transcription,medical_specialty
"HISTORY OF PRESENT ILLNESS:,  The patient is well known to me for a history of iron-deficiency anemia due to chronic blood loss from colitis.  We corrected her hematocrit last year with intravenous (IV) iron.  Ultimately, she had a total proctocolectomy done on 03/14/2007 to treat her colitis.  Her course has been very complicated since then with needing multiple surgeries for removal of hematoma.  This is partly because she was on anticoagulation for a right arm deep venous thrombosis (DVT) she had early this year, complicated by septic phlebitis.,Chart was reviewed, and I will not reiterate her complex history.,I am asked to see the patient again because of concerns for coagulopathy.,She had surgery again last month to evacuate a pelvic hematoma, and was found to have vancomycin resistant enterococcus, for which she is on multiple antibiotics and followed by infectious disease now.,She is on total parenteral nutrition (TPN) as well.,LABORATORY DATA:,  Labs today showed a white blood count of 7.9, hemoglobin 11.0, hematocrit 32.8, and platelets 1,121,000.  MCV is 89.  Her platelets have been elevated for at least the past week, with counts initially at the 600,000 to 700,000 range and in the last couple of day rising above 1,000,000.  Her hematocrit has been essentially stable for the past month or so.  White blood count has improved.,PT has been markedly elevated and today is 44.9 with an INR of 5.0.  This is despite stopping Coumadin on 05/31/2007, and with administration of vitamin K via the TPN, as well as additional doses IV.  The PT is slightly improved over the last few days, being high at 65.0 with an INR of 7.3 yesterday.,PTT has not been checked since 05/18/2007 and was normal then at 28.,LFTs have been elevated.  ALT is 100, AST 57, GGT 226, alkaline phosphatase 505, albumin low at 3.3, uric acid high at 4.9, bilirubin normal, LDH normal, and pre-albumin low at 16.  Creatinine is at 1.5, with an estimated creatinine clearance low at 41.7.  Other electrolytes are fairly normal.,B12 was assessed on 05/19/2007 and was normal at 941.  Folic acid was normal.  Iron saturation has not been checked since March, and was normal then.  Ferritin has not been checked in a couple of months.,CURRENT MEDICATIONS: , Erythropoietin 45,000 units every week, started 05/16/2007.  She is on heparin flushes, loperamide, niacin, pantoprazole, Diovan, Afrin nasal spray, caspofungin, daptomycin, Ertapenem, fentanyl or morphine p.r.n. pain, and Compazine or Zofran p.r.n. nausea.,PHYSICAL EXAMINATION: ,GENERAL:  She is alert, and frustrated with her prolonged hospital stay.  She notes that she had epistaxis a few days ago, requiring nasal packing and fortunately that had resolved now.,VITAL SIGNS:  Today, temperature is 98.5, pulse 99, respirations 16, blood pressure 105/65, and pulse is 95.  She is not requiring oxygen.,SKIN:  No significant ecchymoses are noted.,ABDOMEN:  Ileostomy is in place, with greenish black liquid output.  Midline surgical scar has healed well, with a dressing in place in the middle, with no bleeding noted.,EXTREMITIES:  She has no peripheral edema.,CARDIAC:  Regular rate.,LYMPHATICS:  No adenopathy is noted.,LUNGS:  Clear bilaterally.,IMPRESSION AND PLAN:,  Markedly elevated PT/INR despite stopping Coumadin and administering vitamin K.  I will check mixing studies to see if she has deficiency, which could be due to poor production given her elevated LFTs, decreased albumin, and decreased pre-albumin.,It is possible that she has an inhibitor, which would have to be an acquired inhibitor, generally presenting with an elevated PTT and not PT.  I will check a PTT and check mixing studies if that is prolonged.  It is doubtful that she has a lupus anticoagulant since she has been presenting with bleeding symptoms rather than clotting.  I agree with continuing off of anticoagulation for now.,She has markedly elevated platelet count.  I suspect this is likely reactive to infection, and not from a new myeloproliferative disorder.,Anemia has been stable, and is multifactorial.  Given her decreased creatinine clearance, I agree with erythropoietin support.  She was iron deficient last year, and with her multiple surgeries and poor p.o. intake, may have become iron deficient again.  She has had part of her small bowel removed, so there may be a component of poor absorption as well.  If she is iron deficient, this may contribute also to her elevated platelet counts.  I will check a ferritin.  This may be difficult to interpret because of inflammation.  If it is decreased, plan will be to add iron supplementation intravenously.  If it is elevated, we could consider a bone marrow biopsy to evaluate her iron stores, and also assess her myelopoiesis given the markedly elevated platelet counts.,She needs continued treatment as you are for her infections.,I will discuss the case with Dr. X as well since there is a question as to whether she might need additional surgery.  She is not a surgical candidate now with her elevated PT/INR.",16
"PREPROCEDURE DIAGNOSIS:,  Chest pain secondary to fractured ribs, unmanageable with narcotics.,POSTPROCEDURE DIAGNOSIS:,  Chest pain secondary to fractured ribs, unmanageable with narcotics.,PROCEDURE: , Intercostal block from fourth to tenth intercostal spaces, left.,INDICATIONS: , I was requested by Dr. X to do an intercostal block on this lady who fell and has fractured ribs, whose chest pain is paralyzing and not responding well to increasing doses of narcotics.,PROCEDURE DETAIL:,  After obtaining an informed consent with the patient on her bedside, she was placed in the right decubitus position with the left side up.  The posterior left chest wall was prepped and draped in the usual fashion and then a mixture of 1% Xylocaine 20 mL and Marcaine 0.25% 20 mL were mixed together and the intercostal spaces from the fourth to the tenth ribs were anesthetized.  A total of 30 mL worth of solution was used.  I also injected some local anesthetic subcutaneously into an area of contusion in the left lumbar area.,The patient tolerated the procedure well.  She had no respiratory distress.  Immediately, the patient felt some relief from the pain.  Chest x-ray was ordered for the following day.",28
"HISTORY OF PRESENT ILLNESS: , The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer.  She returns for a routine surveillance visit.,She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the left kidney.  She underwent barium swallow, which demonstrates a small sliding hiatal hernia with minimal reflux.  She has a minimal delayed emptying secondary tertiary contractions.  PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates.  Review of systems, the patient continues to have periodic odynophagia and mid thoracic dysphagia.  This most likely is secondary to tertiary contractions with some delayed emptying.  She has also had increased size of the left calf without tenderness, which has not resolved over the past several months.  She has had a previous DVT in 1975 and 1985.  She denies weight loss, anorexia, fevers, chills, headaches, new aches or pains, cough, hemoptysis, shortness of breath at rest, or dyspnea on exertion.,MEDICATIONS: , Aspirin 81 mg p.o. q.d., Spiriva 10 mcg q.d., and albuterol p.r.n.,PHYSICAL EXAMINATION: , BP:  117/78.  RR:  18.  P:  93.,WT:  186 lbs.  RAS:  100%.,HEENT:  Mucous membranes are moist.  No cervical or supraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIAC:  Regular rate and rhythm without murmurs.,EXTREMITIES:  No cyanosis, clubbing or edema.,NEURO:  Alert and oriented x3.  Cranial nerves II through XII intact.,ASSESSMENT: , The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.,PLAN:  ,She is to return to clinic in six months with a chest CT.  She was given a prescription for an ultrasound of the left lower extremity to rule out DVT.  She will be called with the results.  She was given a prescription for nifedipine 10 mg p.o. t.i.d. p.r.n. esophageal spasm.",34
"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.",21
"PREOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,POSTOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,PROCEDURE:,  Bronchoscopy with brush biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was taken to the operating room where he underwent a general endotracheal anesthesia.  A time-out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4% lidocaine had been infused into the endotracheal tube.  First the trachea and the carina had normal appearance.  The scope was passed into the left side and the bronchial system was found to be normal.  There were scars and mucoid secretions.  Then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and TB.  First, the basal lobes were explored and found to be normal.  Then, the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated.  Then, the bronchi going to the three segments were visualized and no abnormalities or mass were found.  Brush biopsy was obtained from one of the segments and sent to Pathology.,The procedure had to be interrupted several times because of the patient's desaturation, but after a few minutes of Ambu bagging, he recovered satisfactorily.,At the end, the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.,",3
"CHIEF COMPLAINT: , MGUS.,HISTORY OF PRESENT ILLNESS:,  This is an extremely pleasant 86-year-old gentleman, who I follow for his MGUS.  I initially saw him for thrombocytopenia when his ANC was 1300.  A bone marrow biopsy was obtained.  Interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.0 and his white blood cell count was 6.5 with a platelet count of 484,000.  His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia.  All his tests came back as consistent with an MGUS.,Overall, he is doing well.  Since I last saw him, he tells me that he has had onset of atrial fibrillation.  He has now started going to the gym two times per week, and has lost over 10 pounds.  He has a good energy level and his ECOG performance status is 0.  He denies any fever, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Multivitamin q.d., aspirin one tablet q.d., Lupron q. three months, Flomax  0.4 mg q.d., and Warfarin 2.5 mg q.d.,ALLERGIES:  ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post left inguinal hernia repair.,2.  Prostate cancer diagnosed in December 2004, which was a Gleason 3+4.  He is now receiving Lupron.,SOCIAL HISTORY: , He has a very remote history of tobacco use.  He has one to two alcoholic drinks per day.  He is married.,FAMILY HISTORY: , His brother had prostate cancer.,PHYSICAL EXAM:,VIT:",16
"REASON FOR CATHETERIZATION:,  ST-elevation myocardial infarction.,PROCEDURES UNDERTAKEN,1.  Left coronary system cineangiography.,2.  Right coronary system cineangiography.,3.  Left ventriculogram.,4.  PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.,PROCEDURE: , After all risks and benefits were explained to the patient, informed consent was obtained.  The patient was brought to the cardiac cath suite.  Right groin was prepped in usual sterile fashion.  Right common femoral artery was cannulated with the modified Seldinger technique.  A 6-French sheath was introduced.  Next, Judkins right catheter was used to engage the right coronary artery and cineangiography was recorded in multiple views.  Next, an EBU 3.5 guide was used to engage the left coronary system.  Cineangiography was recorded in several views and it was noted to have a 99% proximal left circumflex stenosis.  Angiomax bolus and drip were started after checking an ACT, which was 180, and an Universal wire was advanced through the left circumflex beyond the lesion.  Next, a 3.0 x 12 mm balloon was used to pre-dilate the lesion.  Next a 3.5 x 12 mm Vision bare-metal stent was advanced to the area of stenosis and deployed at 12 atmospheres.  There was noted to be a plaque shift proximally at the edge of the stent.  Therefore, a 3.5 x 8 mm Vision bare-metal stent was advanced to cover the proximal margin of the first stent and deployed at 12 atmospheres.  Next, a 3.75 x 13 mm noncompliant balloon was advanced into the margin of the stent and two inflations at 20 atmospheres were done for 20 seconds.  Final images showed excellent results with initial 99% stenosis reduced to 0%.  The patient continues to have residual stenosis in the mid to distal in the OM branch.  At this point, wire was removed.  Final images confirmed initial stent results, no evidence of dissection, perforation, or complications.,Next, an angled pigtail catheter was advanced into the left ventricular cavity.  LV pressure was measured.  LV gram was done in both the LAO and RAO projections and a pullback gradient across the aortic valve was done and recorded.  Finally, all guides were removed.  Right femoral artery access site was imaged and Angio-Seal deployed to attain excellent hemostasis.  The patient tolerated the procedure very well without complications.,DIAGNOSTIC FINDINGS,1.  Left main:  Left main is a large-caliber vessel bifurcating in LAD and left circumflex with no significant disease.,2.  The LAD:  LAD is a large-caliber vessel, wraps around the apex, gives off multiple septal perforators, three small-to-medium caliber diagonal branches without any significant disease.,3.  Left circumflex:  Left circumflex is a large-caliber vessel, gives off a large distal PDA branch, has a 99% proximal lesion, 50% mid vessel lesion, and a 50% lesion in the OM, which is a distal branch.,4.  Right coronary artery:  Right coronary artery is a moderate-caliber vessel, dominant, bifurcates into PDA and PLV branches, has only mild disease.  Otherwise, no significant stenosis noted.,5.  LV:  The LVEF 50%.  Inferolateral wall hypokinesis.  No significant mitral regurgitation.  No gradient across the aortic valve on pullback.,ASSESSMENT AND PLAN: , ST-elevation myocardial infarction with a 99% stenosis of the proximal portion of the left circumflex treated with a 3.5 x 12 mm Vision bare-metal stent and a 3.5 x 8 mm Vision bare-metal stent.  Excellent results, 0% residual stenosis.  The patient continues to have some residual 50% stenosis in the left circumflex system, some mild disease throughout the other vessels.  Therefore, we will aggressively treat this patient medically with close followup as an outpatient.",3
"TITLE OF OPERATION:,  Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.,INDICATION FOR SURGERY: ,  The patient is a patient well known to my service.  She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull.  I took her to the operating a few days ago for a large right-sided hemicraniectomy to save her life.  I spoke with the family, the mom, especially about the risks, benefits, and alternatives of this procedure, most especially given the fact that she had undergone a very severe traumatic brain injury with a very poor GCS of 3 in some brainstem reflexes.  I discussed with them that this was a life-saving procedure and the family agreed to proceed with surgery as a level 1.  We went to the operating room at that time and we did a very large right-sided hemicraniectomy.  The patient was put in the intensive care unit.  We had placed also at that time a left-sided intracranial pressure monitor both which we took out a few days ago.  Over the last few days, the patient began to slowly deteriorate little bit on her clinical examination, that is, she was at first localizing briskly with the right side and that began to be less brisk.  We obtained a CT scan at this point, and we noted that she had a fair amount of swelling in the left hemisphere with about 1.5 cm of midline shift.  At this point, once again I discussed with the family the possibility of trying to save her life and go ahead and doing a left-sided very large hemicraniectomy with this __________  this was once again a life-saving procedure and we proceeded with the consent of mom to go ahead and do a level 1 hemicraniectomy of the left side.,PROCEDURE IN DETAIL: , The patient was taken to the operating room.  She was already intubated and under general anesthesia.  The head was put in a 3-pin Mayfield headholder with one pin in the forehead and two pins in the back to be able to put the patient with the right-hand side down and the left-hand side up since on the right-hand side, she did not have a bone flap which complicated matters a little bit, so we had to use a 3-pin Mayfield headholder.  The patient tolerated this well.  We sterilely prepped everything and we actually had already done a midline incision prior to this for the prior surgery, so we incorporated this incision into the new incision, and to be able to open the skin on the left side, we did a T-shaped incision with T vertical portion coming from anterior to the ear from the zygoma up towards the vertex of the skull towards the midline of the skin.  We connected this.  Prior to this, we brought in all surgical instrumentation under sterile and standard conditions.  We opened the skin as in opening a book and then we also did a myocutaneous flap.  We brought in the muscle with it.  We had a very good exposure of the skull.  We identified all the important landmarks including the zygoma inferiorly, the superior sagittal suture as well as posteriorly and anteriorly.  We had very good landmarks, so we went ahead and did one bur hole and the middle puncta right above the zygoma and then brought in the craniotome and did a very large bone flap that measured about 7 x 9 cm roughly, a very large decompression of the left side.  At this point, we opened the dura and the dura as soon as it was opened, there was a small subdural hematoma under a fair amount of pressure and cleaned this very nicely irrigated completely the brain and had a few contusions over the operculum as well as posteriorly.  All this was irrigated thoroughly.  Once we made sure we had absolutely great hemostasis without any complications, we went ahead and irrigated once again and we had controlled the meddle meningeal as well as the superior temporal artery very nicely.  We had absolutely good hemostasis.  We put a piece of Gelfoam over the brain.  We had opened the dura in a cruciate fashion, and the brain clearly bulging out despite of the fact that it was in the dependent position.  I went ahead and  irrigated everything thoroughly putting a piece of DuraGen as well as a piece of Gelfoam with very good hemostasis and proceeded to close the skin with running nylon in place.  This running nylon we put in place in order not to put any absorbables, although I put a few 0 popoffs just to approximate the skin nicely.  Once we had done this, irrigated thoroughly once again the skin.  We cleaned up everything and then we took the patient off __________ anesthesia and took the patient back to the intensive care unit.  The EBL was about 200 cubic centimeters.  Her hematocrit went down to about 21 and I ordered the patient to receive one unit of blood intraoperatively which they began to work on as we began to continue to do the work and the sponges and the needle counts were correct.  No complications.  The patient went back to the intensive care unit.",37
"PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:,  This 77-year-old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux.  The patient has a history of chronic osteomyelitis and non-healing ulceration to the left hallux of almost 10 years' duration.  He has failed outpatient antibiotic therapy and conservative methods.  At this time, he desires to attempt surgical correction.  The patient is not interested in a hallux amputation at this time; however, he is consenting to removal of infected bone.  He was counseled preoperatively about the strong probability of the hallux being a ""floppy tail"" after the surgery and accepts the fact.  The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL:  ,The patient's wound was debrided with a #15 blade and down to good healthy tissue preoperatively.  The wound was on the planar medial, distal and dorsal medial.  The wound's bases were fibrous.  They did not break the bone at this point.  They were each approximately 0.5 cm in diameter.  After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection.,Due to the patient's history of diabetes and marked calcifications on x-ray, a pneumatic ankle tourniquet was not applied.  Next, a total of 3 cc of a 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was used to infiltrate the left hallux and perform a digital block.  Next, the foot was prepped and draped in the usual aseptic fashion.  It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected.  Next, a #10 blade was used to make a linear incision approximately 3.5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium.  Next, the incision was deepened through the subcutaneous tissue.  A heavy amount of bleeding was encountered.  Therefore, a Penrose drain was applied at the tourniquet, which failed.  Next, an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis.  Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery.  Next, the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon.  The long extensor tendon was thickened and overall exhibited signs of hypertrophy.  The transverse incision through the long extensor tendon was made with a #15 blade.  Immediately upon entering the joint, yellow discolored fluid was drained from the interphalangeal joint.  Next, the extensor tendon was peeled dorsally and distally off the bone.  Immediately the head of the proximal phalanx was found to be lytic, disease, friable, crumbly, and there were free fragments of the medial aspect of the bone, the head of the proximal phalanx.  This bone was removed with a sharp dissection.  Next, after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx, a sagittal saw was used to resect the approximately one-half of the proximal phalanx.  This was passed off as the infected bone specimen for microbiology and pathology.  Next, the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx.  Next, there was diseased soft tissue envelope around the bone, which was also resected to good healthy tissue margins.  The pulse lavage was used to flush the wound with 1000 cc of gentamicin-impregnated saline.  Next, cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin.  This bone was found to be hard and healthy appearing.  The wound after irrigation was free of all debris and infected tissue.  Therefore anaerobic and aerobic cultures were taken and sent to microbiology.  Next, OsteoSet beads, tobramycin-impregnated, were placed.  Six beads were placed in the wound.  Next, the extensor tendon was re-approximated with #3-0 Vicryl.  The subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  Next, the skin was closed with #4-0 nylon in a horizontal mattress technique.,The Esmarch bandage was released and immediate hyperemic flush was noted at the digits.  A standard postoperative dressing was applied consisting of 4 x 4s, Betadine-soaked #0-1 silk, Kerlix, Kling, and a loosely applied Ace wrap.  The patient tolerated the above anesthesia and procedure without complications.  He was transported via a cart to the Postanesthesia Care Unit.  His vitals signs were stable and vascular status was intact.  He was given a medium postop shoe that was well-formed and fitting.  He is to elevate his foot, but not apply ice.  He is to follow up with Dr. X.  He was given emergency contact numbers.  He is to continue the Vicodin p.r.n. pain that he was taking previously for his shoulder pain and has enough of the medicine at home.  The patient was discharged in stable condition.",37
"PREOPERATIVE DIAGNOSIS:,  Adenocarcinoma of the prostate.,POSTOPERATIVE DIAGNOSIS:,  Adenocarcinoma of the prostate.,TITLE OF OPERATION:,  Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap.,ANESTHESIA: , General by intubation.,Informed consent was obtained for the procedure.  The patient understands the treatment options and wishes to proceed.  He accepts the risks to include bleeding requiring transfusion, infection, sepsis, incontinence, impotence, bladder neck constricture, heart attack, stroke, pulmonary emboli, phlebitis, injury to the bladder, rectum, or ureter, etcetera.,OPERATIVE PROCEDURE IN DETAIL: , The patient was taken to the Operating Room and placed in the supine position, prepped with Betadine solution and draped in the usual sterile fashion.  A 20- French Foley catheter was inserted into the penis and into the bladder and placed to dependent drainage.  The table was then placed in minimal flexed position.  A midline skin incision was then made from the umbilicus to the symphysis pubis.  It was carried down to the anterior rectus fascia into the pelvis proper.  Both obturator fossae were exposed.  Standard bilateral pelvic lymph node dissections were carried out.  The left side was approached first by myself.  The limits of my dissection were from the external iliac vein laterally to the obturator nerve medially, and from the bifurcation of the common iliac vein proximally to Cooper's ligament distally.  Meticulous lymphostasis and hemostasis was obtained using hemoclips and 2-0 silk ligatures.  The obturator nerve was visualized throughout and was not injured.  The right side was carried out by my assistant under my direct and constant supervision.  Again, the obturator nerve was visualized throughout and it was not injured.  Both packets were sent to Pathology where no evidence of carcinoma was found.,My attention was then directed to the prostate itself.  The  endopelvic fascia was opened bilaterally.  Using gentle dissection with a Kitner, I swept the levator muscles off the prostate and exposed the apical portion of the prostate.  A back bleeding control suture of 0 Vicryl was placed at the mid-prostate level.  A sternal wire was then placed behind the dorsal vein complex which was sharply transected.  The proximal and distal portions of this complex were then oversewn with 2-0 Vicryl in a running fashion.  When I was satisfied that hemostasis was complete, my attention was then turned to the neurovascular bundles.,The urethra was then sharply transected and six sutures of 2-0 Monocryl placed at the 1, 3, 5, 7, 9 and 11 o'clock positions.  The prostate was then lifted retrograde in the field and was swept from the anterior surface of the rectum and the posterior layer of Denonvilliers' fascia was incised distally, swept off the rectum and incorporated with the prostate specimen.  The lateral pedicles over the seminal vesicles were then mobilized, hemoclipped and transected.  The seminal vesicles themselves were then mobilized and hemostasis obtained using hemoclips.  Ampullae of the vas were mobilized, hemoclipped and transected.  The bladder neck was then developed using careful blunt and sharp dissection.  The prostate was then transected at the level of the bladder neck and sent for permanent specimen.  The bladder neck was reevaluated and the ureteral orifices were found to be placed well back from the edge.  The bladder neck was reconstructed in standard fashion.  It was closed using a running 2-0 Vicryl.  The mucosa was everted over the edge of the bladder neck using interrupted 3-0 Vicryl suture.  At the end of this portion of the case, the new bladder neck had a stoma-like appearance and would accommodate easily my small finger.  The field was then re-evaluated for hemostasis which was further obtained using hemoclips, Bovie apparatus and 3-0 chromic ligatures.  When I was satisfied that hemostasis was complete, the aforementioned Monocryl sutures were then placed at the corresponding positions in the bladder neck.  A new 20-French Foley catheter was brought in through the urethra into the bladder.  A safety suture of 0 Prolene was brought through the end of this and out through a separate stab wound in the bladder and through the left lateral quadrant.  The table was taken out of flexion and the bladder was then brought into approximation to the urethra and the Monocryl sutures were ligated.  The bladder was then copiously irrigated with sterile water and the anastomosis was found to be watertight.  The pelvis was also copiously irrigated with 2 liters of sterile water.  A 10-French Jackson-Pratt drain was placed in the pelvis and brought out through the right lower quadrant and sutured in place with a 2-0 silk ligature.,The wound was then closed in layers.  The muscle was closed with a running 0 chromic, the fascia with a running 1-0 Vicryl, the subcutaneous tissue with 3-0 plain, and the skin with a running 4-0 Vicryl subcuticular.  Steri-Strips were applied and a sterile dressing.,The patient was taken to the Recovery Room in good condition.  There were no complications.  Sponge and instrument counts were reported correct at the end of the case.",37
"PREOPERATIVE DIAGNOSES:,1.  Right pelvic pain.,2.  Right ovarian mass.,POSTOPERATIVE DIAGNOSES:,1.  Right pelvic pain.,2.  Right ovarian mass.,3.  8 cm x 10 cm right ovarian cyst with ovarian torsion.,PROCEDURE PERFORMED:  ,Laparoscopic right salpingooophorectomy.,ANESTHESIA:  ,General with endotracheal tube.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,TUBES: , None.,DRAINS:,  None.,PATHOLOGY: , The right tube and ovary sent to pathology for review.,FINDINGS: , On exam under anesthesia, a normal-appearing vulva and vagina and normally palpated cervix, a uterus that was normal size, and a large right adnexal mass.  Laparoscopic findings demonstrated a 8 cm x 10 cm smooth right ovarian cyst that was noted to be torsed twice.  Otherwise, the uterus, left tube and ovary, bowel, liver margins, appendix, and gallbladder were noted all to be within normal limits.  There was no noted blood in the pelvis.,INDICATIONS FOR THIS PROCEDURE:,  The patient is a 26-year-old G1 P1 who presented to ABCD General Emergency Room with complaint of right lower quadrant pain since last night, which has been increasing in intensity.  The pain persisted despite multiple pain medications given in the Emergency Room.  The patient reports positive nausea and vomiting.  There was no vaginal bleeding or discharge.  There was no fevers or chills.  Her cultures done in the Emergency Room were pending.  The patient did have an ultrasound that demonstrated an 8 cm right ovarian cyst, questionable hemorrhagic.  The uterus and left ovary were within normal limits.  There was a positive flow noted to bilateral ovaries on ultrasound.  Therefore, it was felt appropriate to take the patient for a diagnostic laparoscopy with a possible oophorectomy.,PROCEDURE:,  After informed consent was obtained, and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where general anesthesia was obtained without any difficulty.  She was placed in dorsal lithotomy position with the use of Allis strips and prepped and draped in the usual sterile fashion.  Her bladder was drained with a red Robinson catheter and she was examined under anesthesia and was noted to have the findings as above.  She was prepped and draped in the usual sterile fashion.  A weighted speculum was placed in the patient's vagina with excellent visualization of the cervix.  The cervix was grasped at 12 o'clock position with a single-toothed tenaculum and pulled into the operative field.  The uterus was then sounded to approximately 3.5 inches and then a uterine elevator was placed.  The vulsellum tenaculum was removed.  The weighted speculum was removed.  Attention was then turned to the abdomen where 1 cm infraumbilical incision was made in the infraumbilical fold.  The Veress step needle was then placed into the abdomen while the abdomen was being tented up with towel clamp.  The CO2 was then turned on with unoccluded flow and excellent pressures.  This was continued till a normal symmetrical pneumoperitoneum was obtained.  Then, a #11 mm step trocar and sleeve were placed into the infraumbilical port without any difficulty and placement was confirmed by laparoscope.  Laparoscopic findings are as noted above.  A suprapubic incision was made with the knife and then a #12 mm step trocar and sleeve were placed in the suprapubic region under direct visualization.  Then, a grasper was used to untorse the ovary.  Then, a #12 mm port was placed in the right flank region under direct visualization using a LigaSure vessel sealing system.  The right tube and ovary were amputated and noted to be hemostatic.  The EndoCatch bag was then placed through the suprapubic port and the ovary was placed into the bag.  The ovary was too large to fit completely into the bag.  Therefore, a laparoscopic needle with a 60 cc syringe was used to aspirate the contents of the ovary while it was still inside the bag.,There was approximately 200 cc of fluid aspirated from the cyst.  This was a clear yellow fluid.  Then, the bag was closed and the ovary was removed from the suprapubic port.  The suprapubic port did have to be extended somewhat to allow for the removal of the ovary.  The trocar and sleeve were then placed back into the port.  The abdomen was copiously irrigated with warm normal saline using the Nezhat-Dorsey suction irrigator and the incision site was noted to be hemostatic.  The pelvis was clear and clean.  ,Pictures were obtained.  The suprapubic port was then removed under direct visualization and then using a #0-vicyrl and UR6.  Two figure-of-eight sutures were placed in the fascia of suprapubic port and fascia was closed and the pneumoperitoneum was maintained after the sutures were placed.  Therefore, the peritoneal surface was noted to be hemostatic.  Therefore, the camera was removed.  All instruments were removed.  The abdomen was allowed to completely deflate and then the trocars were placed back through the sleeves of the right flank #12 port and the infraumbilical port and these were removed.  The infraumbilical port was examined and noted to have a small fascial defect which was repaired with #0-Vicryl and UR6.  The right flank area was palpated and there was no facial defect noted.  The skin was then closed with #4-0 undyed Vicryl in subcuticular fashion.  Dressings were changed.  The weighted speculum was removed from the patient's cervix.  The cervix noted to be hemostatic.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2 and the patient was taken to the Recovery in stable condition.",24
"PREOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,POSTOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,PROCEDURE:,  Exam under anesthesia with control of bleeding via cautery.,ANESTHESIA:,  General endotracheal.,INDICATION: , The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion.  He presents today with diarrhea and bleeding.  Digital exam reveals bright red blood on the finger.  He is for exam under anesthesia and control of hemorrhage at this time.,FINDINGS: , There was an ulcer where most of the polypoid lesion had been excised before.  In a near total fashion the wound had opened and again there was a raw ulcer surface in between the edges of the mucosa.  There were a few discrete sites of mild oozing, which were treated with cautery and #1 suture.  No other obvious bleeding was seen.,TECHNIQUE: , The patient was taken to the operating room and placed on the operative table in supine position.  After adequate general anesthesia was induced, the patient was then placed in modified prone position.  His buttocks were taped, prepped and draped in a sterile fashion.  The anterior rectal wall was exposed using a Parks anal retractor.  The entire wound was visualized with a few rotations of the retractor and a few sites along the edges were seen to be oozing and were touched up with cautery.  There was one spot in the corner that was oozing and this may have been from simply opening the retractor enough to see well.  This was controlled with a 3-0 Monocryl figure-of-eight suture.  At the completion, there was no bleeding, no oozing, it was completely dry, and we removed our retractor, and the patient was then turned and extubated and taken to the recovery room in stable condition.",14
"HISTORY OF PRESENT ILLNESS:  ,The patient is a 50-year-old African American female with past medical history significant for hypertension and endstage renal disease, on hemodialysis secondary to endstage renal disease, last hemodialysis was on June 22, 2007.  The patient presents with no complaints for cadaveric renal transplant.  After appropriate cross match and workup of HLA typing of both recipient and cadaveric kidneys, the patient was deemed appropriate for operative intervention and transplantation of kidney.,PREOPERATIVE DIAGNOSIS:,  Endstage renal disease.,POSTOPERATIVE DIAGNOSIS: , Endstage renal disease.,PROCEDURE:,  Cadaveric renal transplant to right pelvis.,ESTIMATED BLOOD LOSS: , 400 mL.,FLUIDS:  ,One liter of normal saline and one liter of 5% of albumin.,ANESTHESIA:  ,General endotracheal.,SPECIMEN:  ,None.,DRAIN: , None.,COMPLICATIONS: , None.,The patient tolerated the procedure without any complication.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room, prepped and draped in sterile fashion.  After adequate anesthesia was achieved, a curvilinear incision was made in the right pelvic fossa approximately 9 cm in length extending from the 1.5 cm medial of the ASIS down to the suprapubic space.  After this was taken down with a #10 blade, electrocautery was used to take down tissue down to the layer of the subcutaneous fat.  Camper's and Scarpa's were dissected with electrocautery.  Hemostasis was achieved throughout the tissue plains with electrocautery.  The external oblique aponeurosis was identified with musculature and was entered with electrocautery.  Then hemostats were entered in and dissection continued down with electrocautery down through the external internal obliques and the transversalis fascia.  Additionally, the rectus sheath was entered in a linear fashion.  After these planes were entered using electrocautery, the retroperitoneum was dissected free from the transversalis fascia using blunt dissection.  After the peritoneum and peritoneal structures were moved medially and superiorly by blunt dissection, the dissection continued down bluntly throughout the tissue planes removing some alveolar tissue over the right iliac artery.  Upon entering through the transversalis fascia, the epigastric vessels were identified and doubly ligated and tied with #0 silk ties.  After the ligation of the epigastric vessels, the peritoneum was bluntly dissected and all peritoneal structures were bluntly dissected to a superior and medial plane.  This was done without any complication and without entering the peritoneum grossly.  The round ligament was identified and doubly ligated at this time with #0 silk ties as well.  The dissection continued down now to layer of the alveolar tissue covering the right iliac artery.  This alveolar tissue was cleared using blunt dissection as well as electrocautery.  After the external iliac artery was identified, it was cleared circumferentially all the way around and noted to have good flow and had good arterial texture.  The right iliac vein was then identified, and this was cleared again using electrocautery and blunt dissection.  After the right iliac vein was identified and cleared off all the alveolar tissue, it was circumferentially cleared as well.  An additional perforating branch was noted at the inferior pole of the right iliac vein.  This was tied with a #0 silk tie and secured.  Hemostasis was achieved at this time and the tie had adequate control.  The dissection continued down and identified all other vital structures in this area.  Careful preservation of all vital structures was carried out throughout the dissection.  At this time, Satinsky clamp was placed over the right iliac vein.  This was then opened using a #11 blade, approximately 1 cm in length.  The heparinized saline was placed and irrigated throughout the inside of the vein, and the kidney was pulled into the abdominal field still covered in its protective socking with the superior pole marked.  The renal vein was then elevated and identified in this area.  A 5-0 double-ended Prolene stitch was used to secure the renal vein, both superiorly and inferiorly, and after appropriately being secured with 5-0 Prolene, these were tied down and secured.  The renal vein was then anastomosed to the right iliac vein in a circumferential manner in a running fashion until secured at both superior and inferior poles.  The dissection then continued down and the iliac artery was then anastomosed to the renal artery at this time using a similar method with 5-0 Prolene securing both superior and inferior poles.  After such time the 5-0 Prolene was run around in a circumferential manner until secured in both superior and inferior poles once again.  After this was done and the artery was secured, the Satinsky clamp was removed and a bulldog placed over.  The flow was then opened on the arterial side and then opened on the venous side to allow for proper flow.  The bulldog was then placed back on the renal vein and allowed for the hyperperfusion of the kidney.  The kidney pinked up nicely and had a good appearance to it and had appearance of good blood flow.  At this time, all Satinsky clamps were removed and all bulldog clamps were removed.  The dissection then continued down to the layer of the bladder at which time the bladder was identified.  Appropriate area on the dome the bladder was identified for entry.  This was entered using electrocautery and approximately 1 cm length after appropriately sizing and incising of the ureter using the Metzenbaum scissors in a linear fashion.  Before this was done, #0 chromic catgut stitches were placed and secured laterally and inferiorly on the dome of the bladder to elevate the area of the bladder and then the bladder was entered using the electrocautery approximately 1 cm in length.  At this time, a renal stent was placed into the ureter and secured superiorly and the stent was then placed into the bladder and secured as well.  Subsequently, the superior and inferior pole stitches with 5-0 Prolene were used to secure the ureter to the bladder.  This was then run mucosa-to-mucosa in a circumferential manner until secured in both superior and inferior poles once again.  Good flow was noted from the ureter at the time of operation.  Additional Vicryl stitches were used to overlay the musculature in a seromuscular stitch over the dome of the bladder and over the ureter itself.  At this time, an Ethibond stitch was used to make an additional seromuscular closure and rolling of the bladder musculature over the dome and over the anastomosis once again.  This was inspected and noted for proper control.  Irrigation of the bladder revealed that the bladder was appropriately filled and there were no flows and no defects.  At this time, the anastomoses were all inspected, hemostasis was achieved and good closure of the anastomosis was noted at this time.  The kidney was then placed back into its new position in the right pelvic fossa, and the area was once again inspected for hemostasis which was achieved.  A 1-0 Prolene stitch was then used for mass closure of the external, internal, and transversalis fascias and musculature in a running fashion from superior to inferior.  This was secured and knots were dumped.  Subsequently, the area was then checked and inspected for hemostasis which was achieved with electrocautery, and the skin was closed with 4-0 running Monocryl.  The patient tolerated procedure well without evidence of complication, transferred to the Dunn ICU where he was noted to be stable.  Dr. A was present and scrubbed through the entire procedure.",21
"PREOPERATIVE DIAGNOSIS:,  Worrisome skin lesion, left hand.,POSTPROCEDURE DIAGNOSIS:,  Worrisome skin lesion, left hand.,PROCEDURE:,  The patient gave informed consent for his procedure.  After informed consent was obtained, attention was turned toward the area of interest, which was prepped and draped in the usual sterile fashion.,Local anesthetic medication was infiltrated around and into the area of interest.  There was an obvious skin lesion there and this gentleman has a history of squamous cell carcinoma.  A punch biopsy of the worrisome skin lesion was obtained with a portion of the normal tissue included.  The predominant portion of the biopsy was of the lesion itself.,Lesion was removed.  Attention was turned toward the area.  Pressure was held and the area was hemostatic.,The skin and the area were closed with 5-0 nylon suture.  All counts were correct.  The procedure was closed.  A sterile dressing was applied.  There were no complications.  The patient had no neurovascular deficits, etc., after this minor punch biopsy procedure.,",37
"HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.  The patient also has a positive history of smoking in the past.  At the present time, he is admitted for continued,management of respiratory depression with other medical complications.  The patient was treated for multiple problems at Jefferson Hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter.  In addition, he also developed cardiac complications including atrial fibrillation.  The patient was evaluated by the cardiologist as well as the pulmonary service and Urology.  He had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008.  He subsequently underwent cardiac arrest and he was resuscitated at that time.  He was intubated and placed on mechanical ventilatory support.  Subsequent weaning was unsuccessful.  He then had a tracheostomy placed.,CURRENT MEDICATIONS:,1.  Albuterol.,2.  Pacerone.,3.  Theophylline,4.  Lovenox.,5.  Atrovent.,6.  Insulin.,7.  Lantus.,8.  Zestril.,9.  Magnesium oxide.,10.  Lopressor.,11.  Zegerid.,12.  Tylenol as needed.,ALLERGIES:,  PENICILLIN.,PAST MEDICAL HISTORY:,1.  History of coal miner's disease.,2.  History of COPD.,3.  History of atrial fibrillation.,4.  History of coronary artery disease.,5.  History of coronary artery stent placement.,6.  History of gastric obstruction.,7.  History of prostate cancer.,8.  History of chronic diarrhea.,9.  History of pernicious anemia.,10.  History of radiation proctitis.,11.  History of anxiety.,12.  History of ureteral stone.,13.  History of hydronephrosis.,SOCIAL HISTORY: , The patient had been previously a smoker.  No other could be obtained because of tracheostomy presently.,FAMILY HISTORY: , Noncontributory to the present condition and review of his previous charts.,SYSTEMS REVIEW: , The patient currently is agitated.  Rapidly moving his upper extremities.  No other history regarding his systems could be elicited from the patient.,PHYSICAL EXAM:,General:  The patient is currently agitated with some level of distress.  He has rapid respiratory rate.  He is responsive to verbal commands by looking at the eyes.,Vital Signs:  As per the monitors are stable.,Extremities:  Inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage II especially over the dorsum of the hands and forearm areas.  There is also edema of the forearm extending up to the mid upper arm area.  Palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect.  There is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,IMPRESSION:,1.  Ulceration of bilateral upper extremities.,2.  Cellulitis of upper extremities.,3.  Lymphedema of upper extremities.,4.  Other noninfectious disorders of lymphatic channels.,5.  Ventilatory-dependent respiratory failure.",15
"PREOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,POSTOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,PROCEDURE PERFORMED:,1.  Partial tarsectomy navicula, right foot.,2.  Partial metatarsectomy, right foot.,HISTORY:  ,This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint.  The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin.  She states that she has been diagnosed with hereditary osteochondromas.  She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back.  The patient desires surgical treatment at this time.,PROCEDURE:  ,An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal.  Foot was then prepped and draped in the usual sterile orthopedic fashion.,Foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was then inflated to 250 mmHg.  The foot was lowered as well as the operating table.  The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge.  Attention was then directed to the navicular region on the right foot.  The area was palpated until the bony prominence was noted.  A curvilinear incision was made over the area of bony prominence.  At that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site.  The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  The dissection was carried down to the level of the capsule and periosteum.  A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone.  The periosteum and the capsule were then reflected from the navicular bone at this time.  A bony prominence was noted both medially and plantarly to the navicular bone.  An osteotome and mallet were then used to resect the enlarged portion of the navicular bone.  After resection with an osteotome there was noted to be a large plantar shelf.  The surrounding soft tissues were then freed from this plantar area.  Care was taken to protect the attachments of the posterior tibial tendon as much as possible.  Only minimal resection of its attachment to the fiber was performed in order to expose the bone.  Sagittal saw was then used to resect the remaining plantar medial prominent bone.  The area was then smoothed with reciprocating rasp until no sharp edges were noted.  The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted.  The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl.  The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed.,Attention was then directed to the fifth metatarsal.  There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal.  Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal.  The incision was then deepened with #15 blade.  Care was taken to preserve the extensor tendon.  The incision was then created over the capsule and periosteum of the fifth metatarsal head.  Capsule and periosteum were reflected both dorsally, laterally, and plantarly.  At that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal.  A sagittal saw was used to resect both of these osteal prominences.,All remaining sharp edges were then smoothed with reciprocating rasp.  The area was inspected for the remaining bony prominences and none was noted.  The area was flushed with copious amounts of sterile saline.  The capsule and periosteum were then reapproximated with #3-0 Vicryl.  Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line.  Running #5-0 subcutaneous stitch was then performed.  Steri-Strips were applied to both surgical sites.  Dressings consisted of Adaptic, soaked in Betadine, 4x4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred to the PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated.  The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise.",27
"GENERAL: , A well-developed infant in no acute respiratory distress.,VITAL SIGNS:  ,Initial temperature was XX, pulse XX, respirations XX.  Weight XX grams, length XX cm, head circumference XX cm.,HEENT:  ,Head is normocephalic with anterior fontanelle open, soft, and non-bulging.  Eyes:  Red reflex elicited bilaterally.  TMs occluded with vernix and not well visualized.  Nose and throat are patent without palatal defect.,NECK: , Supple without clavicular fracture.,LUNGS:,  Clear to auscultation.,HEART:,  Regular rate without murmur, click, or gallop present.  Pulses are 2/4 for brachial and femoral.,ABDOMEN:,  Soft with bowel sounds present.  No masses or organomegaly.,GENITALIA: , Normal.,EXTREMITIES: , Without evidence of hip defects.,NEUROLOGIC:  ,The infant has good Moro, grasp, and suck reflexes.,SKIN: , Warm and dry without evidence of rash.",29
"PREOPERATIVE DIAGNOSIS: , Left lateral malleolus fracture.,POSTOPERATIVE DIAGNOSIS:,  Left lateral malleolus fracture.,PROCEDURE PERFORMED: , Open reduction and internal fixation of left lateral malleolus.,ANESTHESIA:  ,General.,TOURNIQUET TIME: , 59 minutes.,COMPLICATIONS: , None.,BLOOD LOSS: , Negligible.,CLOSURE: , 2-0 Vicryl and staples.,INDICATIONS FOR SURGERY:,  This is a young gentleman with soccer injury to his left ankle and an x-ray showed displaced lateral malleolus fracture with widening of the mortise now for ORIF.  The risks and perceivable complications of the surgeries were discussed with the patient via a translator as well as nonsurgical treatment options and this was scheduled emergently.,OPERATIVE PROCEDURE: , The patient was taken to the operative room where general anesthesia was successfully introduced.  The right ankle was prepped and draped in standard fashion.  The tourniquet was applied about the right upper thigh.  An Esmarch tourniquet was used to exsanguinate the ankle.  The tourniquet was insufflated to a pressure 325 mm for approximately 59 minutes.  An approximately 6 inch longitudinal incision was made just over the lateral malleolus.  Care was taken to spare overlying nerves and vessels.  An elevator was used to expose the fracture.  The fracture was freed of old hematoma and reduced with a reducing clamp.  An interfragmentary cortical screw was placed of 28 mm with excellent purchase.  The intraoperative image showed excellent reduction.  A 5-hole semitubular plate was then contoured to the lateral malleolus and fixed with 3 cortical screws proximally and 2 cancellous screws distally.  Excellent stability of fracture was achieved.  Final fluoroscopy showed a reduction to be anatomic in 2 planes.  The wound was irrigated with copious amounts of normal saline.  Deep tissue was closed with 2-0 Vicryl.  The skin was approximated with 2-0 Vicryl and closed with staples.  Dry sterile dressing was applied.,The patient tolerated the procedure, was awakened and taken to the recovery room in stable condition.",37
"REASON FOR EXAM: , Aortic valve replacement.  Assessment of stenotic valve.  Evaluation for thrombus on the valve.,PREOPERATIVE DIAGNOSIS:  ,Atrial valve replacement.,POSTOPERATIVE DIAGNOSES:,  Moderate stenosis of aortic valve replacement.  Mild mitral regurgitation.  Normal left ventricular function.,PROCEDURES IN DETAIL: , The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient received a total of 3 mg of Versed and 50 mcg of fentanyl for conscious sedation and pain control.  The oropharynx anesthetized with benzocaine spray and lidocaine solution.,Esophageal intubation was done with no difficulty with the second attempt.  In a semi-Fowler position, the probe was passed to transthoracic views at about 40 to 42 cm.  Multiple pictures obtained.  Assessment of the peak velocity was done later.,The probe was pulled to the mid esophageal level.  Different pictures including short-axis views of the aortic valve was done.  Extubation done with no problems and no blood on the probe.  The patient tolerated the procedure well with no immediate postprocedure complications.,INTERPRETATION: , The left atrium was mildly dilated.  No masses or thrombi were seen.  The left atrial appendage was free of thrombus.  Pulse wave interrogation showed peak velocities of 60 cm per second.,The left ventricle was normal in size and contractility with mild LVH.  EF is normal and preserved.,The right atrium and right ventricle were both normal in size.,Mitral valve showed no vegetations or prolapse.  There was mild-to-moderate regurgitation on color flow interrogation.  Aortic valve was well-seated mechanical valve, bileaflet with acoustic shadowing beyond the valve noticed.  No perivalvular leak was noticed.  There was increased velocity across the valve with peak velocity of 3.2 m/sec with calculated aortic valve area by continuity equation at 1.2 cm2 indicative of moderate aortic valve stenosis based on criteria for native heart valves.,No AIC.,Pulmonic valve was somewhat difficult to see because of acoustic shadowing from the aortic valve.  Overall showed no abnormalities.  The tricuspid valve was structurally normal.,Interatrial septum appeared to be intact, confirmed by color flow interrogation as well as agitated saline contrast study.,The aorta and aortic arch were unremarkable.  No dissection.,IMPRESSION:,1.  Mildly dilated left atrium.,2.  Mild-to-moderate regurgitation.,3.  Well-seated mechanical aortic valve with peak velocity of 3.2 m/sec and calculated valve area of 1.2 cm2 consistent with moderate aortic stenosis.  Reevaluation in two to three years with transthoracic echocardiogram will be recommended.",33
"PREOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE: , Endoscopic carpal tunnel release.,ANESTHESIA: , MAC,PROCEDURE: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease.  Dissection was carried down to the antebrachial fascia, which was cut in a distally based fashion.  Bipolar electrocautery was used to maintain meticulous hemostasis.  I then performed an antebrachial fasciotomy proximally.  I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area.  Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side.  Great care was taken with placement.  A good plane was positively identified.  I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament.,Again, I felt the hook of the hamate ulnar to me.  I had my thumb on the distal aspect of the transverse carpal ligament.  I then partially deployed the blade, and starting 1 mm from the distal edge, the transverse carpal ligament was positively identified.  I pulled back and cut and partially tightened the transverse carpal ligament.  I then feathered through the distal ligament and performed a full-thickness incision through the distal half of the ligament.  I then checked to make sure this was properly performed and then cut the proximal aspect.  I then entered the carpal tunnel again and saw that the release was complete, meaning that the cut surfaces of the transverse carpal ligament were separated; and with the scope rotated, I could see only one in the field at a time.  Great care was taken and at no point was there any longitudinal structure cut.  Under direct vision through the incision, I made sure that the distal antebrachial fascia was cut.  Following this, I irrigated and closed the skin.  The patient was dressed and sent to the recovery room in good condition.",37
"PREOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,PROCEDURE:, Right total knee arthroplasty.,DESCRIPTION OF THE OPERATION:, The patient was brought to the Operating Room and after the successful placement of an epidural, as well as general anesthesia, administration 1 gm of Ancef preoperatively, the patient's right thigh, knee and leg were scrubbed, prepped and draped in the usual sterile fashion. The leg was exsanguinated by gravity and pneumatic tourniquet was inflated to 300 mmHg.,A straight anterior incision was carried down through the skin and subcutaneous tissue. Unilateral flaps were developed and a median retinacular parapatellar incision was made. The extensor mechanism was partially divided and the patella was everted. Some of the femoral bone spurs were resected using an osteotome and a rongeur. Ascending drill hole was made in the distal femur and the distal femoral cut, anterior and posterior and chamfer cuts were accomplished for a 67.5 femoral component.,At this point the ACL was resected. Some of the fat pad and synovium were resected, as well as both medial and lateral menisci. A posterior cruciate retractor was utilized, the tibia brought forward and a centering drill hole made in the tibia. The intramedullary guide was used for cutting the tibia. It was set at 8 mm. An additional 2 mm was resected because of a moderate defect medially.,A trial reduction was done with a 71 tibial baseplate. This was pinned and drilled and then trial reduction done with a 10-mm insert.,This gave good stability and a full range of motion.,The patella was measured with the calibers and 9 mm of bone was resected with an oscillating saw. A 34-mm component was drilled for.,A further trial reduction was done and two liters of pulse lavage were used to clean the bony surfaces. A packet of cement was hand mixed, pressurized with a spatula into the proximal tibia. Multiple drill holes were made on the medial side of the tibia where the bone was somewhat sclerotic. The tibia baseplate was secured and the patella was inserted, held with a clamp. The extraneous cement was removed. At this point the tibial baseplate was locked into place and the femoral component also seated solidly.,The knee was extended, held in this position for another 5-6 minutes until the cement was cured. Further extraneous cement was removed. The pneumatic tourniquet was released, hemostasis was obtained with electrocoagulation.,Retinaculum, quadriceps and extensor were repaired with multiple figure-of-eight #1 Vicryl sutures, the subcutaneous tissue with 2-0 and the skin with skin staples. A sterile, bulky compression dressing was placed. The patient was stable on operative release.",37
"PREOPERATIVE DIAGNOSES:,  Left calcaneal valgus split.,POSTOPERATIVE DIAGNOSES:,  Left calcaneal valgus split.,PROCEDURES:  ,1.  Left calcaneal lengthening osteotomy with allograft.,2.  Partial plantar fasciotomy.,3.  Posterior subtalar and tibiotalar capsulotomy.,4.  Short leg cast placed.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME: , 69 minutes.,The patient in local anesthetic of 20 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS:  ,None.,SPECIMENS: , None.,HISTORY AND PHYSICAL: , The patient is a 13-year-old female who had previous bilateral feet correction at 1 year of age.  Since that time, the patient has developed significant calcaneal valgus deformity with significant pain.  Radiographs confirmed collapse of the spinal arch, as well as valgus position of the foot.  Given the patient's symptoms, surgery is recommended for calcaneal osteotomy and Achilles lengthening.  Risks and benefits of surgery were discussed with the mother.  Risks of surgery include risk of anesthesia; infection; bleeding; changes in sensation in most of extremity; hardware failure; need for later hardware removal; possible nonunion; possible failure to correct all the deformity; and need for other surgical procedures.  The patient will need to be strict nonweightbearing for at least 6 weeks and wear a brace for up to 6 months.  All questions were answered and parents agreed to the above surgical plan.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A bump was placed underneath the left buttock.  A nonsterile tourniquet was placed on the upper aspect of the left thigh.  The extremity was then prepped and draped in a standard surgical fashion.  The patient had a previous incision along the calcaneocuboid lateral part of the foot.  This was marked and extended proximally through the Achilles tendon.  Extremity was wrapped in Esmarch.  Tourniquet inflation was noted to be 250 mmHg.  Decision was then made to protect the sural nerve.  There was one sensory nervous branch that did cross the field though it was subsequently sharply ligated because it was in the way.  Dissection was carried down to Achilles tendon, which was subsequently de-lengthened with the distal half performed down the lateral thigh.  Proximal end was tacked with an 0 Ethibond suture and subsequently repaired end-on-end at length with the heel in neutral.  Dissection was then carried on the lateral border of the foot with identification of the peroneal longus and valgus tendons, which were removed from the sheath and retracted dorsally.  At this time, we also noted that calcaneocuboid joint appeared to be fused.  The area between the anterior and middle facets were plicated on fluoroscopy for planned osteotomy.  This was performed with a saw.  After a partial plantar fasciotomy was performed, this was released off an abductor digiti minimi.  The osteotomy was completed with an osteotome and distracted with the lamina spreader.  A tricortical allograft was then shaped and subsequently impacted into this area.  Final positioning was checked with multiple views of fluoroscopy.  It was subsequently fixed using a 0.94 K-wire and drilled from the heel anteriorly.  A pin was subsequently bent and cut short at the level of the skin.  The wound was then irrigated with normal saline.  The Achilles was repaired with this tie.  Please note during the case, it was noted the patient had continued significant stiffness despite the Achilles lengthening.  A posterior capsulotomy of the tibiotalar and subtalar joints were performed with increased 10 degrees of dorsiflexion.  Wound was then closed using #2-0 Vicryl and #4-0 Monocryl.  The surgical field was irrigated with 0.25% Marcaine and subsequently injected with more Marcaine at the end of the case.  The wound was clean and dry and dressed with Steri-Strips and Xeroform.  Skin was dressed with Xeroform and 4 x 4's.  Everything was wrapped with 4 x 4's in sterile Webril.  The tourniquet was released after 69 minutes.  A short-leg cast was then placed with good return of capillary refill to his toes.  The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for elevation, ice packs, neurovascular checks, and pain control.  The patient to be strict nonweightbearing.  We will arrange for her to get a wheelchair.  The patient will then follow up in about 10 to 14 days for a cast check, as well as pain control.  The patient will need an AFO script at that time.  Intraoperative findings are relayed to the parents.",27
"PAST MEDICAL HISTORY: , She has a history of hypertension and shortness of breath.,PAST SURGICAL HISTORY: , Pertinent for cholecystectomy.,PSYCHOLOGICAL HISTORY: , Negative.,SOCIAL HISTORY: , She is single.  She drinks alcohol once a week.  She does not smoke.,FAMILY HISTORY: , Pertinent for obesity and hypertension.,MEDICATIONS: , Include Topamax 100 mg twice daily, Zoloft 100 mg twice daily, Abilify 5 mg daily, Motrin 800 mg daily, and a multivitamin.,ALLERGIES: , She has no known drug allergies.,REVIEW OF SYSTEMS: , Negative.,PHYSICAL EXAM:  ,This is a pleasant female in no acute distress.  Alert and oriented x 3.  HEENT:  Normocephalic, atraumatic.  Extraocular muscles intact, nonicteric sclerae.  Chest is clear to auscultation bilaterally.  Cardiovascular is normal sinus rhythm.  Abdomen is obese, soft, nontender and nondistended.  Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN:  ,This is a 34-year-old female with a BMI of 43 who is interested in surgical weight via the gastric bypass as opposed to Lap-Band.  ABC will be asking for a letter of medical necessity from Dr. XYZ.  She will also see my nutritionist and social worker and have an upper endoscopy.  Once this is completed, we will submit her to her insurance company for approval.",5
"PREOPERATIVE DIAGNOSIS: , Lipodystrophy of the abdomen and thighs.,POSTOPERATIVE DIAGNOSIS:,  Lipodystrophy of the abdomen and thighs.,OPERATION: , Suction-assisted lipectomy.,ANESTHESIA:,  General.,FINDINGS AND PROCEDURE:,  With the patient under satisfactory general endotracheal anesthesia, the entire abdomen, flanks, perineum, and thighs to the knees were prepped and draped circumferentially in sterile fashion.  After this had been completed, a #15 blade was used to make small stab wounds in the lateral hips, the pubic area, and upper edge of the umbilicus.  Through these small incisions, a cannula was used to infiltrate lactated Ringers with 1000 cc was infiltrated initially into the abdomen.  A 3 and 4-mm cannulas were then used to carry out the liposuction of the abdomen removing a total of 1100 cc of aspirate, which was mostly fat, little fluid, and blood.  Attention was then directed to the thighs both inner and outer.  A total of 1000 cc was infiltrated in both lateral thighs only about 50 cc in the medial thighs.  After this had been completed, 3 and 4-mm cannulas were used to suction 650 cc from each side, approximately 50 cc in the inner thigh and 600 on each lateral thigh.  The patient tolerated the procedure very well.  All of this aspirate was mostly fat with little fluid and very little blood.  Wounds were cleaned and steri-stripped and dressing of ABD pads and ***** was then applied.  The patient tolerated the procedure very well and was sent to the recovery room in good condition.",37
"ADMISSION DIAGNOSIS (ES):,1. Chronic obstructive pulmonary disease.,2. Pneumonia.,3. Congestive heart failure.,4. Diabetes mellitus.,5. Neuropathy.,6. Anxiety.,7. Hypothyroidism.,8. Depression.,9. Hypertension.,DISCHARGE DIAGNOSIS (ES):,1. Severe chronic obstructive pulmonary disease.,2. Diabetes mellitus.,3. Hypothyroidism.,4. Altered mental status, less somnolent, likely secondary to medications, resolved.,5. Lower gastrointestinal bleed.,6. Status post episode of atrial fibrillation.,7. Status post diverticular bleed.,DISCHARGE MEDICATIONS:,1. Albuterol inhaler q.i.d.,2. Xanax 1 mg t.i.d.,3. Cardizem CD 120 mg daily.,4. Colace 100 mg b.i.d.,5. Iron sulfate 325 mg b.i.d.,6. NPH 10 units subcutaneous b.i.d.,7. Atrovent inhaler q.i.d.,8. Statin oral suspension p.o. q.i.d., swish and spit.,9. Paxil 10 mg daily.,10. Prednisone 20 mg daily.,11. Darvocet Darvocet-N 100, one q.4h PRN pain.,12. Metamucil one pack b.i.d.,13. Synthroid 50 mcg daily.,14. Nexium 40 mg daily.,HOSPITAL COURSE:, The patient was a 66-year-old who presented with complaints of shortness of breath and was found to have acute COPD exacerbation. She had previously been at outlying hospital and had left AMA after 10 sets of BiPAP use. Here she was able to be kept off BiPAP later and slowly improved her exacerbation of COPD with the assistance of pulmonary. She was thought to have bronchitis as well and was treated with antibiotics. During hospitalization she developed acute lower GI bleed and was transferred to intensive care unit and transfused packed red blood cells. GI was consulted, performed endoscopy, revealing diverticular disease of the sigmoid colon, with this being the suspected cause of hemorrhage. Plavix is being held for at least 10 days. Lovenox held as well. No further signs of bleeding. The patient's respiratory status did slowly improve to baseline. She is discharged and given the above noted medications. Followup with Dr. Pesce, of diagnostic pulmonary, in the outpatient setting. She will also followup with Dr. Pesce, in the outpatient setting.",10
"GENERAL EVALUATION:,Fetal Cardiac Activity: Normal with a heart rate of 135BPM,Fetal Presentation: Cephalic.,Placenta: Anterior,Placentral grade: II,Previa: ? None.,Amniotic Fluid: 1.5 + 2.5 + 0.0 + 0.0 = 4cm compatible with oligohydramnios.,BIOMETRY:,BPD: 9.0cm consistent with 36weeks, 4days gestation,HC: 34.6cm which equals 40weeks and 1day gestational age.,FL: 6.9cm which equals 35weeks and 3days gestational age.,AC: 34.6cm which equals 38weeks and 4days gestational age.,CI (BPD/OFD):  (70-86) 73,FL/BPD: (71-87) 77,FL/HC: (20.8-22.6) 19.9,FL/AC (20-24) 20,HC/AC: (0.92-1.05) 1.00,GESTATIONAL AGE BY CURRENT ULTRASOUND: 37weeks 4days.,FETAL WEIGHT BY CURRENT ULTRASOUND: 3289grams (7pounds 4ounces).,ESTIMATED FETAL WEIGHT PERCENTILE: 24%.,EDD BY CURRENT ULTRASOUND: 06/04/07.,GESTATIONAL AGE BY DATES: 40weeks 0days.,L M P: Unknown.,EDD BY DATES: 05/18/07.,DATE OF PREVIOUS ULTRASOUND: 03/05/07.,EDD BY PREVIOUS ULTRASOUND: 05/24/07.,FETAL ANATOMY:,Fetal Ventricles: Normal,Fetal Cerebellum: Normal,Fetal Cranium: Normal,Fetal Face: Normal Nose and Mouth,Fetal Heart (4 Chamber View): Normal,Fetal Diaphragm: Normal,Fetal Stomach: Normal,Fetal Cord: Normal three-vessel cord,Fetal Abdominal Wall: Normal,Fetal Spine: Normal,Fetal Kidneys: Normal,Fetal Bladder: Normal,Fetal Limbs: Normal,IMPRESSION:,Active intrauterine pregnancy with a sonographic gestational age of 37weeks and 4days.,AFI=4cm compatible with mild oligohydramnios.,Fetal weight equals 3289grams (7pounds 4ounces). EFW percentile is 24%.,Placental grade is II.,No evidence of gross anatomical abnormality, with a biophysical profile total equal to 8 out of 8.,",33
"CHIEF COMPLAINT:,  Neck pain, thoracalgia, low back pain, bilateral lower extremity pain.,HISTORY OF PRESENT ILLNESS:,  Ms. XYZ is a fairly healthy 69-year-old Richman, Roseburg resident who carries a history of chronic migraine, osteoarthritis, hypothyroidism, hyperlipidemia, and mitral valve prolapse.  She has previously been under the care of Dr. Ninan Matthew in the 1990s and takes Maxalt on a weekly basis and nadolol, omeprazole and amitriptyline for treatment of her migraines, which occur about once a week.  She is under the care of Dr. Bonaparte for hyperlipidemia and hypothyroidism.  She has a long history of back and neck pain with multiple injuries in the 1960s, 1970s, 1980s and 1990s.  In 2000, she developed ""sciatica"" mostly in her right lower extremity.,She is seen today with no outside imaging, except with MRI of her cervical spine and lumbar spine dated February of 2004.  Her cervical MRI reveals an 8 mm central spinal canal at C6-7, multilevel foraminal stenosis, though her report is not complete as we do not have all the pages.  Her lumbar MRI reveals lumbar spinal stenosis at L4-5 with multilevel facet arthropathy and spondylitic changes.,The patient has essentially three major pain complaints.,Her first pain complaint is one of a long history of axial neck pain without particular radicular symptoms.  She complains of popping, clicking, grinding and occasional stiffness in her neck, as well as occasional periscapular pain and upper trapezius myofascial pain and spasms with occasional cervicalgic headaches.  She has been told by Dr. Megahed in the past that she is not considered a surgical candidate.  She has done physical therapy twice as recently as three years ago for treatment of her symptoms.  She complains of occasional pain and stiffness in both hands, but no particular numbness or tingling.,Her next painful complaint is one of midthoracic pain and thoracalgia features with some right-sided rib pain in a non-dermatomal distribution.  Her rib pain was not preceded by any type of vesicular rash and is reproducible, though is not made worse with coughing.  There is no associated shortness of breath.  She denies inciting trauma and also complains of pain along the costochondral and sternochondral junctions anteriorly.  She denies associated positive or negative sensory findings, chest pain or palpitations, dyspnea, hemoptysis, cough, or sputum production.  Her weight has been stable without any type of constitutional symptoms.,Her next painful complaint is one of axial low back pain with early morning pain and stiffness, which improves somewhat later in the day.  She complains of occasional subjective weakness to the right lower extremity.  Her pain is worse with sitting, standing and is essentially worse in the supine position.  Five years ago, she developed symptoms radiating in an L5-S1 distribution and within the last couple of years, began to develop numbness in the same distribution.  She has noted some subjective atrophy as well of the right calf.  She denies associated bowel or bladder dysfunction, saddle area hypoesthesia, or falls.  She has treated her back symptoms with physical therapy as well.,She is intolerant to any type of antiinflammatory medications as well and has a number of allergies to multiple medications.  She participates in home physical therapy, stretching, hand weights, and stationary bicycling on a daily basis.  Her pain is described as constant, shooting, aching and sharp in nature and is rated as a 4-5/10 for her average and current levels of pain, 6/10 for her worst pain, and 3/10 for her least pain.  Exacerbating factors include recumbency, walking, sleeping, pushing, pulling, bending, stooping, and carrying.  Alleviating factors including sitting, applying heat and ice.,PAST MEDICAL HISTORY:,  As per above and includes hyperlipidemia, hypothyroidism, history of migraines, acid reflux symptoms, mitral valve prolapse for which she takes antibiotic prophylaxis.,PAST SURGICAL HISTORY:,  Cholecystectomy, eye surgery, D&C.,MEDICATIONS:,  Vytorin, Synthroid, Maxalt, nadolol, omeprazole, amitriptyline and 81 mg aspirin.,ALLERGIES:,  Multiple.  All over-the-counter medications.  Toradol, Robaxin, Midrin, Darvocet, Naprosyn, Benadryl, Soma, and erythromycin.,FAMILY HISTORY:,  Family history is remarkable for a remote history of cancer. Family history of heart disease and osteoarthritis.,SOCIAL HISTORY:,  The patient is retired.  She is married with three grown children.  Has a high school level education.  Does not smoke, drink, or utilize any illicit substances.,OSWESTRY PAIN INVENTORY:,  Significant impact on every aspect of her quality of life.  She would like to become more functional.,REVIEW OF SYSTEMS:,  A thirteen-point review of systems was surveyed including constitutional, HEENT, cardiac, pulmonary, GI, GU, endocrine, integument, hematological, immunological, neurological, musculoskeletal, psychological and rheumatological.  Cardiac, swelling in the extremities, hyperlipidemia, history of palpitation, varicose veins.  Pulmonary review of systems negative.  GI review of systems is positive for irritable bowel and acid reflux symptoms.  Genitourinary, occasional stress urinary incontinence and history of remote hematuria.  She is postmenopausal and on hormone replacement.  Endocrine is positive for a low libido and thyroid disorder.  Integument:  Dry skin, itching and occasional rashes.  Immunologic is essentially negative.  Musculoskeletal:  As per HPI.  HEENT:  Jaw pain, popping, clicking, occasional hoarseness, dysphagia, dry mouth, and prior history of toothache.  Neurological:  As per history of present illness.  Constitutional:  As history of present illness.,PHYSICAL EXAMINATION:,  Weight 180 pounds, temp 97.6, pulse 56, BP 136/72.  The patient walks with a normal gait pattern.  There is no antalgia, spasticity, or ataxia.  She can alternately leg stand without difficulty, as well as tandem walk, stand on the heels and toes without difficulty.  She can flex her lumbar spine and touch the floor with her fingertips.  Lumbar extension and ipsilateral bending provoke her axial back pain.  There is tenderness over the PSIS on the right and no particular pelvic asymmetry.,Head is normocephalic and atraumatic.  Cranial nerves II through XII are grossly intact.  Cervical range of motion is slightly limited in extension, but is otherwise intact to flexion and lateral rotation.  The neck is supple.  The trachea is midline.  The thyroid is not particularly enlarged.  Lungs are clear to auscultation.  Heart has regular rate and rhythm with normal S1, S2.  No murmurs, rubs, or gallops.  The abdomen is nontender, nondistended, without palpable organomegaly, guarding, rebound, or pulsatile masses.  Skin is warm and dry to the touch with no discernible cyanosis, clubbing or edema.  I can radial, dorsalis pedis and posterior tibial pulses.  The nailbeds on her feet have trophic changes.  Brisk capillary refill is evident over both upper extremities.,Musculoskeletal examination reveals medial joint line tenderness of both knees with some varus laxity of the right lower extremity.  She has chronic osteoarthritic changes evident over both hands.  There is mild restriction of range of motion of the right shoulder, but no active impingement signs.,Inspection of the axial skeleton reveals a cervicothoracic head-forward posture with slight internal rotation of the upper shoulders.  Palpation of the axial skeleton reveals mild midline tenderness at the lower lumbar levels one fingerbreadth lateral to the midline.  There is no midline spinous process tenderness over the cervicothoracic regions.  Palpation of the articular pillars is met with mild provocation of pain.  Palpation of the right posterior, posterolateral and lateral borders of the lower ribs is met with mild provocable tenderness.  There is also tenderness at the sternochondral and costochondral junctions of the right, as well as the left bilaterally.  The xiphoid process is not particularly tender.  There is no dermatomal sensory abnormality in the thoracic spine appreciated.  Mild facetal features are evident over the sacral spine with extension and lateral bending at the level of the sacral ala.,Neurological examination of the upper and lower extremities reveals 3/5 reflexes of the biceps, triceps, brachioradialis, and patellar bilaterally.  I cannot elicit S1 reflexes.  There are no long tract signs.  Negative Hoffman's, negative Spurling's, no clonus, and negative Babinski.  Motor examination of the upper, as well as lower extremities appears to be intact throughout.  I may be able to detect a slight hand of atrophy of the right calf muscles, but this is truly unclear and no measurement was made.,SUMMARY OF DIAGNOSTIC IMAGING:,  As per above.,IMPRESSION:,1.  Osteoarthritis.,2.  Cervical spinal stenosis.,3.  Lumbar spinal stenosis.,4.  Lumbar radiculopathy, mostly likely at the right L5-S1 levels.,5.  History of mild spondylolisthesis of the lumbosacral spine at L4-L5 and right sacroiliac joint dysfunction.,6.  Chronic pain syndrome with myofascial pain and spasms of the trapezius and greater complexes.,PLAN:  ,The natural history and course of the disease was discussed in detail with Mr. XYZ.  Greater than 80 minutes were spent facet-to-face at this visit.  I have offered to re-image her cervical and lumbar spine and have included a thoracic MR imaging and rib series, as well as cervicolumbar flexion and extension views to evaluate for mobile segment and/or thoracic fractures.  I do not suspect any sort of intrathoracic comorbidity such as a neoplasm or mass, though this was discussed.  Pending the results of her preliminary studies, this should be ruled out.  I will see her in followup in about two weeks with the results of her scans.",5
"REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Patient denies fevers, chills, sweats and weight changes.,EYES:  Patient denies any visual symptoms.,EARS, NOSE, AND THROAT:  No difficulties with hearing.  No symptoms of rhinitis or sore throat.,CARDIOVASCULAR:  Patient denies chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.,RESPIRATORY:  No dyspnea on exertion, no wheezing or cough.,GI:  No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia or melena.,GU:  No urinary hesitancy or dribbling.  No nocturia or urinary frequency.  No abnormal urethral discharge.,MUSCULOSKELETAL:  No myalgias or arthralgias.,NEUROLOGIC:  No chronic headaches, no seizures.  Patient denies numbness, tingling or weakness.,PSYCHIATRIC:  Patient denies problems with mood disturbance.  No problems with anxiety.,ENDOCRINE:  No excessive urination or excessive thirst.,DERMATOLOGIC:  Patient denies any rashes or skin changes.",15
"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.",31
"EXAM: , CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.,REASON FOR EXAM:,  A 68-year-old status post fall with multifocal pain.,COMPARISONS: , None.,TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast.  Additional high-resolution sagittal and/or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures.,INTERPRETATIONS:,HEAD:,There is mild generalized atrophy.  Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes.  There are subtle areas of increased attenuation seen within the frontal lobes bilaterally.  Given the patient's clinical presentation, these likely represent small hemorrhagic contusions.  Other differential considerations include cortical calcifications, which are less likely.  The brain parenchyma is otherwise normal in attenuation without evidence of mass, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  The visualized paranasal sinuses and mastoid air cells are clear.  The bony calvarium and skull base are unremarkable.,FACIAL BONES:,The osseous structures about the face are grossly intact without acute fracture or dislocation.  The orbits and extra-ocular muscles are within normal limits.  There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses.  The remaining visualized paranasal sinuses and mastoid air cells are clear.  Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture.,CERVICAL SPINE:,There is mild generalized osteopenia.  There are diffuse multilevel degenerative changes identified extending from C4-C7 with disk space narrowing, sclerosis, and marginal osteophyte formation.  The remaining cervical vertebral body heights are maintained without acute fracture, dislocation, or spondylolisthesis.  The central canal is grossly patent.  The pedicles and posterior elements appear intact with multifocal facet degenerative changes.  There is no prevertebral or paravertebral soft tissue masses identified.  The atlanto-dens interval and dens are maintained.,IMPRESSION:,1.Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions.  There is no associated shift or mass effect at this time.  Less likely, this finding could be secondary to cortical calcifications.  The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated.,2.Atrophy and chronic small vessel ischemic changes in the brain.,3.Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture.,4.Osteopenia and multilevel degenerative changes in the cervical spine as described above.,5.Findings were discussed with Dr. X from the emergency department at the time of interpretation.",27
"REASON FOR CONSULTATION:,  Thrombocytopenia.,HISTORY OF PRESENT ILLNESS:,  Mrs. XXX is a 17-year-old lady who is going to be 18 in about 3 weeks.  She has been referred for the further evaluation of her thrombocytopenia.  This thrombocytopenia was detected on a routine blood test performed on the 10th of June 2006.  Her hemoglobin was 13.3 with white count of 11.8 at that time.  Her lymphocyte count was 6.7.  The patient, subsequently, had a CBC repeated on the 10th at Hospital where her hemoglobin was 12.4 with a platelet count of 26,000.  She had a repeat of her CBC again on the 12th of June 2006 with hemoglobin of 14, white count of 11.6 with an increase in the number of lymphocytes.  Platelet count was 38.  Her rapid strep screen was negative but the infectious mononucleosis screen is positive.  The patient had a normal platelet count prior too and she is being evaluated for this low platelet count.,The patient gives a history of feeling generally unwell for a couple of days towards the end of May.  She was fine for a few days after that but then she had sore throat and fever 2-3 days subsequent to that.  The patient continues to have sore throat.,She denies any history of epistaxis.  Denies any history of gum bleeding.  The patient denies any history of petechiae.  She denies any history of abnormal bleeding.  Denies any history of nausea, vomiting, neck pain, or any headaches at the present time.,The patient was accompanied by her parents.,PAST MEDICAL HISTORY: , Asthma.,CURRENT MEDICATIONS: , Birth control pills, Albuterol, QVAR and Rhinocort.,DRUG ALLERGIES: , None.,PERSONAL HISTORY: , She lives with her parents.,SOCIAL HISTORY:,  Denies the use of alcohol or tobacco.,FAMILY HISTORY: , Noncontributory.,OCCUPATION: , The patient is currently in school.,REVIEW OF SYSTEMS:,Constitutional:  The history of fever about 2 weeks ago.,HEENT:  Complains of some difficulty in swallowing.,Cardiovascular:  Negative.,Respiratory:  Negative.,Gastrointestinal:  No nausea, vomiting, or abdominal pain.,Genitourinary:  No dysuria or hematuria.,Musculoskeletal:  Complains of generalized body aches.,Psychiatric:  No anxiety or depression.,Neurologic:  Complains of episode of headaches about 2-3 weeks ago.,PHYSICAL EXAMINATION:  ,She was not in any distress.  She appears her stated age.  Temperature 97.9.  Pulse 84.  Blood pressure was 110/60.  Weighs 162 pounds.  Height of 61 inches.  Lungs - Normal effort.  Clear.  No wheezing.  Heart - Rate and rhythm regular.  No S3, no S4.  Abdomen - Soft.  Bowel sounds are present.  No palpable hepatosplenomegaly.  Extremities - Without any edema, pallor, or cyanosis.  Neurological:  Alert and oriented x 3.  No focal deficit.  Lymph Nodes - No palpable lymphadenopathy in the neck or the axilla.  Skin examination reveals few petechiae along the lateral aspect of the left thigh but otherwise there were no ecchymotic patches.,DIAGNOSTIC DATA: , The patient's CBC results from before were reviewed.  Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000.,IMPRESSION: , ITP, the patient has a normal platelet count.,PLAN:,1.  I had a long discussion with family regarding the treatment of ITP.  In view of the fact that the patient's platelet count is 26,000 and she is asymptomatic, we will continue to monitor the counts.,2.  An ultrasound of the abdomen will be performed tomorrow.,3.  I have given her a requisition to obtain some blood work tomorrow.",5
"PREOPERATIVE DIAGNOSES,1.  Basal cell nevus syndrome.,2.  Cystic lesion, left posterior mandible.,3.  Corrected dentition.,4.  Impacted teeth 1 and 16.,5.  Maxillary transverse hyperplasia.,POSTOPERATIVE DIAGNOSES,1.  Basal cell nevus syndrome.,2.  Cystic lesion, left posterior mandible.,3.  Corrected dentition.,4.  Impacted teeth 1 and 16.,5.  Maxillary transverse hyperplasia.,PROCEDURE,1.  Removal of cystic lesion, left posterior mandible.,2.  Removal of teeth numbers 4, 13, 20, and 29.,3.  Removal of teeth numbers 1 and 16.,4.  Modified Le Fort I osteotomy.,INDICATIONS FOR THE PROCEDURE:, The patient has undergone previous surgical treatment and had a diagnosis of basal cell nevus syndrome.  Currently our plan is to remove the impacted third molar teeth, to remove a cystic lesion left posterior mandible, to remove 4 second bicuspid teeth as requested by her orthodontist, and to weaken and her maxilla to allow expansion by a modified Le Fort osteotomy.,PROCEDURE IN DETAIL:, The patient was brought into the operating room, placed on the operating table in supine position.  Following treatment under adequate general anesthesia via the orotracheal route, the patient was prepped and draped in a manner consistent with intraoral surgical procedures.  The oral cavity was suctioned, was drained of fluid and a throat pack was placed.  General anesthesia nursing service was notified and which was removed at the end of the procedure.  Lidocaine 1% with epinephrine concentration in 1:100,000 was injected into the labial vestibule of the maxilla bilaterally as well as the lateral areas associated with the extractions sites in lower jaw and the left posterior mandible for a total of 11 mL.  A Bovie electrocautery was utilized to make a vestibular incision, beginning in the second molar region of the maxilla superior to the mucogingival junction extending to the area of the cuspid teeth.  Subperiosteal dissection revealed lateral aspect of the maxilla immediately posterior to the second molar tooth where the third molar tooth was identified and was bony crypt.  Following use of Cerebromaxillary osteotome, elevated, and underwent complete removal of the dental follicle.  Secondly, tooth number 4 was removed.  Tooth number 13 was removed, and the opposite third molar tooth was removed through an identical incision on the opposite side.  Surgeon then utilized a #15 saw to make a horizontal osteotomy through the lateral aspect of the maxilla from the target plates, anteriorly to the area of the buttress region cross the anterior maxilla to a point adjacent to the piriform rim, 5 mm superior to the nasal floor, bilaterally Cerebromaxillary osteotome utilized to separate the maxilla from the target placed posteriorly and a 5 mm Tessier osteotome through a vertical incision anteriorly between roots of teeth numbers 8 and 9.  This resulted in the alternate mobilization of the two halves of the maxilla, or to allow expansion.  These wounds were all irrigated with copious amounts of normal saline and with antibiotic containing solution, closed with 3-0 chromic suture in running fashion for watertight closure.  Attention was directed to the mandible where the left posterior mandible was approached through a lateral vestibular incision overlying the external oblique ridge and brought anteriorly in an old scar.  The surgeons utilized cautery osteotome to identify a cystic lesion associated with the left posterior mandible, which was approximately 1 cm in width and 2.5 to 3 cm in vertical dimension immediately adjacent to the neurovascular bundle.  This wound was then irrigated with copious amounts of normal saline and concentrated solution of clindamycin.  Closed primarily with a 3-0 Vicryl suture in running fashion for a watertight closure.  Teeth number 20 and 29 where removed and 3-0 chromic suture placed.  This concluded the procedure.  All cottonoids and other sponges, throat pack were removed.  No complications were encountered.  The aforementioned cystic lesion was sent with specimen no drains were placed.  The blood loss from this procedure was approximately 100 mL.,The patient was returned over the care of the anesthesia where she was extubated in the operating room, taken from the operating room to the recovery room with stable vital signs and spontaneous respirations.",37
"CHIEF COMPLAINT:,  Neck pain, thoracalgia, low back pain, bilateral lower extremity pain.,HISTORY OF PRESENT ILLNESS:,  Ms. XYZ is a fairly healthy 69-year-old Richman, Roseburg resident who carries a history of chronic migraine, osteoarthritis, hypothyroidism, hyperlipidemia, and mitral valve prolapse.  She has previously been under the care of Dr. Ninan Matthew in the 1990s and takes Maxalt on a weekly basis and nadolol, omeprazole and amitriptyline for treatment of her migraines, which occur about once a week.  She is under the care of Dr. Bonaparte for hyperlipidemia and hypothyroidism.  She has a long history of back and neck pain with multiple injuries in the 1960s, 1970s, 1980s and 1990s.  In 2000, she developed ""sciatica"" mostly in her right lower extremity.,She is seen today with no outside imaging, except with MRI of her cervical spine and lumbar spine dated February of 2004.  Her cervical MRI reveals an 8 mm central spinal canal at C6-7, multilevel foraminal stenosis, though her report is not complete as we do not have all the pages.  Her lumbar MRI reveals lumbar spinal stenosis at L4-5 with multilevel facet arthropathy and spondylitic changes.,The patient has essentially three major pain complaints.,Her first pain complaint is one of a long history of axial neck pain without particular radicular symptoms.  She complains of popping, clicking, grinding and occasional stiffness in her neck, as well as occasional periscapular pain and upper trapezius myofascial pain and spasms with occasional cervicalgic headaches.  She has been told by Dr. Megahed in the past that she is not considered a surgical candidate.  She has done physical therapy twice as recently as three years ago for treatment of her symptoms.  She complains of occasional pain and stiffness in both hands, but no particular numbness or tingling.,Her next painful complaint is one of midthoracic pain and thoracalgia features with some right-sided rib pain in a non-dermatomal distribution.  Her rib pain was not preceded by any type of vesicular rash and is reproducible, though is not made worse with coughing.  There is no associated shortness of breath.  She denies inciting trauma and also complains of pain along the costochondral and sternochondral junctions anteriorly.  She denies associated positive or negative sensory findings, chest pain or palpitations, dyspnea, hemoptysis, cough, or sputum production.  Her weight has been stable without any type of constitutional symptoms.,Her next painful complaint is one of axial low back pain with early morning pain and stiffness, which improves somewhat later in the day.  She complains of occasional subjective weakness to the right lower extremity.  Her pain is worse with sitting, standing and is essentially worse in the supine position.  Five years ago, she developed symptoms radiating in an L5-S1 distribution and within the last couple of years, began to develop numbness in the same distribution.  She has noted some subjective atrophy as well of the right calf.  She denies associated bowel or bladder dysfunction, saddle area hypoesthesia, or falls.  She has treated her back symptoms with physical therapy as well.,She is intolerant to any type of antiinflammatory medications as well and has a number of allergies to multiple medications.  She participates in home physical therapy, stretching, hand weights, and stationary bicycling on a daily basis.  Her pain is described as constant, shooting, aching and sharp in nature and is rated as a 4-5/10 for her average and current levels of pain, 6/10 for her worst pain, and 3/10 for her least pain.  Exacerbating factors include recumbency, walking, sleeping, pushing, pulling, bending, stooping, and carrying.  Alleviating factors including sitting, applying heat and ice.,PAST MEDICAL HISTORY:,  As per above and includes hyperlipidemia, hypothyroidism, history of migraines, acid reflux symptoms, mitral valve prolapse for which she takes antibiotic prophylaxis.,PAST SURGICAL HISTORY:,  Cholecystectomy, eye surgery, D&C.,MEDICATIONS:,  Vytorin, Synthroid, Maxalt, nadolol, omeprazole, amitriptyline and 81 mg aspirin.,ALLERGIES:,  Multiple.  All over-the-counter medications.  Toradol, Robaxin, Midrin, Darvocet, Naprosyn, Benadryl, Soma, and erythromycin.,FAMILY HISTORY:,  Family history is remarkable for a remote history of cancer. Family history of heart disease and osteoarthritis.,SOCIAL HISTORY:,  The patient is retired.  She is married with three grown children.  Has a high school level education.  Does not smoke, drink, or utilize any illicit substances.,OSWESTRY PAIN INVENTORY:,  Significant impact on every aspect of her quality of life.  She would like to become more functional.,REVIEW OF SYSTEMS:,  A thirteen-point review of systems was surveyed including constitutional, HEENT, cardiac, pulmonary, GI, GU, endocrine, integument, hematological, immunological, neurological, musculoskeletal, psychological and rheumatological.  Cardiac, swelling in the extremities, hyperlipidemia, history of palpitation, varicose veins.  Pulmonary review of systems negative.  GI review of systems is positive for irritable bowel and acid reflux symptoms.  Genitourinary, occasional stress urinary incontinence and history of remote hematuria.  She is postmenopausal and on hormone replacement.  Endocrine is positive for a low libido and thyroid disorder.  Integument:  Dry skin, itching and occasional rashes.  Immunologic is essentially negative.  Musculoskeletal:  As per HPI.  HEENT:  Jaw pain, popping, clicking, occasional hoarseness, dysphagia, dry mouth, and prior history of toothache.  Neurological:  As per history of present illness.  Constitutional:  As history of present illness.,PHYSICAL EXAMINATION:,  Weight 180 pounds, temp 97.6, pulse 56, BP 136/72.  The patient walks with a normal gait pattern.  There is no antalgia, spasticity, or ataxia.  She can alternately leg stand without difficulty, as well as tandem walk, stand on the heels and toes without difficulty.  She can flex her lumbar spine and touch the floor with her fingertips.  Lumbar extension and ipsilateral bending provoke her axial back pain.  There is tenderness over the PSIS on the right and no particular pelvic asymmetry.,Head is normocephalic and atraumatic.  Cranial nerves II through XII are grossly intact.  Cervical range of motion is slightly limited in extension, but is otherwise intact to flexion and lateral rotation.  The neck is supple.  The trachea is midline.  The thyroid is not particularly enlarged.  Lungs are clear to auscultation.  Heart has regular rate and rhythm with normal S1, S2.  No murmurs, rubs, or gallops.  The abdomen is nontender, nondistended, without palpable organomegaly, guarding, rebound, or pulsatile masses.  Skin is warm and dry to the touch with no discernible cyanosis, clubbing or edema.  I can radial, dorsalis pedis and posterior tibial pulses.  The nailbeds on her feet have trophic changes.  Brisk capillary refill is evident over both upper extremities.,Musculoskeletal examination reveals medial joint line tenderness of both knees with some varus laxity of the right lower extremity.  She has chronic osteoarthritic changes evident over both hands.  There is mild restriction of range of motion of the right shoulder, but no active impingement signs.,Inspection of the axial skeleton reveals a cervicothoracic head-forward posture with slight internal rotation of the upper shoulders.  Palpation of the axial skeleton reveals mild midline tenderness at the lower lumbar levels one fingerbreadth lateral to the midline.  There is no midline spinous process tenderness over the cervicothoracic regions.  Palpation of the articular pillars is met with mild provocation of pain.  Palpation of the right posterior, posterolateral and lateral borders of the lower ribs is met with mild provocable tenderness.  There is also tenderness at the sternochondral and costochondral junctions of the right, as well as the left bilaterally.  The xiphoid process is not particularly tender.  There is no dermatomal sensory abnormality in the thoracic spine appreciated.  Mild facetal features are evident over the sacral spine with extension and lateral bending at the level of the sacral ala.,Neurological examination of the upper and lower extremities reveals 3/5 reflexes of the biceps, triceps, brachioradialis, and patellar bilaterally.  I cannot elicit S1 reflexes.  There are no long tract signs.  Negative Hoffman's, negative Spurling's, no clonus, and negative Babinski.  Motor examination of the upper, as well as lower extremities appears to be intact throughout.  I may be able to detect a slight hand of atrophy of the right calf muscles, but this is truly unclear and no measurement was made.,SUMMARY OF DIAGNOSTIC IMAGING:,  As per above.,IMPRESSION:,1.  Osteoarthritis.,2.  Cervical spinal stenosis.,3.  Lumbar spinal stenosis.,4.  Lumbar radiculopathy, mostly likely at the right L5-S1 levels.,5.  History of mild spondylolisthesis of the lumbosacral spine at L4-L5 and right sacroiliac joint dysfunction.,6.  Chronic pain syndrome with myofascial pain and spasms of the trapezius and greater complexes.,PLAN:  ,The natural history and course of the disease was discussed in detail with Mr. XYZ.  Greater than 80 minutes were spent facet-to-face at this visit.  I have offered to re-image her cervical and lumbar spine and have included a thoracic MR imaging and rib series, as well as cervicolumbar flexion and extension views to evaluate for mobile segment and/or thoracic fractures.  I do not suspect any sort of intrathoracic comorbidity such as a neoplasm or mass, though this was discussed.  Pending the results of her preliminary studies, this should be ruled out.  I will see her in followup in about two weeks with the results of her scans.",27
"PREOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,POSTOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,PROCEDURE:, Full-mouth extraction of tooth #3,5,6, 7, 8, 9, 10, 11, 12, 13, 14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 31, and alveoloplasty in all four quadrants.,ANESTHESIA:,  Nasotracheal general anesthesia.,IV FLUIDS:, A 700 mL of crystalloid.,EBL:, Minimum.,URINE:, Not recorded.,COMPLICATIONS:, None.,CONDITION:, Good.,DISPOSITION:,  The patient was extubated in OR, transferred to PACU for recovery and will be transferred for 23-hour observation and discharged on subsequent day.,BRIEF HISTORY OF THE PATIENT:, Indicated the patient for surgery.  The patient is a 41-year-old white female with multiple grossly decaying nonrestorable teeth.  After discussing treatment options, she decided she will like to have extraction of remaining teeth with subsequent placement of upper and lower complete dentures.,PAST MEDICAL HISTORY:, Positive for a narcotic abuse, presently on methadone treatment, hepatitis C, and headaches.,PAST SURGICAL HISTORY:, C-section x2.,MEDICATIONS,Right now include:,1.  Methadone.,2.  Beta-blocker.,3.  Xanax.,4.  Norco.,5.  Clindamycin.,ALLERGIES:, THE PATIENT IS ALLERGIC TO PENICILLIN.,PROCEDURE IN DETAIL:, The patient was greeted in preoperative holding area, subsequently transferred to OR #17 where the patient was intubated with anesthesia staff present.  The patient was prepped and draped in sterile fashion.  Local anesthesia consisting of 1% lidocaine and 1:100,000 epinephrine, total 15 mL were injected into the maxillomandible.  Throat pack was placed in the mouth after a thorough suction.,A full-thickness mucoperiosteal flap was reflected from the upper right to the upper left, tooth number 3,5,6,7,8,9,10,11,12,13, and 14 and were elevated and delivered.  Extraction sites were thoroughly curettaged and irrigated.  Bony undercuts were removed then smoothed with rongeurs and bone saw.  After thorough irrigation, the postsurgical site closed in a running fashion with 3-0 chromic sutures.  Subsequently, a full-thickness mucoperiosteal flap was reflected in the mandible, tooth numbers 31, 28, 27, 26, 25, 24, 23, 22, 21, 20, and 19 were elevated and delivered with simple forceps extractions.  Bony undercuts were removed with rongeurs and smoothed with bone saw.,Extraction sites were thoroughly irrigated and curettaged.  Wound was closed in continuous fashion 3-0 chromic.  After adequate hematosis was achieved, 0.5% Marcaine and 1:200,000 epinephrine was injected in the maxillomandible thus to heal to aid in hematosis and pain control.  Total of 8 mL were used.  Throat pack was subsequently removed.  Orogastric tube was passed to suction out the stomach.,The patient was subsequently extubated in OR and transferred to PACU for recovery.  The patient would be placed in 23-hour observation.",37
