1.03, PTT 25.8. Chemistry panel was unremarkable. The patient was given a regular diet after his colonoscopy today. He tolerated it well and is being discharged home. He will be followed closely as an outpatient. He will continue his Pepcid 40 mg at night, Imdur, Synthroid, and metoprolol as prior to admission. He will hold his Plavix for now. They will call me for further dark stools and will avoid Pepto-Bismol. They will follow up in the office on Thursday.