"PREOPERATIVE DIAGNOSIS:,  Right buccal space infection and abscess tooth #T.,POSTOPERATIVE DIAGNOSIS: , Right buccal space infection and abscess tooth #T.,PROCEDURE:,  Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection.,ANESTHESIA:,  General, oral endotracheal tube.,COMPLICATIONS: , None.,SPECIMENS:,  Aerobic and anaerobic cultures were sent.,IV FLUID: , 150 mL.,ESTIMATED BLOOD LOSS:,  10 mL.,PROCEDURE: , The patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, the patient was prepped and draped in the usual fashion for an intraoral procedure.  Gauze throat pack was placed and the right buccal vestibule was palpated and area of the abscess was located.  The abscess cavity was aspirated using a 5 mL syringe with an 18-gauge needle.  Approximately 1 mL of purulent material was aspirated that was placed on aerobic and anaerobic cultures.  Culture swabs and the tooth sent to the laboratory for culture and sensitivity testing.,The area in the buccal vestibule was then opened with approximately 1-cm incision.  Blunt dissection was then used to open up the abscess cavity and explore the abscess cavity.  A small amount of additional purulence was drained from it, approximately 1 mL and at this point, tooth #T was extracted by forceps extraction.  Periosteal elevator was used to explore the area near the extraction site.  This was continuous with abscess cavity, so the abscess cavity was allowed to drain into the extraction site.  No drain was placed.  Upon completion of the procedure, the throat pack was removed.  The pharynx was suctioned.  The stomach was also suctioned and the patient was then awakened, extubated, and taken to the recovery room in stable condition.",7
"INDICATION: , Bradycardia and dizziness.,COMMENTS:,1.  The patient was monitored for 24 hours.,2.  The predominant rhythm was normal sinus rhythm with a minimum heart rate of 56 beats per minute and the maximum heart rate of 114 beats per minute and a mean heart rate of 86 beats per minute.,3.  There were occasional premature atrial contractions seen, no supraventricular tachycardia was seen.,4.  There was a frequent premature ventricular contraction seen.  Between 11:00 a.m. and 11:15 a.m. the patient was in ventricular bigemini and trigemini most of the time.  During rest of the monitoring period, there were just occasional premature ventricular contractions seen.  No ventricular tachycardia was seen.,5.  There were no pathological pauses noted.,6.  The longest RR interval was 1.1 second.,7.  There were no symptoms reported.",3
"without difficulty, into the upper GI tract.  The anatomy and mucosa of the esophagus, gastroesophageal junction, stomach, pylorus, and small bowel were all carefully inspected.  All structures were visually normal in appearance.  Biopsies of the distal duodenum, gastric antrum, and distal esophagus were taken and sent for pathological evaluation.  The endoscope and insufflated air were slowly removed from the upper GI tract.  A repeat look at the structures involved again showed no visible abnormalities, except for the biopsy sites.,The patient tolerated the procedure with excellent comfort and stable vital signs.  After a recovery period in the Endoscopy Suite, the patient is discharged to continue recovering in the family's care at home.  The family knows to follow up with me today if there are concerns about the patient's recovery,from the procedure.  They will follow up with me later this week for biopsy and CLO test results so that appropriate further diagnostic and therapeutic plans can be made.,",14
"PREOPERATIVE DIAGNOSIS:  ,Oropharyngeal foreign body.,POSTOPERATIVE DIAGNOSES:,1.  Foreign body, left vallecula at the base of the tongue.,2.  Airway is patent and stable.,PROCEDURE PERFORMED: , Flexible nasal laryngoscopy.,ANESTHESIA:,  ______ with viscous lidocaine nasal spray.,INDICATIONS: , The patient is a 39-year-old Caucasian male who presented to ABCD General Hospital Emergency Department with acute onset of odynophagia and globus sensation.  The patient stated his symptoms began around mid night after returning home _________ ingesting some chicken.  The patient felt that he had ingested a chicken bone, tried to dislodge this with fluids and other solid foods as well as sticking his finger down his throat without success.  The patient subsequently was seen in the Emergency Department where it was discovered that the patient had a left vallecular foreign body.  Department of Otolaryngology was asked to consult for further evaluation and treatment of this foreign body.,PROCEDURE: , After verbal informed consent was obtained, the patient was placed in the upright position.  The fiberoptic nasal laryngoscope was inserted in the patient's right naris and then the left naris.  There was visualized some bilateral caudal spurring of the septum.  The turbinates were within normal limits.  There was some posterior nasoseptal deviation to the left.  The nasal laryngoscope was then inserted back into the right naris and it was advanced along the floor of the nasal cavity.  The nasal mucous membranes were pink and moist.  There was no evidence of mass, ulceration, lesion, or obstruction.,The scope was further advanced to the level of the nasopharynx where the eustachian tubes were visualized bilaterally.  There was evidence of some mild erythema in the right fossa Rosenmüller.  There was no evidence of mass lesion or ulceration in this area, however.  The eustachian tubes were patent without obstruction.  The scope was further advanced to the level of the oropharynx where the base of the tongue, vallecula, and epiglottis were visualized.  There was evidence of a 1.5 cm left vallecular white foreign body.  The rest of the oropharynx was without abnormality.  The epiglottis was within normal limits and was noted to be omega in shape.  There was no edema or erythema to the epiglottis.  The scope was then further advanced to the level of the hypopharynx to the level of the true vocal cords.  There was no evidence of erythema or edema of the posterior commissure, arytenoid cartilage, or superior surface of the vocal cords.  The laryngeal surface of the epiglottis was within normal limits.  There was no evidence of mass lesion or nodularity of the vocal cords.  The patient was asked to Valsalva and the piriform sinuses were observed without evidence of foreign body or mass lesion.  The patient did have complete glottic closure upon phonation and the airway was patent and stable throughout the exam.  The glottic aperture was completely patent with inspiration.  The anterior commissure, epiglottic folds, false vocal cords, and piriform sinuses were all within normal limits.  The scope was then removed without difficulty.  The patient tolerated the procedure well and remained in stable condition.,FINDINGS:,1.  A 1.5 cm white foreign body consistent with a chicken bone at the left vallecular region.  There is no evidence of supraglottic or piriform sinuses foreign body.,2.  Mild erythema of the right nasopharynx in the region of the fossa Rosenmüller.  No mass is appreciated at this time.,PLAN:,  The patient is to go to the operating room for direct laryngoscopy/microscopic suspension direct laryngoscopy for removal of foreign body under anesthesia this a.m.  Airway precautions were instituted.  The patient currently remained in stable condition.",37
"SINGLE CHAMBER PACEMAKER IMPLANTATION,PREOPERATIVE DIAGNOSIS: , Mobitz type II block with AV dissociation and syncope.,POSTOPERATIVE DIAGNOSIS: , Mobitz type II block, status post single chamber pacemaker implantation, Boston Scientific Altrua 60, serial number 123456.,PROCEDURES:,1.  Left subclavian access under fluoroscopic guidance.,2.  Left subclavian venogram under fluoroscopic evaluation.,3.  Insertion of ventricular lead through left subclavian approach and ventricular lead is Boston Scientific Dextrose model 12345, serial number 123456.,4.  Insertion of single-chamber pacemaker implantation, Altrua, serial number 123456.,5.  Closure of the pocket after formation of pocket for pacemaker.,PROCEDURE IN DETAIL:  ,The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient was brought to the cath lab, draped and prepped in the usual sterile fashion, received 1.5 mg of versed and 25 mg of Benadryl for conscious sedation.,Access to the right subclavian was successful after the second attempt.  The first attempt accessed the left subclavian artery.  The needle was removed and manual compression applied for five minutes followed by re-accessing the subclavian vein successfully.  The J-wire was introduced into the left subclavian vein.,The anterior wall chest was anesthetized with lidocaine 2%, 2-inch incision using a #10 blade was used.,The pocket was formed using blunt dissection as he was using the Bovie cautery for hemostasis.  The patient went asystole during the procedure.  The transcutaneous pacer was used.  The patient was oxygenating well.  The patient had several compression applied by the nurse.  However, her own rhythm resolved spontaneously and the percutaneous pacer was kept on standby.,After that, the J-wire was tunneled into the pocket and then used to put the #7-French sheath into the left subclavian vein.  The lead from the Boston Scientific Dextrose model 12345, serial number 12345 was inserted through the left subclavian to the right atrium; however, it was difficult to really enter the right ventricle; and while the lead was in place, the side port of the sheath was used to inject 15 mL of contrast to assess the subclavian and the right atrium.  The findings were showing different anatomy, may be consistent with persistent left superior vena cava, and the angle to the right ventricle was different.  At that point, the lead stylet was reshaped and was able to cross the tricuspid valve in a position consistent with the mid septal place.,At that point, the lead was actively fixated.  The stylet was removed.  The R-wave measured at 40 millivolts.  The impedance was 580 and the threshold was 1.3 volt.  The numbers were accepted and because of the patient's fragility and the different anatomy noticed in the right atrium, concern about putting a second lead with re-access of the subclavian was high.  I decided to proceed with a single-chamber pacemaker as a backup system.,After that, the lead sleeve was used to actively fixate the lead in the anterior chest with two Ethibond sutures in the usual fashion.,The lead was attached to the pacemaker in the header.  The pacemaker was single-chamber pacemaker Altura 60, serial number 123456.  After that, the pacemaker was put in the pocket.  Pocket was irrigated with normal saline and was closed into two layers, deep interrupted #3-0 Vicryl and surface as continuous #4-0 Vicryl continuous.,The pacemaker was programmed as VVI 60, and with history is 10 to 50 beats per minute.  The lead position will be evaluated with chest x-ray.,No significant bleeding noticed.,CONCLUSION:  ,Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.  No significant bleed.",37
"PREOPERATIVE DIAGNOSIS: , Left hydrocele.,OPERATION: , Left hydrocelectomy.,POSTOPERATIVE DIAGNOSIS: , Left hydrocele.,ANESTHESIA: , General,INDICATIONS AND STUDIES: , This is a 67-year-old male with pain, left scrotum.  He has had an elevated PSA and also has erectile dysfunction.  He comes in now for a left hydrocelectomy.  Physical exam confirmed obvious hydrocele, left scrotum, approximately 8 cm.  Laboratory data included a hematocrit of 43.5, hemoglobin of 15.0, and white count 4700.  Creatinine 1.3, sodium 141, and potassium 4.0.  Calcium 8.6.  Chest x-ray was unremarkable.  EKG was normal.,PROCEDURE: , The patient was satisfactorily given general anesthesia, prepped and draped in supine position, and left scrotal incision was made, carried down to the tunica vaginalis forming the hydrocele.  This was dissected free from the scrotal wall back to the base of the testicle and then excised back to the spermatic cord.  In the fashion, the hydrocele was excised and fluid drained.,Cord was infiltrated with 5 mL of 0.25% Marcaine.  The edges of the tunica vaginalis adjacent to the spermatic cord were oversewn with interrupted 3-0 Vicryl sutures for hemostasis.  The left testicle was replaced into the left scrotal compartment and affixed to the overlying Dartos fascia with a 3-0 Vicryl suture through the edge of the tunica vaginalis and the overlying Dartos fascia.,The left scrotal incision was closed, first closing the Dartos fascia with interrupted 3-0 Vicryl sutures.  Skin was closed with an interrupted running 4-0 chromic suture.  A sterile dressing was applied.  The patient was sent to the recovery room in good condition, upon awakening from general anesthesia.  Plan is to discharge the patient and see him back in the office in a week or 2 in followup.  Further plans will depend upon how he does.",37
"PROCEDURES:,  Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,REASON FOR PROCEDURE: , Child with abdominal pain and rectal bleeding.  Rule out inflammatory bowel disease, allergic enterocolitis, rectal polyps, and rectal vascular malformations.,CONSENT:,  History and physical examination was performed.  The procedure, indications, alternatives available, and complications, i.e. bleeding, perforation, infection, adverse medication reaction, the possible need for blood transfusion, and surgery should a complication occur were discussed with the parents who understood and indicated this.  Opportunity for questions was provided and informed consent was obtained.,MEDICATION:  ,General anesthesia.,INSTRUMENT: , Olympus GIF-160.,COMPLICATIONS:,  None.,FINDINGS: , With the patient in the supine position and intubated, the endoscope was inserted without difficulty into the hypopharynx.  The esophageal mucosa and vascular pattern appeared normal.  The lower esophageal sphincter was located at 25 cm from the central incisors.  It appeared normal.  A Z-line was identified within the lower esophageal sphincter.  The endoscope was advanced into the stomach, which distended with excess air.  Rugal folds flattened completely.  Gastric mucosa appeared normal throughout.  No hiatal hernia was noted.  Pyloric valve appeared normal.  The endoscope was advanced into the first, second, and third portions of duodenum, which had normal mucosa, coloration, and fold pattern.  Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology.  Additional 2 biopsies were obtained for CLO testing in the antrum.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated that part of procedure well.  The patient was turned and the scope was advanced with some difficulty to the terminal ileum.  The terminal ileum mucosa and the colonic mucosa throughout was normal except at approximately 10 cm where a 1 x 1 cm pedunculated juvenile-appearing polyp was noted.  Biopsies were obtained x2 in the terminal ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid, and rectum.  Then, the polyp was snared right at the base of the polyp on the stalk and 20 watts of pure coag was applied in 2-second bursts x3.  The polyp was severed.  There was no bleeding at the stalk after removal of the polyp head.  The polyp head was removed by suction.  Excess air was evacuated from the colon.  The patient tolerated that part of the procedure well and was taken to recovery in satisfactory condition.  Estimated blood loss approximately 5 mL.,IMPRESSION: , Normal esophagus, stomach, duodenum, and colon as well as terminal ileum except for a 1 x 1-cm rectal polyp, which was removed successfully by polypectomy snare.,PLAN:  ,Histologic evaluation and CLO testing.  I will contact the parents next week with biopsy results and further management plans will be discussed at that time.",14
"PREOPERATIVE DIAGNOSIS:,  Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,POSTOPERATIVE DIAGNOSIS:,  Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,PROCEDURE:,  Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.,ANESTHESIA: , General anesthesia via nasal endotracheal intubation.,FLUIDS: , 1800 mL of LR.,ESTIMATED BLOOD LOSS: , 150 mL.,HARDWARE:  ,A 2.3 titanium locking reconstruction plate from Leibinger on the symphysis and a 2.0 reconstruction plate on the left angle.,SPECIMEN: , None.,COMPLICATIONS: , None.,CONDITION: , The patient was extubated to the PACU, breathing spontaneously in excellent good condition.,INDICATIONS FOR THE PROCEDURE: , The patient is a 55-year-old male that he is 12 hour status post interpersonal violence in which he sustained bilateral mandible fractures and positive loss of consciousness.  He reported to the Hospital the day after his altercation complaining of mall occlusion and sore left shoulder.  He was worked up by the emergency department.  His head CT was cleared and his left shoulder was clear of any fractures or soft tissue damage.  Oral maxillary facial surgery was consulted to manage the mandible fracture.  After review of the CT and examination it was determined that the patient would benefit from open reduction, internal fixation of bilateral mandible fractures.  Risks, benefits, and alternative to treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was brought to the operating room #2 at Hospital.  He was laid in supine position on the operating room table.  ASA monitors were attached and stated general anesthesia was induced with IV anesthetic and maintained with nasal endotracheal intubation and inflation anesthetics.,The patient was prepped and draped in the usual oral maxillofacial surgery fashion.  The surgeon approached the operating room table in a sterile fashion.  Approximately 10 mL of 1% lidocaine with 1:100,000 epinephrine was injected into oral vestibule in a nerve block fashion.  Erich arch bars were adapted to the maxilla and mandible, secured in the posterior teeth with 24-gauge surgical steel wire and 26-gauge surgical steel wire in the anterior.  This was done from second molar to second molar on both the maxilla and the mandible secondary to the patient missing multiple teeth.  The patient was manipulated up into maximum intercuspation.  He has a malocclusion with severe bruxism and so wear facets were lined up.  This was secured with 26-gauge surgical steel wire.  Attention was then directed to the symphysis extraorally.  Approximately 5 mL of 1% lidocaine with epinephrine was injected into the area of incision which paralleled the inferior border of the mandible 2 cm below the inferior border of the mandible.,After waiting appropriate time for local anesthesia using a 15 blade, a skin and platysma incision was made.  Then using a series of blunt and sharp dissections, the dissection was carried to the inferior border of the mandible.  The periosteum was incised and reflected with the periosteal elevator.  The fracture was noted and it was displaced.  Manipulation of the segments and checking with the occlusion intraorally, the fracture was aligned.  This was secured with 7-hole 2.3 titanium locking reconstruction plate with bicortical screws.  The wound was then packed with moist Ray-Tec and attention was directed intraorally to the left angle fracture.  Approximately 5 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the left vestibule.  After waiting appropriate time for local anesthesia to take effect, using Bovie electrocautery, a sagittal split incision was made and the fracture was identified.  It was noted that the fracture went through tooth #17 and this needed to be extracted.  Taking a round bur, a buckle trough was made and the tooth was elevated and removed both distal and mesial roots.  The fracture was then reduced and lateral superior border plate 2-0 4 whole with monocortical screws was placed.  The fracture was noted to be well reduced.  The wound was then irrigated with copious amount of sterile water.  The patient was released for excellent intercuspation.  He was then manipulated up into the occlusion easily.  Wound was then closed with running 3-0 chromic gut suture.  Attention was then directed extraorally.  This was irrigated with copious amount of sterile water and closed in a layer fashion with 3-0 Vicryl, 4-0 Vicryl, and 5-0 Prolene on skin.  Attention was then again directed into the mouth.  The throat pack was removed and orogastric tube was placed and stomach content was evacuated.  The patient was then manipulated back up to maximum intercuspation and secured with interdental elastics and a pressure dressing was applied to the extraoral incisions.  At this point, the procedure was then determined to be over.,The patient was extubated and breathing spontaneously, transported to the PACU in excellent condition.",37
"PREOPERATIVE DIAGNOSIS: , Term pregnancy at 40 and 3/7th weeks.,PROCEDURE PERFORMED: , Spontaneous vaginal delivery.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 36-year-old African-American female who is a G-2, P-2-0-0-2 with an EDC of 08/30/2003.  She is blood type AB -ve with antibody screen negative and is also rubella immune, VDRL nonreactive, hepatitis B surface antigen negative, and HIV nonreactive.  She does have a history of sickle cell trait.  She presented to Labor and Delivery Triage at 40 and 3/7th weeks gestation with complaint of contractions every ten minutes.  She also stated that she has lost her mucous plug.  She did have fetal movement, noted no leak of fluid, did have some spotting.  On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.  She was evaluated by sterile vaginal exam and was noted to be 4 cm dilated, 70% effaced, and -3 station.  This was a change from her last office exam, at which she was 1 cm to 2 cm dilated.,PROCEDURE DETAILS:,  The patient was admitted to Labor and Delivery for expected management of labor and AROM was performed and the amniotic fluid was noted to be meconium stained.  After her membranes were ruptured, contractions did increase to every two to three minutes as well as the intensity increased.  She was given Nubain for discomfort with good result.,She had a spontaneous vaginal delivery of a live born female at 11:37 with meconium stained fluid as noted from ROA position.  After controlled delivery of the head, tight nuchal cord was noted, which was quickly double clamped and cut and the shoulders and body were delivered without difficulty.  The infant was taken to the awaiting pediatrician.  Weight was 2870 gm, length was 51 cm.  The Apgars were 6 at 1 minute and 9 at 5 minutes.  There was initial neonatal depression, which was treated by positive pressure ventilation and the administration of Narcan.,Spontaneous delivery of an intact placenta with a three-vessel cord was noted at 11:45.  On examination, there were no noted perineal abrasions or lacerations.  On vaginal exam, there were no noted cervical or vaginal sidewall lacerations.  Estimated blood loss was less than 250 cc.  Mother and infant are in recovery doing well at this time.",24
"PREOPERATIVE DIAGNOSIS:,  Desire for sterility.,POSTOPERATIVE DIAGNOSIS:,  Desire for sterility.,OPERATIVE PROCEDURES: , Vasectomy.,DESCRIPTION OF PROCEDURE: , The patient was brought to the suite, where after oral sedation, the scrotum was prepped and draped.  Then, 1% lidocaine was used for anesthesia.  The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas.  A segment about 3 cm in length was dissected out.  It was clipped proximally and distally, and then the ends were cauterized after excising the segment.  Minimal bleeding was encountered and the scrotal skin was closed with 3-0 chromic.  The identical procedure was performed on the contralateral side.  He tolerated it well.  He was discharged from the surgical center in good condition with Tylenol with Codeine for pain.  He will use other forms of birth control until he has confirmed azoospermia with two consecutive semen analyses in the month ahead.  Call if there are questions or problems prior to that time.",38
"PREOPERATIVE DIAGNOSES,1.  Open wound from right axilla to abdomen with a prosthetic vascular graft, possibly infected.,2.  Diabetes.,3.  Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES,1.  Open wound from right axilla to abdomen with a prosthetic vascular graft, possibly infected.,2.  Diabetes.,3.  Peripheral vascular disease.,OPERATIONS,1.  Wound debridement with removal of Surgisis xenograft and debridement of skin and subcutaneous tissue.,2.  Secondary closure of wound, complicated.,3.  VAC insertion.,DESCRIPTION OF PROCEDURE:,  After obtaining an informed consent, the patient was brought to the operating room where a general anesthetic was given.  A time-out process was followed.  All the staples holding the xenograft were removed as well as all the dressings and the area was prepped with Betadine soap and then painted with Betadine solution and draped in usual fashion.,The xenograft was not adhered at all and was easily removed.  There was some, what appeared to be a seropurulent exudate at the bottom of the incision.  This was towards the abdominal end, under the xenograft.,The graft was fully exposed and it was pulsatile.  We then proceeded to use a pulse spray with bacitracin clindamycin solution to clean up the graft.  A few areas of necrotic skin and subcutaneous tissue were debrided.  Prior to this, samples were taken for aerobic and anaerobic cultures.,Normal saline 3000 cc was used for the irrigation and at the end of that the wound appeared much cleaner and we proceeded to insert the sponges to put a VAC system to it.  There was a separate incision, which was bridged __________ to the incision of the abdomen, which we also put a sponge in it after irrigating it and we put the VAC in the main wound and we created a bridge to the second and more minor wound.  Prior to that, I had inserted a number of Vesseloops through the edges of the skin and I proceeded to approximate those on top of the VAC sponge.  Multiple layers were applied to seal the system, which was suctioned and appeared to be working satisfactorily.,The patient tolerated the procedure well and was sent to the ICU for recovery.",37
"REASON FOR CONSULT:,  Depression.,HPI:,  The patient is an 87-year-old white female admitted for low back pain status post hip fracture sustained a few days before Thanksgiving in 2006.  The patient was diagnosed and treated for a T9 compression fraction with vertebroplasty.  Soon after discharge, the patient was readmitted with severe mid low back pain and found to have a T8 compression fracture.  This was also treated with vertebroplasty.  The patient is now complaining of back pain that fluctuates at time, acknowledging her pain medication works but not all the time.  Her pain is in her upper back around her shoulder blades.  The patient says lying down with the heated pad lessens the pain and that any physical activity increases it.  MRI on January 29, 2007, was positive for possible meningioma to the left of anterior box.,The patient reports of many depressive symptoms, has lost all interest in things she used to do (playing cards, reading).  Has no energy to do things she likes, but does participate in physical therapy, cries often and what she believes for no reason.  Does not see any future for herself.  Reports not being able to concentrate on anything saying she gets distracted by thoughts of how she does not want to live anymore.  Admits to decreased appetite, feeling depressed, and always wanting to be alone.  Claims that before her initial hospitalization for her hip fracture, she was highly active, enjoyed living independently at Terrace.  Denies suicidal ideations and homicidal ideations, but that she did not mind dying, and denies any manic symptoms including decreased need to sleep, inflated self-worth, and impulsivity.  Denies auditory and visual hallucinations.  No paranoid, delusions, or other abnormalities of thought content.  Denies panic attacks, flashbacks, and other feelings of anxiety.  Does admit to feeling restless at times.  Is concerned with her physical appearance while in the hospital, i.e., her hair looking ""awful."",PAST MEDICAL HISTORY:,  Hypertension, cataracts, hysterectomy, MI, osteoporosis, right total knee replacement in April 2004, hip fracture, and newly diagnosed diabetes.  No history of thyroid problems, seizures, strokes, or head injuries.,CURRENT MEDICATIONS:,  Norvasc 10 mg p.o. daily, aspirin 81 mg p.o. daily, Lipitor 20 mg p.o. daily, Klonopin 0.5 mg p.o. b.i.d., digoxin 0.125 mg p.o. daily, Lexapro 10 mg p.o. daily, TriCor 145 mg p.o. each bedtime, Lasix 20 mg p.o. daily, Ismo 20 mg p.o. daily, lidocaine patch, Zestril, Prinivil 40 mg p.o. daily, Lopressor 75 mg p.o. b.i.d., Starlix 120 mg p.o. t.i.d., Pamelor 25 mg p.o. each bedtime, polyethylene glycol 17 g p.o. every other day, potassium chloride 20 mEq p.o. t.i.d., Norco one tablet p.o. q.4h. p.r.n., Zofran 4 mg IV q.6h.,HOME MEDICATIONS:,  Unknown.,ALLERGIES:,  CODEINE (HALLUCINATIONS).,FAMILY MEDICAL HISTORY:,  Unremarkable.,PAST PSYCHIATRIC HISTORY:,  Unremarkable.  Never taken any psychiatric medications or have ever had a family member with psychiatric illness.,SOCIAL/DEVELOPMENTAL HISTORY:,  Unremarkable childhood.  Married for 40 plus years, widowed in 1981.  Worked as administrative assistant in UTMB Hospitals VP's office.  Two children.  Before admission, lived in the Terrace Independent Living Center.  Was happy and very active while living there.  Had friends in the Terrace and would not mind going back there after discharge.  Occasional glass of wine at dinner.  Denies ever using illicit drugs and tobacco.,MENTAL STATUS EXAM:,  The patient is an 87-year-old white female with appropriate appearance, wearing street clothes while lying in bed with her eyes tightly closed.  Slight decrease in motor activity.  Normal eye contact.  Speech, low volume and rate.  Good articulation and inflexion.  Normal concentration.  Mood, labile, tearful at times, depressed, then euthymic.  Affect, mood congruent, full range.  Thought process, logical and goal directed.  Thought content, no delusions, suicidal or homicidal ideations.  Perception, no auditory or visual hallucinations.  Sensorium, alert, and oriented x3.  Memory, fair.  Information and intelligence, average.  Judgment and insight, fair.,MINI MENTAL STATUS EXAM,:  A 28/30.  Could not remember two out of the three recalled words.,ASSESSMENT:,  The patient is an 87-year-old white female with recent history of hip fracture and two thoracic compression fractures.  The patient reports being high functioning prior to admission and says her depression symptoms have occurred while being in the hospital.,Axis I:  Major depression disorder.,Axis II:  Deferred.,Axis III:  Osteoporosis, hypertension, hip fracture, possible diabetes, meningioma, MI, and right total knee replacement.,Axis IV:  Lives independently at Terrace, difficulty walking, hospitalization.,Axis V:  45.,PLAN:,  Continue Lexapro 10 mg daily and Pamelor 25 mg each bedtime monitor for adverse effects of TCA and worsening of depressive symptoms.  Discussed about possible inpatient psychiatric care.,Thank you for the consultation.",32
"CHIEF COMPLAINT:,  The patient comes for bladder instillation for chronic interstitial cystitis.,SUBJECTIVE:,  The patient is crying today when she arrives in the office saying that she has a lot of discomfort.  These bladder instillations do not seem to be helping her.  She feels anxious and worried.  She does not think she can take any more pain.  She is debating whether or not to go back to Dr. XYZ and ask for the nerve block or some treatment modality to stop the pain because she just cannot function on a daily basis and care for her children unless she gets something done about this, and she fears these bladder instillations because they do not seem to help.  They seem to be intensifying her pain.  She has the extra burden of each time she comes needing to have pain medication one way or another, thus then we would not allow her to drive under the influence of the pain medicine.  So, she has to have somebody come with her and that is kind of troublesome to her.  We discussed this at length.  I did suggest that it was completely appropriate for her to decide.  She will terminate these if they are that uncomfortable and do not seem to be giving her any relief, although I did tell her that occasionally people do have discomfort with them and then after the completion of the instillations, they do better and we have also had some people who have had to terminate the instillations because they were too uncomfortable and they could not stand it and they went on to have some other treatment modality.  She had Hysterectomy in the past.,MEDICATIONS: , Premarin 1.25 mg daily, Elmiron 100 mg t.i.d., Elavil 50 mg at bedtime, OxyContin 10 mg three tablets three times a day, Toprol XL 25 mg daily.,ALLERGIES:,  Compazine and Allegra.,OBJECTIVE:,Vital Signs:  Weight:  140 pounds.  Blood pressure:  132/90.  Pulse:  102.  Respirations:  18.  Age:  27.,PLAN:,  We discussed going for another evaluation by Dr. XYZ and seeking his opinion.  She said that she called him on the phone the other day and told him how miserable she was and he told her that he really thought she needed to complete.  The instillations give that a full trial and then he would be willing to see her back.  As we discussed these options and she was encouraged to think it over and decide what she would like to do for I could not makeup her mind for her.  She said she thought that it was unreasonable to quit now when she only had two or three more treatments to go, but she did indicate that the holiday weekend coming made her fearful and if she was uncomfortable after today’s instillation which she did choose to take then she would choose to cancel Friday’s appointment, also that she would not feel too badly over the holiday weekend.  I thought that was reasonable and agreed that that would work out.,PROCEDURE:,:  She was then given 10 mg of morphine subcutaneously because she did not feel she could tolerate the discomfort in the instillation without pain medicine.  We waited about 20 minutes.  The bladder was then instilled and the urethra was instilled with lidocaine gel which she tolerated and then after a 10-minute wait, the bladder was instilled with DMSO, Kenalog, heparin, and sodium bicarbonate, and the catheter was removed.  The patient retained the solution for one hour, changing position every 15 minutes and then voided to empty the bladder.  She seemed to tolerate it moderately well.  She is to call and let me know what she wishes to do about the Friday scheduled bladder instillation if she tolerated this then she is going to consider trying it.  If not, she will cancel and will start over next week or she will see Dr. Friesen.",5
"OPERATIVE NOTE:  ,The patient was taken to the operating room and was placed in the supine position on the operating room table.  A general inhalation anesthetic was administered.  The patient was prepped and draped in the usual sterile fashion.  The urethral meatus was calibrated with a small mosquito hemostat and was gently dilated.  Next a midline ventral type incision was made opening the meatus.  This was done after clamping the tissue to control bleeding.  The meatus was opened for about 3 mm.  Next the meatus was calibrated and easily calibrated from 8 to 12 French with bougie sounds.  Next the mucosal edges were everted and reapproximated to the glans skin edges with approximately five interrupted 6-0 Vicryl sutures.  The meatus still calibrated between 10 and 12 French.  Antibiotic ointment was applied.  The procedure was terminated.  The patient was awakened and returned to the recovery room in stable condition.",38
"PREOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,POSTOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,OPERATION: , Excision of ganglion.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,OPERATION: , After a successful anesthetic, the patient was positioned on the operating table.  A tourniquet applied to the upper arm.  The extremity was prepped in a usual manner for a surgical procedure and draped off.  The superficial vessels were exsanguinated with an elastic wrap and the tourniquet was then inflated to the usual arm pressure.  A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.  By blunt and sharp dissection, it was dissected out from underneath the extensor tendons and the stalk appeared to arise from the distal radiocapitellar joint and the dorsal capsule was excised along with the ganglion and the specimen was removed and submitted.  The small superficial vessels were electrocoagulated and instilled after closing the skin with 4-0 Prolene, into the area was approximately 6 to 7 mL of 0.25 Marcaine with epinephrine.  A Jackson-Pratt drain was inserted and then after the tourniquet was released, it was kept deflated until at least 5 to 10 minutes had passed and then it was activated and then removed in the recovery room.  The dressings applied to the hand were that of Xeroform, 4x4s, ABD, Kerlix, and elastic wrap over a volar fiberglass splint.  The tourniquet was released.  Circulation returned to the fingers.  The patient then was allowed to awaken and left the operating room in good condition.",37
"PROCEDURE: , Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE:  ,INT was placed.  The patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion.  The patient was given sedation and monitored.  Lidocaine 1.5% for skin wheal was made 10 cm from the midline to the bilateral L2 distal vertebral body.  A 20-gauge, 15 cm SMK needle was then directed using AP and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one-third and anterior border on the lateral view and on the AP view the tip of the needle was inside the lateral third of the border of the vertebral body.  At this time a negative motor stimulation was obtained.  Injection of 10 cc of 0.5% Marcaine plus 10 mg of Depo-Medrol was performed. Coagulation was then carried out for 90oC for 90 seconds.  At the conclusion of this, the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated.  This was repeated one more time with a 5 mm withdrawal and coagulation.,At that time, attention was directed to the L3 body where the needle was placed to the upper one-third/distal two-thirds junction and the sequence of injection, coagulation, and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated.  There were no compilations from this.  The patient was discharged to operating room recovery in stable condition.",37
"ALLOWED CONDITION: , Right shoulder sprain and right rotator cuff tear (partial).,CONTESTED CONDITION:,  AC joint arthrosis right aggravation.,DISALLOWED CONDITION: ,",18
"PRE AND POSTOPERATIVE DIAGNOSIS:,  Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR.  After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted.  At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position.  The patient's posterior cervical area was then prepped and draped in the usual sterile fashion.  At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine.  A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated.  After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken.  This showed the spinous process to be at the C4 level.  Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified.  After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken.  This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time.  At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina.  The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe.  This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur.  However, progress was limited because of thickness of the bone.  Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area.  After the bone had been thinned out, further bone was removed using the Kerrison rongeur.  At this point the nerve root was visually inspected and observed to be decompressed.  However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade.  Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery.  After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin.  Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches.  The subcutaneous layer was then reapproximated using 000 Dexon.  The skin was reapproximated using a running 000 nylon.  Sterile dressings were applied.  The patient was then extubated in the OR and transferred to the Recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  minimal.",27
"REASON FOR CONSULTATION: , We were asked to see the patient in regards to a brain tumor.,HISTORY OF PRESENT ILLNESS: ,She was initially diagnosed in September of this year with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis.  She was seen by Dr. X in our group.  Because of her living arrangement, she elected to have treatment through the hospital radiation department and oncology department.  Details of her treatment are not available at the time of this dictation.  Her family has a packet of Temodar 100-mg pills.  She is admitted now with increasing confusion.  A CT shows increase in size of the lesions compared to the preoperative scan.  We are asked to comment on her treatment at this point.  She herself is confused and is unable to provide further history.  ,PAST MEDICAL HISTORY: , From her old chart:  No known past medical history prior to the diagnosis.,SOCIAL HISTORY:  ,She was living alone and is now living in assisted living.  ,MEDICATIONS,1.  Dilantin 300 mg daily.,2.  Haloperidol 1 mg h.s.,3.  Dexamethasone 4 mg q.i.d. ,4.  Docusate 100 mg b.i.d.,5.  Pen-VK 500 mg daily.,6.  Ibuprofen 600 mg daily.,7.  Zantac 150 mg twice a day.,8.  Temodar 100 mg daily.,9.  Magic Mouthwash daily.,10.  Tylenol #3 as needed.,REVIEW OF SYSTEMS,:  Unable.,PHYSICAL EXAMINATION,GENERAL:  Elderly woman, confused.  ,HEENT:  Normal conjunctivae.  Ears and nose normal.  Mouth normal.,NECK:  Supple.,CHEST: Clear.,HEART:  Normal.,ABDOMEN: Soft, positive bowel sounds.,NEUROLOGIC:  Alert, cranial nerves intact.  Left arm slightly weak.  Left leg slightly weak.,IMPRESSION AND PLAN:,  Glioblastoma multiforme, uncertain as to where she is in cancer treatment.  Given the number of pills in the patient's family's hands, it sounds like she has only been treated recently and therefore it is not surprising that she is showing increased problems related to increased size of the tumor.  We will have to talk with Dr. Y in the Clinic to get a better handle on her treatment regimen.  At this point, I will hold Temodar today and consider restarting it tomorrow if we can get her treatment plan clarified.",5
"HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening.  The patient said that he occasionally gets some loose stools.  Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all.  He denies any hypertension, diabetes, or any other problems.  He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea.  Sometimes he gets some loose stools.  Occasionally there is some constipation.  Stools caliber has not changed.  There is no blood in stool or mucus in stool.  No weight loss.  Appetite is good.  No nausea, vomiting, or difficulty in swallowing.  Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3.  Vital signs: Weight is 214 pounds.  Blood pressure is 111/70.  Pulse is 69 per minute.  Respiratory rate is 18.  HEENT: Negative.  Neck: Supple.  There is no thyromegaly.  Cardiovascular: Both heart sounds are heard.  Rhythm is regular.  No murmur.  Lungs: Clear to percussion and auscultation.  Abdomen: Soft and nontender.  No masses felt.  Bowel sounds are heard.  Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy.  I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection.  The patient agreed for it.  We will proceed with it.  I also explained to the patient about conscious sedation.  He agreed for conscious sedation.",14
"IDENTIFYING DATA: , The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother.  Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital.  He says he had a ""panic attack leading to the car wreck"" and denies that any of his behavior was suicidal in nature responding, ""I was just trying to scare my mother."",CHIEF COMPLAINT: , The patient does say, ""I screwed up my whole life and wrecked my car."" The patient claims he is med compliant, although his mother, and stepfather saying he is off his meds.  He had a two-day stay at XYZ Hospital for medical clearance after his car accident, and no injuries were found other than a sore back, which was negative by x-ray and CT scan.,PRESENT ILLNESS:  ,The patient is on a 72-your involuntary hold for danger to self and grave disability.  He has a history of bipolar disorder with mania and depression with anxiety and panic attacks.  Today, he went to involuntary court hearing and was released by the court.  He is now being discharged from second floor ABCD Psychiatric Hospital.,PAST PSYCHIATRIC HISTORY:,  Listed extensively in his admission note and will not be repeated.,MEDICAL HISTORY: , Includes migraine headaches and a history of concussion.  He describes ""allergy"" to Haldol medication.,OUTPATIENT CARE: , The patient sees a private psychiatrist, Dr. X.  Followup with Dr. X is arranged in four days' time and the patient is discharged with four days of medication.  This information is known to Dr. X.,DISCHARGE MEDICATIONS:,The patient is discharged with:,1.  Klonopin 1 mg t.i.d. p.r.n.,2.  Extended-release lithium 450 mg b.i.d.,3.  Depakote 1000 mg b.i.d.,4.  Seroquel 1000 mg per day.,SOCIAL HISTORY:  ,The patient lives with his girlfriend on an on-and-off basis and is unclear if they will be immediately moving back in together.,SUBSTANCE ABUSE: , The patient was actively tox screen positive for benzodiazepines, cocaine, and marijuana.  The patient had an inpatient stay in 2008 at ABC Lodge for drug abuse treatment.,MENTAL STATUS EXAM:,  Notable for lack of primary psychotic symptoms, some agitation, and psychomotor hyperactivity, uncooperative behavior regarding his need for ongoing acute psychiatric treatment and stabilization.  There is an underlying hostile oppositional message in his communications.,FORMULATION: , The patient is a 21-year-old male with a history of bipolar disorder, anxiety, polysubstance abuse, and in addition ADHD.  His recent behavior is may be at least in part associated with active polysubstance abuse and also appears to be a result of noncompliance with meds.,DIAGNOSES:,AXIS I:,1.  Bipolar disorder.,2.  Major depression with anxiety and panic attacks.,3.  Polysubstance abuse, benzodiazepines, and others street meds.,4.  ADHD.,AXIS II: , Deferred at present, but consider personality disorder traits.,AXIS III:,  History of migraine headaches and past history of concussion.,AXIS IV: , Stressors are moderate.,AXIS V: , GAF is 40.,PLAN: , The patient is released from the hospital secondary to court evaluation, which did not extend his involuntary stay.  He has an appointment in four days with his outpatient psychiatrist, Dr. X.  He has four days' worth of medications and agrees to no self-harm or harm of others.  Additionally, he agrees to let staff know or authorities know if he becomes acutely unsafe.  His mother and stepfather have been informed of the patient's discharge and the followup plan.",5
"OPERATIVE NOTE:  ,The patient was placed in the supine position under general anesthesia, and prepped and draped in the usual manner.  The penis was inspected.  The meatus was inspected and an incision was made in the dorsal portion of the meatus up towards the tip of the penis connecting this with the ventral urethral groove.  This was incised longitudinally and closed transversely with 5-0 chromic catgut sutures.  The meatus was calibrated and accepted the calibrating instrument without difficulty, and there was no stenosis.  An incision was made transversely below the meatus in a circumferential way around the shaft of the penis, bringing up the skin of the penis from the corpora.  The glans was undermined with sharp dissection and hemostasis was obtained with a Bovie.  Using a skin hook, the meatus was elevated ventrally and the glans flaps were reapproximated using 5-0 chromic catgut, creating a new ventral portion of the glans using the flaps of skin.  There was good viability of the skin.  The incision around the base of the penis was performed, separating the foreskin that was going to be removed from the coronal skin.  This was removed and hemostasis was obtained with a Bovie.  0.25% Marcaine was infiltrated at the base of the penis for post-op pain relief, and the coronal and penile skin was reanastomosed using 4-0 chromic catgut.  At the conclusion of the procedure, Vaseline gauze was wrapped around the penis.  There was good hemostasis and the patient was sent to the recovery room in stable condition.",37
"PREOPERATIVE DIAGNOSIS:, Tachybrady syndrome.,POSTOPERATIVE DIAGNOSIS:, Tachybrady syndrome.,OPERATIVE PROCEDURE:, Insertion of transvenous pacemaker.,ANESTHESIA:, Local,PROCEDURE AND GROSS FINDINGS:, The patient's chest was prepped with Betadine solution and a small amount of Lidocaine infiltrated.  In the left subclavian region, a subclavian stick was performed without difficulty, and a wire was inserted. Fluoroscopy confirmed the presence of the wire in the superior vena cava.  An introducer was then placed over the wire.  The wire was removed and replace by a ventricular lead that was seated under Fluoroscopy. Following calibration, the lead was attached to a pacemaker generator that was inserted in a subcutaneous pocket in the left subclavian area.  ,The subcutaneous tissues were irrigated and closed with Interrupted 4-O Vicryl, and the skin was closed with staples.  Sterile dressings were placed, and the patient was returned to the ICU in good condition.",37
"PREOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,POSTOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,4.  Postoperative coagulopathy.,OPERATIVE PROCEDURE:,1.  Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass.,2.  Open sternotomy covered with Ioban.,3.  Insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.,ANESTHESIA: , General endotracheal.,OPERATIVE PROCEDURE: , With the patient in the supine position, he was prepped from shin to knees and draped in a sterile field.  A right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass.  A sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm, freeing up the right atrium and the ascending aorta and anterior right ventricle.  The patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava.  A percutaneous catheter for arterial return was placed using Seldinger technique through exposed right femoral artery and then two 3-mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava.  After satisfactory heparinization has been obtained, the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium.  After the heart was brought to the operating room and triggered, the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place.  A cardiectomy was then performed by starting in the right atrium.  The wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the Swan-Ganz catheter was brought out into the operative field.  Cardiectomy was then performed, first resecting the anterior portion of the right atrium and then transecting the aorta, the pulmonary artery, the septum between the right and left atriums, and then the heart was removed.  The right and left atrium, aorta, and pulmonary artery were prepared for the transplant.  First, we did a side-to-side anastomosis, continued to the left atrium and this was performed using 3-0 Prolene suture and a right atrial anastomosis side-to-side was performed using 3-0 Prolene suture.  The pulmonary artery was then anastomosed using 5-0 Prolene and the aorta was anastomosed with 4-0 Prolene.  The arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood.  Air was evacuated and the sutures were tied down.  The clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass.  The patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass.  Blood factors and factor VII were given to try and correct the coagulopathy.  Because of excessive transfusions that were required, a Mahurkar catheter was inserted through the left common femoral vein, first placing a needle into the vein and then guidewire removed, and the needle dilators were then placed and then the Mahurkar catheter was then placed with 2-0 nylon suture.  Hemofiltration was started in the operating room at this time.  After he had satisfactory hemostasis, we decided to do the chest open and cover it with Ioban, which we did, and one chest tube was inserted into the mediastinum through a separate stab wound.  The patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively.  This was left in place and the pulse generation, the pacemaker was in a right infraclavicular position, which was left in place because of the coagulopathy.  The patient received 11 units of packed red blood cells, 7 platelets, 23 fresh-frozen plasma, 20 cryoprecipitates, and factor VII.  Urine output for the procedure was 520 mL.  The preservation time of the heart is in the anesthesia sheet.  The estimated blood loss was at least 6 L.  The patient was taken to the intensive care unit in guarded condition.",37
"CC: ,Bilateral lower extremity numbness.,HX: ,21 y/o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11/5/96. The symptoms became maximal over a 12-24 hour period and have not changed since. The symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally. He noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space. He denied bowel/bladder problems, or weakness or numbness elsewhere. Hot showers may improve his symptoms. He has suffered no recent flu-like illness. Past medical and family histories are unremarkable. He was on no medications.,EXAM:, Unremarkable except for mild distal vibratory sensation loss in the toes (R>L).,LAB:, CBC, Gen Screen, TSH, FT4, SPE, ANA were all WNL.,MRI L-SPINE:, Normal.,COURSE:, Normal exam and diminished symptoms at following visit 4/23/93.",33
"PRESENTATION: , Patient, 13 years old, comes to your office with his mother complaining about severe ear pain.  He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,HISTORY OF PRESENT ILLNESS:  ,Patient reports that he felt good after taking antibiotics with each earache episode and has recently started on the wrestling team.  Mom reports that patient has been afebrile with each of the earache episodes, and he has not had upper respiratory symptoms.  Patient denies any head trauma associated with wrestling practice.,BIRTH AND DEVELOPMENTAL HISTORY:,  Patient's mother reports a normal pregnancy with no complications, having received prenatal care from 12 weeks.  Vaginal delivery was uneventful with a normal perinatal course.  Patient sat alone at 6 months, crawled at 9 months, and walked at 13 months.  His verbal and motor developmental milestones were as expected.,FAMILY/SOCIAL HISTORY: , Patient lives with both parents and two siblings (brother - age 11 years, sister - age 15 years).  He reports enjoying school, remains active in scouts, and is very excited about being on the wresting team.  Mom reports that he has several friends, but she is concerned about the time required for the wrestling team.  Patient is in 8th grade this year and an A/B student.  Both siblings are healthy.  His Dad has hypertension and has frequent heartburn symptoms that he treats with over-the-counter (OTC) medications.  Mom is healthy and has asthma.,PAST MEDICAL HISTORY:  ,Patient has been seen in the clinic yearly for well child exams.  He has had no major illnesses or hospitalizations.  He had one emergency room visit 2 years ago for a knee laceration.  Patient has been healthy except for the past year when he had two episodes of otitis media not associated with respiratory infections.  He received antibiotic therapy (amoxicillin) for the otitis media and both episodes resolved without problems.  Patient's Mom states that he takes no prescribed medications or OTC medications, but he admits that he has been taking his dad's OTC Pepcid AE sometimes when he gets heartburn.  Upon further examination, he reports taking Pepcid when he eats pizza or Mexican food.  He does complain of sore throats sometimes and often feels burning in his throat when he goes to sleep at night after a late evening snack.,NUTRITIONAL HISTORY: , Patient eats cereal bars or pop tarts with milk for breakfast most days.  He takes his lunch (usually a sandwich and chips or yogurt and fruit) for lunch.  Mom or his sister cooks supper in the evening.  The family goes out to eat once or twice a week and he only gets ""fast food"" once or twice a week according to his Mom.  He says he eats ""a lot"" especially after a wrestling meet.,PHYSICAL EXAM:,Height/weight:  Patient weighs 109 pounds (60th percentile) and is 69 inches tall (93rd percentile).  He is following the growth pattern he established in infancy.,Vital signs:  BP 110/60, T 99.2, HR 70, R 16.,General:  Alert, cooperative but a bit shy.,Neuro:  DTRs symmetric, 2+, negative Romberg, able to perform simple calculations without difficulty, short-term memory intact.  He responds appropriately to verbal and visual cues, and movements are smooth and coordinated.,HEENT:  Normocephalic, PEERLA, red reflex present, optic disk and ocular vessels normal.  TMs deep red, dull, landmarks obscured, full bilaterally.  Post auricular and submandibular nodes on left are palpable and slightly tender.,Lungs:  CTA, breath sounds equal bilaterally, excursion and chest configuration normal.,Cardiac:  S1, S2 split, no murmurs, pulses equal bilaterally.,Abdomen:  Soft, rounded, reports no epigastric tenderness but states that heartburn begins in epigastric area and rises to throat.  Bowel sounds active in all quadrants.  No hepatosplenomegaly or tenderness.  No CVA tenderness.,Musculoskeletal:  Full range of motion, all extremities.  Spine straight, able to perform jumping jacks and duck walk without difficulty.,Genital:  Normal male, Tanner stage 4.  Rectal exam - small amount of soft stool, no fissures or masses.,LABS:  ,Stool negative for blood and H. pylori antigen.  Normal CBC and urinalysis.  A barium swallow and upper GI was scheduled for the following week.  It showed marked GE reflux.,ASSESSMENT: , The differential diagnoses for patient included (a) chronic otitis media/treatment failure, (b) peptic ulcer disease/gastritis, (c) gastro esophageal reflux disease (GERD) or carbonated beverage syndrome, (d) trauma.,CHRONIC OTITIS MEDIA. , Chronic otitis media due to a penicillin resistant organism would be the obvious diagnosis in this case.  It is rare for an adolescent to have otitis media with no precipitating factor (such as being on a swim team or otherwise exposed to unusual organisms or in an unusual environment).  It is certainly unusual for him to have three episodes in 1 year.,PEPTIC ULCER DISEASE.,  There were no symptoms of peptic ulcer disease, a negative H. pylori screen and lack of pain made this diagnosis less likely.  Trauma.  Trauma was a possibility, particularly since adolescent males frequently minimize symptoms especially if they might limit participation in a sport but patient maintained that he had not had an event where he struck his head or neck and that he always wore his helmet with ear padding.,GERD.,  The history of ""heartburn"" relieved by his father's medication was striking.  The positive study supported the diagnosis of GERD, which was severe and chronic enough to cause irritation of the mucosal surfaces exposed to the gastric juices and edema, inflammation in the inner ears.,PLAN:,  Patient and his Mom agreed to a trial of omeprazole 20 mg at bedtime for 2 weeks.  Patient was to keep a diary of any episodes of heartburn, including what foods seemed to aggravate it.  The clinician asked him to avoid using any antacid products in the meantime to gage the effectiveness of the medication.  He was also given a prescription for 10 days of Augmentin99 and a follow-up appointment for 2 weeks.  At his follow-up appointment he reported one episode after he ate a whole large pizza after wrestling practice but said it went away pretty quickly after he took his medication.  A 6-month follow up appointment was scheduled.",11
"PREOPERATIVE DIAGNOSES:,1.  Maxillary atrophy.,2.  Severe mandibular atrophy.,3.  Acquired facial deformity.,4.  Masticatory dysfunction.,POSTOPERATIVE DIAGNOSES:,1.  Maxillary atrophy.,2.  Severe mandibular atrophy.,3.  Acquired facial deformity.,4.  Masticatory dysfunction.,PROCEDURE PERFORMED: , Autologous iliac crest bone graft to maxilla and mandible under general anesthetic.,Dr. X and company accompanied the patient to OR #6 at 7:30 a.m.  Nasal trachea intubation was performed per routine.  The bilateral iliac crest harvest was first performed by Dr. X and company under separate OR report.  Once the bone was harvested, surgical templets were used to recontour initially the maxillary graft and the mandibular graft.  Then, CAT scan models were used to find tune and adjust the bony contact regions for the maxillary tricortical block graft and the mandibular tricortical block graft.  Subsequent to the harvest of the bilateral ilium, the intraoral region was scrubbed per routine.  Surgical team scrubbed and gowned in usual fashion and the patient was draped.  Xylocaine 1%, 1:100,000 epinephrine 7 ml was infiltrated into the labial and palatal mucosa.  A primary incision was made in the maxilla starting on the patient's left tuberosity region along the crest of the residual ridge to the contralateral side in similar fashion.  Release incisions were made in the posterior region of the maxilla.,A full-thickness periosteal reflexion first exposed the palatal region.  The contents of the neurovascular canal from the greater palatine foramina were identified.  The hard palate was directly observed.  The facial tissues were then reflected exposing the lateral aspect of the maxilla, the zygomatic arch, the infraorbital nerve, artery and vein, the lateral piriform rim, the inferior piriform rim, and the remaining issue of the nasal spine.  Similar features were reflected on the contralateral side.  The area was re-contoured with rongeurs.  The block of bone, which was formed and harvested from the left ilium was then placed and found to be stable.  A surgical mallet then compressed this bone further into the region.  A series of five 2 mm diameter titanium screws measuring 14 mm to 16 mm long were then used to fixate the block of bone into the residual maxilla.  Particulate bone was then placed around the remaining block of bone.  A piece of AlloDerm mixed with Croften and patient's platelet-rich plasma, which was centrifuged from drawing 20 cc of blood was then mixed together and placed over the lateral aspect of the block.  The tissues were expanded then with a tissue Metzenbaum scissors and once the labial tissue was expanded, the tissues were approximated for primary closure without tension using interrupted and continuous sutures #3-0 Gore-Tex.  Attention was brought then to the mandible.  1% Xylocaine, 1:100,000 epinephrine was infiltrated in the labial mucosa 5 cc were given.  A primary incision was made between the mental foramina and the residual crest of the ridge and reflected first to the lingual area observing the superior genial tubercle in the facial area degloving the mentalis muscle and exposing the anterior body.  The anterior body was found to be approximately 3 mm in height.  A posterior tunnel was done first on the left side along the mylohyoid ridge and then under retromolar pad to the external oblique and the ridge was then degloved.  A tunnel was formed in the posterior region separating the mental nerve artery and vein from the flap and exposing that aspect of the body of the mandible.  A similar procedure was done on the contralateral side.  The tissues were stretched with tissue scissors and then a high speed instrumentation was used to decorticate the anterior mandible using a 1.6 mm twist drill and a pear shaped bur was used in the posterior region to begin original exploratory phenomenon of repair.  A block of bone was inserted between the mental foramina and fixative with three 16 cm screws first with a twist drill then followed with self-tapping 2 mm diameter titanium screws.  The block of bone was further re-contoured in situ.  Particulate bone was then injected into the posterior tunnels bilaterally.  A piece of AlloDerm was placed over those particulate segments.  The tissues were approximated for primary closure using #3-0 Gore-Tex suture both interrupted and horizontal mattress in form.  The tissues were compressed for about four minutes to allow platelet clots to form and to help adhere the flap.,The estimated blood loss in the harvest of the hip was 100 cc.  The estimated blood loss in the intraoral procedure was 220 cc.  Total blood loss for the procedure 320 cc.  The fluid administered 300 cc.  The urine out 180.  All sponges were counted encountered for as were sutures.  The patient was taken to Recovery at approximately 12 o'clock noon.",37
"PRINCIPAL DIAGNOSIS: , Mullerian adenosarcoma.  ,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old presenting with a large mass aborted through the cervix.,PHYSICAL EXAM:,CHEST:  Clear.  There is no heart murmur.,ABDOMEN:  Nontender.,PELVIC:  There is a large mass in the vagina.  ,HOSPITAL COURSE: , The patient went to surgery on the day of admission.  The postoperative course was marked by fever and ileus.  The patient regained bowel function.  She was discharged on the morning of the seventh postoperative day.,OPERATIONS: , July 25, 2006:  Total abdominal hysterectomy, bilateral salpingo-oophorectomy.,DISCHARGE CONDITION: , Stable.,  ,PLAN: , The patient will remain at rest initially with progressive ambulation thereafter.  She will avoid lifting, driving, stairs, or intercourse.  She will call me for fevers, drainage, bleeding, or pain.  Family history, social history, and psychosocial needs per the social worker.  The patient will follow up in my office in one week.,PATHOLOGY:,  Mullerian adenosarcoma.,MEDICATIONS:,  Percocet 5, #40, one q.3 h. p.r.n. pain.",10
"PREOPERATIVE DIAGNOSIS: , Large and invasive recurrent pituitary adenoma.,POSTOPERATIVE DIAGNOSIS:,  Large and invasive recurrent pituitary adenoma.,OPERATION PERFORMED: , Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma, endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus, harvesting of dermal fascia abdominal fat graft, placement of abdominal fat graft into sella turcica, reconstruction of sellar floor using autologous nasal bone creating a cranioplasty of less than 5 cm, repair of nasal septal deviation, using the operating microscope and microdissection technique, and placement of lumbar subarachnoid catheter connected to reservoir for aspiration and infusion.,INDICATIONS FOR PROCEDURE: , This man has undergone one craniotomy and 2 previous transsphenoidal resections of his tumor, which is known to be an invasive pituitary adenoma.  He did not return for followup or radiotherapy as instructed, and the tumor has regrown.  For this reason, he is admitted for transsphenoidal reoperation with an attempt to remove as much tumor as possible.  The high-risk nature of the procedure and the fact that postoperative radiation is mandatory was made clear to him.  Many risks including CSF leak and blindness were discussed in detail.  After clear understanding of all the same, he elected to proceed ahead with surgery.,PROCEDURE:  ,The patient was placed on the operating table, and after adequate induction of general anesthesia, he was placed in the left lateral decubitus position.  Care was taken to pad all pressure points appropriately.  The back was prepped and draped in usual sterile manner.,A 14-gauge Tuohy needle was introduced into the lumbar subarachnoid space.  Clear and colorless CSF issued forth.  A catheter was inserted to a distance of 40 cm, and the needle was removed.  The catheter was then connected to a closed drainage system for aspiration and infusion.,This no-touch technique is now a standard of care for treatment of patients with large invasive adenomas.  Via injections through the lumbar drain, one increases intracranial pressure and produces gentle migration of the tumor.  This improves outcome and reduces complications by atraumatically dissecting the tumor away from the optic apparatus.,The patient was then placed supine, and the 3-point headrest was affixed.  He was placed in the semi-sitting position with the head turned to the right and a roll placed under the left shoulder.  Care was taken to pad all pressure points appropriately.  The fluoroscope C-arm unit was then positioned so as to afford an excellent view of the sella and sphenoid sinus in the lateral projection.  The metallic arm was then connected to the table for the use of the endoscope.  The oropharynx, nasopharynx, and abdominal areas were then prepped and draped in the usual sterile manner.,A transverse incision was made in the abdominal region, and several large pieces of fat were harvested for later use.  Hemostasis was obtained.  The wound was carefully closed in layers.,I then advanced a 0-degree endoscope up the left nostril.  The middle turbinate was identified and reflected laterally exposing the sphenoid sinus ostium.  Needle Bovie electrocautery was used to clear mucosa away from the ostium.  The perpendicular plate of the ethmoid had already been separated from the sphenoid.  I entered into the sphenoid.,There was a tremendous amount of dense fibrous scar tissue present, and I slowly and carefully worked through all this.  I identified a previous sellar opening and widely opened the bone, which had largely regrown out to the cavernous sinus laterally on the left, which was very well exposed, and the cavernous sinus on the right, which I exposed the very medial portion of.  The opening was wide until I had the horizontal portion of the floor to the tuberculum sella present.,The operating microscope was then utilized.  Working under magnification, I used hypophysectomy placed in the nostril.,The dura was then carefully opened in the midline, and I immediately encountered tissue consistent with pituitary adenoma.  A frozen section was obtained, which confirmed this diagnosis without malignant features.,Slowly and meticulously, I worked to remove the tumor.  I used the suction apparatus as well as the bipolar coagulating forceps and ring and cup curette to begin to dissect tumor free.  The tumor was moderately vascular and very fibrotic.,Slowly and carefully, I systematically entered the sellar contents until I could see the cavernous sinus wall on the left and on the right.  There appeared to be cavernous sinus invasion on the left.  It was consistent with what we saw on the MRI imaging.,The portion working into the suprasellar cistern was slowly dissected down by injecting saline into the lumbar subarachnoid catheter.  A large amount of this was removed.  There was a CSF leak, as the tumor was removed for the upper surface of it was very adherent to the arachnoid and could not be separated free.,Under high magnification, I actually worked up into this cavity and performed a very radical excision of tumor.  While there may be a small amount of tumor remaining, it appeared that a radical excision had been created with decompression of the optic apparatus.  In fact, I reinserted the endoscope and could see the optic chiasm well.,I reasoned that I had therefore achieved the goal with that is of a radical excision and decompression.  Attention was therefore turned to closure.,The wound was copiously irrigated with Bacitracin solution, and meticulous hemostasis was obtained.  I asked Anesthesiology to perform a Valsalva maneuver, and there was no evidence of bleeding.,Attention was turned to closure and reconstruction.  I placed a very large piece of fat in the sella to seal the leak and verified that there was no fat in the suprasellar cistern by using fluoroscopy and looking at the pattern of the air.  Using a polypropylene insert, I reconstructed the sellar floor with this implant making a nice tight sling and creating a cranioplasty of less than 5 cm.,DuraSeal was placed over this, and the sphenoid sinus was carefully packed with fat and DuraSeal.,I inspected the nasal passages and restored the septum precisely to the midline repairing a previous septal deviation.  The middle turbinates were then restored to their anatomic position.  There was no significant intranasal bleeding, and for this reason, an open nasal packing was required.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left to the recovery room in excellent condition.  The sponge and needle counts were reported as correct, and there were no intraoperative complications.,Specimens were sent to Pathology consisting of tumor.",22
"PROCEDURES PERFORMED: , Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.,PROCEDURE CODES: , 64640 times one, 64614 times two, 95873 times two.,PREOPERATIVE DIAGNOSIS: , Spastic right hemiparetic cerebral palsy, 343.1.,POSTOPERATIVE DIAGNOSIS:,  Spastic right hemiparetic cerebral palsy, 343.1.,ANESTHESIA:,  MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient.  She was brought to the minor procedure area and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.  The right obturator nerve was identified using active EMG stimulation lateral to the adductor longus tendon origin and below the femoral pulse.  Approximately 6 mL of 5% phenol was injected in this location.  At all sites of phenol injections, injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation.  Approximately 100 units was injected in the right pectoralis major and 100 units in the right rectus femoris and vastus intermedius muscles.  Total amount of botulinum toxin injected was 200 units diluted 25 units to 1 mL.  The patient tolerated the procedure well and no complications were encountered.",37
"PREOPERATIVE/POSTOPERATIVE DIAGNOSES:,1.  Severe tracheobronchitis.,2.  Mild venous engorgement with question varicosities associated pulmonary hypertension.,3.  Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.,PROCEDURE PERFORMED: , Flexible fiberoptic bronchoscopy with:,a.  Right lower lobe bronchoalveolar lavage.,b.  Right upper lobe endobronchial biopsy.,SAMPLES: , Bronchoalveolar lavage for cytology and for microbiology of the right lower lobe endobronchial biopsy of the right upper lobe.,INDICATIONS: , The patient with persistent hemoptysis of unclear etiology.,PROCEDURE: , After obtaining informed consent, the patient was brought to Bronchoscopy Suite.  The patient had previously been on Coumadin and then heparin.  Heparin was discontinued approximately one-and-a-half hours prior to the procedure.  The patient underwent topical anesthesia with 10 cc of 4% Xylocaine spray to the left nares and nasopharynx.  Blood pressure, EKG, and oximetry monitoring were applied and monitored continuously throughout the procedure.  Oxygen at two liters via nasal cannula was delivered with saturations in the 90% to 100% throughout the procedure.  The patient was premedicated with 50 mg of Demerol and 2 mg of Versed.  After conscious sedation was achieved, the bronchoscope was advanced through the left nares into the nasopharynx and oropharynx.  There was minimal redundant oral soft tissue in the oropharynx.  There was mild erythema.  Clear secretions were suctioned.,Additional topical anesthesia was applied to the larynx and then throughout the tracheobronchial tree for the procedure, a total of 16 cc of 2% Xylocaine was applied.  Vocal cord motion was normal.  The bronchoscope was then advanced through the larynx into the trachea.  There was evidence of moderate inflammation with prominent vascular markings and edema.  No frank blood was visualized.  The area was suction clear of copious amounts of clear white secretions.  Additional topical anesthesia was applied and the bronchoscope was advanced into the left main stem.  The bronchoscope was then sequentially advanced into each segment and sub-segment of the left upper lobe and left lower lobe.  There was significant amount of inflammation, induration, and vascular tortuosity in these regions.  No frank blood was identified.  No masses or lesions were identified.  There was senile bronchiectasis with slight narrowing and collapse during the exhalation.  The air was suctioned clear.  The bronchoscope was withdrawn and advanced into the right main stem.  Bronchoscope was introduced into the right upper lobe and each sub-segment was visualized.  Again significant amounts of tracheobronchitis was noted with vascular infiltration.  In the sub-carina of the anterior segment of the right upper lobe, there was evidence of a submucosal hematoma without frank mass underneath this.  The bronchoscope was removed and advanced into the right middle and right lower lobe.  There was marked injection and inflammation in these regions.  In addition, there was marked vascular engorgement with near frank varicosities identified throughout the region.  Again, white clear secretions were identified.  No masses or other processes were noted.  The area was suctioned clear.  A bronchoalveolar lavage was subsequently performed in the anterior segment of the right lower lobe.  The bronchoscope was then withdrawn and readvanced into the right upper lobe.  Endobronchial biopsies of the carina of the sub-segment and anterior segment of the right upper lobe were obtained.  Minimal hemorrhage occurred after the biopsy, which stopped after 1 cc of 1:1000 epinephrine.  The area remained clear.  No further hemorrhage was identified.  The bronchoscope was subsequently withdrawn.  The patient tolerated the procedure well and was stable throughout the procedure.  No further hemoptysis was identified.  The patient was sent to Recovery in good condition.",3
"EXAM: , CT of the abdomen and pelvis without contrast.,HISTORY: , Lower abdominal pain.,FINDINGS:,  Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis.  There is a 1.6 cm nodular density at the left posterior sulcus.,Noncontrast technique limits evaluation of the solid abdominal organs.  Cardiomegaly and atherosclerotic calcifications are seen.,Hepatomegaly is observed.  There is calcification within the right lobe of the liver likely related to granulomatous changes.  Subtle irregularity of the liver contour is noted, suggestive of cirrhosis.  There is splenomegaly seen.  There are two low-attenuation lesions seen in the posterior aspect of the spleen, which are incompletely characterized that may represent splenic cyst.  The pancreas appears atrophic.  There is a left renal nodule seen, which measures 1.9 cm with a Hounsfield unit density of approximately 29, which is indeterminate.,There is mild bilateral perinephric stranding.  There is an 8-mm fat density lesion in the anterior inner polar region of the left kidney, compatible in appearance with angiomyolipoma.  There is a 1-cm low-attenuation lesion in the upper pole of the right kidney, likely representing a cyst, but incompletely characterized on this examination.  Bilateral ureters appear normal in caliber along their visualized course.  The bladder is partially distended with urine, but otherwise unremarkable.,Postsurgical changes of hysterectomy are noted.  There are pelvic phlebolith seen.  There is a calcified soft tissue density lesion in the right pelvis, which may represent an ovary with calcification, as it appears continuous with the right gonadal vein.,Scattered colonic diverticula are observed.  The appendix is within normal limits.  The small bowel is unremarkable.  There is an anterior abdominal wall hernia noted containing herniated mesenteric fat.  The hernia neck measures approximately 2.7 cm.  There is stranding of the fat within the hernia sac.,There are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis.  Degenerative changes of the spine are observed.,IMPRESSION:,1.  Anterior abdominal wall hernia with mesenteric fat-containing stranding, suggestive of incarcerated fat.,2.  Nodule in the left lower lobe, recommend follow up in 3 months.,3.  Indeterminate left adrenal nodule, could be further assessed with dedicated adrenal protocol CT or MRI.,4.  Hepatomegaly with changes suggestive of cirrhosis.  There is also splenomegaly observed.,5.  Low-attenuation lesions in the spleen may represent cyst, that are incompletely characterized on this examination.,6.  Fat density lesion in the left kidney, likely represents angiomyolipoma.,7.  Fat density soft tissue lesion in the region of the right adnexa, this contains calcifications and may represent an ovary or possibly dermoid cyst.",14
"PREOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,POSTOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,PROCEDURES:,1.  Rigid bronchoscopy with removal of foreign body, prolonged procedure taking two hours to remove the stent piecemeal in a very difficult and trying situation.,2.  Excision of granulation tissue tumor.,3.  Bronchial dilation with a balloon bronchoplasty, right main bronchus.,4.  Argon plasma coagulation to control bleeding in the trachea.,5.  Placement of a tracheal and bilateral bronchial stents with a silicon wire stent.,ENDOSCOPIC FINDINGS:,1.  Normal true vocal cords.,2.  Proximal trachea with high-grade occlusion blocking approximately 90% of the trachea due to granulation tissue tumor and break down of metallic stent.,3.  Multiple stent fractures in the mid portion of the trachea with granulation tissue.,4.  High-grade obstruction of the right main bronchus by stent and granulation tissue.,5.  Left main bronchus was covered by the distal portion of the stent and was only being ventilated through the struts of the stent.,6.  All in all a high-grade terrible airway obstruction with involvement of the carina, left and right main stem bronchus, mid, distal, and proximal trachea.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient, he was brought into the operating field.  A rapid sequence induction was done.  He was intubated with a rigid scope.  Jet ventilation technique was carried out using a rigid and flexible scope.  A thorough airway inspection was carried out with findings as described above.,Dr. D was present in the operating room and we conferred on operative strategy and agreed that the best of strategy would be to first dilate the right main bronchus, cauterize it to control bleeding and then piecemeal removed the stent from distal to proximal.  This is the technique that was carried out in a painstaking fashion removing bits of the stent piecemeal with finally getting all of the visible stent out of the airway.  It should be noted that Dr. Donovan and I felt that two of the metallic stents were probably in place but we cannot be sure because of the terrible anatomy and the fact that the stent pieces were coming out twisted metal in fragments.  Nevertheless, all the visible stent was removed, and the airway was much better after with the dilation of balloon and the rigid scope.  We took measurements and decided to place stents in the trachea, left and right main bronchus using a Dumon Y-stent.  It was measured 18 mm in tracheal diameter and 14 mm in bronchial diameter.  The right main stem stent was 2.25 cm in length, the left main stem stent was 3 cm in length and the tracheal portion was 9 cm in length.  After it was placed, excellent placement was achieved with the proximal end of the stent 3 cm below the true vocal cords.  The patient tolerated the procedure well and was brought to the recovery room extubated.",3
"PREOPERATIVE DIAGNOSES:,1.  Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2.  Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3.  A 1 cm x 1 cm seborrheic keratosis of the mid neck.,4.  A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5.  A 1 cm x 1 cm actinic keratosis of the right mid cheek.,POSTOPERATIVE DIAGNOSES:,1.  Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2.  Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3.  A 1 cm x 1 cm seborrheic keratosis of the mid neck.,4.  A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5.  A 1 cm x 1 cm actinic keratosis of the right mid cheek.,TITLE OF PROCEDURES:,1.  Excision of the left upper cheek actinic neoplasm defect measuring 1.5 cm x 1.8 cm with two-layer plastic closure.,2.  Excision of the left lower cheek upper neck, 1 cm x 1.5 cm skin neoplasm with two-layer plastic closure.,3.  Shave excision of the mid neck seborrheic keratosis that measured 1 cm x 1.5 cm.,4.  Shave excision of the right superior pinna auricular rim, 1 cm x 1.5 cm verrucous keratotic neoplasm.,5.  A 50% trichloroacetic acid treatment of the right mid cheek, 1 cm x 1 cm actinic neoplasm.,ANESTHESIA: , Local.  I used a total of 6 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS:,  Less than 30 mL.,COMPLICATIONS: , None.,COUNTS:  ,Sponge and needle counts were all correct.,PROCEDURE:,  The patient was evaluated preop and noted to be in stable condition.  Chart and informed consent were all reviewed preop.  All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  She is aware of risks include but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures, etc.  The areas of concern were marked with the marking pen.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,I began excising the left upper cheek and left lower cheek neck lesions as listed above.  These were excised with the #15 blade.  The left upper cheek lesion measures 1 cm x 1.5 cm, defect after excision is 1.5 cm x 1.8 cm.  A suture was placed at the 12 o'clock superior margin.  Clinically, this appears to be either actinic keratosis or possible basal cell carcinoma.  The healthy margin of healthy tissue around this lesion was removed.  Wide underminings were performed and the lesion was closed in a two-layered fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,The left upper neck lesion was also removed in the similar manner.  This is dark and black, appears to be either an intradermal nevus or pigmented seborrheic keratosis.  It was excised using a #15 blade down the subcutaneous tissue with the defect 1 cm x 1.5 cm.  After wide underminings were performed, a two-layer plastic closure was performed with 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,The lesion of the mid neck and the auricular rim were then shave excised for the upper dermal layer with the Ellman radiofrequency wave unit.  These appeared to be clinically seborrheic keratotic neoplasms.,Finally proceeded with the right cheek lesion, which was treated with the 50% TCA.  This was also an actinic keratosis.  It is new in onset, just within the last week.  Once a light frosting was obtained from the treatment site, bacitracin ointment was applied.  Postop care instructions have been reviewed in detail.  The patient is scheduled a recheck in one week for suture removal.  We will make further recommendations at that time.",8
"PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammer toe, right foot, second, third, fourth and fifth toes.,3.  Tailor's bunionette, right foot.,4.  Degenerative joint disease, right first metatarsophalangeal joint.,5.  Rheumatoid arthritis.,6.  Contracted fourth right metatarsophalangeal joint.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammer toe, right foot, second, third, fourth and fifth toes.,3.  Tailor's bunionette, right foot.,4.  Degenerative joint disease, right first metatarsophalangeal joint.,5.  Rheumatoid arthritis.,6.  Contracted fourth right metatarsophalangeal joint.,PROCEDURES PERFORMED:,1.  Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint.,2.  Arthrodesis, right second, third, and fourth toes with external rod fixation.,3.  Hammertoe repair, right fifth toe.,4.  Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint.,5.  Modified Tailor's bunionectomy, right fifth metatarsal.,ANESTHESIA:,  TIVA/local.,HISTORY:,  This 51-year-old female presented to ABCD preoperative holding area after keeping herself NPO since mid night for surgery on her painful right foot bunion, hammer toes, and Tailor's bunion.  The patient has a long history of crippling severe rheumatoid arthritis.  She has pain with shoe gear and pain with every step.  She has tried multiple conservative measures under Dr. X's supervision consisting of wide shoe's and accommodative padding all which have provided inadequate relief.  At this time, she desires attempted surgical reconstruction/correction.  The consent is available on the chart for review and the risks versus benefits of this procedure have been discussed with patient in detail by Dr. X.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position and a safety strap was placed across her waist for her protection.  Next, copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied over the Webril.  Next, after adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine were instilled into the right foot using a standard ankle block technique.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 230 mmHg.  The foot was lowered in the operative field.  The sterile stockinette was reflected and attention was directed to the right first metatarsophalangeal joint.  The joint was found to be severely contracted with lateral deviation of the hallux with a slightly overlapping contracted second toe.  In addition, the range of motion was less than 5 degrees of the first ray.  There was medial pinch callus and callus on the plantar right second metatarsal.  Using a #10 blade, a linear incision over the first metatarsophalangeal joint was then created approximately 4 cm in length.  Next, a #15 blade was used to deepen the incision to the subcutaneous tissue all which was found to be very thin taking care to protect the medial neurovascular bundle and the lateral extensor hallucis longus tendon.  Any small vein traversing the operative site were clamped with hemostat and ligated with electrocautery.  Next, the medial and lateral wound margins were undermined with sharp dissection.  The joint capsule was then visualized.  Two apparent soft tissue masses probably consistent with rheumatoid nodules were found at the distal medial aspect of the first metatarsal capsule.  A dorsal linear incision to the capsular tissue down to bone was performed with a #15 blade.  The capsule and periosteal tissues were elevated sharply off the metatarsal head and the base of proximal  phalanx.,A large amount of hypertrophic synovium was encountered over the metatarsophalangeal joint.  In addition, multiple hypertrophic exostosis were found dorsally, medially, and laterally over the metatarsal.  Upon entering the joint, the base of the proximal phalanx was grossly deformed and the medial and lateral aspect were widely flared and encompassing the metatarsal head.  A sagittal saw was used to carefully remove the base of the proximal phalanx just distal to the metaphyseal flare.  Next, the bone was passed out as specimen.  The head of the metatarsal had evidence of erosion and eburnation.  The tibial sesamoid was practically absent, but was found to be a conglomeration of hypertrophic synovium and poorly differentiated appearing exostosis and bony tissue.  This was hindering the range of motion of the joint and was removed.  The fibular sesamoid was in the interspace.  A lateral release was performed in addition.  Next, the McGlamry elevators were inserted into the first metatarsal head and all of the plantar adhesions were freed.  The metatarsal head was remodeled with a sagittal saw and all of the medial eminence the dorsal and lateral hypertropic bone was removed and the metatarsal head was shaped into more acceptable contoured structure.  Next, the Biopro sizer was used and it was found that a median large implant would be the best fit for this patient's joint.  A small drill hole was made in the central aspect at the base of the proximal phalanx.  The trial sizer median large was placed in the joint and an excellent fit and increased range of motion was observed.,Next, the joint was flushed with copious amounts of saline.  A median large porous Biopro implant was inserted using the standard technique and was tapped with the mallet into position.  It had an excellent fit and the range of motion again was markedly increased from the preoperative level.  Next, the wound was again flushed with copious amounts of saline.  The flexor tendon was inspected and was found to be intact plantarly.  A #3-0 Vicryl was used to close the capsule in a running fashion.  A medial capsulorrhaphy performed and the toe assumed to more rectus position and the joint was more congruous.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  Next, the skin was closed with #5-0 Monocryl in a running subcuticular fashion.,Attention was directed to the right second toe, which was found to be markedly contracted and rigid in nature.  There was a clavus in the dorsal aspect of the head of the proximal phalanx noted.  A linear incision was made over the proximal phalanx approximately 2 cm in length.  The incision was deepened with #15 blade down to the subcutaneous tissue.  Next, the medial and lateral aspects of the wound were undermined with sharp dissection taking care to protect the neurovascular structures.,Next, after identifying the extensor expansion and long extensor tendon, a #15 blade was used to transect the tendon at the level of the joint.  The tendon was peeled off sharply, proximally, and distally.  The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound.  The bone was found to be extremely soft in the toe joints and the head of the proximal phalanx was oddly shaped and the cartilage was eroded.  The base of the middle phalanx, however, had a normal-appearing cartilage.  A sagittal saw was used to transect the head of the proximal phalanx just proximal to metaphyseal flare.  Next, the base of the middle phalanx was also resected.  A 0.045 inch Kirschner wire was retrograded out at the end of the toe and then back through the residual proximal phalanx shaft.  The toe assumed a straight and markedly increased straight position.  An extensor hood resection was performed to assist in keeping the proximal phalanx plantar flexed.  The joint was flushed with copious amounts of saline.  A #3-0 Vicryl was used to reapproximate the tendon after arthrodesis.  A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress suture technique.  The wire was cut, capped, and bent in the usual fashion.,Attention was directed to the right third toe where an exact same procedure as performed in the second digit was repeated.  The same suture material was used and the same 0.045 Kirschner wire was used for external wire fixation.,Attention was directed to the right fourth toe with exact same procedure was repeated.  The same suture material was used.  However, a 0.062 Kirschner wire was used to fixate the arthrodesis site as the bone was very soft and a 0.045 Kirschner wire was attempted but was found to be slipping in the soft bone and was inadequately holding the arthrodesis site tight.  Next, attention was directed to the fifth digit, which was found to be contracted as well.  A linear incision was made over the proximal phalanx with a #10 blade approximately 2 cm in length.  A #15 blade was used to deepen the incision to the subcutaneous tissue down to the level of the long extensor tendon, which was identified and transected.  The medial and lateral collateral ligaments were transected and the head of the proximal phalanx was delivered into the wound.  A sagittal saw was used to resect the head of the proximal phalanx just proximal to metaphyseal flare.  The toe assumed to more rectus position.  The reciprocating rasp was used to smooth the all bony surfaces.  The joint was again flushed with saline.  Next, the long extensor tendon was reapproximated with #3-0 Vicryl in a simple interrupted technique.  The skin was closed with #4-0 nylon in a simple interrupted technique.,Next, attention was directed to the fifth metatarsal head, which was found to have a lateral exostosis and bursa under the skin.  A #10 blade was used to make a 2.5 cm dorsal incision over the fifth metatarsal head.  The incision was deepened with a #15 blade to the subcutaneous tissue.  Any small vein traversing subcutaneous layer were ligated with electrocautery.  Care was taken to avoid abductor digiti minimi tendon and extensor digitorum longus tendon respectively.  Next, the dorsal linear capsular incision was made down to the bone with a #15 blade.  The capsular and periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound.  Hypertrophic bone was noted to be found dorsally and laterally as well as plantarly.  A sagittal saw was used to resect all hypertrophic bone.  A reciprocating rasp was used to smooth all bony surfaces.  Next, the wound was flushed with copious amounts of saline.  The capsular and periosteal tissues wee closed with #3-0 Vicryl in a simple interrupted technique.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  A bursa which was found consisting of a white glistening hypertrophic synovium was removed and sent as specimen as was also found in two of the second and third digit in the above procedures.  The skin was closed with #5-0 Monocryl in a running subcuticular fashion.  The ______ was reinforced with horizontal mattress sutures with #5-0 Monocryl.  Attention was directed to the fourth metatarsophalangeal joint where the joint was found to be contracted and the proximal phalanx was still found to be elevated.  Therefore, a #15 blade was used to make a stab incision over the joint lateral to the extensor digitorum longus tendon.  The tendon was transected.  Next, a blade was inserted in the dorsal, medial, and lateral aspects of the metatarsophalangeal joint and tenotomy was performed.  Next, the proximal phalanx residual bone was plantar flexed and found to assume a more rectus position.  One #4-0 nylon suture was placed in the skin.,Mastisol tape was applied to the first metatarsal and fifth metatarsal postoperative wounds.  Betadine-soaked Owen silk was applied to all wounds.  Betadine-soaked 4 x 4 splints were applied to all toes.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits.  All the wires have previously been bent and cut and all were capped.  A standard postoperative consisting of 4x4s, Kling, Kerlix, and Coban were applied.  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.  She was given prescription for Tylenol #3, #40 one to two p.o. q.4-6h. p.r.n. pain and Naprosyn 375 mg p.o. b.i.d. p.c.  She is to continue her rheumatoid arthritis drugs preoperatively prescribed by the rheumatologist.,She is to follow up with Dr. X in the office.  She was given emergency contact numbers and standard postoperative instructions.  She was given Darco OrthoWedge shoe and a pair of crutches.  She was discharged in stable condition.",37
"PREOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,POSTOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,PROCEDURE PERFORMED:  ,Debridement left ischial ulcer.,ANESTHESIA: ,Local MAC.,INDICATIONS:,  This is a 27-year-old white male patient, with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic.  The patient has a nonhealing decubitus ulcer in the left ischial region, which is quite deep.  It appears to be right down to the bone.  MRI shows findings suggestive of osteomyelitis.  The patient is being brought to operating room for debridement of this ulcer.  Procedure, indication, and risks were explained to the patient.  Consent obtained.,PROCEDURE IN DETAIL: ,The patient was put in right lateral position and left buttock and ischial region was prepped and draped.  Examination at this time showed fair amount of chronic granulation tissue and scarred tissue circumferentially as well as the base of this decubitus ulcer.  This was sharply excised until bleeding and healthy tissue was obtained circumferentially as well as the base.  The ulcer does not appear to be going into the bone itself as there was a covering on the bone, which appears to be quite healthy, normal and bone itself appeared solid.,I did not rongeur the bone.  The deeper portion of the excised tissue was also sent for tissue cultures.  Hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated Kerlix.  Sterile dressing was applied.  The patient transferred to recovery room in stable condition.",37
"DIAGNOSIS: , Multiparous female, desires permanent sterilization.,NAME OF OPERATION: , Laparoscopic bilateral tubal ligation with Falope rings.,ANESTHESIA: , General, ET tube.,COMPLICATIONS:,  None.,FINDINGS:  ,Normal female anatomy except for mild clitoromegaly and a posterior uterine fibroid.,PROCEDURE: , The patient was taken to the operating room and placed on the table in the supine position.  After adequate general anesthesia was obtained, she was placed in the lithotomy position and examined.  She was found to have an anteverted uterus and no adnexal mass.  She was prepped and draped in the usual fashion.  The Foley catheter was placed.  A Hulka cannula was inserted into the cervix and attached to the anterior lip of the cervix.,An infraumbilical incision was made with the knife.  A Veress needle was inserted into the abdomen.  Intraperitoneal location was verified with approximately 10 cc of sterile solution.  A pneumoperitoneum was created.  The Veress needle was then removed, and a trocar was inserted directly without difficulty.  Intraperitoneal location was verified visually with the laparoscope.  There was no evidence of any intra-abdominal trauma.,Each fallopian tube was elevated with a Falope ring applicator, and a Falope ring was placed on each tube with a 1-cm to 1.5-cm portion of the tube above the Falope ring.,The pneumoperitoneum was evacuated, and the trocar was removed under direct visualization.  An attempt was made to close the fascia with a figure-of-eight suture.  However, this was felt to be more subcutaneous.  The skin was closed in a subcuticular fashion, and the patient was taken to the recovery room awake with vital signs stable.",37
"INDICATION: , This 69-year-old man is undergoing a preoperative evaluation for anticipated prostate surgery.  He is having a transurethral prostate resection performed by Dr. X for treatment of severely symptomatic prostatic hypertrophy.  He has recently completed radiation therapy to T11 for a plasmacytoma.  He has recently complained of left anterior chest pain, which radiates down the left upper arm towards the elbow.  This occurs during quiet periods such as in bed at night.  It may last all night and still be present in the morning.  It usually dissipates as the day progresses.  There are no obvious triggers and there are no obvious alleviating factors.  The patient has no known cardiac risk factors.  He is currently taking Avodart 0.5 mg daily, Wellbutrin 300 mg daily, Xanax 0.25 mg p.r.n., Uroxatral 10 mg daily, and omeprazole 20 mg daily.,PHYSICAL EXAMINATION: , On physical examination, the patient appears pale and fatigued.  He is 66 inches tall, 205 pounds for a body mass index of 32.  His resting heart rate is 80.  His resting blood pressure is 120/84.  His lungs are clear.  His heart exam reveals a regular rhythm and normal S1 and S2 without murmur, gallop, or rub appreciated.  The carotid upstroke is normal with no bruit identified.  The peripheral pulses are intact.  The resting electrocardiogram showed a sinus rhythm at 68 beats per minute and is normal.,DESCRIPTION: , The patient exercised according to the standard Bruce protocol stopping at 4 minutes and 39 seconds with fatigue.  He did not experience his left anterior chest pain with exercise.  He did achieve a maximal heart rate of 129 beats per minute, which is 85% of his maximal predicted heart rate.  His maximal blood pressure was 200/84, double product of 24,000 and achieving 7 METs.  As noted the resting electrocardiogram was normal.  With exercise, there were no significant deviations from baseline and no arrhythmias.,CONCLUSION:,1.  Reduced exercise capacity for age.,2.  No chest pain with exercise.,3.  No significant ST segment changes with exercise.,4.  Symptoms of left anterior chest pain were not provoked with exercise.,5.  Hypertensive response noted with exercise.",3
"REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  The patient is unable to provide further history.  The patient's son is at the bedside and confirmed his history.  The patient was given IV antibiotics in the emergency room.  He was also given some hydration.,PAST MEDICAL HISTORY:,1.  History of CAD.,2.  History of dementia.,3.  History of CVA.,4.  History of nephrolithiasis.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Ambien.,2.  Milk of magnesia.,3.  Tylenol.,4.  Tramadol.,5.  Soma.,6.  Coumadin.,7.  Zoloft.,8.  Allopurinol.,9.  Digoxin.,10.  Namenda.,11.  Zocor.,12.  BuSpar.,13.  Detrol.,14.  Coreg.,15.  Colace.,16.  Calcium.,17.  Zantac.,18.  Lasix.,19.  Seroquel.,20.  Aldactone.,21.  Amoxicillin.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , The patient lives in a board and care.  No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness, otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is currently afebrile.  Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,GENERAL:  The patient is awake.  Not oriented x3, in no acute distress.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Mucous membranes are dry.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Irregularly irregular, brady.,LUNGS:  Clear to auscultation bilaterally anteriorly.,ABDOMEN:  Positive normoactive bowel sounds.  Soft.  Tenderness in the suprapubic region without rebound.,EXTREMITIES:  No clubbing, cyanosis or edema in upper and lower extremities.",16
"CHIEF COMPLAINT:,  Back pain and right leg pain.  The patient has a three-year history of small cell lung cancer with metastases.,HISTORY OF PRESENT ILLNESS:,  The patient is on my schedule today to explore treatment of the above complaints.  She has a two-year history of small cell lung cancer, which she says has spread to metastasis in both femurs, her lower lumbar spine, and her pelvis.  She states she has had numerous chemotherapy and radiation treatments and told me that she has lost count.  She says she has just finished a series of 10 radiation treatments for pain relief.  She states she continues to have significant pain symptoms.  Most of her pain seems to be in her low back on the right side, radiating down the back of her right leg to her knee.  She has also some numbness in the bottom of her left foot, and some sharp pain in the left foot at times.  She complains of some diffuse, mid back pain.  She describes the pain as sharp, dull, and aching in nature.  She rates her back pain as 10, her right leg pain as 10, with 0 being no pain and 10 being the worst possible pain.  She states that it seems to be worse while sitting in the car with prolonged sitting, standing, or walking.  She is on significant doses of narcotics.  She has had multiple CT scans looking for metastasis.,PAST MEDICAL HISTORY:,  Significant for cancer as above.  She also has a depression.,PAST SURGICAL HISTORY:,  Significant for a chest port placement.,CURRENT MEDICATIONS:,  Consist of Duragesic patch 250 mcg total, Celebrex 200 mg once daily, iron 240 mg twice daily, Paxil 20 mg daily, and Percocet.  She does not know of what strength up to eight daily.  She also is on warfarin 1 mg daily, which she states is just to keep her chest port patent.  She is on Neurontin 300 mg three times daily.,HABITS:,  She smokes one pack a day for last 30 years.  She drinks beer approximately twice daily.  She denies use of recreational drugs.,SOCIAL HISTORY:,  She is married.  She lives with her spouse.,FAMILY HISTORY: , Significant for two brothers and father who have cancer.,REVIEW OF SYSTEMS:,  Significant mainly for her pain complaints.  For other review of systems the patient seems stable.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant somewhat emaciated Caucasian female.,Vital Signs:  Height is 5 feet 2 inches.  Weight is 130 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Chest:  Clear to auscultation.,Heart:  Regular rate and rhythm.,Abdomen:  Soft, regular bowel sounds.,Musculoskeletal:  Examination shows functional range of joint movements.  No focal muscle weakness.  She is deconditioned.,Neurologic:  She is alert and oriented with appropriate mood and affect.  The patient has normal tone and coordination.  Reflexes are 2+ in both knees and absent at both ankles.  Sensations are decreased distally in the left foot, otherwise intact to pinprick.,Spine:  Examination of her lumbar spine shows normal lumbar lordosis with fairly functional range of movement.  The patient had significant tenderness at her lower lumbar facet and sacroiliac joints, which seems to reproduce a lot of her low back and right leg complaints.,FUNCTIONAL EXAMINATION: , Gait has a normal stance and swing phase with no antalgic component to it.,INVESTIGATION: , She has had again multiple scans including a whole body bone scan, which showed abnormal uptake involving the femurs bilaterally.  She has had increased uptake in the sacroiliac joint regions bilaterally.  CT of the chest showed no evidence of recurrent metastatic disease.  CT of the abdomen showed no evidence of metastatic disease.  MRI of the lower hip joints showed heterogenous bone marrow signal in both proximal femurs.  CT of the pelvis showed a trabecular pattern with healed metastases.  CT of the orbits showed small amount of fluid in the mastoid air cells on the right, otherwise normal CT scan.  MR of the brain showed no acute intracranial abnormalities and no significant interval changes.,IMPRESSION:,1.  Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs.,2.  Symptomatic facet and sacroiliac joint syndrome on the right.,3.  Chronic pain syndrome.,RECOMMENDATIONS:,  Dr. XYZ and I discussed with the patient her pathology.  Dr. XYZ explained her although she does have lung cancer metastasis, she seems to be symptomatic with primarily pain at her lower lumbar facet and sacroiliac joints on the right.  Secondary to the patient's significant pain complaints today, Dr. XYZ will plan on injecting her right sacroiliac and facet joints under fluoroscopy today.  I explained the rationale for the procedure, possible complications, and she voiced understanding and wished to proceed.  She understands that she is on warfarin therapy and that we generally do not perform injections while they are on this.  We have asked for stat protime today.  She is on a very small dose, she states she has had previous biopsies while on this before, and did not have any complications.  She is on significant dose of narcotics already, however, she continues to have pain symptoms.  Dr. XYZ advised that if she continues to have pain, even after this injection, she could put on an extra 50 mcg patch and take a couple of extra Percocet if needed.  I will plan on evaluating her in the Clinic on Tuesday.  I have also asked that she stop her Paxil, and we plan on starting her on Cymbalta instead.  She voiced understanding and is in agreement with this plan.  I have also asked her to get an x-ray of the lumbar spine for further evaluation.  Physical exam, findings, history of present illness, and recommendations were performed with and in agreement with Dr. G's findings.  Peripheral neuropathy of her left foot is most likely secondary to her chemo and radiation treatments.",27
"PROCEDURE PERFORMED,1.  Placement of a subclavian single-lumen tunneled Hickman central venous catheter.,2.  Surgeon-interpreted fluoroscopy.,OPERATION IN DETAIL:,  After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and anesthesia was administered.  Next, a #18-gauge needle was used to locate the subclavian vein.  After aspiration of venous blood, a J wire was inserted through the needle using Seldinger technique.  The needle was withdrawn.  The distal tip location of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next, a separate stab incision was made approximately 3 fingerbreadths below the wire exit site.  A subcutaneous tunnel was created, and the distal tip of the Hickman catheter was pulled through the tunnel to the level of the cuff.  The catheter was cut to the appropriate length.  A dilator and sheath were passed over the J wire.  The dilator and J wire were removed, and the distal tip of the Hickman catheter was threaded through the sheath, which was simultaneously withdrawn.  The catheter was flushed and aspirated without difficulty.  The distal tip was confirmed to be in good location with surgeon-interpreted fluoroscopy.  A 2-0 nylon was used to secure the cuff down to the catheter at the skin level.  The skin stab site was closed with a 4-0 Monocryl.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition.",37
"PROBLEM:  ,Prescription evaluation for Crohn's disease., ,HISTORY: , This is a 46-year-old male who is here for a refill of Imuran.  He is taking it at a dose of 100 mg per day.  He is status post resection of the terminal ileum and has experienced intermittent obstructive symptoms for the past several years.  In fact, he had an episode three weeks ago in which he was seen at the emergency room after experiencing sudden onset of abdominal pain and vomiting. An x-ray was performed, which showed no signs of obstruction per his report.  He thinks that the inciting factor of this incident was too many grapes eaten the day before.  He has had similar symptoms suggestive of obstruction when eating oranges or other high-residue fruits in the past.  The patient's normal bowel pattern is loose stools and this is unchanged recently.  He has not had any rectal bleeding. He asks today about a rope-like vein on his anterior right arm that has been a little tender and enlarged after he was in the emergency room and they had difficulty with IV insertion.  He has not had any fever, red streaking up the arm, or enlargement of lymph nodes.  The tenderness has now completely resolved.  , ,He had a colonoscopy performed in August of 2003, by Dr. S.  An anastomotic stricture was found at the terminal ileum/cecum junction.  Dr. S recommended that if the patient experienced crampy abdominal pain or other symptoms of obstruction, that he may consider balloon dilation.  No active Crohn's disease was found during the colonoscopy.  , ,Earlier this year, he experienced a non-specific hepatitis with elevation of his liver function tests.  At that time he was taking a lot of Tylenol for migraine-type headaches.  Under Dr. S's recommendation, he stopped the Imuran for one month and reduced his dose of Tylenol.  Since that time his liver enzymes have normalized and he has restarted the Imuran with no problems.  , ,He also reports heartburn that is occurring on a slightly more frequent basis than it has in the past.  It used to occur once a week only, but has now increased in frequency to twice a week.  He takes over-the-counter H2 blockers as needed, as well as Tums.  He associates the onset of his symptoms with eating spicy Mexican food., ,PAST MEDICAL HISTORY: , Reviewed and unchanged.,ALLERGIES: , No known allergies to medications.,OPERATIONS: , Unchanged.,ILLNESSES: , Crohn's disease, vitamin B12 deficiency.,MEDICATIONS:,  Imuran, Nascobal, Vicodin p.r.n., ,REVIEW OF SYSTEMS: , Dated 08/04/04 is reviewed and noted.  Please see pertinent GI issues as discussed above.  Otherwise unremarkable., ,PHYSICAL EXAMINATION:  , GENERAL:  Pleasant male in no acute distress.  Well nourished and well developed. SKIN: indurated, cord-like superficial vein on the right anterior forearm, approx. 3 cm in length.  Non-tender to palpation. No erythema or red streaking.  No edema. LYMPH:  No epitrochlear or axillary lymph node enlargement or tenderness on the right side. , ,DATA REVIEWED: Labs from June 8th and July 19th reviewed.  Liver function tests normal with AST 14 and ALT 44.  WBCs were slightly low at 4.8.  Hemoglobin dropped slightly from 14.1 on 6/8 to 12.9 on 7/19. Hematocrit dropped slightly as well from 43.2 on 6/804 to 40.0 on 7/19/04.  These results were reviewed by Dr. S and lab results letter sent., ,IMPRESSION:  ,1. Crohn's disease, status post terminal ileum resection, on Imuran.  Intermittent symptoms of bowel obstruction.  Last episode three weeks ago.,2.  History of non-specific hepatitis while taking high doses of Tylenol.  Now resolved. ,2.  Increased frequency of reflux symptoms.,3.  Superficial thrombophlebitis, resolving. ,4.  Slightly low H&H., ,PLAN:  ,1.  We discussed Dr. S's recommendation that the patient undergo balloon dilation for recurrent bowel obstruction type symptoms.  The patient emphatically states that he does not want to consider dilation at this time.  The patient is strongly encouraged to call us when he does experience any obstructive symptoms, including abdominal pain, nausea, vomiting, or change in bowel habits.  He states understanding of this. Advised to maintain low residue diet to avoid obstructions. ,2.  Continue with liver panel and ABC every month per Dr. S's instructions.,3.  Continue Imuran 100 mg per day.,4.  Continue to minimize Tylenol use.  The patient is wondering if he can take another type of medication for migraines that is not Tylenol or antiinflammatories or aspirin.  Dr. S is consulted and agrees that Imitrex is an acceptable alternative for migraine headaches since he does not have advanced liver disease. The patient will make an appointment with his primary care provider to discuss this further. ,5.  Reviewed the importance of prophylactic treatment of reflux-type symptoms.  Encouraged the patient to take over-the-counter H2 blockers on a daily basis to prevent symptoms from occurring.  The patient will try this and if he remains symptomatic, then he will call our office and a prescription for Zantac 150 mg per day will be provided.  Reviewed the potential need for upper endoscopy should his symptoms continue or become more frequent.  He does not want to undergo any type of procedure such as that at this time.,6.",5
"TITLE OF OPERATION: , Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.,INDICATIONS FOR SURGERY:  ,Please refer to medical record, but in short, the patient is a 43-year-old male known to me, status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.  Risks and benefits of surgery were explained in detail including risk of bleeding, infection, stroke, heart attack, paralysis, need for further surgery, hardware failure, persistent symptoms, and death.  This list was inclusive, but not exclusive.  An informed consent was obtained after all patient's questions were answered.,PREOPERATIVE DIAGNOSIS:  ,Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,POSTOPERATIVE DIAGNOSIS: , Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,ANESTHESIA: , General anesthesia and endotracheal tube intubation.,DISPOSITION: , The patient to PACU with stable vital signs.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room.  After adequate general anesthesia with endotracheal tube intubation was obtained, the patient was placed prone on the Jackson table.  Lumbar spine was shaved, prepped, and draped in the usual sterile fashion.  An incision was carried out from L4 to S1.  Hemostasis was obtained with bipolar and Bovie cauterization.  A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4, L5, and sacrum.  At this time, laminectomy was carried out of L5-S1.  Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space.  At this time, the disk was entered with a #15 blade and bipolar.  The disk was entered with straight up and down-biting pituitaries, curettes, and the high speed drill and we were able to takedown calcified herniated disk.  We were able to reestablish the disk space, it was very difficult, required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal, very carefully holding the spinal canal out of harm's way as well as the exiting nerve root.  Once this was done, we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic.  At this time, Dr. X will dictate the posterolateral fusion, pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound.  There were no complications.",23
"CLINICAL HISTORY: , Patient is a 37-year-old female with a history of colectomy for adenoma.  During her preop evaluation it was noted that she had a lesion on her chest x-ray.  CT scan of the chest confirmed a left lower mass.,SPECIMEN: , Lung, left lower lobe resection.,IMMUNOHISTOCHEMICAL STUDIES:,  Tumor cells show no reactivity with cytokeratin AE1/AE3.  No significant reactivity with CAM5.2 and no reactivity with cytokeratin-20 are seen.  Tumor cells show partial reactivity with cytokeratin-7.  PAS with diastase demonstrates no convincing intracytoplasmic mucin.  No neuroendocrine differentiation is demonstrated with synaptophysin and chromogranin stains.  Tumor cells show cytoplasmic and nuclear reactivity with S100 antibody.  No significant reactivity is demonstrated with melanoma marker HMB-45 or Melan-A.  Tumor cell nuclei (spindle cell and pleomorphic/giant cell carcinoma components) show nuclear reactivity with thyroid transcription factor marker (TTF-1).  The immunohistochemical studies are consistent with primary lung sarcomatoid carcinoma with pleomorphic/giant cell carcinoma and spindle cell carcinoma components.,FINAL DIAGNOSIS:,Histologic Tumor Type:  Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.,Tumor Size:  2.7 x 2.0 x 1.4 cm.,Visceral Pleura Involvement:  The tumor closely approaches the pleural surface but does not invade the pleura.,Vascular Invasion:  Present.,Margins:  Bronchial resection margins and vascular margins are free of tumor.,Lymph Nodes:  Metastatic sarcomatoid carcinoma into one of four hilar lymph nodes.,Pathologic Stage:  pT1N1MX.",3
"EXAM:,MRI OF THE LEFT KNEE WITHOUT CONTRAST,CLINICAL:,Left knee pain. Twisting injury.,FINDINGS:,The images reveal a sizable joint effusion. The joint effusion appears to be complex with mixed signal intensity material within. The patella is slightly laterally tilted towards the left. The mid portion of the patella cartilage shows some increased signal and focal injury to the patellar cartilage is suspected. Mildly increased bone signal overlying the inferolateral portion of the patella is identified. No significant degenerative changes about the patella can be seen. The quadriceps tendon as well as the infrapatellar ligament both look intact. There is some prepatellar soft tissue edema.,The bone signal shows a couple of small areas of cystic change in the proximal aspect of the tibia. NO significant areas of bone edema are appreciated.,There is soft tissue edema along the lateral aspect of the knee. There is a partial tear of the lateral collateral ligament complex. The medial collateral ligament complex looks intact. A small amount of edema is identified immediately adjacent to the medial collateral ligament complex.,The posterior cruciate ligament looks intact. The anterior cruciate ligament is thickened with significant increased signal. I suspect at least a high grade partial tear.,The posterior horn of the medial meniscus shows some myxoid degenerative changes. The posterior horn and anterior horn of the lateral meniscus likewise shows myxoid degenerative type changes. I don’t see a definite tear extending to the articular surface.,IMPRESSION:,Sizeable joint effusion which is complex and may contain blood products.,Myxoid degenerative type changes medial and lateral meniscus with no definite evidence of a tear.,Soft tissue swelling and partial tear of the lateral collateral ligament complex.,At least high grade partial tear of the anterior cruciate ligament with significant thickening and increased signal of this structure.,The posterior cruciate ligament is intact.,Injury to the patellar cartilage as above.",33
"OPERATIVE NOTE:,  The patient was taken to the operating room and placed in the supine position on the operating room table.  The patient was prepped and draped in usual sterile fashion.  An incision was made in the groin crease overlying the internal ring.  This incision was about 1.5 cm in length.  The incision was carried down through the Scarpa's layer to the level of the external oblique.  This was opened along the direction of its fibers and carried down along the external spermatic fascia.  The cremasteric fascia was then incised and the internal spermatic fascia was grasped and pulled free.  A hernia sac was identified and the testicle was located.  Next the internal spermatic fascia was incised and the hernia sac was dissected free inside the internal ring.  This was performed by incising the transversalis fascia circumferentially.  The hernia sac was ligated with a 3-0 silk suture high and divided and was noted to retract into the abdominal cavity.  Care was taken not to injure the testicular vessels.  Next the abnormal attachments of the testicle were dissected free distally with care not to injure any long loop vas and these were divided beneath the testicle for a fair distance.  The lateral attachments tethering the cord vessels were freed from the sidewalls in the retroperitoneum high.  This gave excellent length and very adequate length to bring the testicle down into the anterior superior hemiscrotum.  The testicle was viable.  This was wrapped in a moist sponge.,Next a hemostat was passed down through the inguinal canal down into the scrotum.  A small 1 cm incision was made in the anterior superior scrotal wall.  Dissection was carried down through the dartos layer.  A subdartos pouch was formed with blunt dissection.  The hemostat was then pushed against the tissues and this tissue was divided.  The hemostat was then passed through the incision.  A Crile hemostat was passed back up into the inguinal canal.  The distal attachments of the sac were grasped and pulled down without twisting these structures through the incision.  The neck was then closed with a 4-0 Vicryl suture that was not too tight, but tight enough to prevent retraction of the testicle.  The testicle was then tucked down in its proper orientation into the subdartos pouch and the subcuticular tissue was closed with a running 4-0 chromic and the skin was closed with a running 6-0 subcuticular chromic suture.  Benzoin and a Steri-Strip were placed.  Next the transversus abdominis arch was reapproximated to the iliopubic tract over the top of the cord vessels to tighten up the ring slightly.  This was done with 2 to 3 interrupted 3-0 silk sutures.  The external oblique was then closed with interrupted 3-0 silk suture.  The Scarpa's layer was closed with a running 4-0 chromic and the skin was then closed with a running 4-0 Vicryl intracuticular stitch.  Benzoin and Steri-Strip were applied.  The testicle was in good position in the dependent portion of the hemiscrotum and the patient had a caudal block, was awakened, and was returned to the recovery room in stable condition.",38
"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.",3
"CONFORMAL SIMULATION WITH COPLANAR BEAMS,This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated.  It allows us to highly focus the beam of radiation and shape the beam to the target volume, delivering a homogenous dosage through it while sparing the surrounding, more radiosensitive, normal tissues.  This will allow us to give the optimum chance of tumor control while minimizing the acute and long-term side effects.,A conformal simulation is a simulation which involves extended physician, therapist, and dosimetrist time and effort.  The patient is initially taken into a conventional simulator room, where appropriate markers are placed, and the patient is positioned and immobilized.  One then approximates the field sizes and arrangements (gantry angles, collimator angles, and number of fields).  Radiographs are taken, and these fields are marked on the patient's skin.  The patient is then transferred to the diagnostic facility and placed on a flat CT scan table.  Scans are then performed through the targeted area.  The CT scans are evaluated by the radiation oncologist, and the tumor volume, target volume, and critical structures are outlined on each slice of the CT scan.  The dosimetrist then evaluates each individual slice in the treatment planning computer with the appropriately marked structures.  This volume is then reconstructed in 3-dimensional space.  Utilizing the beam's-eye view features, the appropriate blocks are designed.  Multiplane computerized dosimetry is performed throughout the volume.  Field arrangements and blocking are modified as necessary to provide homogenous coverage of the target volume while minimizing the dose to normal structures.  Once all appropriate beam parameters and isodate distributions have been confirmed on the computer scan, each individual slice is then reviewed by the physician.  The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician.  Once these are approved, Cerrobend blocks will be custom fabricated.,If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where the computer-designed fields are re-simulated.",33
"PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,The child was placed in a Circumstraint board and restrained in the usual fashion.  The area of the penis and scrotum were prepared with povidone iodine solution.  The area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure.  A dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine.  A dorsal slit was made, and the prepuce was dissected away from the glans penis.  A ** Gomco clamp was properly placed for 5 minutes.  During this time, the foreskin was sharply excised using a #10 blade.  With removal of the clamp, there was a good cosmetic outcome and no bleeding.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.",38
"PREOPERATIVE DIAGNOSIS:,  Bilateral axillary masses, rule out recurrent Hodgkin's disease.,POSTOPERATIVE DIAGNOSIS:  ,Bilateral axillary masses, rule out recurrent Hodgkin's disease.,PROCEDURE PERFORMED:,1.  Left axillary dissection with incision and drainage of left axillary mass.,2.  Right axillary mass excision and incision and drainage.,ANESTHESIA: , LMA.,SPECIMENS:,  Left axillary mass with nodes and right axillary mass.,ESTIMATED BLOOD LOSS:  ,Less than 30 cc.,INDICATION: , This 56-year-old male presents to surgical office with history of bilateral axillary masses.  Upon evaluation, it was noted that the patient has draining bilateral masses with the left mass being approximately 8 cm in diameter upon palpation and the right being approximately 4 cm in diameter.  The patient had been continued on antibiotics preoperatively.  The patient with history of Hodgkin's lymphoma approximately 18 years ago and underwent therapy at that time and he was declared free of disease since that time.  Consent for possible recurrence of Hodgkin's lymphoma warranted exploration and excision of these masses.  The patient was explained the risks and benefits of the procedure and informed consent was obtained.,GROSS FINDINGS: , Upon dissection of the left axillary mass, the mass was removed in toto and noted to have a cavity within it consistent with an abscess.,No loose structures were identified and sent for frozen section, which upon intraoperative consultation with Pathology Department revealed no obvious evidence of lymphoma, however, the confirmed pathology report is pending at this time.  The right axillary mass was excised without difficulty without requiring full axillary dissection.,PROCEDURE: , The patient was placed in supine position after appropriate anesthesia was obtained and a sterile prep and drape complete.  A #10 blade scalpel was used to make an elliptical incision about the mass itself extending this incision further to aid in the mobilization of the mass.  Sharp dissection was utilized with Metzenbaum scissors about the mass to maintain the injury to the skin structure and upon showing out the mass, Bovie electrocautery was utilized adjacent to the wall structure to maintain hemostasis.  Identification of the axillary anatomy was made and care was made to avoid injury to nerve, vessel or musculature.  Once this mass was removed in toto, lymph node structures were as well delivered with this mass and sent to frozen section as well the specimen was sent to gram stain and culture.  Upon revaluation of the incisional site, it was noted to be hemostatic.  Warm lap sponge was then left in place at this site.  Next, attention was turned to the right axilla where a #10 blade scalpel was used to make a 4 cm incision about the mass including the cutaneous structures involved with the erythematous reaction.  This was as well removed in toto and sent to Pathology for gram stain and culture as well as pathologic evaluation.  This site was then made hemostatic as well with the aid of Bovie electrocautery and approximation of the deep dermal tissues after irrigation with warm saline was then done with #3-0 Vicryl suture followed by #4-0 Vicryl running subcuticular stitch.  Steri-Strips were applied.  Attention was returned back left axilla, which upon re-exploration was noted to be hemostatic and a #7 mm JP was then introduced making a skin stab inferior to the incision and bringing the end of the drain through this incision.  This was placed within the incision site, ________ drainage of the axillary potential space.  Approximation of the deep dermal tissues were then done with #3-0 Vicryl in an interrupted technique followed by #4-0 Vicryl with running subcuticular technique.  Steri-Strips and sterile dressings were applied.  JP bulb was then placed to suction and sterile dressings were applied to both axilla.  The patient tolerated the procedure well and sent to postanesthesia care unit in a stable condition.  He will be discharged to home upon ability of the patient to have pain tolerance with Vicodin 1-2 as needed every six hours for pain and continue on Keflex antibiotics until gram stain culture proves otherwise.",37
"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.",37
"ADMISSION DIAGNOSES:,1.  Pneumonia, failed outpatient treatment.,2.  Hypoxia.,3.  Rheumatoid arthritis.,DISCHARGE DIAGNOSES:,1.  Atypical pneumonia, suspected viral.,2.  Hypoxia.,3.  Rheumatoid arthritis.,4.  Suspected mild stress-induced adrenal insufficiency.,HOSPITAL COURSE: , This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.  She was seen on multiple occasions at Urgent Care and in her physician's office.  Initial x-ray showed some mild diffuse patchy infiltrates.  She was first started on Avelox, but had a reaction, switched to Augmentin, which caused loose stools, and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin.  Her O2 saturations drifted downward.  They were less than 88% when active; at rest, varied between 88% and 92%.  Decision was made because of failed outpatient treatment of pneumonia.  Her medical history is significant for rheumatoid arthritis.  She is on 20 mg of methotrexate every week as well as Remicade every eight weeks.  Her last dose of Remicade was in the month of June.  Hospital course was relatively unremarkable.  CT scan was performed and no specific focal pathology was seen.  Dr. X, pulmonologist was consulted.  He also was uncertain as to the exact etiology, but viral etiology was most highly suspected.  Because of her loose stools, C. difficile toxin was ordered, although that is pending at the time of discharge.  She was continued on Rocephin IV and azithromycin.  Her fever broke 18 hours prior to discharge, and O2 saturations improved, as did her overall strength and clinical status.  She was instructed to finish azithromycin.  She has two pills left at home.  She is to follow up with Dr. X in two to three days.  Because she is on chronic prednisone therapy, it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia.  She is to continue the increased dose of prednisone at 20 mg (up from 5 mg per day).  We will consult her rheumatologist as to whether to continue her methotrexate, which we held this past Friday.  Methotrexate is known on some occasions to cause pneumonitis.",3
"PREOPERATIVE DIAGNOSIS:,  Herniated lumbar disk with intractable back pain.,POSTOPERATIVE DIAGNOSIS: , Herniated lumbar disk with intractable back pain.,OPERATION PERFORMED: , L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.,ANESTHESIA: , Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY:  ,The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion.  The patient was given sedation and monitored.  Local anesthetic was used to insufflate the skin over sacral hiatus.  A 16-gauge RK needle was placed at the sacral hiatus into the caudal canal with no CSF or blood.  A Racz tunnel catheter was then placed to the needle and guided up to the L3-L4 level.  After negative aspiration 4 cc of 0.5% Marcaine and 80 mg of Depo-Medrol were injected.  The catheter was then repositioned at the L4-L5 level where after negative aspiration same local anesthetic steroid mixture was injected.  Needle and catheter were removed intact.  The patient was discharged in stable condition.",28
"PREOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.,POSTOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion, and potentially unstable cervical spine.,OPERATIVE PROCEDURE:  ,Application of PMT large halo crown and vest.,ESTIMATED BLOOD LOSS: , None.,ANESTHESIA:  ,Local, conscious sedation with Morphine and Versed.,COMPLICATIONS: , None.  Post-fixation x-rays, nonalignment, no new changes.  Post-fixation neurologic examination normal.,CLINICAL HISTORY:  ,The patient is a 41-year-old female who presented to me with severe cervical spondylosis and myelopathy.  She was referred to me by Dr. X.  The patient underwent a complicated anterior cervical discectomy, 2-level corpectomy, spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate.  Surgery had gone well, and the patient has done well in the last 2 days.  She is neurologically improved and is moving all four extremities.  No airway issues.  It was felt that the patient was now a candidate for a halo vest placement given that chance of going to the OR were much smaller.  She was consented for the procedure, and I sought the help of ABC and felt that a PMT halo would be preferable to a Bremer halo vest.  The patient had this procedure done at the bedside, in the SICU room #1.  I used a combination of some morphine 1 mg and Versed 2 mg for this procedure.  I also used local anesthetic, with 1% Xylocaine and epinephrine a total of 15 to 20 cc.,PROCEDURE DETAILS:,  The patient's head was positioned on some towels, the retroauricular region was shaved, and the forehead and the posterolateral periauricular regions were prepped with Betadine.  A large PMT crown was brought in and fixed to the skull with pins under local anesthetic.  Excellent fixation achieved.  It was lateral to the supraorbital nerves and 1 fingerbreadth above the brows and the ear pinnae.,I then put the vest on, by sitting the patient up, stabilizing her neck.  The vest was brought in from the front as well and connected.  Head was tilted appropriately, slightly extended, and in the midline.  All connections were secured and pins were torqued and tightened.,During the procedure, the patient did fine with no significant pain.,Post-procedure, she is neurologically intact and she remained intact throughout.  X-rays of the cervical spine AP, lateral, and swimmer views showed excellent alignment of the hardware construct in the graft with no new changes.,The patient will be subjected to a CT scan to further define the alignment, and barring any problems, she will be ambulating with the halo on.,The patient will undergo pin site care as per protocol, and likely she will go in the next 2 to 3 days.  Her prognosis indeed is excellent, and she is already about 90% or so better from her surgery.  She is also on a short course of Decadron, which we will wean off in due course.,The matter was discussed with the patient and the patient's family.",27
"GENERAL: , Alert, well developed, in no acute distress.,MENTAL STATUS: , Judgment and insight appropriate for age.  Oriented to time, place and person.  No recent loss of memory.  Affect appropriate for age.,EYES:  ,Pupils are equal and reactive to light.  No hemorrhages or exudates.  Extraocular muscles intact.,EAR, NOSE AND THROAT: , Oropharynx clean, mucous membranes moist.  Ears and nose without masses, lesions or deformities.  Tympanic membranes clear bilaterally.  Trachea midline.  No lymph node swelling or tenderness.,RESPIRATORY:  ,Clear to auscultation and percussion.  No wheezing, rales or rhonchi.,CARDIOVASCULAR: , Heart sounds normal.  No thrills.  Regular rate and rhythm, no murmurs, rubs or gallops.,GASTROINTESTINAL: , Abdomen soft, nondistended.  No pulsatile mass, no flank tenderness or suprapubic tenderness.  No hepatosplenomegaly.,NEUROLOGIC: , Cranial nerves II-XII grossly intact.  No focal neurological deficits.  Deep tendon reflexes +2 bilaterally.  Babinski negative.  Moves all extremities spontaneously.  Sensation intact bilaterally.,SKIN: , No rashes or lesions.  No petechia.  No purpura.  Good turgor.  No edema.,MUSCULOSKELETAL: , No cyanosis or clubbing.  No gross deformities.  Capable of free range of motion without pain or crepitation.  No laxity, instability or dislocation.,BONE: , No misalignment, asymmetry, defect, tenderness or effusion.  Capable of from of joint above and below bone.,MUSCLE:  ,No crepitation, defect, tenderness, masses or swellings.  No loss of muscle tone or strength.,LYMPHATIC:,  Palpation of neck reveals no swelling or tenderness of neck nodes.  Palpation of groin reveals no swelling or tenderness of groin nodes.",5
"PREOPERATIVE DIAGNOSIS:,  Squamous cell carcinoma of right temporal bone/middle ear space.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of right temporal bone/middle ear space.,PROCEDURE: , Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the operating room, placed on the table in supine position.  General endotracheal anesthesia was obtained in the usual fashion.  The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen.  The neck was prepped as well.  After this was performed, I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl.  A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle.  After this was performed, I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible.  The condyle was skeletonized so that it could be easily seen.  The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared.  The neck contents to the hyoid were dissected out.  The hypoglossal nerve, vagus nerve, and spinal accessory nerve were dissected towards the jugular foramen.  The neck contents were removed as a separate specimen.  The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis.  A large posterior facial vein was identified and likewise clipped for later use.  I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus, dissecting or exposing the dura to the level of the jugular bulb.  It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router, I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube.  The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made.  I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion.  Once this was dissected out, Dr. X entered the procedure for completion of the resection with the craniotomy.  For details, please see his operative note.,After Dr. X had completed the resection, I then harvested the rectus free flap.  A skin paddle was drawn out next to the umbilicus about 4 x 4 cm.  The skin paddle was incised with the Bovie and down to the anterior rectus sheath.  Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle.  The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin.  The skin paddle was then sutured to the fascia and muscle with interrupted 3-0 Vicryl.  The anterior rectus sheath was then reflected off the rectus muscle, which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction.  The vascular pedicle could be seen entering the muscle in usual fashion.  The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel.  The wound was then packed with saline impregnated sponges.  The rectus muscle with attached skin paddle was then transferred into the neck.  The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9-0 Ethilon with standard microvascular technique.  Ischemia time was less than 10 minutes.  Likewise, the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9-0 Ethilon as well.  There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case.  The wound was irrigated with copious amounts of saline.  The eustachian tube was obstructed with bone wax.  The muscle was then laid into position with the skin paddle underneath the conchal bowl.  I removed most the skin of the conchal bowl de-epithelializing and leaving the fat in place.  The wound was closed in layers overlying the muscle, which was secured superiorly to the muscle overlying the temporal skull.  The subcutaneous tissues were closed with interrupted 3-0 Vicryl.  The skin was closed with skin staples.  There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself.  The skin paddle was closed with interrupted 4-0 Prolene to the edges of the conchal bowl.,The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with #1 Prolene with the more running suture, taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors.  The subcutaneous tissues were closed with interrupted 2-0 Vicryl and skin was closed with skin staples.  The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened.  The patient was then transferred to the PACU in stable condition with spontaneous respirations, having tolerated the procedure well.",22
"TITLE OF OPERATION:,1.  Irrigation and debridement of postoperative wound infection (CPT code 10180).,2.  Removal of foreign body, deep (CPT code 28192).,3.  Placement of vacuum-assisted closure device, less than 50 centimeter squared (CPT code 97605).,PREOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,POSTOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,PROCEDURE DETAIL:  ,The patient is a 59-year-old gentleman who is status post open reduction and internal fixation of bilateral calcanei.  He was admitted for a left wound breakdown with drainage.  He underwent an irrigation and debridement with VAC placement 72 hours prior to this operative visit.  It was decided to bring him back for a repeat irrigation and debridement and VAC change prior to Plastics doing a local flap.  The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves and vital structures, need for reoperation, pain or stiffness, arthritis, fracture, the risk of anesthesia.  The patient understood these risks and wished to proceed.  The patient was admitted, and the operative site was marked.,The patient was brought to the operating room and given general anesthetic.  He was placed in the right lateral decubitus, and all bony prominences were well padded.  An axillary roll was placed.  A well-padded thigh tourniquet was placed on the left leg.  The patient then received antibiotics on the floor prior to coming down to the operating room which satisfied the preoperative requirement.  Left leg was then prepped and draped in usual sterile fashion.  The previous five antibiotic spacer beads were removed without difficulty.  The wound was then rongeured and curetted, and all bone was cleaned down to healthy bleeding bone.  The wound actually looked quite good with evidence of purulence or drainage.  Skin edges appeared to be viable.  Hardware all looked to be intact.  At this point, the wound was irrigated with 9 liters of bibiotic solution.  A VAC sponge was then placed over the wound, and the patient's leg was placed into a posterior splint.  The patient was awakened and then taken to recovery in good condition.,Dr. X was present for the timeouts and for all critical portions of the procedure.  He was immediately available for any questions during the case.,PLAN:,1.  A CAM walker boots.,2.  A VAC change on Sunday by the nurse.,3.  A flap per Plastic Surgery.",27
"REASON FOR VISIT: , This is a new patient evaluation for Mr. A. There is a malignant meningioma.  He is referred by Dr. X.,HISTORY OF PRESENT ILLNESS: , He said he has had two surgeries in 07/06 followed by radiation and then again in 08/07.  He then had a problem with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently.  He is unable to stand at the moment.  He is unable to care for himself. ,I reviewed the information that was sent down with him from the nursing home which includes his medical history.,MEDICATIONS:  ,Keppra 1500 twice a day and Decadron 6 mg four times a day.  His other medicines include oxycodone, an aspirin a day, Prilosec, Dilantin 300 a day, and Flagyl.,FINDINGS:,  On examination, he is lying on the stretcher.  He has oxygen on and has periods of spontaneous hyperventilation.  He is unable to lift his right arm or right leg.  He has an expressive dysphasia and confusion.,I reviewed the imaging studies from summer from the beginning of 10/07, end of 10/07 as well as the current MRI he had last week.  This shows that he has had progression of disease with recurrence along the surface of the brain and there is significant brain edema.  This is a malignant meningioma by diagnosis.,ASSESSMENT/PLAN: , In summary, Mr. A has significant disability and is not independent currently.  I believe that because of this that the likelihood of benefit from surgery is small and there is a very good chance that he would not be able to recover from surgery.  I do not think that surgery will help his quality of life and a need to control the tumor would be dependent on another therapy impacting the tumor.  Given that there are not good therapies and chemotherapy would be the option at the moment, and he certainly is not in a condition where chemotherapy would be given, I believe that surgery would not be in his best interest.  I discussed this both with him, although it is not clear to me how much he understood, as well as his family.",22
"PREOPERATIVE DIAGNOSIS: , Complex right lower quadrant mass with possible ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1.  Right ruptured tubal pregnancy.,2.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Laparoscopy with removal of tubal pregnancy and right partial salpingectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS:  ,Less than 100 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 25-year-old African-American female, gravida 7, para-1-0-5-1 with two prior spontaneous abortions with three terminations who presents with pelvic pain.  She does have a slowly increasing beta HCG starting at 500 to 849 and the max to 900.  Ultrasound showed a complex right lower quadrant mass with free fluid in the pelvis.  It was decided to perform a laparoscopy for the possibility of an ectopic pregnancy.,FINDINGS: , On bimanual exam, the uterus was approximately 10 weeks' in size, mobile, and anteverted.  There were no adnexal masses appreciated although there was some fullness in the right lower quadrant.  The cervical os appeared parous.,Laparoscopic findings revealed a right ectopic pregnancy, which was just distal to the right fallopian tube and attached to the fimbria as well as adherent to the right ovary.  There were some pelvic adhesions in the right abdominal wall as well.  The left fallopian tube and ovary and uterus appeared normal.  There was no evidence of endometriosis.  There was a small amount of blood in the posterior cul-de-sac.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped, placed under general anesthesia, and placed in the dorsal lithotomy position.  The bimanual exam was performed, which revealed the above findings.  A weighted speculum was placed in the patient's posterior vaginal vault and the 12 o' clock position of the cervix was grasped with the vulsellum tenaculum.  The cervix was then serially dilated using Hank dilators up to a #10.  A sharp curette was then introduced and curettage was performed obtaining a mild amount of tissue.  The tissue was sent to pathology for evaluation.  The uterine elevator was then placed in the patient's cervix.  Gloves were changed.  The attention was turned to the anterior abdominal wall where a 1 cm infraumbilical skin incision was made.  While tenting up the abdominal wall, the Veress needle was placed without difficulty.  The abdomen was then insufflated with appropriate volume and flow of CO2.  The #11 step trocar was then placed without difficulty in abdominal wall.  The placement was confirmed with a laparoscope.  It was then decided to put a #5 step trocar approximately 2 cm above the pubis symphysis in order to manipulate the pelvic contents.  The above findings were then noted.  Because the tubal pregnancy was adherent to the ovary, an additional port was placed in the right lateral aspect of the patient's abdomen.  A #12 step trocar port was placed under direct visualization.  Using a grasper, Nezhat-Dorsey suction irrigator, the mass was hydro-dissected off of the right ovary and further shelled away with graspers.  This was removed with the gallbladder grasper through the right lateral port site.  There was a small amount of oozing at the distal portion of the fimbria where the mass has been attached.  Partial salpingectomy was therefore performed.  This was done using the LigaSure.  The LigaSure was clamped across the portion of the tube including distal tube and ligated and transected.  Good hemostasis was obtained in all of the right adnexal structures.  The pelvis was then copiously suction irrigated.  The area again was then visualized and again found to be hemostatic.  The instruments were then removed from the patient's abdomen under direct visualization.  The abdomen was then desufflated and the #11 step trocar was removed.  The incisions were then repaired with #4-0 undyed Vicryl and dressed with Steri-Strips.  The uterine elevator was removed from the patient's vagina.,The patient tolerated the procedure well.  The sponge, lap, and needle count were correct x2.  She will follow up postoperatively as an outpatient.",37
"PREOPERATIVE DIAGNOSES:,1.  Dysphagia.,2.  Right parapharyngeal hemorrhagic lesion.,POSTOPERATIVE DIAGNOSES:,1.  Dysphagia with no signs of piriform sinus pooling or aspiration.,2.  No parapharyngeal hemorrhagic lesion noted.,3.  Right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.,PROCEDURE PERFORMED: ,Fiberoptic nasolaryngoscopy.,ANESTHESIA: , None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 93-year-old Caucasian male who was admitted to ABCD General Hospital on 08/07/2003 secondary to ischemic ulcer on the right foot.  ENT was asked to see the patient regarding postop dysphagia with findings at that time of the consultation on 08/17/03 with a fiberoptic nasolaryngoscopy, a right parapharyngeal hemorrhagic lesion possibly secondary to LMA intubation.  The patient subsequently resolved with his dysphagia and workup of Speech was obtained, which showed no aspiration, no pooling, minimal premature spillage with solids, but good protection of the airway.  This is a reevaluation of the right parapharyngeal hemorrhagic lesion that was noted prior.,PROCEDURE DETAILS: ,The patient was brought in the semi-Fowler's position, a fiberoptic nasal laryngoscope was then passed into the patient's right nasal passage, all the way to the nasopharynx.  The scope was then flexed caudally and advanced slowly through the nasopharynx into the oropharynx, and down to the hypopharynx.  The patient's oro and nasopharynx all appeared normal with no signs of any gross lesions, edema, or ecchymosis.,Within the hypopharynx although there was an area of fullness and on the right side around the level of the thyroid cartilage cornu that seemed to be prominent and within the lumen of the hypopharynx.  There were no signs of any obstruction.  The epiglottis, piriform sinuses, vallecula, and base of tongue all appeared normal with no signs of any gross lesions.  The patient with excellent phonation with good glottic closure upon phonation and no signs of any aspiration or pooling of secretions.  The scope was then pulled out and the patient tolerated the procedure well.  At this time, we will follow up as an outpatient and possibly there is a need for a microscopic suspension direct laryngoscopy for evaluation of this right parapharyngeal lesion.",37
"CC:, Found down.,HX:, 54y/o RHF went to bed at 10 PM at her boyfriend's home on 1/16/96. She was found lethargic by her son the next morning. Three other individuals in the house were lethargic and complained of HA that same morning. Her last memory was talking to her granddaughter at 5:00PM on 1/16/96. She next remembered riding in the ambulance from a Hospital. Initial Carboxyhemoglobin level was 24% (normal < 1.5%) and ABG 7.41/30/370 with O2Sat 75% on 100%FiO2.,MEDS:, unknown anxiolytic, estrogen.,PMH:, PUD, ?stroke and memory difficulty in the past 1-2 years.,FHX:, unknown.,SHX:, divorced. unknown history of tobacco/ETOH/illicit drug use.,EXAM: ,BP126/91, HR86, RR 30, 37.1C.,MS:, Oriented to name only. Speech without dysarthria. 2/3 recall at 5minutes.,CN:, unremarkable.,MOTOR: ,full strength throughout with normal muscle tone and bulk.,SENSORY: ,unremarkable.,COORD/STATION:, unremarkable.,GAIT:, not tested on admission.,GEN EXAM:, notable for erythema of the face and chest.,COURSE:, She underwent a total of four dives under Hyperbaric Oxygen ( 2 dives on 1/17 and 2 dives on 1/18). Neuropsychologic assessment on 1/18/96 revealed marked cognitive impairments with defects in anterograde memory, praxis, associative fluency, attention, and speed of information processing. She was discharged home on 1/19/96 and returned on 2/11/96 after neurologic deterioration. She progressively developed more illogical behavior, anhedonia, anorexia and changes in sleep pattern. She became completely dependent and could not undergo repeat neuropsychologic assessment in 2/96. She was later transferred to another care facility against medical advice. The etiology for these changes became complicated by a newly discovered history of possible ETOH abuse and usual ""anxiety"" disorder.,MRI brain, 2/14/96, revealed increased T2 signal within the periventricular white matter, bilaterally. EEG showed diffuse slowing without epileptiform activity.",33
"PREOPERATIVE DIAGNOSIS:  ,Right lower lobe mass, possible cancer.,POSTOPERATIVE DIAGNOSIS: , Non-small cell carcinoma of the right lower lobe.,PROCEDURES:,1.  Right thoracotomy.,2.  Extensive lysis of adhesions.,3.  Right lower lobectomy.,4.  Mediastinal lymphadenectomy.,ANESTHESIA: , General.,DESCRIPTION OF THE PROCEDURE: , The patient was taken to the operating room and placed on the operating table in the supine position.  After an adequate general anesthesia was given, she was placed in the left lateral decubitus and the right chest was prepped and draped in the sterile fashion.  Lateral thoracotomy was performed on the right side anterior to the tip of the scapula, and this was carried down through the subcutaneous tissue.  The latissimus dorsi muscle was partially transected and then the serratus was reflected anteriorly.  The chest was entered through the fifth intercostal space.  A retractor was placed and then extensive number of adhesions between the lung and the pleura were lysed carefully with sharp and blunt dissection.  The right lower lobe was identified.  There was a large mass in the superior segment of the lobe, which was very close to the right upper lobe, and because of the adhesions, it could not be told if the tumor was extending into the right upper lobe, but it appeared that it did not.  Dissection was then performed at the lower lobe of the fissure, and a GIA stapler was placed through here to separate the tumor from the upper lobe including a small segment of the upper lobe with the lower lobe.  Then, dissection of the hilum was performed, and the branches of the pulmonary artery to the lower lobe were ligated with #2-0 silk freehand ties proximally and distally and #3-0 silk transfixion stitches and then transected.  The inferior pulmonary vein was dissected after dividing the ligament, and it was stapled proximally and distally with a TA30 stapler and then transected.  Further dissection of the fissure allowed for its completion with a GIA stapler and then the bronchus was identified and dissected.  The bronchus was stapled with a TA30 bronchial stapler and then transected, and the specimen was removed and sent to the Pathology Department for frozen section diagnosis.  The frozen section diagnosis was that of non-small cell carcinoma, bronchial margins free and pleural margins free.  The mediastinum was then explored.  No nodes were identified around the pulmonary ligament or around the esophagus.  Subcarinal nodes were dissected, and hemostasis was obtained with clips.  The space below and above the osseous was opened, and the station R4 nodes were dissected.  Hemostasis was obtained with clips and with electrocautery.  All nodal tissue were sent to Pathology as permanent specimen.  Following this, the chest was thoroughly irrigated and aspirated.  Careful hemostasis was obtained and a couple of air leaks were controlled with #6-0 Prolene sutures.  Then, two #28 French chest tubes were placed in the chest, one posteriorly and one anteriorly, and secured to the skin with #2-0 nylon stitches.  The incision was then closed with interrupted #2-0 Vicryl pericostal stitches.  A running #1 PDS on the muscle layer, a running 2-0 PDS in the subcutaneous tissue, and staples on the skin.  A sterile dressing was applied, and the patient was then awakened and transferred to the following Intensive Care Unit in stable and satisfactory condition.,ESTIMATED BLOOD LOSS: , 100 mL.,TRANSFUSIONS:,  None.,COMPLICATIONS:,  None.,CONDITION: , Condition of the patient on arrival to the intensive care unit was satisfactory.",37
"REASON FOR CONSULTATION:,  Abnormal cardiac enzyme profile.,HISTORY OF PRESENT ILLNESS:,  The patient is a 66-year-old gentleman, was brought into emergency room with obtundation.  The patient was mechanically ventilated originally.  His initial diagnosis was septic shock.  His labs showed elevated cardiac enzyme profile.  This is a consultation for evaluation of the same.  The patient is unable to give history.  History obtained through the family members.  As per the patient's son, he does not have history of cardiac disease.  He lives in Utah, presently spending few months in Arizona.  As I understand, he has been followed by a physician back in Utah and believes that he had some workup done from cardiac standpoint which has been negative so far.  No prior history of chest pain, shortness of breath as per the family members.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status borderline elevated, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Foot surgery as per the family members.,MEDICATIONS:,1.  Vitamin supplementation.,2.  Prednisone.,3.  Cyclobenzaprine.,4.  Losartan 50 mg daily.,5.  Nifedipine 90 mg daily.,6.  Lasix.,7.  Potassium supplementation.,ALLERGIES:,  SULFA.,PERSONAL HISTORY:,  He is an ex-smoker.  Does not consume alcohol.,PAST MEDICAL HISTORY: , Pulmonary fibrosis, on prednisone, oxygen-dependent cellulitis status post foot surgery with infection recuperating from the same.  Presentation today with respiratory acidosis, septicemia and septic shock, presently on mechanical ventilation.  No prior cardiac history.  Elevated cardiac enzyme profile.,REVIEW OF SYSTEMS: , Limited.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 94, blood pressure 98/57, respiratory rate as per setting.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.,LUNGS:  Air entry bilaterally clear, rales are scattered.,HEART:  PMI displaced.  S1, S2 regular.  Systolic murmur, grade 2/6.,ABDOMEN:  Soft, nontender.,EXTREMITIES:  Chronic skin changes, markings in the lower extremities noted.  Pulses found palpable.  Dressing also noted.,LABORATORY AND DIAGNOSTIC DATA: , EKG, normal sinus rhythm with wide complex.  Labs, white count of 20,000, H&H 10 and 33, platelets of 163, INR 1.36, BUN of 158, creatinine 8.7, potassium 7.3, of bicarbonate is 11.  Cardiac enzyme profile, troponin 0.05, total CK 312, myoglobin 1423.  Chest x-ray, no acute changes.,IMPRESSION:,1.  The patient is a 66-year-old gentleman with pulmonary fibrosis, on prednisone, oxygen dependent with respiratory acidosis.,2.  Septicemia, septic shock secondary to cellulitis of the leg.,3.  Acute renal shutdown.,4.  Elevated cardiac enzyme profile without prior cardiac history possibly due to sepsis and also acute renal failure.,RECOMMENDATIONS:,1.  Echocardiogram to assess LV function to rule out any cardiac valvular involvement.,2.  Aggressive medical management including dialysis.,3.  From cardiac standpoint, conservative treatment at this juncture.  His cardiac enzyme profile could be elevated secondary to sepsis and also underlying renal failure.,4.  Explained to patient's family in detail regarding condition which is critical which they are aware of.",5
"SUBJECTIVE:,  This 32-year-old female comes in again still having not got a primary care physician.  She said she was at Dr. XYZ office today for her appointment, and they cancelled her appointment because she has not gotten her Project Access insurance into affect.  She says that Project Access is trying to find her a doctor.  She is not currently on Project Access, and so she is here to get something for the pain in her foot.  I did notice that she went in to see Dr. XYZ for a primary care physician on 05/14/2004.  She said she does not have a primary care physician.  She was in here just last week and saw Dr. XYZ for back pain and was put on pain medicines and muscle relaxers.  She has been in here multiple times for different kinds of pain.  This pain she is having is in her foot.  She had surgery on it, and she has plates and screws.  She said she was suppose to see Dr. XYZ about getting some of the hardware out of it.  The appointment was cancelled, and that is why she came here.  It started hurting a lot yesterday, but she had this previous appointment with Dr. XYZ so she thought she would take care of it there, but they would not see her.  She did not injure her foot in any way recently.  It is chronically painful.  Every time she does very much exercise it hurts more.  We have x-rayed it in the past.  She has some hardware there.  It does not appear to be grossly abnormal or causing any loosening or problems on x-ray.,PHYSICAL EXAM: , Examination of her foot shows some well-healed surgical scars.  On the top of her foot she has two, and then on the lateral aspect below her ankle she has a long scar.  They are all old, and the surgery was done over a year ago.  She is walking with a very slight limp.  There is no redness.  No heat.  No swelling of the foot or the ankle.  It is mildly tender around the medial side of the foot just inferior to the medial malleolus.  It is not warm or red.,ASSESSMENT:,  Foot pain.,PLAN:,  She has been in here before.  She seems very pleasant.  Thought maybe she certainly might be having some significant pain, so I gave her some Lortab 7.5 to take with a refill.  After she left, I got to thinking about it and looked into her record.  She has been in here multiple times for pain medicine.  She has a primary care physician, and now she is telling us she does not have a primary care physician even though she had seen Dr. XYZ not too long ago.  We called Dr. XYZ office.  Dr. XYZ nurse said that the patient did not have an appointment today.  She has an appointment on June 15, 2004, for a postop check.  They did not tell her they would not see her today because of insurance, so the patient was lying to me.  We will keep that in mind the next time she returns, because she will likely be back.  She did say that Project Access will be approving her insurance next week, so she will be able to see Dr. XYZ soon.",34
"PREOPERATIVE DIAGNOSES,1.  Carious teeth #2, #5, #12, #15, #18, #19, and #31.,2.  Left mandibular vestibular abscess.,POSTOPERATIVE DIAGNOSES,1.  Carious teeth #2, #5, #12, #15, #18, #19, and #31.,2.  Left mandibular vestibular abscess.,PROCEDURE,1.  Extraction of teeth #2.  #5, #12, #15, #18, #19, #31.,2.  Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,ANESTHESIA:,  General nasotracheal.,COMPLICATIONS: , None.,DRAIN:,  Quarter-inch Penrose drain place in left mandibular vestibule adjacent to teeth #18 and #19, secured with 3-0 silk suture.,CONDITION:,  The patient was taken to the PACU in stable condition.,INDICATION:,  Patient is a 32-year-old female who was admitted yesterday 03/04/10 with left facial swelling and a number of carious teeth which were also abscessed particularly those on the lower left and this morning, the patient was brought to the operating room for extraction of the carious teeth and incision and drainage of left vestibular abscess.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure.  A gauze throat pack was placed and local anesthetic was administered in all four quadrants, a total of 6.8 mL of lidocaine 2% with 1:100,000 epinephrine, and 3.6 mL of Marcaine 0.5% with 1:200,000 epinephrine.  The area in the left vestibular area adjacent to the teeth #18 and #19 was aspirated with 5 cc syringe with an 18-guage needle and approximately 1 mL of purulent material was aspirated.  This was placed on the culture medium in the aerobic and anaerobic culture tubes and the tubes were then sent to the lab.  An incision was then made in the left mandibular vestibule adjacent to teeth #18 and #19.  The area was bluntly dissected with a curved hemostat and a small amount of approximately 3 mL of purulent material was drained.  Penrose drain was then placed using a curved hemostat.  The drain was secured with 3-0 silk suture.  The extraction of the teeth was then begun on the left side removing teeth #12, #15, #18 and #19 with forceps extraction, then moving to the right side teeth #2, #5, and #31 were removed with forceps extraction uneventfully.  After completion of the procedure, the throat pack was removed, the pharynx was suctioned.  The anesthesiologist then placed an orogastric tube and suctioned approximately 10 cc of stomach contents with the nasogastric tube.  The nasogastric tube was then removed.  Patient was then extubated and taken to the PACU in stable condition.",7
"PREOPERATIVE DIAGNOSIS:,  Melena.,POSTOPERATIVE DIAGNOSIS:,  Solitary erosion over a fold at the GE junction, gastric side.,PREMEDICATIONS: , Versed 5 mg IV.,REPORTED PROCEDURE:,  The Olympus gastroscope was used.  The scope was placed in the upper esophagus under direct visit.  The esophageal mucosa was entirely normal.  There was no evidence of erosions or ulceration.  There was no evidence of varices.  The body and antrum of the stomach were normal.  They pylorus duodenum bulb and descending duodenum are normal.  There was no blood present within the stomach.,The scope was then brought back into the stomach and retroflexed in order to inspect the upper portion of the body of the stomach.  When this was done, a prominent fold was seen lying along side the GE junction along with gastric side and there was a solitary erosion over this fold.  The lesion was not bleeding.  If this fold were in any other location of the stomach, I would consider the fold, but at this location, one would have to consider that this would be an isolated gastric varix.  As such, the erosion may be more significant.  There was no bleeding.  Obviously, no manipulation of the lesion was undertaken.  The scope was then straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Solitary erosion overlying a prominent fold at the gastroesophageal junction, gastric side – may simply be an erosion or may be an erosion over a varix.,2.  Otherwise unremarkable endoscopy - no evidence of a bleeding lesion of the stomach.,PLAN:,1.  Liver profile today.,2.  Being Nexium 40 mg a day.,3.  Scheduled colonoscopy for next week.",14
"PREOPERATIVE DIAGNOSIS: , Lipodystrophy of the abdomen and thighs.,POSTOPERATIVE DIAGNOSIS:,  Lipodystrophy of the abdomen and thighs.,OPERATION: , Suction-assisted lipectomy.,ANESTHESIA:,  General.,FINDINGS AND PROCEDURE:,  With the patient under satisfactory general endotracheal anesthesia, the entire abdomen, flanks, perineum, and thighs to the knees were prepped and draped circumferentially in sterile fashion.  After this had been completed, a #15 blade was used to make small stab wounds in the lateral hips, the pubic area, and upper edge of the umbilicus.  Through these small incisions, a cannula was used to infiltrate lactated Ringers with 1000 cc was infiltrated initially into the abdomen.  A 3 and 4-mm cannulas were then used to carry out the liposuction of the abdomen removing a total of 1100 cc of aspirate, which was mostly fat, little fluid, and blood.  Attention was then directed to the thighs both inner and outer.  A total of 1000 cc was infiltrated in both lateral thighs only about 50 cc in the medial thighs.  After this had been completed, 3 and 4-mm cannulas were used to suction 650 cc from each side, approximately 50 cc in the inner thigh and 600 on each lateral thigh.  The patient tolerated the procedure very well.  All of this aspirate was mostly fat with little fluid and very little blood.  Wounds were cleaned and steri-stripped and dressing of ABD pads and ***** was then applied.  The patient tolerated the procedure very well and was sent to the recovery room in good condition.",2
"CHIEF COMPLAINT:,  Followup on hypertension and hypercholesterolemia.,SUBJECTIVE:,  This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago.  He has done well with that.  He does most of the things that he wants to do.  He travels at every chance he has, and he just got back from a cruise.  He denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations.  He sees Dr. Ferguson.  He is known to have Crohn's and he takes care of that for him.  He sees Dr. Roszhart for his prostate check.  He is a nonsmoker and denies swelling in his ankles.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION:, ,Vitals:  Wt; 172 lbs, up 2 lbs,  B/P; 150/60, T; 96.4, P; 72 and regular.  ,General:  A 78-year-old male who does not appear to be in any acute distress.  Glasses.  Good dentition.,CV: Distant S1, S2 without murmur or gallop. No carotid bruits. P: 2+ all around.,Lungs: Diminished with increased AP diameter. ,Abdomen:  Soft, bowel sounds active x 4 quadrants. No tenderness, no distention, no masses or organomegaly noted.,Extremities:  Well-healed surgical scar on the right knee.  No edema.  Hand grasps are strong and equal.,Back:  Surgical scar on the lower back.,Neuro: Intact.  A&O. Moves all four with no focal motor or sensory deficits.,IMPRESSION:,1.  Hypertension.,2.  Hypercholesterolemia.,3.  Osteoarthritis.,4.  Fatigue.,PLAN:,  We will check a BMP, lipid, liver profile, CPK, and CBC.  Refill his medications x 3 months.  I gave him a copy of Partners in Prevention.  Increase his Altace to 5 mg day for better blood pressure control.  Diet, exercise, and weight loss, and we will see him back in three months and p.r.n.",15
"Sample Address,RE:  Sample Patient,Dear Doctor:,We had the pleasure of seeing Abc and his mother in the clinic today.  As you certainly know, he is now a 9-month-old male product of a twin gestation complicated by some very mild prematurity.  He has been having problems with wheezing, cough and shortness of breath over the last several months.  You and your partners have treated him aggressively with inhaled steroids and bronchodilator.  Despite this, however; he has had persistent problems with a cough and has been more recently started on both a short burst of prednisolone as well as a more prolonged alternating day course.  ,Although there is no smoke exposure there is a significant family history with both Abc's father and uncle having problems with asthma as well as his older sister.  The parents now maintain separate households and there has been a question about the consistency of his medication administration at his father's house.  ,On exam today, Abc had some scattered rhonchi which cleared with coughing but was otherwise healthy.  ,We spent the majority of our 45-minute just reviewing basic principles of asthma management and I believe that Abc's mother is fairly well versed in this.  I think the most important thing to realize is that Abc probably does have fairly severe childhood asthma and fortunately has avoided hospitalization.  ,I think it would be prudent to continue his alternate day steroids until he is completely symptom free on the days off steroids but it would be reasonable to continue to wean him down to as low as 1.5 milligrams (0.5 milliliters on alternate days).  I have encouraged his mother to contact our office so that we can answer questions if necessary by phone.,Thanks so much for allowing us to be involved in his care.  ,Sincerely,",29
"PREOPERATIVE DIAGNOSIS: , Cataract, left eye.,POSTOPERATIVE DIAGNOSIS:  ,Cataract, left eye.,PROCEDURE PERFORMED:  ,Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE: , After the induction of topical anesthesia with 4% Xylocaine drops, the left eye was prepped and draped in the usual fashion.  A speculum was inserted, and the microscope was moved into position.,A 3.2-mm incision was made in clear cornea at the limbus with a diamond keratome at the 3 o'clock position, and 0.1 cc of 1% Xylocaine without preservative was instilled into the anterior chamber.  It was then filled with viscoelastic.  A stab incision was made into the anterior chamber at the limbus at 5 o'clock position with a microblade.,A cystitome was used to make a capsulotomy, and the capsulorrhexis forceps were used to complete a circular capsulorrhexis.  The nucleus was hydrodelineated and hydrodissected with balanced salt solution on a 26-gauge cannula, and the phacoemulsifier was used to phacoemulsify the nucleus using a bimanual technique with the nucleus rotator inserted through the keratotomy incision.  The irrigation-aspiration handpiece was used to systematically aspirate cortex 360 degrees.  The posterior capsule was vacuumed; it was clear and intact.,The capsular bag and the anterior chamber were filled with viscoelastic.  A model MA30AC lens, power 21.5 diopters, serial number 864414.095, was folded, grasped with the lens insertion forceps and inserted into the capsular bag.  The trailing loop was placed inside the bag.  The viscoelastic was removed with the irrigation-aspiration handpiece.  The lens centered well.  A single 10-0 nylon suture was placed to close the wound.  It was checked and ascertained to be watertight.  Decadron 0.25 cc, 0.25 cc of antibiotic and 0.25 cc of Xylocaine were injected subconjunctivally.  Dexacidin ointment was placed in the eye, and the procedure was terminated.,The procedure was well tolerated by the patient who was returned to the recovery room in good condition.",26
"HISTORY: , Neurologic consultation was requested to assess and assist with her seizure medication.  The patient is a 3-year 3 months old girl with refractory epilepsy.  She had been previously followed by XYZ, but has been under the care of the UCSF epilepsy program and recently by Dr. Y.  I reviewed her pertinent previous neurology evaluations at CHCC and also interviewed mom.,The patient had seizure breakthrough in August 2007, which requires inpatient admission, Thanksgiving and then after that time had seizures every other day, up-to-date early December.  She remained seizure-free until 12/25/2007 when she had a breakthrough seizure at home treated with Diastat.  She presented to our ER today with prolonged convulsive seizure despite receiving 20 mg of Diastat at home.  Mom documented 103 temperature at home.  In the ER, this was 101 to 102 degrees Fahrenheit.  I reviewed the ER notes.  At 0754 hours, she was having intermittent generalized tonic-clonic seizures despite receiving a total of 1.5 mg of lorazepam x5.  UCSF fellow was contacted.  She was given additional fosphenytoin and had a total dose of 15 mg/kg administered.  Vital weight was 27.  Seizures apparently had stopped.  The valproic acid level obtained at 0835 hours was 79.  According to mom, her last dose was at 6 p.m. and she did not receive her morning dose.  Other labs slightly showed leukocytosis with white blood cell count 21,000 and normal CMP.,Previous workup here showed an EEG on 2005, which showed a left posterior focus.  MRI on June 2007 and January 2005 were within normal limits.  Mom describes the following seizure types:,1.  Eye blinking with unresponsiveness.,2.  Staring off to one side.,3.  Focal motor activity in one arm and recently generalized tonic seizure.,She also said that she was supposed to see Dr. Y this Friday, but had postponed it to some subsequent time when results of genetic testing would be available.  She was being to physicians' care as Dr. Z had previously being following her last UCSF.,She had failed most of the first and second line anti-epileptic drugs.  These include Keppra, Lamictal, Trileptal, phenytoin and phenobarbital.  These are elicited to allergies, but she has not had any true allergic reactions to these.  Actually, it has resulted in an allergic reaction resulting in rash and hypotension.,She also had been treated with Clobazam.  Her best control is with her current regimen of valproic acid and Tranxene.  Other attempts to taper Topamax, but this resulted increased seizures.  She also has oligohidrosis during this summertime.,CURRENT MEDICATIONS: , Include Diastat 20 mg; Topamax 25 mg b.i.d., which is 3.3 per kilo per day; Tranxene 15 mg b.i.d.; Depakote 125 mg t.i.d., which is 25 per kilo per day.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight 15 kg.,GENERAL:  The patient was awake, she appeared sedated and postictal.,NECK:  Supple.,NEUROLOGICAL:  She had a few brief myoclonic jerks of her legs during drowsiness, but otherwise no overt seizure, no seizure activity nor involuntary movements were observed.,She was able to follow commands such as when I request that she gave mom a kiss.  She acknowledged her doll.  Left fundus is sharp.  She resisted the rest of the exam.  There was no obvious lateralized findings.,ASSESSMENT:,  Status epilepticus resolved.  Triggered by a febrile illness, possibly viral.  Refractory remote symptomatic partial epilepsy.,IMPRESSION: , I discussed the maximizing Depakote to mom and she concurred.  I recommend increasing her maintenance dose to one in the morning, one in the day, and two at bedtime.  For today, she did give an IV Depacon 250 mg and the above dosage can be continued IV until she is taking p.o.  Dr. X agreed with the changes and orders were written for this.  She can continue her current doses of Topamax and Tranxene.  This can be given by NG if needed.  Topamax can be potentially increased to 25 mg in the morning and 50 mg at night.  I will be available as needed during the rest of her hospitalization.  Mom will call contact Dr. Y an update him about the recent changes.",5
"PREOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,POSTOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,PROCEDURE PERFORMED: ,Removal of bilateral #32-French chest tubes with closure of wound.,COMPLICATIONS:,  None.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old African-American male who has been in the intensive care unit for over a month with bilateral chest tubes for chronic draining pleural effusions with serous drainage.  A decision was made to proceed with removal of these chest tubes and because of the fistulous tracts, this necessitated to close the wounds with sutures.  The patient was agreeable to proceed.,OPERATIVE PROCEDURE:  ,The patient was prepped and draped at the bedside over both chest tube sites.  The pressures applied over the sites and the skin was closed with interrupted #3-0 Ethilon sutures.  The skin was then cleansed and Vaseline occlusive dressing was applied over the sites.  The same procedure was performed on the other side.  The chest tubes were removed on full inspiration.  Vital signs remained stable throughout the procedure.  The patient will remain in the intensive care unit for continued monitoring.,",3
"CC:, Fall with questionable associated loss of consciousness.,HX: ,This 81 y/o RHM fell down 20 steps on the evening of admission, 1/10/93, while attempting to put his boots on at the top of the staircase. He was evaluated locally and was amnestic to the event at the time of examination. A HCT scan was obtained and he was transferred to UIHC, Neurosurgery.,MEDS:, Lasix 40mg qd, Zantac 150mg qd, Lanoxin 0.125mg qd, Capoten 2.5mg bid, Salsalate 750mg tid, ASA 325mg qd, ""Ginsana"" (Ginseng) 100mg bid.,PMH: ,1)Atrial fibrillation, 2)Right hemisphere stroke, 11/22/88, with associated left hemiparesis and amaurosis fugax. This was followed by a RCEA, 12/1/88 for 98% stenosis. The stroke symptoms/signs resolved. 3)DJD, 4)Right TKR 2-3 years ago, 5)venous stasis; with no h/o DVT, 6)former participant in NASCET, 7)TURP for BPH. No known allergies.,FHX:, Father died of an MI at unknown age, Mother died of complications of a dental procedure. He has one daughter who is healthy.,SHX:, Married. Part-time farmer. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP157/86, HR100 and irregular, RR20, 36.7C, 100%SaO2,MS: A&O to person, place, time. Speech fluent and without dysarthria.,CN: Pupils 3/3 decreasing to 2/2 on exposure to light. EOM intact. VFFTC. Optic disks were flat. Face was symmetric with symmetric movement. The remainder of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station/Gait: not mentioned in chart.,Reflexes: symmetric. Plantar responses were flexor, bilaterally.,Gen Exam: CV:IRRR without murmur. Lungs: CTA. Abdomen: NT, ND, NBS.,HEENT: abrasion over the right forehead.,Extremity: distal right leg edema/erythema (just above the ankle). tender to touch.,COURSE:, 1/10/93, (outside)HCT was reviewed, It revealed a left parietal epidural hematoma. GS, PT/PTT, UA, and CBC were unremarkable. RLE XR revealed a fracture of the right lateral malleolus for which he was casted. Repeat HCTs showed no change in the epidural hematoma and he was discharged home on DPH.",22
"TITLE OF OPERATION:,  Diagnostic laparoscopy.,INDICATION FOR SURGERY: , The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,PREOP DIAGNOSIS: , Possible ruptured ectopic pregnancy.,POSTOP DIAGNOSIS: , No evidence of ectopic pregnancy or ruptured ectopic pregnancy.,ANESTHESIA: , General endotracheal.,SPECIMEN: , Peritoneal fluid.,EBL: , Minimal.,FLUIDS:,  900 cubic centimeters crystalloids.,URINE OUTPUT: , 400 cubic centimeters.,FINDINGS: , Adhesed left ovary with dilated left fallopian tube, tortuous right fallopian tube with small 1 cm ovarian cyst noted on right ovary, perihepatic lesions consistent with history of PID, approximately 1-200 cubic centimeters of more serous than sanguineous fluid.  No evidence of ectopic pregnancy.,COMPLICATIONS: , None.,PROCEDURE:,  After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was administered.  She was examined under anesthesia.  An 8-10 cm anteverted uterus was noted.  The patient was placed in the dorsal-lithotomy position and prepped and draped in the usual sterile fashion, a sponge on a sponge stick was used in the place of a HUMI in order to not instrument the uterus in the event that this was a viable intrauterine pregnancy and this may be a desired intrauterine pregnancy.  Attention was then turned to the patient's abdomen where a 5-mm incision was made in the inferior umbilicus.  The abdominal wall was tented and VersaStep needle was inserted into the peritoneal cavity.  Access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water.  No peritoneum was obtained without difficulty using 4 liters of CO2 gas.  The 5-mm trocar and sleeve were then advanced in to the intraabdominal cavity and access was confirmed with the laparoscope.,The above-noted findings were visualized.  A 5-mm skin incision was made approximately one-third of the way from the ASI to the umbilicus at McBurney's point.  Under direct visualization, the trocar and sleeve were advanced without difficulty.  A third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the VersaStep.  The peritoneal fluid was aspirated and sent for culture and wash and cytology.  The abdomen and pelvis were surveyed with the above-noted findings.  No active bleeding was noted.  No evidence of ectopic pregnancy was noted.  The instruments were removed from the abdomen under good visualization with good hemostasis noted.  The sponge on a sponge stick was removed from the vagina.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.,The attending, Dr. X, was present and scrubbed for the entire procedure.",24
"PROCEDURE PERFORMED:,  Right heart catheterization.,INDICATION: , Refractory CHF to maximum medical therapy.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient and the patient's family in detail, informed consent was obtained both verbally and in writing.  The patient was taken to Cardiac Catheterization Suite where the right internal jugular region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein.  Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right internal jugular vein.  A steel guidewire was then inserted through the needle into the vessel without resistance.  Small nick was then made in the skin and the needle was removed.  An #8.5 French venous sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  A Swan-Ganz catheter was inserted to 20 cm and the balloon was inflated.  Under fluoroscopic guidance, the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position.  Hemodynamics were measured along the way.  Pulmonary artery saturation was obtained.  The Swan was then kept in place for the patient to be transferred to the ICU for further medical titration.  The patient tolerated the procedure well.  The patient returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,  Body surface area equals 2.04, hemoglobin equals 9.3, O2 is at 2 liters nasal cannula.  Pulmonary artery saturation equals 37.8.  Pulse oximetry on 2 liters nasal cannula equals 93%.  Right atrial pressure is 8, right ventricular pressure equals 59/9, pulmonary artery pressure equals 61/31 with mean of 43, pulmonary artery wedge pressure equals 21, cardiac output equals 3.3 by the Fick method, cardiac index is 1.6 by the Fick method, systemic vascular resistance equals 1821, and transpulmonic gradient equals 22.,IMPRESSION:  ,Exam and Swan findings consistent with low perfusion given that the mixed venous O2 is only 38% on current medical therapy as well as elevated right-sided filling pressures and a high systemic vascular resistance.,PLAN: , Given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve, the patient will need to be discharged home on Primacor.  The patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia.  At this time, we will transfer the patient to the Intensive Care Unit for titration of the Primacor therapy.  We will also increase his Lasix to 80 mg IV q.d.  We will increase his amiodarone to 400 mg daily.  We will also continue with his Coumadin therapy.  As stated previously, we will discontinue vasodilator therapy starting with the Isordil.",3
"IDENTIFYING DATA: , This is a 26-year-old Caucasian male of unknown employment, who has been living with his father.,CHIEF COMPLAINT AND/OR REACTION TO HOSPITALIZATION: , The patient is unresponsive.,HISTORY OF PRESENT ILLNESS: , The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.  It is unknown how long the patient has been decompensated after a stay at Hospital.,PAST PSYCHIATRIC HISTORY: , Inpatient ITA stay at Hospital one year ago, outpatient at Valley Cities, but currently not engaged in treatment.,MEDICAL HISTORY: , Due to the patient being unresponsive and very little information available in the chart, the only medical history that we can identify is to observe that the patient is quite thin for height.  He is likely dehydrated, as it appears that he has not had food or fluids for quite some time.,CURRENT MEDICATIONS:,  Prior to admission, we do not have that information.  He has been started on Ativan 2 mg p.o. or IM if he refuses the p.o. and this would be t.i.d. to treat the catatonia.,SOCIAL AND DEVELOPMENTAL HISTORY:  ,The patient has been living in his father's home and this is all the information that we have available from the chart.,SUBSTANCE AND ALCOHOL HISTORY:  ,It is unknown with the exception of nicotine use.,LEGAL HISTORY: , Unknown.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAM:,Attitude:  The patient is unresponsive.,Appearance:  He is lying in bed in the fetal position with a blanket over his head.,Psychomotor:  Catatonic.,EPS/TD:  Unable to assess though his limbs are quite contracted.,Affect:  Unresponsive.,Mood:  Unresponsive.,Speech:  Unresponsive.,Thought Process And Thought Content:  Unresponsive.,Psychosis:  Unable to elicit information to make this assessment.,Suicidal/Homicidal:  Also unable to elicit this information.,Cognitive Assessment:  Unable to elicit.,Judgment And Insight:  Unable to elicit.,Assets:  The patient is young.,Limitations:  Severe decompensation.,FORMULATION:  ,This is a 26-year-old Caucasian male with a diagnosis of psychosis, NOS, admitted with catatonia.,DIAGNOSES:,AXIS I:  Psychosis, NOS.,AXIS II:  Deferred.,AXIS III:  Dehydration.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 10 to 14 days.,RECOMMENDATIONS AND PLAN:,1.  Stabilize medically from the dehydration per internal medicine.,2.  Medications, milieu therapy to assist with re-compensation.",32
"HISTORY: , The patient is scheduled for laparoscopic gastric bypass.  The patient has been earlier seen by Dr. X, her physician.  She has been referred to us from Family Practice.  In short, she is a 33-year-old lady with a BMI of 43, otherwise healthy with unsuccessful nonsurgical methods of weight loss. ,She was on laparoscopic gastric bypass for weight loss. ,She meets the National Institute of Health Criteria.  She is very well educated and motivated and has no major medical contraindications for the procedure.,PHYSICAL EXAMINATION:,  On physical examination today, she weighs 216 pounds with a BMI of 43.5, pulse is 96, temperature is 97.6, blood pressure is 122/80.  Lungs are clear.  Abdomen is soft, nontender.  There is stigmata for morbid obesity.  She has cesarean section scars in the lower abdomen with no herniation. ,DISCUSSION: , I had a long talk with the patient about laparoscopic gastric bypass, possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines.  I also explained to her complications including rare cases of death secondary to DVT, PE, leak , peritonitis, sepsis, shock, multisystem organ failure, need for re-operation including for leak or bleeding, gastrostomy or jejunostomy for feeding, rare case of respiratory failure requiring mechanical ventilation, etc., with myocardial infarction, pneumonia, atelectasis in the postoperative period were also discussed. ,Short-term complications of gastric bypass including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or anti-inflammatory drug intake which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which were discussed.  The patient would alert us for earlier intervention.  Symptomatic gallstone formation secondary to rapid weight loss were also discussed.  How to avoid it by taking ursodiol were also discussed.  Long-term complications of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, need for major lifestyle and exercise and habit changes, avoiding pregnancy in the first two years, etc., were all stressed.  The patient understands.  She wants to go to surgery. ,In preparation of surgery, she will undergo very low-calorie diet through Medifast to decrease the size of the liver to make laparoscopic approach more successful and also to optimize her cardiopulmonary and metabolic comorbidities.  She will also see a psychologist, nutritionist, and exercise physiologist for a multidisciplinary effort for short and long-term success for weight loss surgery.  I will see her two weeks before the plan of surgery for further discussion and any other questions at that point of time.",5
"PREOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Left subclavian vein occlusion.,3.  Status post chronic tracheostomy.,4.  Status post coronary artery bypass grafting.,5.  Right subclavian vein stenosis.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Left subclavian vein occlusion.,3.  Status post chronic tracheostomy.,4.  Status post coronary artery bypass grafting.,5.  Right subclavian vein stenosis.,OPERATIVE PROCEDURE,Creation of autologous right brachiobasilic arteriovenous fistula - first stage.,INDICATIONS FOR THE PROCEDURE,This patient has a known left subclavian vein occlusion.  The right subclavian vein has an estimated 50% stenosis.  The patient has a catheter traversed in the right innominate vein.  The right basilic vein was judged to be suitable for usage on vein mapping.,OPERATIVE FINDINGS,The basilic vein was of an adequate size, but somewhat sclerotic.  A first stage autologous right brachiobasilic arteriovenous fistula was created.  A grade 2 was felt at completion.,OPERATIVE PROCEDURE IN DETAIL,After informed consent was obtained, the patient was taken to the operating room.  The patient was placed in the supine position.  The patient received regional nerve block.  The patient also received intravenous sedation.  The right arm was prepped and draped in the usual sterile fashion.  We used ultrasound to locate the basilic vein at the cubital fossa.,A small transverse incision was made slightly above the basilic vein.  The basilic vein was identified and immobilized.  The basilic vein was of a good size, but somewhat sclerotic.  The underlying fascia was incised and the brachial artery was identified and immobilized.  The brachial artery was normal.  We then divided the basilic vein distally.  The distal end was ligated using silk suture.  The brachial artery was clamped proximally and distally.  A small longitudinal arteriotomy was made in the brachial artery.  We did not give heparin.  The end of the basilic vein was then sewn end-to-side to the brachial artery using a running 7-0 Prolene suture.  ,Just prior to completion of the anastomosis, it was flushed and anastomosis was completed.  Flow was then established.  A grade 2 was felt in the outflow basilic fistula.  Hemostasis was secured.  The wound was then closed in layers using interrupted PDS sutures for the fascia and a running 4-0 Monocryl subcuticular suture for the skin.  A sterile dry dressing was applied.,The patient tolerated the procedure well.  There were no operative complications.  The sponge, instrument, and needle counts were correct at the end of the case.  I was present and participated in all aspects of the procedure.  The patient was transferred to the recovery room in satisfactory condition.",37
"PREOPERATIVE DIAGNOSIS:,  History of bladder tumor with abnormal cytology and areas of erythema.,POSTOPERATIVE DIAGNOSIS: , History of bladder tumor with abnormal cytology and areas of erythema.,PROCEDURE PERFORMED:,1.  Cystoscopy.,2.  Bladder biopsy with fulguration.,ANESTHESIA: , IV sedation with local.,SPECIMEN: , Urine cytology and right lateral wall biopsies.,PROCEDURE:,  After the consent was obtained, the patient was brought to the operating room and given IV sedation.  He was then placed in dorsal lithotomy position and prepped and draped in standard fashion.  A #21 French cystoscope was then used to visualized the entire urethra and bladder.  There was noted to be a narrowing of the proximal urethra, however, the scope was able to pass through.  The patient was noted to have a previously resected prostate.  On visualization of the bladder, the patient did have areas of erythema on the right as well as the left lateral walls, more significant on the right side.  The patient did have increased vascularity throughout the bladder.  The ________ two biopsies of the right lateral wall and those were sent for pathology.  The Bovie cautery was then used to cauterize the entire area of the biopsy as well as surrounding erythema.  Bovie was also utilized to cauterize the areas of erythema on the left lateral wall.  No further bleeding was identified.  The bladder was drained and the cystoscope was removed.  The patient tolerated the procedure well and was transferred to the recovery room.,He will have his defibrillator restarted and will followup with Dr. X in approximately two weeks for the result.  He will be discharged home with antibiotics as well as pain medications.  He is to restart his Coumadin not before Sunday.",38
"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.",37
"ADMISSION DIAGNOSIS: , Microinvasive carcinoma of the cervix.,DISCHARGE DIAGNOSIS: , Microinvasive carcinoma of the cervix.,PROCEDURE PERFORMED: , Total vaginal hysterectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old, white female, gravida 7, para 5, last period mid March, status post tubal ligation.  She had an abnormal Pap smear in the 80s, which she failed to followup on until this year.  Biopsy showed a microinvasive carcinoma of the cervix and a cone biopsy was performed on 02/12/2007 also showing microinvasive carcinoma with a 1 mm invasion.  She has elected definitive therapy with a total vaginal hysterectomy.  She is aware of the future need of Pap smears.,PAST MEDICAL HISTORY: , Past history is significant for seven pregnancies, five term deliveries, and significant past history of tobacco use.,PHYSICAL EXAMINATION: , Physical exam is within normal limits with a taut normal size uterus and a small cervix, status post cone biopsy.,LABORATORY DATA AND DIAGNOSTIC STUDIES: , Chest x-ray was clear.  Discharge hemoglobin 10.8.,HOSPITAL COURSE: , She was taken to the operating room on 04/02/2007 where a total vaginal hysterectomy was performed under general anesthesia.  There was an incidental cystotomy at the time of the creation of the bladder flap.  This was repaired intraoperatively without difficulty.  Postoperative, she did very well.  Bowel and bladder function returned quickly.  She is ambulating well and tolerating a regular diet.,Routine postoperative instructions given and understood.  Followup will be in ten days for a cystogram and catheter removal with followup in the office at that time. ,DISCHARGE MEDICATIONS:,  Vicodin, Motrin, and Macrodantin at bedtime for urinary tract infection suppression.  ,DISCHARGE CONDITION: , Good.,Final pathology report was free of residual disease.",10
"SUBJECTIVE:,  The patient is a 75-year-old female who comes in today with concerns of having a stroke.  She states she feels like she has something in her throat.  She started with some dizziness this morning and some left hand and left jaw numbness.  She said that she apparently had something about three weeks ago where she was dizzy and ended up falling down and she saw Dr. XYZ for that who gave her some Antivert.  She said that today though she woke up in the middle of the night and her left hand was numb and she was having numbness on the left side of her face, as well as the left side of her neck.  She said she had an earache a day or so ago.  She has not had any cold symptoms.,ALLERGIES:,  Demerol and codeine.,MEDICATIONS: , Lotensin, Lopid, metoprolol, and Darvocet.,REVIEW OF SYSTEMS:,  The patient says that she feels little bit nauseated at times.  She denies chest pain or shortness of breath and again feels like she has something in her throat.  She has been able to swallow liquids okay.  She said that she did brush her teeth this morning and did not have any fluid dripping out of her mouth.  She does say that she occasionally has numbness in her left hand prior to today.,PHYSICAL EXAMINATION:,General:  She is awake and alert, no acute distress.,Vital Signs:  Blood pressure:  175/86.  Temperature:  She is afebrile.  Pulse:  78.  Respiratory rate:  20.  O2 sat:  93% on room air.,HEENT:  Her TMs are normal bilaterally.  Posterior pharynx is unremarkable.  It should be noted that her uvula did not deviate and neither did her tongue.  When she smiles though she has some drooping of the left side of her face, as well as some mild nasolabial fold flattening.,Neck:  Without adenopathy or thyromegaly.  Carotids pulses are brisk without bruits.,Lungs:  Clear to auscultation.,Heart:  Regular rate and rhythm without murmur.,Extremities:  Her muscle strength is symmetrical and intact bilaterally.  DTRs are 2+/4+ bilaterally and muscle strength is intact in the upper extremities.  She has a positive Tinel’s sign on her left wrist.,Neurological:  I also took monofilament and she could sense it easily when testing her sensation on her face.,ASSESSMENT:,  Bell’s Palsy.,PLAN:,  We did get an EKG showed some ST segment changes anterolaterally.  The only EKG I have here is from 1998 and she actually had bypass in 1999, but there certainly does not appear to be anything acute on his EKG.  I assured her that it does not look like she has a stroke.  If she wants to prevent a stroke, obviously quitting her smoking would help.  It should be noted she also takes Synthroid and Zocor.  We are going to give her Valtrex 1 g t.i.d. for seven days and then if she starts noticing any other drooping or worsening of her symptoms on the left side of her face, she needs to come back, but I will not start her on steroids at this time, which she agreed with.",34
"PROCEDURE:,  Subcutaneous ulnar nerve transposition.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve.  Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected.,Osborne's fascia was released, an ulnar neurolysis performed, and the ulnar nerve was mobilized.  Six cm of the medial intermuscular septum was excised, and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly.,The subcutaneous plane just superficial to the flexor-pronator mass was developed.  Meticulous hemostasis was maintained with bipolar electrocautery.  The nerve was transposed anteriorly, superficial to the flexor-pronator mass.  Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve.,A semicircular medially based flap of flexor-pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating.  The subcutaneous tissue and skin were closed with simple interrupted sutures.  Marcaine with epinephrine was injected into the wound.  The elbow was dressed and splinted.  The patient was awakened and sent to the recovery room in good condition, having tolerated the procedure well.",23
"PREOPERATIVE DIAGNOSIS: , Voluntary sterility.,POSTOPERATIVE DIAGNOSIS: , Voluntary sterility.,OPERATIVE PROCEDURE:,  Bilateral vasectomy.,ANESTHESIA:,  Local.,INDICATIONS FOR PROCEDURE:  ,A gentleman who is here today requesting voluntary sterility.  Options were discussed for voluntary sterility and he has elected to proceed with a bilateral vasectomy.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, and after appropriately identifying the patient, the patient was prepped and draped in the standard surgical fashion and placed in a supine position on the OR table.  Then, 0.25% Marcaine without epinephrine was used to anesthetize the scrotal skin.  A small incision was made in the right hemiscrotum.  The vas deferens was grasped with a vas clamp.  Next, the vas deferens was skeletonized.  It was clipped proximally and distally twice.  The cut edges were fulgurated.  Meticulous hemostasis was maintained.  Then, 4-0 chromic was used to close the scrotal skin on the right hemiscrotum.  Next, the attention was turned to the left hemiscrotum, and after the left hemiscrotum was anesthetized appropriately, a small incision was made in the left hemiscrotum.  The vas deferens was isolated.  It was skeletonized.  It was clipped proximally and distally twice.  The cut edges were fulgurated.  Meticulous hemostasis was maintained.  Then, 4-0 chromic was used to close the scrotal skin.  A jockstrap and sterile dressing were applied at the end of the case.  Sponge, needle, and instruments counts were correct.",38
"PREOPERATIVE DIAGNOSIS: , Epigastric hernia.,POSTOPERATIVE DIAGNOSIS: , Epigastric hernia.,OPERATIONS:,  Epigastric herniorrhaphy.,ANESTHESIA: , General inhalation.,PROCEDURE: , Following attainment of satisfactory anesthesia, the patient's abdomen was prepped with Hibiclens and draped sterilely.  The hernia mass had been marked preoperatively.  This area was anesthetized with a mixture of Marcaine and Xylocaine.  A transverse incision was made over the hernia and dissection carried down to the entrapped fat.  Sharp dissection was carried around the fat down to the fascial edge.  The preperitoneal fat could not be reduced; therefore, it is trimmed away and the small fascial defect then closed with interrupted 0-Ethibond sutures.  The fascial edges were injected with the local anesthetic mixture.  Subcutaneous tissues were then closed with interrupted 4-0 Vicryl and skin edges closed with running subcuticular 4-0 Vicryl.  Steri-Strips and a sterile dressing were applied to complete the closure.  The patient was then awakened and taken to the PACU in satisfactory condition.,ESTIMATED BLOOD LOSS: , 10 mL.,SPONGE AND NEEDLE COUNT: , Reported as correct.,COMPLICATIONS: , None.",37
"CHIEF COMPLAINT:,  Recurrent bladder tumor.,HISTORY OF PRESENT ILLNESS: , The patient is a 79-year-old woman, the patient of Dr. X, who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.  The patient underwent TUR of several transitional cell carcinomas of the bladder on the bladder neck in 2006.  This was followed by bladder instillation of BCG.  At this time, the patient denies any voiding symptoms or hematuria.  The patient opting for TUR and electrofulguration of the recurrent tumors.,ALLERGIES: , None known.,MEDICATIONS: , Atenolol 5 mg daily.,OPERATIONS: , Status post bilateral knee replacements and status post TUR of bladder tumors.,REVIEW OF SYSTEMS: , Other than some mild hypertension, the patient is in very, very good health.  No history of diabetes, shortness of breath or chest pain.,PHYSICAL EXAMINATION: , Well-developed and well-nourished woman, alert and oriented.  Her lungs are clear.  Heart, regular sinus rhythm.  Back, no CVA tenderness.  Abdomen, soft and nontender.  No palpable masses.,IMPRESSION: , Recurrent bladder tumors.,PLAN: , The patient to have CBC, chem-6, PT, PTT, EKG, and chest x-ray beforehand.",38
"DESCRIPTION OF PROCEDURE: , After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table.  Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty.  The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally.  Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants.  A lens ring was secured to the eye using 7-0 Vicryl suture.",26
"ADMISSION DIAGNOSES:,1.  Atypical chest pain.,2.  Nausea.,3.  Vomiting.,4.  Diabetes.,5.  Hypokalemia.,6.  Diarrhea.,7.  Panic and depression.,8.  Hypertension.,DISCHARGE DIAGNOSES:,1.  Serotonin syndrome secondary to high doses of Prozac.,2.  Atypical chest pain with myocardial infarction ruled out.,3.  Diabetes mellitus.,4.  Hypertension.,5.  Diarrhea resolved.,ADMISSION SUMMARY: , The patient is a 53-year-old woman with history of hypertension, diabetes, and depression.  Unfortunately her husband left her 10 days prior to admission and she developed severe anxiety and depression.  She was having chest pains along with significant vomiting and diarrhea.  Of note, she had a nuclear stress test performed in February of this year, which was normal.  She was readmitted to the hospital to rule out myocardial infarction and for further evaluation.,ADMISSION PHYSICAL: , Significant for her being afebrile.  Apparently there was one temperature registered mildly high at 100.  Her blood pressure was 140/82, heart rate 83, oxygen saturation was 100%.  She was tearful.  HEART:  Heart sounds were regular.  LUNGS:  Clear.  ABDOMEN:  Soft.  Apparently there were some level of restlessness and acathexia.  She was also pacing.,ADMISSION LABS:  ,Showed CBC with a white count of 16.9, hematocrit of 46.9, platelets 318,000.  She had 80% neutrophils, no bands.  UA on 05/02 came out negative.  Chemistry panel shows sodium 138, potassium 3.5, creatinine 0.6, calcium 8.3, lactate 0.9, ALT was 39, AST 38, total bilirubin 0.6.  Her initial CK came out at 922.  CK-MB was low.  Troponin was 0.04.  She had a normal amylase and lipase.  Previous TSH few days prior was normal.  Chest x-ray was negative.,HOSPITAL COURSE:,1.  Serotonin syndrome.  After reevaluation of the patient including evaluation of the lab abnormalities it was felt that she likely had serotonin syndrome with obvious restlessness, increased bowel activity, agitation, and elevated white count and CPK.  She did not have fever, tremor or hyperreflexia.  Her CPK improved with IV fluids.  She dramatically improved with this discontinuation of her Prozac.  Her white count came back down towards normal.  At time of discharge, she was really feeling back to normal.,2.  Depression and anxiety with history of panic attacks exacerbated by her husband leaving her 2 weeks ago.  We discussed this.  Also, discussed the situation with a psychiatrist who is available on Friday and I discussed the situation with the patient.  In regards to her medications, we are discontinuing the Prozac and she is being reevaluated by Dr. X on Monday or Tuesday.  Cymbalta has been recommended as a good alternative medication for her.  The patient does have a counselor.  It is going to be difficult for her to go home alone.  I discussed the resources with her.  She has a daughter who will be coming to town in a couple of weeks, but she does have a friend that she can call and stay the next few days with.,3.  Hypertension.  She will continue on her usual medications.,4.  Diabetes mellitus.  She will continue on her usual medications.,5.  Diarrhea resolved.  Her electrolyte abnormalities resolved.  She had received fluid rehydration.,DISPOSITION:,  She is being discharged to home.  She will stay with a friend for a couple of days.  She will be following up with Dr. X on Monday or Tuesday.  Apparently Dr. Y has already discussed the situation and the plan with her.  She will continue on her usual medications except for discontinuing the Prozac.,DISCHARGE MEDICATIONS: , Include,1.  Omeprazole 20 mg daily.,2.  Temazepam 15 mg at night.,3.  Ativan 1 mg one-half to one three times a day as needed.,4.  Cozaar 50 daily.,5.  Prandin 1 mg before meals.,6.  Aspirin 81 mg.,7.  Multivitamin daily.,8.  Lantus 60 units at bedtime.,9.  Percocet 10/325 one to two at night for chronic pain.  She is running out of that, so we are calling a prescription for #10 of those.",10
"EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.,FINDINGS:,Examination was performed on 9/1/05.,There is marked supraspinatus tendinosis and extensive tearing of the substance of the tendon and articular surface, extending into the myotendinous junction as well. There is still a small rim of tendon along the bursal surface, although there may be a small tear at the level of the rotator interval. There is no retracted tendon or muscular atrophy (series #6 images #6-17).,Normal infraspinatus tendon.,There is subscapularis tendinosis with fraying and partial tearing of the superior most fibers extending to the level of the rotator interval (series #9 images #8-13; series #3 images #8-14). There is no complete tear, gap or fiber retraction and there is no muscular atrophy.,There is tendinosis and superficial tearing of the long biceps tendon within the bicipital groove, and there is high grade (near complete) partial tearing of the intracapsular portion of the tendon. The biceps anchor is intact. There are degenerative changes in the greater tuberosity of the humerus but there is no fracture or subluxation.,There is degeneration of the superior labrum and there is a small nondisplaced tear in the posterior superior labrum at the one to two o’clock position (series #6 images #12-14; series #3 images #8-10; series #9 images #5-8). There is a small sublabral foramen at the eleven o’clock position (series #9 image #6). There is no osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is hypertrophic osteoarthropathy of the acromioclavicular joint with narrowing of the subacromial space and flattening of the superior surface of the supraspinatus musculotendinous junction, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion (series #8 images #3-12).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments. There is minimal fluid within the glenohumeral joint. There is no atrophy of the deltoid muscle.,IMPRESSION:,  There is extensive supraspinatus tendinosis and partial tearing as described. There is no retracted tendon or muscular atrophy, but there may be a small tear along the anterior edge of the tendon at the level of the rotator interval, and this associated partial tearing of the superior most fibers of the subscapularis tendon.  There is also a high-grade partial tear of the long biceps tendon as it courses under the transverse humeral ligament. There is no evidence of a complete tear or retracted tendon. Small nondisplaced posterior superior labral tear. Outlet narrowing from the acromioclavicular joint, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion.",33
"PREOPERATIVE DIAGNOSIS:,  Cholelithiasis; possible choledocholithiasis.",37
"PREOPERATIVE DIAGNOSES,1.  Right buccal space abscess/cellulitis.,2.  Nonrestorable caries teeth #1, #29, and #32.,POSTOPERATIVE DIAGNOSES,1.  Right buccal space abscess/cellulitis.,2.  Nonrestorable caries teeth #1, #29, and #32.,PROCEDURE,1.  Incision and drainage of right buccal space abscess.,2.  Extraction of teeth #1, #29, and #32.,ANESTHESIA,GETA,EBL,20 mL.,IV FLUIDS,900 mL.,URINE OUTPUT,Not measured.,COMPLICATIONS,None.,SPECIMENS,1.  Aerobic culture was sent from the right buccal space abscess/cellulitis.,2.  Anaerobic culture from the same space was also obtained.,PROCEDURE IN DETAIL,The patient was identified in the appropriate holding area and transported to #13.  The patient was intubated by anesthesia orotracheally using a #7 ET tube.  The patient was induced in effective sleep using a propofol and gas inhalation anesthetics.  Following intubation, the patient's mouth was cleaned with chlorhexidine and a toothbrush following placement of a throat pack.  At that point, approximately 5 mL of 2% lidocaine with 1:20,000 epinephrine was injected for a right inferior alveolar block, as well as local infiltration in the right long buccal nerve area as well as the right cheek area.  Local infiltration also was done near the tooth #32.  At this point, a periosteal elevator was used to loosen up the gingival tissue of the teeth #1, #29, and #32; and all 3 teeth were extracted using simple extraction, using elevators and forceps.  In addition, the previous Penrose drain was removed by removing the suture, and the incision that was used for I&D on the previous day was extended laterally.  A hemostat was used to puncture through to the right buccal space.  Approximately, 2.5 to 3 mL of purulence was drained, and that was used for Gram stain and culture, as mentioned above.  Following copious irrigation of the area, following the extraction and following the incision and drainage, 2 quarter-inch Penrose drains were placed in the anterior as well as the posterior section of the incision into the buccal space.  At this point copious irrigation was done again, the throat pack was removed, and the procedure was ended.  Note that the patient was extubated without incident.  Dr. B was present for all critical aspects of patient care.",7
"Sample Address,RE:  Sample Patient,Dear Doctor:,We had the pleasure of seeing Abc and his mother in the clinic today.  As you certainly know, he is now a 9-month-old male product of a twin gestation complicated by some very mild prematurity.  He has been having problems with wheezing, cough and shortness of breath over the last several months.  You and your partners have treated him aggressively with inhaled steroids and bronchodilator.  Despite this, however; he has had persistent problems with a cough and has been more recently started on both a short burst of prednisolone as well as a more prolonged alternating day course.  ,Although there is no smoke exposure there is a significant family history with both Abc's father and uncle having problems with asthma as well as his older sister.  The parents now maintain separate households and there has been a question about the consistency of his medication administration at his father's house.  ,On exam today, Abc had some scattered rhonchi which cleared with coughing but was otherwise healthy.  ,We spent the majority of our 45-minute just reviewing basic principles of asthma management and I believe that Abc's mother is fairly well versed in this.  I think the most important thing to realize is that Abc probably does have fairly severe childhood asthma and fortunately has avoided hospitalization.  ,I think it would be prudent to continue his alternate day steroids until he is completely symptom free on the days off steroids but it would be reasonable to continue to wean him down to as low as 1.5 milligrams (0.5 milliliters on alternate days).  I have encouraged his mother to contact our office so that we can answer questions if necessary by phone.,Thanks so much for allowing us to be involved in his care.  ,Sincerely,",20
"INDICATION:,  Coronary artery disease, severe aortic stenosis by echo.,PROCEDURE PERFORMED:,1.  Left heart catheterization.,2.  Right heart catheterization.,3.  Selective coronary angiography.,PROCEDURE: , The patient was explained about all the risks, benefits and alternatives to the procedure.  The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in usual sterile fashion.  After local anesthesia with 2% lidocaine, 6-French sheath was inserted in the right femoral artery and 7-French sheath was inserted in the right femoral vein.  Then right heart cath was performed using 7-French Swan-Ganz catheter.  Catheter was placed in the pulmonary capillary wedge position.  Pulmonary capillary wedge pressure, PA pressure was obtained, cardiac output was obtained, then RV, RA pressures were obtained.  The right heart catheter _______ pulled out.  Then selective coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheter.  Then attempt was made to cross the aortic valve with 6-French pigtail catheter, but it was unsuccessful.  After the procedure, catheters were pulled out, sheath was pulled out and hemostasis was obtained by manual pressure.  The patient tolerated the procedure well.  There were no complications.,HEMODYNAMICS:,1.  Cardiac output was 4.9 per liter per minute.  Pulmonary capillary wedge pressure, mean was 7, PA pressure was 20/14, RV 26/5, RA mean pressure was 5.,2.  Coronary angiography, left main is calcified _______ dense complex.,3.  LAD proximal 70% calcified stenosis present and patent stent to the mid LAD and diagonal 1 is a moderate-size vessel, has 70% stenosis.  Left circumflex has diffuse luminal irregularities.  OM1 has 70% stenosis, is a moderate-size vessel.  Right coronary is dominant and has minimal luminal irregularities.,SUMMARY: , Three-vessel coronary artery disease with aortic stenosis by echo with normal pulmonary artery systolic pressure.,RECOMMENDATION: , Aortic valve replacement with coronary artery bypass surgery.",37
"PREOPERATIVE DIAGNOSIS: , Coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.,DESCRIPTION OF PROCEDURE:,LEFT HEART CATHETERIZATION WITH ANGIOGRAPHY AND MID ABDOMINAL AORTOGRAPHY:,Under local anesthesia with 2% lidocaine with premedication, a right groin preparation was done.  Using the percutaneous Seldinger technique via the right femoral artery, a left heart catheterization was performed.  Coronary arteriography was performed with 6-French performed coronary catheters.  We used a 6-French JR4 and JL4 catheters to take multiple cineangiograms of the right and left coronary arteries.  After using the JR4 6-French catheter, nitroglycerin was administered because of the possibility of ostial spasm, and following that, we used a 5-French JR4 catheter for additional cineangiograms of the right coronary artery.  A pigtail catheter was placed in the mid abdominal aorta and abdominal aortic injection was performed to rule out abdominal aortic aneurysm, as there was dense calcification in the mid abdominal aorta.,ANALYSIS OF PRESSURE DATA: , Left ventricular end-diastolic pressure was 5 mmHg.  On continuous tracing from the left ventricle to the ascending aorta, there is no gradient across the aortic valve.  The aortic pressures were normal.  Contours of intracardiac pressure were normal.,ANALYSIS OF ANGIOGRAMS:,  Selective cineangiograms were obtained with injection of contrast to the left ventricle, coronary arteries, and mid abdominal aorta.  A pigtail catheter was introduced into the left ventricle and ventriculogram performed in right anterior oblique position.  The mitral valve is competent and demonstrates normal mobility.  The left ventricular cavity is normal in size with excellent contractility.  Aneurysmal dilatation and/or dyskinesia absent.  The aortic valve is tricuspid and normal mobility.  The ascending aorta appeared normal.,Pigtail catheter was introduced in the mid abdominal aorta and placed just above the renal arteries.  An abdominal aortic injection was performed.  Under fluoroscopy, we see heavy dense calcification of the mid abdominal aorta between the renal artery and the bifurcation.  There was some difficulty initially with maneuvering the wire pass that area and it was felt that might be a tight stenosis.  The abdominal aortogram reveals wide patency of that area with mild intimal irregularity.  There is a normal left renal artery, normal right renal artery.  The celiac seems to be normal, but what I believe is the splenic artery seen initially at its origin is normal.  The common left iliac and common right iliac arteries are essentially normal in this area.,CORONARY ANATOMY:,  One notes ostial coronary calcification of the right coronary artery.  Cineangiogram obtained with 6-French JR4 and 5-French JR4 catheters.  Prior to the introduction of the 5-French JR4 nitroglycerin was administered sublingually.  The 6-French JR4 catheters appeared to a show an ostial lesion of over 50%.  There was backwash of dye into the aorta, although there is a fine funneling of the ostium towards the proximal right coronary artery.  In the proximal portion of the right coronary artery just into the Shepherd turn, there is a 50% smooth tapering of the right coronary artery in the proximal third.  Then the artery seems to have a little bit more normal size and it divides into a large posterior descending artery posterolateral branch vessel.  The distal portion of the vessel is free of disease.  The conus branch is seen arising right at the beginning part of the right coronary artery.  We then removed the 6-French catheter and following nitroglycerin and sublingually we placed a 5-French catheter and again finding a stenosis, may be less than 50%.  At the ostium of the right coronary artery, calcification again is identified.  Backwash of dye noted at the proximal lesion, looked about the same 50% along the proximal turn of the Shepherd turn area.,The left coronary artery is normal, although there is a rim of ostial calcification, but there is no tapering or stenosis.  It forms the left anterior descending artery, the ramus branch, and the circumflex artery.,The left anterior descending artery is a very large vessel, very tortuous in its proximal segment, very tortuous in its mid and distal segment.  There appears to be some mild stenosis of 10% in the proximal segment.  It gives off a large diagonal branch in the proximal portion of the left anterior descending artery and it is free of disease.  The remaining portion of the left anterior descending artery is free of disease.  Upon injection of the left coronary artery, we see what I believe is the dye enters probably directly into the left ventricle, but via fistula excluding the coronary sinus, and we get a ventriculogram performed.  I could not identify an isolated area, but it seems to be from the interventricular septal collaterals that this is taking place.,The ramus branch is normal and free of disease.,The left circumflex artery is a tortuous vessel over the lateral wall and terminating in the inferoposterior wall that is free of disease.,The patient has a predominantly right coronary system.  There is no _______ circulation connecting the right and left coronary systems.,The patient tolerated the procedure well.  The catheter was removed.  Hemostasis was achieved.  The patient was transferred to the recovery room in a stable condition.,IMPRESSION:,1.  Excellent left ventricular contractility with normal left ventricular cavity size.,2.  Calcification of the mid abdominal aorta with wide patency of all vessels.  The left and right renal arteries are normal.  The external iliac arteries are normal.,3.  Essentially normal left coronary artery with some type of interventricular septal to left ventricular fistula.,4.  Ostial stenosis of the right coronary artery that appears to be about 50% or greater.  The proximal right coronary artery has 50% stenosis as well.,5.  Coronary calcification is seen under fluoroscopy at the ostia of the left and right coronary arteries.,RECOMMENDATIONS:  ,The patient has heavy calcification of the coronary arteries and continued risk factor management is needed.  The ostial lesion of the right coronary artery may be severe.  It is at least 50%, but it could be worse.  Therefore, she will be evaluated for the possibility of an IVUS and/or _______ analysis of the proximal right coronary artery.  We will reevaluate her stress nuclear study as well.  Continue aggressive medical therapy.",37
"REASON FOR CATHETERIZATION:,  ST-elevation myocardial infarction.,PROCEDURES UNDERTAKEN,1.  Left coronary system cineangiography.,2.  Right coronary system cineangiography.,3.  Left ventriculogram.,4.  PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.,PROCEDURE: , After all risks and benefits were explained to the patient, informed consent was obtained.  The patient was brought to the cardiac cath suite.  Right groin was prepped in usual sterile fashion.  Right common femoral artery was cannulated with the modified Seldinger technique.  A 6-French sheath was introduced.  Next, Judkins right catheter was used to engage the right coronary artery and cineangiography was recorded in multiple views.  Next, an EBU 3.5 guide was used to engage the left coronary system.  Cineangiography was recorded in several views and it was noted to have a 99% proximal left circumflex stenosis.  Angiomax bolus and drip were started after checking an ACT, which was 180, and an Universal wire was advanced through the left circumflex beyond the lesion.  Next, a 3.0 x 12 mm balloon was used to pre-dilate the lesion.  Next a 3.5 x 12 mm Vision bare-metal stent was advanced to the area of stenosis and deployed at 12 atmospheres.  There was noted to be a plaque shift proximally at the edge of the stent.  Therefore, a 3.5 x 8 mm Vision bare-metal stent was advanced to cover the proximal margin of the first stent and deployed at 12 atmospheres.  Next, a 3.75 x 13 mm noncompliant balloon was advanced into the margin of the stent and two inflations at 20 atmospheres were done for 20 seconds.  Final images showed excellent results with initial 99% stenosis reduced to 0%.  The patient continues to have residual stenosis in the mid to distal in the OM branch.  At this point, wire was removed.  Final images confirmed initial stent results, no evidence of dissection, perforation, or complications.,Next, an angled pigtail catheter was advanced into the left ventricular cavity.  LV pressure was measured.  LV gram was done in both the LAO and RAO projections and a pullback gradient across the aortic valve was done and recorded.  Finally, all guides were removed.  Right femoral artery access site was imaged and Angio-Seal deployed to attain excellent hemostasis.  The patient tolerated the procedure very well without complications.,DIAGNOSTIC FINDINGS,1.  Left main:  Left main is a large-caliber vessel bifurcating in LAD and left circumflex with no significant disease.,2.  The LAD:  LAD is a large-caliber vessel, wraps around the apex, gives off multiple septal perforators, three small-to-medium caliber diagonal branches without any significant disease.,3.  Left circumflex:  Left circumflex is a large-caliber vessel, gives off a large distal PDA branch, has a 99% proximal lesion, 50% mid vessel lesion, and a 50% lesion in the OM, which is a distal branch.,4.  Right coronary artery:  Right coronary artery is a moderate-caliber vessel, dominant, bifurcates into PDA and PLV branches, has only mild disease.  Otherwise, no significant stenosis noted.,5.  LV:  The LVEF 50%.  Inferolateral wall hypokinesis.  No significant mitral regurgitation.  No gradient across the aortic valve on pullback.,ASSESSMENT AND PLAN: , ST-elevation myocardial infarction with a 99% stenosis of the proximal portion of the left circumflex treated with a 3.5 x 12 mm Vision bare-metal stent and a 3.5 x 8 mm Vision bare-metal stent.  Excellent results, 0% residual stenosis.  The patient continues to have some residual 50% stenosis in the left circumflex system, some mild disease throughout the other vessels.  Therefore, we will aggressively treat this patient medically with close followup as an outpatient.",37
"EXAM: , Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.,REASON FOR EXAM: , Abnormal stress test and episode of shortness of breath.,PROCEDURE: , Right common femoral artery, 6-French sheath, JL4, JR4, and pigtail catheters were used.,FINDINGS:,1.  Left main is a large-caliber vessel.  It is angiographically free of disease,,2.  LAD is a large-caliber vessel.  It gives rise to two diagonals and septal perforator.  It erupts around the apex.  LAD shows an area of 60% to 70% stenosis probably in its mid portion.  The lesion is a type A finishing before the takeoff of diagonal 1.  The rest of the vessel is angiographically free of disease.,3.  Diagonal 1 and diagonal 2 are angiographically free of disease.,4.  Left circumflex is a small-to-moderate caliber vessel, gives rise to 1 OM.  It is angiographically free of disease.,5.  OM-1 is angiographically free of disease.,6.  RCA is a large, dominant vessel, gives rise to conus, RV marginal, PDA and one PL.  RCA has a tortuous course and it has a 30% to 40% stenosis in its proximal portion.,7.  LVEDP is measured 40 mmHg.,8.  No gradient between LV and aorta is noted.,Due to contrast concern due to renal function, no LV gram was performed.,Following this, right common femoral angiogram was performed followed by StarClose closure of the right common femoral artery.,IMPRESSION:,1.  60% to 70% mid left anterior descending stenosis.,2.  Mild 30% to 40% stenosis of the proximal right coronary artery.,3.  Status post StarClose closure of the right common femoral artery.,PLAN:  ,Plan will be to perform elective PCI of the mid LAD.",33
"CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission.  He described the pain as 8/10 in severity and the intensity varied.  The symptoms persisted and he subsequently developed nausea and vomiting at 3 a.m. in the morning of admission.  The patient vomited twice and he states that he did note a temporary decrease in pain following his vomiting.  The patient was brought to the emergency room approximately 4 a.m. and evaluation including the CT scan, which revealed dilated loops of bowel without obvious obstruction.  The patient was subsequently admitted for possible obstruction.  The patient does have a history of previous small bowel obstruction approximately 20 times all but 2 required hospitalization, but all resolved with conservative measures (IV fluid, NG tube decompression, bowel rest.)  He has had previous abdominal surgeries including colon resection for colon CA and cholecystectomy as well as appendectomy.,PAST HISTORY: , Hypertension treated with Cozaar 100 mg daily and Norvasc 10 mg daily.  Esophageal reflux treated with Nexium 40 mg daily.  Allergic rhinitis treated with Allegra 180 mg daily.  Sleep disturbances, depression and anxiety treated with Paxil 25 mg daily, Advair 10 mg nightly and Ativan 1 mg nightly.  Glaucoma treated with Xalatan drops.  History of chronic bronchitis with no smoking history for which he uses p.r.n. Flovent and Serevent.,PREVIOUS SURGERIES:  ,Partial colon resection of colon carcinoma in 1961 with no recurrence, cholecystectomy 10 years ago, appendectomy, and glaucoma surgery.,FAMILY HISTORY: , Father died at age 85 of ""old age,"" mother died at age 89 of ""old age.""  Brother died at age 92 of old age, 2 brothers died in their 70s of Parkinson disease.  Son is at age 58 and has a history of hypertension, hypercholesterolemia, rheumatoid arthritis, and glaucoma.,SOCIAL HISTORY:  ,The patient is widowed and a retired engineer.  He denies cigarettes smoking or alcohol intake.,REVIEW OF SYSTEMS: , Denies fevers or weight loss.  HEENT:  Denies headaches, visual abnormality, decreased hearing, tinnitus, rhinorrhea, epistaxis or sore throat.  Neck:  Denies neck stiffness, no pain or masses in the neck.  Respiratory:  Denies cough, sputum production, hemoptysis, wheezing or shortness of breath.  Cardiovascular:  Denies chest pain, angina pectoris, DOE, PND, orthopnea, edema or palpitation.  Gastrointestinal:  See history of the present illness.  Urinary:  Denies dysuria, frequency, urgency or hematuria.  Neuro:  Denies seizure, syncope, incoordination, hemiparesis or paresthesias.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-developed, well-nourished elderly white male who is currently in no acute distress after receiving analgesics.,HEENT:  Atraumatic, normocephalic.  Eyes, EOMs full, PERRLA.  Fundi benign.  TMs normal.  Nose clear.  Throat benign.,NECK:  Supple with no adenopathy.  Carotid upstrokes normal with no bruits.  Thyroid is not enlarged.,LUNGS:  Clear to percussion and auscultation.,HEART:  Regular rate, normal S1 and S2 with no murmurs or gallops.  PMI is nondisplaced.,ABDOMEN:  Mildly distended with mild diffuse tenderness.  There is no rebound or guarding.  Bowel sounds are hypoactive.,EXTREMITIES:  No cyanosis, clubbing or edema.  Pulses are strong and intact throughout.,GENITALIA:  Atrophic male, no scrotal masses or tenderness.  Testicles are atrophic.  No hernia is noted.,RECTAL:  Unremarkable, prostate was not enlarged and there were no nodules or tenderness.,LAB DATA:,  WBC 12.1, hemoglobin and hematocrit 16.9/52.1, platelets 277,000.  Sodium 137, potassium 3.9, chloride 100, bicarbonate 26, BUN 27, creatinine 1.4, glucose 157, amylase 103, lipase 44.  Alkaline phosphatase, AST and ALT are all normal.  UA is negative.,Abdomen and pelvic CT showed mild stomach distention with multiple fluid-filled loops of bowel, no obvious obstruction noted.,IMPRESSION:,1.  Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction.,2.  Hypertension.,3.  Esophageal reflux.,4.  Allergic rhinitis.,5.  Glaucoma.,PLAN: , The patient is admitted to the medical floor.  He has been kept NPO and will be given IV fluids.  He will also be given antiemetic medications with Zofran and an analgesic as necessary.  General surgery consultation was obtained.  Abdominal series x-ray will be done.",5
"TITLE OF OPERATION: , Transnasal transsphenoidal approach in resection of pituitary tumor.,INDICATION FOR SURGERY: , The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.  She was started on Dostinex with increasing dosages.  The most recent MRI demonstrated an increased growth with hemorrhage.  This was then discontinued.  Most recent prolactin was at 70, although normalized, the recommendation was surgical resection given the size of the sellar lesion.  All the risks, benefits, and alternatives were explained in great detail via translator.,PREOP DIAGNOSIS: , Pituitary tumor.,POSTOP DIAGNOSIS: , Pituitary tumor.,PROCEDURE DETAIL:  ,The patient brought to the operating room, positioned on the horseshoe headrest in a neutral position supine.  The fluoroscope was then positioned.  The approach will be dictated by Dr. X. Once the operating microscope and the endoscope were then used to approach it through transnasal, this was complicated and complex secondary to the drilling within the sinus.  Once this was ensured, the tumor was identified, separated from the pituitary gland, it was isolated and then removed.  It appeared to be hemorrhagic and a necrotic pituitary, several sections were sent.  Once this was ensured and completed and hemostasis obtained, the wound was irrigated.  There might have been a small CSF leak with Valsalva, so the recommendation was for a reconstruction, Dr. X will dictate.  The fat graft was harvested from the left lower quadrant and closed primarily, this was soaked in fat and used to close the closure.  All sponge and needle counts were correct.  The patient was extubated and transported to the recovery room in stable condition.  Blood loss was minimal.",23
"DIAGNOSIS:  ,Shortness of breath.  Fatigue and weakness.  Hypertension.  Hyperlipidemia.,INDICATION: , To evaluate for coronary artery disease.,",33
"REASON FOR CONSULT:, Renal insufficiency.,HISTORY OF PRESENT ILLNESS:, A 48-year-old African-American male with a history of coronary artery disease, COPD, congestive heart failure with EF of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. The patient denies any chest pain, palpitations, syncope, or fever. Denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. Nephrology is consulted regarding renal insufficiency.,REVIEW OF SYSTEMS:, Reviewed entirely and negative except for HPI.,PAST MEDICAL HISTORY:, Hypertension, congestive heart failure with ejection fraction of 20%-25% in December 2005, COPD, mild diffuse coronary artery disease, and renal insufficiency.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, Lipitor 20 at bedtime, Toprol XL 100 daily.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY:, The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 180/110. Temperature 98.1. Pulse rate 60. Respiratory rate 23. O2 sat 95% on room air.,GENERAL: A 48-year-old African-American male in no acute distress.,HEENT: Pupils equal, round, and reactive to light and accommodation. No pallor or icterus.,NECK: No JVD, bruit, or lymphadenopathy.,HEART: S1 and S2, regular rate and rhythm, no murmurs, rubs, or gallops.,LUNGS: Clear. No wheezes or crackles.,ABDOMEN: Soft, nontender, nondistended, no organomegaly, bowel sounds present.,EXTREMITIES: No cyanosis, clubbing, or edema.,CNS: Exam is nonfocal.,LABS:, WBC 7, H and H 13 and 40, platelets 330, PT 12, PTT 26, CO2 20, BUN 27, creatinine 3.1, cholesterol 174, BNP 973, troponin 0.18. Previous creatinine levels were 2.7 in December. Urine drug screen positive for cocaine.,ASSESSMENT:, A 48-year-old African-American male with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency with:,1. Hypertensive emergency.,2. Acute on chronic renal failure.,3. Urine drug screen positive.,4. Question CHF versus COPD exacerbation.,PLAN:,1. Most likely, renal insufficiency is a chronic problem. Hypertensive etiology worsened by the patient's chronic cocaine abuse.,2. Control blood pressure with medications as indicated. Hypertensive emergency most likely related to cocaine drug abuse.,Thank you for this consult. We will continue to follow the patient with you.",21
"PREOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,POSTOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,PROCEDURE PERFORMED:,1.  Evacuation of epidural hematoma.,2.  Insertion of epidural drain.,ANESTHESIA: , General.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,200 cc.,HISTORY:  ,This is a 64-year-old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction.  She was then transferred to Beaumont Hospital, at which point, she developed a sternal abscess.  The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren, Michigan at which point, she developed a second what was termed minor myocardial infarction.,The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later, brings us to the month of August, at which time she was at home ambulating with a walker or a cane, and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI, which showed record signal change.  The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery, but objectively there was not much improvement.  Approximately 10 days after the surgery, brings us to today's date, the health officer was notified of the patient's labored breathing.  When she examined the patient, she also noted that the patient was unable to move her extremities.  She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic.  I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma.  On clinical examination, there was swelling in the posterior aspect of the neck.  The patient has no active movement in the upper and lower extremity muscle groups.  Reflexes are absent in the upper and lower extremities.  Long track signs are absent.  Sensory level is at the C4 dermatome.  Rectal tone is absent.  I discussed the findings with the patient and also the daughter.  We discussed the possibility of this is permanent quadriplegia, but at this time, the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery.  They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery.,OPERATIVE PROCEDURE:  ,The patient was taken to OR #1 at ABCD General Hospital on a gurney.  Department of Anesthesia administered fiberoptic intubation and general anesthetic.  A Foley catheter was placed in the bladder.  The patient was log rolled in a prone position on the Jackson table.  Bony prominences were well padded.  The patient's head was placed in the prone view anesthesia head holder.  At this point, the wound was examined closely and there was hematoma at the caudal pole of the wound.  Next, the patient was prepped and draped in the usual sterile fashion.  The previous skin incision was reopened.  At this point, hematoma properly exits from the wound.  All sutures were removed and the epidural spaces were encountered at this time.  The self-retaining retractors were placed in the depth of the wound.  Consolidated hematoma was now removed from the wound.  Next, the epidural space was encountered.  There was no additional hematoma in the epidural space or on the thecal sac.  A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac.  The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well.  Next, the wound was irrigated copiously with one liter of saline using a syringe.  The walls of the wound were explored.  There was no active bleeding.  Retractors were removed at this time and even without pressure on the musculature, there was no active bleeding.  A #19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space.  Fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissue with #3-0 Vicryl sutures.  Steri-Strips covered the incision and dressing was then applied over the incision.  The patient was then log rolled in the supine position on the hospital gurney.  She remained intubated for airway precautions and transferred to the recovery room in stable condition.  Once in the recovery room, she was alert.  She was following simple commands and using her head to nod, but she did not have any active movement of her upper or lower extremities.  Prognosis for this patient is guarded.",22
"OPERATION,1.  Ivor-Lewis esophagogastrectomy.,2.  Feeding jejunostomy.,3.  Placement of two right-sided #28-French chest tubes.,4.  Right thoracotomy.,ANESTHESIA:  ,General endotracheal anesthesia with a dual-lumen tube.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Prior to administration of general anesthesia, the patient had an epidural anesthesia placed.  In addition, he had a dual-lumen endotracheal tube placed.  The patient was placed in the supine position to begin the procedure.  His abdomen and chest were prepped and draped in the standard surgical fashion.  After applying sterile dressings, a #10-blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus.  Dissection was carried down through the linea using Bovie electrocautery.  The abdomen was opened.  Next, a Balfour retractor was positioned as well as a mechanical retractor.  Next, our attention was turned to freeing up the stomach.  In an attempt to do so, we identified the right gastroepiploic artery and arcade.  We incised the omentum and retracted it off the stomach and gastroepiploic arcade.  The omentum was divided using suture ligature with 2-0 silk.  We did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2-0 silk.  Next, we turned our attention to performing a Kocher maneuver.  This was done and the stomach was freed up.  We took down the falciform ligament as well as the caudate attachment to the diaphragm.  We enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest.  We also did a portion of the esophageal dissection from the abdomen into the chest area.  The esophagus and the esophageal hiatus were identified in the abdomen.  We next turned our attention to the left gastric artery.  The left gastric artery was identified at the base of the stomach.  We first took the left gastric vein by ligating and dividing it using 0 silk ties.  The left gastric artery was next taken using suture ligature with silk ties followed by 2-0 stick tie reinforcement.  At this point the stomach was freely mobile.  We then turned our attention to performing our jejunostomy feeding tube.  A 2-0 Vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of Treitz.  We then used Bovie electrocautery to open the jejunum at this site.  We placed a 16-French red rubber catheter through this site.  We tied down in place.  We then used 3-0 silk sutures to perform a Witzel.  Next, the loop of jejunum was tacked up to the abdominal wall using 2-0 silk ties.  After doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately, we turned our attention to closing the abdomen.  This was done with #1 Prolene.  We put in a 2nd layer of 2-0 Vicryl.  The skin was closed with 4-0 Monocryl.,Next, we turned our attention to performing the thoracic portion of the procedure.  The patient was placed in the left lateral decubitus position.  The right chest was prepped and draped appropriately.  We then used a #10 blade scalpel to make an incision in a posterolateral, non-muscle-sparing fashion.  Dissection was carried down to the level of the ribs with Bovie electrocautery.  Next, the ribs were counted and the 5th interspace was entered.  The lung was deflated.  We placed standard chest retractors.  Next, we incised the peritoneum over the esophagus.  We dissected the esophagus to just above the azygos vein.  The azygos vein, in fact, was taken with 0 silk ligatures and reinforced with 2-0 stick ties.  As mentioned, we dissected the esophagus both proximally and distally down to the level of the hiatus.  After doing this, we backed our NG tube out to above the level where we planned to perform our pursestring.  We used an automatic pursestring and applied.  We then transected the proximal portion of the stomach with Metzenbaum scissors.  We secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus.  The pursestring was then tied down without difficulty.  Next, we tabularized our stomach using a #80 GIA stapler.  After doing so, we chose a portion of the stomach more distally and opened it using Bovie electrocautery.  We placed our EEA stapler through it and then punched out through the gastric wall.  We connected our anvil to the EEA stapler.  This was then secured appropriately.  We checked to make sure that there was appropriate muscle apposition.  We then fired the stapler.  We obtained 2 complete rings, 1 of the esophagus and 1 of the stomach, which were sent for pathology.  We also sent the gastroesophageal specimen for pathology.  Of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins.  We then turned our attention to closing the gastrostomy opening.  This was closed with 2-0 Vicryl in a running fashion.  We then buttressed this with serosal 3-0 Vicryl interrupted sutures.  We returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it.  Next, we placed two #28-French chest tubes, 1 anteriorly and 1 posteriorly, taking care not to place it near the anastomosis.  We then closed the chest with #2 Vicryl in an interrupted figure-of-eight fashion.  The lung was brought up.  We closed the muscle layers with #0 Vicryl followed by #0 Vicryl; then we closed the subcutaneous layer with 2-0 Vicryl and the skin with 4-0 Monocryl.  Sterile dressing was applied.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was extubated in the operating room and transferred to the ICU in good condition.",37
"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.",26
"SUBJECTIVE:,  The patient is brought in by an assistant with some of his food diary sheets.  They wonder if the patient needs to lose anymore weight.,OBJECTIVE:,  The patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month.  He has lost a total of 34-1/2 pounds.  I praised this.  I went over his food diary and praised all of his positive food choices reported, especially his use of sugar-free Kool-Aid, sugar-free pudding, and diet pop.  I encouraged him to continue all of that, as well as his regular physical activity.,ASSESSMENT:,  The patient is losing weight at an acceptable rate.  He needs to continue keeping a food diary and his regular physical activity.,PLAN:,  The patient plans to see Dr. XYZ at the end of May 2005.  I recommended that they ask Dr. XYZ what weight he would like for the patient to be at.  Follow up will be with me June 13, 2005.",34
"REASON FOR REFERRAL:  ,The patient was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.,BRIEF SUMMARY & IMPRESSIONS:,RELEVANT HISTORY:,Historical information was obtained from a review of available medical records and an interview with ,the patient.,The patient presented to Dr. X on August 05, 2008 as she had been recently hospitalized for prolonged episodes of syncope.  She was referred to Dr. X for diagnostic differentiation for possible seizures or other causes of syncope.  The patient reports an extensive neurological history.  Her mother used alcohol during her pregnancy with the patient.  In spite of exposure to alcohol in utero, the patient reported that she achieved ""honors in school"" and ""looked smart.""  She reported that she began to experience migraines at 11 years of age.  At 15 years of age, she reported that she was thought to have hydrocephalus.  She reported that she will frequently ""bang her head against the wall"" to relieve the pain.  The patient gave birth to her daughter at 17 years of age.  At 18 years of age, she received a spinal tap as a procedure to determine the cause of her severe headaches.  She reported, in 1995 to 1996 she experienced a severe head injury, as she was struck by a car as a pedestrian and ""thrown two and a half city blocks.""  The patient reported that she could recall before being hit, but could not recall the activities of that same day or the following day.  She reported that she had difficulty walking following this head injury, but received rehabilitation for approximately one month.  Her migraines became more severe following the head injury.  In 1998, she reportedly was experiencing episodes of syncope where she would experience a headache with photophobia, phonophobia, and flashing lights.  Following the syncope episode, she would experience some confusion.  These episodes reportedly were related to her donating plasma.,The patient also reported that her ex-husband stated that she frequently jerked and would shake in her sleep.  She reported that upon awakening, she would feel off balanced and somewhat confused.  These episodes diminished from 2002 to June 2008.  When making dinner, she suddenly dropped and hit the back of her head on refrigerator.  She reported that she was unconscious for five to six minutes.  A second episode occurred on July 20th when she lost consciousness for may be a full day.  She was admitted to Sinai Hospital and assessed by a neurologist.  Her EEG and head CT were considered to be completely normal.  She did not report any typical episodes during the time of her 36-hour EEG.  She reported that her last episode of syncope occurred prior to her being hospitalized.  She stated that she had an aura of her ears ringing, vision being darker and ""tunnel vision"" (vision goes smaller to a pinpoint), and she was ""spazzing out"" on the floor.  During these episodes, she reports that she cannot talk and has difficulty understanding.,The patient also reports that she has experienced some insomnia since she was 6 years old.  She reported that she was a heavy drinker until about 1998 or 1999 and that she would drink a gallon daily of Jack Daniel.  She stopped the use of alcohol and that time she experienced a suicide attempt.  In 2002, she was diagnosed with bipolar disorder and was started on medication.  At the time of the neuropsychological evaluation, she had stopped taking her medicine as she felt that she was now in remission and could manage her symptoms herself.  The patient's medical history is also significant for postpartum depression.,The patient reported that she has been experiencing difficulty with cognitive abilities of attention/concentration, spelling, tangential and slow thinking, poor sequencing memory for events, and variable verbal memory.  She reported that she sometimes has difficulty understanding what people say, specifically she has difficulty understanding jokes.  She finds that she often has difficulty with expressing her thoughts, as she is very tangential.  She experiences episodes of not recalling what she was speaking of or remembering what activities she was trying to perform.  She reported that she had a photographic memory for directions.  She said that she experienced a great deal of emotional lability, but in general her personality has become more subdued.  At the present time, her daughter has now moved on to college.  The patient is living with her biological mother.  Although she is going through divorce, she reported that it was not really stressful.  She reported that she spends her day driving other people around and trying to be helpful to them.,At the time of the neuropsychological evaluation, the patient's medication included Ativan, Imitrex, Levoxyl, vitamin B12, albuterol metered dose inhaler as needed, and Zofran as needed.  (It should be noted that The patient by the time of the feedback on September 19, 2008 had resumed taking her Trileptal for bipolar disorder.).  The patient's familial medical history is significant for alcohol abuse, diabetes, hypertension, and high cholesterol.,TESTS ADMINISTERED:,Clinical Interview,Cognistat,Mattis Dementia Rating Scale,Wechsler Adult Intelligence Scale - III (WAIS-III),Wechsler Abbreviated Scale of Intelligence (WASI),Selected Subtests from the Delis Kaplan Executive Function System (DKEFS),  Trail Making Test,  Verbal Fluency (Letter Fluency & Category Fluency),  Design Fluency,  Color-Word Interference Test,  Tower,Wisconsin Card Sorting Test (WCST),Stroop Test,Color Trails,Trails A & B,Test of Variables of Attention,Multilingual Aphasia Examination II,  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test-2 (BNT-2),Animal Naming Test,The Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI),The Beery-Buktenica Developmental Test of Motor Coordination,The Beery-Buktenica Developmental Test of Visual Perception,Judgment Line Orientation,Grooved Pegboard,Purdue Pegboard,Finger Tapping Test,Rey Complex Figure,Wechsler Memory Scale -III (WMS-III),California Verbal Learning Test",5
"PREOPERATIVE DIAGNOSIS AND INDICATIONS:,  Acute non-ST-elevation MI.,POSTOPERATIVE DIAGNOSIS AND SUMMARY:,  The patient presented with an acute non-ST-elevation MI.  Despite medical therapy, she continued to have intermittent angina.  Angiography demonstrated the severe LAD as the culprit lesion.  This was treated as noted above with angioplasty alone as the stent could not be safely advanced.  She has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual LAD lesions as noted above.  She will be continued on her medical therapy.  At age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.,PROCEDURE PERFORMED: , Selective coronary angiography, coronary angioplasty.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position.  The area of the right femoral artery was prepped and draped in a sterile fashion.  Using the percutaneous technique, a 6-French sheath was placed in the right femoral artery under fluoroscopic guidance.  With the guidewire in place, a 5-French JL-4 catheter was used to selectively angiogram the left coronary system.  The catheter was removed.  The sheath flushed.  The 5-French 3DRC catheter was then used to selectively angiogram the right coronary artery.  The cath removed, the sheath flushed.,It was decided that intervention was needed in the severe lesions in the LAD, which appeared to be the culprit lesions for the non-ST elevation-MI.  The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained, we rebolused and the ACT was slightly lower.  We repeated the level and it was slightly higher.  We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV.  Additionally, the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started.,A 6-French CLS 3.5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal.  An Apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated.  Angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent.  The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium.  The balloon was inflated and removed, repeat angiography performed.  We attempted to advance a Driver 2.5 x 24 mm bare metal stent, but I could not advance it beyond the proximal LAD, where there was significant calcification.  The stent was removed.  Attempts to advance the same 2.5 x 15 mm Apex balloon that was previously used were unsuccessful.  It was removed, a new Apex 2.5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed.  Repeat angiography demonstrated no evidence of dissection.  One more attempt was made to advance the Driver 2.5 x 24 mm bare metal stent, but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal.  I felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed.  The guidewires and guide cath were removed.  The sheath flushed and sutured into position.  The patient moved to ICU in stable condition with no chest discomfort at all.,CONTRAST: , Isovue-370, 120 mL.,FLUORO TIME: , 9.4 minutes.,ESTIMATED BLOOD LOSS: , 30 mL.,HEMODYNAMICS:,  Aorta 185/54.,Left ventriculography was not performed.  I did not make an attempt to cross this severely stenotic aortic valve.,The left main is a large vessel, giving rise to LAD and circumflex vessels.  The left main has no significant disease other than calcification in the walls.,The LAD is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal.  The LAD has significant calcification proximally.  There is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent.  This resulted in a 30% residual, mostly eccentric calcified plaque.  Following this, there was a 50% stenosis in the LAD just after the takeoff of the third diagonal.  This was not ballooned.  Beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal.  These 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal.  As noted above, this area was not stented because I could not safely advance the stent.  Note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.,The circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches.  The proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal.  The remainder of the vessel was without significant disease.,The right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch.  The right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch.  The remainder of the right coronary and its branches were without significant disease.",37
"PREOPERATIVE DIAGNOSIS:  ,Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:,  Right trigger thumb.,OPERATIONS PERFORMED:,  Trigger thumb release.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia applied by surgeon with local.,COMPLICATIONS:,",37
"PREOPERATIVE DIAGNOSIS:,  Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS:,  Right inguinal hernia.,PROCEDURE:,  Right inguinal hernia repair.,INDICATIONS FOR PROCEDURE: , This patient is a 9-year-old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia.  The patient is being taken to the operating room for inguinal hernia repair.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's inguinal and scrotal area were prepped and draped in the usual sterile fashion.  An incision was made in the right inguinal skin crease.  The incision was taken down to the level of the aponeurosis of the external oblique, which was incised up to the level of the external ring.  The hernia sac was verified and dissected at the level of the internal ring and a high ligation performed.  The distal remnant was taken to its end and excised.  The testicle and cord structures were placed back in their native positions.  The aponeurosis of the external oblique was reapproximated with 3-0 Vicryl as well as the Scarpa's, the skin closed with 5-0 Monocryl and dressed with Steri-Strips.  The patient was extubated in the operating room and taken back to the recovery room.  The patient tolerated the procedure well.",38
"HISTORY OF PRESENT ILLNESS:,  A 14-day-old was seen by private doctor because of blister.  On Friday, she was noted to have a small blister near her umbilicus.  They went to their doctor on Saturday, culture was drawn.  It came back today, growing MRSA.  She has been doing well.  They put her on bacitracin ointment near the umbilicus.  That has about healed up.  However today, they noticed a small blister on her left temporal area.  They called the private doctor.  They direct called the Infectious Disease doctor here and was asked that they come into the hospital.  Mom states she has been diagnosed with MRSA on her buttocks as well and is on some medications.  The child has not had any fever.  She has not been lethargic or irritable.  She has been eating well up to 2 ounces every feed.  Eating well and sleeping well.  No other changes have been noted.,PAST MEDICAL HISTORY:,  She was born full term.  No complications.  Home with mom.  No hospitalization, surgeries, allergies.,MEDICATIONS: , As noted.,IMMUNIZATIONS: , Up-to-date.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No ill contacts.  No travel or changes in living condition.,REVIEW OF SYSTEMS:  ,Ten systems were asked, all of them were negative except as noted above.,PHYSICAL EXAMINATION:  ,GENERAL:  Awake, alert female, no acute distress at this time.,HEENT:  Fontanelle soft and flat.  PERRLA.  EOMI.  Conjunctivae are clear.  TMS are clear.  Nares are clear.  Mucous membranes pinks and moist.  Throat clear.  No oral lesions.,NECK:  Supple.,LUNGS:  Clear.,HEART:  Regular rate and rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding, no rebound.  No rashes seen.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  5/5 strength in all extremities.,SKIN:  Her umbilicus looks completely clear.  There is no evidence of erythema.  The area that the parents point where the blister was, appears to be well healed.  There is no evidence of lesion noted, at this time.  On her left temple area and just inside her hairline, there is a small vesicle.  It is not a pustule.  It is almost flat and it has minimal fluid underneath that.  There is no surrounding erythema, tenderness.  I have inspected the body, head to toe.  No other areas of lesions seen.,EMERGENCY DEPARTMENT COURSE: , I spoke with Infectious Disease, Dr. X.  He states, we should treat for MRSA with Bactrim p.o.  There has been no evidence of jaundice with this little girl.  Hibiclens and Bactroban.  I spoke with Dr. X's associate to call back after Dr. X recommended a Herpes culture be done, just for completeness and that was done.  Blood culture was done here to make sure she did not have MRSA in her blood, which clinically, she does not appear to have.  She was discharged in stable condition.,IMPRESSION: , Methicillin-resistant Staphylococcus aureus infection.,PLAN: ,  MRSA Instructions were given as above and antibiotics were prescribed.  To follow up with their doctor.",12
"SOCIAL HISTORY, FAMILY HISTORY, AND PAST MEDICAL HISTORY:, Reviewed.  There are no changes, otherwise.,REVIEW OF SYSTEMS:,  Fatigue, pain, difficulty with sleep, mood fluctuations, low stamina, mild urgency frequency and hesitancy, preponderance of lack of stamina, preponderance of pain particularly in the left shoulder.,EXAMINATION: , The patient is alert and oriented.  Extraocular movements are full.  The face is symmetric.  The uvula is midline.  Speech has normal prosody.  Today there is much less guarding of the left shoulder.  In the lower extremities, iliopsoas, quadriceps, femoris and tibialis anterior are full.  The gait is narrow based and noncircumductive.  Rapid alternating movements are slightly off bilaterally.  The gait does not have significant slapping characteristics.  Sensory examination is largely unremarkable.  Heart, lungs, and abdomen are within normal limits.,IMPRESSION: , Mr. ABC is doing about the same.  We discussed the issue of adherence to Copaxone.  In order to facilitate this, I would like him to take Copaxone every other day, but on a regular rhythm.  His wife continues to inject him.  He has not been able to start himself on the injections.,Greater than 50% of this 40-minute appointment was devoted to counseling.",5
"PREOPERATIVE DIAGNOSIS: , Severe tricompartmental osteoarthritis, left knee with varus deformity.,POSTOPERATIVE DIAGNOSIS:,  Severe tricompartmental osteoarthritis, left knee with varus deformity.,PROCEDURE PERFORMED:  ,Left total knee cemented arthroplasty.,ANESTHESIA: , Spinal with Duramorph.,ESTIMATED BLOOD LOSS:  ,50 mL.,NEEDLE AND SPONGE COUNT:,  Correct.,SPECIMENS: , None.,TOURNIQUET TIME:  ,Approximately 77 minutes.,IMPLANTS USED:,1.  Zimmer NexGen posterior stabilized LPS-Flex GSF femoral component size D, left.,2.  All-poly patella, size 32/8.5 mm thickness.,3.  Prolong highly cross-linked polyethylene 12 mm.,4.  Stemmed tibial component, size 2.,5.  Palacos cement with antibiotics x2 batches.,INDICATION: , The patient is an 84-year-old female with significant endstage osteoarthritis of the left knee, who has had rapid progression with pain and disability.  Surgery was indicated to relieve her pain and improve her functional ability.  Goal objectives and the procedure were discussed with the patient.  Risks and benefits were explained.  No guarantees have been made or implied.  Informed consent was obtained.,DESCRIPTION OF THE PROCEDURE:  ,The patient was taken to the operating room and once an adequate spinal anesthesia with Duramorph was achieved, her left lower extremity was prepped and draped in a standard sterile fashion.  A nonsterile tourniquet was placed proximally in the thigh.  Antibiotics were infused prior to Foley catheter insertion.  Time-out procedure was called.,A straight longitudinal anterior midline incision was made.  Dissection was carried down sharply down the skin, subcutaneous tissue and the fascia.  Deep fascia was exposed.  The tourniquet was inflated at 300 mmHg prior to the skin incision.  A standard medial parapatellar approach was made.  The quadriceps tendon was incised approximately 1 cm from the vastus medialis insertion.  Incision was then carried down distally and distal arthrotomy was completed.  Patellar tendon was well protected.  Retinaculum and capsule was incised approximately 5 mm from the medial border of the patella for later repair.  The knee was exposed very well.  Significant tricompartmental osteoarthritis was noted.  The osteophytes were removed with a rongeur.  Anterior and posterior cruciate ligaments were excised.  Medial and lateral meniscectomies were performed.  Medial dissection was performed subperiosteally along the medial aspect of the proximal tibia to address the varus deformity.  The medial compartment was more affected than lateral.  Medial ligaments were tied.  Retropatellar fat pad was excised.  Osteophytes were removed.  Using a Cobb elevator, the medial soft tissue periosteum envelope was well reflected.,Attention was placed for the preparation of the femur.  The trochlear notch was ossified.  A rongeur was utilized to identify the notch and then using an intramedullary drill guide, a starting hole was created slightly anterior to the PCL attachment.  The anterior portal was 1 cm anterior to the PCL attachment.  The anterior femoral sizer was positioned keeping 3 degrees of external rotation.  Rotation was also verified using the transepicondylar axis and Whiteside line.  The pins were positioned in the appropriate holes.  Anterior femoral cut was performed after placing the cutting guide.  Now, the distal cutting guide was attached to the alignment and 5 degrees of valgus cut was planned.  A distal femoral cut was made which was satisfactory.  A sizer was positioned which was noted to be D.  The 5-in-1 cutting block size D was secured with spring pins over the resected bone.  Using an oscillating saw, cuts were made in a sequential manner such as anterior condyle, posterior condyle, anterior chamfer, and posterior chamfer.  Then using a reciprocating saw, intercondylar base notch cut and side cuts were made.  Following this, the cutting block for High-Flex knee was positioned taking 2 mm of additional posterior condyle.  Using a reciprocating saw, the side cuts were made and bony intercondylar notch cut was completed.  The bone with its attached soft tissue was removed.  Once the femoral preparation was completed, attention was placed for the preparation of the tibia.  The medial and the lateral collateral ligaments were well protected with a retractor.  The PCL retractor was positioned and the tibia was translated anteriorly.  Osteophytes were removed.  The extramedullary tibial alignment guide was affixed to the tibia and appropriate amount of external rotation was considered reference to the medial 1/3rd of the tibial tubercle.  Similarly, horseshoe alignment guide was positioned and the alignment guide was well aligned to the distal 1/3rd of the crest of the tibia as well as the 2nd toe.  Once the alignment was verified in a coronal plane, the tibial EM guide was well secured and then posterior slope was also aligned keeping the alignment rod parallel to the tibial crest.  A built-in 7-degree posterior slope was considered with instrumentation.  Now, the 2 mm stylus arm was positioned over the cutting block medially, which was the most affected site.  Tibial osteotomy was completed 90 degrees to the mechanical axis in the coronal plane.  The resected thickness of the bone was satisfactory taken 2 mm from the most affected site.  The resected surface shows some sclerotic bone medially.  Now, attention was placed for the removal of the posterior osteophytes from the femoral condyle.  Using curved osteotome, angle curette, and a rongeur, the posterior osteophytes were removed.  Now, attention was placed for confirming the flexion-extension gap balance using a 10 mm spacer block in extension and 12 mm in flexion.  Rectangular gap was achieved with appropriate soft tissue balance in both flexion and extension.  The 12 mm spacer block was satisfactory with good stability in flexion and extension.,Attention was now placed for completion of the tibia.  Size 2 tibial trial plate was positioned.  Appropriate external rotation was maintained with the help of the horseshoe alignment rod.  Reference to the tibial crest distally and 2nd toe was considered as before.  The midpoint of the trial tray was collinear with the medial 1/3rd of the tibial tubercle.  The rotation of tibial plate was satisfactory as required and the preparation of the tibia was completed with intramedullary drill followed by broach impactor.  At this point, trial femoral and tibial components were reduced using a 12 mm trial liner.  The range of motion and stability in both flexion and extension was satisfactory.  No further soft tissue release was indicated.  I was able to achieve 0 degrees of extension and complete flexion of the knee.,Attention was now placed for the preparation of the patella.  Using a patellar caliper, the thickness was measured to be 21.5 mm.  This gives an ideal resection of 8.5 mm keeping 13 mm of bone intact.  Reaming was initiated with a patellar reamer reaming up to 13 mm with the reaming alignment guide.  Using a caliper, the resected patella was measured, which was noted to be 13 mm.  A 32 sizer was noted to accommodate the resected surface very well.  Drilling was completed and trial 32 button was inserted without any difficulty.  The tracking was satisfactory.  There was no evidence of any subluxation or dislocation of the patella.  The trial components position was satisfactory.  The alignment and the rotation of all 3 components were satisfactory.  All the trial components were removed and the wound was thoroughly irrigated with Pulsavac lavage irrigation mechanical system.  The resected surfaces were dried with a sponge.  Two batches of Palacos cement were mixed.  The cementing was initiated starting with tibia followed by femur and patella.  Excess peripheral cement were removed with the curette and knife.  The knee was positioned in extension with a 12 mm trial liner.  Patellar clamp was placed after cementing the all-poly patella.  Once the cement was set hard and cured, tourniquet was deflated.  Hemostasis was achieved.  The trial 12 mm liner was replaced with definitive Prolong highly cross-linked polyethylene liner.  Range of motion and stability was verified at 0 degrees and flexion of 120 degrees.  Anterior-posterior drawer test was satisfactory.  Medial and lateral stability was satisfactory.  Patellar tracking was satisfactory.  The wound was thoroughly irrigated.  Hemostasis was achieved.  A local cocktail was injected, which included the mixture of 0.25% plain Marcaine, 30 mg of Toradol, and 4 mg of morphine.  The quadriceps mechanism and distal arthrotomy was repaired with #1 Vicryl in figure-of-8 fashion.  The subcutaneous closure was performed in layers using 2-0 Vicryl and 0 Vicryl followed by 2-0 Vicryl proximally.  The skin was approximated with staples.  Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias.  The patient was then transferred to the recovery room in a stable condition.  There were no intraoperative complications noted.  She tolerated the procedure very well.",37
"PREOPERATIVE DIAGNOSIS:  Large juxtarenal abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS:  Large juxtarenal abdominal aortic aneurysm.,ANESTHESIA:  General endotracheal anesthesia.,OPERATIVE TIME:  Three hours.,ANESTHESIA TIME:  Four hours.,DESCRIPTION OF PROCEDURE:  After thorough preoperative evaluation, the patient was brought to the operating room and placed on the operating table in supine position and after placement of upper extremity IV access and radial A-line, general endotracheal anesthesia was induced.  A Foley catheter was placed and a right internal jugular central line was placed.  The chest, abdomen, both groin, and perineum were prepped widely with Betadine and draped as a sterile field with an Ioban drape.  A long midline incision from xiphoid to pubis was created with a scalpel and the abdomen was carefully entered.  A sterile Omni-Tract was introduced into the field to retract the abdominal wall and gentle exploration of the abdomen was performed.  With the exception of the vascular findings to be described, there were no apparent intra-abdominal abnormalities.,The transverse colon retracted superiorly.  The small bowel was wrapped in moist green towel and retracted in the right upper quadrant.  The posterior peritoneum overlying the aneurysm was scribed mobilizing the ligament of Treitz thoroughly ligating and dividing the inferior mesenteric vein.  Dissection continued superiorly to identify the left renal vein and the right and left inferior renal arteries.  The mid left renal artery was likewise identified.  The perirenal aorta was prepared for clamp superior to the inferior left renal artery.  During this portion of the dissection, the patient was given multiple small doses of intravenous mannitol to establish an osmotic diuresis.  The distal dissection was then completed exposing each common iliac artery.  The arteries were suitable for control.,The patient was then given 8000 units of intravenous sodium heparin and systemic anticoagulation verified by activated clotting time.  The aneurysm was repaired.,First, the common carotid arteries were controlled with atraumatic clamps.  The inferior left renal artery was controlled with a microvascular clamp and a straight aortic clamp was used to control the aorta superior to this renal artery.  The aneurysm was opened on the right anterior lateral aspect and an endarterectomy of the aneurysm sac was performed.  There was a high-grade stenosis at the origin of the inferior mesenteric artery and an eversion endarterectomy was performed at this site.  The vessel was controlled with a microvascular clamp.  Two pairs of lumbar arteries were oversewn with 2-0 silk.  A 14 mm Hemashield tube graft was selected and sewn end-to-end fashion to the proximal aorta using a semi continuous 3-0 Prolene suture.  At the completion of anastomosis three patch stitches of 3-0 Prolene were required for hemostasis.  The graft was cut to appropriate length and sewn end-to-end at the iliac bifurcation using semi-continuous 3-0 Prolene suture.  Prior to completion of this anastomosis, the graft was flushed of air and debris and blood flow was reestablished slowly to the distal native circulation first to the pelvis with external compression on the femoral vessels and finally to the distal native circulation.  The distal anastomosis was competent without leak.,The patient was then given 70 mg of intravenous protamine and final hemostasis obtained using electrocoagulation.  The back bleeding from the inferior mesenteric artery was assessed and was pulsatile and vigorous.  The colon was normal in appearance and this vessel was oversewn using 2-0 silk.  The aneurysm sac was then closed about the grafts snuggly using 3-0 PDS in a vest-over-pants fashion.  The posterior peritoneum was reapproximated using running 3-0 PDS.  The entire large and small bowel were inspected and these structures were well perfused with a strong pulse within the SMA normal appearance of the entire viscera.  The NG tube was positioned in the fundus of the stomach and the viscera returned to their anatomic location.  The midline fascia was then reapproximated using running #1 PDS suture.  The subcutaneous tissues were irrigated with bacitracin and kanamycin solution.  The skin edges coapted using surgical staples.,At the conclusion of the case, sponge and needle counts were correct and a sterile occlusive compressive dressing was applied.",14
"CHIEF COMPLAINT:, Neck and lower back pain.,VEHICULAR TRAUMA HISTORY:, Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient’s vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off the road into a utility pole. The other vehicle had reportedly been driven by a drunk driver and ran a traffic signal. Estimated impact speed was 80 m.p.h. The driver of the other vehicle was reportedly cited by police. The patient was transiently unconscious and came to the scene. There was immediate onset of headaches, neck and lower back pain. The patient was able to exit the vehicle and was subsequently transported by Rescue Squad to St. Thomas Memorial Hospital, evaluated in the emergency room and released.,NECK AND LOWER BACK PAIN HISTORY:, The patient relates the persistence of pain since the motor vehicle accident. Symptoms began immediately following the MVA. Because of persistent symptoms, the patient subsequently sought chiropractic treatment. Neck pain is described as severe. Neck pain remains localized and is non-radiating. There are no associated paresthesias. Back pain originates in the lumbar region and radiates down both lower extremities. Back pain is characterized as worse than the neck pain. There are no associated paresthesias.",27
"HISTORY OF PRESENT ILLNESS:,  Patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today.  He did not note any immediate reaction.  Since that time, he has noted some increasing redness and swelling to his left hand, but he denies any generalized symptoms such as itching, hives, or shortness of breath.  He denies any sensation of tongue swelling or difficulty swallowing.,The patient states he was stung approximately one month ago without any serious reaction.  He did windup taking Benadryl at that time.  He has not taken anything today for his symptoms, but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day.,ALLERGIES: , HE DOES HAVE MEDICATION INTOLERANCES TO SULFA DRUGS (HEADACHE), MORPHINE (NAUSEA AND VOMITING), AND TORADOL (ULCER).,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife, who is here with him.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp and vital signs are all within normal limits.,GENERAL:  In general, the patient is an elderly white male who is sitting on the stretcher in no acute distress.,HEENT:  Head is normocephalic and atraumatic.  The face shows no edema.  The tongue is not swollen and the airway is widely patent.,NECK:  No stridor.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,EXTREMITIES:  Upper extremities, there is some edema and erythema to the dorsum of the left hand in the region of the distal third to fifth metacarpals.  There was some slight edema of the fourth digit, on which he still is wearing his wedding band.  The right hand shows no reaction.  The right knee is not swollen either.,The left fourth digit was wrapped in a rubber tourniquet to express the edema and using some Surgilube, I was able to remove his wedding band without any difficulty.  Patient was given Claritin 10 mg orally for what appears to be a simple local reaction to an insect sting.  I did explain to him that his swelling and redness may progress over the next few days.,ASSESSMENT: , Local reaction secondary to insect sting.,PLAN: , The patient was reassured that this is not a serious reaction to an insect sting and he should not progress to such a reaction.  I did urge him to use Claritin 10 mg once daily until the redness and swelling has gone.  I did explain that the swelling may worsen over the next two to three days, it may produce a large local reaction, but that anti-histamines were still the mainstay of therapy for such a reaction.  If he is not improved in the next four days, follow up with his PCP for a re-exam.",15
"POSTOPERATIVE DIAGNOSIS: , Type 4 thoracoabdominal aneurysm.,OPERATION/PROCEDURE: , A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.,DESCRIPTION OF PROCEDURE IN DETAIL: , Patient was brought to the operating room and put in supine position, and general endotracheal anesthesia was induced through a double-lumen endotracheal tube.  Patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30-degree angle.  The left groin, abdominal and chest were prepped and draped in a sterile fashion.  A thoracoabdominal incision was made.  The 8th interspace was entered.  The costal margin was divided.  The retroperitoneal space was entered and bluntly dissected free to the psoas, bringing all the peritoneal contents to the midline, exposing the aorta.  The inferior pulmonary ligament was then taken down so the aorta could be dissected free at the T10 level just above the diaphragm.  It was dissected free circumferentially.  The aortic bifurcation was dissected free, dissecting free both iliac arteries.  The left inferior pulmonary vein was then dissected free, and a pursestring of 4-0 Prolene was placed on this.  The patient was heparinized.  Through a stab wound in the center of this, a right-angle venous cannula was then placed at the left atrium and secured to a Rumel tourniquet.  This was hooked to a venous inflow of left heart bypass machine.  A pursestring of 4-0 Prolene was placed on the aneurysm and through a stab wound in the center of this, an arterial cannula was placed and hooked to outflow.  Bypass was instituted.  The aneurysm was cross clamped just above T10 and also, cross clamped just below the diaphragm.  The area was divided at this point.  A 26-mm graft was then sutured in place with running 3-0 Prolene suture.  The graft was brought into the diaphragm.  Clamps were then placed on the iliacs, and the pump was shut off.  The aorta was opened longitudinally, going posterior between the left and right renal arteries, and it was completely transected at its bifurcation.  The SMA, celiac and right renal artery were then dissected free as a complete island, and the left renal was dissected free as a complete Carrell patch.  The island was laid in the graft for the visceral liner, and it was sutured in place with running 4-0 Prolene suture with pledgetted 4-0 Prolene sutures around the circumference.  The clamp was then moved below the visceral vessels, and the clamp on the chest was removed, re-establishing flow to the visceral vessels.  The graft was cut to fit the bifurcation and sutured in place with running 3-0 Prolene suture.  All clamps were removed, and flow was re-established.  An 8-mm graft was sutured end-to-end to the Carrell patch and to the left renal.  A partial-occlusion clamp was placed.  An area of graft was removed.  The end of the graft was cut to fit this and sutured in place with running Prolene suture.  The partial-occlusion clamp was removed.  Protamine was given.  Good hemostasis was noted.  The arterial cannula, of course, had been removed when that part of the aneurysm was removed.  The venous cannula was removed and oversewn with a 4-0 Prolene suture.  Good hemostasis was noted.  A 36 French posterior and a 32 French anterior chest tube were placed.  The ribs were closed with figure-of-eight #2 Vicryl.  The fascial layer was closed with running #1 Prolene, subcu with running 2-0 Dexon and the skin with running 4-0 Dexon subcuticular stitch.  Patient tolerated the procedure well.",37
"CLINICAL HISTORY: ,This 78-year-old black woman has a history of hypertension, but no other cardiac problems. She noted complaints of fatigue, lightheadedness, and severe dyspnea on exertion. She was evaluated by her PCP on January 31st and her ECG showed sinus bradycardia with a rate of 37 beats per minute. She has had intermittent severe sinus bradycardia alternating with a normal sinus rhythm, consistent with sinoatrial exit block, and she is on no medications known to cause bradycardia. An echocardiogram showed an ejection fraction of 70% without significant valvular heart disease.,PROCEDURE:, Implantation of a dual chamber permanent pacemaker.,APPROACH:, Left cephalic vein.,LEADS IMPLANTED: ,Medtronic model 12345 in the right atrium, serial number 12345. Medtronic 12345 in the right ventricle, serial number 12345.,DEVICE IMPLANTED: ,Medtronic EnRhythm model 12345, serial number 12345.,LEAD PERFORMANCE: ,Atrial threshold less than 1.3 volts at 0.5 milliseconds. P wave 3.3 millivolts. Impedance 572 ohms. Right ventricle threshold 0.9 volts at 0.5 milliseconds. R wave 10.3. Impedance 855.,ESTIMATED BLOOD LOSS:, 20 mL.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with Versed and fentanyl. The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. A 2-1/2-inch incision was made below the left clavicle and electrocautery was used for hemostasis. Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator. The deltopectoral groove was explored and a medium-sized cephalic vein was identified. The distal end of the vein was ligated and a venotomy was performed. Two guide wires were advanced to the superior vena cava and peel-away introducer sheaths were used to insert the two pacing leads. The venous pressures were elevated and there was a fair amount of back-bleeding from the vein, so a 3-0 Monocryl figure-of-eight stitch was placed around the tissue surrounding the vein for hemostasis. The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage. The leads were tested with a pacing systems analyzer and the results are noted above. The leads were then anchored in place with #0-silk around their suture sleeve and connected to the pulse generator. The pacemaker was noted to function appropriately. The pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket. The incision was closed with two layers of 3-0 Monocryl and a subcuticular closure of 4-0 Monocryl. The incision was dressed with Steri-Strips and a sterile bandage and the patient was returned to her room in good condition.,IMPRESSION: ,Successful implantation of a dual chamber permanent pacemaker via the left cephalic vein. The patient will be observed overnight and will go home in the morning.",37
"PREOPERATIVE DIAGNOSIS: , Necrotizing infection of the left lower abdomen and left peritoneal area.,POSTOPERATIVE DIAGNOSIS:,  Necrotizing infection of the left lower abdomen and left peritoneal area.,PROCEDURE PERFORMED:,  Debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area.,ANESTHESIA:,  General.,FLUIDS:,  800 cc given.,ESTIMATED BLOOD LOSS:  ,350 cc.,SPECIMEN,:  Pannus and left peritoneal specimen sent to Pathology.,REASON FOR PROCEDURE:,  This is a 53-year-old white male who presented to ABCD General Hospital on 09/05/03 with a chief complaint of drainage from his left groin.  The patient is a diabetic who requires insulin, but has been noncompliant and states that his blood sugars have been out of control.  He has had a groin abdominal wound drained for about four days.  The patient states that there has been pus that has saturated his sheath.  He has had a possible fever at home that he did not chart with a thermometer.  He has had the same groin infection twice in the past with tunneling lesions.  The patient states that his wife noted there was a round scar on his abdomen and that was black and had crept up in the last day.  Bowel habits and eating were essentially normal.,Urinary habits were normal.  The patient is morbidly obese and is approximately 450 lb.  He has not been following a diabetic diet or using insulin secondary to lack of funds to put his medications.,PAST MEDICAL HISTORY:,  Diabetes, morbid obesity, and nephrolithiasis.,PAST SURGICAL HISTORY:,  Appendectomy and stone extraction.,PROCEDURE: , The patient was examined in the Emergency Room by Dr. X and was found to have multiple areas of erythematous tissue, which could potentially be consistent with a necrotizing fascitis texture.  The patient had a white count of 11.4 and a hemoglobin of 13.4.  Please note that the patient is a Jehovah's Witness and has adamantly refused receiving any blood products.  The risks and benefits of such were discussed with the patient at length prior to surgery and he was permitted to make sure not to receive blood and his wishes will be granted.  In the operative suite, he was prepped and draped in the usual sterile fashion.  The patient was placed in a lithotomy position to visualize the peritoneum as well as the abdomen.  Copious amounts of Betadine solution were used to cleanse the area and the wound was visualized.  Approximately, 10 cm x 5 cm elliptical incision was made on the lower left quadrant of the abdomen surrounding the area of necrosis.  Necrotic tissue comprised approximately 2 cm x 2 cm area and was indurated.  The abdomen appeared to have a large erythematous border, however, the true indurated tissue was approximately the size of a deck of cards.  The area was incised using a #10 blade scalpel and then Bovie cauterization was used to achieve good hemostasis.  The tissue was removed using an Allis forceps as well as a Bovie to double the incision down to the fascia.  The necrotic tissue was lifted out of the abdomen.  All bleeding was cauterized using the Bovie.  A solution of gentamicin and sterile saline was placed into a high-powered water pump device and the wound was copiously irrigated and suctioned.  A wet Kerlix dressing was passed into the wound and it will be left opened with wet-to-dry dressing.  The left groin area was also incised using an elliptical incision that was approximately 13 cm x 6 cm.  The tissue was incised to the muscle layer of the muscle.  There was a pus pocket that was visible with capsule as well and there was an area of the necrotic tissue as well.  There was a mild amount of pus that drained from the wound.  Cultures were taken from the groin wound and were sent to pathology.  The specimen was excised using traction with the Allis clamps as well as Bovie set on coag.  Once the tissue was excised from the ________, the area was fully irrigated using the gentamicin sterile saline solution in the high-powered water irrigation unit.  After the irrigation, the wound was packed using a wet Kerlix dressing and will be left open to heal.,It was determined at this time that both wounds will be left open to heal with the wet-to-dry dressings in place and we will come back and close the wounds at a later date.  The skin excised from the left lower abdominal quadrant as well as the left groin was sent to pathology.  The patient tolerated the procedure well and was taken to recovery in good condition.",37
"NERVE CONDUCTION TESTING AND EMG EVALUATION,1.  Right median sensory response 3.0, amplitude 2.5, distance 100.,2.  Right ulnar sensory response 2.1, amplitude 1, distance 90.,3.  Left median sensory response 3.0, amplitude 1.2, distance 100.,4.  Left median motor response distal 4.2, proximal 9, amplitude 2.2, distance 290, velocity 60.4 m/sec.,5.  Right median motor response distal 4.3, proximal 9.7, amplitude 2, and velocity 53.7 m/sec.,6.  Right ulnar motor response distal 2.5, proximal 7.5, amplitude 2, distance 300, velocity 60 m/sec.,NEEDLE EMG TESTING,1.  ,RIGHT BICEPS:,  Fibrillations 0, fasciculations occasional, positive waves 0.  Motor units, increased needle insertional activity and mild decreased number of motor units firing.,2.  ,RIGHT TRICEPS:,  Fibrillations 1+, fasciculations occasional to 1+, positive waves 1+.  Motor units, increased needle insertional activity and decreased number of motor units firing.,3.  ,EXTENSOR DIGITORUM:,  Fibrillations 0, fasciculations rare, positive waves 0, motor units probably normal.,4.  ,FIRST DORSAL INTEROSSEOUS: , Fibrillations 2+, fasciculations 1+, positive waves 2+.  Motor units, decreased number of motor units firing.,5.  ,RIGHT ABDUCTOR POLLICIS BREVIS:,  Fibrillations 1+, fasciculations 1+, positive waves 0.  Motor units, decreased number of motor units firing.,6. , FLEXOR CARPI ULNARIS:,  Fibrillations 1+, occasionally entrained, fasciculations rare, positive waves 1+.  Motor units, decreased number of motor units firing.,7.  ,LEFT FIRST DORSAL INTEROSSEOUS:,  Fibrillations 1+, fasciculations 1+, positive waves occasional.  Motor units, decreased number of motor units firing.,8.  ,LEFT EXTENSOR DIGITORUM:,  Fibrillations 1+, fasciculations 1+.  Motor units, decreased number of motor units firing.,9.  ,RIGHT VASTUS MEDIALIS:,  Fibrillations 1+ to 2+, fasciculations 1+, positive waves 1+.  Motor units, decreased number of motor units firing.,10.  ,ANTERIOR TIBIALIS: , Fibrillations 2+, occasionally entrained, fasciculations 1+, positive waves 1+.  Motor units, increased proportion of polyphasic units and decreased number of motor units firing.  There is again increased needle insertional activity.,11.  ,RIGHT GASTROCNEMIUS:,  Fibrillations 1+, fasciculations 1+, positive waves 1+.  Motor units, marked decreased number of motor units firing.,12.  ,LEFT GASTROCNEMIUS:,  Fibrillations 1+, fasciculations 1+, positive waves 2+.  Motor units, marked decreased number of motor units firing.,13.  ,LEFT VASTUS MEDIALIS: , Fibrillations occasional, fasciculations occasional, positive waves 1+.  Motor units, decreased number of motor units firing.,IMPRESSION: ",33
"OPERATION,1.  Ivor-Lewis esophagogastrectomy.,2.  Feeding jejunostomy.,3.  Placement of two right-sided #28-French chest tubes.,4.  Right thoracotomy.,ANESTHESIA:  ,General endotracheal anesthesia with a dual-lumen tube.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Prior to administration of general anesthesia, the patient had an epidural anesthesia placed.  In addition, he had a dual-lumen endotracheal tube placed.  The patient was placed in the supine position to begin the procedure.  His abdomen and chest were prepped and draped in the standard surgical fashion.  After applying sterile dressings, a #10-blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus.  Dissection was carried down through the linea using Bovie electrocautery.  The abdomen was opened.  Next, a Balfour retractor was positioned as well as a mechanical retractor.  Next, our attention was turned to freeing up the stomach.  In an attempt to do so, we identified the right gastroepiploic artery and arcade.  We incised the omentum and retracted it off the stomach and gastroepiploic arcade.  The omentum was divided using suture ligature with 2-0 silk.  We did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2-0 silk.  Next, we turned our attention to performing a Kocher maneuver.  This was done and the stomach was freed up.  We took down the falciform ligament as well as the caudate attachment to the diaphragm.  We enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest.  We also did a portion of the esophageal dissection from the abdomen into the chest area.  The esophagus and the esophageal hiatus were identified in the abdomen.  We next turned our attention to the left gastric artery.  The left gastric artery was identified at the base of the stomach.  We first took the left gastric vein by ligating and dividing it using 0 silk ties.  The left gastric artery was next taken using suture ligature with silk ties followed by 2-0 stick tie reinforcement.  At this point the stomach was freely mobile.  We then turned our attention to performing our jejunostomy feeding tube.  A 2-0 Vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of Treitz.  We then used Bovie electrocautery to open the jejunum at this site.  We placed a 16-French red rubber catheter through this site.  We tied down in place.  We then used 3-0 silk sutures to perform a Witzel.  Next, the loop of jejunum was tacked up to the abdominal wall using 2-0 silk ties.  After doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately, we turned our attention to closing the abdomen.  This was done with #1 Prolene.  We put in a 2nd layer of 2-0 Vicryl.  The skin was closed with 4-0 Monocryl.,Next, we turned our attention to performing the thoracic portion of the procedure.  The patient was placed in the left lateral decubitus position.  The right chest was prepped and draped appropriately.  We then used a #10 blade scalpel to make an incision in a posterolateral, non-muscle-sparing fashion.  Dissection was carried down to the level of the ribs with Bovie electrocautery.  Next, the ribs were counted and the 5th interspace was entered.  The lung was deflated.  We placed standard chest retractors.  Next, we incised the peritoneum over the esophagus.  We dissected the esophagus to just above the azygos vein.  The azygos vein, in fact, was taken with 0 silk ligatures and reinforced with 2-0 stick ties.  As mentioned, we dissected the esophagus both proximally and distally down to the level of the hiatus.  After doing this, we backed our NG tube out to above the level where we planned to perform our pursestring.  We used an automatic pursestring and applied.  We then transected the proximal portion of the stomach with Metzenbaum scissors.  We secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus.  The pursestring was then tied down without difficulty.  Next, we tabularized our stomach using a #80 GIA stapler.  After doing so, we chose a portion of the stomach more distally and opened it using Bovie electrocautery.  We placed our EEA stapler through it and then punched out through the gastric wall.  We connected our anvil to the EEA stapler.  This was then secured appropriately.  We checked to make sure that there was appropriate muscle apposition.  We then fired the stapler.  We obtained 2 complete rings, 1 of the esophagus and 1 of the stomach, which were sent for pathology.  We also sent the gastroesophageal specimen for pathology.  Of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins.  We then turned our attention to closing the gastrostomy opening.  This was closed with 2-0 Vicryl in a running fashion.  We then buttressed this with serosal 3-0 Vicryl interrupted sutures.  We returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it.  Next, we placed two #28-French chest tubes, 1 anteriorly and 1 posteriorly, taking care not to place it near the anastomosis.  We then closed the chest with #2 Vicryl in an interrupted figure-of-eight fashion.  The lung was brought up.  We closed the muscle layers with #0 Vicryl followed by #0 Vicryl; then we closed the subcutaneous layer with 2-0 Vicryl and the skin with 4-0 Monocryl.  Sterile dressing was applied.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was extubated in the operating room and transferred to the ICU in good condition.",3
"PROCEDURE:,  Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance.,INDICATIONS:  ,The patient is a 78-year-old female with back pain referring into the left side.  She has had a couple of epidurals in the past, both of which led to only short-term improvement with intralaminar and caudal placements.  Therefore, transforaminal approach was selected for today's procedure.,Risks and benefits were discussed with the patient.  She agreed to accept the risks and signed informed consent to proceed.,PROCEDURE DETAILS:,  The patient was placed prone on the table.  The skin was thoroughly cleansed with betadine swabs x3 and wiped off with a sterile gauze.  The subcutaneous intramuscular and interligamentous region was anesthetized with buffered 1% lidocaine.,A 5-inch, 22-gauge spinal needle was directed under intermittent fluoroscopic guidance using an oblique approach at the opening of the L5 nerve root.  Once bony contact was made, a lateral was obtained and showed the needle tip to be against the posterior spinal body in the anterior epidural space.  Then an AP view was obtained which showed the needle tip to be below the 6 o'clock position of the pedicle.,EPIDUROGRAM: , Omnipaque 300, 1 mL, was placed through the foraminal opening of the L5 nerve root on the left.  This did show dye spread pattern which was narrowed consistent with foraminal stenosis.  The dye did traverse the foraminal opening and was seen spreading around the pedicle into the anterior epidural space.  It was also spreading peripherally along the L5 nerve root.,The patient tolerated the procedure well.  She did feel that the needle tip was placed at the epicenter of her pain, and this was improved with the placement of the anesthetic.,I will see the patient back in the office in the next few weeks to monitor response of the injection.",28
"Mr. XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice.  For all these reasons, this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history because of the physical effort required in extracting information from this patient.  The patient was seen late because he had not filled in the patient questionnaire.  To summarize the history here, Mr. XYZ who is not very clear on events from the past, sustained a work-related injury some time in 1998.  At that time, he was driving an 18-wheeler truck.  The patient indicated that he slipped off the rear of his truck while loading vehicles to his trailer.  He experienced severe low back pain and eventually a short while later, underwent a fusion of L4-L5 and L5-S1.  The patient had an uneventful hospital course from the surgery, which was done somewhere in Florida by a surgeon, who he does not remember.  He was able to return to his usual occupation, but then again had a second work-related injury in May of 2005.  At that time, he was required to boat trucks to his rig and also to use a chain-pulley system to raise and lower the vehicles.  Mr. XYZ felt a popping sound in his back and had excruciating low back pain and had to be transported to the nearest hospital.  He was MRI'ed at that time, which apparently showed a re-herniation of an L5-S1 disc and then, he somehow ended up in Houston, where he underwent fusion by Dr. W from L3 through S2.  This was done on 12/15/2005.  Initially, he did fairly well and was able to walk and move around, but then gradually the pain reappeared and he started getting severe left-sided leg pain going down the lateral aspect of the left leg into his foot.  He is still complaining of the severe pain right now with tingling in the medial two toes of the foot and significant weakness in his left leg.  The patient was referred to Dr. A, pain management specialist and Dr. A has maintained him on opioid medications consisting of Norco 10/325 mg for breakthrough pain and oxycodone 30 mg t.i.d. with Lunesta 3 mg q.h.s. for sleep, Carisoprodol 350 mg t.i.d., and Lyrica 100 mg q.daily.  The patient states that he is experiencing no side effects from medications and takes medications as required.  He has apparently been drug screened and his drug screening has been found to be normal.  The patient underwent an extensive behavioral evaluation on 05/22/06 by TIR Rehab Center.  At that time, it was felt that Mr. XYZ showed a degree of moderate level of depression.  There were no indications in the evaluation that Mr. XYZ showed any addictive or noncompliant type behaviors.  It was felt at that time that Mr. XYZ would benefit from a brief period of individual psychotherapy and a course of psychotropic medications.  Of concern to the therapist at that time was the patient's untreated and unmonitored hypertension and diabetes.  Mr. XYZ indicated at that time, they had not purchased any prescription medications or any of these health-related issues because of financial limitations.  He still apparently is not under really good treatment for either of these conditions and on today's evaluation, he actually denies that he had diabetes.  The impression was that the patient had axis IV diagnosis of chronic functional limitations, financial loss, and low losses with no axis III diagnosis.  This was done by Rhonda Ackerman, Ph.D., a psychologist.  It was also suggested at that time that the patient should quit smoking.  Despite these evaluations, Mr. XYZ really did not get involved in psychotherapy and there was poor attendance of these visits, there was no clearance given for any surgical interventions and it was felt that the patient has benefited from the use of SSRIs.  Of concern in June of 2006 was that the patient had still not stopped smoking despite warnings.  His hypertension and diabetes were still not under good control and the patient was assessed at significant risk for additional health complications including stroke, reduced mental clarity, and future falls.  It was felt that any surgical interventions should be put on hold at that time.  In September of 2006, the patient was evaluated at Baylor College of Medicine in the Occupational Health Program.  The evaluation was done by a physician at that time, whose report is clearly documented in the record.  Evaluation was done by Dr. B.  At present, Mr. XYZ continues on with his oxycodone and Norco.  These were prescribed by Dr. A two and a half weeks ago and the patient states that he has enough medication left to last him for about another two and a half weeks.  The patient states that there has been no recent change in either the severity or the distribution of his pain.  He is unable to sleep because of pain and his activities of daily living are severely limited.  He spends most of his day lying on the floor, watching TV and occasionally will walk a while.  ***** from detailed questioning shows that his activities of daily living are practically zero.  The patient denies smoking at this time.  He denies alcohol use or aberrant drug use.  He obtains no pain medications from no other sources.  Review of MRI done on 02/10/06 shows laminectomies at L3 through S1 with bilateral posterior plates and pedicle screws with granulation tissue around the thecal sac and around the left L4-5 and S1 nerve roots, which appear to be retracted posteriorly.  There is a small right posterior herniation at L1-L2.,PAST MEDICAL HISTORY:,  Significant for hypertension, hypercholesterolemia and non-insulin-dependent diabetes mellitus.  The patient does not know what medications he is taking for diabetes and denies any diabetes.  CABG in July of 2006 with no preoperative angina, shortness of breath, or myocardial infarction.  History of depression, lumbar fusion surgery in 2000, left knee surgery 25 years ago.,SOCIAL HISTORY:,  The patient is on disability.  He does not smoke.  He does not drink alcohol.  He is single.  He lives with a girlfriend.  He has minimal activities of daily living.  The patient cannot recollect when last a urine drug screen was done.,REVIEW OF SYSTEMS:,  No fevers, no headaches, chest pain, nausea, shortness of breath, or change in appetite.  Depressive symptoms of crying and decreased self-worth have been noted in the past.  No neurological history of strokes, epileptic seizures.  Genitourinary negative.  Gastrointestinal negative.  Integumentary negative.  Behavioral, depression.,PHYSICAL EXAMINATION:,  The patient is short of hearing.  His cognitive skills appear to be significantly impaired.  The patient is oriented x3 to time and place.  Weight 185 pounds, temperature 97.5, blood pressure 137/92, pulse 61.  The patient is complaining of pain of a 9/10.,Musculoskeletal:  The patient's gait is markedly antalgic with predominant weightbearing on the left leg.  There is marked postural deviation to the left.  Because of pain, the patient is unable to heel-toe or tandem gait.  Examination of the neck and cervical spine are within normal limits.  Range of motion of the elbow, shoulders are within normal limits.  No muscle spasm or abnormal muscle movements noted in the neck and upper extremities.  Head is normocephalic.  Examination of the anterior neck is within normal limits.  There is significant muscle wasting of the quadriceps and hamstrings on the left, as well as of the calf muscles.  Skin is normal.  Hair distribution normal.  Skin temperature normal in both the upper and lower extremities.  The lumbar spine curvature is markedly flattened.  There is a well-healed central scar extending from T12 to L1.  The patient exhibits numerous positive Waddell's signs on exam of the low back with inappropriate flinching and wincing with even the lightest touch on the paraspinal muscles.  Examination of the paraspinal muscles show a mild to moderate degree of spasm with a significant degree of tenderness and guarding, worse on the left than the right.  Range of motion testing of the lumbar spine is labored in all directions.  It is interesting that the patient cannot flex more than 5  in the standing position, but is able to sit without any problem.  There is a marked degree of sciatic notch tenderness on the left.  No abnormal muscle spasms or muscle movements were noted.  Patrick's test is negative bilaterally.  There are no provocative facetal signs in either the left or right quadrants of the lumbar area.  Neurological exam:  Cranial nerves II through XII are within normal limits.  Neurological exam of the upper extremities is within normal limits with good motor strength and normal biceps, triceps and brachioradialis reflexes.  Neurological exam of the lower extremities shows a 2+ right patellar reflex and -1 on the left.  There is no ankle clonus.  Babinski is negative.  Sensory testing shows a minimal degree of sensory loss on the right L5 distribution.  Muscle testing shows decreased L4-L5 on the left with extensor hallucis longus +2/5.  Ankle extensors are -3 on the left and +5 on the right.  Dorsiflexors of the left ankle are +2 on the left and +5 on the right.  Straight leg raising test is positive on the left at about 35 .  There is no ankle clonus.  Hoffman's test and Tinel's test are normal in the upper extremities.,Respiratory:  Breath sounds normal.  Trachea is midline.,Cardiovascular:  Heart sounds normal.  No gallops or murmurs heard.  Carotid pulses present.  No carotid bruits.  Peripheral pulses are palpable.,Abdomen:  Hernia site is intact.  No hepatosplenomegaly.  No masses.  No areas of tenderness or guarding.,IMPRESSION:,1.  Post-laminectomy low back syndrome.,2.  Left L5-S1 radiculopathy.,3.  Severe cognitive impairment with minimal ***** for rehabilitation or return to work.,4.  Opioid dependence for pain control.,TREATMENT PLAN:,  The patient will continue on with his medications prescribed by Dr. Chang and I will see him in two weeks' time and probably suggest switching over from OxyContin to methadone.  I do not think this patient is a good candidate for spinal cord stimulation due to his grasp of exactly what is happening and his cognitive impairment.  I will get a behavioral evaluation from Mr. Tom Welbeck and refer the patient for ongoing physical therapy.  The prognosis here for any improvement or return to work is zero.",4
"REASON FOR CONSULTATION:  ,Followup of seizures.,HISTORY OF PRESENT ILLNESS:,  This is a 47-year-old African-American female, well known to the neurology service, who has been referred to me for the first time evaluation of her left temporal lobe epilepsy that was diagnosed in August of 2002.  At that time, she had one generalized tonic-clonic seizure.  Apparently she had been having several events characterized by confusion and feeling unsteady lasting for approximately 60 seconds.  She said these events were very paroxysmal in the sense they suddenly came on and would abruptly stop.  She had two EEGs at that time, one on August 04, 2002 and second on November 01, 2002, both of which showed rare left anterior temporal sharp waves during drowsiness and sleep.  She also had an MRI done on September 05, 2002, with and without contrast that was negative.  Her diagnosis was confirmed by Dr. X at Johns Hopkins Hospital who reviewed her studies as well as examined the patient and felt that actually her history and findings were consistent with diagnosis of left temporal lobe epilepsy.  She was initially started on Trileptal, but had some problems with the medication subsequently Keppra, which she said made her feel bad and subsequently changed in 2003 to lamotrigine, which she has been taking since then.  She reports no seizures in the past several years.  She currently is without complaint.,In terms of seizure risk factors she denies head trauma, history of CNS infection, history of CVA, childhood seizures, febrile seizures.  There is no family history of seizures.,PAST MEDICAL HISTORY: , Significant only for hypertension and left temporal lobe epilepsy.,FAMILY HISTORY: , Remarkable only for hypertension in her father.  Her mother died in a motor vehicle accident.,SOCIAL HISTORY:  ,She works running a day care at home.  She has three children.  She is married.  She does not smoke, use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , Please see note in chart.  Only endorses weight gain and the history of seizures, as well as some minor headaches treated with over-the-counter medications.,CURRENT MEDICATIONS:  ,Lamotrigine 150 mg p.o. b.i.d., verapamil, and hydrochlorothiazide.,ALLERGIES: , Flagyl and aspirin.,PHYSICAL EXAMINATION: , Blood pressure is 138/88, heart rate is 76, respiratory rate is 18, and weight is 224 pounds, pain scale is none.,General Examination:  Please see note in chart, which is essentially unremarkable except mild obesity.,NEUROLOGICAL EXAMINATION: , Again, please see note in chart.  Mental status is normal, cranial nerves are intact, motor is normal bulk and tone throughout with no weakness appreciated in upper and lower extremities bilaterally.  There is no drift and there are no abnormalities to orbit.  Sensory examination, light touch, and temperature intact at all distal extremities.  Cerebellar examination, she has normal finger-to-nose, rapid alternating movements, heel-to-shin, and foot tap.,She rises easily from the chair.  She has normal step, stride, arm swing, toe, heel, and tandem.  Deep tendon reflexes are 2 and equal at biceps, brachioradialis, patella, and 1 at the ankles.,She was seen in the emergency room for chest pain one month ago.  CT of the head was performed, which I reviewed, dated September 07, 2006.  The findings were within the range of normal variation.  There is no evidence of bleeding, mass, lesions, or any evidence of atrophy.,IMPRESSION: , This is a pleasant 47-year-old African-American female with what appears to be cryptogenic left temporal lobe epilepsy that is very well controlled on her current dose of lamotrigine.,PLAN:,1.  Continue lamotrigine 150 mg p.o. b.i.d.,2.  I discussed with the patient the option of a trial of medications.  We need to repeat her EEG as well as her MRI prior to weaning her medications.  The patient wants to continue her lamotrigine at this time.  I concur.,3.  The patient will be following up with me in six months.,",5
"SUBJECTIVE:,  The patient is in with several medical problems.  He complains his mouth being sore since last week and also some ""trouble with my eyes.""  He states that they feel ""funny"" but he is seeing okay.  He denies any more diarrhea or abdominal pain.  Bowels are working okay.  He denies nausea or diarrhea.  Eating is okay.  He is emptying his bladder okay.  He denies dysuria.  His back is hurting worse.  He complains of right shoulder pain and neck pain over the last week but denies any injury.  He reports that his cough is about the same.,CURRENT MEDICATIONS:,  Metronidazole 250 mg q.i.d., Lortab 5/500 b.i.d., Allegra 180 mg daily, Levothroid 100 mcg daily, Lasix 20 mg daily, Flomax 0.4 mg at h.s., aspirin 81 mg daily, Celexa 40 mg daily, verapamil SR 180 mg one and a half tablet daily, Zetia 10 mg daily, Feosol b.i.d.,ALLERGIES: , Lamisil, Equagesic, Bactrim, Dilatrate, cyclobenzaprine.,OBJECTIVE:,General:  He is a well-developed, well-nourished, elderly male in no acute distress.,Vital Signs:  His age is 66.  Temperature:  97.7.  Blood pressure:  134/80.  Pulse:  88.  Weight:  201 pounds.,HEENT:  Head was normocephalic.  Examination of the throat reveals it to be clear.  He does have a few slight red patches on his upper inner lip consistent with yeast dermatitis.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Extremities:  He has full range of motion of his shoulders but some tenderness to the trapezius over the right shoulder.  Back has limited range of motion.  He is nontender to his back.  Deep tendon reflexes are 2+ bilaterally in lower extremities.  Straight leg raising is positive for back pain on the right side at 90 degrees.,Abdomen:  Soft, nontender without hepatosplenomegaly or mass.  He has normal bowel sounds.,ASSESSMENT:,1.  Clostridium difficile enteritis, improved.,2.  Right shoulder pain.,3.  Chronic low back pain.,4.  Yeast thrush.,5.  Coronary artery disease.,6.  Urinary retention, which is doing better.,PLAN:,  I put him on Diflucan 200 mg daily for seven days.  We will have him stop his metronidazole little earlier at his request.  He can drop it down to t.i.d. until Friday of this week and then finish Friday’s dose and then stop the metronidazole and that will be more than a 10-day course.  I ordered physical therapy to evaluate and treat his right shoulder and neck as indicated x 6 visits and he may see Dr. XYZ p.r.n. for his eye discomfort and his left eye pterygium which is noted on exam (minimal redness is noted to the conjunctiva on the left side but no mattering was seen.)  Recheck with me in two to three weeks.",15
"CHIEF COMPLAINT:, ""I can’t walk as far as I used to."",HISTORY OF PRESENT ILLNESS:, The patient is a 66-year-old African American gentleman with a past medical history of atrial fibrillation and arthritis who presented c/o progressively worsening shortness of breath. The patient stated that he had been in his usual state of health six years ago at which time he had been able to walk more than five blocks without difficulty. Approximately five years prior to admission, he began to note a decreased tolerance to exercise. This progressed with a gradual worsening in his functional capacity such that he is presently unable to walk for more than 25 feet. Over the two years prior to admission, he has been having a gradually worsening non-productive cough associated with shortness of breath. His shortness of breath is worse when he lies flat, and he periodically wakes at night gasping for air. He sleeps with three pillows. He has also noted swelling of his legs and states that he has had two episodes of syncope at home for which he has not sought medical attention. Approximately one month prior to admission he was seen in an outside clinic where he states that he was started on medications for heart failure. He stated that he had had a brother who died of heart failure at age 72.,He did report that he had had an episode of hemoptysis approximately 2 years prior to admission for which he did not seek medical attention. He denied any history of chest pain and did not report any history of myocardial infarction. He denied fever, chills, and night sweats. He denied diarrhea, dysuria, hematuria, urgency and frequency. He denied any history of rash. He had been diagnosed with osteoarthritis of the knees and had undergone arthroscopy years prior to admission.,PAST MEDICAL HISTORY :,  Atrial fibrillation on anticoagulation, osteoarthritis of the knees bilaterally, h/o retinal tear.,PAST SURGICAL HISTORY :,  Hernia repair, bilateral arthroscopic evaluation, h/o surgical correction of retinal tear.,FAMILY HISTORY:, The Father of the patient died at age 69 with a CVA. The Mother of the patient died at age 79 when her ""heart stopped"". There were 12 siblings. Four siblings have died, two due to diabetes, one cause unknown, and one brother died at age 72 with heart failure. The patient has four children with no known medical problems.,SOCIAL HISTORY:, The patient retired one year PTA due to his disability. He was formerly employed as an electronic technician for the US postal service. The patient lives with his wife and daughter in an apartment. He denied any smoking history. He used to drink alcohol rarely but stopped entirely with the onset of his symptoms. He denied any h/o drug abuse. He denied any recent travel history.,MEDICATIONS:,1.  Spironolactone 25 mg po qd.,2.  Digoxin 0.125 mg po qod.,3.  Coumadin 3 mg Monday and Tuesday and 4.5 mg Saturday and Sunday.,4.  Metolazone 10 mg po qd.,5.  Captopril 25 mg po tid.,6.  Torsemide 40 mg po qam and 20 mg po qpm.,7.  Carvedilol 3.125 mg po bid.,ALLERGIES:, No known drug allergies.,REVIEW OF SYSTEMS:, No headaches. No visual, hearing, or swallowing difficulties. No changes in bowel or urinary habits.,PHYSICAL EXAM:,Temperature: 98.4 degrees Fahrenheit.,Blood pressure: 134/84.,Heart rate: 98 beats per minute.,Respiratory rate: 18 breaths per minute.,Pulse oximetry: 92% on 2L O 2 via nasal canula.,GEN: Elderly gentleman lying in bed in mild respiratory distress, thin, tired appearing, wife and daughter present at bedside, articulate.,HEENT: The right eye was opacified. The left pupil was reactive to light. There was mild bitemporal wasting. The tongue was moist. There was no lymphadenopathy. The sclerae were anicteric. The oropharynx was clear. The conjunctivae were pink.,NECK: The neck was supple with 15 cm of jugular venous distension.,HEART: Irregularly irregular. No murmurs, gallops, rubs. No displaced PMI.,LUNGS: Breath sounds were absent over two thirds of the right lower lung field. There were trace crackles at the left base.,ABDOMEN: Soft, nontender, nondistended, bowel sounds were present. There was no hepatosplenomegaly. No rebound or guarding.,EXT: Bilateral pitting edema to the thighs with diminished peripheral pulses bilaterally.,NEURO: The patient was alert and oriented x three. Cranial nerves were intact. The DTRs were 2+ bilaterally and symmetrically. Motor strength and sensation were within normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes were present.,SKIN: Warm, no rashes, no lesions; no tattoos.,MUSCULOSKELETAL: No synovitis. There were no joint deformities. Full range of motion b/l throughout.,STUDIES:,CXR: Large right sided pleural effusion. A small pleural effusion with atelectatic changes are seen on the left. The heart size is borderline.,ECHO: LV size is normal. There is severe concentric LV hypertrophy. Global hypokinesis. LV function is severely depressed. Estimate EF is 20-24%. There is RV hypertrophy. RV size is mildly enlarged. RV function is severely depressed. RV wall motion is severely hypokinetic. LA size is moderately enlarged. RA size is mildly enlarged. Trace aortic regurgitation. Moderate tricuspid regurgitation. Estimated PA systolic pressure is 46-51 mmHg, assuming a mean RAP of 15-20mmHg. Small anterior and posterior pericardial effusion.,HOSPITAL COURSE:, The patient was admitted to the hospital for workup and management. A diagnostic procedure was performed.",5
"PROCEDURES:,1.  Robotic-assisted pyeloplasty.,2.  Anterograde right ureteral stent placement.,3.  Transposition of anterior crossing vessels on the right.,4.  Nephrolithotomy.,DIAGNOSIS:,  Right ureteropelvic junction obstruction.,DRAINS:,1.  Jackson-Pratt drain times one from the right flank.,2.  Foley catheter times one.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,SPECIMENS:,1.  Renal pelvis.,2.  Kidney stones.,INDICATIONS:  ,The patient is a 30-year-old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries.  Up on consideration of various modalities and therapy, the patient decided to undergo surgical therapy.,PROCEDURE IN DETAIL:  ,The patient was verified by armband and the procedure being robotic-assisted right pyeloplasty with nephrolithotomy was verified, and the procedure was carried out.  After institution of general endotracheal anesthesia and intravenous preoperative antibiotics, the patient was positioned into the right flank position with his right flank elevated.  Great care was taken to pad all pressure points and a right arm hanger was used.  The patient was flexed slightly, and a kidney rest was used.  Sequential compression devices were also placed.  Next, the patient was prepped and draped in normal sterile fashion with povidone-iodine.  Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test.  A low pressure, high flow pneumoperitoneum was adequately obtained using CO2 gas.  Next, a 12-mm camera port was placed near the umbilicus.  The camera was inserted, and no bowel injury was seen.  Next, under direct vision flanking 8 mm camera ports, a 12 mm assist port, a 5 mm liver retraction port, and 5 mm assist port were placed.  The robot was docked and the instruments passed through respective checks.  Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially.  Next, the right lateral duodenum was cauterized for further access to the right retroperitoneum.  At this point, the right kidney was in clear view, and the fascia was entered.  Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection.  It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole.  These arteries were dissected carefully and vessel loops were applied.  Next, a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out.  The pyelotomy was extended so that the renal collecting system could be directly inspected.  Sequentially, each major calyx was inspected under direct vision and irrigated.  A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient.  At this point, we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis.  The proximal ureter was spatulated using cold scissors.  Next, redundant renal pelvis was excised using cold scissors and sent for permanent section.  We then identified the most inferior/dependent portion of the renal pelvis and placed a heel stitch at this for ureteral-renal pelvis anastomosis in a semi running fashion.  3-0 Monocryl sutures were used to re-anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis.  Next, remainder of the pyelotomy was closed to itself also using 2-0 Monocryl sutures.  Before final stitches were placed, a 6x28 ureteral stent was placed anterograde.  This was accomplished by placing the stents over a guidewire, placing the guidewire under direct vision anterograde through the ureter.  This was done until the proximal end was in the renal pelvis, the guidewire was removed, and good proximal curl was verified by direct vision.  Then, the pyelotomy was completely closed again with 2-0 Monocryl sutures.  Next, attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis.  Good pulsation was verified by direct vision proximal and distal to these pexy sutures.  Next, Gerota's fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum.  Hemostasis appeared excellent at this point.  There was no obvious urine extravasation.  At this time, the procedure was terminated.  The robot was undocked.  Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion.  Then, all skin port sites were closed with 4-0 Monocryl in a subcuticular fashion and Dermabond and band-aids were applied over this.  Also, notably a Jackson-Pratt drain was placed in the area of the right kidney and additional right flank stab incision.  The patient tolerated the procedure well and no immediate perioperative complication was noted.,DISPOSITION: , The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery.",21
"GENERAL APPEARANCE: , This is a well-developed and well-nourished, ??,VITAL SIGNS: , Blood pressure ??, heart rate ?? and regular, respiratory rate ??, temperature is ?? degrees Fahrenheit.  Height is ?? feet ?? inches.  Weight is ?? pounds.  This yields a body mass index of ??.,HEAD, EYES, EARS, NOSE AND THROAT:,  The pupils were equal, round and reactive to light.  Extraocular movements are intact.  Sclera are nonicteric.  Ears, nose, mouth and throat - Externally the ears and nose are normal.  The mucous membranes are moist and midline.,NECK:  ,The neck is supple without masses.  No thyromegaly, no carotid bruits, no adenopathy.,LUNGS:  ,There is a normal respiratory effort.  Bilateral breath sounds are clear.  No wheezes or rales or rhonchi.,CARDIAC: , Normal cardiac impulse location.  S1 and S2 are normal.  No rubs, murmurs or gallops.  A regular rate and rhythm.  There are no abdominal aortic bruits.  The carotid, brachial, radial, femoral, popliteal and dorsalis pedis pulses are 2+ and equal bilaterally.,EXTREMITIES: , The extremities are without clubbing, cyanosis, or edema.,CHEST: , The chest examination is unremarkable.,BREASTS:  ,The breasts show no masses or tenderness.  No axillary adenopathy.,ABDOMEN:,  The abdomen is flat, soft, nontender, no organomegaly, no masses, normal bowel sounds are present.,RECTAL: , Examination was deferred.,LYMPHATIC: , No neck, axillary or groin adenopathy was noted.,SKIN EXAMINATION:,  Unremarkable.,MUSCULOSKELETAL EXAMINATION: , Grossly normal.,NEUROLOGIC: , The cranial nerves two through twelve are grossly intact.  Patellar and biceps reflexes are normal.,PSYCHIATRIC: , The patient is awake, alert and oriented times three.  Judgment and insight are good.  Affect is appropriate.",5
"GENERAL REVIEW OF SYSTEMS,General:  No fevers, chills, or sweats.  No weight loss or weight gain.,Cardiovascular:  No exertional chest pain, orthopnea, PND, or pedal edema.  No palpitations.,Neurologic:  No paresis, paresthesias, or syncope.,Eyes:  No double vision or blurred vision.,Ears:  No tinnitus or decreased auditory acuity.,ENT:  No allergy symptoms, such as rhinorrhea or sneezing.,GI:  No indigestion, heartburn, or diarrhea.  No blood in the stools or black stools.  No change in bowel habits.,GU:  No dysuria, hematuria, or pyuria.  No polyuria or nocturia.  Denies slow urinary stream.,Psych:  No symptoms of depression or anxiety.,Pulmonary:  No wheezing, cough, or sputum production.,Skin:  No skin lesions or nonhealing lesions.,Musculoskeletal:  No joint pain, bone pain, or back pain.  No erythema at the joints.,Endocrine:  No heat or cold intolerance.  No polydipsia.,Hematologic:  No easy bruising or easy bleeding.  No swollen lymph nodes.,PHYSICAL EXAM,Vital: Blood pressure today was *, heart rate *, respiratory rate *.,Ears:  TMs intact bilaterally.  Throat is clear without hyperemia.,Mouth:  Mucous membranes normal.  Tongue normal.,Neck:  Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation; no dullness to percussion.,Heart:  Revealed a regular rhythm, normal S1 and S2.  No murmurs, clicks or gallops.,Abdomen:  Soft to palpation without guarding or rebound.  No masses or hepatosplenomegaly palpable.  Bowel sounds are normoactive.,Extremities:  bilaterally symmetrical.  Peripheral pulses 2+ in all extremities.  No pedal edema.,Neurologic examination:  Essentially intact including cranial nerves II through XII intact bilaterally.  Deep tendon reflexes 2+ and symmetrical.,Genitalia:  Bilaterally descended testes without tenderness or masses.  No hernias palpable.  Rectal examination revealed normal sphincter tone, no rectal mass.  Prostate was *.  Stool was Hemoccult negative.",15
"PREOPERATIVE DIAGNOSIS: , Acute infected olecranon bursitis, left elbow.,POSTOPERATIVE DIAGNOSIS: , Infection, left olecranon bursitis.,PROCEDURE PERFORMED:,1.  Incision and drainage, left elbow.,2.  Excision of the olecranon bursa, left elbow.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,NEEDLE AND SPONGE COUNT: , Correct.,SPECIMENS: , Excised bursa and culture specimens sent to the microbiology.,INDICATION:  ,The patient is a 77-year-old male who presented with 10-day history of pain on the left elbow with an open wound and drainage purulent pus followed by serous drainage.  He was then scheduled for I&D and excision of the bursa.  Risks and benefits were discussed.  No guarantees were made or implied.,PROCEDURE: , The patient was brought to the operating room and once an adequate sedation was achieved, the left elbow was injected with 0.25% plain Marcaine.  The left upper extremity was prepped and draped in standard sterile fashion.  On examination of the left elbow, there was presence of thickening of the bursal sac.  There was a couple of millimeter opening of skin breakdown from where the serous drainage was noted.  An incision was made midline of the olecranon bursa with an elliptical incision around the open wound, which was excised with skin.  The incision was carried proximally and distally.  The olecranon bursa was significantly thickened and scarred.  Excision of the olecranon bursa was performed.  There was significant evidence of thickening of the bursa with some evidence of adhesions.  Satisfactory olecranon bursectomy was performed.  The wound margins were debrided.  The wound was thoroughly irrigated with Pulsavac irrigation lavage system mixed with antibiotic solution.  There was no evidence of a loose body.  There was no bleeding or drainage.  After completion of the bursectomy and I&D, the skin margins, which were excised were approximated with 2-0 nylon in horizontal mattress fashion.  The open area of the skin, which was excised was left _________ and was dressed with 0.25-inch iodoform packing.  Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias.  The patient tolerated the procedure very well.  He was then extubated and transferred to the recovery room in a stable condition.  There were no intraoperative complications noticed.",27
"PREOPERATIVE DIAGNOSIS:,  Right frontotemporal chronic subacute subdural hematoma.,POSTOPERATIVE DIAGNOSIS:,  Right frontotemporal chronic subacute subdural hematoma.,TITLE OF THE OPERATION: , Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.,ASSISTANT: , None.,INDICATIONS: , The patient is a 75-year-old man with a 6-week history of decline following a head injury.  He was rendered unconscious by the head injury.  He underwent an extensive syncopal workup in Mississippi.  This workup was negative.  The patient does indeed have a heart pacemaker.  The patient was admitted to ABCD three days ago and yesterday underwent a CT scan, which showed a large appearance of subdural hematoma.  There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes.  I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity.  The patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room where general and endotracheal anesthesia was obtained.  The head was turned over to the left side and was supported on a cushion.  There was a roll beneath the right shoulder.  The right calvarium was shaved and prepared in the usual manner with Betadine-soaked scrub followed by Betadine paint.  Markings were applied.  Sterile drapes were applied.  A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline.  Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia.  Weitlaner retractors were inserted.  A single bur hole was placed underneath the temporalis muscle.  I placed the craniotomy a bit low in order to have better cosmesis.  A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm.  The bone was set aside.  The dura was clearly discolored and very tense.  The dura was opened in a cruciate fashion with a #15 blade.  There was immediate flow of a thin motor oil fluid under high pressure.  Literally the fluid shot out several inches with the first nick in the membranous cavity.  The dura was reflected back and biopsy of the membranes was taken and sent for permanent section.  The margins of the membrane were coagulated.  The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery.  The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none.  The dura was then closed in a watertight fashion using running locking 4-0 Nurolon.  Tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system.  The wound was irrigated thoroughly once more and was closed in layers.  Muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 Vicryl.  Finally, the skin was closed with running locking 3-0 nylon.,Estimated blood loss for the case was less than 30 mL.  Sponge and needle counts were correct.,FINDINGS: , Chronic subdural hematoma with multiple septations and thickened subdural membrane.,I might add that the arachnoid was not violated at all during this procedure.  Also, it was noted that there was no subarachnoid blood but only subdural blood.",37
"PREOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,POSTOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,OPERATION: , Removal of an ingrown part of the left big toenail with excision of the nail matrix.,DESCRIPTION OF PROCEDURE:  ,After obtaining informed consent, the patient was taken to the minor OR room and intravenous sedation with morphine and Versed was performed and the toe was blocked with 1% Xylocaine after having been prepped and draped in the usual fashion.  The ingrown part of the toenail was freed from its bed and removed, then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail.  The matrix was excised down to the bone and then the skin flap was placed over it.  Hemostasis had been achieved with a cautery.  A tubular dressing was performed to provide a bulky dressing.,The patient tolerated the procedure well.  Estimated blood loss was negligible.  The patient was sent back to Same Day Surgery for recovery.",31
"SUBJECTIVE:,  This is a 12-year-old young man who comes in with about 10 days worth of sinus congestion.  He does have significant allergies including ragweed.  The drainage has been clear.  He had a little bit of a headache yesterday.  He has had no fever.  No one else is ill at home currently.,CURRENT MEDICATIONS:,  Advair and Allegra.  He has been taking these regularly.  He is not sure the Allegra is working for him anymore.  He does think though better than Claritin.,PHYSICAL EXAM:,General:  Alert young man in no distress.,HEENT:  TMs clear and mobile.  Pharynx clear.  Mouth moist.  Nasal mucosa pale with clear discharge.,Neck:  Supple without adenopathy.,Heart:  Regular rate and rhythm without murmur.,Lungs:  Lungs clear, no tachypnea, wheezing, rales or retractions.,Abdomen:  Soft, nontender, without masses or splenomegaly.,ASSESSMENT:,  I think this is still his allergic rhinitis rather than a sinus infection.,PLAN:,  Change to Zyrtec 10 mg samples were given.  He is not using nasal spray, but he has some at home.  He should restart this.  Continue to watch his peak flows to make sure his asthma does not come under poor control.  Call if any further problems.",15
"PREOPERATIVE DIAGNOSIS:,  Aortoiliac occlusive disease.,POSTOPERATIVE DIAGNOSIS:, Aortoiliac occlusive disease.,PROCEDURE PERFORMED:, Aortobifemoral bypass.,OPERATIVE FINDINGS: , The patient was taken to the operating room.  The abdominal contents were within normal limits.  The aorta was of normal size and consistency consistent with arteriosclerosis.  A 16x8 mm Gore-Tex graft was placed without difficulty.  The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.,PROCEDURE: , The patient was taken to the operating room, placed in a supine position, and prepped and draped in the usual sterile manner with Betadine solution.  A longitudinal incision was made after a Betadine-coated drape was placed over the incisional area.  Longitudinal incision was made over each groin initially and carried down to the subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The common deep and superficial femoral arteries were exposed and then these incisions were covered with antibiotic soaked sponges.  Attention was then turned to the abdomen, where a longitudinal incision was made from the pubis xiphoid, carried down subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The abdomen was entered above the umbilicus and then this was extended with care inferiorly as the patient has undergone previous abdominal surgery.  Mild adhesions were lysed.  The omentum was freed.  The small and large intestine were run with no evidence of abnormalities.  The liver and gallbladder were within normal limits.  No abnormalities were noted.  At this point, the Bookwalter retractor was placed.  NG tube was placed in the stomach and placed on suction.  The intestines were gently packed intraabdominally and laterally.  The rest of the peritoneum was then opened.  The aorta was cleared, both proximally and distally.  The left iliac was completely occluded.  The right iliac was to be cleansed.  At this point, 5000 units of aqueous heparin was administered to allow take effect.  The aorta was then clamped below the renal arteries and opened in a longitudinal fashion.  A single lumbar was ligated with #3-0 Prolene.  The inferior mesenteric artery was occluded intraluminally and required no suture closure.  Care was taken to preserve collaterals.  The aorta was measured, and a 16 mm Gore-Tex graft was brought on the field and anastomosed to the proximal aorta using #3-0 Prolene in a running fashion.  Last stitch was tied.  Hemostasis was excellent.  The clamp was gradually removed and additional Prolene was placed in the right posterolateral aspect to obtain better hemostasis.  At this point, strong pulses were present within the graft.  The limbs were vented and irrigated.  Using bimanual technique, the retroperitoneal tunnels were developed immediately on top of the iliac arteries into the groin.  The grafts were then brought through these, care being taken to avoid twisting of the graft.  At this point, the right iliac was then ligated using #0 Vicryl and the clamp was removed.  Hemostasis was excellent.  The right common femoral artery was then clamped proximally and distally, opened with #11 blade extended with Potts scissors.  The graft was _____ and anastomosed to the artery using #5-0 Prolene in a continuous fashion with a stitch _______ running fashion.  Prior to tying the last stitch, the graft and artery were vented and the last stitch was tied.  Flow was initially restored proximally then distally with good results.  Attention was then turned to the left groin and the artery grafts were likewise exposed, cleared proximally and distally.  The artery was opened, extended with a Potts scissors and anastomosis was performed with #5-0 Prolene again with satisfactory hemostasis.  The last stitch was tied.  Strong pulses were present within the artery and graft itself.  At this point, 25 mg of protamine was administered.  The wounds were irrigated with antibiotic solution.  The groins were repacked.  Attention was then returned to the abdomen.  The retroperitoneal area and the anastomotic sites were checked for bleeding and none was present.  The shell of the aorta was closed over the proximal anastomosis and the retroperitoneum was then repaired over the remaining portions of the graft.  The intraabdominal contents were then allowed to resume their normal position.  There was no evidence of ischemia to the large or small bowel.  At this point, the omentum and stomach were repositioned.  The abdominal wall was closed in a running single layer fashion using #1 PDS.  The skin was closed with skin staples.  The groins were again irrigated, closed with #3-0 Vicryl and #4-0 undyed Vicryl and Steri-Strips.  The patient was then taken into the recovery room in satisfactory condition after tolerating the procedure well.  Sponges and instrument counts were correct.  Estimated blood loss 900 cc.",37
"PREOPERATIVE DIAGNOSES:,1.  Medial meniscal tear, posterior horn of left knee.,2.  Carpal tunnel syndrome chronic right hand with intractable pain, numbness, and tingling.,3.  Impingement syndrome, right shoulder with acromioclavicular arthritis, bursitis, and chronic tendonitis.,POSTOPERATIVE DIAGNOSES:,1.  Carpal tunnel syndrome, right hand, severe.,2.  Bursitis, tendonitis, impingement, and AC arthritis, right shoulder.,3.  Medial and lateral meniscal tears, posterior horn old, left knee.,PROCEDURE:,1.  Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection.,2.  Right carpal tunnel release.,3.  Left knee arthroscopy and partial medial and lateral meniscectomy.,ANESTHESIA: , General with regional.,COMPLICATIONS:  ,None.,DISPOSITION: , To recovery room in awake, alert, and in stable condition.,OPERATIVE INDICATIONS: , A very active 50-year-old gentleman who had the above problems and workup revealed the above problems.  He failed nonoperative management.  We discussed the risks, benefits, and possible complications of operative and continued nonoperative management, and he gave his fully informed consent to the following procedure.,OPERATIVE REPORT IN DETAIL: , The patient was brought to the operating room and placed in the supine position on the operating room table.  After adequate induction of general anesthesia, he was placed in the left lateral decubitus position.  All bony prominences were padded.  The right shoulder was prepped and draped in the usual sterile manner using standard Betadine prep, entered through three standard arthroscopic portals anterolateral and posterior incising the skin with a knife using sharp and blunt trocar.,Serial examination of the intraarticular portion of the shoulder showed all the structures to be normal including the biceps tendon ligaments, articular surfaces, and labrum.  Subacromial space was entered.  Visualization was poor due to the hemorrhagic bursitis, and this was resected back.  It was essentially a type-3 acromion, which was converted to a type 1 by aiming the burr anterior from the posterior portal excising the larger anterior spur.  Rotator cuff was little bit fray, but otherwise intact.  Thus, the deep deltoid bursa and the markedly thickened coracoacromial ligament were removed.  The burr was then introduced to the anterior portal and the distal clavicle excision carried out.  The width of burr about 6 mm being careful to preserve the ligaments in the capsule, but removing the spurs and the denuded arthritic joint.,The patient tolerated the procedure very well.  The shoulder was then copiously irrigated, drained free of any residual debris.  The wound was closed with 3-0 Prolene.  Sterile compressive dressing applied.,The patient was then placed on his back in the supine position and the right upper extremity and the left lower extremity were prepped and draped in usual sterile manner using a standard Betadine prep.,The attention was first turned to the right hand where it was elevated, exsanguinated using an Esmarch bandage, and the tourniquet was inflated to 250 mmHg for about 25 minutes.  Volar approach to the carpal ligament was performed incising the skin with a knife and using cautery for hemostasis.  Tenotomy and forceps dissection carried out through the superficial palmar fascia, carried down to the volar carpal ligament, which was then transected sharply with a knife and carried proximal and distal under direct vision using the scissors being careful to avoid the neurovascular structures.,Cautery was used for hemostasis.  The never had an hourglass appearance where it was a kind of constricted as a result of the compression from the ligament, and so a small amount of Celestone was dripped onto the nerve to help quite it down.  The patient tolerated this portion of the procedure very well.  The hand was then irrigated, closed with Monocryl and Prolene, and sterile compressive dressing was applied and the tourniquet deflated.,Attention was then turned to the left knee where it was entered through inferomedial and inferolateral portals incising the skin with a knife and using sharp and blunt trocars.  After entering the knee through inferomedial and inferolateral standard arthroscopic portals, examination of the knee showed a displaced bucket-handle tear in the medial meniscus and a radial tear at the lateral meniscus.  These were resected back to the stable surface using a basket forceps and full-radius shaver.  There was no evidence of any other significant arthritis in the knee.  There was a lot of synovitis, and so after the knee was irrigated out and free of any residual debris, the knee was injected with Celestone and Marcaine with epinephrine.,The patient tolerated the procedure very well, and the wounds were closed with 3-0 Prolene and sterile compressive dressing was applied, and then the patient was taken to the recovery room, extubated, awake, alert, and in stable condition.",37
"HISTORY:,  The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.  He had undergone staged repair beginning on 04/21/1997 with a right modified Blalock-Taussig shunt followed on 09/02/1999 with a bilateral bidirectional Glenn shunt, and left pulmonary artery to main pulmonary artery pericardial patch augmentation.  These procedures were performed at Medical College Hospital.  Family states that they moved to the United States.  Evaluation at the Children's Hospital earlier this year demonstrated complete occlusion of the right bidirectional Glenn shunt as well as occlusion of the proximal right pulmonary artery.  He was also found to have elevated Glenn pressures at 22 mmHg, transpulmonary gradient axis of 14 mmHg.  The QP:QS ratio of 0.6:1.  A large decompressing venous collateral was also appreciated.  The patient was brought back to cardiac catheterization in an attempt to reconstitute the right caval pulmonary anastomosis and to occlude the venous collateral vessel.,DESCRIPTION OF PROCEDURE: , After sedation and local Xylocaine anesthesia, 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 6-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava into the right-sided atrium pulmonary veins and the right ventricle.,Using a 6-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta and ascending aorta.  A separate port of arterial access was obtained in the left femoral artery utilizing a 5-French sheath.,Percutaneous access into the right jugular vein was attempted, but unsuccessful.  Ultrasound on the right neck demonstrated a complete thrombosis of the right internal jugular vein.  Using percutaneous technique and a 5-French sheath, 5-French wedge catheter was inserted into the left internal jugular vein and advanced along the left superior vena cava across the left caval-pulmonary anastomosis into the main pulmonary artery and left pulmonary artery with aid of guidewire.  This catheter then also advanced into the bridging innominate vein.  The catheter was then exchanged over wire for a 4-French Bernstein catheter, which was advanced to the blind end of the right superior vena cava.  A balloon wedge angiogram of the right lower pulmonary vein demonstrated back filling of a small right lower pulmonary artery.  There was no vascular continuity to the stump of the right Glenn.  The jugular venous catheter and sheaths were exchanged over a wire for a 6-French flexor sheath, which was advanced to the proximal right superior vena cava.  The Bernstein catheter was then reintroduced using a Terumo guidewire.  Probing of the superior vena cava facilitated access into the right lower pulmonary artery.  The angiogram in the right pulmonary artery showed a diminutive right lower pulmonary artery and severe long segment proximal stenosis.  The distal pulmonary measured approximately 5.5 to 60 mm in diameter with a long segment stenosis measuring approximately 31 mm in length.  The length of the obstruction was balloon dilated using ultra-thin SD 4 x 2 cm balloon catheter with complete disappearance of the waist.  This facilitated advancement of a flexor sheath into the proximal portion of the stenosis.  A PG 2960 BPX Genesis stent premounted on a 6 mm OptiProbe.  A balloon catheter was advanced across the area of narrowing and inflated with a near-complete disappearance of proximal waist.  Angiogram demonstrated a good stent apposition to the caval wall.  Further angioplasty was then performed utilizing an ultra-thin SDS 8 x 3 cm balloon catheter inflated to 19 atmospheres pressure with complete disappearance of a distinct proximal waist.  Angiogram demonstrated wide patency of reconstituted right caval pulmonary anastomosis though there was no flow seen to the right upper pulmonary artery.  The balloon wedge angiograms were then obtained in the right upper pulmonary veins suggesting the presence of right upper pulmonary artery and not contiguous with the right lower pulmonary artery.  Bernstein catheter was advanced into the main pulmonary artery where a wire probing of the stump of the proximal right pulmonary artery facilitated access to the right upper pulmonary artery.  Angiogram demonstrated severe long segment stenosis of the proximal right pulmonary artery.  Angioplasty of the right pulmonary was then performed using the OptiProbe 6-mm balloon catheter inflated to 16 atmospheres pressure with disappearance of a distinct waist.  Repeat angiogram showed improvement in caliber of right upper pulmonary artery with filling defect of the proximal right pulmonary artery.  The proximal right pulmonary artery was then dilated and stent implanted using a PG 2980 BPX Genesis stent premounted on 8-mm OptiProbe balloon catheter and implanted with complete disappearance of the waist.  Distal right upper pulmonary artery was then dilated and stent implanted utilizing a PG 1870 BPX Genesis stent premounted on 7-mm OptiProbe balloon catheter.  Repeat angiograms were then performed.  Attention was then directed to the large venous collateral vessel arising from the left superior vena cava with a contrast filling of a left-sided azygos vein.  A selective angiogram demonstrated a large azygos vein of the midsection measuring approximately 9.4 mm in diameter.  An Amplatzer 12 mm vascular plug was loaded on the delivery catheter and advanced through the flexor sheath into the azygos vein.  Once stable device was confirmed, the device was released from the delivery catheter.  The 4-French Bernstein catheter was then reintroduced and 5 inch empirical 0.038 inch, 10 cm x 8 mm detachable coils were then implanted above the vascular plug filling the proximal azygos vein.  A pigtail catheter was then introduced into the left superior vena cava for final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the coronary sinus of pulmonary veins, the innominate vein, superior vena cava, the main pulmonary artery, and azygos vein.,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 normal mixed venous saturation, but was low due to systemic arterial desaturation of 79%.  The pulmonary veins were fully saturated with partial pressure of oxygen ranging between 120 and 169 mmHg in 30% oxygen.  Remaining saturations reflected complete admixture.  There was increased saturation in the left pulmonary artery due to aortopulmonary collateral flow.  Phasic right atrial pressures were normal with an A-wave somewhat to the normal right ventricular end-diastolic pressure of 9 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending, descending pressures were similar and normal.  Mean Glenn pressures at initiation of the case were slightly elevated at 14 mmHg with a transpulmonary gradient of 9 mmHg.  The calculated systemic flow was a normal pulmonary flows reduced with a QP:QS ratio of 0.6:1.  The pulmonary vascular resistance was elevated at 4.4 Woods units.  Following stent implantation in the right caval pulmonary anastomosis and right pulmonary artery, there was a slight increase in the Glenn venous pressures to 16 mmHg.  Following embolization of the azygos vein, there was increase in systemic arterial saturation to 84% and increase in mixed venous saturation.  There was similar increase in Glenn pressures to 28 mmHg with a transpulmonary gradient of 14 mmHg.  There was an increase in arterial pressure.  The calculated systemic flow increased from 3.1 liters /minute/meter squared to 4.3 liters/minute/meter squared.  Angiogram within the innominate vein following stent implantation demonstrated appropriate stent position without significant distortion of the innominate vein or proximal cava.  There appeared unobstructed contrast flow to the right lower pulmonary artery of a 1-mmHg mean pressure gradient.  There was absence of contrast filling of the right middle and right upper pulmonary artery.  Final angiogram with a contrast injection in the left superior vena cava showed a forward flow through the right Glenn, a good contrast filling of the right lower pulmonary artery, and a widely patent left Glenn negative contrast washout of the proximal right pulmonary artery and left pulmonary artery presumably due to aortopulmonary collateral flow.  Contrast injection within the right upper pulmonary artery following the stent implantation demonstrated widely patent proximal right pulmonary artery along the length of the implanted stents though with retrograde contrast flow.,INITIAL DIAGNOSES:  ,1.  Asplenia syndrome.,2.  Dextrocardia bilateral superior vena cava.,3.  Atrioventricular septal defect.,4.  Total anomalous pulmonary venous return to the right-sided atrium.,5.  Double outlet right ventricle with malposed great vessels.,6.  Severe pulmonary stenosis.,7.  Separate hepatic venous drainage into the atria.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Right modified Blalock-Taussig shunt.,2.  Bilateral bidirectional Glenn shunt.,3.  Patch augmentation of the main pulmonary to left pulmonary artery.,CURRENT DIAGNOSES:  ,1.  Obstructed right caval pulmonary anastomosis.,2.  Obstructed right proximal pulmonary artery.,3.  Venovenous collateral vessel.,CURRENT INTERVENTION:  ,1.  Balloon dilation of the right superior vena cava and stent implantation.,2.  Balloon dilation of the proximal right pulmonary artery, stent implantation.,3.  Embolization of venovenous collateral vessel.,MANAGEMENT: , The case will be discussed in Combined Cardiology Cardiothoracic Surgery case conference.  A repeat catheterization is recommended in 3 months to assess for right pulmonary artery growth and to assess candidacy for Fontan completion.  The patient will be maintained on anticoagulant medications of aspirin and Plavix.  Further cardiology care will be directed by Dr. X.",3
"HISTORY OF PRESENT ILLNESS: , Hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response, which was resistant to treatment with diltiazem and amiodarone, being followed by Dr. X of cardiology through most of the day.  This afternoon, when I am seeing the patient, nursing informs me that rate has finally been controlled with esmolol, but systolic blood pressures have dropped to the 70s with a MAP of 52.  Dr. X was again consulted from the bedside.  We agreed to try fluid boluses and then to consider Neo-Synephrine pressure support if this is not successful.  In addition, over the last 24 hours, extensive discussions have been held with the family and questions answered by nursing staff concerning the patient's possible move to Tahoe Pacific or a long-term acute care.  Other issues requiring following up today are elevated transaminases, continuing fever, pneumonia, resolving adult respiratory distress syndrome, ventilatory-dependent respiratory failure, hypokalemia, non-ST-elevation MI, hypernatremia, chronic obstructive pulmonary disease, BPH, atrial flutter, inferior vena cava filter, and diabetes.,PHYSICAL EXAMINATION,VITAL SIGNS:  T-max 103.2, blood pressure at this point is running in the 70s/mid 40s with a MAP of 52, heart rate is 100.,GENERAL:  The patient is much more alert appearing than my last examination of approximately 3 weeks ago.  He denies any pain, appears to have intact mentation, and is in no apparent distress.,EYES:  Pupils round, reactive to light, anicteric with external ocular motions intact.,CARDIOVASCULAR:  Reveals an irregularly irregular rhythm.,LUNGS:  Have diminished breath sounds but are clear anteriorly.,ABDOMEN:  Somewhat distended but with no guarding, rebound, or obvious tenderness to palpation.,EXTREMITIES:  Show trace edema with no clubbing or cyanosis.,NEUROLOGICAL:  The patient is moving all extremities without focal neurological deficits.,LABORATORY DATA: , Sodium 149; this is down from 151 yesterday.  Potassium 3.9, chloride 114, bicarb 25, BUN 35, creatinine 1.5 up from 1.2 yesterday, hemoglobin 12.4, hematocrit 36.3, WBC 16.5, platelets 231,000.  INR 1.4.  Transaminases are continuing to trend upwards of SGOT 546, SGPT 256.  Also noted is a scant amount of very concentrated appearing urine in the bag.,IMPRESSION: , Overall impressions continues to be critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,PLAN,1.  Hypotension.  I would aggressively try and fluid replete the patient giving him another liter of fluids.  If this does not work as discussed with Dr. X, we will start some Neo-Synephrine, but also continue with aggressive fluid repletion as I do think that indications are that with diminished and concentrated urine that he may still be down and fluids will still be required even if pressure support is started.,2.  Increased transaminases.  Presumably this is from increased congestion.  This is certainly concerning.  We will continue to follow this.  Ultrasound of the liver was apparently negative.,3.  Fever and elevated white count.  The patient does have a history of pneumonia and empyema.  We will continue current antibiotics per infectious disease and continue to follow the patient's white count.  He is not exceptionally toxic appearing at this time.  Indeed, he does look improved from my last examination.,4.  Ventilatory-dependent respiratory failure.  The patient has received a tracheostomy since my last examination.  Vent management per PMA.,5.  Hypokalemia.  This has resolved.  Continue supplementation.,6.  Hypernatremia.  This is improving somewhat.  I am hoping that with increased fluids this will continue to do so.,7.  Diabetes mellitus.  Fingerstick blood glucoses are reviewed and are at target.  We will continue current management.  This is a critically ill patient with multiorgan dysfunction and signs of worsening renal, hepatic, and cardiovascular function with extremely guarded prognosis.  Total critical care time spent today 37 minutes.",34
"FINDINGS:,There is a large intrasellar mass lesion producing diffuse expansion of the sella turcica. This mass lesions measures approximately 16 x 18 x 18mm (craniocaudal x AP x mediolateral) in size.",22
"PROCEDURE CODES:  64640 times two, 64614 time two, 95873 times two, 29405 times two.,PREOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,POSTOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,ANESTHESIA:  MAC.,COMPLICATIONS:  None.,DESCRIPTION OF TECHNIQUE:  Informed consent was obtained from the patient's mom.  The patient was brought to minor procedures 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 with active EMG stimulation.  Approximately 4 mL of 5% phenol was injected in this location bilaterally.  Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation.  Approximately 50 units was injected in the rectus femoris bilaterally, 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally.  Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL.  After injections were performed, bilateral short leg fiberglass casts were applied.  The patient tolerated the procedure well and no complications were encountered.",22
"OPERATIVE PROCEDURE:,  Bronchoscopy brushings, washings and biopsies.,HISTORY: , This is a 41-year-old woman admitted to Medical Center with a bilateral pulmonary infiltrate, immunocompromise.,INDICATIONS FOR THE PROCEDURE:,  Bilateral infiltrates, immunocompromised host, and pneumonia.,Prior to procedure, the patient was intubated with 8-French ET tube orally by Anesthesia due to her profound hypoxemia and respiratory distress.,DESCRIPTION OF PROCEDURE: , Under MAC and fluoroscopy, fiberoptic bronchoscope was passed through the ET tube.,ET tube was visualized approximately 2 cm above the carina.  Fiberoptic bronchoscope subsequently was passed through the right lower lobe area and transbronchial biopsies under fluoroscopy were done from the right lower lobe x3 as well as the brushings were obtained and the washings.  The patient tolerated the procedure well.  Postprocedure, the patient is to be placed on a ventilator as well as postprocedure chest x-ray pending.  Specimens are sent for immunocompromise panel including PCP stains.,POSTPROCEDURE DIAGNOSIS:,  Pneumonia, infiltrates.",37
"CARDIOLITE TREADMILL EXERCISE STRESS TEST,CLINICAL DATA:,  This is a 72-year-old female with history of diabetes mellitus, hypertension, and right bundle branch block.,PROCEDURE:,  The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS.  There was a normal blood pressure response.  The patient did not complain of any symptoms during the test and other than the right bundle branch block that was present at rest, no other significant electrographic abnormalities were observed.,Myocardial perfusion imaging was performed at rest following the injection of 10 mCi Tc-99 Cardiolite.  At peak pharmacological effect, the patient was injected with 30 mCi Tc-99 Cardiolite.,Gating poststress tomographic imaging was performed 30 minutes after the stress.,FINDINGS:,1.  The overall quality of the study is fair.,2.  The left ventricular cavity appears to be normal on the rest and stress studies.,3.  SPECT images demonstrate fairly homogeneous tracer distribution throughout the myocardium with no overt evidences of fixed and/or reperfusion defect.,4.  The left ventricular ejection fraction was normal and estimated to be 78%.,IMPRESSION: , Myocardial perfusion imaging is normal.  Result of this test suggests low probability for significant coronary artery disease.",33
"PROCEDURE PERFORMED: , Umbilical hernia repair.,PROCEDURE:,  After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine.  The patient was prepped and draped in the usual sterile manner.,A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.  The sac was cleared of overlying adherent tissue, and the fascial defect was delineated.  The fascia was cleared of any adherent tissue for a distance of 1.5 cm from the defect.  The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures.  The umbilicus was then re-formed using 4-0 Vicryl to tack the umbilical skin to the fascia.,The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The skin was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.",38
"REASON FOR VISIT: , The patient referred by Dr. X for evaluation of her possible tethered cord.,HISTORY OF PRESENT ILLNESS:,  Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.  The last surgery was in 03/95.  She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM.,Denies any new bowel or bladder dysfunction or increased sensory loss.  She had some patchy sensory loss from L4 to S1.,MEDICATIONS: , Singulair for occasional asthma.,FINDINGS: , She is awake, alert, and oriented x 3.  Pupils equal and reactive.  EOMs are full.  Motor is 5 out of 5.  She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus.  There is no evidence of clonus.  There is diminished sensation from L4 to S1, having proprioception.,ASSESSMENT AND PLAN: , Possible tethered cord.  I had a thorough discussion with the patient and her parents.  I have recommended a repeat MRI scan.  The prescription was given today.  MRI of the lumbar spine was just completed.  I would like to see her back in clinic.  We did discuss the possible symptoms of this tethering.",22
"A 1 cm infraumbilical skin incision was made.  Through this a Veress needle was inserted into the abdominal cavity.  The abdomen was filled with approximately 2 liters of CO2 gas.  The Veress needle was withdrawn.  A trocar sleeve was placed through the incision into the abdominal cavity.  The trocar was withdrawn and replaced with the laparoscope.  A 1 cm suprapubic skin incision was made.  Through this a second trocar sleeve was placed into the abdominal cavity using direct observation with the laparoscope.  The trocar was withdrawn and replaced with a probe.,The patient was placed in Trendelenburg position, and the bowel was pushed out of the pelvis.  Upon visualization of the pelvis organs, the uterus, fallopian tubes and ovaries were all normal.  The probe was withdrawn and replaced with the bipolar cautery instrument.  The right fallopian tube was grasped approximately 1 cm distal to the cornual region of the uterus.  Electrical current was applied to the tube at this point and fulgurated.  The tube was then regrasped just distal to this and refulgurated.  It was then regrasped just distal to the lateral point and refulgurated again.  The same procedure was then carried out on the opposite tube.  The bipolar cautery instrument was withdrawn and replaced with the probe.  The fallopian tubes were again traced to their fimbriated ends to confirm the burn points on the tubes.  The upper abdomen was visualized, and the liver surface was normal.  The gas was allowed to escape from the abdomen, and the instruments were removed.  The skin incisions were repaired.  The instruments were removed from the vagina.,There were no complications to the procedure.  Blood loss was minimal.  The patient went to the postanesthesia recovery room in stable condition.",37
"REASON FOR CONSULTATION:,  Newly diagnosed head and neck cancer.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old gentleman who was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.  He was also noted to have palpable level 2 cervical lymph nodes.  His staging is T3 N2c M0 Stage IV invasive squamous cell carcinoma of the head and neck.  The patient comes in to the clinic today after radiation Oncology consultation.  His Otolaryngologist performed a direct laryngoscopy with biopsy on July 29, 2010.  The patient reports that in December-January timeframe, he had noted some difficulty swallowing and ear pain.  He had a work up by his local physician that was relatively negative, and he was treated for gastroesophageal reflux disease.  His symptoms continued to progress, and he developed difficulty with his speech, dysphagia, otalgia and odynophagia.  He was then referred to Dr. X and examination revealed a mass at the right base of the tongue that extended across the midline to include the left base of the tongue as well as posterior extension involved in the right tonsillar fossa.  He was noted to have bilateral neck nodes.  His biopsy was positive for squamous cell carcinoma.,PAST MEDICAL HISTORY:,  Significant for mild hypertension.  He has had cataract surgery, gastroesophageal reflux disease and a history of biceps tendon tear.,ALLERGIES: ,  Penicillin.,CURRENT MEDICATIONS: , Lisinopril/hydrochlorothiazide 20/25 mg q.d., alprazolam 0.5 mg q.d., omeprazole 20 mg b.i.d., Lortab 7.5/500 mg q 4h p.r.n.,FAMILY HISTORY: , Significant for father who has stroke and grandfather with lung cancer.,SOCIAL HISTORY: , The patient is married but has been separated from his wife for many years, they remain close, and they have two adult sons.  He is retired from the Air Force, currently works for Lockheed Martin.  He was born and raised in New York.  He does have a smoking history, about a 20 pack-year history and he reports quitting on July 27.  He does drink alcohol socially. No use of illicit drugs.,REVIEW OF SYSTEMS:  ,The patient's chief complaint is fatigue.  He has difficulty swallowing and dysphagia.  He is responding well to Lortab and Tylenol for pain control.  He denies any chest pain, shortness of breath, fevers, chills and night sweats.  The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:",16
"REASON FOR CONSULTATION:, Please evaluate stomatitis, possibly methotrexate related.,HISTORY OF PRESENT ILLNESS:, The patient is a very pleasant 57-year old white female, a native of Cuba, being seen for evaluation and treatment of sores in her mouth that she has had for the last 10-12 days.  The patient has a long history of severe and debilitating rheumatoid arthritis for which she has had numerous treatments, but over the past ten years she has been treated with methotrexate quite successfully.  Her dosage has varied somewhere between 20 and 25 mg per week.  About the beginning of this year, her dosage was decreased from 25 mg to 20 mg, but because of the flare of the rheumatoid arthritis, it was increased to 22.5 mg per week.  She has had no problems with methotrexate as far as she knows.  She also took an NSAID about a month ago that was recently continued because of the ulcerations in her mouth.  About two weeks ago, just about the time the stomatitis began she was placed on an antibiotic for suspected upper respiratory infection.  She does not remember the name of the antibiotic.  Although she claims she remembers taking this type of medication in the past without any problems.  She was on that medication three pills a day for three to four days.  She notes no other problems with her skin.  She remembers no allergic reactions to medication.  She has no previous history of fever blisters.  ,PHYSICAL EXAMINATION:, Reveals superficial erosions along the lips particularly the lower lips.  The posterior buccal mucosa along the sides of the tongue and also some superficial erosions along the upper and lower gingiva.  Her posterior pharynx was difficult to visualize, but I saw no erosions on the areas today.  There did however appear to be one small erosion on the soft palate.  Examination of the rest of her skin revealed no areas of dermatitis or blistering.  There were some macular hyperpigmentation on the right arm where she has had a previous burn, plus the deformities from her rheumatoid arthritis on her hands and feet as well as scars on her knees from total joint replacement surgeries.  ,IMPRESSION: , Erosive stomatitis probably secondary to methotrexate even though the medication has been used for ten years without any problems.  Methotrexate may produce an erosive stomatitis and enteritis after such a use. The patient also may have an enteritis that at this point may have become more quiescent as she notes that she did have some diarrhea about the time her mouth problem developed. She has had no diarrhea today, however. She has noted no blood in her stools and has had no episodes of nausea or vomiting.  ,I am not as familiar with the NSAID causing an erosive stomatitis.  I understand that it can cause gastrointestinal upset, but given the choice between the two, I would think the methotrexate is the most likely etiology for the stomatitis.  ,RECOMMENDED THERAPY: ,I agree with your therapeutic regimen regarding this condition with the use of prednisone and folic acid.  I also agree that the methotrexate must be discontinued in order to produce a resolution of this patients’ skin problem. However, in my experience, this stomatitis may take a number of weeks to go away completely if a patient been on methotrexate, for an extended period of time, because the medication is stored within the liver and in fatty tissue.  Topically I have prescribed Lidex gel, which I find works extremely well in stomatitis conditions.  It can be applied t.i.d.  ,Thank you very much for allowing me to share in the care of this pleasant patient.  I will follow her with you as needed.",5
"PREOPERATIVE DIAGNOSIS: , Intrauterine pregnancy at term with previous cesarean section.,SECONDARY DIAGNOSES,1.  Desires permanent sterilization.,2.  Macrosomia.,POSTOPERATIVE DIAGNOSES,1.  Desires permanent sterilization.,2.  Macrosomia.,3.  Status post repeat low transverse cesarean and bilateral tubal ligation.,PROCEDURES,1.  Repeat low transverse cesarean section.,2.  Bilateral tubal ligation (BTL).,ANESTHESIA: , Spinal.,FINDINGS:,  A viable female infant weighing 7 pounds 10 ounces, assigned Apgars of 9 and 9.  There was normal pelvic anatomy, normal tubes.  The placenta was normal in appearance with a three-vessel cord.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room with an IV running and a Foley catheter in place, satisfactory spinal anesthesia was administered following which a wedge was placed under the right hip.  The abdomen was prepped and draped in a sterile fashion.  A Pfannenstiel incision was made and carried sharply down to the level of fascia.  The fascia was incised transversely.  The fascia was dissected away from the underlying rectus muscles.  With sharp and blunt dissection, rectus muscles were divided in midline.  The perineum was entered bluntly.  The incision was carried vertically with scissors.  Transverse incision was made across the bladder peritoneum.  The bladder was dissected away from the underlying lower uterine segment.  Bladder retractor was placed to protect the bladder.  The lower uterine segment was entered sharply with a scalpel.  Incision was carried transversely with bandage scissors.  Clear amniotic fluids were encountered.  The infant was out of the pelvis and was in oblique vertex presentation.  The head was brought down into the incision and delivered easily as were the shoulders and body.  The mouth and oropharynx were suctioned vigorously.  The cord was clamped and cut.  The infant was passed off to the waiting pediatrician in satisfactory condition.  Cord bloods were taken.,Placenta was delivered spontaneously and found to be intact.  Uterus was explored and found to be empty.  Uterus was delivered through the abdominal incision and massaged vigorously.  Intravenous Pitocin was administered.  T clamps were placed about the margins of the uterine incision, which was closed primarily with a running locking stitch of 0 Vicryl with adequate hemostasis.  Secondary running locking stitch was placed for extra strength to the wound.  At this point, attention was diverted to the patient's tubes, a Babcock clamp grasped the isthmic portion of each tube and approximately 1-cm knuckle on either side was tied off with two lengths of 0 plain catgut.  Intervening knuckle was excised and passed off the field.  The proximal end of the tubal mucosa was cauterized.  Cul-de-sac and gutters were suctioned vigorously.  The uterus was returned to its proper anatomic position in the abdomen.  The fascia was closed with a simple running stitch of 0 PDS.,The skin was closed with running subcuticular of 4-0 Monocryl.  Uterus was expressed of its contents.  Patient was brought to the recovery room in satisfactory condition.  There were no complications.  There was 600 cc of blood loss.  All sponge, needle, and instrument counts were reported to be correct.,SPECIMEN: , Tubal segments.,DRAIN: , Foley catheter draining clear yellow urine.",37
"CIRCUMCISION - OLDER PERSON,OPERATIVE NOTE:,  The patient was taken to the operating room and placed in the supine position on the operating table.  General endotracheal anesthesia was administered.  The patient was prepped and draped in the usual sterile fashion.  A 4-0 silk suture is used as a stay-stitch of the glans penis.  Next, incision line was marked circumferentially on the outer skin 3 mm below the corona.  The incision was then carried through the skin and subcutaneous tissues down to within a layer of * fascia.  Next, the foreskin was retracted.  Another circumferential incision was made 3 mm proximal to the corona.  The intervening foreskin was excised.  Meticulous hemostasis was obtained with electrocautery.  Next, the skin was reapproximated at the frenulum with a U stitch of 5-0 chromic followed by stitches at 12, 3, and 9 o'clock.  The stitches were placed equal distance among these to reapproximate all the skin edges.  Next, good cosmetic result was noted with no bleeding at the end of the procedure.  Vaseline gauze, Telfa, and Elastoplast dressing was applied.  The stay-stitch was removed and pressure held until bleeding stopped.  The patient tolerated the procedure well and was returned to the recovery room in stable condition.",37
"HISTORY: , The patient is a 61-year-old male patient.  I was asked to evaluate this patient because of the elevated blood urea and creatinine.  The patient has ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, history of congestive heart failure status post AICD.  The patient has a history of exposure to asbestos in the past, history of diabetes mellitus of 15 years duration, hypertension, and peripheral vascular disease.  The patient came in with a history of abdominal distention of about one to two months with bruises on the right flank about two days status post fall.  The patient has been having increasing distention of the abdomen and frequent nosebleeds.,PAST MEDICAL HISTORY:,  As above.,PAST SURGICAL HISTORY: , The patient had a pacemaker placed.,ALLERGIES: , NKDA.,REVIEW OF SYSTEMS: , Showed no history of fever, no chills, no weight loss.  No history of sore throat.  No history of any ascites.  No history of nausea, vomiting, or diarrhea.  No black stools.  No history of any rash.  No back pain.  No leg pain.  No neuropsychiatric problems.,FAMILY HISTORY: , History of hypertension, diabetes present.,SOCIAL HISTORY:,  He is a nonsmoker, nonalcoholic, and not a drug user.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure is 124/66, heart rate around 68 per minute, and temperature 96.4.,HEENT:  The patient is atraumatic and normocephalic.  Pupils are equal and reactive to light.  Extraocular muscles are intact.,NECK:  Supple.  No JVD and no thyromegaly.,HEART:  S1 and S2 heard.  No murmurs or extra sounds.,ABDOMEN:  Distention of the abdomen present.,EXTREMITIES:  No pedal edema.,LABORATORY: , His lab investigation showed WBC of 6.2, H&H is 11 and 34.  PT, PTT, and INR is normal.  Urinalysis showed 2+ protein and 3+ blood, and 5 to 10 rbc's.  Potassium is 5.3, BUN of 39, and creatinine of 1.9.  Liver function test, ALT was 12, AST 15, albumin 3, TSH of 4.8, and T3 of 1.33.,IMPRESSION AND PLAN:  ,The patient is admitted with a diagnosis of acute on chronic renal insufficiency, rule out hepatorenal insufficiency could be secondary to congestive heart failure, cardiac cirrhosis, rule out possibility of ascites secondary to mesothelioma because the patient has got history of exposure to asbestos and has got pulmonary nodule, rule out diabetic nephropathy could be secondary to hypertensive nephrosclerosis.  The patient has hematuria could be secondary to benign prostatic hypertrophy, rule out malignancy.  We will do urine for cytology.  We will do a renal ultrasound, and 24-hour urine collection for protein/creatinine, creatinine clearance, immunofixation, serum electrophoresis, serum uric acid, serum iron, TIBC, and serum ferritin levels.  We will send a PSA level and if needed may be a urology consult.",5
"PREOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Multiple strokes.,POSTOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Multiple strokes.,PROCEDURES PERFORMED:,1.  Tracheostomy.,2.  Thyroid isthmusectomy.,ANESTHESIA: , General endotracheal tube.,BLOOD LOSS: , Minimal, less than 25 cc.,INDICATIONS:,  The patient is a 50-year-old gentleman who presented to the Emergency Department who had had multiple massive strokes.  He had required ventilator assistance and was transported to the ICU setting.  Because of the numerous deficits from the stroke, he is expected to have a prolonged ventilatory course and he will be requiring long-term care.,PROCEDURE: , After all risks, benefits, and alternatives were discussed with multiple family members in detail, informed consent was obtained.  The patient was brought to the Operative Suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube.  The neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt-tip marker.  The skin was then anesthetized with a mixture of 1% lidocaine and 1:100,000 epinephrine solution.  The patient was prepped and draped in usual fashion.  The surgeons were gowned and gloved.  A vertical skin incision was then made with a #15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage.  Blunt dissection was then carried down until the fascia overlying the strap muscles were identified.  At this point, the midline raphe was identified and the strap muscles were separated utilizing the Bovie cautery.  Once the strap muscles have been identified, palpation was performed to identify any arterial aberration.  A high-riding innominate was not identified.  At this point, it was recognized that the thyroid gland was overlying the trachea could not be mobilized.  Therefore, dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland, which was then doubly clamped and ligated with Bovie cautery.  Suture ligation with #3-0 Vicryl was then performed on the thyroid gland in a double interlocking fashion.  This cleared a significant portion of the trachea.  The overlying pretracheal fascia was then cleared with use of pressured forceps as well as Bovie cautery.  Now, a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea.  The second tracheal ring was identified.  The Bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based.  At this point, the anesthetist was appropriately alerted to deflate the endotracheal tube cuff.  The airway was entered and inferior to the base, window was created.  The anesthetist then withdrew the endotracheal tube until the tip of the tube was identified.  At this point, a #8 Shiley tracheostomy tube was inserted freely into the tracheal lumen.  The balloon was inflated and the ventilator was attached.  He was immediately noted to have return of the CO2 waveform and was ventilating appropriately according to the anesthetist.  Now, all surgical retractors were removed.  The baseplate of the tracheostomy tube was sutured to the patient's skin with #2-0 nylon suture.  The tube was further secured around the patient's neck with IV tubing.  Finally, a drain sponge was placed.  At this point, procedure was felt to be complete.  The patient was returned to the ICU setting in stable condition where a chest x-ray is pending.",37
"PREOPERATIVE DIAGNOSIS:,  Left thyroid mass.,POSTOPERATIVE DIAGNOSIS:,  Left thyroid mass.,PROCEDURE PERFORMED:,  Left total thyroid lumpectomy.,ANESTHESIA,:  General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:,  None.,INDICATIONS FOR PROCEDURE:,  The patient is a 76-year-old Caucasian female with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.  The patient was then discussed the risks, complications, and consequences of a surgical procedure and a written consent was obtained.,PROCEDURE:  ,The patient is brought to the operative suite by Anesthesia.  The patient was placed on the operative table in supine position.  After this, the patient was placed under general endotracheal intubation anesthesia and the patient was then placed upon a shoulder roll.  After this, the skin incision was marked approximately two fingerbreadths above the sternal notch.  It was then localized with 1% lidocaine with epinephrine 1:1000 approximately 7 cc total.,After this, the patient was then prepped and draped in the usual sterile fashion and a #10 blade was then utilized to make a skin incision.  The subcutaneous tissue was then bluntly dissected utilizing a Ray-Tec sponge and a bear claw was then utilized to retract the upper incisional skin with counter retraction performed to allow a subplatysmal plane of skin flaps to be performed in superior and inferolateral directions.  After this, the midline was then identified and grasped on either side with a DeBakey forceps.  The raphe was noted and Bovie cauterization was utilized to cut down into this region.  The fine stats were utilized to further open this area with exposure and bisection of the sternothyroid muscle.  It was separated on the left side from the patient's sternothyroid muscle.  After this, the sternothyroid muscle was identified, grasped with the DeBakey forceps and infiltrated initially through its fascial plane with the Metzenbaum scissors.  Blunt dissection was then utilized to free the sternothyroid muscle from the thyroid gland in superior and inferior directions and laterally with the help of Kitners.  After this, the plane was rotated more anteriorly with the superior and inferior parathyroid glands identified.  The fat cap was noted to be attached on the superior parathyroid to the posterior aspect of the thyroid itself.  It was freed from the thyroid gland and reflected laterally and posteriorly.  The inferior parathyroid gland actually appeared to be attached also to the inferior aspect of the thyroid itself and was reflected laterally.  After this, the patient's thyroid gland was palpated noting a thyroid nodule in the posterior inferior aspect along with the calcification laterally.  The nodule appeared to be sort of rubbery in consistency and approximately 1 cm diameter.  As the gland was rotated more anteriorly, the recurrent laryngeal nerve on the left side was identified and further dissection along Berry's ligament on the medial aspect was performed.  The middle thyroid vein and inferior thyroid artery were both cauterized with a bipolar cautery and bisected.  After this, the gland was easily rotated anteriorly with further dissection carried up to the superior pole.  The superior pole was exposed with the help of a Richardson and Army-Navy retractors with cross-clamping and tying of the superior laryngeal artery and vein.  Further, the small bleeding vessels were identified and bipolared, and cut with the Metzenbaum scissors.  The superior pole was finally freed and the gland was rotated more anteriorly onto the anterior aspect of the trachea.  Berry's ligament was finally freed and the gland was cross-clamped on the opposing thyroid isthmus with a mosquito.  After this, the gland was cut with a Metzenbaum scissors and tied with a #3-0 undyed Vicryl tie.  The defect on the neck now was thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization.  Surgicel was then cut in small strips and three replaced in the lateral part of the neck.,The opposing side of the thyroid gland on the right was palpated with no noticeable nodules or masses.  The strap muscles were then reapproximated with #3-0 Vicryl on a SH, followed by reapproximation of the subcutaneous tissue with #4-0 Vicryl, followed by reapproximation of the skin by running subcuticular #5-0 Prolene and a #6-0 fast absorbing gut.  Mastisol, Steri-Strips, and bacitracin were placed followed by a sterile 4 x 4 dressing.  The patient was then turned back to Anesthesia, extubated in the operating room, and transferred to Recovery in stable condition.  The patient tolerated the procedure well and will be admitted to hospital for 23-hour observation and will be followed up in one week afterwards.",13
"EXAM:,  Ultrasound-guided paracentesis,HISTORY: , Ascites.,TECHNIQUE AND FINDINGS:  ,Informed consent was obtained from the patient after the risks and benefits of the procedure were thoroughly explained.  Ultrasound demonstrates free fluid in the abdomen.  The area of interest was localized with ultrasonography.  The region was sterilely prepped and draped in the usual manner.  Local anesthetic was administered.  A 5-French Yueh catheter needle combination was taken.  Upon crossing into the peritoneal space and aspiration of fluid, the catheter was advanced out over the needle.  A total of approximately 5500 mL of serous fluid was obtained.  The catheter was then removed.  The patient tolerated the procedure well with no immediate postprocedure complications.,IMPRESSION: , Ultrasound-guided paracentesis as above.",37
"HISTORY:  ,The patient is a 53-year-old male who was seen for evaluation at the request of Dr. X regarding recurrent jaw pain.  This patient has been having what he described as numbness and tingling along the jaw, teeth, and tongue.  This numbness has been present for approximately two months.  It seems to be there ""all the time.""  He was seen by his dentist and after dental evaluation was noted to be ""okay.""  He had been diagnosed with a throat infection about a week ago and is finishing a course of Avelox at this time.  He has been taking cough drops and trying to increase his fluids.  He has recently stopped tobacco.  He has been chewing tobacco for about 30 years.  Again, there is concern regarding the numbness he has been having.  He has had a loss of sensation of taste as well.  Numbness seems to be limited just to the left lateral tongue and the jaw region and extends from the angle of the jaw to the lip.  He does report he has had about a 20-pound of weight gain over the winter, but notes he has had this in the past just simply from decreased activity.  He has had no trauma to the face.  He does note a history of headaches.  These are occasional and he gets these within the neck area when they do flare up.  The headaches are noted to be less than one or two times per month.  The patient does note he has a history of anxiety disorder as well.  He has tried to eliminate his amount of tobacco and he is actually taking Nicorette gum at this time.  He denies any fever or chills.  He is not having any dental pain with biting down.  He has had no jaw popping and no trismus noted.  The patient is concerned regarding this numbness and presents today for further workup, evaluation, and treatment.,REVIEW OF SYSTEMS: , Other than those listed above were otherwise negative.,PAST SURGICAL HISTORY: , Pertinent for hernia repair.,FAMILY HISTORY: , Pertinent for hypertension.,CURRENT MEDICATIONS:,  Tylenol.  He is on Nicorette gum.,ALLERGIES:  ,He is allergic to codeine, unknown reaction.,SOCIAL HISTORY:  ,The patient is single, self-employed carpenter.  He chews tobacco or having chewing tobacco for 30 years, about half a can per day, but notes he has been recently off, and he does note occasional moderate alcohol use.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Blood pressure is 138/82, pulse 64 and regular, temperature 98.3, and weight is 191 pounds.,GENERAL:  The patient is an alert, cooperative, obese, 53-year-old male with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  Both ears, external ears are normal.  The ear canals are clean and dry.  The drums are intact and mobile.  He does have moderate tympanosclerosis noted, no erythema.  Weber exam is midline.  Hearing is grossly intact and normal.,NASAL:  Reveals a deviated nasal septum to the left, moderate, clear drainage, and no erythema.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  He does have slightly decreased sensation to the left jaw.  He is able to feel pressure on touch.  This extends also on to the left lateral tongue and the left intrabuccal mucosa.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,PROCEDURE: , A fiberoptic nasopharyngoscopy was also performed.  See separate operative report in chart.  This does reveal a moderately deviated nasal septum to the left, large inferior turbinates, no mass or neoplasm noted.,IMPRESSION:  ,1.  Persistent paresthesia of the left manual teeth and tongue, consider possible neoplasm within the mandible.,2.  History of tobacco use.,3.  Hypogeusia with loss of taste.,4.  Headaches.,5.  Xerostomia.,RECOMMENDATIONS:,  I have ordered a CT of the head.  This includes sinuses and mandible.  This is primarily to evaluate and make sure there is not a neoplasm as the source of this numbness that he has had.  On the mucosal surface, I do not see any evidence of malignancy and no visible or palpable masses were noted.  I did recommend he increase his fluid intake.  He is to remain off the tobacco.  I have scheduled a recheck with me in the next two to three weeks to make further recommendations at that time.",11
"HEENT:,  No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.,GASTROINTESTINAL:,  No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems.,GENITOURINARY: , No dysuria, hematuria, frequency, incontinence or colic.,NERVOUS SYSTEM: , No gait problems, strokes, numbness or muscle weakness.,PSYCHIATRIC: , No history of emotional lability, depression or sleep disturbances.,ONCOLOGIC:,  No history of any cancer, change in moles or rashes.  No history of weight loss.  The patient has a good energy level.,ALLERGIC/LYMPH: , No history of systemic allergy, abnormal lymph nodes or swelling.,MUSCULOSKELETAL: , No fractures, motor weakness, arthritis or other joint pains.",5
"PREOPERATIVE DIAGNOSIS: , Morbid obesity. ,POSTOPERATIVE DIAGNOSIS: , Morbid obesity. ,PROCEDURE:,  Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. ,ANESTHESIA: , General with endotracheal intubation. ,INDICATIONS FOR PROCEDURE: , This is a 50-year-old male who has been overweight for many years and has tried multiple different weight loss diets and programs.  The patient has now begun to have comorbidities related to the obesity.  The patient has attended our bariatric seminar and met with our dietician and psychologist.  The patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form.,PROCEDURE IN DETAIL: , The risks and benefits were explained to the patient.  Consent was obtained.  The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation.  A Foley catheter was placed for bladder decompression.  All pressure points were carefully padded, and sequential compression devices were placed on the legs.  The abdomen was prepped and draped in standard, sterile, surgical fashion.  Marcaine was injected into the umbilicus.",37
"OPERATION,1.  Insertion of a left subclavian Tesio hemodialysis catheter.,2.  Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and MAC anesthesia was administered.  Next, the patient's chest and neck were prepped and draped in the standard surgical fashion.  Lidocaine 1% was used to infiltrate the skin in the region of the procedure.  Next a #18-gauge finder needle was used to locate the left subclavian vein.  After aspiration of venous blood, Seldinger technique was used to thread a J wire through the needle.  This process was repeated.  The 2 J wires and their distal tips were confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next, the subcutaneous tunnel was created.  The distal tips of the individual Tesio hemodialysis catheters were pulled through to the level of the cuff.  A dilator and sheath were passed over the individual J wires.  The dilator and wire were removed, and the distal tip of the Tesio hemodialysis catheter was threaded through the sheath, which was simultaneously withdrawn.  The process was repeated.  Both distal tips were noted to be in good position.  The Tesio hemodialysis catheters were flushed and aspirated without difficulty.  The catheters were secured at the cuff level with a 2-0 nylon.  The skin was closed with 4-0 Monocryl.  Sterile dressing was applied.  The patient tolerated the procedure well and was transferred to the PACU in good condition.",37
"PREOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,POSTOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,ANESTHESIA:,  MAC (monitored anesthesia care) with local anesthesia.,TITLE OF PROCEDURES:,1.  Left frontal craniotomy for placement of deep brain stimulator electrode.,2.  Right frontal craniotomy for placement of deep brain stimulator electrode.,3.  Microelectrode recording of deep brain structures.,4.  Stereotactic volumetric CT scan of head for target coordinate determination.,5.  Intraoperative programming and assessment of device.,INDICATIONS:  ,The patient is a 61-year-old woman with a history of dystonic tremor.  The movements have been refractory to aggressive medical measures, felt to be candidate for deep brain stimulation.  The procedure is discussed below.,I have discussed with the patient in great deal the risks, benefits, and alternatives.  She fully accepted and consented to the procedure.,PROCEDURE IN DETAIL:,  The patient was brought to the holding area and to the operating room in stable condition.  She was placed on the operating table in seated position.  Her head was shaved.  Scalp was prepped with Betadine and a Leksell frame was mounted after anesthetizing the pin sites with a 50:50 mixture of 0.5% Marcaine and 2% lidocaine in all planes.  IV antibiotics were administered as was the sedation.  She was then transported to the CT scan and stereotactic volumetric CT scan of the head was undertaken.  The images were then transported to the surgery planned work station where a 3-D reconstruction was performed and the target coordinates were then chosen.  Target coordinates chosen were 20 mm to the left of the AC-PC midpoint, 3 mm anterior to the AC-PC midpoint, and 4 mm below the AC-PC midpoint.  Each coordinate was then transported to the operating room as Leksell coordinates.,The patient was then placed on the operating table in a seated position once again.  Foley catheter was placed, and she was secured to the table using the Mayfield unit.  At this point then the patient's right frontal and left parietal bossings were cleaned, shaved, and sterilized using Betadine soap and paint in scrubbing fashion for 10 minutes.  Sterile drapes placed around the perimeter of the field.  This same scalp region was then anesthetized with same local anesthetic mixture.,A bifrontal incision was made as well as curvilinear incision was made over the parietal bossings.  Bur holes were created on either side of the midline just behind the coronal suture.  Hemostasis was controlled using bipolar and Bovie, and self-retaining retractors had been placed in the field.  Using the drill, then two small grooves were cut in the frontal bone with a 5-mm cutting burs and Stryker drill.  The bur holes were then curetted free, the dura cauterized, and then opened in a cruciate manner on both sides with a #11 blade.  The cortical surface was then nicked with a #11 blade on both sides as well.  The Leksell arc with right-sided coordinate was dialed in, was then secured to the frame.  Microelectrode drive was secured to the arc.  Microelectrode recording was then performed.  The signatures of the cells were recognized.  Microelectrode unit was removed.  Deep brain stimulating electrode holding unit was mounted.  The DBS electrode was then loaded into target and intraoperative programming and testing was performed.  Using the screener box and standard parameters, the patient experienced some relief of symptoms on her left side.  This electrode was secured in position using bur-hole ring and cap system.,Attention was then turned to the left side, where left-sided coordinates were dialed into the system.  The microelectrode unit was then remounted.  Microelectrode recording was then undertaken.  After multiple passes, the microelectrode unit was removed.  Deep brain stimulator electrode holding unit was mounted at the desired trajectory.  The DBS electrode was loaded into target, and intraoperative programming and testing was performed once again using the screener box.  Using standard parameters, the patient experienced similar results on her right side.  This electrode was secured using bur-hole ring and cap system.  The arc was then removed.  A subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel.,We then closed the electrode, replaced subgaleally.  Copious amounts of Betadine irrigation were used.  Hemostasis was controlled using the bipolar only.  Closure was instituted using 3-0 Vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples.  Sterile dressings were applied.  The Leksell arc was then removed.,She was rotated into the supine position and transported to the recovery room in stable and satisfactory condition.  All needle, sponge, cottonoid, and blade counts were correct x2 as verified by the nurses.",22
"PREOPERATIVE DIAGNOSES:,1.  Chondromalacia patella.,2.  Patellofemoral malalignment syndrome.,POSTOPERATIVE DIAGNOSES:,1.  Grade-IV chondromalacia patella.,2.  Patellofemoral malalignment syndrome.,PROCEDURE PERFORMED:,1.  Diagnostic arthroscopy with partial chondroplasty of patella.,2.  Lateral retinacular release.,3.  Open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws.,ANESTHESIA:,  General.,COMPLICATIONS: , None.,TOURNIQUET TIME: , Approximately 70 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , Grade-IV chondromalacia noted to the central and lateral facet of the patella.  There was a grade II to III chondral changes to the patellar groove.  The patella was noted to be displaced laterally riding on the edge of the lateral femoral condyle.  The medial lateral meniscus showed small amounts of degeneration, but no frank tears were seen.  The articular surfaces and the remainder of the knee appeared intact.  Cruciate ligaments also appeared intact to direct stress testing.,HISTORY:  ,This is a 36-year-old Caucasian female with a long-standing history of right knee pain.  She has been diagnosed in the past with chondromalacia patella.  She has failed conservative therapy.  It was discussed with her the possibility of a arthroscopy lateral release and a tubercle transfer (anterior medialization of the tibial tubercle) to release stress from her femoral patellofemoral joint.  She elected to proceed with the surgical intervention.  All risks and benefits of the surgery were discussed with her.  She was in agreement with the treatment plan.,PROCEDURE: , On 09/04/03, she was taken to Operating Room at ABCD General Hospital.  She was placed supine on the operating table with the general anesthesia administered by the Anesthesia Department.  Her leg was placed in a Johnson knee holder and sterilely prepped and draped in the usual fashion.  A stab incision was made in inferolateral and parapatellar regions.  Through this the cannula was placed and the knee was inflated with saline solution.  Intraoperative pictures were obtained.  The above findings were noted.  Second portal site was initiated in the inferomedial parapatellar region.  Through this, a arthroscopic shaver was placed and the chondroplasty in the patella was performed and removed the loose articular debris.  Next, the camera was placed through the inferomedial portal.  An arthroscopic Bovie was placed through the inferolateral portal.  A release of lateral retinaculum was then performed using the Bovie.  Hemostasis was controlled with electrocautery.  Next, the knee was suctioned dry.  An Esmarch was used to exsanguinate the lower extremity.  Tourniquet was inflated to 325 mmHg.  An oblique incision was made along the medial parapatellar region of the knee.  The subcuticular tissues were carefully dissected and the hemostasis was again controlled with electrocautery.  The retinaculum was then incised in line with the incision.  The patellar tendon was identified.  The lateral and medial border of the tibial tubercle were cleared of all soft tissue debris.  Next, an osteotome was then used to cut the tibial tubercle to 45 degree angle leaving the base of the bone incision intact.  The tubercle was then pushed anteriorly and medially decreasing her Q-angle and anteriorizing the tibial tubercle.  It was then held in place with a Steinmann pin.  Following this, a two 4.5 mm cannulated screws, partially threaded, were drilled in place using standard technique to help fixate the tibial tubercle.  There was excellent fixation noted.  The Q-angle was noted to be decreased to approximately 15 degrees.  She was transferred approximately 1 cm in length.  The wound was copiously irrigated and suctioned dry.  The medial retinaculum was then plicated causing further medialization of the patella.  The retinaculum was reapproximated using #0 Vicryl.  Subcuticular tissue were reapproximated with #2-0 Vicryl.  Skin was closed with #4-0 Vicryl running PDS suture.  Sterile dressing was applied to the lower extremities.  She was placed in a Donjoy knee immobilizer locked in extension.  It was noted that the lower extremity was warm and pink with good capillary refill following deflation of the tourniquet.  She was transferred to recovery room in apparent stable and satisfactory condition.,Prognosis of this patient is poor secondary to the advanced degenerative changes to the patellofemoral joint.  She will remain in the immobilizer approximately six weeks allowing the tubercle to reapproximate itself to the proximal tibia.",37
"PROCEDURE:, Flexible bronchoscopy.,PREOPERATIVE DIAGNOSIS (ES):, Chronic wheezing.,INDICATIONS FOR PROCEDURE:, Evaluate the airway.,DESCRIPTION OF PROCEDURE: ,This was done in the pediatric endoscopy suite with the aid of Anesthesia. The patient was sedated with sevoflurane and propofol. One mL of 1% lidocaine was used for airway anesthesia. The 2.8-mm flexible pediatric bronchoscope was passed through the left naris. The upper airway was visualized. The epiglottis, arytenoids, and vocal cords were all normal. The scope was passed below the cords. The subglottic space was normal. The patient had normal tracheal rings and a normal membranous portion of the trachea. There was noted to be slight deviation of the trachea to the right. At the carina, the right and left mainstem were evaluated. The right upper lobe, right middle lobe, and right lower lobe were all anatomically normal. The scope was wedged in the right middle lobe, 10 mL of saline was infused, 10 was returned. This was sent for cell count, cytology, lipid index, and quantitative bacterial cultures. The left side was then evaluated and there was noted to be the normal cardiac pulsations on the left. There was also noted to be some dynamic collapse of the left mainstem during the respiratory cycle. The left upper lobe and left lower lobe were normal. The scope was withdrawn. The patient tolerated the procedure well.,ENDOSCOPIC DIAGNOSIS:, Left mainstem bronchomalacia.",3
"PREOPERATIVE DIAGNOSIS:,  Squamous cell carcinoma of right temporal bone/middle ear space.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of right temporal bone/middle ear space.,PROCEDURE: , Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the operating room, placed on the table in supine position.  General endotracheal anesthesia was obtained in the usual fashion.  The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen.  The neck was prepped as well.  After this was performed, I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl.  A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle.  After this was performed, I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible.  The condyle was skeletonized so that it could be easily seen.  The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared.  The neck contents to the hyoid were dissected out.  The hypoglossal nerve, vagus nerve, and spinal accessory nerve were dissected towards the jugular foramen.  The neck contents were removed as a separate specimen.  The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis.  A large posterior facial vein was identified and likewise clipped for later use.  I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus, dissecting or exposing the dura to the level of the jugular bulb.  It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router, I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube.  The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made.  I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion.  Once this was dissected out, Dr. X entered the procedure for completion of the resection with the craniotomy.  For details, please see his operative note.,After Dr. X had completed the resection, I then harvested the rectus free flap.  A skin paddle was drawn out next to the umbilicus about 4 x 4 cm.  The skin paddle was incised with the Bovie and down to the anterior rectus sheath.  Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle.  The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin.  The skin paddle was then sutured to the fascia and muscle with interrupted 3-0 Vicryl.  The anterior rectus sheath was then reflected off the rectus muscle, which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction.  The vascular pedicle could be seen entering the muscle in usual fashion.  The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel.  The wound was then packed with saline impregnated sponges.  The rectus muscle with attached skin paddle was then transferred into the neck.  The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9-0 Ethilon with standard microvascular technique.  Ischemia time was less than 10 minutes.  Likewise, the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9-0 Ethilon as well.  There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case.  The wound was irrigated with copious amounts of saline.  The eustachian tube was obstructed with bone wax.  The muscle was then laid into position with the skin paddle underneath the conchal bowl.  I removed most the skin of the conchal bowl de-epithelializing and leaving the fat in place.  The wound was closed in layers overlying the muscle, which was secured superiorly to the muscle overlying the temporal skull.  The subcutaneous tissues were closed with interrupted 3-0 Vicryl.  The skin was closed with skin staples.  There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself.  The skin paddle was closed with interrupted 4-0 Prolene to the edges of the conchal bowl.,The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with #1 Prolene with the more running suture, taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors.  The subcutaneous tissues were closed with interrupted 2-0 Vicryl and skin was closed with skin staples.  The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened.  The patient was then transferred to the PACU in stable condition with spontaneous respirations, having tolerated the procedure well.",23
"SUBJECTIVE: , The patient is a 20-year-old Caucasian male admitted via ABCD Hospital Emergency Department for evaluation of hydrocarbon aspiration.  The patient ingested ""tiki oil"" (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission.  He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting.  He was seen in the ABCD Hospital Emergency Department, toxic appearing with an abnormal chest x-ray demonstrating bilateral lower lobe infiltrates, greater on the right.  He had a temperature of 38.3 with tachycardia approximating 130.  White count was 59,300 with a marked left shift.  Arterial blood gases showed pH 7.48, pO2 79, and pCO2 35.  He was admitted for further medical management.,PAST MEDICAL HISTORY:,  Aplastic crisis during childhood requiring splenectomy and a cholecystectomy at age 9.,DRUG ALLERGIES: , NONE KNOWN.,CURRENT MEDICATIONS: , None.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,The patient works at a local Christmas tree farm.  He smokes cigarettes approximately one pack per day.,REVIEW OF SYSTEMS:,  Ten-system review significant for nausea, vomiting, fever, hemoptysis, and pleuritic chest pain.,PHYSICAL EXAMINATION,GENERAL:  A toxic-appearing 20-year-old Caucasian male, in mild respiratory distress.,VITAL SIGNS:  Blood pressure 122/74, pulse 130 and regular, respirations 24, temperature 38.3, and oxygen saturation 93%.,SKIN:  No rashes, petechiae or ecchymoses.,HEENT:  Within normal limits.  Pupils are equally round and reactive to light and accommodation.  Ears clean.  Throat clean.,NECK:  Supple without thyromegaly.  Lymph nodes are nonpalpable.,CHEST:  Decreased breath sounds bilaterally, greater on the right, at the right base.,CARDIAC:  No murmur or gallop rhythm.,ABDOMEN:  Mild direct diffuse tenderness without rebound.  No detectable masses, pulsations or organomegaly.,EXTREMITIES:  No edema.  Pulses are equal and full bilaterally.,NEUROLOGIC:  Nonfocal.,DATABASE: , Chest x-ray, bilateral lower lobe pneumonia, greater on the right.  EKG, sinus tachycardia, rate of 130, normal intervals, no ST changes.  Arterial blood gases on 2 L of oxygen, pH 7.48, pO2 79, and pCO2 35.,BLOOD STUDIES: , Hematocrit is 43, WBC 59,300 with a left shift, and platelet count 394,000.  Sodium is 130, potassium 3.8, chloride 97, bicarbonate 24, BUN 14, creatinine 0.8, random blood sugar 147, and calcium 9.4.,IMPRESSION,1.  Hydrocarbon aspiration.,2.  Bilateral pneumonia with pneumonitis secondary to aspiration.,3.  Asplenic patient.,PLAN,1.  ICU monitoring.,2.  O2 protocol.,3.  Hydration.,4.  Antiemetic therapy.,5.  Parenteral antibiotics.,6.  Prophylactic proton pump inhibitors.,The patient will need ICU monitoring and Pulmonary Medicine evaluation pending clinical course.,",15
"CHIEF COMPLAINT: , Right distal ureteral calculus.,HISTORY OF PRESENT ILLNESS:  ,The patient had hematuria and a CT urogram at ABC Radiology on 01/04/07 showing a 1 cm non-obstructing calcification in the right distal ureter.  He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.  He comes in now for right ureteroscopy, Holmium laser lithotripsy, right ureteral stent placement.,PAST MEDICAL HISTORY:,1.  Prostatism.,2.  Coronary artery disease.,PAST SURGICAL HISTORY:,1.  Right spermatocelectomy.,2.  Left total knee replacement in 1987.,3.  Right knee in 2005.,MEDICATIONS:,1.  Coumadin 3 mg daily.,2.  Fosamax.,3.  Viagra p.r.n.,ALLERGIES: , NONE.,REVIEW OF SYSTEMS:,  CARDIOPULMONARY:  No shortness of breath or chest pain.  GI:  No nausea, vomiting, diarrhea or constipation.  GU:  Voids well.  MUSCULOSKELETAL:  No weakness or strokes.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL APPEARANCE:  An alert male in no distress.,HEENT:  Grossly normal.,NECK:  Supple.,LUNGS:  Clear.,HEART:  Normal sinus rhythm.  No murmur or gallop.,ABDOMEN:  Soft.  No masses.,GENITALIA:  Normal penis.  Testicles descended bilaterally.,RECTAL:  Examination benign.,EXTREMITIES:  No edema.,IMPRESSION: , Right distal ureteral calculus.,PLAN: , Right ureteroscopy, ureteral lithotripsy.  Risks and complications discussed with the patient.  He signed a true informed consent.  No guarantees or warrantees were given.",5
"PREOPERATIVE DIAGNOSES,1.  End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2.  Ischemic cardiomyopathy, ejection fraction 20%.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2.  Ischemic cardiomyopathy, ejection fraction 20%.,OPERATION,Left forearm arteriovenous fistula between cephalic vein and radial artery.,INDICATION FOR SURGERY,This is a patient referred by Dr. Michael Campbell.  He is a 44-year-old African-American, who has end-stage renal disease and also ischemic cardiomyopathy.  This morning, he received coronary angiogram by Dr. A, which was reportedly normal, after which, he was brought to the operating room for an AV fistula.  All the advantages, disadvantages, risks, and benefits of the procedure were explained to him for which he had consented.,ANESTHESIA,Monitored anesthesia care.,DESCRIPTION OF PROCEDURE,The patient was identified, brought to the operating room, placed supine, and IV sedation given.  This was done under monitored anesthesia care.  He was prepped and draped in the usual sterile fashion.  He received local infiltration of 0.25% Marcaine with epinephrine in the region of the proposed incision.,Incision was about 2.5 cm long between the cephalic vein and the distal part of the forearm and the radial artery.  Incision was deepened down through the subcutaneous fascia.  The vein was identified, dissected for a good length, and then the artery was identified and dissected.  Heparin 5000 units was given.  The artery clamped proximally and distally, opened up in the middle.  It was found to have Monckeberg's arteriosclerosis of a moderate intensity.  The vein was of good caliber and size.,The vein was clipped distally, fashioned to size and shape, and arteriotomy created in the distal radial artery and end-to-side anastomosis was performed using 7-0 Prolene and bled prior to tying it down.  Thrill was immediately felt and heard.,The incision was closed in two layers and sterile dressing applied.",21
"DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - ""This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant."",When and how did subject of donation arise - ""My mom and I talked about it together as a family."",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer:  ""I would rather not go there.  Well, since we were talking, ""I will tell you that my mother really does not understand.  She is very worried.  She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor.  I don't think my mom really understands, and I know that she really needs a kidney.  I think she is coming around to accepting."",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - ""Well, my children are fine and my husband is very supportive."",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - ""My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate."",How would your family and friends react if you decided not to be a donor - ""I don't think that is going to happen."",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - ""I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother.  I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup."",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - ""That is my mother."",How your relationship with the recipient change if you donate your kidney - ""I am not sure that it will change at all.  I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others."",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact.  I am away from my children and my husband a lot because of I travel with my job.  So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - ""Yes, I have a very good understanding of the transplant process.  I work as a contract nursing all over the country.  I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process."",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - ""Yes, I do understand all the risks.  I have had a long conversation with the coordinator and we have talked about these things."",Have you thought about how you might feel if the kidney is rejected - ""I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine.  It is a part of the way I am managing my stress about this."",Do you have any doubts or concerns about donating - ""No, I don't have any doubts or any concerns right now.  I just wish this headache would go away.,Do you understand that there will be pain after the transplant - ""Of course, I do."",What are your expectations about your recuperation - ""I am planning on staying with my mom for three months in the Houston area after the transplant.  We live outside of Tampa, Florida; so this will be an adventure for both of us."",Do you need to speak further to any of the transplant team members - ""No, I have had a long talk with ABC.  I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - ""I had a one cesarian section, and I also suffered from asthma as a child.  I am in otherwise good health."",Are you currently on any medication - ""Yes, I am on Folic acid."",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - ""No, I have not.  I have a good supportive system and a lot of people that I can talk to when I need to."",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - ""No."",Any typical drinks you prefer - ""I am a nondrinker."",What kinds of recreational drugs have you tried?  Have you used any recently - ""None."",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS:  LENGTH OF TIME MARRIED:  ""I live with my family, my husband, and my two children with good relationship.  We have been married for 29 years."",NAME OF SPOUSE/PARTNER:  ""His name is Xyz."",AGE AND HEALTH OF SPOUSE/PARTNER:  He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter.  Our elder child has just finished college."",CHILDREN:  I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - ""I will stay with a friend.  He lives in the Houston area.  I am staying with that friend right now, while I am here for my workup."",CURRENT OCCUPATION:,What is your current occupation - ""I currently work on a contract basis as a nurse.  I go on assignments all over the country, and I work until the contract is over.  This allowed me to be flexible and the best candidate for donation to mom."",Do you have the support of your employer - ""Absolutely."",PAID OFF TIME:,Paid leave - ""None."",Disability coverage:  ""None."",SUPPORTIVE ENVIRONMENT:,  ""Yes.""",32
"FINAL DIAGNOSES:,  Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks.  The patient underwent a 2-day induction.  On the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress.  During the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration.  Secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication.  There was a slightly enlarged blood loss at approximately 1200 mL, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees Fahrenheit temperature right at delivery.  It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay.  The patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees Fahrenheit.  The maternal tachycardia resolved within a day.  The patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns.  The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20%.  It should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively.  Therefore, there was anemia but not an unexplained anemia.,PHYSICAL EXAMINATION ON DISCHARGE: , Includes the stable vital signs, afebrile state.  An alert and oriented patient who is desirous at discharge.  Full range of motion, all extremities; fully ambulatory.  Pulse is regular and strong.  Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus.  The incision is beautiful and soft and nontender.  There is scant lochia and there is minimal edema.,LABORATORY STUDIES: , Include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge.,FOLLOWUP: , For the patient includes pelvic rest, regular diet.  Follow up with me in 1 to 2 weeks.  Motrin 800 mg p.o. q.8h. p.r.n. cramps, Tylenol No.  3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d.",5
"PROCEDURE IN DETAIL:,  After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table.  Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty.  The patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus.  The 4 rectus muscles were looped and isolated using 2-0 silk suture.  The retinal periphery was then inspected via indirect ophthalmoscopy.",26
"PREOPERATIVE DIAGNOSES:,1.  Displaced intraarticular fracture, right distal radius.,2.  Right carpal tunnel syndrome.,PREOPERATIVE DIAGNOSES:,1.  Displaced intraarticular fracture, right distal radius.,2.  Right carpal tunnel syndrome.,OPERATIONS PERFORMED:,1.  Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture.,2.  Right carpal tunnel release.,ANESTHESIA: , General.,CLINICAL SUMMARY: , The patient is a 37-year-old right-hand dominant Hispanic female who sustained a severe fracture to the right wrist approximately one week ago.  This was an intraarticular four-part fracture that was displaced dorsally.  In addition, the patient previously undergone a carpal tunnel release, but had symptoms of carpal tunnel preop.  She is admitted for reconstructive operation.  The symptoms of carpal tunnel were present preop and worsened after the injury.,OPERATION:,  The patient was brought from the ambulatory care unit and placed on the operating table in a supine position and administered general anesthetic by Anesthesia.  Once adequate anesthesia had been obtained, the right upper extremity was prepped and draped in the usual sterile manner.  Tourniquet was placed around the right upper extremity.  The upper extremity was then elevated and exsanguinated using an Esmarch dressing.  The tourniquet was elevated to 250 mmHg.  The entire operation was performed with 4.5 loop magnification.  At this time an approximately 8 cm longitudinal incision was then made overlying the right flexor carpi radialis tendon from the flexion crease to the wrist proximally.  This was carried down to the flexor carpi radialis, which was then retracted ulnarly.  The floor of the flexor carpi radialis was then incised exposing the flexor pronator muscles.  The flexor pollicis longus was retracted ulnarly and the pronator quadratus was longitudinally incised 1 cm from its origin.  It was then elevated off of the fracture site exposing the fracture site, which was dorsally displaced.  This was an intraarticular four-part fracture.  Under image control, the two volar pieces and dorsal pieces were then carefully manipulated and reduced.  Then, 2.06 two-inch K-wires were drilled radial into the volar ulnar fragment and then a second K-wire was then drilled from the dorsal radial to the dorsal ulnar piece.  A third K-wire was then drilled from the volar radial to the dorsal ulnar piece.  The fracture was then manipulated.  The fracture ends were copiously irrigated with normal saline and curetted and then the fracture was reduced in the usual fashion by recreating the defect and distracting it.  Further K-wires were then placed through the radial styloid into the proximal fragment.  A Hand Innovations DVR plate of regular size for the right wrist was then fashioned over and placed over the distal radius and secured with two K-wires.  At this time, the distal screws were then placed.  The distal screws were the small screws.  These were non-locking screws, all eight screws were placed.  They were placed in the usual fashion by drilling with a small drill bit removing the small introducers and then using its depth.  Again, these were 18-20 mm screws.  After placing three of the screws it was necessary to remove the K-wires.  There was excellent reduction of the fragments and the fracture; excellent reduction of the intraarticular component and the fracture.  After the distal screws were placed, the fracture was reduced and held in place with K-wires, which were replaced and the proximal screws were drilled with the drill guide and the larger drill bit.  The screws were then placed.  These were 12 mm screws.  They were placed 4 in number.  The K-wires were then removed.  Finally, a 3 cm intrathenar incision was made beginning 1 cm distal to the flexor crease of the wrist.  This was carried down to the transverse carpal ligament, which was divided throughout the length of the incision, upon entering the carpal canal, the median nerve was found to be adherent to the undersurface of the structure.  It was dissected free from the structure out to its trifurcation.  The motor branches seen entering the thenar fascia and obstructed.  The nerve was then retracted dorsally and the patient had a great deal of scar tissue in the area of the volar flexion crease to the wrist where she had a previous incision that extended from the volar flexion crease of the wrist overlying the palmaris longus proximally for 1 cm.  In this area, careful dissection was performed in order to move the nerve from the surrounding structures and the most proximal aspect of the transverse carpal ligament, the more proximally located volar carpal ligament was then divided 5 cm into the distal forearm on the ulnar side of the palmaris longus tendon.  Incisions were then copiously irrigated with normal saline.  Homeostasis was maintained with electrocautery.  The pronator quadratus was closed with 3-0 Vicryl and the above skin incisions were closed proximally with 4-0 nylon and palmar incision with 5-0 nylon in the horizontal mattress fashion.  A large bulky dressing was then applied with a volar short-arm splint maintaining the wrist in neutral position.  The tourniquet was let down.  The fingers were immediately pink.  The patient was awakened and taken to the recovery room in good condition.  There were no operative complications.  The patient tolerated the procedure well.",27
"PREOPERATIVE DIAGNOSES:,1.  Pregnancy at 38 weeks and three days.,2.  Previous cesarean section x2.,3.  Refusing trial of labor.,4.  Multiparity, seeking family planning.,POSTOPERATIVE DIAGNOSES:,1.  Pregnancy at 38 weeks and three days.,2.  Previous cesarean section x2.,3.  Refusing trial of labor.,4.  Multiparity, seeking family planning.,5.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Repeat low transverse cervical cesarean section with delivery of a viable female neonate.,2.  Bilateral tubal ligation and partial salpingectomy.,3.  Lysis of adhesions.,ANESTHESIA: , Spinal with Astramorph.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 800 cc.,FLUIDS: , 1800 cc of crystalloids.,URINE OUTPUT:,  600 cc of clear urine at the end of the procedure.,INDICATIONS:  ,This is a 36-year-old African-American female gravida 4, para-2-0-1-2, who presents for elective repeat cesarean section.  The patient has previous cesarean section x2 and refuses trial of labor.  The patient also requests a tubal ligation for permanent sterilization and family planning.,FINDINGS:,  A female infant in cephalic presentation in a ROP position.  Apgars of 9 and 9 at one and five minutes respectively.  Weight is 6 lb 2 oz and loose nuchal cord x1.  Normal uterus, tubes, and ovaries.,PROCEDURE:  ,After consent was obtained, the patient was taken to the operating room, where spinal anesthetic was found to be adequate.  The patient was placed in the dorsal supine position with a leftward tilt and prepped and draped in the normal sterile fashion.  The patient's previous Pfannenstiel scar incision was removed and the incision was carried through the underlying layer of fascia using the second knife.  The fascia was incised in the midline and the fascial incision was extended laterally using the second knife.  The rectus muscles were separated in the midline.  The peritoneum was identified, grasped with hemostats, and entered sharply with Metzenbaum scissors.  This incision was extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was then inserted and vesicouterine peritoneum was identified, grasped with an Allis clamp and entered sharply with Metzenbaum scissors.  This incision was extended laterally and the bladder flap created digitally.  The bladder blade was then reinserted and a small transverse incision was made along the lower uterine segment.  This incision was extended laterally manually.  The amniotic fluid was ruptured at this point with clear fluid obtained.  The infant's head was delivered atraumatically.  The nose and mouth were both suctioned on delivery.  The cord was doubly clamped and cut.  The infant was handed off to the awaiting pediatrician.  Cord gases and cord bloods were obtained and sent.  The placenta was then removed manually and the uterus exteriorized and cleared of all clots and debris.  The uterine incision was reapproximated with #0 chromic in a running lock fashion.  A second layer of the same suture was used with excellent hemostasis.  Attention was now turned to the right fallopian tube, which was grasped with the Babcock and avascular space below the tube was entered using a hemostat.  The tube was doubly clamped using hemostat and the portion between the clamps was removed using Metzenbaum scissors.  The ends of the tube were cauterized using the Bovie and they were then tied off with #2-0 Vicryl.  Attention was then turned to the left fallopian tube, which was grasped with the Babcock and avascular space beneath the tube was entered using a hemostat.  The tube was then doubly clamped with hemostat and the portion of tube between them was removed using the Metzenbaum scissors.  The ends of the tubes were cauterized and the tube was suture-ligated with #2-0 Vicryl.  There were some adhesions of the omentum to the bilateral adnexa.  These were carefully taken down using Metzenbaum scissors with excellent hemostasis noted.  The uterus was then returned to the abdomen and the bladder was cleared of all clots.  The uterine incision was reexamined and found to be hemostatic.  The fascia was then reapproximated with #0 Vicryl in a running fashion.  Several interrupted sutures of #3-0 chromic were placed in the subcutaneous tissue.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  The patient was taken to the recovery room in satisfactory condition.  She will be followed immediately postoperatively within the hospital.",37
"PREOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,PROCEDURE:, Right phacoemulsification of cataract with intraocular lens implantation.,DESCRIPTION OF THE OPERATION:, Under topical anesthesia with monitored anesthesia care, the patient was prepped, draped and positioned under the operating microscope. A lid speculum was applied to the right eye, and a stab incision into the anterior chamber was done close to the limbus at about the 1 o'clock position with a Superblade, and Xylocaine 1% preservative free 0.25 mL was injected into the anterior chamber, which was then followed by Healon to deepen the anterior chamber. Using a keratome, another stab incision was done close to the limbus at about the 9 o'clock position and with the Utrata forceps, anterior capsulorrhexis was performed, and the torn anterior capsule was totally removed. Hydrodissection and hydrodelineation were performed with the tuberculin syringe filled with BSS. The tip of the phaco unit was introduced into the anterior chamber, and anterior sculpting of the nucleus was performed until about more than two-thirds of the nucleus was removed. Using the phaco tip and the Drysdale hook, the nucleus was broken up into 4 pieces and then phacoemulsified.,The phaco tip was then exchanged for the aspiration/irrigation tip, and cortical materials were aspirated. Posterior capsule was polished with a curette polisher, and Healon was injected into the capsular bag. Using the Monarch intraocular lens inserter, the posterior chamber intraocular lens model SN60WF power +19.50 was placed into the inserter after applying some Healon, and the tip of the inserter was gently introduced through the cornea tunnel wound, into the capsular bag and then the intraocular lens was then inserted inferior haptic first into the back and the superior haptic was placed into the bag with the same instrument. Intraocular lens was then rotated about half a turn with a collar button hook. Healon was removed with the aspiration/irrigation tip, and balanced salt solution was injected through the side port to deepen the anterior chamber. It was found that there was no leakage of fluid through the cornea tunnel wound. For this reason, no suture was applied. Vigamox, Econopred and Nevanac eye drops were instilled and the eye was covered with a perforated shield. The patient tolerated the procedure well. There were no complications.",26
"PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Diverticulosis coli.,2.  Internal hemorrhoids.,3.  Poor prep.,PROCEDURE PERFORMED:,  Colonoscopy with photos.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMENS:,  None.,HISTORY:,  The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia.  She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time.  A coloscopy is now being performed for completion.,PROCEDURE:,  After proper informed consent was obtained, the patient was brought to the Endoscopy Suite.  She was placed in the left lateral position and was given sedation by the Anesthesia Department.  A digital rectal exam was performed and there was no evidence of mass.  The colonoscope was then inserted into the rectum.  There was some solid stool encountered.  The scope was maneuvered around this.  There was relatively poor prep as the scope was advanced through the sigmoid colon and portions of the descending colon.  The scope was then passed through the transverse colon and ascending colon to the cecum.  No masses or polyps were noted.  Visualization of the portions of the colon was however somewhat limited.  There were scattered diverticuli noted in the sigmoid.,The scope was slowly withdrawn carefully examining all walls.  Once in the rectum, the scope was retroflexed and nonsurgical internal hemorrhoids were noted.  The scope was then completely withdrawn.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  She will be placed on a high-fiber diet and Colace and we will continue to monitor her hemoglobin.",14
"REASON FOR VISIT:,  This is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation.  Her chief complaint today is shortness of breath.,HISTORY OF PRESENT ILLNESS:,  I last saw her in 09/2008.  Since then, she has been admitted to ABCD Hospital from 11/05/2008 through 11/08/2008 for a near syncopal episode.  She was found to have a fast heart rate in the atrial fibrillation.  She was also found to be in heart failure and so they diuresed her.  They wanted to send her home on furosemide 40 mg daily, but unfortunately they never gave her a prescription for this and so she now is not on any furosemide and since being discharged she has regained fluid to no one's great surprise.  My plan advent is to control her heart rate.  This has been a bit difficult with her retaining fluid.  We will try again to diurese her as an outpatient and go forward from there with rate control and anticoagulation.  She may need to have a pacemaker placed and her AV node ablated if this does not work.,She notes the shortness of breath and wheezing at nights.  I think these are manifestations of heart failure.  She has peripheral edema.  She is short of breath when she tries to walk a city block.  I believe she takes her medications as directed, but I am never sure she actually is taking them correctly.  In any case, she did not bring her medications with her today.,Today, she had an ECG which shows atrial fibrillation with a ventricular response of 117 beats per minute.  There is a nonspecific IVCD.  This is unchanged from her last visit except that her heart rate is faster.  In addition, I reviewed her echocardiogram done at XYZ.  Her ejection fraction is 50% and she has paradoxical septal motion.  Her right ventricular systolic pressure is normal.  There are no significant valvular abnormalities.,MEDICATIONS:  ,1.  Fosamax - 70 mg weekly.,2.  Lisinopril - 20 mg daily.,3.  Metformin - 850 mg daily.,4.  Amlodipine - 5 mg daily.,5.  Metoprolol - 150 mg twice daily.,6.  Warfarin - 5 mg daily.,7.  Furosemide - none.,8.  Potassium - none.,9.  Magnesium oxide - 200 mg daily.,ALLERGIES: , Denied.,MAJOR FINDINGS:,  On my comprehensive cardiovascular examination, she again looks the same which is in heart failure.  Her blood pressure today was 130/60 and her pulse 116 blood pressure and regular.  She is 5 feet 11 inches and her weight is 167 pounds, which is up from 158 pounds from when I saw her last visit.  She is breathing 1two times per minute and it is unlabored.  Eyelids are normal.  She has vitiligo.  Pupils are round and reactive to light.  Conjunctivae are clear and sclerae are anicteric.  There is no oral thrush or central cyanosis.  She has marked keloid formation on both sides of her neck, the left being worse than the right.  The jugular venous pressure is elevated.  Carotids are brisk are without bruits.  Lungs are clear to auscultation and percussion.  The precordium is quiet.  The rhythm is irregularly irregular.  She has a variable first and second heart sounds.  No murmurs today.  Abdomen is soft without hepatosplenomegaly or masses, although she does have hepatojugular reflux.  She has no clubbing or cyanosis, but does have 1+ peripheral edema.  Distal pulses are good.  On neurological examination, her mentation is normal.  Her mood and affect are normal.  She is oriented to person, place, and time.,ASSESSMENTS: , She has chronic atrial fibrillation and heart failure now.,PROBLEMS DIAGNOSES:  ,1.  Chronic atrial fibrillation, anticoagulated and the plan is rate control.,2.  Heart failure and she needs more diuretic.,3.  High blood pressure controlled.,4.  Hyperlipidemia.,5.  Diabetes mellitus type 2.,6.  Nonspecific intraventricular conduction delay.,7.  History of alcohol abuse.,8.  Osteoporosis.,9.  Normal left ventricular function.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I have restarted her Lasix at 80 mg daily and I have asked her to return in about 10 days to the heart failure clinic.  There, I would like them to recheck her heart rate and if still elevated, and she is truly on 150 mg of metoprolol twice a day, one could switch her amlodipine from 5 mg daily to diltiazem 120 mg daily.  If this does not work, in terms of controlling her heart rate, then she will need to have a pacemaker and her AV node ablated.,Thank you for asking me to participate in her care.,MEDICATION CHANGES: , See the above.",5
"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:,",11
"PREOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,POSTOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,PROCEDURE: , Ultrasound-guided right pleurocentesis.,ANESTHESIA: , Local with lidocaine.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient and his mother, the chest was scanned with portable ultrasound.  Findings revealed a normal right hemidiaphragm, a moderate right pleural effusion without septation or debris, and no gliding sign of the lung on the right.  Using sterile technique and with ultrasound as a guide, a pleural catheter was inserted and serosanguinous fluid was withdrawn, a total of 1 L.  The patient tolerated the procedure well.  Portable x-ray is pending.",37
"Subsequently, the patient developed a moderately severe depression.  She was tried on various medications, which caused sweating, nightmares and perhaps other side effects.  She was finally put on Effexor 25 mg two tablets h.s. and trazodone 100 mg h.s., and has done fairly well, although she still has significant depression.,Her daughter brought her in today to be sure that she does not have dementia.  There is no history of memory loss.  There is no history of focal neurologic symptoms or significant headaches.,The patient's complaints, according to the daughter, include not wanted to go out in public, shamed regarding her appearance (25-pound weight loss over the past year), eating poorly, not doing things unless asked, hiding food to prevent having to eat it, nervousness, and not taking a shower.  She has no focal neurologic deficits.  She does complain of constipation.  She has severe sleep maintenance insomnia and often sleeps only 2 hours before awakening frequently for the rest of the night.,The patient was apparently visiting her daughter in northern California in December 2003.  She was taken to her daughter's primary care physician.  She underwent vitamin B12 level, RPR, T4 and TSH, all of which were normal.,On 05/15/04, the patient underwent MRI scan of the brain.  I reviewed the scan in the office today.  This shows moderate cortical and central atrophy and also shows mild-to-moderate deep white matter ischemic changes.,PAST MEDICAL HISTORY: , The patient has generally been in reasonably good physical health.  She did have a ""nervous breakdown"" in 1975 after the death of her husband.  She was hospitalized for several weeks and was treated with ECT.  This occurred while she was living in Korea.,She does not smoke or drink alcoholic beverages.  She has had no prior surgeries.  There is a past history of hypertension, but this is no longer present.,FAMILY HISTORY: , Negative for dementia.  Her mother died of a stroke at the age of 62.,PHYSICAL EXAMINATION:,Vital Signs:  Blood pressure 128/80, pulse 84, temperature 97.4 F, and weight 105 lbs (dressed).,General:  Well-developed, well-nourished Korean female in no acute distress.,Head:  Normocephalic, without evidence of trauma or bruits.,Neck:  Supple, with full range of motion.  No spasm or tenderness.  Carotid pulsations are of normal volume and contour bilaterally without bruits.  No thyromegaly or adenopathy.,Extremities:  No clubbing, cyanosis, edema, or deformity.  Range of motion full throughout.,NEUROLOGICAL EXAMINATION:,Mental Status:  The patient is awake, alert and oriented to time, place, and person and generally appropriate.  She exhibits mild psychomotor retardation and has a flat or depressed affect.  She knows the current president of Korea and the current president of the United States.  She can recall 3 out of 3 objects after 5 minutes.  Calculations are performed fairly well with occasional errors.  There is no right-left confusion, finger agnosia, dysnomia or aphasia.,Cranial Nerves:,II:",5
"PREOPERATIVE DIAGNOSIS: , Left mesothelioma, focal.,POSTOPERATIVE DIAGNOSIS: , Left pleural-based nodule.,PROCEDURES PERFORMED:,1.  Left thoracoscopy.,2.  Left mini thoracotomy with resection of left pleural-based mass.,FINDINGS:,  Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.,FLUIDS: , 800 mL of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS, TUBES, CATHETERS: , 24-French chest tube in the left thorax plus Foley catheter.,SPECIMENS: , Left pleural-based nodule.,INDICATION FOR OPERATION:  ,The patient is a 59-year-old female with previous history of follicular thyroid cancer, approximately 40 years ago, status post resection with recurrence in the 1980s, who had a left pleural-based mass identified on chest x-ray.  Preoperative evaluation included a CT scan, which showed focal mass.  CT and PET confirmed anterior lesion.  Therefore the patient was seen in our thoracic tumor board where it was recommended to have resection performed with chest wall reconstruction.  In the outpatient setting, the patient was willing to proceed.,PROCEDURE PERFORMED IN DETAIL: , After informed consent was obtained, the patient identified correctly.  She was taken to the operating room where an epidural catheter was placed by Anesthesia without difficulty.  She was sedated and intubated with double-lumen endotracheal tube without difficulty.  She was positioned with left side up.  Appropriate pressure points were padded.  The left chest was prepped and draped in the standard surgical fashion.  The skin incision was made in the posterior axillary line, approximately 7th intercostal space with #10 blade, taken down through tissues and Bovie electrocautery.,Pleura was entered.  There was good deflation of the left lung.  __________ port was placed, followed by the 0-degree 10-mm scope with appropriate patient positioning.  Posteriorly a pedunculated 2.5 x 3-cm pleural-based mass was identified on the anterior chest wall.  There were thin adhesions to the pleura, but no invasion of the chest wall that could be identified.  The tumor was very mobile and was on a pedunculated stalk, approximately 1.5 cm.  It was felt that this could be resected without the need of chest wall reconstruction because of the narrow stalk.,Therefore a 2nd port was placed in the anterior axillary line approximately 8th intercostal space in the usual fashion.  Camera was placed through this port.  Laparoscopic scissors were placed through the posterior port, but it was necessary to have another instrument to provide more tension than just gravity.  Therefore because of the need to bring the specimen through the chest wall, a small 3-cm thoracotomy was made, which incorporated the posterior port site.  This was taken down to the subcutaneous tissue with Bovie electrocautery.  Periosteal elevator was used to lift the intercostal muscle off.  The ribs were not spread.  Through this 3-cm incision, both the laparoscopic scissors as well as Prestige graspers could be placed.  Prestige graspers were used to pull the specimen from the chest wall.  Care was taken not to injure the capsule.  The laparoscopic scissors on cautery were used to resect the parietal pleural off of the chest wall.  Care was taken not to transect the stalk.  Specimen came off the chest wall very easily.  There was good hemostasis.,At this point, the EndoCatch bag was placed through the incision.  Specimen was placed in the bag and then removed from the field.  There was good hemostasis.  Camera was removed.  A 24-French chest tube was placed through the anterior port and secured with 2-0 silk suture.  The posterior port site was closed 1st with 2-0 Vicryl in a running fashion for the intercostal muscle layer, followed by 2-0 closure of the latissimus fascia as well as subdermal suture, 4-0 Monocryl was used for the skin, followed by Steri-Strips and sterile drapes.  The patient tolerated the procedure well, was extubated in the operating room and returned to the recovery room in stable condition.",3
"PREOPERATIVE DIAGNOSIS:  ,Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,OPERATION PERFORMED: , Bilateral orchiopexy.,ANESTHESIA: , General.,HISTORY: , This 8-year-old boy has been found to have a left inguinally situated undescended testes.  Ultrasound showed metastasis to be high in the left inguinal canal.  The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum.  Both testes appeared to be normal in size for the boy's age.,OPERATIVE FINDINGS: , As above, both testes appeared viable and normal in size, no masses.  There is a hernia on the left side.  The spermatic cord was quite short on the left and required Prentiss Maneuver to achieve adequate length for scrotal placement.,OPERATIVE PROCEDURE: , The boy was taken to the operating room, where he was placed on the operating table.  General anesthesia was administered by Dr. X, after which the boy's lower abdomen and genitalia were prepared with Betadine and draped aseptically.  A 0.25% Marcaine was infiltrated subcutaneously in the skin crease in the left groin in the area of the intended incision.  An inguinal incision was then made through this area, carried through the subcutaneous tissues to the anterior fascia.  External ring was exposed with dissection as well.  The fascia was opened in direction of its fibers exposing the testes, which lay high in the canal.  The testes were freed with dissection by removing cremasteric and spermatic fascia.  The hernia sac was separated from the cord, twisted and suture ligated at the internal ring.  Lateral investing bands of the spermatic cords were divided high into the inguinal internal ring.  However, this would only allow placement of the testes in the upper scrotum with some tension.,Therefore, the left inguinal canal was incised and the inferior epigastric artery and vein were ligated with #4-0 Vicryl and divided.  This maneuver allowed for placement of the testes in the upper scrotum without tension.,A sub dartos pouch was created by separating the abdominal fascia from the scrotal skin after making an incision in the left hemiscrotum in the direction of the vessel.  The testes were then brought into the pouch and anchored with interrupted #4-0 Vicryl sutures.  The skin was approximated with interrupted #5-0 chromic catgut sutures.  Inspection of the spermatic cord in the inguinal area revealed no twisting and the testicular cover was good.  Internal oblique muscle was approximated to the shelving edge and Poupart ligament with interrupted #4-0 Vicryl over the spermatic cord and the external oblique fascia was closed with running #4-0 Vicryl suture.  Additional 7 mL of Marcaine was infiltrated subfascially and the skin was closed with running #5-0 subcuticular after placing several #4-0 Vicryl approximating sutures in the subcutaneous tissues.,Attention was then turned to the opposite side, where an orchiopexy was performed in a similar fashion.  However, on this side, there was no inguinal hernia.  The testes were located in a superficial pouch of the inguinal canal and there was adequate length on the spermatic cord, so that the Prentiss maneuver was not required on this side.  The sub dartos pouch was created in a similar fashion and the wounds were closed similarly as well.,The inguinal and scrotal incisions were cleansed after completion of the procedure.  Steri-Strips and Tegaderm were applied to the inguinal incisions and collodion to the scrotal incision.  The child was then awakened and transported to post-anesthetic recovery area apparently in satisfactory condition.  Instrument and sponge counts were correct.  There were no apparent complications.  Estimated blood loss was less than 20 to 30 mL.",37
"PREPROCEDURE DIAGNOSIS:,  Change in bowel function.,POSTPROCEDURE DIAGNOSIS:,  Proctosigmoiditis.,PROCEDURE PERFORMED:,  Colonoscopy with biopsy.,ANESTHESIA: , IV sedation.,POSTPROCEDURE CONDITION: , Stable.  ,INDICATIONS:,  The patient is a 33-year-old with a recent change in bowel function and hematochezia.  He is here for colonoscopy.  He understands the risks and wishes to proceed.  ,PROCEDURE: , The patient was brought to the endoscopy suite where he was placed in left lateral Sims position, underwent IV sedation.  Digital rectal examination was performed, which showed no masses, and a boggy prostate.  The colonoscope was placed in the rectum and advanced, under direct vision, to the cecum.  In the rectum and sigmoid, there were ulcerations, edema, mucosal abnormalities, and loss of vascular pattern consistent with proctosigmoiditis.  Multiple random biopsies were taken of the left and right colon to see if this was in fact pan colitis.,RECOMMENDATIONS: , Follow up with me in 2 weeks and we will begin Canasa suppositories.",37
"CHIEF COMPLAINT: , Severe back pain and sleepiness.,The patient is not a good historian and history was obtained from the patient's husband at bedside.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 76-year-old obese Caucasian female with past medical conditions that includes hypertension, history of urinary incontinence, dementia, and chronic back pain, basically brought by the husband to the emergency room because of having excruciating back pain.  As per the husband, the patient has this back pain for about almost 1 year and seeing Dr. X in Neurosurgery and had an epidural injection x2, and then the patient's pain somewhat got better between, but last time the patient went to see Dr. X, the patient given injection and the patient passed out, so the doctor stopped giving any other epidural injection.  The patient has severe pain and all in all, the patient cries at home.  As per the husband, the patient woke up in the morning with severe pain, unable to eat, drink today, and crying in the morning, so brought her to the emergency room for further evaluation.  The patient denied any history of fever, cough, chest pain, diarrhea, dysuria or polyuria.  While I was examining the patient, the patient explained about possible diagnosis and treatment plan and possible nursing home discharge for pain control.  The patient passed out for about 3 to 4 minutes, unable to respond to even painful stimuli.  The patient's heart rate went down to 50s and blood pressure was 92 systolic, so the patient was later on given IV fluid and blood pressure checked.  The patient woke up after 5 to 6 minutes, so the patient was later on evaluated for admission because of near syncopal episode.,PAST MEDICAL CONDITIONS:,  Include hypertension, dementia, urinary incontinence, chronic back pain, and degenerative joint disease of the spine.  No history of diabetes, stroke or coronary artery disease.,SURGICAL HISTORY: , Include left total hip replacement many years ago, history of hysterectomy, and appendectomy in the young age.,ALLERGIES: , DENIED.,CURRENT MEDICATIONS: , According to the list shows the patient takes hydrocodone 10/325 mg every 6 hours, Flexeril 10 mg p.o. at bedtime, and Xanax 0.25 mg p.o. 4 times a day.  The patient also takes Neurontin 200 mg 3 times a day, propranolol 10 mg twice a day, oxybutynin 5 mg p.o. twice a day, Namenda 10 mg p.o. daily, and Aricept 10 mg p.o. daily.,SOCIAL HISTORY: , She lives with her husband, usually walks with a walker and wheelchair-bound, does not walk much as per the husband knows.  No history of alcohol abuse or smoking.,PHYSICAL EXAMINATION:,GENERAL:  Currently lying in the bed without apparent distress, very lethargic.,VITAL SIGNS:  Pulse rate of 55, blood pressure is 92/52, after IV fluid came up to 105/58.,CHEST:  Shows bilateral air entry present, clear to auscultate.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft, nondistended, and nontender.,EXTREMITIES:  Shows the patient's straight leg raising to be only up to 30% causing the patient severe back pain.,IMAGING: , The patient's x-ray of the lumbosacral spine done shows there is a L1 compression fracture with some osteophyte formation in the lumbar spine suggestive of degenerative joint disease.,LABORATORY DATA: , The patient's lab test is not done currently, but previous lab test done in 3/2009 seems to be in acceptable range.,IMPRESSION: , The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes in front of me with a low blood pressure.,1.  Vasovagal syncope versus polypharmacy because of 3 to 4 medications and muscle relaxants.,2.  Osteoporosis of the spine with L1 compression fracture causing the patient severe pain.,3.  Hypertension, now hypotension.,4.  Incontinence of the bladder.,5.  Dementia, most likely Alzheimer type.,PLAN AND SUGGESTION: , Initial plan was to send the patient to the nursing home, but because of the patient's low blood pressure and heart rate low, we will admit the patient to DOU for 23-hour observation, start the patient on IV fluid, normal saline, 20 mEq KCl, and Protonix 40 mg, and we will also continue the patient's Namenda and Aricept.  I will hold the patient's hydrocodone.  I will hold the Flexeril and I will also hold gabapentin at this moment.  We will give the patient's pain control with Percocet and very minimal morphine sulfate as needed.  Also give the patient calcium with vitamin D and physical therapy.  We will also order a blood test and further management will be based on the patient's all test results.  I also explained to the husband that tomorrow if the patient is better and more alert and awake, then we will send her to the nursing care versus home, it depends on the pain control.",15
"PREOPERATIVE DIAGNOSIS: , Left adrenal mass, 5.5 cm.,POSTOPERATIVE DIAGNOSES:,1.  Left adrenal mass, 5.5 cm.,2.  Intraabdominal adhesions.,PROCEDURE PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Laparoscopic left adrenalectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Less than 100 cc.,FLUIDS: , 3500 cc crystalloids.,DRAINS:,  None.,DISPOSITION:,  The patient was taken to recovery room in stable condition.  Sponge, needle, and instrument counts were correct per OR staff.,HISTORY:,  This is a 57-year-old female who was found to have a large left adrenal mass, approximately 5.5 cm in size.  She had undergone workup previously with my associate, Dr. X as well as by Endocrinology, and showed this to be a nonfunctioning mass.  Due to the size, the patient was advised to undergo an adrenalectomy and she chose the laparoscopic approach due to her multiple pulmonary comorbidities.,INTRAOPERATIVE FINDINGS: , Showed multiple intraabdominal adhesions in the anterior abdominal wall.  The spleen and liver were unremarkable.  The gallbladder was surgically absent.,There was large amount of omentum and bowel in the pelvis, therefore the gynecological organs were not visualized.  There was no evidence of peritoneal studding or masses.  The stomach was well decompressed as well as the bladder.,PROCEDURE DETAILS: , After informed consent was obtained from the patient, she was taken to the operating room and given general anesthesia.  She was placed on a bean bag and secured to the table.  The table was rotated to the right to allow gravity to aid in our retraction of the bowel.,Prep was performed.  Sterile drapes were applied.  Using the Hassan technique, we placed a primary laparoscopy port approximately 3 cm lateral to the umbilicus on the left.  Laparoscopy was performed with ___________.  At this point, we had a second trocar, which was 10 mm to 11 mm port.  Using the non-cutting trocar in the anterior axillary line and using Harmonic scalpel, we did massive lysis of adhesions from the anterior abdominal wall from the length of the prior abdominal incision, the entire length of the abdominal incision from the xiphoid process to the umbilicus.  The adhesions were taken down off the entire anterior abdominal wall.,At this point, secondary and tertiary ports were placed.  We had one near the midline in the subcostal region and to the left midline and one at the midclavicular line, which were also 10 and 11 ports using a non-cutting blade.,At this point, using the Harmonic scalpel, we opened the white line of Toldt on the left and reflected the colon medially, off the anterior aspect of the Gerota's fascia.  Blunt and sharp dissection was used to isolate the upper pole of the kidney, taking down some adhesions from the spleen.  The colon was further mobilized medially again using gravity to aid in our retraction.  After isolating the upper pole of the kidney using blunt and sharp dissection as well as the Harmonic scalpel, we were able to dissect the plane between the upper pole of the kidney and lower aspect of the adrenal gland.  We were able to isolate the adrenal vein, dumping into the renal vein, this was doubly clipped and transected.  There was also noted to be vascular structure of the upper pole, which was also doubly clipped and transected.  Using the Harmonic scalpel, we were able to continue free the remainder of the adrenal glands from its attachments medially, posteriorly, cephalad, and laterally.,At this point, using the EndoCatch bag, we removed the adrenal gland through the primary port in the periumbilical region and sent the flap for analysis.  Repeat laparoscopy showed no additional findings.  The bowel was unremarkable, no evidence of bowel injury, no evidence of any bleeding from the operative site.,The operative site was irrigated copiously with saline and reinspected and again there was no evidence of bleeding.  The abdominal cavity was desufflated and was reinspected.  There was no evidence of bleeding.,At this point, the camera was switched to one of the subcostal ports and the primary port in the periumbilical region was closed under direct vision using #0 Vicryl suture.  At this point, each of the other ports were removed and then with palpation of each of these ports, this indicated that the non-cutting ports did close and there was no evidence of fascial defects.,At this point, the procedure was terminated.  The abdominal cavity was desufflated as stated.  The patient was sent to Recovery in stable condition.  Postoperative orders were written.  The procedure was discussed with the patient's family at length.",37
"S: , The patient presents to podiatry clinic today at the request of her primary physician, Dr. XYZ for initial examination, evaluation, and treatment of her nails.  The patient has last seen primary in December 2006.,PRIMARY MEDICAL HISTORY: , Edema, venous insufficiency, schizophrenia, and anemia.,ALLERGIES: , THE PATIENT HAS NO KNOWN ALLERGIES.,MEDICATIONS: , Refer to chart.,O: , The patient presents in wheelchair, verbal and alert.  Vascular:  She has absent pedal pulses bilaterally.  Trophic changes include absent hair growth and mycotic nails.  Skin texture is dry.  Skin color is rubor.  Classic findings include temperature change and  edema +1.  Nails:  Hypertrophic with crumbly subungual debris, #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left.,A:,1.  Onychomycosis present, #1, #2, #3, #4, and #5 right and left.,2.  Peripheral vascular disease as per classic findings.,3.  Pain on palpation.,P: , Nails #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left were debrided for length and thickness.  The patient will be seen again at the request of the nursing staff for treatment of painful mycotic nails.",31
"TECHNIQUE: , Sequential axial CT images were obtained through the cervical spine without contrast.  Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures.  ,FINDINGS: , The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture, dislocation, or spondylolisthesis.  The vertebral body heights and disc spaces are maintained.  The central canal is patent.  The pedicles and posterior elements are intact.  The paravertebral soft tissues are within normal limits.  The atlanto-dens interval and the dens are intact.  The visualized lung apices are clear.,IMPRESSION: , No acute abnormalities.",27
"CLINICAL HISTORY: ,This 78-year-old black woman has a history of hypertension, but no other cardiac problems. She noted complaints of fatigue, lightheadedness, and severe dyspnea on exertion. She was evaluated by her PCP on January 31st and her ECG showed sinus bradycardia with a rate of 37 beats per minute. She has had intermittent severe sinus bradycardia alternating with a normal sinus rhythm, consistent with sinoatrial exit block, and she is on no medications known to cause bradycardia. An echocardiogram showed an ejection fraction of 70% without significant valvular heart disease.,PROCEDURE:, Implantation of a dual chamber permanent pacemaker.,APPROACH:, Left cephalic vein.,LEADS IMPLANTED: ,Medtronic model 12345 in the right atrium, serial number 12345. Medtronic 12345 in the right ventricle, serial number 12345.,DEVICE IMPLANTED: ,Medtronic EnRhythm model 12345, serial number 12345.,LEAD PERFORMANCE: ,Atrial threshold less than 1.3 volts at 0.5 milliseconds. P wave 3.3 millivolts. Impedance 572 ohms. Right ventricle threshold 0.9 volts at 0.5 milliseconds. R wave 10.3. Impedance 855.,ESTIMATED BLOOD LOSS:, 20 mL.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with Versed and fentanyl. The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. A 2-1/2-inch incision was made below the left clavicle and electrocautery was used for hemostasis. Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator. The deltopectoral groove was explored and a medium-sized cephalic vein was identified. The distal end of the vein was ligated and a venotomy was performed. Two guide wires were advanced to the superior vena cava and peel-away introducer sheaths were used to insert the two pacing leads. The venous pressures were elevated and there was a fair amount of back-bleeding from the vein, so a 3-0 Monocryl figure-of-eight stitch was placed around the tissue surrounding the vein for hemostasis. The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage. The leads were tested with a pacing systems analyzer and the results are noted above. The leads were then anchored in place with #0-silk around their suture sleeve and connected to the pulse generator. The pacemaker was noted to function appropriately. The pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket. The incision was closed with two layers of 3-0 Monocryl and a subcuticular closure of 4-0 Monocryl. The incision was dressed with Steri-Strips and a sterile bandage and the patient was returned to her room in good condition.,IMPRESSION: ,Successful implantation of a dual chamber permanent pacemaker via the left cephalic vein. The patient will be observed overnight and will go home in the morning.",3
"CC:, Intermittent binocular horizontal, vertical, and torsional diplopia.,HX: ,70y/o RHM referred by Neuro-ophthalmology for evaluation of neuromuscular disease. In 7/91, he began experiencing intermittent binocular horizontal, vertical and torsional diplopia which was worse and frequent at the end of the day, and was eliminated when closing one either eye. An MRI Brain scan at that time was unremarkable. He was seen at UIHC Strabismus Clinic in 5/93 for these symptoms. On exam, he was found to have intermittent right hypertropia in primary gaze, and consistent diplopia in downward and rightward gaze. This was felt to possibly represent Grave's disease. Thyroid function studies were unremarkable, but orbital echography suggested Graves orbitopathy. The patient was then seen in the Neuro-ophthalmology clinic on 12/23/92. His exam remained unchanged. He underwent Tensilon testing which was unremarkable. On 1/13/93, he was seen again in Neuro-ophthalmology. His exam remained relatively unchanged and repeat Tensilon testing was unremarkable. He then underwent a partial superior rectus resection, OD, with only mild improvement of his diplopia. During his 8/27/96 Neuro-ophthalmology clinic visit he was noted to have hypertropia OD with left pseudogaze palsy and a right ptosis. The ptosis improved upon administration of Tensilon and he was placed on Mestinon 30mg tid. His diplopia subsequently improved, but did not resolve. The dosage was increased to 60mg tid and his diplopia worsened and the dose decreased back to 30mg tid. At present he denied any fatigue on repetitive movement. He denied dysphagia, SOB, dysarthria, facial weakness, fevers, chills, night sweats, weight loss or muscle atrophy.,MEDS: , Viokase, Probenecid, Mestinon 30mg tid.,PMH:, 1) Gastric ulcer 30 years ago, 2) Cholecystectomy, 3) Pancreatic insufficiency, 4) Gout, 5) Diplopia.,FHX:, Mother died age 89 of ""old age."" Father died age 89 of stroke. Brother, age 74 with CAD, Sister died age 30 of cancer.,SHX:, Retired insurance salesman and denies history of tobacco or illicit drug us. He has no h/o ETOH abuse and does not drink at present.,EXAM: ,BP 155/104.  HR 92. RR 12.  Temp 34.6C. WT 76.2kg.,MS: Unremarkable. Normal speech with no dysarthria.,CN: Right hypertropia (worse on rightward gaze and less on leftward gaze). Minimal to no ptosis, OD. No ptosis, OS. VFFTC. No complaint of diplopia. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,SENSORY: No deficits appreciated on PP/VIB/LT/PROP/TEMP testing.,Coordination/Station/Gait: Unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor on the right and withdrawal on the left.,HEENT and GEN EXAM: Unremarkable.,COURSE:, EMG/NCV, 9/26/96: Repetitive stimulation studies of the median, facial, and spinal accessory nerves showed no evidence of decrement at baseline, and at intervals up to 3 minutes following exercise. The patient had been off Mestinon for 8 hours prior to testing. Chest CT with contrast, 9/26/96, revealed a 4x2.5x4cm centrally calcified soft tissue anterior mediastinal mass adjacent to the aortic arch. This was highly suggestive of a thymoma. There were diffuse emphysematous disease with scarring in the lung bases. A few nodules suggestive of granulomas and few calcified perihilar lymph nodes. He underwent thoracotomy and resection of the mass. Pathologic analysis was consistent with a thymoma, lymphocyte predominant type, with capsular and pleural invasion, and extension to the phrenic nerve resection margin. Acetylcholine Receptor-binding antibody titer 12.8nmol/L (normal<0.7), Acetylcholine receptor blocking antibody <10% (normal), Acetylcholine receptor modulating antibody 42% (normal<19), Striated muscle antibody 1:320 (normal<1:10). Striated muscle antibody titers tend to be elevated in myasthenia gravis associated with thymoma. He was subsequently treated with XRT and continued to complain of fatigue at his 4/18/97 Oncology visit.",22
"REASON FOR CONSULTATION: , Congestive heart failure.,HISTORY OF PRESENT ILLNESS: , The patient is a 75-year-old gentleman presented through the emergency room.  Symptoms are of shortness of breath, fatigue, and tiredness.  Main complaints are right-sided and abdominal pain.  Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure.  Given history and his multiple risk factors and workup recently, which has been as mentioned below, the patient was admitted for further evaluation.  Incidentally, his x-ray confirms pneumonia.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, active smoker, cholesterol elevated, questionable history of coronary artery disease, and family history is positive.,FAMILY HISTORY: , Positive for coronary artery disease.,PAST SURGICAL HISTORY: , The patient denies any major surgeries.,MEDICATIONS:  ,Aspirin, Coumadin adjusted dose, digoxin, isosorbide mononitrate 120 mg daily, Lasix, potassium supplementation, gemfibrozil 600 mg b.i.d., and metoprolol 100 mg b.i.d.,ALLERGIES: , None reported.,PERSONAL HISTORY:,  Married, active smoker, does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, smoking history, coronary artery disease, cardiomyopathy, COPD, and presentation as above.  The patient is on anticoagulation on Coumadin, the patient does not recall the reason.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  History of blurry vision and hearing impaired.  No glaucoma.,CARDIOVASCULAR:  Shortness of breath, congestive heart failure, and arrhythmia.  Prior history of chest pain.,RESPIRATORY:  Bronchitis and pneumonia.  No valley fever.,GASTROINTESTINAL:  No nausea, vomiting, hematemesis, melena, or abdominal pain.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,SKIN:  Non-significant.,NEUROLOGICAL:  No TIA.  No CVA or seizure disorder.,ENDOCRINE:  Non-significant.,HEMATOLOGICAL:  Non-significant.,PSYCHOLOGICAL:  Anxiety.  No depression.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 60, blood pressure of 129/73, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.,LUNGS:  Air entry bilaterally decreased in the basilar areas with scattered rales, especially right side greater than left lung.,HEART:  PMI displaced.  S1 and S2, regular.  Systolic murmur.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  Trace edema of the ankle.  Pulses are feebly palpable.  Clubbing plus.  No cyanosis.,CNS:  Grossly intact.,MUSCULOSKELETAL:  Arthritic changes.,PSYCHOLOGICAL:  Normal affect.,LABORATORY AND DIAGNOSTIC DATA: , EKG shows sinus bradycardia, intraventricular conduction defect.  Nonspecific ST-T changes.,Laboratories noted with H&H 10/32 and white count of 7.  INR 1.8.  BUN and creatinine within normal limits.  Cardiac enzyme profile first set 0.04, BNP of 10,000.,Nuclear myocardial perfusion scan with adenosine in the office done about a couple of weeks ago shows ejection fraction of 39% with inferior reversible defect.,IMPRESSION: , The patient is a 75-year-old gentleman admitted for:",3
"HISTORY OF PRESENT ILLNESS:,  The patient is an 85-year-old gentleman who follows as an outpatient with Dr. A.  He is known to us from his last admission.  At that time, he was admitted with a difficulty voiding and constipation.  His urine cultures ended up being negative.  He was seen by Dr. B and discharged home on Levaquin for five days.,He presents to the ER today with hematuria that began while he was sleeping last night.  He denies any pain, nausea, vomiting or diarrhea.  In the ER, a Foley catheter was placed and was irrigated with saline.  White count was 7.6, H and H are 10.8 and 38.7, and BUN and creatinine are of 27 and 1.9.  Urine culture is pending.  Chest x-ray is pending.  His UA did show lots of red cells.  The patient currently is comfortable.  CBI is running.  His urine is clear.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  High cholesterol.,3.  Bladder cancer.,4.  Bilateral total knee replacements.,5.  Cataracts.,6.  Enlarged prostate.,ALLERGIES:,  SULFA.,MEDICATIONS AT HOME:,1.  Atenolol.,2.  Cardura.,3.  Zegerid.,4.  Flomax.,5.  Levaquin.,6.  Proscar.,7.  Vicodin.,8.  Morphine.,9.  Phenergan.,10.  Ativan.,11.  Zocor.,12.  Prinivil.,13.  Hydrochlorothiazide.,14.  Folic acid.,15.  Digoxin.,16.  Vitamin B12.,17.  Multivitamin.,SOCIAL HISTORY: , The patient lives at home with his daughter.  He does not smoke, occasionally drinks alcohol.  He is independent with his activities of daily living.,REVIEW OF SYSTEMS:,  Not additionally rewarding.,PHYSICAL EXAMINATION:,GENERAL:  An awake and alert 85-year-old gentleman who is afebrile.,VITAL SIGNS:  BP of 162/60 and pulse oximetry of 98% on room air.,HEENT:  Pink conjunctivae.  Anicteric sclerae.  Oral mucosa is moist.,NECK:  Supple.,CHEST:  Clear to auscultation.,HEART:  Regular S1 and S2.,ABDOMEN:  Soft and nontender to palpation.,EXTREMITIES:  Without edema.,He has a Foley catheter in place.  His urine is clear.,LABORATORY DATA:,  Reviewed.,IMPRESSION:,1.  Hematuria.",5
"EXAM: , Screening full-field digital mammogram.,HISTORY:,  Screening examination of a 58-year-old female who currently denies complaints.  Patient has had diagnosis of right breast cancer in 1984 with subsequent radiation therapy.  The patient's sister was also diagnosed with breast cancer at the age of 59.,TECHNIQUE: , Standard digital mammographic imaging was performed.  The examination was performed with iCAD Second Look Version 7.2.,COMPARISON: , Most recently obtained __________.,FINDINGS: , The right breast is again smaller than the left.  There is a scar marker with underlying skin thickening and retraction along the upper margin of the right breast.  The breasts are again composed of a mixture of adipose tissue and a moderate amount of heterogeneously-dense fibroglandular tissue.  There is again some coarsening of the right breast parenchyma with architectural distortion which is unchanged and most consistent with postsurgical and postradiation changes.  A few benign-appearing microcalcifications are present.,No dominant malignant-appearing mass lesion, developing area of architectural distortion or suspicious-appearing cluster of microcalcifications are identified.  The skin is stable.  No enlarged axillary lymph node is seen.,IMPRESSION:,1.  No significant interval changes are seen.  No mammographic evidence of malignancy is identified.,2.  Annual screening mammography is recommended or sooner if clinical symptoms warrant.,BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.",24
"PROCEDURE:,  Circumcision.,ANESTHESIA: , EMLA.,FINDINGS: , Normal penis.  The foreskin was normal in appearance and measured 1.6 cm.  There was no bleeding at the circumcision site.,PROCEDURE:,  Patient was placed on the circumcision restraint board.  EMLA had been applied approximately 90 minutes before.  A time-out was completed satisfactorily per protocol.  The area was prepped with Betadine.  The foreskin was grasped with sterile clamps and was dissected away from the corona and the glans penis with blunt dissection.  A Mogen clamp was applied to the cervix.  The excess foreskin was excised with the scalpel.  The clamp was removed.  At this point, the procedure was terminated.  Sterile Vaseline and gauze was applied to the glans penis.  There were no complications.  There was minimal blood loss.",38
"PREOPERATIVE DIAGNOSIS: , Possible inflammatory bowel disease.,POSTOPERATIVE DIAGNOSIS: , Polyp of the sigmoid colon.,PROCEDURE PERFORMED:  ,Total colonoscopy with photography and polypectomy.,GROSS FINDINGS: , The patient had a history of ischiorectal abscess.  He has been evaluated now for inflammatory bowel disease.  Upon endoscopy, the colon prep was good.  We were able to reach the cecum without difficulty.  There are no diverticluli, inflammatory bowel disease, strictures, or obstructing lesions.  There was a pedunculated polyp approximately 4.5 cm in size located in the sigmoid colon at approximately 35 cm.  This large polyp was removed using the snare technique.,OPERATIVE PROCEDURE:  ,The patient was taken to the endoscopy suite, prepped and draped in left lateral decubitus position.  IV sedation was given by Anesthesia Department.  The Olympus videoscope was inserted into anus.  Using air insufflation, the colonoscope was advanced through the anus to the rectum, sigmoid colon, descending colon, transverse colon, ascending colon and cecum, the above gross findings were noted.  The colonoscope was slowly withdrawn and carefully examined the lumen of the bowel.  When the polyp again was visualized, the snare was passed around the polyp.  It required at least two to three passes of the snare to remove the polyp in its totality.  There was a large stalk on the polyp.  ________ the polyp had been removed down to the junction of the polyp in the stalk, which appeared to be cauterized and no residual adenomatous tissue was present.  No bleeding was identified.  The colonoscope was then removed and patient was sent to recovery room in stable condition.",14
"1.  Pelvic tumor.,2.  Cystocele.,3.  Rectocele.,POSTOPERATIVE DIAGNOSES:,1.  Degenerated joint.,2.  Uterine fibroid.,3.  Cystocele.,4.  Rectocele.,PROCEDURE PERFORMED:  ,1.  Total abdominal hysterectomy.,2.  Bilateral salpingooophorectomy.,3.  Repair of bladder laceration.,4.  Appendectomy.,5.  Marshall-Marchetti-Krantz cystourethropexy.,6.  Posterior colpoperineoplasty.,GROSS FINDINGS:  The patient had a history of a rapidly growing mass on the abdomen, extending from the pelvis over the past two to three months.  She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus.  Curettings were negative for malignancy.  The patient did have a large cystocele and rectocele, and a collapsed anterior and posterior vaginal wall.,Upon laparotomy, there was a giant uterine tumor extending from the pelvis up to the above the umbilicus compatible with approximately four to five-month pregnancy.  The ovaries appeared to be within normal limits.  There was marked adherence between the bladder and the giant uterus and mass with edema and inflammation, and during dissection, a laceration inadvertently occurred and it was immediately recognized.  No other pathology noted from the abdominal cavity or adhesions.  The upper right quadrant of the abdomen compatible with a previous gallbladder surgery.  The appendix is in its normal anatomic position.  The ileum was within normal limits with no Meckel's diverticulum seen and no other gross pathology evident.  There was no evidence of metastasis or tumors in the left lobe of the liver.,Upon frozen section, diagnosis of initial and partial is that of a degenerating uterine fibroid rather than a malignancy.,OPERATIVE PROCEDURE:  The patient was taken to the Operating Room, prepped and draped in the low lithotomy position under general anesthesia.  A midline incision was made around the umbilicus down to the lower abdomen.  With a #10 Bard Parker blade knife, the incision was carried down through the fascia.  The fascia was incised in the midline, muscle fibers were splint in the midline, the peritoneum was grasped with hemostats and with a #10 Bard Parker blade after incision was made with Mayo scissors.  A Balfour retractor was placed into the wound.  This giant uterus was soft and compatible with a possible leiomyosarcoma or degenerating fibroid was handled with care.  The infundibular ligament on the right side was isolated and ligated with #0 Vicryl suture brought to an avascular area, doubly clamped and divided from the ovary and the ligament again re-ligated with #0 Vicryl suture.  The right round ligament was ligated with #0 Vicryl suture, brought to an avascular space within the broad ligament and divided from the uterus.  The infundibulopelvic ligament on the left side was treated in a similar fashion as well as the round ligament.  An attempt was made to dissect the bladder flap from the anterior surface of the uterus and this was remarkably edematous and difficult to do, and during dissection the bladder was inadvertently entered.  After this was immediately recognized, the bladder flap was wiped away from the anterior surface of the uterus.  The bladder was then repaired with a running locking stitch #0 Vicryl suture incorporating serosal muscularis mucosa and then the second layer of overlapping seromuscular sutures were used to make a two-layer closure of #0 Vicryl suture.  After removing the uterus, the bladder was tested with approximately 400 cc of sterile water and there appeared to be no leak.  Progressing and removing of the uterus was then carried out and the broad ligament was clamped bilaterally with a straight Ochsner forceps and divided from the uterus with Mayo scissors, and the straight Ochsner was placed by #0 Vicryl suture thus controlling the uterine blood supply.  The cardinal ligaments containing the cervical blood supply was serially clamped bilaterally with a curved Ochsner forceps, divided from the uterus with #10 Bard Parker blade knife and a curved Ochsner was placed by #0 Vicryl suture.  The cervix was again grasped with a Lahey tenaculum and pubovesicocervical ligament was entered and was divided using #10 Bard Parker blade knife and then the vaginal vault and with a double pointed sharp scissors.  A single-toothed tenaculum was placed on the cervix and then the uterus was removed from the vagina using hysterectomy scissors.  The vaginal cuff was then closed using a running #0 Vicryl suture in locking stitch incorporating all layers of the vagina, the cardinal ligaments of the lateral aspect and uterosacral ligaments on the posterior aspect.  The round ligaments were approximated to the vaginal cuff with #0 Vicryl suture and the bladder flap approximated to the round ligaments with #000 Vicryl suture.  The ______ was re-peritonealized with #000 Vicryl suture and then the cecum brought into the incision.  The pelvis was irrigated with approximately 500 cc of water.  The appendix was grasped with Babcock forceps.  The mesoappendix was doubly clamped with curved hemostats and divided with Metzenbaum scissors.  The curved hemostats were placed with #00 Vicryl suture.  The base of the appendix was ligated with #0 plain gut suture, doubly clamped and divided from the distal appendix with #10 Bard Parker blade knife, and the base inverted with a pursestring suture with #00 Vicryl.  No bleeding was noted.  Sponge, instrument, and needle counts were found to be correct.  All packs and retractors were removed.  The peritoneum muscle fascia was closed in single-layer closure using running looped #1 PDS, but prior to closure, a Marshall-Marchetti-Krantz cystourethropexy was carried out by dissecting the space of Retzius identifying the urethra in the vesical junction approximating the periurethral connective tissue to the symphysis pubis with interrupted #0 Vicryl suture.  Following this, the abdominal wall was closed as previously described and the skin was closed using skin staples.  Attention was then turned to the vagina, where the introitus of the vagina was grasped with an Allis forceps at the level of the Bartholin glands.  An incision was made between the mucous and the cutaneous junction and then a midline incision was made at the posterior vaginal mucosa in a tunneling fashion with Metzenbaum scissors.  The flaps were created bilaterally by making an incision in the posterior connective tissue of the vagina and wiping the rectum away from the posterior vaginal mucosa, and flaps were created bilaterally.  In this fashion, the rectocele was reduced and the levator ani muscles were approximated in the midline with interrupted #0 Vicryl suture.  Excess vaginal mucosa was excised and the vaginal mucosa closed with running #00 Vicryl suture.  The bulbocavernosus and transverse perinei muscles were approximated in the midline with interrupted #00 Vicryl suture.  The skin was closed with a running #000 plain gut subcuticular stitch.  The vaginal vault was packed with a Betadine-soaked Kling gauze sponge.  Sterile dressing was applied.  The patient was sent to recovery room in stable condition.",37
"PREOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,POSTOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,ANESTHESIA:,  General.,PROCEDURE: , Excision of recurrent pyogenic granuloma.,INDICATIONS: , The patient is 12-year-old young lady, who has a hand-sized congenital vascular malformation on her left lateral thigh below the greater trochanter, which was described by her parents as a birthmark.  This congenital cutaneous vascular malformation faded substantially over the first years of her life and has regressed to a flat, slightly hyperpigmented lesion.  Although no isolated injury event can be recalled, the patient has developed a pyogenic granuloma next to the distal portion of this lesion on her mid thigh, and it has been treated with topical cautery in her primary care doctor's office, but with recurrence.  She is here today for excision.,OPERATIVE FINDINGS: , The patient had what appeared to be a classic pyogenic granuloma arising from this involuted vascular malformation.,DESCRIPTION OF OPERATION:  ,The patient came to the operating room, had an uneventful induction of general anesthesia.  We conducted a surgical time-out, reiterated her important and unique identifying information and confirmed that the excision of the left thigh pyogenic granuloma was the procedure planned for today.  Preparation and draping was __________ ensued with a chlorhexidine based prep solution.  The pyogenic granuloma was approximately 6 to 7 mm in greatest dimension and to remove it required creating an elliptical incision of about 1 to 1.2 cm.  This entire area was infiltrated with 0.25% Marcaine with dilute epinephrine to provide a wide local field block and then an elliptical incision was made with a #15 scalpel blade, excising the pyogenic granuloma, its base, and a small rim of surrounding normal skin.  Some of the abnormal vessels in the dermal and subdermal layer were cauterized with the needle-tip electrocautery pencil.  The wound was closed in layers with a deep dermal roll of 5-0 Monocryl stitches supplemented by 5-0 intradermal Monocryl and Steri-Strips for final skin closure.  The patient tolerated the procedure well.  This nodule was submitted to pathology for confirmation of its histology as a pyogenic granuloma.  Blood loss was less than 5 mL and there were no complications.",37
"PREOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,POSTOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,PROCEDURE:  ,The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.,FINDINGS: , Normal-appearing thyroid gland with a possible lump in the inferior aspect, there was a parathyroid gland that by frozen section _________  was not thyroid, it was reimplanted to the left lower sternocleidomastoid region.,ESTIMATED BLOOD LOSS:  ,Approximately 10 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS: , None.,DRAINS: , Rubber band drain in the neck.,CONDITION:,  Stable.,PROCEDURE:  ,The patient placed supine under general anesthesia.  First, a shoulder roll was placed, 1% lidocaine and 1:100,000 epinephrine was injected into the old scar, natural skin fold, and Betadine prep.  Sterile dressing was placed.  The laryngeal monitoring was noted to be working fine.  Then, an incision was made in this area in a curvilinear fashion through the old scar, taken through the fat and the platysma level.  The strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid, the thyroid gland was then found.  Then, using bipolar cautery and a Coblation dissector, the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally, the thyroid gland was released, then came into the Berry ligaments.  The Berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels, which were crossed with the Harmonic scalpel and removed.  No bleeding was seen.  There was a small nick in the external jugular vein that was tied with a 4-0 Vicryl suture ligature.  After this was completed, on examining the specimen, there appeared to be a lobule on it and it was sent off as possibly parathyroid, therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature.  After this was completed, no bleeding was seen.  The laryngeal nerve could be seen and intact and then Rubber band  drain was placed throughout the neck along the thyroid bed and 4-0 Vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5-0 nylon was used to close the skin and Mastisol and Steri-Strips were placed along the skin edges and then on awakening, both laryngeal nerves were working normally.  Procedure was then terminated at that time.",37
"REASON:,  Right lower quadrant pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 48-year-old female with an approximately 24-hour history of right lower quadrant pain, which she describes as being stabbed with a knife, radiating around her side to her right flank.  She states that is particularly bad when up and walking around, goes away when she is lying down.  She has no nausea or vomiting, no dysuria, no fever or chills, though she said she did feel warm.  She states that she feels a bit like she did when she had her gallbladder removed nine years ago.  Additionally, I should note that the patient is currently premenopausal with irregular menses, going anywhere from one to two months between cycles.  She has no abnormal vaginal discharge, and she is sexually active.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS,1.  Hydrochlorothiazide 25 mg p.o. daily.,2.  Lisinopril 10 mg p.o. daily.,3.  Albuterol p.r.n.,PAST MEDICAL HISTORY:  ,Hypertension and seasonal asthma.,PAST SURGICAL HISTORY: , Left bilateral breast biopsy for benign disease.  Cholecystitis/cholecystectomy following tubal pregnancy 22 years ago.,FAMILY HISTORY: , Mother is alive and well.  Father with coronary artery disease.  She has siblings who have increased cholesterol.,SOCIAL HISTORY:  ,The patient does not smoke.  She quit 25 years ago.  She drinks one beer a day.  She works as a medical transcriptionist.,REVIEW OF SYSTEMS: , Positive for an umbilical hernia, but otherwise negative with the exception of what is noted above.,PHYSICAL EXAMINATION,GENERAL:  Reveals a morbidly obese female who is alert and oriented x3, pleasant and well groomed, and in mild discomfort.,VITAL SIGNS:  Her temperature is 38.7, pulse 113, respirations 18, and blood pressure 144/85.,HEENT:  Normocephalic and atraumatic.  Sclerae are without icterus.  Conjunctivae are not injected.,NECK:  Neck is supple.  Carotids 2+.  Trachea is midline.  Carotids are without bruits.,LYMPH NODES:  There is no cervical, supraclavicular, or occipital adenopathy.,LUNGS:  Clear to auscultation.,CARDIAC:  Regular rate and rhythm.,ABDOMEN:  Soft.  No hepatosplenomegaly.  She has a positive Rovsing sign and a positive obturator sign.  She is tender in the right lower quadrant with mild rebound and no guarding.,EXTREMITIES:  Reveal 2+ femoral, popliteal, dorsalis pedis, and posterior tibial pulses.  She has only trace edema with varicosities around the bilateral ankles.,CNS:  Without gross neurologic deficits.,INTEGUMENTARY:  Skin integrity is excellent.,DIAGNOSTICS: , Urine, specific gravity is 1.010, blood is 50, leukocytes 1+, white blood cells 10 to 25, rbc's 2 to 5, and 2 to 5 squamous epithelial cells.  White blood cell count is 20,000 with 75 polys and 16 lymphs.  H&H is 13.7 and 39.7.  Total bilirubin 1.3, direct bilirubin 0.2, and alk phos 98.  Sodium 138, potassium 3.1, chloride 101, CO2 26, calcium 9.5, glucose 103, BUN 16, and creatinine 0.91.  Lipase is 19.  CAT scan is negative for acute appendicitis.  In fact, it mentions that the appendix is not discretely identified.  There are no focal inflammatory masses, abscess, ascites, or pneumoperitoneum.,IMPRESSION: , Abdominal pain right lower quadrant, etiology is unclear.,PLAN:,  Plan is to admit the patient.  Recheck the white blood cell count in the morning.  Re-examine her and further plan is pending, the results of that evaluation.",14
"PROCEDURE: , Newborn circumcision.,INDICATIONS: , Parental preference.,ANESTHESIA:,  Dorsal penile nerve block.,DESCRIPTION OF PROCEDURE:,  The baby was prepared and draped in a sterile manner.  Lidocaine 1% 4 mL without epinephrine was instilled into the base of the penis at 2 o'clock and 10 o'clock.  The penile foreskin was removed using a XXX Gomco.  Hemostasis was achieved with minimal blood loss.  There was no sign of infection.  The baby tolerated the procedure well.  Vaseline was applied to the penis, and the baby was diapered by nursing staff.",38
"PREOPERATIVE DIAGNOSIS: , Right inguinal hernia. ,POSTOPERATIVE DIAGNOSIS:,  Right direct inguinal hernia. ,PROCEDURE:,  Right direct inguinal hernia repair with PHS mesh system. ,ANESTHESIA:,  General with endotracheal intubation. ,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was administered with endotracheal intubation.  The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion.  An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease.  Dissection was taken down through the skin and subcutaneous tissue.  Scarpa's fascia was divided, and the external ring was located.  The external oblique was divided from the external ring up towards the anterior superior iliac spine.  The cord structures were then encircled.  Careful inspection of the cord structures did not reveal any indirect sac along the cord structures.  I did, however, feel a direct sac with a direct defect.  I opened the floor of the inguinal canal and dissected out the preperitoneal space at the direct sac and cut out the direct sac.  Once I cleared out the preperitoneal space, I placed a PHS mesh system with a posterior mesh into the preperitoneal space, and I made sure that it laid flat along Cooper's ligament and covered the myopectineal orifice.  I then tucked the extended portion of the anterior mesh underneath the external oblique between the external oblique and the internal oblique, and I then tacked the medial portion of the mesh to the pubic tubercle with a 0 Ethibond suture.  I tacked the superior portion of the mesh to the internal oblique and the inferior portion of the mesh to the shelving edge of the inguinal ligament.  I cut a hole in the mesh in order to incorporate the cord structures and recreated the internal ring, making sure that it was not too tight so that it did not strangulate the cord structures.  I then closed the external oblique with a running 3-0 Vicryl.  I closed the Scarpa's with interrupted 3-0 Vicryl, and I closed the skin with a running Monocril.  Sponge, instrument and needle counts were correct at the end of the case.  The patient tolerated the procedure well and without any complications.",37
"PREOPERATIVE DIAGNOSES:,1.  Right hydronephrosis.,2.  Right flank pain.,3.  Atypical/dysplastic urine cytology.,POSTOPERATIVE DIAGNOSES:,1.  Right hydronephrosis.,2.  Right flank pain.,3.  Atypical/dysplastic urine cytology.,4.  Extrarenal pelvis on the right.,5.  No evidence of obstruction or ureteral/bladder lesions.,PROCEDURE PERFORMED:,1.  Cystoscopy.,2.  Bilateral retrograde ureteropyelograms.,3.  Right ureteral barbotage for urine cytology.,4.  Right ureterorenoscopy, diagnostic.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Urine and saline wash barbotage from right ureter through the ureteral catheter.,ESTIMATED BLOOD LOSS:  ,Minimal.,INDICATIONS FOR PROCEDURE: , This is a 70-year-old female who reports progressive intermittent right flank pain associated with significant discomfort and disability.  She presented to the emergency room where she was found to have significant hydronephrosis on the right without evidence of a stone.  She has some ureteral thickening in her distal right ureter.  She has persistent microscopic hematuria and her urine cytology and cytomolecular diagnosis significant for urothelial dysplasia with neoplasia-associated karyotypic profile.  She was brought to the operating room for further evaluation and treatment.,DESCRIPTION OF OPERATION: , After preoperative counseling, the patient was taken to the operating room and administered a spinal anesthesia.  She was placed in the lithotomy position, prepped and draped in the usual sterile fashion.  The 21-French cystoscope was inserted per urethra into the bladder.  The bladder was inspected and found to be without evidence of intravesical tumors, stones or mucosal abnormalities.  The right ureteral orifice was visualized and cannulated with an open-ended ureteral catheter.  This was gently advanced to the mid ureter.  Urine was collected for cytology.  Retrograde injection of saline through the ureteral catheter was then also used to enhance collection of the specimen.  This too was collected and sent for a pooled urine cytology as specimen from the right renal pelvis and ureter.  An 0.038 guidewire was then passed up through the open-ended ureteral catheter.  The open-ended ureteral catheter and cystoscope were removed, and over the guidewire the flexible ureteroscope was passed up to the level of the renal pelvis.  Using direct vision and fluoroscopy to confirm location, the entire renal pelvis and calyces were inspected.  The renal pelvis demonstrated an extrarenal pelvis, but no evidence of obstruction at the renal UPJ level.  There were no intrapelvic or calyceal stones.  The ureter demonstrated no significant mucosal abnormalities, no visible tumors, and no areas of apparent constriction on multiple passes of the ureteroscope through the ureter to evaluate.  The ureteroscope was then removed.  The cystoscope was reinserted.  Once again, retrograde injection of contrast through an open-ended ureteral catheter was undertaken in the right ureter and collecting system.  No evidence of extravasation or significant change in anatomy was visualized.  The left ureteral orifice was then visualized and cannulated with an open-ended ureteral catheter, and retrograde injection of contrast demonstrated a normal left ureter and collecting system.  The cystoscope was removed.  Foley catheter was inserted.  The patient was placed in the supine position and transferred to the recovery room in satisfactory condition.",37
"PREOPERATIVE DIAGNOSIS:,  Bilateral upper lobe cavitary lung masses.,POSTOPERATIVE DIAGNOSES:,1.  Bilateral upper lobe cavitary lung masses.,2.  Final pending pathology.,3.  Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left.  There are also changes of inflammation throughout.,PROCEDURE PERFORMED: , Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.,ANESTHESIA: , Conscious sedation was with Demerol 150 mg and Versed 4 mg IV.,OPERATIVE REPORT: , The patient is residing in the endoscopy suite.  After appropriate anesthesia and sedation, the bronchoscope was advanced transorally due to the patient's recent history of epistaxis.  Topical lidocaine was utilized for anesthesia.  Epiglottis and vocal cords demonstrated some mild asymmetry of the true cords with right true and false vocal cord appearing slightly more prominent.  This may be normal anatomic variant.  The scope was advanced into the trachea.  The main carina was sharp in appearance.  Right upper, middle, and lower segmental bronchi as well as left upper lobe and lower lobe segmental bronchi were serially visualized.  Immediately noted were some abnormalities including circumferential narrowing and probable edema involving the posterior and apical segmental bronchi on the right and to a lesser degree the anterior segmental bronchus on the left.  No specific intrinsic masses were noted.  Under direct visualization, the scope was utilized to lavage the posterior segmental bronchus in the right upper lobe.  Also cytologic brushings and protected bacteriologic brushing specimens were obtained.  Three biopsies were attempted within the cavitary lesion in the posterior segment of the right upper lobe.  During lavage, some caseous appearing debris appeared intermittently.  The specimens were collected and sent to the lab.  Procedure was terminated with hemostasis having been verified.  The patient tolerated the procedure well.,Throughout the procedure, the patient's vital signs and oximetry were monitored and remained within satisfactory limits.,The patient will be returned to her room with orders as per usual.",37
"DIAGNOSIS:,  Desires vasectomy.,NAME OF OPERATION: , Vasectomy.,ANESTHESIA:,  General.,HISTORY: , Patient, 37, desires a vasectomy.,PROCEDURE: , Through a midline scrotal incision, the right vas was identified and separated from the surrounding tissues, clamped, transected, and tied off with a 4-0 chromic.  No bleeding was identified.,Through the same incision the left side was identified, transected, tied off, and dropped back into the wound.  Again no bleeding was noted.,The wound was closed with 4-0 Vicryl times two.  He tolerated the procedure well.  A sterile dressing was applied.  He was awakened and transferred to the recovery room in stable condition.",37
"PREOPERATIVE DIAGNOSIS: , Right colon tumor.,POSTOPERATIVE DIAGNOSES:,1.  Right colon cancer.,2.  Ascites.,3.  Adhesions.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Lysis of adhesions.,3.  Right hemicolectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,URINE OUTPUT: , 200 cc.,CRYSTALLOIDS GIVEN: , 2700 cc.,INDICATIONS FOR THIS PROCEDURE:  ,The patient is a 53-year-old African-American female who presented with near obstructing lesion at the hepatic flexure.  The patient underwent a colonoscopy which found this lesion and biopsies were taken proving invasive adenocarcinoma.  The patient was NG decompressed preoperatively and was prepared for surgery.  The need for removal of the colon cancer was explained at length.  The patient was agreeable to proceed with the surgery and signed preoperatively informed consent.,PROCEDURE: , The patient was taken to the Operative Suite and placed in the supine position under general anesthesia per Anesthesia Department and NG and Foley catheters were placed preoperatively.  She was given triple antibiotics IV.  Due to her near obstructive symptoms, a formal ________ was not performed.,The abdomen was prepped and draped in the usual sterile fashion.  A midline laparotomy incision was made with a #10 blade scalpel and subcutaneous tissues were separated with electrocautery down to the anterior abdominal fascia.  Once divided, the intraabdominal cavity was accessed and bowel was protected as the rest of the abdominal wall was opened in the midline.  Extensive fluid was seen upon entering the abdomen, ascites fluid, which was clear straw-colored and this was sampled for cytology.  Next, the small bowel was retracted with digital exploration and there was a evidence of hepatic flexure, colonic mass, which was adherent to the surrounding tissues.  With mobilization of the colon along the line of Toldt down to the right gutter, the entire ileocecal region up to the transverse colon was mobilized into the field.  Next, a window was made 5 inches from the ileocecal valve and a GIA-75 was fired across the ileum.  Next, a second GIA device was fired across the proximal transverse colon, just sparring the middle colic artery.  The dissection was then carried down along the mesentry, down to the root of the mesentry.  Several lymph nodes were sampled carefully, and small radiopaque clips were applied along the base of the mesentry.  The mesentry vessels are hemostated and tied with #0-Vicryl suture sequentially, ligated in between.  Once this specimen was submitted to pathology, the wound was inspected.  There was no evidence of bleeding from any of the suture sites.  Next, a side-by-side anastomosis was performed between the transverse colon and the terminal ileum.  A third GIA-75 was fired side-by-side and GIA-55 was used to close the anastomosis.  A patent anastomosis was palpated.  The anastomosis was then protected with a #2-0 Vicryl #0-muscular suture.  Next, the mesenteric root was closed with a running #0-Vicryl suture to prevent any chance of internal hernia.  The suture sites were inspected and there was no evidence of leakage.  Next, the intraabdominal cavity was thoroughly irrigated with sterile saline and the anastomosis was carried into the right lower gutter.  Omentum was used to cover the intestines which appeared dilated and indurated from the near obstruction.  Next, the abdominal wall was reapproximated and the fascial layer using a two running loop PDS sutures meeting in the middle with good approximation of both the abdominal fascia.  Additional sterile saline was used to irrigate the subcutaneous fat and then the skin was closed with sequential sterile staples.,Sterile dressing was applied and the skin was cleansed and the patient was awakened from anesthesia without difficulty and extubated in the Operating Room and she was transferred to Recovery Room in stable condition and will be continued to be monitored on the Telemetry Floor with triple antibiotics and NG decompression.,",37
"CHIEF COMPLAINT:,  Rule out obstructive sleep apnea syndrome.,Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years.  He denies any gasping, choking, or coughing episodes while asleep at night.  His bedtime is between 10 to 11 p.m., has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed.  He has two to three episodes of nocturia per night.  He denies any morning symptoms.  He has mild excess daytime sleepiness manifested by dozing off during boring activities.,PAST MEDICAL HISTORY:,  Hypertension, gastritis, and low back pain.,PAST SURGICAL HISTORY:,  TURP.,MEDICATIONS:,  Hytrin, Motrin, Lotensin, and Zantac.,ALLERGIES:,  None.,FAMILY HISTORY:,  Hypertension.,SOCIAL HISTORY:,  Significant for about a 20-pack-year tobacco use, quit in 1991.  No ethanol use or illicit drug use.  He is married.  He has one dog at home.  He used to be employed at Budd Automotors as a die setter for about 37 to 40 years.,REVIEW OF SYSTEMS:,  His weight has been steady over the years.  Neck collar size is 17½"".  He denies any chest pain, cough, or shortness of breath.  Last chest x-ray within the past year, per his report, was normal.,PHYSICAL EXAM:,  A pleasant, obese, African-American male in no apparent respiratory distress.  T:  98.  P:  90.  RR:  20.  BP:  156/90.  O2 saturation:  97% on room air.  Ht:  5' 5"".  Wt:  198 lb.  HEENT:  A short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no JVD.  CARDIAC:  Regular rate and rhythm without any adventitious sounds.  CHEST:  Clear lungs bilaterally. ABDOMEN:  An obese abdomen with active bowel sounds.  EXTREMITIES:  No cyanosis, clubbing, or edema.  NEUROLOGIC:  Non-focal.,IMPRESSION:,1.  Probable obstructive sleep apnea syndrome.,2.  Hypertension.,3.  Obesity.,4.  History of tobacco use.,PLAN:,1.  We will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome.,2.  Encouraged weight loss.,3.  Check TSH.,4.  Asked not to drive and engage in any activity that could endanger himself or others while sleepy.,5.  Asked to return to the clinic one week after sleep the study is done.",5
"PROCEDURE:,  A 21-channel digital electroencephalogram was performed on a patient in the awake state.  Per the technician's notes, the patient is taking Depakene.,The recording consists of symmetric 9 Hz alpha activity.  Throughout the recording, repetitive episodes of bursts of 3 per second spike and wave activity are noted.  The episodes last from approximately1 to 7 seconds.  The episodes are exacerbated by hyperventilation.,IMPRESSION:,  Abnormal electroencephalogram with repetitive bursts of 3 per second spike and wave activity exacerbated by hyperventilation.  This activity could represent true petit mal epilepsy.  Clinical correlation is suggested.",35
"The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period.  She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus.  She states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus.  However, she states she did not know that she was pregnant at this time.  She denies any abdominal pain or vaginal bleeding.  She states that the pregnancy is unplanned; however, she would desire to continue the pregnancy.,PAST MEDICAL HISTORY:  Diabetes mellitus which resolved after weight loss associated with gastric bypass surgery.,PAST SURGICAL HISTORY:,1.  Gastric bypass.,2.  Bilateral carpal tunnel release.,3.  Laparoscopic cholecystectomy.,4.  Hernia repair after gastric bypass surgery.,5.  Thoracotomy.,6.  Knee surgery.,MEDICATIONS:,1.  Lexapro 10 mg daily.,2.  Tramadol 50 mg tablets two by mouth four times a day.,3.  Ambien 10 mg tablets one by mouth at bedtime.,ALLERGIES:  AMOXICILLIN CAUSES THROAT SWELLING.  AVELOX CAUSES IV SITE SWELLING.,SOCIAL HISTORY:  The patient denies tobacco, ethanol, or drug use.  She is currently separated from her partner who is the father of her 21-month-old daughter.  She currently lives with her parents in Greenville.  However, she was visiting the estranged boyfriend in Wilkesboro, this week.,GYN HISTORY:  The patient denies history of abnormal Pap smears or STDs.,OBSTETRICAL HISTORY:  Gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery.  Gravida 2 is current.,REVIEW OF SYSTEMS:  The 14-point review of systems was negative with the exception as noted in the HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 134/45, pulse 130, respirations 28.  Oxygen saturation 100%.,GENERAL:  Patient lying quietly on a stretcher.  No acute distress.,HEENT:  Normocephalic, atraumatic.  Slightly dry mucous membranes.,CARDIOVASCULAR EXAM:  Regular rate and rhythm with tachycardia.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No rebound or guarding.,SKIN:  Normal turgor.  No jaundice.  No rashes noted.,EXTREMITIES:  No clubbing, cyanosis, or edema.,NEUROLOGIC:  Cranial nerves II through XII grossly intact.,PSYCHIATRIC:  Flat affect.  Normal verbal response.,ASSESSMENT AND PLAN:  A 34-year-old Caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.,1.  Given the substances taken, medications are unlikely to affect the development of the fetus.  There have been no reported human anomalies associated with Ambien or tramadol use.  There is, however, a 4% risk of congenital anomalies in the general population.,2.  Recommend quantitative HCG and transvaginal ultrasound for pregnancy dating.,3.  Recommend prenatal vitamins.,4.  The patient to follow up as an outpatient for routine prenatal care.,",5
"PREOPERATIVE DIAGNOSIS:,  Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS:  ,Rule out temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsy.,ANESTHESIA:,  Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:,  I was consulted by Dr. X for this patient with bilateral temporal headaches to rule out temporal arteritis.  I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way.  After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery.  The temporal artery was identified and was grossly normal on both sides.  Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult.  The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm.  They were sent as separate specimens, right and left labeled.  The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond.  She tolerated the procedure well.",23
"PREOPERATIVE DIAGNOSIS: , Extremely large basal cell carcinoma, right lower lid.,POSTOPERATIVE DIAGNOSIS:,  Extremely large basal cell carcinoma, right lower lid.,TITLE OF OPERATION: , Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.,PROCEDURE: , The patient was brought into the operating room and prepped and draped in usual fashion.  Xylocaine 2% with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid.  A frontal nerve block was also given on the right upper lid.  The anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect.  The area was marked with a marking pen with margins of 3 to 4 mm, and a #15 Bard-Parker blade was used to make an incision at the nasal and temporal margins of the lesion.,The incision was carried inferiorly, and using a Steven scissors the normal skin, muscle, and conjunctiva was excised inferiorly.  The specimen was then marked and sent to pathology for frozen section.  Bleeding was controlled with a wet-field cautery, and the right upper lid was everted, and an incision was made 3 mm above the lid margin with the Bard-Parker blade in the entire length of the upper lid.  The incision reached the orbicularis, and Steven scissors were used to separate the tarsus from the underlying orbicularis.  Vertical cuts were made nasally and temporally, and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly.  It was placed into the defect in the lower lid and sutured with multiple interrupted 6-0 Vicryl sutures nasally, temporally, and inferiorly.,The defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region.  The defect was closed with interrupted 5-0 Prolene sutures, and the preauricular graft was sutured in place with multiple interrupted 6-0 silk sutures.  The upper border of the graft was attached to the upper lid after incision was made in the gray line with a Superblade, and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision.,Cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins, and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied.  The patient tolerated the procedure well and was sent to recovery room in good condition.",16
"PREOPERATIVE DIAGNOSIS: , Blighted ovum, severe cramping.,POSTOPERATIVE DIAGNOSIS:,  Blighted ovum, severe cramping.,OPERATION PERFORMED: , Vacuum D&C.,DRAINS: , None.,ANESTHESIA: , General.,HISTORY: , This 21-year-old white female gravida 1, para 0 who was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.  Due to the severe cramping, a decision to undergo vacuum D&C was made.  At the time of the procedure, moderate amount of tissue was obtained.,PROCEDURE:  ,The patient was taken to the operating room and placed in a supine position, at which time a general form of anesthesia was administered by the anesthesia department.  The patient was then repositioned in a modified dorsal lithotomy position and then prepped and draped in the usual fashion.  A weighted vaginal speculum was placed in the posterior vaginal vault.  Anterior lip of the cervix was grasped with single tooth tenaculum, and the cervix was dilated to approximately 8 mm straight.  Plastic curette was placed into the uterine cavity and suction was applied at 60 mmHg to remove the tissue.  This was followed by gentle curetting of the lining as well as followed by suction curetting and then another gentle curetting and a final suction.  Methargen 0.2 mg was given IM and Pitocin 40 units and a 1000 was also started at the time of the procedure.  Once the procedure was completed, the single tooth tenaculum was removed from the vaginal vault with some _____ remaining blood and the weighted speculum was also removed.  The patient was repositioned to supine position and taken to recovery room in stable condition.",24
"PROCEDURE IN DETAIL: , Following instructions and completion of an oral colonoscopy prep, the patient, having been properly informed of, with signature consenting to total colonoscopy and indicated procedures, the patient received premedications of Vistaril 50 mg, Atropine 0.4 mg IM, and then intravenous medications of Demerol 50 mg and Versed 5 mg IV.  Perirectal inspection was normal.  The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum.  No abnormalities were seen of the terminal ileum, the ileocecal valve, cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, rectosigmoid and rectum.  Retroflexion exam in the rectum revealed no other abnormality and withdrawal terminated the procedure.",14
"HISTORY:,  This 75-year-old man was transferred from the nursing home where he lived to the hospital late at night on 4/11 through the Emergency Department in complete urinary obstruction.  After catheterization, the patient underwent cystoscopy on 4/13.  On 4/14 the patient underwent a transurethral resection of the prostate and was discharged back to the nursing home later that day with voiding improved.  Final diagnosis was adenocarcinoma of the prostate.  Because of his mental status and general debility, the patient's family declined additional treatment.,LABORATORY:,  None,PROCEDURES:,Cystoscopy:  Blockage of the urethra by a markedly enlarged prostate.,Transurethral resection of prostate:  45 grams of tissue were sent to the Pathology Department for analysis.,PATHOLOGY: , Well differentiated adenocarcinoma, microacinar type, in 1 of 25 chips of prostatic tissue.",38
"REASON FOR CONSULTATION: , Renal failure.,HISTORY OF PRESENT ILLNESS:,  Thank you for referring Ms. Abc to ABCD Nephrology.  As you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to XYZ Hospital.  She had been admitted at that time with chest pain and was subsequently transferred to University of A and had a cardiac catheterization, which did not show any coronary artery disease.  She also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin.  Her creatinine both at XYZ Hospital and University of A was elevated at 2.4.  I do not have the results from the prior years.  A repeat creatinine on 08/16/06 was 2.3.  The patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration.  She also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection.  She had bladder studies a long time ago.  She complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria.  She also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones.  She denies any nonsteroidal antiinflammatory drug use.  She denies any other over-the-counter medication use.  She has chronic hypokalemia and has been on potassium supplements recently.  She is unsure of the dose.  ,PAST MEDICAL HISTORY: ,1.  Hypertension on and off for years.  She states she has been treated intermittently but lately has again been off medications.,2.  Gastroesophageal reflux disease.,3.  Gastritis.,4.  Hiatal hernia.,5.  H. pylori infection x3 in the last six months treated.,6.  Chronic hypokalemia secondary to chronic diarrhea.,7.  Recurrent admissions with nausea, vomiting, and dehydration.  ,8.  Renal cysts found on a CAT scan of the abdomen.,9.  No coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease.  ,10.  Stomach bypass surgery 1975 with chronic diarrhea.,11.  History of UTI multiple times recently.,12.  Questionable history of kidney stones.,13.  History of gingival infection secondary to chronic steroid use, which was discontinued in July 2001.,14.  Depression.,15.  Diffuse degenerative disc disease of the spine.,16.  Hypothyroidism.,17.  History of iron deficiency anemia in the past.  ,18.  Hyperuricemia.  ,19.  History of small bowel resection with ulcerative fibroid.  ,20.  Occult severe GI bleed in July 2001.,PAST SURGICAL HISTORY: ,  The patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck April 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor August 4, 2005.  ,CURRENT MEDICATIONS: ,1.  Nexium 40 mg q.d.,2.  Synthroid 1 mg q.d. ,3.  Potassium one q.d., unsure about the dose.  ,4.  No history of nonsteroidal drug use.,ALLERGIES:",5
"CC:, Confusion and slurred speech.,HX , (primarily obtained from boyfriend): This 31 y/o RHF experienced a ""flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found ""passed out"" in bed, and when awoken appeared confused, and lethargic. She apparently recovered within 24 hours. For two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). She left a stove on.,She began slurring her speech 2 days prior to admission. On the day of presentation she developed right facial weakness and began stumbling to the right. She denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. There was no history of illicit drug/ETOH use or head trauma.,PMH:, Migraine Headache.,FHX: , Unremarkable.,SHX: ,Divorced. Lives with boyfriend. 3 children alive and well. Denied tobacco/illicit drug use. Rarely consumes ETOH.,ROS:, Irregular menses.,EXAM: ,BP118/66.  HR83. RR 20. T36.8C.,MS: Alert and oriented to name only. Perseverative thought processes. Utilized only one or two word answers/phrases. Non-fluent. Rarely followed commands. Impaired writing of name.,CN: Flattened right nasolabial fold only.,Motor: Mild weakness in RUE manifested by pronator drift. Other extremities were full strength.,Sensory: withdrew to noxious stimulation in all 4 extremities.,Coordination: difficult to assess.,Station: Right pronator drift.,Gait: unremarkable.,Reflexes: 2/2BUE, 3/3BLE, Plantars were flexor bilaterally.,General Exam: unremarkable.,INITIAL STUDIES:, CBC, GS, UA, PT, PTT, ESR, CRP, EKG were all unremarkable. Outside HCT showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified).,COURSE: ,MRI Brian Scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left MCA distribution suggesting slow flow. The latter suggested a vasculopathy such as Moya Moya, or fibromuscular dysplasia. HIV, ANA, Anti-cardiolipin Antibody titer, Cardiac enzymes, TFTs, B12, and cholesterol studies were unremarkable.,She underwent a cerebral angiogram on 2/12/92. This revealed an occlusion of the left MCA just distal to its origin. The distal distribution of the left MCA filled on later films through collaterals from the left ACA. There was also an occlusion of the right MCA just distal to the temporal branch. Distal branches of the right MCA filled through collaterals from the right ACA. No other vascular abnormalities were noted. These findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as Moya Moya disease. She was subsequently given this diagnosis. Neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. She had long latencies responding and understood only simple questions. Affect was blunted and there was distinct lack of concern regarding her condition. She was subsequently discharged home on no medications.,In 9/92 she was admitted for sudden onset right hemiparesis and mental status change. Exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. OB/GYN exam including cervical biopsy, and abdominal/pelvic CT scanning revealed stage IV squamous cell cancer of the cervix. She died 9/24/92 of cervical cancer.",22
"REASON FOR CONSULTATION: , Management of pain medications.,HISTORY OF PRESENT ILLNESS: , This is a 60-year-old white male with history of coronary artery disease, status post CABG in 1985 with subsequent sternal dehiscence with rewiring in December 2005 and stent placement in LAD region in 2005, who developed sudden chest pain and was taken to San Jacinto via ambulance where he was diagnosed with acute MI and then went into atrial fibrillation.  An intraaortic balloon pump was placed for cardiogenic shock, and then he was transferred to the ABCD Hospital on October 22, 2006, for continued critical care.  He was in a state of cardiogenic shock and multiorgan system failure including respiratory failure and acute renal insufficiency when he was transferred.  He is currently on dialysis due to end-stage renal disease and has a tracheostomy.  He is receiving fentanyl since he has been here for back pain, leg pain, abdominal pain, and pain in the feet.  He states that he is currently in pain and the fentanyl only helps for about an hour or so before the pain resumes.  He currently rates his pain as 7 out of 10.  He denies a depressed mood or anxiety and states that he knows he is getting better.  He describes his sleep as erratic and states that he will sleep for 1 hour after giving fentanyl IV and then will wake up until he gets another fentanyl.  He has PEG for tube feeding.  He has weakness on left side of his body as well as both legs since his MI.  He has been switched from fentanyl IV q.2h. to the fentanyl patch today.  He also has been started on Seroquel 12.5 mg p.o. at bedtime and will receive his first dose on the evening of Monday, February 12, 2007.  He denies any other psychiatric symptoms including auditory or visual hallucinations or delusions.  His wife was present in the room and both him and his wife seemed to be offended by the suggestion of any psychiatric history or any psychiatric problems.,PAST MEDICAL HISTORY:,1.  DVT in December 2005.,2.  Three MI's (1996, 2005, and 2006).,3.  Diabetes for 5 years.,4.  Coronary artery disease for 10 years.,PAST SURGERIES:,1.  Appendectomy as a child.,2.  CABG x3, November 2005.,3.  Sternal rewiring, December 2005.,MEDICATIONS:,1.  Restoril 7.5 mg p.o. at bedtime p.r.n.,2.  Acetaminophen 650 mg p.o. q.6h. p.r.n. fever.,3.  Aspirin 81 mg p.o. daily.,4.  Bisacodyl suppository 10 mg per rectum daily.,5.  Erythropoietin injection 100 mcg subcutaneously every week at 5 p.m.,6.  Esomeprazole 40 mg IV q.12h.,7.  Fentanyl patch 25 mcg per hour.,8.  Transderm patch every 72 hours.,9.  Heparin IV.,10.  Lactulose 30 mL p.o. daily p.r.n. constipation.,11.  Metastron injection 4 mg IV q.6h. p.r.n. nausea.,12.  Seroquel 12 mg p.o. at bedtime.,13.  Saliva substitute 30 mL spray p.o. q.3h. p.r.n. dry mouth.,14.  Simethicone drops 80 mg per G-tube p.r.n. gas pain.,15.  Bactrim suspension p.o. daily.,16.  Insulin medium dose sliding scale.,17.  Albumin 25% IV p.r.n. hemodialysis.,18.  Ipratropium solution for nebulizer.,ALLERGIES:,  No known drug allergies.,PAST PSYCHIATRIC HISTORY:,  The patient denies any past psychiatric problems.  No medications.  He denies any outpatient visits or inpatient hospitalizations for psychiatric reasons.,SOCIAL HISTORY:,  He lives with his wife in New Jersey.  He has 2 children.  One son in Texas City and 1 daughter in Florida.  He is a master mechanic for a trucking company since 1968.  He retired in the May 2006.  The highest level of education that he received was 1 year in college.,Ethanol, tobacco, or drugs; he smoked 2 packs per day for 40 years, but quit in 1996.  He occasionally has a beer, but denies any continuous use of alcohol.  He denies any illicit drug use.,FAMILY HISTORY:,  Both parents died with myocardial infarctions.  He has 2 sisters and a brother with diabetes mellitus and coronary artery disease.  He denies any history of psychiatric problems in family.,MENTAL STATUS EXAMINATION:,  The patient was sitting in his bed in hospital gown with tracheostomy and receiving tube feeding.  The patient's appearance was appropriate with fair-to-good grooming and hygiene.  He had little-to-no psychomotor activity secondary to weakness post MI.  He had good eye contact.  His speech was of decreased rate volume and flexion secondary to tracheostomy.  The patient was cooperative.  He described his mood is not good in congruent stable and appropriate affect with decreased range.  His thought process is logical and goal directed.  His thought content was negative for delusions, phobias, obsessions, suicidal ideation, or homicidal ideation.  He denied any perceptional disturbances including any auditory or visual hallucinations.  He was alert and oriented x3.,Mini mental status exams not completed.,ASSESSMENT:,AXIS I:  Pain with physical symptoms and possibly psychological symptoms.,AXIS II:  Deferred.,AXIS III:  See above.",5
"SUBJECTIVE:,  This 47-year-old white female presents with concern about possible spider bite to the left side of her neck.  She is not aware of any specific injury.  She noticed a little tenderness and redness on her left posterior shoulder about two days ago.  It seems to be getting a little bit larger in size, and she saw some red streaks extending up her neck.  She has had no fever.  The area is very minimally tender, but not particularly so.,CURRENT MEDICATIONS:,  Generic Maxzide, Climara patch, multivitamin, Tums, Claritin, and vitamin C.,ALLERGIES:,  No known medicine allergies.,OBJECTIVE:,Vital Signs:  Weight is 150 pounds.  Blood pressure 122/82.,Extremities:  Examination of the left posterior shoulder near the neckline is an area of faint erythema which is 6 cm in diameter.  In the center is a tiny mark which could certainly be an insect or spider bite.  There is no eschar there, but just a tiny marking.  There are a couple of erythematous streaks extending towards the neck.,ASSESSMENT:,  Possible insect bite with lymphangitis.,PLAN:,1.  Duricef 1 g daily for seven days.,2.  Cold packs to the area.,3.  Discussed symptoms that were suggestive of the worsening, in which case she would need to call me.,4.  Incidentally, she has noticed a little bit of dryness and redness on her eyelids, particularly the upper ones’ and the lower lateral areas.  I suspect she has a mild contact dermatitis and suggested hydrocortisone 1% cream to be applied sparingly at bedtime only.",15
"CC:, Progressive lower extremity weakness.,HX: ,This 54 y/o RHF presented on 7/3/93 with a 2 month history of lower extremity weakness. She was admitted to a local hospital on 5/3/93 for a 3 day h/o of progressive BLE weakness associated with incontinence and BLE numbness. There was little symptom of upper extremity weakness at that time, according to the patient. Her evaluation was notable for a bilateral L1 sensory level and 4/4 strength in BLE. A T-L-S Spine MRI revealed a T4-6 lipomatosis with anterior displacement of the cord without cord compression. CSF analysis yielded: opening pressure of 14cm H20, protein 88, glucose 78, 3 lymphocytes and 160 RBC, no oligoclonal bands or elevated IgG index, and negative cytology. Bone marrow biopsy was negative. B12, Folate, and Ferritin levels were normal. CRP 5.2 (elevated). ANA was positive at 1:5,120 in speckled pattern. Her hospital course was complicated by deep venous thrombosis, which recurred after heparin was stopped to do the bone marrow biopsy. She was subsequently placed on Coumadin. EMG/NCV testing revealed "" lumbosacral polyradiculopathy with axonal degeneration and nerve conduction block."" She was diagnosed with atypical Guillain-Barre vs. polyradiculopathy and received a single course of Decadron; and no plasmapheresis or IV IgG. She was discharged home o 6/8/93.,She subsequently did not improve and after awaking from a nap on her couch the day of presentation, 7/3/93, she found she was paralyzed from the waist down. There was associated mild upper lumbar back pain without radiation. She had had no bowel movement or urination since that time. She had no recent trauma, fever, chills, changes in vision, dysphagia or upper extremity deficit.,MEDS:, Coumadin 7.5mg qd, Zoloft 50mg qd, Lithium 300mg bid.,PMH:, 1) Bi-polar Affective Disorder, dx 1979 2) C-section.,FHX:, Unremarkable.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM: ,BP118/64, HR103, RR18, Afebrile.,MS: ,A&O to person, place, time. Speech fluent without dysarthria. Lucid thought processes.,CN: ,Unremarkable.,MOTOR:, 5/5 strength in BUE. Plegic in BLE. Flaccid muscle tone.,SENSORY:, L1 sensory level (bilaterally) to PP and TEMP, without sacral sparing. Proprioception was lost in both feet.,CORD: ,Normal in BUE.,Reflexes were 2+/2+ in BUE. They were not elicited in BLE. Plantar responses were equivocal, bilaterally.,RECTAL: ,Poor rectal tone. stool guaiac negative. She had no perirectal sensation.,COURSE:, CRP 8.8 and ESR 76. FVC 2.17L. WBC 1.5 (150 bands, 555 neutrophils, 440 lymphocytes and 330 monocytes), Hct 33%, Hgb 11.0, Plt 220K, MCV 88, GS normal except for slightly low total protein (8.0). LFT were normal. Creatinine 1.0. PT and PTT were normal. ABCG 7.46/25/79/96% O2Sat. UA notable for 1+ proteinuria. EKG normal.,MRI L-spine, 7/3/93, revealed an area of abnormally increased T2 signal extending from T12 through L5. This area causes anterior displacement of the spinal cord and nerve roots. The cauda equina are pushed up against the posterior L1 vertebral body. There bilaterally pulmonary effusions. There is also abnormally increased T2 signal in the center of the spinal cord extending from the mid thoracic level through the conus. In addition, the Fila Terminale appear thickened. There is increased signal in the T3 vertebral body suggestion a hemangioma. The findings were felt consistent with a large epidural lipoma displacing the spinal cord anteriorly. there also appeared spinal cord swelling and increased signal within the spinal cord which suggests an intramedullary process.,CSF analysis revealed: protein 1,342, glucose 43, RBC 4,900, WBC 9. C3 and C$ complement levels were 94 and 18 respectively (normal) Anticardiolipin antibodies were negative. Serum Beta-2 microglobulin was elevated at 2.4 and 3.7 in the CSF and Serum, respectively. It was felt the patient had either a transverse myelitis associated with SLE vs. partial cord infarction related to lupus vasculopathy or hypercoagulable state. She was place on IV Decadron. Rheumatology felt that a diagnosis of SLE was likely. Pulmonary effusion analysis was consistent with an exudate. She was treated with plasma exchange and place on Cytoxan.,On 7/22/93 she developed fever with associated proptosis and sudden loss of vision, OD. MRI Brain, 7/22/93, revealed a 5mm thick area of intermediate signal adjacent to the posterior aspect of the right globe, possibly representing hematoma. Ophthalmology felt she had a central retinal vein occlusion; and it was surgically decompressed.,She was placed on prednisone on 8/11/93 and Cytoxan was started on 8/16/93. She developed a headache with meningismus on 8/20/93. CSF analysis revealed: protein 1,002, glucose2, WBC 8,925 (majority were neutrophils). Sinus CT scan negative. She was placed on IV Antibiotics for presumed bacterial meningitis. Cultures were subsequently negative. She spontaneously recovered. 8/25/93, cisternal tap CSF analysis revealed: protein 126, glucose 35, WBC 144 (neutrophils), RBC 95, Cultures negative, cytology negative. MRI Brain scan revealed diffuse leptomeningeal enhancement in both brain and spinal canal.,DSDNA negative. She developed leukopenia in 9/93, and she was switched from Cytoxan to Imuran. Her LFT's rose and the Imuran was stopped and she was placed back on prednisone.,She went on to have numerous deep venous thrombosis while on Coumadin. This required numerous hospital admissions for heparinization. Anticardiolipin antibodies and Protein C and S testing was negative.",22
"PREOPERATIVE DIAGNOSIS:,  Torn rotator cuff, right shoulder.,POSTOPERATIVE DIAGNOSES:,1.  Torn rotator cuff, right shoulder.,2.  Subacromial spur with impingement syndrome, right shoulder.,PROCEDURE PERFORMED:,1.  Diagnostic arthroscopy with subacromial decompression.,2.  Open repair of rotator cuff using three Panalok suture anchors.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Approximately 200 cc.,INTRAOPERATIVE FINDINGS: , There was noted to be a full thickness tear to the supraspinatus tendon at the insertion of the greater tuberosity.  There is moderate amount of synovitis noted throughout the glenohumeral joint.  There is a small subacromial spur noted on the very anterolateral border of the acromion.,HISTORY: , This is a 62-year-old female who previously underwent a repair of rotator cuff.  She continued to have pain within the shoulder.  She had a repeat MRI performed, which confirmed the clinical diagnosis of re-tear of the rotator cuff.  She wished to proceed with a repair.  All risks and benefits of the surgery were discussed with her at length.  She was in agreement with the above treatment plan.,PROCEDURE: , On 08/21/03, she was taken to the Operative Room at ABCD General Hospital.  She was placed supine on the operating table.  General anesthesia was applied by the Anesthesiology Department.  She was placed in the modified beachchair position.  Her upper extremity was sterilely prepped and draped in usual fashion.  A stab incision was made in the posterior aspect of the glenohumeral joint.  A camera was placed in the joint and was insufflated with saline solution.  Intraoperative pictures were obtained and the above findings were noted.  A second port site was initiated anteriorly.  Through this a probe was placed and the intraarticular structures were palpated and found to be intact.  A tear of the inner surface of the rotator cuff was identified.  The camera was then taken to the subacromial space.  A straight lateral portal was also used and a shaver was placed into the subacromial space.  Further debridement of the anterolateral border of the acromion was performed to remove evidence of the subacromial spur, which had reformed.  The edges of the rotator cuff were then debrided.  The camera was then removed and the shoulder was suction and dried.  A lateral incision was made over the anterolateral border of the acromion.  Subcuticular tissues were carefully dissected.  Hemostasis was controlled with electrocautery.  The deltoid musculature was then incised and aligned with its fibers exposing the rotator cuff tear and the edges were further debrided using a rongeur.  A trough was then made in the greater tuberosity using the rongeur.  Two Panalok anchors were then placed within the trough and weaved through the suture and third Panalok anchor was placed medial to the trough and weaved through the rotator cuff.  The ends of the suture were tied down from the fixating the rotator cuff within the trough.  The rotator cuff was then further oversewed using the Panalok suture.  The wound was then copiously irrigated and it was then suction dried.  The deltoid muscle was reapproximated using #1 Vicryl.  A continuous infusion pump catheter was placed into the subacromial space to help with postoperative pain control.  The subcutaneous tissues were reapproximated with #2-0 Vicryl.  The skin was closed with #4-0 PDS running subcuticular stitch.  Sterile dressing was applied to the upper extremity.  She was then placed in a shoulder immobilizer.  She was transferred to the recovery room in apparent stable and satisfactory condition.  Prognosis for this patient was guarded.  She will begin pendulum exercises postoperative day #3.  She will follow back in the office in 10 to 14 days for reevaluation.  Physical therapy initiated approximately six weeks postoperatively.",37
"PREOPERATIVE DIAGNOSIS (ES):,1. Cholelithiasis.,2. Cholecystitis.,POSTOPERATIVE DIAGNOSIS (ES):,1. Acute perforated gangrenous cholecystitis.,2. Cholelithiasis.,PROCEDURE:,1. Attempted laparoscopic cholecystectomy.,2. Open cholecystectomy.,ANESTHESIA:, General endotracheal anesthesia.,COUNTS:, Correct.,COMPLICATIONS:, None apparent.,ESTIMATED BLOOD LOSS:, 275 mL.,SPECIMENS:,1. Gallbladder.,2. Lymph node.,DRAINS:, One 19-French round Blake.,DESCRIPTION OF THE OPERATION:, After consent was obtained and the patient was properly identified, the patient was transported to the operating room and after induction of general endotracheal anesthesia, the patient was prepped and draped in a normal sterile fashion.,After infiltration with local, a vertical incision was made at the umbilicus and utilizing graspers, the underlying fascia was incised and was divided sharply. Dissecting further, the peritoneal cavity was entered. Once this done, a Hasson trocar was secured with #1 Vicryl and the abdomen was insufflated without difficulty. A camera was placed into the abdomen and there was noted to be omentum overlying the subhepatic space. A second trocar was placed in the standard fashion in the subxiphoid area; this was a 10/12 mm non-bladed trocar. Once this was done, a grasper was used to try and mobilize the omentum and a second grasper was added in the right costal margin; this was a 5-mm port placed, it was non-bladed and placed in the usual fashion under direct visualization without difficulty. A grasper was used to mobilize free the omentum which was acutely friable and after a significant time-consuming effort was made to mobilize the omentum, it was clear that the gallbladder was well incorporated by the omentum and it would be unsafe to proceed with a laparoscopy procedure and then the procedure was converted to open.,The trocars were removed and a right subcostal incision was made incorporating the 10/12 subxiphoid port. The subcutaneous space was divided with electrocautery, as well as the muscles and fascia. The Bookwalter retraction system was then set up and retractors were placed to provide exposure to the right subhepatic space. Then utilizing a right-angle and electrocautery, the omentum was freed from the gallbladder. An ensuing retrograde cholecystectomy was performed, in which, electrocautery and blunt dissection were used to mobilize the gallbladder from the gallbladder fossa; this was done down to the infundibulum. After meticulous dissection, the cystic artery was identified and it was ligated between 3-0 silks. Several other small ties were placed on smaller bleeding vessels and the cystic duct was identified, was skeletonized, and a 3-0 stick tie was placed on the proximal portion of it. After it was divided, the gallbladder was freed from the field.,Once this was done, the liver bed was inspected for hemostasis and this was achieved with electrocautery. Copious irrigation was also used. A 19-French Blake drain was placed in Morrison's pouch lateral to the gallbladder fossa and was secured in place with 2-0 nylon; this was a 19-French round Blake. Once this was done, the umbilical port was closed with #1 Vicryl in an interrupted fashion and then the wound was closed in two layers with #1 Vicryl in an interrupted fashion. The skin was closed with and absorbable stitch.,The patient was then awakened from anesthesia, extubated, and transported to the recovery room in stable condition.",14
"PREOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, and progressive quadriparesis.,POSTOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, progressive quadriparesis, and very poor bone quality as well as difficulty with hemostasis with the patient having been on aspirin.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression at C3-C4, C4-C5, and C5-C6.,2.  Microscope.,3.  Fusion with machined allografts at C3-C4, C4-C5, and C5-C6.,4.  Eagle titanium plate from C3 to C6.,5.  Jackson-Pratt drain placement.,6.  Intraoperative monitoring with EMGs and SSEPs.,ESTIMATED BLOOD LOSS: , 350 cc.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:  ,None.,COUNTS: , Correct.,SPECIMENS SENT:  ,None.,CLINICAL HISTORY:  ,The patient is a 77-year-old male who was admitted through the emergency room for progressive weakness and falling.  He was worked by the neurologist, Dr. X, and found to have cervical spondylosis with myelopathy.  I was consulted and elected to do a lumbar and cervical myelogram CT scan, which showed lumbar stenosis but also cervical stenosis with more pathology anteriorly than posteriorly.  The patient had worst disease at level C3-C4, C4-C5, and C5-C6.  The patient was significantly weak and almost quadriparetic, stronger on the right side than on the left side.  I thought that surgery was indicated to prevent progressive neurological deterioration, as well as to prevent a central cord syndrome if the patient were to get into a motor vehicle accident or simply fall.  Conservative management was not an option.  The patient was preoped and consented, and was medically cleared.  I discussed the indications, risks, and benefits of the surgery with the patient and the patient's family.  The risks of bleeding, hoarseness, swallowing difficulty, pseudoarthrosis as well as plate migration and hardware failure were all discussed with the patient.  An informed consent was obtained from the patient as such.  He was brought into the OR today for the operative procedure.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the OR, intubated, and given a general anesthetic.  Intubation was done under C-spine precautions.  The patient received preoperative vancomycin and Decadron.  He was hooked up to the SSEP apparatus and had poor baselines and delays.,With a large a shoulder roll, I extended the patient's neck, and landmark incision in crease in the right upper neck, and the area was then prepped and sterilely draped.  All the lines had been put in and the arms were padded.,Using a knife and cautery, I took the incision down through the skin and subcutaneous tissue and arrived at the cervical spine.  Prominent osteophyte at C5-C6 was noted, lesser at C4-C5.  Intraoperative x-ray confirmed our levels, and we were fully exposed from C3-C6.,Trimline retractors were put in, and I cut the discs out as well as removed the superficial hyperstatic bone and osteophytes.,With the drill, I performed a superficial discectomy and endplate resection, curetting the endplate as I went.  I then brought in the microscope, under the microscopic guidance, firmly removed the end plates and drilled through the posterior longitudinal ligament to decompress the spinal cord.  Worst findings at C3-C4 followed C5-C6 and then C4-C5.  Excellent thecal sac decompression was achieved and foraminal decompression was also achieved.  With change in intraoperative monitoring, a microscope was used for this decompressive procedure.,The patient was very oozy throughout this procedure, and during the decompression part, the oozing was constant.  This was partly due to the patient's cancellous bone, but he had been on aspirin which was stopped only 2 days ago, and the option was not available to wait 2 to 3 weeks which would have made this man worse simply over time.  I thus elected to give him DDAVP, platelets, and used Horsley bone wax for excellent hemostasis.  This took literally half-an-hour to an hour and added to the complexity and difficulty of this case.  Eventually, with blood pressure controlled and all the other parameters under control, bleeding was somewhat slow.,I then selected two 10 and one 9-mm cadaveric allograft, which had soaking in bacitracin solution.  These were trimmed to the desired dimensions, and under slight distraction, these were tapped into position.  Excellent graft alignment was achieved.,I now brought in a DePuy titanium eagle plate, and I fixed it to the spine from C3 to C6.  Fourteen millimeter screws were used; all the screws were tightened and torqued.  The patient's bone quality was poor, but the screws did torque appropriately.  I inspected the plate, controlled the hemostasis, assessed post-fixation x-ray, and was really happy with the screw length and the overall alignment.,The wound was irrigated with antibiotic solution; a Jackson-Pratt drain 10-French was put in with trocar.  Decision was made to start the closure.  So, I closed the platysma with 3-0 Vicryl and used staples for the skin.  A simple Primapore or Medpore dressing was applied.  The patient was extubated in the OR and taken to the PSU in stable medical condition.,When I saw the patient in the ICU, he was awake, alert, and moving all four extremities, somewhat weak on the left side.  He had done well from the surgery.  Blood loss was 350 cc.  All instrument, needle, and sponge counts were correct.  No complications, no change in intraoperative monitoring.  No specimens were sent.,The patient's wife was spoken to and fully appraised of the intraoperative findings and the expected prognosis.  The patient will be kept n.p.o. tonight and will gradually advance his diet, and also will gradually advance his activity.  I will keep him on Decadron and keep the collar on.  I do not think there is need for halo rest.  We will be obtaining formal C-spine films in the morning.  Prognosis is guarded but favorable at this time.",27
"CC:, Stable expressive aphasia and decreased vision.,HX:, This 72y/o woman was diagnosed with a left sphenoid wing meningioma on 6/3/80. She was 59 years old at the time and presented with a 6 month history of increasing irritability and left occipital-nuchal headaches. One month prior to that presentation she developed leftward head turning, and 3 days prior to presentation had an episode of severe dysphasia. A HCT (done locally) revealed a homogenously enhancing lesion of the left sphenoid wing. Skull X-rays showed deviation of the pineal to the right. She was transferred to UIHC and was noted to have a normal neurologic exam (per Neurosurgery note). Angiography demonstrated a highly vascular left temporal/sphenoid wing tumor. She under went left temporal craniotomy and ""complete resection"" of the tumor which on pathologic analysis was consistent with a meningioma.,The left sphenoid wing meningioma recurred and was excised 9/25/84. There was regrowth of this tumor seen on HCT, 1985. A 6/88 HCT revealed the left sphenoid meningioma and a new left tentorial meningioma. HCT in 1989 revealed left temporal/sphenoid, left tentorial, and new left frontal lesions. On 2/14/91 she presented with increasing lethargy and difficulty concentrating. A 2/14/91, HCT revealed increased size and surrounding edema of the left frontal meningioma. The left frontal and temporal meningiomas were excised on 2/25/91. These tumors all recurred and a left parietal lesion developed. She underwent resection of the left frontal meningioma on 11/21/91 due to right sided weakness and expressive aphasia. The weakness partially resolved and though the speech improved following resection it did not return to normal. In May 1992 she experienced 3 tonic-clonic type seizures, all of which began with a Jacksonian march up the RLE then RUE before generalizing. Her Phenobarbital prophylaxis which she had been taking since her 1980 surgery was increased. On 12/7/92, she underwent a left fronto-temporo-parieto-occipital craniotomy and excision of five meningiomas. Postoperatively she developed worsened right sided weakness and expressive aphasia. The weakness and aphasia improved by 3/93, but never returned to normal.",5
"CC:, Left third digit numbness and wrist pain.,HX: ,This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.,SHX/FHX:, 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.,EXAM: ,Vital signs unremarkable.,MS:, A & O to person, place, time. Fluent speech without dysarthria.,CN II-XII: ,Unremarkable,MOTOR:, 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.,SENSORY:, Decreased PP in third digit of left hand only (palmar and dorsal sides).,STATION/GAIT/COORD:, Unremarkable.,REFLEXES: ,1+ throughout, plantar responses were downgoing bilaterally.,GEN EXAM: ,Unremarkable.,Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.,CLINICAL IMPRESSION: ,Left Carpal Tunnel Syndrome,EMG/NCV: ,Unremarkable.,MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.,COURSE:, The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.",33
"REASON FOR CONSULTATION: , Management of blood pressure.,HISTORY OF PRESENT ILLNESS: , The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.  She is on multiple medications, unable to control the blood pressure.  From cardiac standpoint, the patient denies any symptoms of chest pain, or shortness of breath.  She complains of fatigue and tiredness.  The child had some congenital anomaly, was transferred to Hospital, where the child has had surgery.  The patient is in intensive care unit.,CORONARY RISK FACTORS:,  History of hypertension, history of gestational diabetes mellitus, nonsmoker, and cholesterol is normal.  No history of established coronary artery disease and family history noncontributory for coronary disease.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY:  ,No major surgery except for C-section.,MEDICATIONS:,  Presently on Cardizem and metoprolol were discontinued.  Started on hydralazine 50 mg t.i.d., and labetalol 200 mg b.i.d., hydrochlorothiazide, and insulin supplementation.,ALLERGIES: , None.,PERSONAL HISTORY: , Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,  Hypertension, gestational diabetes mellitus, pre-eclampsia, this is her third child with one miscarriage.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR:  No congestive heart.  No arrhythmia.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis, or melena.,UROLOGIC:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGICAL:  No TIA.  No CVA.  No seizure disorder.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 86, blood pressure 175/86, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.,LUNGS:  Clear.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.,LABORATORY DATA: , EKG shows sinus tachycardia with nonspecific ST-T changes.  Labs were noted.  BUN and creatinine within normal limits.,IMPRESSION:,1.  Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.,2.  No prior history of cardiac disease except for borderline gestational diabetes mellitus.,RECOMMENDATIONS:,1.  We will get an echocardiogram for assessment left ventricular function.,2.  The patient will start on labetalol and hydralazine to see how see fairs.,3.  Based on response to medication, we will make further adjustments.  Discussed with the patient regarding plan of care, fully understands and consents for the same.  All the questions answered in detail.",24
"SUBJECTIVE:,  This 45-year-old gravida 3, para 2, SAB 1 white female presents for exam and Pap.  Last Pap was a year ago and normal.  LMP was 08/29/2004.  Her cycles are usually regular, although that one came about a week early.  Her husband has had a vasectomy.  Overall, she is feeling well.,Health history form was reviewed.  There has been no change in her personal history.  She notes that a brother who was treated 12 years ago for a brain tumor has had a recurrence and had surgery again.  Social history is unchanged.,HEALTH HABITS: , She states that for a while she was really exercising regularly and eating lots of fruits and vegetables.  Right now, she is not doing nearly as well.  She has perhaps two dairy servings daily, trying to cut down.  She is not exercising at all and fruit and vegetable intake varies.  She is a nonsmoker.  Last cholesterol was in 2003 and was normal.  She had a mammogram which was normal recently.  She is current on her tetanus update.,REVIEW OF SYSTEMS:,HEENT:  She feels as though she may have some allergies at night.  Most of her symptoms occur then, not during the day.  She will wake up with some congestion, sneezing, and then rhinorrhea.  Currently, she uses Tylenol Sinus.  Today, her symptoms are much better.  We did have rain this morning.,Respiratory and CV:  Negative.,GI:  She tends to have a little gas which is worse when she is eating more fruits and vegetables.  She had been somewhat constipated but that is better.,GU:  Negative.,Dermatologic:  She noticed an area of irritation on her right third finger on the ulnar side at the PIP joint.  It was very sensitive to water.  It seems to be slowly improving.,OBJECTIVE:,Vital Signs:  Her weight was 154 pounds, which is down 2 pounds.  Blood pressure 104/66.,General:  She is a well-developed, well-nourished, pleasant white female in no distress.,Neck:  Supple without adenopathy.  No thyromegaly or nodules palpable.,Lungs:  Clear to A&P.,Heart:  Regular rate and rhythm without murmurs.,Breasts:  Symmetrical without masses, nipple, or skin retraction, discharge, or axillary adenopathy.,Abdomen:  Soft without organomegaly, masses, or tenderness.,Pelvic:  Reveals no external lesions.  The cervix is parous.  Pap smear done.  Uterus is anteverted and normal in size, shape, and consistency, and nontender.  No adnexal enlargement.,Extremities:  Examination of her right third finger shows an area of eczematous dermatitis approximately 2 cm in length on the ulnar side.,ASSESSMENT:,1.  Normal GYN exam.,2.  Rhinitis, primarily in the mornings.  Vasomotor versus allergic.,3.  Eczematous dermatitis on right third finger.,PLAN:,1.  Discussed vasomotor rhinitis.  I suggested she try Ayr Nasal saline gel.  Another option would be a steroid spray and a sample of Nasonex is given to use two sprays in each nostril daily.,2.  Exam with Pap annually.,3.  Hydrocortisone cream to be applied to the area of eczematous dermatitis.,4.  Discussed nutrition and exercise.  I recommended at least five fruits and vegetables daily, no more than three dairy servings daily, and regular exercise at least three times a week.",24
"PROCEDURE PERFORMED: , Esophagogastroduodenoscopy performed in the emergency department.,INDICATION: , Melena, acute upper GI bleed, anemia, and history of cirrhosis and varices.,FINAL IMPRESSION,1.  Scope passage massive liquid in stomach with some fresh blood near the fundus, unable to identify source due to gastric contents.,2.  Endoscopy following erythromycin demonstrated grade I esophageal varices.  No stigmata of active bleeding.  Small amount of fresh blood within the hiatal hernia.  No definite source of bleeding seen.,PLAN,1.  Repeat EGD tomorrow morning following aggressive resuscitation and transfusion.,2.  Proton-pump inhibitor drip.,3.  Octreotide drip.,4.  ICU bed.,PROCEDURE DETAILS:  ,Prior to the procedure, physical exam was stable.  During the procedure, vital signs remained within normal limits.  Prior to sedation, informed consent was obtained.  Risks, benefits, and alternatives including, but not limited to risk of bleeding, infection, perforation, adverse reaction to medication, failure to identify pathology, pancreatitis, and death explained to the patient and his wife, who accepted all risks.  The patient was prepped in the left lateral position.  IV sedation was given to a total of fentanyl 100 mcg and midazolam 4 mg for the initial EGD.  An additional 50 mcg of fentanyl and 2 mg of midazolam were given following erythromycin.  Scope tip of the Olympus gastroscope was passed into the esophagus.  Proximal, middle, and distal thirds of the esophagus were well visualized.  There was fresh blood in the esophagus, which was washed thoroughly, but no source was seen.  No evidence of varices was seen.  The stomach was entered.  The stomach was filled with very large clot and fresh blood and liquid, which could not be suctioned due to the clot burden.  There was a small amount of bright red blood near the fundus, but a source could not be identified due to the clot burden.  Because of this, the gastroscope was withdrawn.  The patient was given 250 mg of erythromycin in the Emergency Department and 30 minutes later, the scope was repassed.  On the second look, the esophagus was cleared.  The liquid gastric contents were cleared.  There was still a moderate amount of clot burden in the stomach, but no active bleeding was seen.  There was a small grade I esophageal varices, but no stigmata of bleed.  There was also a small amount of fresh blood within the hiatal hernia, but no source of bleeding was identified.  The patient was hemodynamically stable; therefore, a decision was made for a second look in the morning.  The scope was withdrawn and air was suctioned.  The patient tolerated the procedure well and was sent to recovery without immediate complications.",14
"PREOPERATIVE DIAGNOSIS:,  Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE:,  Right carpal tunnel release.,ANESTHESIA:,  Bier block to the right hand.,TOTAL TOURNIQUET TIME: , 20 minutes.,COMPLICATIONS: , None.,DISPOSITION: , Stable to PACU.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,GROSS OPERATIVE FINDINGS:,  We did find a compressed right median nerve upon entering the carpal tunnel, otherwise, the structures of the carpal canal are otherwise unremarkable.  No evidence of tumor was found.,BRIEF HISTORY OF PRESENT ILLNESS:  ,This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.,PROCEDURE: , The patient was taken to the operative room and placed in the supine position.  The patient underwent a Bier block by the Department of Anesthesia on the upper extremity.  The upper extremity was prepped and draped in usual sterile fashion and left free.  Attention was drawn then to the palm of the hand.  We did identify area of incision that we would make, which was located over the carpal tunnel.,Approximately, 1.5 cm incision was made using a #10 blade scalpel.  Dissection was carried through the skin and fascia over the palm down to the carpal tunnel taking care during dissection to avoid any branches of nerves.  Carpal tunnel was then entered and the rest of the transverse carpal ligament was incised sharply with a #10 scalpel.  We inspected the median nerve and found that it was flat and compressed from the transverse carpal ligament.  We found no evidence of tumor or space occupying lesion in the carpal tunnel.  We then irrigated copiously.  Tourniquet was taken down at that time and pressure was held.  There was no evidence of obvious bleeders.  We approximated the skin with nylon and placed a postoperative dressing with a volar splint.  The patient tolerated the procedure well.  She was placed back in the gurney and taken to PACU.",37
"LEXISCAN MYOVIEW STRESS STUDY,REASON FOR THE EXAM: , Chest discomfort.,INTERPRETATION: , The patient exercised according to the Lexiscan study, received a total of 0.4 mg of Lexiscan IV injection.  At peak hyperemic effect, 24.9 mCi of Myoview were injected for the stress imaging and earlier 8.2 mCi were injected for the resting and the usual SPECT and gated SPECT protocol was followed and the data was analyzed using Cedars-Sinai software.  The patient did not walk because of prior history of inability to exercise long enough on treadmill.,The resting heart rate was 57 with the resting blood pressure 143/94.  Maximum heart rate achieved was 90 with a maximum blood pressure unchanged.,EKG at rest showed sinus rhythm with no significant ST-T wave changes of reversible ischemia or injury.  Subtle nonspecific in III and aVF were seen.  Maximum stress test EKG showed inverted T wave from V4 to V6.  Normal response to Lexiscan.,CONCLUSION:  ,Maximal Lexiscan perfusion with subtle abnormalities non-conclusive.  Please refer to the Myoview interpretation.,MYOVIEW INTERPRETATION: , The left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end-diastolic volume of 115 and end-systolic of 51.  EF estimated and calculated at 56%.,Cardiac perfusion reviewed, showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring.,IMPRESSION:,1.  Normal stress/rest cardiac perfusion with no indication of ischemia.,2.  Normal LV function and low likelihood of significant epicardial coronary narrowing.,",33
"PREOPERATIVE DIAGNOSIS: , Adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Adenoid hypertrophy.,PROCEDURE PERFORMED:  ,Adenoidectomy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia.  The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.  The nasopharynx was inspected with the laryngeal mirror.  Serial passages of the curettes were utilized to remove the nasopharyngeal tissue, following which the nasopharynx was packed with 2 cherry gauze sponges coated in a solution of 0.25% Neo-Synephrine and tannic acid powder.,Attention was then redirected to the oropharynx.  The McIvor was reopened, packs removed, and the bleeding was controlled with the suction Bovie unit.  The catheters were removed, and the nasal passages and oropharynx were suctioned free of debris.  The McIvor was then removed, and the procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.",11
"XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear XYZ:,Thank you very much for your kind referral of Mrs. ABC who you referred to me for narrow angles and possible associated glaucoma.  I examined Mrs. ABC initially on MM/DD/YYYY.  At that time, she expressed a chief concern of occasional pain around her eye, but denied any flashing lights, floaters, halos, or true brow ache.  She reports a family history of glaucoma in her mother, but is unsure of the specific kind.  Her past ocular history has been fairly unremarkable.  As you know, she has a history of non-insulin dependent diabetes.  She is unaware of her last hemoglobin A1c levels, but reports a blood sugar of 158 taken on the morning of her appointment with me.  She is followed by Dr. X here locally.,Upon examination, her visual acuity measured 20/20-1 in either eye with her glasses.  Presenting intraocular pressures were14 mmHg in either eye at 2:03 p.m.  Pupillary reactions, confrontational visual fields, and ocular motility were normal.  The slit lamp exam revealed narrow anterior chambers and on gonioscopy only the buried anterior trabecular meshwork was visible in either eye, but the angle deepened with gonio-compression suggesting appositional and not synechial closure.  I deferred the dilated portion of the exam on that day.,We proceeded with peripheral iridectomies and following this upon her most recent visit on MM/DD/YYYY, I was able to safely dilate her eyes as her chambers had deepened and the PIs were patent.  I note that she has an increased CD ratio measuring 0.65 in the right eye and 0.7 in the left and although her FDT visual fields and GDX testing were normal at your office, she does have an enlarged blind spot in either eye on Humphrey visual fields and retinal tomography also shows some suspicious changes.  Therefore, I feel she has sustained some optic nerve damage perhaps from intermittent angle closure in the past.,In summary, Mrs. ABC has a history of narrow angles not successfully treated with laser PIs.  Her intraocular pressures have remained stable.  I will continue to monitor her closely.,Thank you very much once again for allowing me to have shared in her care.  If I can provide any additional information or be of further service, do let me know.,Sincerely,,",20
"DIAGNOSIS: , Aortic valve stenosis with coronary artery disease associated with congestive heart failure.  The patient has diabetes and is morbidly obese.,PROCEDURES: , Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.,ANESTHESIA: , General endotracheal,INCISION: , Median sternotomy,INDICATIONS: , The patient presented with severe congestive heart failure associated with the patient's severe diabetes.  The patient was found to have moderately stenotic aortic valve.  In addition, The patient had significant coronary artery disease consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system.  The patient also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to the patient's right system.  It was decided to perform a valve replacement as well as coronary artery bypass grafting procedure.,FINDINGS: , The left ventricle is certainly hypertrophied· The aortic valve leaflet is calcified and a severe restrictive leaflet motion.  It is a tricuspid type of valve.  The coronary artery consists of a large left anterior descending artery which is associated with 60% stenosis but a large obtuse marginal artery which has a tight proximal stenosis.,The radial artery was used for the left anterior descending artery.  Flow was excellent.  Looking at the targets in the posterior descending artery territory, there did not appear to be any large branches.  On the angiogram these vessels appeared to be quite small.  Because this is a chronically occluded vessel and the patient has limited conduit due to the patient's massive obesity, attempt to bypass to this area was not undertaken.  The patient was brought to the operating room,PROCEDURE: , The patient was brought to the operating room and placed in supine position.  A median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh.  The patient weighs nearly three hundred pounds.  There was concern as to taking down the left internal mammary artery.  Because the radial artery appeared to be a good conduit The patient would have arterial graft to the left anterior descending artery territory.  The patient was cannulated after the aorta and atrium were exposed and full heparinization.,The patient went on cardiopulmonary bypass and the aortic cross-clamp was applied Cardioplegia was delivered through the coronary sinuses in a retrograde manner.  The patient was cooled to 32 degrees.  Iced slush was applied to the heart.  The aortic valve was then exposed through the aortic root by transverse incision.  The valve leaflets were removed and the #23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures.  At this point, aortotomy was closed.,The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow.  Proximal anastomosis was then carried out to the foot of the aorta.  The left anterior descending artery does not have severe disease but is also a very good target and the radial artery was anastomosed to this target in an end-to-side manner.  The two proximal anastomoses were then carried out to the root of the aorta.,The patient came off cardiopulmonary bypass after aortic cross-clamp was released.  The patient was adequately warmed.  Protamine was given without adverse effect.  Sternal closure was then done using wires.  The subcutaneous layers were closed using Vicryl suture.  The skin was approximated using staples.",37
"PREOPERATIVE DIAGNOSIS:,  Critical left carotid stenosis.,POSTOPERATIVE DIAGNOSIS: , Critical left carotid stenosis.,PROCEDURE PERFORMED:,  Left carotid endarterectomy with endovascular patch angioplasty.,ANESTHESIA:,  Cervical block.,GROSS FINDINGS:  ,The patient is a 57-year-old black female with chronic renal failure.  She does have known critical carotid artery stenosis.  She wishes to undergo bilateral carotid endarterectomy, however, it was felt necessary by Dr. X to perform cardiac catheterization.  She was admitted to the hospital yesterday with chest pain.  She has been considered for coronary artery bypass grafting.  I have been asked to address the carotid stenosis, left being more severe, this was addressed first.  Intraoperatively, an atherosclerotic plaque was noted in the common carotid artery extending into the internal carotid artery.  The internal carotid artery is quite torturous.  The external carotid artery was occluded at its origin.  When the endarterectomy was performed, the external carotid artery back-bled nicely.  The internal carotid artery had good backflow bleeding noted.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite and placed in the supine position.  Then neck, shoulder, and chest wall were prepped and draped in appropriate manner.  Longitudinal incision was created along the anterior border of the left sternocleidal mastoid muscle and this was taken through the subcutaneous tissue and platysmal muscle utilizing electrocautery.,Utilizing both blunt and sharp dissections, the common carotid artery, the internal carotid artery beyond the atherosclerotic back, the external carotid artery, and the superior thyroid artery were isolated and encircled with a umbilical tape.  During the dissection, facial veins were ligated with #4-0 silk ligature prior to dividing them.  Also during the dissection, ansa cervicalis, hypoglossal, and vagus nerve identified and preserved.  There was some inflammation above the carotid bulb, but this was not problematic.,The patient had been administered 5000 units of aqueous heparin after allowing adequate circulating time.  The internal carotid artery is controlled with Heifitz clip followed by the external carotid artery and the superior thyroid artery being controlled with Heifitz clips.  The common carotid artery was controlled with profunda clamp.  The patient remained neurologically intact.  A longitudinal arteriotomy was created along the posterior lateral border of the common carotid artery.  This was extended across the lobe on to the internal carotid artery.  An endarterectomy was then performed.  The ________ intima was cleared of all debris and the ________ was flushed with copious amounts of heparinized saline.  As mentioned before, the internal carotid artery is quite torturous.  This was shortened by imbricating the internal carotid artery with horizontal mattress stitches of #7-0 Prolene suture.,The wound was copiously irrigated, rather an endovascular patch was then brought on to the field.  This was cut to shape and length.  This was sutured in place with continuous running #6-0 Prolene suture.  The suture line began at both sites.  The suture was tied in the center along the anterior and posterior walls.  Prior to completing the closure, the common carotid artery was flushed.  The internal carotid artery permitted to back bleed.  The clamp was placed after completing the closure.  The clamp was placed at the origin of the internal carotid artery.  Flow was first directed into the external carotid artery then into the internal carotid artery.  The patient remained neurologically intact.  Topical ________ Gelfoam was utilized.  Of note, during the endarterectomy, the patient did receive an additional 7000 units of aqueous heparin.  The wound was copiously irrigated with antibiotic solution.  Sponge, needle, and all counts were correct.  All surgical sites were inspected.  Good hemostasis noted.  The incision was closed in layers with absorbable suture.  Stainless steel staples approximated skin.  Sterile dressings were applied.  The patient tolerated the procedure well, grossly neurologically intact.",37
"SUBJECTIVE:,  This patient was seen in clinic for a school physical.,NUTRITIONAL HISTORY:,  She eats well, takes meats, vegetables, and fruits, but her calcium intake is limited.  She does not drink a whole lot of pop.  Her stools are normal.  Brushes her teeth, sees a dentist.,Developmental History:  Hearing and vision is okay.  She did well in school last year.  She will be going to move to Texas, will be going to Bowie High School.  She will be involved in cheerleading, track, volleyball, and basketball.  She will be also playing the clarinet and will be a freshman in that school.  Her menarche was 06/30/2004.,PAST MEDICAL HISTORY:,  She is still on medications for asthma.  She has a problem with her eye lately, this has been bothering her, and she also has had a rash in the left leg.  She had been pulling weeds on 06/25/2004 and then developed a rash on 06/27/2004.,Review of her immunizations, her last tetanus shot was 06/17/2003.,MEDICATIONS:  ,Advair 100/50 b.i.d., Allegra 60 mg b.i.d., Flonase q.d., Xopenex, Intal, and albuterol p.r.n.,ALLERGIES: , No known drug allergies.,OBJECTIVE:,Vital Signs:  Weight:  112 pounds about 40th percentile.  Height:  63-1/4 inches, also the 40th percentile.  Her body mass index was 19.7, 40th percentile.  Temperature:  97.7 tympanic.  Pulse:  80.  Blood pressure:  96/64.,HEENT:  Normocephalic.  Fundi benign.  Pupils equal and reactive to light and accommodation.  No strabismus.  Her vision was 20/20 in both eyes and each with contacts.  Hearing:  She passed that test.  Her TMs are bilaterally clear and nonerythematous.  Throat was clear.  Good mucous membrane moisture and good dentition.,Neck:  Supple.  Thyroid normal sized.  No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Abdomen:  No hepatosplenomegaly.,Respiratory:  Clear.  No wheezes.  No crackles.  No tachypnea.  No retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal.  No murmur.,Abdomen:  Soft.  No organomegaly and no masses.,GU:  Normal female genitalia.  Tanner stage 3, breast development and pubic hair development.  Examination of the breasts was negative for any masses or abnormalities or discharge from her areola.,Extremities:  She has good range of motion of upper and lower extremities.  Deep tendon reflexes were 2+/4+ bilaterally and equal.  Romberg negative.,Back:  No scoliosis.  She had good circumduction at shoulder joint and her duck walk was normal.,SKIN:  She did have some rash on the anterior left thigh region and also some on the right lower leg that had Kebner phenomenon and maculopapular vesicular eruption.  No honey crusting was noted on the skin.  She also had some mild rash on the anterior abdominal area near the panty line similar to that rash.  It was raised and blanch with pressure, it was slightly erythematous.,ASSESSMENT AND PLAN:,1.  Sports physical.,2.  The patient received her first hepatitis A vaccine.  She will get a booster in 6 to 12 months.  Prescription for Atarax 10 mg tablets one to two tablets p.o. q.4-6h. p.r.n. and a prescription for Elocon ointment to be applied topically, except for the face, once a day with a refill.  She will be following up with an allergist as soon as she gets to Texas and needs to find a primary care physician.  We talked about anticipatory guidance including breast exam, which we have reviewed with her today, seatbelt use, and sunscreen.  We talked about avoidance of drugs and alcohol and sexual activity.  Continue on her present medications and if her rash is not improved and goes to the neck or the face, she will need to be on PO steroid medication, but presently that was held and moved to treatment with Atarax and Elocon.  Also talked about cleaning her clothes and bedding in case she has any poison ivy oil that is harboring on any clothing.",29
"PREOPERATIVE DIAGNOSES,1.  EMG-proven left carpal tunnel syndrome.,2.  Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3.  Dupuytren's nodule in the palm.,POSTOPERATIVE DIAGNOSES,1.  EMG-proven left carpal tunnel syndrome.,2.  Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3.  Dupuytren's nodule in the palm.,PROCEDURE: , Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.,ANESTHESIA: , Local plus IV sedation (MAC).,ESTIMATED BLOOD LOSS:  ,Zero.,SPECIMENS:  ,None.,DRAINS: , None.,PROCEDURE DETAIL: , Patient brought to the operating room.  After induction of IV sedation the left hand was anesthetized suitable for carpal tunnel release; 10 cc of a mixture of 1% Xylocaine and 0.5% Marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery.  Routine prep and drape was employed.  Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet and tourniquet inflated to 250 mmHg pressure.  Hand was positioned palm up in the lead hand-holder.  A short curvilinear incision about the base of the thenar eminence was made.  Skin was sharply incised.  Sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin.  Care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm.  Proximally the antebrachial fascia was released for a distance of 2-3 cm proximal to the wrist crease to insure complete decompression of the median nerve.  Retinacular flap was retracted radially to expose the contents of the carpal canal.  Median nerve was identified, seen to be locally compressed with moderate erythema and mild narrowing.  Locally adherent tenosynovium was present and this was carefully dissected free.  Additional tenosynovium was dissected from the flexor tendons, individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal.  Epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium.  When this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5-0 nylon horizontal mattress sutures.  A syringe with 3 cc of Kenalog-10 and 3 cc of 1% Xylocaine using a 25 gauge short needle was then selected; 1 cc of this mixture was injected into the third finger A1 and A2 pulley tendon sheaths using standard trigger finger injection technique; 1 cc was injected into the fourth finger A1/A2 pulley tendon sheath using standard tendon sheath injection technique; 1 cc was injected into the Dupuytren's nodule in the midpalm to relieve local discomfort.  Routine postoperative hand dressing with well-padded, well-molded volar plaster splint and lightly compressive Ace wrap was applied.  Tourniquet was deflated.  Good vascular color and capillary refill were seen to return to the tips of all digits.  Patient discharged to the ambulatory recovery area and from there discharged home.  Discharge medication is Darvocet-N 100, 30 tablets, one to two PO q.4h. p.r.n.  Patient asked to begin gentle active flexion, extension and passive nerve glide exercises beginning 24-48 hours after surgery.  She was asked to keep the dressings clean, dry and intact and follow up in my office.",28
"HISTORY AND CLINICAL DATA:  ,The patient is an 88-year-old gentleman followed by Dr. X, his primary care physician, Dr. Y for the indication of CLL and Dr. Z for his cardiovascular issues.  He presents to the Care Center earlier today with approximately a one-week history of increased progressive shortness of breath, orthopnea over the course of the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea presenting this morning.,He reports no clear-cut chest discomfort or difficulty with angina.  He has had no dizziness, lightheadedness, no near or true syncope, nothing supportive of CVA, TIA, nor peripheral vascular claudication.,REVIEW OF SYSTEMS:,  General review of system is significant for difficulty with intermittent constipation, which has been problematic recently.  He reports no fever, shaking chills, nothing supportive of GI or GU blood loss, no productive or nonproductive cough.,PAST MEDICAL HISTORY:,  Remarkable for hypertension, diabetes, prostate cancer, status post radium seed implant, COPD, single vessel coronary disease, esophageal reflux, CLL, osteopenia, significant hearing loss, anxiety, and degenerative joint disease.,SOCIAL HISTORY: , Remarkable for being married, retired, quit smoking in 1997, rare use of alcohol, lives locally with his wife.,MEDICATIONS AT HOME:,  Include, Lortab 7.5 mg up to three times daily for chronic arthritic discomfort, Miacalcin nasal spray once daily, omeprazole 20 mg daily, Diovan 320 mg daily, Combivent two puffs t.i.d., folate, one adult aspirin daily, glyburide 5 mg daily, atenolol 50 mg daily, furosemide 40 mg daily, amlodipine 5 mg daily, hydralazine 50 mg p.o. t.i.d., in addition to Tekturna 150 mg daily, Zoloft 25 mg daily.,ALLERGIES:  ,He has known history of allergy to clonidine, Medifast does fatigue.,DIAGNOSTIC AND LABORATORY DATA: , Chest x-ray upon presentation to the Ellis Emergency Room this evening demonstrate significant congestive heart failure with moderate-sized bilateral pleural effusions.,A 12-lead EKG, sinus rhythm at a rate of 68 per minute, right bundle-branch block type IVCV with moderate nonspecific ST changes.  Low voltage in the limb leads.,WBC 29,000, hemoglobin 10.9, hematocrit 31, platelets 187,000.  Low serum sodium at 132, potassium 4, BUN 28, creatinine 1.2, random glucose 179.  Low total protein 5.7.  Magnesium level 2.3, troponin 0.404 with the B-natriuretic peptide of 8200.,PHYSICAL EXAMINATION:  ,He is an elderly gentleman, who appears to be in no acute distress, lying comfortably flat at 30 degrees, measured pressure of 150/80 with a pulse of 68 and regular.  JVD difficult to assess.  Normal carotids with obvious bruits.  Conjunctivae pink.  Oropharynx clear.  Mild kyphosis.  Diffusely depressed breath sounds halfway up both posterior lung fields.  No active wheezing.  Cardiac Exam:  Regular, soft, 1-2/6 early systolic ejection murmur best heard at the base.  Abdomen:  Soft, nontender, protuberant, benign.  Extremities:  2+ bilateral pitting edema to the level of the knees.  Neuro Exam:  Appears alert, oriented x3.  Appropriate manner and affect, exceedingly hard of hearing.,OVERALL IMPRESSION:,  An 88-year-old white male with the following major medical issues:,1.  Presentation consists with subclinical congestive heart failure possibly systolic, no recent echocardiogram available for review.,2.  Hypertension with suboptimal controlled currently.,3.  Diabetes.,4.  Prostate CA, status post radium seed implant.,5.  COPD, on metered-dose inhaler.,6.  CLL followed by Dr. Y.,7.  Single-vessel coronary disease, no recent anginal quality chest pain, no changes in ECG suggestive of acute ischemia; however, initial troponin 0.4 - to be followed with serial enzyme determinations and telemetry.,8.  Hearing loss, anxiety.,9.  Significant degenerative joint disease.,PLAN:,1.  Admit to A4 with telemetry, congestive heart failure pathway, intravenous diuretic therapy.,2.  Strict I&O, Foley catheter has already been placed.,3.  Daily BMP.,4.  Two-dimensional echocardiogram to assess left ventricular systolic function.  Serum iron determination to exclude the possibility of a subclinical ischemic cardiac event.  Further recommendations will be forthcoming pending his clinical course and hospital.",5
"HISTORY OF PRESENT ILLNESS: , This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month.  The patient also reports a 15-pound weight loss.  He denies fever, chills and sweats.  He denies cough and diarrhea.  He has mild anorexia.,PAST MEDICAL HISTORY:,  Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis.  He had a recent PPD which was negative in August 1994.,MEDICATIONS: , None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , He occasionally drinks and is a nonsmoker.  The patient participated in homosexual activity in Haiti during 1982 which he described as ""very active."" Denies intravenous drug use.  The patient is currently employed.,FAMILY HISTORY:,  Unremarkable.,PHYSICAL EXAMINATION:,GENERAL:  This is a thin, black cachectic man speaking in full sentences with oxygen.,VITAL SIGNS:  Blood pressure 96/56, heart rate 120.  No change with orthostatics.  Temperature 101.6 degrees Fahrenheit.  Respirations 30.,HEENT:  Funduscopic examination normal.  He has oral thrush.,LYMPH:  He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.,NECK:  No goiter, no jugular venous distention.,CHEST:  Bilateral basilar crackles, and egophony at the right and left middle lung fields.,HEART:  Regular rate and rhythm, no murmur, rub or gallop.,ABDOMEN:  Soft and nontender.,GENITOURINARY:  Normal.,RECTAL:  Unremarkable.,SKIN:  The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender.  He has very pale palms., ,LABORATORY AND X-RAY DATA: , Sodium 133, potassium 5.3, BUN 29, creatinine 1.8.  Hemoglobin 14, white count 7100, platelet count 515.  Total protein 10, albumin 3.1, AST 131, ALT 31.  Urinalysis shows 1+ protein, trace blood.  Total bilirubin 2.4, direct bilirubin 0.1.  Arterial blood gases:  pH 7.46, pC02 32, p02 46 on room air.  Electrocardiogram shows normal sinus rhythm.  Chest x-ray shows bilateral alveolar and interstitial infiltrates.,IMPRESSION:,1.  Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.,2.  Thrush.,3.  Elevated unconjugated bilirubins.,4.  Hepatitis.,5.  Elevated globulin fraction.,6.  Renal insufficiency.,7.  Subcutaneous nodules.,8.  Risky sexual behavior in 1982 in Haiti.,PLAN:,1.  Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.,2.  Begin intravenous Bactrim and erythromycin.,3.  Begin prednisone.,4.  Oxygen.,5.  Nystatin swish and swallow.,6.  Dermatologic biopsy of lesions.,7.  Check HIV and RPR.,8.  Administer Pneumovax, tetanus shot and Heptavax if indicated.",5
"PREOPERATIVE DIAGNOSES:  ,1.  Fractured and retained lumbar subarachnoid spinal catheter.,2.  Pseudotumor cerebri (benign intracranial hypertension).,PROCEDURES:  ,1.  L1 laminotomy.,2.  Microdissection.,3.  Retrieval of foreign body (retained lumbar spinal catheter).,4.  Attempted insertion of new external lumbar drain.,5.  Fluoroscopy.,ANESTHESIA: , General.,HISTORY:  ,The patient had a lumbar subarachnoid drain placed yesterday.  All went well with the surgery.  The catheter stopped draining and on pulling back the catheter, it fractured and CT scan showed that the remaining fragment is deep to the lamina.  The patient continues to have right eye blindness and headaches, presumably from the pseudotumor cerebri.,DESCRIPTION OF PROCEDURE:  ,After induction of general anesthesia, the patient was placed prone on the operating room table resting on chest rolls.  Her face was resting in a pink foam headrest.  Extreme care was taken positioning her because she weighs 92 kg.  There was a lot of extra padding for her limbs and her limbs were positioned comfortably.  The arms were not hyperextended.  Great care was taken with positioning of the head and making sure there was no pressure on her eyes especially since she already has visual disturbance.  A Foley catheter was in place.  She received IV Cipro 400 mg because she is allergic to most antibiotics.,Fluoroscopy was used to locate the lower end of the fractured catheter and the skin was marked.  It was also marked where we would try to insert the new catheter at the L4 or L3 interspinous space.,The patient was then prepped and draped in a sterile manner.,A 7-cm incision was made over the L1 lamina.  The incision was carried down through the fascia all the way down to the spinous processes.  A self-retaining McCullough retractor was placed.  The laminae were quite deep.  The microscope was brought in and using the Midas Rex drill with the AM-8 bit and removing some of the spinous process of L1-L2 with double-action rongeurs, the laminotomy was then done using the drill and great care was taken and using a 2-mm rongeur, the last layer of lamina was removed exposing the epidural fat and dura.  The opening in the bone was 1.5 x 1.5 cm.,Occasionally, bipolar cautery was used for bleeding of epidural veins, but this cautery was kept to a minimum.,Under high magnification, the dura was opened with an 11 blade and microscissors.  At first, there was a linear incision vertically to the left of midline, and I then needed to make a horizontal incision more towards the right.  The upper aspect of the cauda equina was visualized and perhaps the lower end of the conus.  Microdissection under high magnification did not expose the catheter.  The fluoroscope was brought in 2 more times including getting a lateral view and the fluoroscope appeared to show that the catheter should be in this location.,I persisted with intensive microdissection and finally we could see the catheter deep to the nerves and I was able to pull it out with the microforceps.,The wound was irrigated with bacitracin irrigation.,At this point, I then attempted lumbar puncture by making a small incision with an 11 blade in the L4 interspinous space and then later in the L3 interspinous space and attempted to puncture the dural sac with the Tuohy needle.  Dr. Y also tried.  Despite using the fluoroscope and our best attempts, we were not able to convincingly puncture the lumbar subarachnoid space and so the attempted placement of the new lumbar catheter had to be abandoned.  It will be done at a later date.,I felt it was unsafe to place a new catheter at this existing laminotomy site because it was very high up near the conus.  The potential for complications involving her spinal cord was greater and we have already had a complication of the catheter now and I just did not think it was safe to put in this location.,Under high magnification, the dura was closed with #6-0 PDS interrupted sutures.,After the dura was closed, a piece of Gelfoam was placed over the dura.  The paraspinous muscles were closed with 0 Vicryl interrupted sutures.  The subcutaneous fascia was also closed with 0 Vicryl interrupted suture.  The subcutaneous layer was closed with #2-0 Vicryl interrupted suture and the skin with #4-0 Vicryl Rapide.  The 4-0 Vicryl Rapide sutures were also used at the lumbar puncture sites to close the skin.,The patient was then turned carefully on to her bed after sterile dressings were applied and then taken to the recovery room.  The patient tolerated procedure well.  No complications.  Sponge and needle counts correct.  Blood loss minimal, none replaced.  This procedure took 5 hours.  This case was also extremely difficult due to patient's size and the difficulty of locating the catheter deep to the cauda equina.",37
"SUBJECTIVE:,  The patient is a 78-year-old female with the problem of essential hypertension.  She has symptoms that suggested intracranial pathology, but so far work-up has been negative.,She is taking hydrochlorothiazide 25-mg once a day and K-Dur 10-mEq once a day with adequate control of her blood pressure.  She denies any chest pain, shortness of breath, PND, ankle swelling, or dizziness.,OBJECTIVE:,  Heart rate is 80 and blood pressure is 130/70.  Head and neck are unremarkable.  Heart sounds are normal.  Abdomen is benign.  Extremities are without edema.,ASSESSMENT AND PLAN:,  The patient reports that she had an echocardiogram done in the office of Dr. Sample Doctor4 and was told that she had a massive heart attack in the past.  I have not had the opportunity to review any investigative data like chest x-ray, echocardiogram, EKG, etc.  So, I advised her to have a chest x-ray and an EKG done before her next appointment, and we will try to get hold of the echocardiogram on her from the office of Dr. Sample Doctor4.  In the meantime, she is doing quite well, and she was advised to continue her current medication and return to the office in three months for followup.",3
"EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day.  Fever.  Right upper quadrant pain for one day.  ,COMPARISON: , None. ,TECHNIQUE:,  CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement.  ,CT ABDOMEN: , Lung bases are clear.  The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable.  The aorta is normal in caliber.  There is no retroperitoneal lymphadenopathy.  ,CT PELVIS: , The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change.  Per CT, the colon and small bowel are unremarkable.  The bladder is distended.  No free fluid/air.  Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1.  Unremarkable exam; specifically no evidence for acute appendicitis. ,2.  No acute nephro-/ureterolithiasis. ,3.  No secondary evidence for acute cholecystitis.,Results were communicated to the ER at the time of dictation.",14
"HISTORY: , Smoking history 50-pack years of smoking.,INDICATION: , Dyspnea.,PROCEDURE: , FVC was 59%.  FEV1 was 45%.  FEV1/FVC ratio was 52%. The predicted was 67%.  FEF 25/75% was 22%, improved about 400-cc, which represents 89% improvement with bronchodilator.  SVC was 91%. Inspiratory capacity was 70%.  Residual volume was 225% of its predicted.  Total lung capacity was 128%.  ,IMPRESSION:,1.  Moderate obstructive lung disease with some improvement with bronchodilator indicating bronchospastic element.,2.  Probably there is some restrictive element because of fibrosis.  The reason for that is that the inspiratory capacity was limited and the total lung capacity did not increase to the same extent as the residual volume and expiratory residual volume.,3.  Diffusion capacity was not measured.  The flow volume loop was consistent with the above.,",3
"SUBJECTIVE: , Review of the medical record shows that the patient is a 97-year-old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation.  The patient does have a longstanding history of COPD.  However, she does not use oxygen at her independent assisted living home.  Yesterday, she had made improvement since being here at the hospital.  She needed oxygen.  She was tested for home O2 and qualified for it yesterday also.  Her lungs were very tight.  She did have wheezes bilaterally and rhonchi on the right side mostly.  She appeared to be a bit weak and although she was requesting to be discharged home, she did not appear to be fit for it.,Overnight, the patient needed to use the rest room.  She stated that she needed to urinate.  She awoke, decided not to call for assistance.  She stated that she did have her nurse call light button next to her and she was unable to gain access to her walker.  She attempted to walk to the rest room on her own.  She sustained a fall.  She stated that she just felt weak.  She bumped her knee and her elbow.  She had femur x-rays, knee x-rays also.  There was possibility of subchondral fracture and some swelling of her suprapatellar bursa on the right side.  This morning, she denied any headache, back pain or neck pain.  She complained mostly of right anterior knee pain for which she had some bruising and swelling.,OBJECTIVE:,VITAL SIGNS:  The patient's max temperature over the past 24 hours was 36.5; her blood pressure is 148/77, her pulse is 87 to 106.  She is 95% on 2 L via nasal cannula.,HEART:  Regular rate and rhythm without murmur, gallop or rub.,LUNGS:  Reveal no expiratory wheezing throughout.  She does have some rhonchi on the right mid base.  She did have a productive cough this morning and she is coughing green purulent sputum finally.,ABDOMEN:  Soft and nontender.  Her bowel sounds x4 are normoactive.,NEUROLOGIC:  She is alert and oriented x3.  Her pupils are equal and reactive.  She has got a good head and facial muscle strength.  Her tongue is midline.  She has got clear speech.  Her extraocular motions are intact.  Her spine is nontender on palpation from neck to lumbar spine.  She has good range of motion with regard to her shoulders, elbows, wrists and fingers.  Her grip strengths are equal bilaterally.  Both elbows are strong from extension to flexion.  Her hip flexors and extenders are also strong and equal bilaterally.  Extension and flexion of the knee bilaterally and ankles also are strong.  Palpation of her right knee reveals no crepitus.  She does have suprapatellar inflammation with some ecchymosis and swelling.  She has got good joint range of motion however.,SKIN:  She did have a skin tear involving her right forearm lateral, which is approximately 2 to 2.5 inches in length and is at this time currently Steri-Stripped and wrapped with Coban and is not actively bleeding.,ASSESSMENT:,1.  Acute on chronic COPD exacerbation.,2.  Community acquired pneumonia both resolving.  However, she may need home O2 for a short period of time.,3.  Generalized weakness and deconditioning secondary to the above.  Also sustained a fall secondary to instability and not using her walker or calling for assistance.  The patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed.,PLAN:,1.  I will have PT and OT evaluate the patient and give recommendation to safety and appliance use at home i.e. walker.  Myself and one of her daughter's spoke today about the fact that she generally lives independently at the Brooke and she may need assisted living along with physical therapy and oxygen for a period of time rather than going back to independent living.,2.  We will obtain an orthopedic consult secondary to her fall to evaluate her x-rays and function.",34
"CHIEF COMPLAINT: , Nausea and feeling faint.,HPI:  ,The patient is a 74-year-old white female brought in by husband.  The patient is a vague historian at times.  She reports her appetite has been fair over the last several days.  Today, she complains of some nausea.  She feels weak.  No other specific complaints.,REVIEW OF SYSTEMS:  ,The patient denies fever, chills, sweats, ear pain, URI symptoms, cough, dyspnea, chest pain, vomiting, diarrhea, abdominal pain, melena, hematochezia, urinary symptoms, headache, neck pain, back pain, weakness or paresthesias in extremities.,CURRENT MEDICATIONS:  ,Diovan, estradiol, Norvasc, Wellbutrin SR inhaler, and home O2.,ALLERGIES: , MORPHINE CAUSES VOMITING.,PAST MEDICAL HISTORY:  ,COPD and hypertension.,HABITS:  ,Tobacco use, averages two cigarettes per day.  Alcohol use, denies.,LAST TETANUS IMMUNIZATION: , Not sure.,LAST MENSTRUAL PERIOD: , Status post hysterectomy.,SOCIAL HISTORY:  ,The patient is married and retired.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 98.2, pulse is 105, respirations 20, and BP 137/80.  GENERAL:  A well developed, well nourished, alert, cooperative, nontoxic, and appears hydrated.  SKIN:  Warm, dry, and good color.  EYES:  EOMI.  PERRL.  MOUTH:  Clear.  Mucous membranes moist.  NECK:  Supple.  No JVD.  LUNGS:  Reveal faint expiratory wheeze heard in the posterior lung fields.  HEART:  Slightly tachycardic without murmur.  ABDOMEN:  Soft, positive bowel sounds, and nontender.  No rebound or guarding is appreciated.  BACK:  No CVA tenderness.  EXTREMITIES:  Moves all four extremities.  No pretibial edema.  NEURO:  Cranial nerves II to XII, motor, and cerebellar are grossly intact and nonfocal.,LABORATORY STUDIES: , WBC 9200, differential with 82 neutrophils, 8 lymphocytes, 6 monocytes, and 4 eosinophils.  Hemoglobin 10.7 and hematocrit 31.2 both are decreased.  Comprehensive medical profile normal except for decreased sodium of 129, decreased chloride of 92, calcium decreased 8.4, total protein decreased 6.1, and albumin decreased 3.2.  Amylase and lipase both normal.  Clean catch urinalysis is unremarkable.  Review of EMR indicates on 05/09/06 hemoglobin was 12.1, on 05/10/07 hemoglobin was 9.9, and today hemoglobin is 10.7.  It seems to indicate that the patient had previous problems with anemia.,RADIOLOGY STUDIES: , Chest x-ray indicates chronic changes, reviewed by me, official report is pending.,ED STUDIES: , O2 sat on room air is 92%, which is satisfactory for this patient with COPD.  Monitor indicates sinus tachycardia at rate 103.  No ectopy.,ED COURSE:  ,The patient was assessed for orthostatic vital sign changes and none were detected by the nurse.  The patient was given albuterol unit dose small volume nebulizer treatment.  Repeat lung exam reveals resolution of expiratory wheezing.  The patient later had normal saline lock started by the nurse.  She was given IV fluids of normal saline 1L wide open over approximately one hour.  She was able to void urine indicating that she is well hydrated.  Rectal examination was performed with female nurse in attendance.  Good sphincter tone.  No masses.  The rectal secretions were heme negative.  The patient was reassessed.  She feels slightly better.  Monitor now shows normal sinus rhythm, rate 81, no ectopy.  Blood pressure is 136/66.  The patient is stable and will be discharged.,MEDICAL DECISION MAKING: , This patient presents with the above history.  Laboratory evaluation today indicates the following problems, anemia and hyponatremia.  This could contribute the patient's feelings of tiredness and not feeling well.  There is no evidence of rectal bleeding at this time.  The patient was advised that she needs to follow up with Dr. X to further investigate these problems.  The patient is hemodynamically stable and will be discharged.,ASSESSMENT:,1.  Acute tiredness.,2.  Anemia of unknown etiology.,3.  Acute hyponatremia.,PLAN:  ,The patient is advised to put salt on her food for the next week.  Should be given discharge instruction sheet for anemia.  Recommend follow up with personal physician, Dr. X in two to three days for recheck.  Return to ED sooner if condition changes or worsen anyway.  Discharged in stable condition.",12
"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.",33
"PREOPERATIVE DIAGNOSES:,1.  Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2.  Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3.  Inability to pass a Foley catheter x3.,POSTOPERATIVE DIAGNOSES:,1.  Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2.  Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3.  Inability to pass a Foley catheter x3.,PROCEDURES:,1.  Cystoscopy.,2.  Transurethral resection of the prostate (TURP).,ANESTHESIA: , General laryngeal mask.,INDICATIONS: , This patient is a 61-year-old white male who has been treated at the VA in Houston for a bladder cancer.  His history dates back to 2003 when he had a non-muscle invasive bladder cancer.  He had multiple cystoscopies and followups since that time with no evidence of recurrence.  However, on recent cystoscopy, he had what appeared to be a recurrent tumor and was taken to the operating room and had this resected with findings of a Ta grade III transitional cell carcinoma associated with carcinoma in situ.  Retrograde pyelograms were suspicious on the right and cleared with ureteroscopy and the left renal pelvic washing was positive but this may represent contamination from the lower urinary tract as radiographically, there were no abnormalities.  I had cystoscoped the patient in the office showed during the period of time when he had significant irritative burning symptoms, and there were still healing biopsy sites.  We elected to allow his bladder to recover before starting the BCG.  We were ready to do that last week but two doctors and a nurse including myself were unable to pass Foley catheter.  I repeated a cystoscopy in the office with findings of a high bladder neck and BPH.  After a lengthy discussion with the patient and his wife, we elected to proceed with TURP after a full informed consent.,FINDINGS: , At cystoscopy, there was bilobular prostatic hyperplasia and a very high riding bladder neck, which may have been the predominant cause of his difficulty catheterizing and obstructive symptoms.  There were mucosal changes on the left posterior wall in the midline suspicious for carcinoma in situ.,PROCEDURE IN DETAIL: , The patient was brought to the cystoscopy suite and after adequate general laryngeal mask anesthesia obtained and placed in the dorsal lithotomy position, his perineum and genitalia were sterilely prepped and draped in the usual fashion.  A cystourethroscopy was performed with a #23 French ACMI panendoscope and 70-degree lens with the findings as described.  We removed the cystoscope and passed a #28 French continuous flow resectoscope sheath under visual obturator after dilating the meatus to #32 French with van Buren sounds.  Inspection of bladder again was made noting the location of the ureteral orifices relative to the bladder neck.  The groove was cut at 6 o'clock to open the bladder neck to verumontanum and then the left lobe was resected from 1 o'clock to 5 o'clock.  Hemostasis was achieved, and then a similar procedure performed in the right side.  We resected the anterior stromal tissue and the apical tissue and then obtained complete hemostasis.  Chips were removed with Ellik evacuator.  There was no bleeding at the conclusion of the procedure, and the resectoscope was removed.  A #24 French three-way Foley catheter was placed with efflux of clear irrigant.  The patient was returned to the supine position, awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.",37
"PREOPERATIVE DIAGNOSIS: , Recurrent bladder tumors.,POSTOPERATIVE DIAGNOSIS:,  Recurrent bladder tumors.,OPERATION: , Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors.,ANESTHESIA:,  General.,INDICATIONS: , A 79-year-old woman with recurrent bladder tumors of the bladder neck.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, prepped and draped in lithotomy position under satisfactory general anesthesia.  A #21-French cystourethroscope was inserted into the bladder.  Examination of the bladder showed approximately a 3-cm area of erythema and recurrent papillomatosis just above and lateral to the left ureteral orifice.  No other lesions were noted.  Using a cold punch biopsy forceps, a random biopsy was obtained.  The entire area was electrofulgurated using the Bugbee electrode.  The patient tolerated the procedure well and left the operating room in satisfactory condition.",38
"REASON FOR VISIT:,  This is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation.  Her chief complaint today is shortness of breath.,HISTORY OF PRESENT ILLNESS:,  I last saw her in 09/2008.  Since then, she has been admitted to ABCD Hospital from 11/05/2008 through 11/08/2008 for a near syncopal episode.  She was found to have a fast heart rate in the atrial fibrillation.  She was also found to be in heart failure and so they diuresed her.  They wanted to send her home on furosemide 40 mg daily, but unfortunately they never gave her a prescription for this and so she now is not on any furosemide and since being discharged she has regained fluid to no one's great surprise.  My plan advent is to control her heart rate.  This has been a bit difficult with her retaining fluid.  We will try again to diurese her as an outpatient and go forward from there with rate control and anticoagulation.  She may need to have a pacemaker placed and her AV node ablated if this does not work.,She notes the shortness of breath and wheezing at nights.  I think these are manifestations of heart failure.  She has peripheral edema.  She is short of breath when she tries to walk a city block.  I believe she takes her medications as directed, but I am never sure she actually is taking them correctly.  In any case, she did not bring her medications with her today.,Today, she had an ECG which shows atrial fibrillation with a ventricular response of 117 beats per minute.  There is a nonspecific IVCD.  This is unchanged from her last visit except that her heart rate is faster.  In addition, I reviewed her echocardiogram done at XYZ.  Her ejection fraction is 50% and she has paradoxical septal motion.  Her right ventricular systolic pressure is normal.  There are no significant valvular abnormalities.,MEDICATIONS:  ,1.  Fosamax - 70 mg weekly.,2.  Lisinopril - 20 mg daily.,3.  Metformin - 850 mg daily.,4.  Amlodipine - 5 mg daily.,5.  Metoprolol - 150 mg twice daily.,6.  Warfarin - 5 mg daily.,7.  Furosemide - none.,8.  Potassium - none.,9.  Magnesium oxide - 200 mg daily.,ALLERGIES: , Denied.,MAJOR FINDINGS:,  On my comprehensive cardiovascular examination, she again looks the same which is in heart failure.  Her blood pressure today was 130/60 and her pulse 116 blood pressure and regular.  She is 5 feet 11 inches and her weight is 167 pounds, which is up from 158 pounds from when I saw her last visit.  She is breathing 1two times per minute and it is unlabored.  Eyelids are normal.  She has vitiligo.  Pupils are round and reactive to light.  Conjunctivae are clear and sclerae are anicteric.  There is no oral thrush or central cyanosis.  She has marked keloid formation on both sides of her neck, the left being worse than the right.  The jugular venous pressure is elevated.  Carotids are brisk are without bruits.  Lungs are clear to auscultation and percussion.  The precordium is quiet.  The rhythm is irregularly irregular.  She has a variable first and second heart sounds.  No murmurs today.  Abdomen is soft without hepatosplenomegaly or masses, although she does have hepatojugular reflux.  She has no clubbing or cyanosis, but does have 1+ peripheral edema.  Distal pulses are good.  On neurological examination, her mentation is normal.  Her mood and affect are normal.  She is oriented to person, place, and time.,ASSESSMENTS: , She has chronic atrial fibrillation and heart failure now.,PROBLEMS DIAGNOSES:  ,1.  Chronic atrial fibrillation, anticoagulated and the plan is rate control.,2.  Heart failure and she needs more diuretic.,3.  High blood pressure controlled.,4.  Hyperlipidemia.,5.  Diabetes mellitus type 2.,6.  Nonspecific intraventricular conduction delay.,7.  History of alcohol abuse.,8.  Osteoporosis.,9.  Normal left ventricular function.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I have restarted her Lasix at 80 mg daily and I have asked her to return in about 10 days to the heart failure clinic.  There, I would like them to recheck her heart rate and if still elevated, and she is truly on 150 mg of metoprolol twice a day, one could switch her amlodipine from 5 mg daily to diltiazem 120 mg daily.  If this does not work, in terms of controlling her heart rate, then she will need to have a pacemaker and her AV node ablated.,Thank you for asking me to participate in her care.,MEDICATION CHANGES: , See the above.",3
"PREOPERATIVE DIAGNOSIS:  ,Cervical spondylosis and herniated nucleus pulposus of C4-C5.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis and herniated nucleus pulposus of C4-C5.,TITLE OF OPERATION:,  Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,OPERATIVE PROCEDURE IN DETAIL: , After identification, the patient was taken to the operating room and placed in supine position.  Following the induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  A shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position.  A preoperative x-ray was obtained to identify the operative level and neck position.  An incision was marked at the C4-C5 level on the right side.  The incision was opened with #10 blade knife.  Dissection was carried down through subcutaneous tissues using Bovie electrocautery.  The platysma muscle was divided with the cautery and mobilized rostrally and caudally.  The anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection.  The avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia.  This was opened with scissors and dissected rostrally and caudally with the peanut dissectors.  The operative level was confirmed with an intraoperative x-ray.  The longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator.  The anterior longitudinal ligament was then taken down with the insulated Bovie electrocautery tip exposing the vertebral bodies of C4 and C5.  Self-retaining retractor was placed in submuscular position, and distraction pins were placed in the vertebral bodies of C4 and C5, and distraction was instituted.  We then incise the annulus of C4-C5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes.  Operating microscope was draped and brought into play.  Dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went.  We now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally.  Bone was then removed with 2 mm Kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm Kerrison punch.  There was a transligamentous disc herniation, which was removed during this process.  We then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent.  Cord was seen to be pulsating freely behind the dura.  There appeared to be no complications and the decompression appeared adequate.  We now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the C5 vertebral body.  An 8 mm lordotic trial was used and appeared perfect.  We then used a corticocancellous 8 mm lordotic graft.  This was tapped into position.  Distraction was released, appeared to be in excellent position.  We then positioned an 18 mm Vector plate over the inner space.  Intraoperative x-ray was obtained with the stay screw in place; plates appeared to be in excellent position.  We then use a 14 mm self-tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion.  All of the screws locked to the plate and this was confirmed on visual inspection.  Intraoperative x-ray was again obtained.  Construct appeared satisfactory.  Attention was then directed to closure.  The wound was copiously irrigated.  All of the self-retaining retractors were removed.  Bleeding points were controlled with bone wax and bipolar electrocautery.  The platysma layer was now closed with interrupted 3-0 Vicryl sutures.  The skin was closed with running 3-0 Vicryl subcuticular stitch.  Steri-Strips were applied.  A sterile bandage was applied.  All sponge, needle, and cottonoid counts were reported as correct.  The patient tolerated the procedure well.  He was subsequently extubated in the operating room and transferred to PACU in satisfactory condition.",27
"PROCEDURE PERFORMED:,1.  Right heart catheterization.,2.  Left heart catheterization.,3.  Left ventriculogram.,4.  Aortogram.,5.  Bilateral selective coronary angiography.,ANESTHESIA:,  1% lidocaine and IV sedation including Versed 1 mg.,INDICATION:,  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.  She has had atrial fibrillation and previous episodes of congestive heart failure.  She has dyspnea on exertion and occasionally orthopnea and paroxysmal nocturnal dyspnea.,PROCEDURE:,  After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, informed consent was obtained, both verbally and in writing.  The patient was taken to the Cardiac Catheterization Lab where the procedure was performed.  The right inguinal area was thoroughly cleansed with Betadine solution and the patient was draped in the usual manner.  1% lidocaine solution was used to anesthetize the right inguinal area.  Once adequate anesthesia had been attained, a thing wall Argon needle was used to cannulate the right femoral vein.  A guidewire was advanced into the lumen of the vein without resistance.  The needle was removed and the guidewire was secured to the sterile field.  The needle was flushed and then used to cannulate the right femoral artery.  A guidewire was advanced through the lumen of the needle without resistance.  A small nick was made in the skin and the needle was removed.  This pressure was held.  A #6 French arterial sheath was advanced over the guidewire without resistance.  The dilator and guidewire were removed.  FiO2 sample was obtained and the sheath was flushed.  An #8 French sheath was advanced over the guidewire into the femoral vein after which the dilator and guidewire were removed and the sheath was flushed.  A Swan-Ganz catheter was advanced through the venous sheath into a pulmonary capillary was positioned and the balloon was temporarily deflated.  An angulated pigtail catheter was advanced into the left ventricle under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to a manifold and flushed.  Left ventricular pressures were continuously measured and the balloon was re-inflated and pulmonary capillary wedge pressure was remeasured.  Using dual transducers together and the mitral valve radius was estimated.  The balloon was deflated and mixed venous sample was obtained.  Hemodynamics were measured.  The catheter was pulled back in to the pulmonary artery right ventricle and right atrium.  The right atrial sample was obtained and was negative for shunt.  The Swan-Ganz catheter was then removed and a left ventriculogram was performed in the RAO projection with a single power injection of non-ionic contrast material.  Pullback was then performed which revealed a minimal LV-AO gradient.  Since the patient had aortic insufficiency on her echocardiogram, an aortogram was performed in the LAO projection with a single power injection of non-ionic contrast material.  The pigtail catheter was then removed and a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was carefully engaged.  Using multiple hand injections of non-ionic contrast material, the left coronary system was evaluated in different views.  This catheter was then removed and a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the right coronary artery was then engaged and using hand injections of non-ionic contrast material, the right coronary system was evaluated in different views.  This catheter was removed.  The sheaths were flushed final time.  The patient was taken to the Postcatheterization Holding Area in stable condition.,FINDINGS:,HEMODYNAMICS: , Right atrial pressure 9 mmHg, right ventricular pressure is 53/14 mmHg, pulmonary artery pressure 62/33 mmHg with a mean of 46 mmHg.  Pulmonary capillary wedge pressure is 29 mmHg.  Left ventricular end diastolic pressure was 13 mmHg both pre and post left ventriculogram.  Cardiac index was 2.4 liters per minute/m2.  Cardiac output 4.0 liters per minute.  The mitral valve gradient was 24.5 and mitral valve area was calculated to be 0.67 cm2.  The aortic valve area is calculated to be 2.08 cm2.,LEFT VENTRICULOGRAM: , No segmental wall motion abnormalities were noted.  The left ventricle was somewhat hyperdynamic with an ejection fraction of 70%.  2+ to 3+ mitral regurgitation was noted.,AORTOGRAM: , There was 2+ to 3+ aortic insufficiency noted.  There was no evidence of aortic aneurysm or dissection.,LEFT MAIN CORONARY ARTERY: , This was a moderate caliber vessel and it is rather long.  It bifurcates into the LAD and left circumflex coronary artery.  No angiographically significant stenosis is noted.,LEFT ANTERIOR DESCENDING ARTERY:,  The LAD begins as a moderate caliber vessel ________ anteriorly in the intraventricular groove.  It tapers in its mid portion to become small caliber vessel.  Luminal irregularities are present, however, no angiographically significant stenosis is noted.,LEFT CIRCUMFLEX CORONARY ARTERY: , The left circumflex coronary artery begins as a moderate caliber vessel.  Small obtuse marginal branches are noted and this is the nondominant system.  Lumen irregularities are present throughout the circumflex system.  However no angiographically significant stenosis is noted.,RIGHT CORONARY ARTERY: , This is the moderate caliber vessel and it is the dominant system.  No angiographically significant stenosis is noted, however, mild luminal irregularities are noted throughout the vessel.,IMPRESSION:,1.  Nonobstructive coronary artery disease.,2.  Severe mitral stenosis.,3.  2+ to 3+ mitral regurgitation.,4.  2+ to 3+ aortic insufficiency.",3
"HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.  She has had a dry cough and a fever as high as 100, but this has not been since the first day.  She denies any vomiting or diarrhea.  She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe, but she does not think that this has helped.,FAMILY HISTORY: , The patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,REVIEW OF SYSTEMS:,  The patient does note some pressure in her sinuses.  She denies any skin rash.,SOCIAL HISTORY:,  Patient lives with her mother, who is here with her.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits.  Room air oximetry is 100%.,GENERAL:  Patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,HEENT:  Head is normocephalic, atraumatic.  Pharynx shows no erythema, tonsillar edema, or exudate.  Both TMs are easily visualized and are clear with good light reflex and no erythema.  Sinuses do show some mild tenderness to percussion.,NECK:  No meningismus or enlarged anterior/posterior cervical lymph nodes.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,SKIN:  No rash.,ASSESSMENT:,  Viral upper respiratory infection (URI) with sinus and eustachian congestion.,PLAN:,  I did educate the patient about her problem and urged her to switch to Advil Cold & Sinus for the next three to five days for better control of her sinus and eustachian discomfort.  I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses.  If she is unimproved in five days, follow up with her PCP for re-exam.",5
"SUBJECTIVE:,  The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.  She was last seen in the Pulmonary Medicine Clinic in January 2004.  Since that time, her respiratory status has been quite good.  She has had no major respiratory difficulties; however, starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort.  She denies any problems with cough or sputum production.  No fevers or chills.  Recently, she has had a bit more problems with fatigue.  For the most part, she has had no pulmonary limitations to her activity.,CURRENT MEDICATIONS:,  Synthroid 0.112 mg daily; Prilosec 20 mg daily; prednisone, she was 2.5 mg daily, but discontinued this on 06/16/2004; Plaquenil 200 mg b.i.d.; Imuran 100 mg daily; Advair one puff b.i.d.; Premarin 0.3 mg daily; Lipitor 10 mg Monday through Friday; Actonel 35 mg weekly; and aspirin 81 mg daily.  She is also on calcium, vitamin D, vitamin E, vitamin C and a multivitamin.,ALLERGIES:,  Penicillin and also intolerance to shellfish.,REVIEW OF SYSTEMS:,  Noncontributory except as outlined above.,EXAMINATION:,General:  The patient was in no acute distress.,Vital signs:  Blood pressure 122/60, pulse 72 and respiratory rate 16.,HEENT:  Nasal mucosa was mild-to-moderately erythematous and edematous.  Oropharynx was clear.,Neck:  Supple without palpable lymphadenopathy.,Chest:  Chest demonstrates decreased breath sounds, but clear.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft and nontender.,Extremities:  Without edema.  No skin lesions.,O2 saturation was checked at rest.  On room air it was 96% and on ambulation it varied between 94% and 96%.  Chest x-ray obtained today showed mild increased interstitial markings consistent with a history of lupus pneumonitis.  She has not had the previous chest x-ray with which to compare; however, I did compare the markings was less prominent when compared with previous CT scan.,ASSESSMENT:,1.  Lupus with mild pneumonitis.,2.  Respiratory status is stable.,3.  Increasing back and joint pain, possibly related to patient’s lupus, however, in fact may be related to recent discontinuation of prednisone.,PLAN:,  At this time, I have recommended to continue her current medications.  We would like to see her back in approximately four to five months, at which time I would like to recheck her pulmonary function test as well as check CAT scan.  At that point, it may be reasonable to consider weaning her Imuran if her pulmonary status is stable and the lupus appears to be under control.",3
"INTERPRETATION: , MRI of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal.  At C4-C5, there were minimal uncovertebral osteophytes with mild associated right foraminal compromise.  At C5-C6, there were minimal diffuse disc bulge and uncovertebral osteophytes with indentation of the anterior thecal sac, but no cord deformity or foraminal compromise.  At C6-C7, there was a central disc herniation resulting in mild deformity of the anterior aspect of the cord with patent neuroforamina.  MRI of the thoracic spine showed normal vertebral body height and alignment.  There was evidence of disc generation, especially anteriorly at the T5-T6 level.  There was no significant central canal or foraminal compromise.  Thoracic cord normal in signal morphology.  MRI of the lumbar spine showed normal vertebral body height and alignment.  There is disc desiccation at L4-L5 and L5-S1 with no significant central canal or foraminal stenosis at L1-L2, L2-L3, and L3-L4.  There was a right paracentral disc protrusion at L4-L5 narrowing of the right lateral recess.  The transversing nerve root on the right was impinged at that level.  The right foramen was mildly compromised.  There was also a central disc protrusion seen at the L5-S1 level resulting in indentation of the anterior thecal sac and minimal bilateral foraminal compromise.,IMPRESSION: , Overall impression was mild degenerative changes present in the cervical, thoracic, and lumbar spine without high-grade central canal or foraminal narrowing.  There was narrowing of the right lateral recess at L4-L5 level and associated impingement of the transversing nerve root at that level by a disc protrusion.  This was also seen on a prior study.,",22
"HISTORY OF PRESENT ILLNESS:,  The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room.  She was intubated and fishbone.,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract.,ALLERGIES:  ,No known drug allergies.,CURRENT MEDICATIONS: , Prevacid, Humulin, Diprivan, Proventil, Unasyn, and Solu-Medrol.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , Negative for illicit drugs, alcohol, and tobacco.,PHYSICAL EXAMINATION:  ,Please see the hospital chart.,LABORATORY DATA: , Please see the hospital chart.,HOSPITAL COURSE: , The patient was taken to the operating room by Dr. X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed.  The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated.  If not she would require tracheostomy.  The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated.  She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home.  So, the patient is being prepared for discharge at this point.  We will have Dr. X evaluate her before she leaves to make sure I do not have any problem with her going home.  Dr. Y feels she could be discharged today and will have her return to see him in a week.",5
"IDENTIFYING DATA:  ,Mr. T is a 45-year-old white male.,CHIEF COMPLAINT: , Mr. T presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.  His confidence and self-esteem are significantly low.  He stated he has excessive somnolence, his energy level is extremely low, motivation is low, and he has a lack for personal interests.  He has had suicidal ideation, but this is currently in remission.  Furthermore, he continues to have hopeless thoughts and crying spells.  Mr. T stated these symptoms appeared approximately two months ago.,HISTORY OF PRESENT ILLNESS: , On March 25, 2003, Mr. T was fired from his job secondary, to an event at which he stated he was first being harassed by another employee."" This other, employee had confronted Mr. T with a very aggressive, verbal style, where this employee had placed his face directly in front of Mr. T was spitting on him, and called him ""bitch."" Mr. T then retaliated, and went to hit the other employee.  Due to this event, Mr. T was fired.  It should be noted that Mr. T stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to ""deal with it."",There are no other apparent stressors in Mr. T's life at this time or in recent months.  Mr. T stated that work was his entire life and he based his entire identity on his work ethic.  It should be noted that Mr. T was a process engineer for Plum Industries for the past 14 years.,PAST PSYCHIATRIC HISTORY:,  There is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to Mr. T's family physician, Dr. B at which point Mr. T was placed on Lexapro with an unknown dose at this time.  Mr. T is currently seeing Dr. J for psychotherapy where he has been in treatment since April, 2003.,PAST PSYCHIATRIC REVIEW OF SYSTEMS:,  Mr. T denied any history throughout his childhood, adolescence, and early adulthood for depressive, anxiety, or psychotic disorders.  He denied any suicide attempts, or profound suicidal or homicidal ideation.  Mr. T furthermore stated that his family psychiatric history is unremarkable.,SUBSTANCE ABUSE HISTORY:,  Mr. T stated he used alcohol following his divorce in 1993, but has not used it for the last two years.  No other substance abuse was noted.,LEGAL HISTORY: , Currently, charges are pending over the above described incident.,MEDICAL HISTORY: , Mr. T denied any hospitalizations, surgeries, or current medications use for any heart disease, lung disease, liver disease, kidney disease, gastrointestinal disease, neurological disease, closed head injury, endocrine disease, infectious, blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia.,PERSONAL AND SOCIAL HISTORY: , Mr. T was born in Dwyne, Missouri, with no complications associated with his birth.  Originally, he was raised by both parents, but they separated at an early age.  When he was about seven years old, he was raised by his mother and stepfather.  He did not sustain a relationship with his biological father from that time on.  He stated his parents moved a lot, and because this many times he was picked on in his new environments, Mr. T stated he was, at times, a rebellious teenager, but he denied any significant inability to socialize, and denied any learning disabilities or the need for special education.,Mr. T stated his stepfather was somewhat verbally abusive, and that he committed suicide when Mr. T was 18 years old.  He graduated from high school and began work at Dana Corporation for two to three years, after which he worked as an energy, auditor for a gas company.  He then became a homemaker while his wife worked for Chrysler for approximately two years.  Mr. T was married for eleven years, and divorced in 1993.  He has a son who is currently 20 years old.  After being a home maker, Mr. T worked for his mother in a restaurant, and moved on from there to work for Borg-Warner corporation for one to two years before beginning at Plum Industries, where he worked for 14 years and worked his way up to lead engineer.,Mental Status Exam:  Mr. T presented with a hyper vigilant appearance, his eye contact was appropriate to the interview, and his motor behavior was tense.  At times he showed some involuntary movements that would be more akin to a resting tremor.  There was no psychomotor retardation, but there was some mild psychomotor excitement.  His speech was clear, concise, but pressured.  His attitude was overly negative and his mood was significant for moderate depression, anxiety, anhedonia and loneliness, and mild evidence of anger.  There was no evidence of euphoria or diurnal mood variation.  His affective expression was restricted range, but there was no evidence of lability.  At times, his affective tone and facial expressions were inappropriate to the interview.  There was no evidence of auditory, visual, olfactory, gustatory, tactile or visceral hallucinations.  There was no evidence of illusions, depersonalizations, or derealizations.  Mr. T presented with a sequential and goal directed stream of thought.  There was no evidence of incoherence, irrelevance, evasiveness, circumstantiality, loose associations, or concrete thinking.  There was no evidence of delusions; however, there was some ambivalence, guilt, and self-derogatory thoughts.  There was evidence of concreteness for similarities and proverbs.  His intelligence was average.  His concentration was mildly impaired, and there was no evidence of distractibility.  He was oriented to time, place, person and situation.  There was no evidence of clouded consciousness or dissociation.  His memory was intact for immediate, recent, and remote events.,He presented with poor appetite, easily fatigued, and decreased libidinal drive, as well as excessive somnolence.  There was a moderate preoccupation with his physical health pertaining to his headaches.  His judgment was poor for finances, family relations, social relations, employment, and, at this time, he had no future plans.  Mr. T's insight is somewhat moderate as he is aware of his contribution to the problem.  His motivation for getting well is good as he accepts offered treatment, complies with recommended treatment, and seeks effective treatments.  He has a well-developed empathy for others and capacity for affection.,There was no evidence of entitlement, egocentricity, controllingness, intimidation, or manipulation.  His credibility seemed good.  There was no evidence for potential self-injury, suicide, or violence.  The reliability and completeness of information was very good, and there were no barriers to communication.  The information gathered was based on the patient's self-report and objective testing and observation.  His attitude toward the examiner was neutral and his attitude toward the examination process was neutral.  There was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings, and there was no lack of cooperation with the evaluation or poor compliance with treatment, and no evidence of antisocial personality disorder.,IMPRESSIONS: , Major Depressive Disorder, single episode,RECOMMENDATIONS AND PLAN: , I recommend Mr. T continue with psychopharmacologic care as well as psychotherapy.  At this time, the excessive amount of psychiatric symptoms would impede Mr. T from seeking employment.  Furthermore, it appears that the primary precipitating event had occurred on March 25, 2003, when Mr. T was fired from his job after being harassed for over a year.  As Mr. T placed his entire identity and sense of survival on his work, this was a deafening blow to his psychological functioning.  Furthermore, it only appears logical that this would precipitate a major depressive episode.",18
"PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSES: , Dysphagia, possible stricture.,POSTOPERATIVE DIAGNOSIS: , Gastroparesis.,MEDICATION: , MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum.  The hypopharynx was normal.  The esophagus had a normal upper esophageal sphincter, normal contour throughout, and a normal gastroesophageal junction viewed at 39 cm from the incisors.  There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair.  There was no sign of reflux esophagitis.  On entering the gastric lumen, a large bezoar of undigested food was seen occupying much of the gastric fundus and body.  It had 2 to 3 mm diameter.  This was broken up using a scope into smaller pieces.  There was no retained gastric liquid.  The antrum appeared normal and the pylorus was patent.  The scope passed easily into the duodenum, which was normal through the second portion.  On withdrawal of the scope, additional views of the cardia were obtained, and there was no evidence of any tumor or narrowing.  The scope was withdrawn.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Normal postoperative hernia repair.,2.  Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.,3.  Otherwise normal upper endoscopy to the descending duodenum.,RECOMMENDATIONS:,1.  Continue proton pump inhibitors.,2.  Use Reglan 10 mg three to four times a day.",37
"HISTORY: , A 34-year-old male presents today self-referred at the recommendation of Emergency Room physicians and his nephrologist to pursue further allergy evaluation and treatment.  Please refer to chart for history and physical, as well as the medical records regarding his allergic reaction treatment at ABC Medical Center for further details and studies.  In summary, the patient had an acute event of perioral swelling, etiology uncertain, occurring on 05/03/2008 requiring transfer from ABC Medical Center to XYZ Medical Center due to a history of renal failure requiring dialysis and he was admitted and treated and felt that his allergy reaction was to Keflex, which was being used to treat a skin cellulitis dialysis shunt infection.  In summary, the patient states he has some problems with tolerating grass allergies, environmental and inhalant allergies occasionally, but has never had anaphylactic or angioedema reactions.  He currently is not taking any medication for allergies.  He is taking atenolol for blood pressure control.  No further problems have been noted upon his discharge and treatment, which included corticosteroid therapy and antihistamine therapy and monitoring.,PAST MEDICAL HISTORY:,  History of urticaria, history of renal failure with hypertension possible source of renal failure, history of dialysis times 2 years and a history of hypertension.,PAST SURGICAL HISTORY:,  PermCath insertion times 3 and peritoneal dialysis.,FAMILY HISTORY: , Strong for heart disease, carcinoma, and a history of food allergies, and there is also a history of hypertension.,CURRENT MEDICATIONS: , Atenolol, sodium bicarbonate, Lovaza, and Dialyvite.,ALLERGIES: , Heparin causing thrombocytopenia.,SOCIAL HISTORY: , Denies tobacco or alcohol use.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Age 34, blood pressure 128/78, pulse 70, temperature is 97.8, weight is 207 pounds, and height is 5 feet 7 inches.,GENERAL:  The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,HEAD:  Normocephalic.  No masses or lesions noted.,FACE:  No facial tenderness or asymmetry noted.,EYES:  Pupils are equal, round and reactive to light and accommodation bilaterally.  Extraocular movements are intact bilaterally.,EARS:  The tympanic membranes are intact bilaterally with a good light reflex.  The external auditory canals are clear with no lesions or masses noted.  Weber and Rinne tests are within normal limits.,NOSE:  The nasal cavities are patent bilaterally.  The nasal septum is midline.  There are no nasal discharges.  No masses or lesions noted.,THROAT:  The oral mucosa appears healthy.  Dental hygiene is maintained well.  No oropharyngeal masses or lesions noted.  No postnasal drip noted.,NECK:  The neck is supple with no adenopathy or masses palpated.  The trachea is midline.  The thyroid gland is of normal size with no nodules.,NEUROLOGIC:  Facial nerve is intact bilaterally.  The remaining cranial nerves are intact without focal deficit.,LUNGS:  Clear to auscultation bilaterally.  No wheeze noted.,HEART:  Regular rate and rhythm.  No murmur noted.,IMPRESSION:  ,1.  Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.,2.  Renal failure requiring dialysis.,3.  Hypertension.,RECOMMENDATIONS:  ,RAST allergy testing for both food and environmental allergies was performed, and we will get the results back to the patient with further recommendations to follow.  If there is any specific food or inhalant allergen that is found to be quite high on the sensitivity scale, we would probably recommend the patient to avoid the offending agent to hold off on any further reactions.  At this point, I would recommend the patient stopping any further use of cephalosporin antibiotics, which may be the cause of his allergic reaction, and I would consider this an allergy.  Being on atenolol, the patient has a more difficult time treating acute anaphylaxis, but I do think this is medically necessary at this time and hopefully we can find specific causes for his allergic reactions.  An EpiPen was also prescribed in the event of acute angioedema or allergic reaction or sensation of impending allergic reaction and he is aware he needs to proceed directly to the emergency room for further evaluation and treatment recommendations after administration of an EpiPen.",5
"PREOPERATIVE DIAGNOSIS: , Ruptured distal biceps tendon, right elbow.,POSTOPERATIVE DIAGNOSIS:,  Ruptured distal biceps tendon, right elbow.,PROCEDURE PERFORMED: , Repair of distal biceps tendon, right elbow.,PROCEDURE:  ,The patient was taken to OR, Room #2 and administered a general anesthetic.  The right upper extremity was then prepped and draped in the usual manner.  A sterile tourniquet was placed on the proximal aspect of the right upper extremity.  The extremity was then elevated and exsanguinated with an Esmarch bandage and tourniquet was inflated to 250 mmHg.  Tourniquet time was 74 minutes.  A curvilinear incision was made in the antecubital fossa of the right elbow down through the skin.  Hemostasis was achieved utilizing electrocautery.  Subcutaneous fat was separated and the skin flaps elevated.  The _________ was identified.  It was incised.  The finger was placed approximately up the anterior aspect of the arm and the distal aspect of the biceps tendon was found.  There was some serosanguineous fluid from the previous rupture.  This area was suctioned clean.  The biceps tendon ends were then placed over a sterile tongue blade and were then sharply cut approximately 5 mm to 7 mm from the tip to create a fresh surface.  At this point, the #2 fiber wire was then passed through the tendon.  Two fiber wires were utilized in a Krackow-type suture.  Once this was completed, dissection was taken digitally down into the antecubital fossa in the path where the biceps tendon had been previously.  The radial tuberosity was palpated.  Just ulnar to this, a curved hemostat was passed through the soft tissues and was used to tent the skin on the radial aspect of the elbow.  A skin incision was made over this area.  Approximately two inches down to the skin and subcutaneous tissues, the fascia was split and the extensor muscle was also split.,A stat was then attached through the tip of that stat and passed back up through the antecubital fossa.  The tails of the fiber wire suture were grasped and pulled down through the second incision.  At this point, they were placed to the side.  Attention was directed at exposure of the radial tuberosity with a forearm fully pronated.  The tuberosity came into view.  The margins were cleared with periosteal elevator and sharp dissection.  Utilizing the power bur, a trough approximately 1.5 cm wide x 7 mm to 8 mm high was placed in the radial tuberosity.  Three small drill holes were then placed along the margin for passage of the suture.  The area was then copiously irrigated with gentamicin solution.  A #4-0 pullout wire was utilized to pass the sutures through the drill holes, one on each outer hole and two in the center hole.  The elbow was flexed and the tendon was then pulled into the trough with the forearm supinated.  The suture was tied over the bone islands.  Both wounds were then copiously irrigated with gentamicin solution and suctioned dry.  Muscle fascia was closed with running #2-0 Vicryl suture on the lateral incision followed by closure of the skin with interrupted #2-0 Vicryl and small staples.  The anterior incision was approximated with interrupted #2-0 Vicryl for Subq. and then skin was approximated with small staples.  Both wounds were infiltrated with a total of 30 cc of 0.25% Marcaine solution for postop analgesia.  A bulky fluff dressing was applied to the elbow, followed by application of a long-arm plaster splint maintaining the forearm in the supinated position.  Tourniquet was inflated prior to application of the splint.  Circulatory status returned to the extremity immediately.  The patient was awakened.  He was rather boisterous during his awakening, but care was taken to protect the right upper extremity.  He was then transferred to the recovery room in apparent satisfactory condition.",37
"PROCEDURE:,  Laparoscopic cholecystectomy.,DISCHARGE DIAGNOSES:,1.  Acute cholecystitis.,2.  Status post laparoscopic cholecystectomy.,3.  End-stage renal disease on hemodialysis.,4.  Hyperlipidemia.,5.  Hypertension.,6.  Congestive heart failure.,7.  Skin lymphoma 5 years ago.,8.  Hypothyroidism.,HOSPITAL COURSE: , This is a 78-year-old female with past medical condition includes hypertension, end-stage renal disease, hyperlipidemia, hypothyroidism, and skin lymphoma who had a left AV fistula done about 3 days ago by Dr. X and the patient went later on home, but started having epigastric pain and right upper quadrant pain and mid abdominal pain, some nauseated feeling, and then she could not handle the pain, so came to the emergency room, brought by the family.  The patient's initial assessment, the patient's vital signs were stable, showed temperature 97.9, pulse was 106, and blood pressure was 156/85.  EKG was not available and ultrasound of the abdomen showed there is a renal cyst about 2 cm.  There is sludge in the gallbladder wall versus a stone in the gallbladder wall.  Thickening of the gallbladder wall with positive Murphy sign.  She has a history of cholecystitis.  Urine shows positive glucose, but negative for nitrite and creatinine was 7.1, sodium 131, potassium was 5.2, and lipase and amylase were normal.  So, the patient admitted to the Med/Surg floor initially and the patient was started on IV fluid as well as low-dose IV antibiotic and 2-D echocardiogram and EKG also was ordered.  The patient also had history of CHF in the past and recently had some workup done.  The patient does not remember initially.  Surgical consult also requested and blood culture and urine culture also ordered.  The same day, the patient was seen by Dr. Y and the patient should need cholecystectomy, but the patient also needs dialysis and also needs to be cleared by the cardiologist, so the patient later on seen by Dr. Z and cleared the patient for the surgery with moderate risk and the patient underwent laparoscopic cholecystectomy.  The patient also seen by nephrologist and underwent dialysis.  The patient's white count went down 6.1, afebrile.  On postop day #1, the patient started eating and also walking.  The patient also had chronic bronchitis.  The patient was later on feeling fine, discussed with surgery.  The patient was then able to discharge to home and follow with the surgeon in about 3-5 days.  Discharged home with Synthroid 0.5 mg 1 tablet p.o. daily, Plavix 75 mg p.o. daily, folic acid 1 mg p.o. daily, Diovan 80 mg p.o. daily, Renagel 2 tablets 800 mg p.o. twice a day, Lasix 40 mg p.o.  2 tablets twice a day, lovastatin 20 mg p.o. daily, Coreg 3.125 mg p.o. twice a day, nebulizer therapy every 3 hours as needed, also Phenergan 25 mg p.o. q.8 hours for nausea and vomiting, Pepcid 20 mg p.o. daily, Vicodin 1 tablet p.o. q.6 hours p.r.n. as needed, and Levaquin 250 mg p.o. every other day for the next 5 days.  The patient also had Premarin that she was taking, advised to discontinue because of increased risk of heart disease and stroke explained to the patient.  Discharged home.",10
"REASON FOR REFERRAL:  ,The patient was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.,BRIEF SUMMARY & IMPRESSIONS:,RELEVANT HISTORY:,Historical information was obtained from a review of available medical records and an interview with ,the patient.,The patient presented to Dr. X on August 05, 2008 as she had been recently hospitalized for prolonged episodes of syncope.  She was referred to Dr. X for diagnostic differentiation for possible seizures or other causes of syncope.  The patient reports an extensive neurological history.  Her mother used alcohol during her pregnancy with the patient.  In spite of exposure to alcohol in utero, the patient reported that she achieved ""honors in school"" and ""looked smart.""  She reported that she began to experience migraines at 11 years of age.  At 15 years of age, she reported that she was thought to have hydrocephalus.  She reported that she will frequently ""bang her head against the wall"" to relieve the pain.  The patient gave birth to her daughter at 17 years of age.  At 18 years of age, she received a spinal tap as a procedure to determine the cause of her severe headaches.  She reported, in 1995 to 1996 she experienced a severe head injury, as she was struck by a car as a pedestrian and ""thrown two and a half city blocks.""  The patient reported that she could recall before being hit, but could not recall the activities of that same day or the following day.  She reported that she had difficulty walking following this head injury, but received rehabilitation for approximately one month.  Her migraines became more severe following the head injury.  In 1998, she reportedly was experiencing episodes of syncope where she would experience a headache with photophobia, phonophobia, and flashing lights.  Following the syncope episode, she would experience some confusion.  These episodes reportedly were related to her donating plasma.,The patient also reported that her ex-husband stated that she frequently jerked and would shake in her sleep.  She reported that upon awakening, she would feel off balanced and somewhat confused.  These episodes diminished from 2002 to June 2008.  When making dinner, she suddenly dropped and hit the back of her head on refrigerator.  She reported that she was unconscious for five to six minutes.  A second episode occurred on July 20th when she lost consciousness for may be a full day.  She was admitted to Sinai Hospital and assessed by a neurologist.  Her EEG and head CT were considered to be completely normal.  She did not report any typical episodes during the time of her 36-hour EEG.  She reported that her last episode of syncope occurred prior to her being hospitalized.  She stated that she had an aura of her ears ringing, vision being darker and ""tunnel vision"" (vision goes smaller to a pinpoint), and she was ""spazzing out"" on the floor.  During these episodes, she reports that she cannot talk and has difficulty understanding.,The patient also reports that she has experienced some insomnia since she was 6 years old.  She reported that she was a heavy drinker until about 1998 or 1999 and that she would drink a gallon daily of Jack Daniel.  She stopped the use of alcohol and that time she experienced a suicide attempt.  In 2002, she was diagnosed with bipolar disorder and was started on medication.  At the time of the neuropsychological evaluation, she had stopped taking her medicine as she felt that she was now in remission and could manage her symptoms herself.  The patient's medical history is also significant for postpartum depression.,The patient reported that she has been experiencing difficulty with cognitive abilities of attention/concentration, spelling, tangential and slow thinking, poor sequencing memory for events, and variable verbal memory.  She reported that she sometimes has difficulty understanding what people say, specifically she has difficulty understanding jokes.  She finds that she often has difficulty with expressing her thoughts, as she is very tangential.  She experiences episodes of not recalling what she was speaking of or remembering what activities she was trying to perform.  She reported that she had a photographic memory for directions.  She said that she experienced a great deal of emotional lability, but in general her personality has become more subdued.  At the present time, her daughter has now moved on to college.  The patient is living with her biological mother.  Although she is going through divorce, she reported that it was not really stressful.  She reported that she spends her day driving other people around and trying to be helpful to them.,At the time of the neuropsychological evaluation, the patient's medication included Ativan, Imitrex, Levoxyl, vitamin B12, albuterol metered dose inhaler as needed, and Zofran as needed.  (It should be noted that The patient by the time of the feedback on September 19, 2008 had resumed taking her Trileptal for bipolar disorder.).  The patient's familial medical history is significant for alcohol abuse, diabetes, hypertension, and high cholesterol.,TESTS ADMINISTERED:,Clinical Interview,Cognistat,Mattis Dementia Rating Scale,Wechsler Adult Intelligence Scale - III (WAIS-III),Wechsler Abbreviated Scale of Intelligence (WASI),Selected Subtests from the Delis Kaplan Executive Function System (DKEFS),  Trail Making Test,  Verbal Fluency (Letter Fluency & Category Fluency),  Design Fluency,  Color-Word Interference Test,  Tower,Wisconsin Card Sorting Test (WCST),Stroop Test,Color Trails,Trails A & B,Test of Variables of Attention,Multilingual Aphasia Examination II,  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test-2 (BNT-2),Animal Naming Test,The Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI),The Beery-Buktenica Developmental Test of Motor Coordination,The Beery-Buktenica Developmental Test of Visual Perception,Judgment Line Orientation,Grooved Pegboard,Purdue Pegboard,Finger Tapping Test,Rey Complex Figure,Wechsler Memory Scale -III (WMS-III),California Verbal Learning Test",22
"IDENTIFYING DATA:,  The patient is a 36-year-old Caucasian male.,CHIEF COMPLAINT:,  The patient relates that he originally came to this facility because of failure to accomplish task, difficulty saying what he wanted to say, and being easily distracted.,HISTORY OF PRESENT ILLNESS:,  The patient has been receiving services at this facility previously, under the care of ABC, M.D., and later XYZ, M.D.  Historically, he has found it very easy to be distracted in the ""cubicle"" office setting where he sometimes works.  He first remembers having difficulty with concentration in college, but his mother has pointed out to him that at some point in his early education, one teacher commented that he may have problems with attention-deficit hyperactivity disorder.  Symptoms have included difficulty sustaining attention (especially in reading), not seeming to listen one spoke into directly, failure to finish task, difficulty with organization, avoiding task requiring sustained mental effort, losing things, being distracted by extraneous stimuli, being forgetful.  In the past, probably in high school, the patient recalled being more figidity than now.  He tensed to feel anxious.  Sleep has been highly variable.  He will go for perhaps months at a time with middle insomnia and early morning awakening (3:00 a.m.), and then may sleep well for a month.  Appetite has been good.  He has recently gained about 15 pounds, but notes that he lost about 30 pounds during the time he was taking Adderall.  He tends to feel depressed.  His energy level is ""better now,"" but this was very problematic in the past.  He has problems with motivation.  In the past, he had passing thoughts of suicide, but this is no longer a problem.,PSYCHIATRIC HISTORY:,  The patient has never been hospitalized for psychiatric purposes.  His only treatment has been at this facility.  He tried Adderall for a time, and it helped, but he became hypertensive.  Lunesta is effective for his insomnia issues.  Effexor has helped to some degree.  He has been prescribed Provigil, as much as 200 mg q.a.m., but has been cutting it down to 100 mg q.a.m. with some success.  He sometimes takes the other half of the tablet in the afternoon.",32
"Pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete, and then as she began to push, there were additional decelerations of the baby's heart rate, which were suspicions of cord around the neck.  These were variable decelerations occurring late in the contraction phase.  The baby was in a +2 at a 3 station in an occiput anterior position, and so a low-forceps delivery was performed with Tucker forceps using gentle traction, and the baby was delivered with a single maternal pushing effort with retraction by the forceps.  The baby was a little bit depressed at birth because of the cord around the neck, and the cord had to be cut before the baby was delivered because of the tension, but she responded quickly to stimulus and was given an Apgar of 8 at 1 minute and 9 at 5 minutes.  The female infant seemed to weigh about 7.5 pounds, but has not been officially weighed yet.  Cord gases were sent and the placenta was sent to Pathology.  The cervix, the placenta, and the rectum all seemed to be intact.  The second-degree episiotomy was repaired with 2-O and 3-0 Vicryl.  Blood loss was about 400 mL.,Because of the hole in the dura, plan is to keep the patient horizontal through the day and a Foley catheter is left in place.  She is continuing to be attended to by the anesthesiologist who will manage the epidural catheter.  The baby's father was present for the delivery, as was one of the patient's sisters.  All are relieved and pleased with the good outcome.",24
"REPORT:,  The electroencephalogram shows background activity at about 9-10 cycle/second bilaterally.  Little activity in the beta range is noted.  Waves of 4-7 cycle/second of low amplitude were occasionally noted.  Abundant movements and technical artifacts are noted throughout this tracing.  Hyperventilation was not performed.  Photic stimulation reveals no important changes.,CLINICAL INTERPRETATION:,  The electroencephalogram is essentially normal.",22
"PREOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,POSTOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,PROCEDURES:,1.  Left abdominal flap 5 x 5 cm to left forearm.,2.  Debridement of skin, subcutaneous tissue, muscle, and bone.,3.  Closure of wounds, simple closure approximately 8 cm.,4.  Placement of VAC negative pressure wound dressing.,INDICATIONS: , This 3-year-old male suffered amputation of his left upper extremity with complications of injury.  He presents at this time for further attempts at closure.,OPERATIVE FINDINGS: , A clean wound to left upper extremity with partial dehiscence of previously closed wounds and also the closure was satisfactory.,DESCRIPTION OF PROCEDURE: , Under inhalational anesthesia, he was prepped and draped in usual fashion exposing left upper extremity and also exposing continuity of the left abdomen, chest, and groin.  He underwent systematic evaluation of his wound of his left upper extremity and we excised first the whole wound prior to doing some additional closure.  Some areas were dehisced and appeared to be because it was approximation of granulation tissue and as a result the edges were freshened up prior to approximating them.  In this fashion, simple closure was accomplished and its total length was approximately 8 cm.  It should be noted that prior to doing any procedure that appropriate timeout was performed and he received prophylactic antibiotics as indicated and did not require DVT prophylaxis.  At this time, once we accomplished debridement and simple closure removing skin, subcutaneous tissue, muscle and bone as well as closing the arm, we could design our flap for the abdomen.  The flap was designed as a slightly greater than 1:1 ellipse of skin from just below the costal margin.  This was elevated at the level of the external oblique and then laid on the left forearm.  The donor's site was closed using interrupted 4-0 Vicryl in the deep dermis and running subcuticular 4-0 Monocryl on the skin.  Steri-Strips were applied.  At this time, the flap was inset using again 4-0 Monocryl sutures and then ultimately the VAC negative pressure wound dressing was applied to help hold this in place and optimize the vascularization of the flap.  The patient tolerated the procedure well and he returned to the recovery room in satisfactory condition.",37
"PREOPERATIVE DIAGNOSIS: , Achilles tendon rupture, left lower extremity.,POSTOPERATIVE DIAGNOSIS: , Achilles tendon rupture, left lower extremity.,PROCEDURE PERFORMED:,  Primary repair left Achilles tendon.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME:  ,40 minutes at 325 mmHg.,POSITION:,  Prone.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 26-year-old African-American male who states that he was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg.  The patient was placed in posterior splint and followed up at ABC orthopedics for further care.,PROCEDURE:,  After all potential complications, risks, as well as anticipated benefits of the above-named procedure were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the patient, the operative surgeon, Department Of Anesthesia, and nursing staff.  While in this hospital, the Department Of Anesthesia administered general anesthetic to the patient.  The patient was then transferred to the operative table and placed in the prone position.  All bony prominences were well padded at this time.,A nonsterile tourniquet was placed on the left upper thigh of the patient, but not inflated at this time.  Left lower extremity was sterilely prepped and draped in the usual sterile fashion.  Once this was done, the left lower extremity was elevated and exsanguinated using an Esmarch and the tourniquet was inflated to 325 mmHg and kept up for a total of 40 minutes.  After all bony and soft tissue land marks were identified, a 6 cm longitudinal incision was made paramedial to the Achilles tendon from its insertion proximal.  Careful dissection was then taken down to the level of the peritenon.  Once this was reached, full thickness flaps were performed medially and laterally.  Next, retractor was placed.  All neurovascular structures were protected.  A longitudinal incision was then made in the peritenon and opened up exposing the tendon.  There was noted to be complete rupture of the tendon approximately 4 cm proximal to the insertion point.  The plantar tendon was noted to be intact.  The tendon was debrided at this time of hematoma as well as frayed tendon.  Wound was copiously irrigated and dried.  Most of the ankle appeared that there was sufficient tendon links in order to do a primary repair.  Next #0 PDS on a taper needle was selected and a Krackow stitch was then performed.  Two sutures were then used and tied individually ________ from the tendon.  The tendon came together very well and with a tight connection.  Next, a #2-0 Vicryl suture was then used to close the peritenon over the Achilles tendon.  The wound was once again copiously irrigated and dried.  A #2-0 Vicryl sutures were then used to close the skin and subcutaneous fashion followed by #4-0 suture in the subcuticular closure on the skin.  Steri-Strips were then placed over the wound and the sterile dressing was applied consisting of 4x4s, Kerlix roll, sterile Kerlix and a short length fiberglass cast in a plantar position.  At this time, the Department of anesthesia reversed the anesthetic.  The patient was transferred back to hospital gurney to the Postanesthesia Care Unit.  The patient tolerated the procedure well.  There were no complications.",37
"PREOPERATIVE DIAGNOSIS:,  12 week incomplete miscarriage.,POSTOPERATIVE DIAGNOSIS: , 12 week incomplete miscarriage.,OPERATION PERFORMED: , Dilation and evacuation.,ANESTHESIA: , General.,OPERATIVE FINDINGS:  ,The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue.  The fetus of 12 week had been delivered previously by Dr. X in the ER.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,COMPLICATIONS:  ,None.,SPONGE AND NEEDLE COUNT: , Correct.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room placed in the operating table in supine position.  After adequate anesthesia, the patient was placed in dorsal lithotomy position.  The vagina was prepped.  The patient was then draped.  A speculum was placed in the vagina.  Previously mentioned products of conception were teased out with a ring forceps.  The anterior lip of the cervix was then grasped with a ring forceps as well and with a 10-mm suction curette multiple curettages were performed removing fairly large amount of tissue for a 12-week pregnancy.  A sharp curettage then was performed and followed by two repeat suction curettages.  The procedure was then terminated and the equipment removed from the vagina, as well as the speculum.  The patient tolerated the procedure well.  Blood type is Rh negative.  We will see the patient back in my office in 2 weeks.",37
"EXAM: , CT cervical spine.,REASON FOR EXAM: , MVA, feeling sleepy, headache, shoulder and rib pain.,TECHNIQUE:,  Axial images through the cervical spine with coronal and sagittal reconstructions.,FINDINGS:,  There is reversal of the normal cervical curvature at the vertebral body heights.  The intervertebral disk spaces are otherwise maintained.  There is no prevertebral soft tissue swelling.  The facets are aligned.  The tip of the clivus and occiput appear intact.  On the coronal reconstructed sequence, there is satisfactory alignment of C1 on C2, no evidence of a base of dens fracture.,The included portions of the first and second ribs are intact.  There is no evidence of a posterior element fracture.  Included portions of the mastoid air cells appear clear.  There is no CT evidence of a moderate or high-grade stenosis.,IMPRESSION: , No acute process, cervical spine.",33
"PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma, left nasal cavity.,POSTOPERATIVE DIAGNOSIS:,  Squamous cell carcinoma, left nasal cavity.,OPERATIONS PERFORMED:,1.  Nasal endoscopy.,2.  Partial rhinectomy.,ANESTHESIA:,  General endotracheal.,INDICATIONS: , This is an 81-year-old gentleman who underwent septorhinoplasty many years ago.  He also has a history of a skin lesion, which was removed from the nasal ala many years ago, the details of which he does not recall.  He has been complaining of tenderness and induration of his nasal tip for approximately two years and has been treated unsuccessfully for folliculitis and cellulitis of the nasal tip.  He was evaluated by Dr. A, who performed the septorhinoplasty, and underwent an intranasal biopsy, which showed histologic evidence of invasive squamous cell carcinoma.  The preoperative examination shows induration of the nasal tip without significant erythema.  There is focal tenderness just cephalad to the alar crease.  There is no lesion either externally or intranasally.,PROCEDURE AND FINDINGS: , The patient was taken to the operating room and placed in supine position.  Following induction of adequate general endotracheal anesthesia, the left nose was decongested with Afrin.  He was prepped and draped in standard fashion.  The left nasal cavity was examined by anterior rhinoscopy.  The septum was midline.  There was slight asymmetry of the nares.  No lesion was seen within the nasal cavity either in the area of the intercartilaginous area, which was biopsied by Dr. A, the septum, the lateral nasal wall, and the floor.  The 0-degree nasal endoscope was then used to examine the nasal cavity more completely.  No lesion was detectable.  A left intercartilaginous incision was made with a #15 blade since this was the area of previous biopsy by Dr. A.  The submucosal tissue was thickened diffusely, but there was no identifiable distinct or circumscribed lesion present.  Random biopsies of the submucosal tissue were taken and submitted to pathology for frozen section.  A diagnosis of diffuse invasive squamous cell carcinoma was rendered.  An alar incision was made with a #15 blade and the full-thickness incision was completed with the electrocautery.  The incision was carried more cephalad through the lower lateral cartilage up to the area of the upper lateral cartilage at the superior margin.  The full unit of the left nasal tip was excised completely and submitted to pathology after tagging and labeling it.  Frozen section examination again revealed diffuse squamous cell carcinoma throughout the soft tissues involving all margins.  Additional soft tissue was then taken from all margins tagging them for the pathologist.  The inferior margins were noted to be clear on the next frozen section report, but there was still disease present in the region of the upper lateral cartilage at its insertion with the nasal bone.  A Joseph elevator was used to elevate the periosteum off the maxillary process and off the inferior aspect of the nasal bone.  Additional soft tissue was taken in these regions along the superior margin.  The frozen section examination revealed persistent disease medially and additional soft tissue was taken and submitted to pathology.  Once all margins had been cleared histologically, additional soft tissue was taken from the entire wound.  A 5-mm chisel was used to take down the inferior aspect of the nasal bone and the medial-most aspect of the maxilla.  This was all submitted to pathology for routine permanent examination.  Xeroform gauze was then fashioned to cover the defect and was sutured along the periphery of the wound with interrupted 6-0 nylon suture to provide a barrier and moisture.  The anesthetic was then discontinued as the patient was extubated and transferred to the PACU in good condition having tolerated the procedure well.  Sponge and needle counts were correct.",37
"PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,OPERATIVE PROCEDURE PERFORMED:,  Left carpal tunnel release.,FINDINGS:,  Showed severe compression of the median nerve on the left at the wrist.,SPECIMENS:  ,None.,FLUIDS:,  500 mL of crystalloids.,URINE OUTPUT:,  No Foley catheter.,COMPLICATIONS: , None.,ANESTHESIA: , General through a laryngeal mask.,ESTIMATED BLOOD LOSS: , None.,CONDITION: , Resuscitated with stable vital signs.,INDICATION FOR THE OPERATION: , This is a case of a very pleasant 65-year-old forensic pathologist who I previously had performed initially a discectomy and removal of infection at 6-7, followed by anterior cervical discectomy with anterior interbody fusion at C5-6 and C6-7 with spinal instrumentation.  At the time of initial consultation, the patient was also found to have bilateral carpal tunnel and for which we are addressing the left side now.  Operation, expected outcome, risks, and benefits were discussed with him for most of the risk would be that of infection because of the patient's diabetes and a previous history of infection in the form of pneumonia.  There is also the possibility of bleeding as well as the possibility of injury to the median nerve on dissection.  He understood this risk and agreed to have the procedure performed.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress.  After smooth induction of anesthesia and placement of a laryngeal mask, he remained supine on the operating table.  The left upper extremity was then prepped with Betadine soap and antiseptic solution.  After sterile drapes were laid out, an incision was made following inflation of blood pressure cuff to 250 mmHg.  Clamp time approximately 30 minutes.  An incision was then made right in the mid palm area between the thenar and hypothenar eminence.  Meticulous hemostasis of any bleeders were done.  The fat was identified.  The palmar aponeurosis was identified and cut and this was traced down to the wrist.  There was severe compression of the median nerve.  Additional removal of the aponeurosis was performed to allow for further decompression.  After this was all completed, the area was irrigated with saline and bacitracin solution and closed as a single layer using Prolene 4-0 as interrupted vertical mattress stitches.  Dressing was applied.  The patient was brought to the recovery.",37
"CHIEF COMPLAINT (1/1): , This 19 year old female presents today complaining of acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use.  Location:  She indicates the problem location is the chin, right temple and left temple locally.  Severity:  Severity of condition is worsening.,Menses:  Onset:  13 years old.  Interval:  22-27 days.  Duration:  4-6 days.  Flow:  light.  Complications:  none.,ALLERGIES: , Patient admits allergies to penicillin resulting in difficulty breathing.,MEDICATION HISTORY:,  Patient is currently taking Alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001 medication was prescribed by Obstetrician-Gynecologist A.,PAST MEDICAL HISTORY:,  Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles.,PAST SURGICAL HISTORY:,  No previous surgeries.,FAMILY HISTORY: , Patient admits a family history of anxiety, stress disorder associated with mother.,SOCIAL HISTORY:,  Patient admits caffeine use She consumes 3-5 servings per day, Patient admits alcohol use Drinking is described as social, Patient admits good diet habits, Patient admits exercising regularly, Patient denies STD history.,REVIEW OF SYSTEMS:,  Integumentary: (+) periodic reddening of face, (+) acne problems, Allergic /,Immunologic: (-) allergic or immunologic symptoms, Constitutional Symptoms: (-) constitutional symptoms,such as fever, headache, nausea, dizziness.,PHYSICAL EXAM:,  Patient is a 19 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.  Skin:  Examination of scalp shows no abnormalities.  Hair growth and distribution is normal.  Inspection of skin outside of affected area reveals no abnormalities.  Palpation of skin shows no abnormalities.  Inspection of eccrine and apocrine glands shows no evidence of hyperidrosis, chromidrosis or bromhidrosis.  Face shows keratotic papule.,IMPRESSION:,  Acne vulgaris.,PLAN:,  Recommended treatment is antibiotic therapy.  Patient received extensive counseling about acne.  She understands acne treatment is usually long-term.  Return to clinic in 4 week (s).,PATIENT INSTRUCTIONS:,  Patient received literature regarding acne vulgaris.  Discussed with the patient the prescription for Tetracycline and handed out information regarding the side effects and the proper method of ingestion.,PRESCRIPTIONS:,  Tetracycline  Dosage:  250 mg capsule  Sig:  BID  Dispense:  60  Refills:  0  Allow Generic:  Yes",5
"REASON FOR EXAM:  ,Left arm and hand numbness.,TECHNIQUE: , Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.,FINDINGS:  ,There is an approximately 5-mm shift of the midline towards the right side.  Significant low attenuation is seen throughout the white matter of the right frontal, parietal, and temporal lobes.  There is loss of the cortical sulci on the right side.  These findings are compatible with edema.  Within the right parietal lobe, a 1.8 cm, rounded, hyperintense mass is seen.,No hydrocephalus is evident.,The calvarium is intact.  The visualized paranasal sinuses are clear.,IMPRESSION:  ,A 5 mm midline shift to the left side secondary to severe edema of the white matter of the right frontal, parietal, and temporal lobes.  A 1.8 cm high attenuation mass in the right parietal lobe is concerning for hemorrhage given its high density.  A postcontrast MRI is required for further characterization of this mass.  Gradient echo imaging should be obtained.",22
"TITLE OF OPERATION:,  Completion thyroidectomy with limited right paratracheal node dissection.,INDICATION FOR SURGERY:,  A 49-year-old woman with a history of a left dominant nodule in her thyroid gland, who subsequently underwent left thyroid lobectomy and isthmusectomy, was found to have multifocal papillary thyroid carcinoma throughout her left thyroid lobe and isthmus.  Consideration given to completion thyroidectomy.  Risks, benefits, and alternatives of this procedure was discussed with the patient in great detail.  Risks included but were not limited to anesthesia, bleeding, infection, injury to nerves including vocal fold paralysis, hoarseness, low calcium, scar, cosmetic deformity, need for thyroid hormone replacement, and also need for further management.  The patient understood all of this and then wished to proceed.,PREOP DIAGNOSIS:,  Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen.,POSTOP DIAGNOSIS: , Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen.,PROCEDURE DETAIL:,  After identifying the patient, the patient was placed supine in the operating room table.  After establishment of general anesthesia via orotracheal intubation with a number 6 nerve integrity monitoring system endotracheal tube, the eyes were protected with Tegaderm.  Nerve integrity monitoring system endotracheal tube was confirmed to be working adequately and secured.  The previous skin incision for a thyroidectomy was then planned, then incorporated into an ellipse.  The patient was prepped and draped in a sterile fashion.  Subsequently, the ellipse around the previous incision was deformed.  The scar was then excised.  Subplatysmal flaps were raised to the thyroid notch and sternal notch respectively.  Strap muscles were isolated in the midline and dissected and mobilized from the thyroid lobe on the right side.  There was some dense fibrosis and inflammation surrounding the right thyroid lobe.  Careful dissection along the thyroid lobe allowed for identification of the superior thyroid artery and vein which were individually ligated with a Harmonic scalpel.  The right inferior and superior parathyroid glands were identified and preserved and recurrent laryngeal nerve was identified and traced superiorly, then preserved.  Of note is that there were multiple lymph nodes in the paratracheal region on the right side.  These lymph nodes were carefully dissected away from the recurrent laryngeal nerve, trachea, and the carotid artery, and sent as a separate specimen labeled right paratracheal lymph nodes.  The wound was copiously irrigated.  Valsalva maneuver was given.  Surgicel was placed in the wound bed.  Strap muscles were reapproximated in the midline with 3-0 Vicryl and incision was then closed with interrupted 3-0 Vicryl and Indermil for the skin.  The patient was extubated in the operating room table, sent to the postanesthesia care unit in good condition.",37
"PREOPERATIVE DIAGNOSIS:,  Endometrial carcinoma.,POSTOPERATIVE DIAGNOSIS: , Endometrial carcinoma.,PROCEDURE PERFORMED:,  Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology; uterus with attached right tube and ovary; pelvic and paraaortic lymph node dissection; obturator lymph node dissection.,INDICATIONS FOR PROCEDURE: , The patient was recently found to have a grade II endometrial cancer.  She was counseled to undergo laparoscopic staging.,FINDINGS:,  During the laparoscopy, the uterus was noted to be upper limits of normal size, with a normal-appearing right fallopian tubes and ovaries.  No ascites was present.  On assessment of the upper abdomen, the stomach, diaphragm, liver, gallbladder, spleen, omentum, and peritoneal surfaces of the bowel, were all unremarkable in appearance.,PROCEDURE: , The patient was brought into the operating room with an intravenous line in placed, and anesthetic was administered.  She was placed in a low anterior lithotomy position using Allen stirrups.  The vaginal portion of the procedure included placement of a ZUMI uterine manipulator with a Koh colpotomy ring and a vaginal occluder balloon.,The laparoscopic port sites were anesthetized with intradermal injection of 0.25% Marcaine.  There were five ports placed, including a 3-mm left subcostal port, a 10-mm umbilical port, a 10-mm suprapubic port, and 5-mm right and left lower quadrant ports.  The Veress needle was placed through a small incision at the base of the umbilicus, and a pneumoperitoneum was insufflated without difficulty.  The 3-mm port was then placed in the left subcostal position without difficulty, and a 3-mm scope was placed.  There were no adhesions underlying the previous vertical midline scar.  The 10-mm port was placed in the umbilicus, and the laparoscope was inserted.  Remaining ports were placed under direct laparoscopic guidance.  Washings were obtained from the pelvis, and the abdomen was explored with the laparoscope, with findings as noted.,Attention was then turned to lymphadenectomy.  An incision in the retroperitoneum was made over the right common iliac artery, extending up the aorta to the retroperitoneal duodenum.  The lymph node bundle was elevated from the aorta and the anterior vena cava until the retroperitoneal duodenum had been reached.  Pedicles were sealed and divided with bipolar cutting forceps.  Excellent hemostasis was noted.  Boundaries of dissection included the ureters laterally, common ileac arteries at uterine crossover inferiorly, and the retroperitoneal duodenum superiorly with careful preservation of the inferior mesenteric artery.  Right and left pelvic retroperitoneal spaces were then opened by incising lateral and parallel to the infundibulopelvic ligament with the bipolar cutting forceps.  The retroperitoneal space was then opened and the lymph nodes were dissected, with boundaries of dissection being the bifurcation of the common iliac artery superiorly, psoas muscle laterally, inguinal ligament inferiorly, and the anterior division of the hypogastric artery medially.  The posterior boundary was the obturator nerve, which was carefully identified and preserved bilaterally.  The left common iliac lymph node was elevated and removed using the same technique.,Attention was then turned to the laparoscopic hysterectomy.  The right infundibulopelvic ligament was divided using the bipolar cutting forceps.  The mesovarium was skeletonized.  A bladder flap was mobilized by dividing the round ligaments using the bipolar cutting forceps, and the peritoneum on the vesicouterine fold was incised to mobilize the bladder.  Once the Koh colpotomy ring was skeletonized and in position, the uterine arteries were sealed using the bipolar forceps at the level of the colpotomy ring.  The vagina was transected using a monopolar hook (or bipolar spatula), resulting in separation of the uterus and attached tubes and ovaries.  The uterus, tubes, and ovaries were then delivered through the vagina, and the pneumo-occluder balloon was reinserted to maintain pneumoperitoneum.  The vaginal vault was closed with interrupted figure-of-eight stitches of 0-Vicryl using the Endo-Stitch device.  The abdomen was irrigated, and excellent hemostasis was noted.,The insufflation pressure was reduced, and no evidence of bleeding was seen.  The suprapubic port was then removed, and the fascia was closed with a Carter-Thomason device and 0-Vicryl suture.  The remaining ports were removed under direct laparoscopic guidance, and the pneumoperitoneum was released.  The umbilical port was removed using laparoscopic guidance.  The umbilical fascia was closed with an interrupted figure-of-eight stitch using 2-0 Vicryl.  The skin was closed with interrupted subcuticular stitches using 4-0 Monocryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was awakened and taken to the post anesthesia care unit in stable condition.",37
"PROCEDURE: , Fiberoptic bronchoscopy.,PREOPERATIVE DIAGNOSIS:,  Right lung atelectasis.,POSTOPERATIVE DIAGNOSIS:,  Extensive mucus plugging in right main stem bronchus.,PROCEDURE IN DETAIL:,  Fiberoptic bronchoscopy was carried out at the bedside in the medical ICU after Versed 0.5 mg intravenously given in 2 aliquots.  The patient was breathing supplemental nasal and mask oxygen throughout the procedure.  Saturations and vital signs remained stable throughout.  A flexible fiberoptic bronchoscope was passed through the right naris.  The vocal cords were visualized.  Secretions in the larynx were as aspirated.  As before, he had a mucocele at the right anterior commissure that did not obstruct the glottic opening.  The ports were anesthetized and the trachea entered.  There was no cough reflex helping explain the propensity to aspiration and mucus plugging.  Tracheal secretions were aspirated.  The main carinae were sharp.  However, there were thick, sticky, grey secretions filling the right mainstem bronchus up to the level of the carina.  This was gradually lavaged clear.  Saline and Mucomyst solution were used to help dislodge remaining plugs.  The airways appeared slightly friable, but were patent after the airways were suctioned.  O2 saturations remained in the mid-to-high 90s.  The patient tolerated the procedure well.  Specimens were submitted for microbiologic examination.  Despite his frail status, he tolerated bronchoscopy quite well.",37
"REASON FOR EVALUATION:,",27
"REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.",16
"PREOPERATIVE DIAGNOSIS: , Closed type-III supracondylar fracture, left distal humerus.,POSTOPERATIVE DIAGNOSES:,1.  Closed type-III supracondylar fracture, left distal humerus.,2.  Tethered brachial artery, left elbow.,PROCEDURE PERFORMED: , Closed reduction percutaneous pinning, left distal humerus.,SPECIFICATIONS: , The entire operative procedure was done in the inpatient operating suite, room #2 at ABCD General Hospital.  A portion of the procedure was done in consult with Dr. X with separate dictation by him.,HISTORY AND GROSS FINDINGS:  ,This is a 4-year-old white male, apparently dominantly right-handed who suffered a severe injury to his left distal humerus after jumping off of a swing.  He apparently had not had previous problems with his left arm.  He was seen in the Emergency with a grossly deformed left elbow.  His parents' were both present preoperatively.  His x-ray exam as well as physical exam was consistent with a closed type-III supracondylar fracture of the left distal humerus with rather severe puckering of the skin anteriorly with significant ecchymosis in the same region.  Gross neurologic exam revealed his ulnar, median, and radial nerves to be mostly intact, although a complete exam was impossible.  He did have a radial pulse palpable.,PROCEDURE: , After discussing the alternatives of the case as well as advantages and disadvantages, risks, complications, and expectations with the patient's parents including malunion, nonunion, gross deformity, growth arrest, infection, loss of elbow motions, stiffness, instability, need for surgery in the future, nerve problems, artery problems, and compartment syndrome, they elected to proceed.,The patient was laid supine upon operative table after receiving general anesthetic by Anesthesia Department.  Closed reduction was accomplished in a sequential manner.  Milking of the soft tissue envelope was carried out to try and reduce the shaft of the humerus back into its plane relative to the brachialis muscle and the neurovascular bundle anteriorly.  Then a slow longitudinal traction was carried out.  The elbow was hyperflexed.  Pressure placed upon the olecranon tip and two 0.045 K-wires placed first, one being on the lateral side and with this placement on the medial side of medial epicondyle with care taken to protect the ulnar nerve.  The close reduction was deemed to be acceptable once viewed on C-arm.,After this, pulse was attempted to be palpated distally.  Prior to the procedure, I talked to Dr. X of Vascular Surgery at ABCD Hospital.  He had scrubbed in to the case to follow up on the loss of the radial artery distally.  This was not present palpatory, but also by Doppler.  A weak ulnar artery pulse was present via Doppler.  Because of this, the severe displacement of the injury and the fact that the Doppler sound had an occlusion-type sound just above the fracture site or _______.  A long discussion was carried out with Dr. X and myself, and we decided to proceed with exploration of the brachial artery.  Prior to this, I went out to the waiting room to discuss with the patient's parents, the reasoning what we are going to do and the reasoning for this.  I then came back in and then we proceeded.  He was prepped and draped in the usual sterile manner.  Please see Dr. X's report for the discussion of the exploration and release of the brachial artery.  There was no indication that it was actually in the fracture site, the soft tissue had tethered in its right angle towards the fracture site, thus reducing its efficiency of providing blood distally.  Once it was released, both clinically on the table as well as by Doppler, the patient had bounding pulses.,We then proceeded to close utilizing a #4-0 Vicryl for subcutaneous fat closure and a running #5-0 Vicryl subcuticular stitch for skin closure.  Steri-Strips were placed.  The patient's arm was placed in just a slight degree of flexion with a neutral position.  He was splinted posteriorly.  Adaptic and fluffs have been placed around the patient's pin sites.  K-wires have been bent, cut, and pin caps placed.,Expected surgical prognosis on this patient is guarded for the obvious reasons noted above.  There is concern for growth plate disturbance.  He will be watched very closely for the potential development of re-perfusing compartment syndrome.,A full and complete neurologic exam will be impossible tonight, but will be carried on a sequential basis starting tomorrow morning.  There is always a potential for loss of elbow motion, overall cosmetic elbow alignment, and elbow function.",37
"PREOPERATIVE DIAGNOSIS: , Postoperative hemorrhage.,POSTOPERATIVE DIAGNOSIS:,  Postoperative hemorrhage.,SURGICAL PROCEDURE:  ,Examination under anesthesia with control of right parapharyngeal space hemorrhage.,ANESTHESIA:  ,General endotracheal technique.,SURGICAL FINDINGS: , Right lower pole bleeder cauterized with electrocautery with good hemostasis.,INDICATIONS FOR SURGERY: , The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy.  Previously, in the day she had undergone a tonsillectomy with adenoidectomy and was recovering without difficulty.  However, in the PACU after a coughing spell she began bleeding from the right oropharynx, and was taken back to the operative suite for control of hemorrhage.,DESCRIPTION OF SURGERY:  ,The patient was placed supine on the operating room table and general anesthetic was administered, once appropriate anesthetic findings achieved the patient was intubated and then prepped and draped in usual sterile manner for a parapharyngeal space hemorrhage.  A Crowe-Davis type mouth gag was introduced in the oropharynx and under operating headlight the oropharynx was clearly visualized.  There was a small bleeder present at the inferior mid pole of the right oropharynx in the tonsillar fossa, this area was cauterized with suction cautery and irrigated.  There was no other bleeding noted.  The patient was repositioned and the mouth gag, the tongue was rotated to the left side of the mouth and the right parapharyngeal space carefully examined.  There was a small amount of oozing noted in the right tonsillar bed, and this was cauterized with suction cautery.  No other bleeding was noted and the patient was recovered from general anesthetic.  She was extubated and left the operating room in good condition to postoperative recovery room area.  Prior to extubation the patient's tonsillar fossa were injected with a 6 mL of 0.25% Marcaine with 1:100,000 adrenalin solution to facilitate postoperative analgesia and hemostasis.",11
"PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,OPERATION PERFORMED: , Excision of nasal tip basal carcinoma.  Total area of excision, approximately 1 cm to 12 mm frozen section x2, final margins clear.,INDICATION: , A 66-year-old female for excision of nasal basal cell carcinoma.  This area is to be excised accordingly and closed.  We had multiple discussions regarding types of closure.,SUMMARY: , The patient was brought to the OR in satisfactory condition and placed supine on the OR table.  Underwent general anesthesia along with Marcaine in the nasal tip areas for planned excision.  The area was injected, after sterile prep and drape, with Marcaine 0.25% with 1:200,000 adrenaline.,The specimen was sent to pathology.  Margins were still positive at the inferior 6 o'clock ***** margin and this was resubmitted accordingly.  Final margins were clear.,Closure consisted of undermining circumferentially.  Advancement closure with dog ear removal distally and proximally was accomplished without difficulty.  Closure with interrupted 5-0 Monocryl running 7-0 nylon followed by Xeroform gauze, light pressure dressing, and Steri-Strips.,The patient is discharged on minocycline and Darvocet-N 100.,NOTE:,  The 2.6 mm loupe magnification was utilized throughout the procedure.  No complications noted with excellent and all clear margins at the termination.  An advancement closure technique was utilized.",37
"EXAM: , Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.,REASON FOR EXAM: , Abnormal stress test and episode of shortness of breath.,PROCEDURE: , Right common femoral artery, 6-French sheath, JL4, JR4, and pigtail catheters were used.,FINDINGS:,1.  Left main is a large-caliber vessel.  It is angiographically free of disease,,2.  LAD is a large-caliber vessel.  It gives rise to two diagonals and septal perforator.  It erupts around the apex.  LAD shows an area of 60% to 70% stenosis probably in its mid portion.  The lesion is a type A finishing before the takeoff of diagonal 1.  The rest of the vessel is angiographically free of disease.,3.  Diagonal 1 and diagonal 2 are angiographically free of disease.,4.  Left circumflex is a small-to-moderate caliber vessel, gives rise to 1 OM.  It is angiographically free of disease.,5.  OM-1 is angiographically free of disease.,6.  RCA is a large, dominant vessel, gives rise to conus, RV marginal, PDA and one PL.  RCA has a tortuous course and it has a 30% to 40% stenosis in its proximal portion.,7.  LVEDP is measured 40 mmHg.,8.  No gradient between LV and aorta is noted.,Due to contrast concern due to renal function, no LV gram was performed.,Following this, right common femoral angiogram was performed followed by StarClose closure of the right common femoral artery.,IMPRESSION:,1.  60% to 70% mid left anterior descending stenosis.,2.  Mild 30% to 40% stenosis of the proximal right coronary artery.,3.  Status post StarClose closure of the right common femoral artery.,PLAN:  ,Plan will be to perform elective PCI of the mid LAD.",3
"CAUDAL EPIDURAL STEROID INJECTION,PROCEDURE:,:,1.  Caudal epidural steroid injection with contrast.,2.  Utilization of fluoroscopy for confirmation of needle placement.,PREPROCEDURE PREPARATION:,  After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form.  The patient was placed in the prone position and standard ASA monitors applied.  Intravenous access was established and IV sedation was used.  For further details of IV sedation and infusion, please refer to anesthesia notes.  Fluoroscopy was used to identify the appropriate anatomy.  The skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure.,PROCEDURE DETAILS:,",28
"PROCEDURE CODES:  64640 times two, 64614 time two, 95873 times two, 29405 times two.,PREOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,POSTOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,ANESTHESIA:  MAC.,COMPLICATIONS:  None.,DESCRIPTION OF TECHNIQUE:  Informed consent was obtained from the patient's mom.  The patient was brought to minor procedures 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 with active EMG stimulation.  Approximately 4 mL of 5% phenol was injected in this location bilaterally.  Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation.  Approximately 50 units was injected in the rectus femoris bilaterally, 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally.  Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL.  After injections were performed, bilateral short leg fiberglass casts were applied.  The patient tolerated the procedure well and no complications were encountered.",37
"SUBJECTIVE:,  This 9-month-old Hispanic male comes in today for a 9-month well-child check.  They are visiting from Texas until the end of April 2004.  Mom says he has been doing well since last seen.  He is up-to-date on his immunizations per her report.  She notes that he has developed some bumps on his chest that have been there for about a week.  Two weeks ago he was diagnosed with left otitis media and was treated with antibiotics.  Mom says he has been doing fine since then.  She has no concerns about him.,PAST MEDICAL HISTORY:,  Significant for term vaginal delivery without complications.,MEDICATIONS: , None.,ALLERGIES:,  None.,SOCIAL HISTORY:,  Lives with parents.  There is no smoking in the household.,REVIEW OF SYSTEMS:,  Developmentally is appropriate.  No fevers.  No other rashes.  No cough or congestion.  No vomiting or diarrhea.  Eating normally.,OBJECTIVE:,  His weight is 16 pounds 9 ounces.  Height is 26-1/4 inches.  Head circumference is 44.75 cm.  Pulse is 124.  Respirations are 26.  Temperature is 98.1 degrees.  Generally, this is a well-developed, well-nourished, 9-month-old male, who is active, alert, and playful in no acute distress.,HEENT:  Normocephalic, atraumatic.  Anterior fontanel is soft and flat.  Tympanic membranes are clear bilaterally.  Conjunctivae are clear.  Pupils 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.,GU:  Normal male external genitalia.  Uncircumcised penis.  Bilaterally descended testes.  Femoral pulses 2/4.,EXTREMITIES:  Moves all four extremities equally.  Minimal tibial torsion.,SKIN:  Without abnormalities other than five small molluscum contagiosum with umbilical herniation noted on chest.,ASSESSMENT/PLAN:,1.  Well-child check.  Is doing well.  Will recommend a followup well-child check at 1 year of age and immunizations at that time.  Discussed safety issues, including poisons, choking hazards, pet safety, appropriate nutrition with Mom.  She is given a parenting guide handout.,2.  Molluscum contagiosum.  Described the viral etiology of these.  Told her they are self limited, and we will continue to monitor at this time.,3.  Left otitis media, resolved.  Continue to monitor.  We will plan on following up in three months if they are still in the area, or p.r.n.",29
"PREOPERATIVE DIAGNOSIS: , Need for intravenous access.,POSTOPERATIVE DIAGNOSIS: , Need for intravenous access.,PROCEDURE PERFORMED:  ,Insertion of a right femoral triple lumen catheter.,ANESTHESIA: , Includes 4 cc of 1% lidocaine locally.,ESTIMATED BLOOD LOSS: , Minimum.,INDICATIONS:,  The patient is an 86-year-old Caucasian female who presented to ABCD General Hospital secondary to drainage of an old percutaneous endoscopic gastrostomy site.  The patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.,PROCEDURE:,  The patient's legal guardian was talked to.  All questions were answered and consent was obtained.  The patient was sterilely prepped and draped.  Approximately 4 cc of 1% lidocaine was injected into the inguinal site.  A strong femoral artery pulse was felt and triple lumen catheter Angiocath was inserted at 30-degree angle cephalad and aspirated until a dark venous blood was aspirated.  A guidewire was then placed through the needle.  The needle was then removed.  The skin was ________ at the base of the wire and a dilator was placed over the wire.  The triple lumen catheters were then flushed with bacteriostatic saline.  The dilator was then removed from the guidewire and a triple lumen catheter was then inserted over the guidewire with the guidewire held at all times.,The wire was then carefully removed.  Each port of the lumen catheter was aspirated with 10 cc syringe with normal saline till dark red blood was expressed and then flushed with bacteriostatic normal saline and repeated on the remaining two ports.  Each port was closed off and also kept off.  Straight needle suture was then used to suture the triple lumen catheter down to the skin.  Peristatic agent was then placed at the site of the lumen catheter insertion and a Tegaderm was then placed over the site.  The surgical site was then sterilely cleaned.  The patient tolerated the full procedure well.  There were no complications.  The nurse was then contacted to allow for access of the triple lumen catheter.",3
"PREOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,POSTOPERATIVE DIAGNOSIS: ,  Leaking anastomosis from esophagogastrectomy. ,PROCEDURE: ,  Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,COMPLICATIONS:,  None. ,ANESTHESIA: , General oroendotracheal intubation. ,PROCEDURE:  , After adequate general anesthesia was administered, the patient's abdomen was prepped and draped aseptically. Sutures and staples were removed. The abdomen was opened. The were some very early stage adhesions that were easy to separate. Dissection was carried up toward the upper abdomen where the patient was found to have a stool filled descended colon. This was retracted caudally to expose the stomach. There were a number of adhesions to the stomach. These were carefully dissected to expose initially the closure over the gastrotomy site. Initially this looked like this was leaking but it was actually found to be intact.  The pyloroplasty was identified and also found to be intact with no evidence of leakage. Further dissection up toward the hiatus revealed an abscess collection. This was sent for culture and sensitivity and was aspirated and lavaged. Cavity tracked up toward the hiatus. Stomach itself appeared viable, there was no necrotic sections. Upper apex of the stomach was felt to be viable also. I did not pull the stomach and esophagus down into the abdomen from the mediastinum, but placed a sucker up into the mediastinum where additional turbid fluid was identified. Carefully placed a 10 mm flat Jackson-Pratt drain into the mediastinum through the hiatus to control this area of leakage. Two additional Jackson-Pratt drains were placed essentially through the gastrohepatic omentum. This was the area that most of the drainage had collected in. As I had previously discussed with Dr. Sageman I did not feel that mobilizing the stomach to redo the anastomosis in the chest would be a recoverable situation for the patient. I therefore did not push to visualize any focal areas of the anastomosis with the intent of repair. Once the drains were secured, they were brought out through the anterior abdominal wall and secured with 3-0 silk sutures and secured to bulb suction. The midline fascia was then closed using running #2 Prolene sutures bolstered with retention sutures. Subcutaneous tissue was copiously lavaged and then the skin was closed with loosely approximated staples. Dry gauze dressing was placed. The patient tolerated the procedure well, there were no complications.",37
"EYES: , The conjunctivae are clear.  The lids are normal appearing without evidence of chalazion or hordeolum.  The pupils are round and reactive.  The irides are without any obvious lesions noted.  Funduscopic examination shows sharp disk margins.  There are no exudates or hemorrhages noted.  The vessels are normal appearing.,EARS, NOSE, MOUTH AND THROAT:,  The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.,NECK:,  The neck is nontender and supple.  The trachea is midline.  The thyroid is without any evidence of thyromegaly.  No obvious adenopathy is noted to the neck.,RESPIRATORY: , The patient has normal respiratory effort.  There is normal lung excursion.  Percussion of the chest is without any obvious dullness.  There is no tactile fremitus or egophony noted.  There is no tenderness to the chest wall or ribs.  There are no obvious abnormalities.  The lungs are clear to auscultation.  There are no wheezes, rales or rhonchi heard.  There are no obvious rubs noted.,CARDIOVASCULAR: , There is a normal PMI on palpation.  I do not hear any obvious abnormal sounds.  There are no obvious murmurs.  There are no rubs or gallops noted.  The carotid arteries are without bruit.  No obvious thrill is palpated. There is no evidence of enlarged abdominal aorta to palpation.  There is no abdominal mass to suggest enlargement of the aorta.  Good strong femoral pulses are palpated.  The pedal pulses are intact.  There is no obvious edema noted to the extremities.  There is no evidence of any varicosities or phlebitis noted.,GASTROINTESTINAL: , The abdomen is soft.  Bowel sounds are present in all quadrants.  There are no obvious masses.  There is no organomegaly, and no liver or spleen is palpable.  No obvious hernia is noted.  The perineum and anus are normal in appearance.  There is good sphincter tone and no obvious hemorrhoids are noted.  There are no masses.  On digital examination, there is no evidence of any tenderness to the rectal vault; no lesions are noted.  Stool is brown and guaiac negative.,GENITOURINARY (FEMALE): , The external genitalia is normal appearing with no obvious lesions, no evidence of any unusual rash.  The vagina is normal in appearance with normal-appearing mucosa.  The urethra is without any obvious lesions or discharge.  The cervix is normal in color with no obvious cervical discharge.  There are no obvious cervical lesions noted.  The uterus is nontender and small, and there is no evidence of any adnexal masses or tenderness.  The bladder is nontender to palpation.  It is not enlarged.,GENITOURINARY (MALE): , Normal scrotal contents are noted.  The testes are descended and nontender.  There are no masses and no swelling to the epididymis noted.  The penis is without any lesions.  There is no urethral discharge.  Digital examination of the prostate reveals a nontender, non-nodular prostate.,BREASTS:,  The breasts are normal in appearance.  There is no puckering noted.  There is no evidence of any nipple discharge.  There are no obvious masses palpable.  There is no axillary adenopathy.  The skin is normal appearing over the breasts.,LYMPHATICS: , There is no evidence of any adenopathy to the anterior cervical chain.  There is no evidence of submandibular nodes noted.  There are no supraclavicular nodes palpable.  The axillae are without any abnormal nodes.  No inguinal adenopathy is palpable.  No obvious epitrochlear nodes are noted.,MUSCULOSKELETAL/EXTREMITIES: , The patient has normal gait and station.  The patient has normal muscle strength and tone to all extremities.  There is no obvious evidence of any muscle atrophy.  The joints are all stable.  There is no evidence of any subluxation or laxity to any of the joints.  There is no evidence of any dislocation.  There is good range of motion of all extremities without any pain or tenderness to the joints or extremities.  There is no evidence of any contractures or crepitus.  There is no evidence of any joint effusions.  No obvious evidence of erythema overlying any of the joints is noted.  There is good range of motion at all joints.  There are normal-appearing digits.  There are no obvious lesions to any of the nails or nail beds.,SKIN:,  There is no obvious evidence of any rash.  There are no petechiae, pallor or cyanosis noted.  There are no unusual nodules or masses palpable.,NEUROLOGIC: , The cranial nerves II XII are tested and are intact.  Deep tendon reflexes are symmetrical bilaterally.  The toes are downgoing with normal Babinskis.  Sensation to light touch is intact and symmetrical.  Cerebellar testing reveals normal finger nose, heel shin.  Normal gait.  No ataxia.,PSYCHIATRIC:  ,The patient is oriented to person, place and time.  The patient is also oriented to situation.  Mood and affect are appropriate for the present situation.  The patient can remember 3 objects after 3 minutes without any difficulties.  Remote memory appears to be intact.  The patient seems to have normal judgment and insight into the situation.",15
"S - ,This patient has reoccurring ingrown infected toenails.  He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border.  The right great toenail is ingrown on the lateral nail border only.  There is mild redness and granulation tissue growing on the borders of the toes.  One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe.  These lesions measure 0.5 cm in diameter each.  I really do not understand why this young man continues to develop ingrown nails and infections.,A - ,1.  Onychocryptosis.,",31
"REASON FOR CONSULT:, Renal insufficiency.,HISTORY OF PRESENT ILLNESS:, A 48-year-old African-American male with a history of coronary artery disease, COPD, congestive heart failure with EF of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. The patient denies any chest pain, palpitations, syncope, or fever. Denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. Nephrology is consulted regarding renal insufficiency.,REVIEW OF SYSTEMS:, Reviewed entirely and negative except for HPI.,PAST MEDICAL HISTORY:, Hypertension, congestive heart failure with ejection fraction of 20%-25% in December 2005, COPD, mild diffuse coronary artery disease, and renal insufficiency.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, Lipitor 20 at bedtime, Toprol XL 100 daily.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY:, The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 180/110. Temperature 98.1. Pulse rate 60. Respiratory rate 23. O2 sat 95% on room air.,GENERAL: A 48-year-old African-American male in no acute distress.,HEENT: Pupils equal, round, and reactive to light and accommodation. No pallor or icterus.,NECK: No JVD, bruit, or lymphadenopathy.,HEART: S1 and S2, regular rate and rhythm, no murmurs, rubs, or gallops.,LUNGS: Clear. No wheezes or crackles.,ABDOMEN: Soft, nontender, nondistended, no organomegaly, bowel sounds present.,EXTREMITIES: No cyanosis, clubbing, or edema.,CNS: Exam is nonfocal.,LABS:, WBC 7, H and H 13 and 40, platelets 330, PT 12, PTT 26, CO2 20, BUN 27, creatinine 3.1, cholesterol 174, BNP 973, troponin 0.18. Previous creatinine levels were 2.7 in December. Urine drug screen positive for cocaine.,ASSESSMENT:, A 48-year-old African-American male with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency with:,1. Hypertensive emergency.,2. Acute on chronic renal failure.,3. Urine drug screen positive.,4. Question CHF versus COPD exacerbation.,PLAN:,1. Most likely, renal insufficiency is a chronic problem. Hypertensive etiology worsened by the patient's chronic cocaine abuse.,2. Control blood pressure with medications as indicated. Hypertensive emergency most likely related to cocaine drug abuse.,Thank you for this consult. We will continue to follow the patient with you.",15
"PREOPERATIVE DIAGNOSES: , Vault prolapse and rectocele.,POSTOPERATIVE DIAGNOSES:,  Vault prolapse and rectocele.,OPERATION: , Colpocleisis and rectocele repair.,ANESTHESIA:  ,Spinal.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT: , This is an 85-year-old female who presented to us with a vaginal mass.  On physical exam, the patient was found to have grade 3 rectocele and poor apical support, and history of hysterectomy.  The patient had good anterior support at the bladder.  Options were discussed such as watchful waiting, pessary, repair with and without mesh, and closing of the vagina (colpocleisis) were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, morbidity, and mortality of the procedure were discussed., ,Risk of infection and abscess formation were discussed.  The patient understood all the risks and benefits and wanted to proceed with the procedure.  Risk of retention and incontinence were discussed.  Consent was obtained through the family members.,DETAILS OF THE OR:,  The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient had a Foley catheter placed.  The posterior side of the rectocele was visualized with grade 3 rectocele and poor apical support.  A 1% lidocaine with epinephrine was applied for posterior hydrodissection, which was very difficult to do due to the significant scarring of the posterior part.  Attempts were made to lift the vaginal mucosa off of the rectum, which was very, very difficult to do at this point due to the patient's overall poor medical condition in terms of poor mobility and significant scarring.  Discussion was done with the family in the waiting area regarding simply closing the vagina and doing a colpocleisis since the patient is actually inactive.  Family agreed that she is not active and they rather not have any major invasive procedure especially in light of scarring and go ahead and perform the colpocleisis.  Oral consent was obtained from the family and her surgery was preceded.  The vaginal mucosa was denuded off using electrocautery and Metzenbaum scissors.  Using 0 Vicryl, 2 transverse longitudinal stitches were placed to bring the anterior and the posterior part of the vagina together and was started at the apex and was brought all the way out to the introitus.  The vaginal mucosa was pretty much completely closed off all the way up to the introitus.  Indigo carmine was given.  Cystoscopy revealed there was a good efflux of urine from both of the ureteral openings.  There was no injury to the bladder or kinking of the ureteral openings.  The bladder was normal.  Rectal exam was normal at the end of the colpocleisis repair.  There was good hemostasis., ,At the end of the procedure, Foley was removed and the patient was brought to recovery in a stable condition.",24
"PREOPERATIVE DIAGNOSIS:  ,Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,POSTOPERATIVE DIAGNOSIS: , Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,OPERATIONS:,1.  Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm.,2.  Open reduction, right both bone forearm fracture with placement of long-arm cast.,COMPLICATIONS:,  None.,TOURNIQUET: , None.,ESTIMATED BLOOD LOSS:,  25 mL.,ANESTHESIA: , General.,INDICATIONS:  ,The patient suffered injury at which time he fell over a concrete bench.  He landed mostly on the right arm.  He noted some bleeding at the time of the injury and a small puncture wound.  He was taken to the emergency room and diagnosed a compound both bone forearm fracture, and based on this, he was seen for malalignment.,He was indicated the above-noted procedure.  This procedure as well as alternatives of this procedure was discussed at length with the patient's parents and they understood them well.  Risks and benefits were also discussed.  Risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain on full range of motion, risk of continued discomfort, risk of need for repeat debridement, risk of need for internal fixation, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  They understood these well.  All questions were answered and they signed the consent for procedure as described.,DESCRIPTION OF PROCEDURE:  ,The patient was placed on the operating table and general anesthesia was achieved.  The right forearm was inspected.  There was noted to be a 3-mm puncture-type wound over the volar aspect of the forearm in the middle one-third overlying the radial one-half.  There was bleeding in this region.  No gross contamination was seen.  At this point, under fluoroscopic control, I did attempt to see a fracture.  I was unable to do the forearm under the close reduction techniques.  At this point, the right upper extremity was then prepped and draped in the usual sterile manner.  An incision was made through the puncture wound site extending this proximally and distally.  There was noted to be some slight amount of nonviable tissue at the skin edge and debridement was required and performed.  I also did perform a light debridement of the nonviable subcutaneous tissue, muscle, and small bony fragments were also removed.  These were all completely debrided appropriately and then at this point, a thorough irrigation was performed of the radius, which I communicated through the puncture wound.  Both ends were clearly visualized, and thorough irrigation was performed using total of 6 L of antibiotic solution.  All nonviable gross contaminated tissue was removed.  At this point with the bones in direct visualization, I did reduce the bony ends to anatomic alignment with excellent bony approximation.  Proper alignment of tissue and angulation was confirmed.,At this point, under fluoroscopic control confirmed the radius and ulna in anatomic position, which will be completely displaced and shortened previously.  The ulna was now also noted to be in anatomic alignment.,At this point, the region was thoroughly irrigated.  Hemostasis confirmed and closure then begun.  The skin was reapproximated using 3-0 nylon suture.  The visual puncture wound region was left open and this was intact with the depth of the wound down the bone using 1.5-inch Nugauze with iodoform.  Sterile dressing applied and a long-arm cast with the forearm in neutral position was applied.  X-ray with fluoroscopic evaluation was performed, which confirmed.  They maintained excellent bony approximation and the anatomic alignment.  The long-arm cast was then completely mature.  No complications were encountered throughout the procedure.  The patient tolerated the procedure well.  The patient was then taken to the recovery room in stable condition.",27
"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: , External genitalia without erythema, exudate or discharge.  Vaginal vault is without discharge.  Cervix is of normal color without lesion.  The os is closed.  There is no bleeding noted.  Uterus is noted to be of normal size and nontender.  No cervical motion tenderness is seen.  No masses are palpated.  The adnexa are without masses or 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.",25
"PROCEDURE PERFORMED:,1.  Left heart catheterization, left ventriculogram, aortogram, coronary angiogram.,2.  PCI of the LAD and left main coronary artery with Impella assist device.,INDICATIONS FOR PROCEDURE: , Unstable angina and congestive heart failure with impaired LV function.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state.  The right groin was prepped and draped in the usual sterile manner.  Lidocaine 2% was used for infiltration anesthesia.  Using modified Seldinger technique, a 7-French sheath was introduced into the right common femoral artery and a 6-French sheath was introduced into the right common femoral vein.  Through the arterial sheath, angiography of the right common femoral artery was obtained.  Thereafter, 6-French pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained.  Thereafter, a 4-French sheath was introduced into the left common femoral artery using modified Seldinger technique.  Thereafter, the pigtail catheter was advanced over an 0.035-inch J-wire into the left ventricle and LV-gram was performed in RAO view and after pullback, an aortogram was performed in the LAO view.  Therefore, a 6-French JL4 and JR4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained.,ANGIOGRAPHIC FINDINGS:  ,1.  LV-gram:  LVEDP was 15 mmHg.  LV ejection fraction 10% to 15% with global hypokinesis.  Only anterior wall is contracting.  There was no mitral regurgitation.  There was no gradient across the aortic valve upon pullback, and on aortography, there was no evidence of aortic dissection or aortic regurgitation.,2.  The right coronary artery is a dominant vessels with a mid 50% to 70% stenosis which was not treated.  The left main coronary artery calcified vessel with disease.,2.  The left anterior descending artery had an 80% to 90% mid-stenosis.  First diagonal branch had a more than 90% stenosis.,3.  The circumflex coronary artery had a patent stent.,INTERVENTION: , After reviewing the angiographic images, we elected to proceed with intervention of the left anterior descending artery.  The 4-French sheath in the left common femoral artery was upsized to a 12-French Impella sheath through which an Amplatz wire and a 6-French multipurpose catheter were advanced into the left ventricle.  The Amplatz wire was exchanged for an Impella 0.018-inch stiff wire.  The multipurpose catheter was removed, and the Impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2.5 l/min.  Thereafter, a 7-French JL4 guiding catheter was used to engage the left coronary artery and an Asahi soft 0.014-inch wire was advanced into the left anterior descending artery and a second 0.014-inch Asahi soft wire was advanced into the diagonal branch.  The diagonal branch was predilated with a 2.5 x 30-mm Sprinter balloon at nominal atmospheres and thereafter a 2.5 x 24 Endeavor stent was successfully deployed in the mid-LAD and a 3.0 x 15-mm Endeavor stent was deployed in the proximal LAD.  The stent delivery balloon was used to post-dilate the overlapping segment.  The LAD, the diagonal was rewires with an 0.014-inch Asahi soft wire and a 3.0 x 20-mm Maverick balloon was advanced into the LAD for post-dilatation and a 2.0 x 30-mm Sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres.  At this point, it was noted that the left main had a retrograde dissection.  A 3.5 x 18-mm Endeavor stent was successfully deployed in the left main coronary artery.  The Asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery.  Kissing inflations of the LAD and the circumflex coronary artery were performed using 3.0 x 20 Maverick balloons x2 balloons, inflated at high atmospheres of 14.,RESULTS: , Lesion reduction in the LAD FROM 90% to 0% and TIMI 3 flow obtained.  Lesion reduction in the diagonal from 90% to less than 60% and TIMI 3 flow obtained.  Lesion reduction in the left maintained coronary artery from 50% to 0% and TIMI 3 flow obtained.,The patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability.  The Impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the Impella was removed from the body and the 2 Perclose sutures were tightened.  From the right common femoral artery, a 6-French IMA catheter was advanced and an 0.035-inch wire down into the left common femoral and superficial femoral artery, over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes.  The right common femoral artery and vein sheaths were both sutured in place for further observation.  Of note, the patient received Angiomax during the procedure and an ACT above 300 was maintained.,IMPRESSION:,1.  Left ventricular dysfunction with ejection fraction of 10% to 15%.,2.  High complex percutaneous coronary intervention of the left main coronary artery, left anterior descending artery, and diagonal with Impella circulatory support.,COMPLICATIONS: , None.,The patient tolerated the procedure well with no complications.  The estimated blood loss was 200 ml.  Estimated dye used was 200 ml of Visipaque.  The patient remained hemodynamically stable with no hypotension and no hematomas in the groins.,PLAN:  ,1.  Aspirin, Plavix, statins, beta blockers, ACE inhibitors as tolerated.,2.  Hydration.,3.  The patient will be observed over night for any hemodynamic instability or ischemia.  If she remains stable, the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis.",37
"CHIEF COMPLAINT:  ,Blood in toilet.,HISTORY: , Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet.  They did not note any urine or stool in the toilet and the patient had no acute complaints.  The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events.  The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints.  There is no other history provided by the nursing staff from XYZ.  There apparently were no clots noted within there.  She does not have a history of being on anticoagulants.,PAST MEDICAL HISTORY: , Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.,PAST SURGICAL HISTORY:  ,Unknown.,SOCIAL HISTORY: , No tobacco or alcohol.,MEDICATIONS: , Listed in the medical records.,ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.,GENERAL:  This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress.,HEENT:  Visually normal.  Pupils are reactive.  TMs, canals, nasal mucosa, and oropharynx are intact.,NECK:  No lymphadenopathy or JVD.,HEART:  Regular rate and rhythm.  S1, S2.  No murmurs, gallops, or rubs.,LUNGS:  Clear to auscultation.  No wheeze, rales, or rhonchi.,ABDOMEN:  Benign, flat, soft, nontender, and nondistended.  Bowel sounds active.  No organomegaly or mass noted.,GU/RECTAL:  External rectum was normal.  No obvious blood internally.  There is no stool noted within the vault.  There is no gross amount of blood noted within the vault.  Guaiac was done and was trace positive.  Visual examination anteriorly during the rectal examination noted no blood within the vaginal region.,EXTREMITIES:  No significant abnormalities.,WORKUP: , CT abdomen and pelvis was negative.  CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%.  CMP also within normal limits.  PTT, PT, and INR were normal.  Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization.,ER COURSE:,  Uneventful.  I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient.  We have decided to send the patient back to XYZ with observation by the staff there.  She will have a CBC done daily for the next 3 days with results to Dr. X.  They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood.,ASSESSMENT: , Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",5
"PREOPERATIVE DIAGNOSIS:,  Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,POSTOPERATIVE DIAGNOSIS:,  Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,PROCEDURES:,1.  Osteosynthesis of acetabular fracture on the left, complex variety.,2.  Total hip replacement.,ANESTHESIA: , General.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient in the left side up lateral position under adequate general endotracheal anesthesia, the patient's left lower extremity and buttock area were prepped with iodine and alcohol in the usual fashion, draped with sterile towels and drapes so as to create a sterile field.  Kocher Langenbeck variety incision was utilized and carried down through the fascia lata with the split fibers of the gluteus maximus in line.  The femoral insertion of gluteus maximus was tenotomized close to its femoral insertion.  The piriformis and obturator internus tendons and adjacent gemelli were tenotomized close to their femoral insertion, tagged, and retractor was placed in the lesser notch as well as a malleable retractor in the greater notch enabling the exposure of the posterior column.  The major transverse fracture was freed of infolded soft tissue, clotted blood, and lavaged copiously with sterile saline solution and then reduced anatomically with the aid of bone hook in the notch and provisionally stabilized utilizing a tenaculum clamp and definitively stabilized utilizing a 7-hole 3.5 mm reconstruction plate with the montage including two interfragmentary screws.  It should be mentioned that prior to reduction and stabilization of the acetabular fracture its femoral head component was removed from the joint enabling direct visualization of the articular surface.  Once a stable fixation of the reduced fracture of the acetabulum was accomplished, it should be mentioned that in the process of doing this, the posterior wall fragment was hinged on its soft tissue attachments and a capsulotomy was made in the capsule in line with the rent at the level of the posterior wall.  Once this was accomplished, the procedure was turned over to Dr. X and his team, who proceeded with placement of cup and femoral components as well and cup was preceded by placement of a trabecular metal tray for the cup with screw fixation of same.  This will be dictated in separate note.  The patient tolerated the procedure well.  The sciatic nerve was well protected and directly visualized to the level of the notch.",37
"CHIEF REASON FOR CONSULTATION:,  Evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.,HISTORY OF PRESENT ILLNESS:,  This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes.  During this time, patient felt extremely short of breath and dizzy.  Palpitations lasted for about five to ten minutes without any recurrence.  Patient also gives history of having tightness in the chest after she walks briskly up to a block.  Chest tightness starts in the retrosternal area with radiation across the chest.  Chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest.  Patient gives history of having hypertension for the last two months.  Patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident.,MEDICATIONS: , ,1.  Astelin nasal spray.,2.  Evista 60 mg daily.,3.  Lopressor 25 mg daily.,4.  Patient was given a sample of Diovan 80 mg daily for the control of hypertension from my office.,PAST HISTORY:,  The patient underwent right foot surgery and C-section.,FAMILY HISTORY:,  The patient is married, has six children who are doing fine.  Father died of a stroke many years ago.  Mother had arthritis.,SOCIAL HISTORY:, The patient does not smoke or take any drinks.  ,ALLERGIES:,  THE PATIENT IS NOT ALLERGIC TO ANY MEDICATIONS.,REVIEW OF SYSTEMS:,  Otherwise negative.  ,PHYSICAL EXAMINATION: , ,GENERAL:  Well-built, well-nourished white female in no acute distress. ,VITAL SIGNS:  Blood pressure is 160/80.  Respirations 18 per minute.  Heart rate 70 beats per minute.  Patient weighs 133 pounds, height 64 inches.  BMI is 22.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good.,NECK:  Supple.  No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries.  Trachea in midline. Thyroid not enlarged.  JVP flat at 45°.,CHEST:  Chest is symmetrical on both sides, moves well with respirations.  Vesicular breath sounds heard over the lung fields.  No wheezing, crepitation, or pleural friction rub heard.  ,CARDIOVASCULAR SYSTEM:  PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character.  There is a II/VI systolic murmur best heard at the apex.  There is no diastolic murmur or gallop heard.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or ascites.  No bruit heard over the aorta or renal vessels.,EXTREMITIES:  No pedal edema.  Femoral arterial pulsations are 3+, popliteal 2+.  Dorsalis pedis and posterior tibialis are 1+ on both sides.,NEURO:  Normal.,EKG from Dr. Xyz's office shows normal sinus rhythm, ST and T wave changes.  Lipid profile, random blood sugar, BUN, creatinine, CBC, and LFTs are normal.,IMPRESSION:,",5
"PAST MEDICAL HISTORY:,  Significant for hypertension.  The patient takes hydrochlorothiazide for this.  She also suffers from high cholesterol and takes Crestor.  She also has dry eyes and uses Restasis for this.  She denies liver disease, kidney disease, cirrhosis, hepatitis, diabetes mellitus, thyroid disease, bleeding disorders, prior DVT, HIV and gout.  She also denies cardiac disease and prior history of cancer.,PAST SURGICAL HISTORY: , Significant for tubal ligation in 1993.  She had a hysterectomy done in 2000 and a gallbladder resection done in 2002.,MEDICATIONS: , Crestor 20 mg p.o. daily, hydrochlorothiazide 20 mg p.o. daily, Veramist spray 27.5 mcg daily, Restasis twice a day and ibuprofen two to three times a day.,ALLERGIES TO MEDICATIONS: , Bactrim which causes a rash.  The patient denies latex allergy.,SOCIAL HISTORY: , The patient is a life long nonsmoker.  She only drinks socially one to two drinks a month.  She is employed as a manager at the New York department of taxation.  She is married with four children.,FAMILY HISTORY: , Significant for type II diabetes on her mother's side as well as liver and heart failure.  She has one sibling that suffers from high cholesterol and high triglycerides.,REVIEW OF SYSTEMS: , Positive for hot flashes.  She also complains about snoring and occasional slight asthma.  She does complain about peripheral ankle swelling and heartburn.  She also gives a history of hemorrhoids and bladder infections in the past.  She has weight bearing joint pain as well as low back degenerating discs.  She denies obstructive sleep apnea, kidney stones, bloody bowel movements, ulcerative colitis, Crohn's disease, dark tarry stools and melena.,PHYSICAL EXAMINATION:  ,On examination temperature is 97.7, pulse 84, blood pressure 126/80, respiratory rate was 20.  Well nourished, well developed in no distress.  Eye exam, pupils equal round and reactive to light.  Extraocular motions intact.  Neuro exam deep tendon reflexes 1+ in the lower extremities.  No focal neuro deficits noted.  Neck exam nonpalpable thyroid, midline trachea, no cervical lymphadenopathy, no carotid bruit.  Lung exam clear breath sounds throughout without rhonchi or wheezes however diminished.  Cardiac exam regular rate and rhythm without murmur or bruit.  Abdominal exam positive bowel sounds, soft, nontender, obese, nondistended abdomen.  No palpable tenderness.  No right upper quadrant tenderness.  No organomegaly appreciated.  No obvious hernias noted.  Lower extremity exam +1 edema noted.  Positive dorsalis pedis pulses.,ASSESSMENT: , The patient is a 56-year-old female who presents to the bariatric surgery service with a body mass index of 41 with obesity related comorbidities.  The patient is interested in gastric bypass surgery.  The patient appears to be an excellent candidate and would benefit greatly in the management of her comorbidities.,PLAN: , In preparation for surgery will obtain the usual baseline laboratory values including baseline vitamin levels.  Will proceed with our usual work up with an upper GI series as well as consultations with the dietician and the psychologist preoperatively.  I have recommended six weeks of Medifast for the patient to obtain a 10% preoperative weight loss.",5
"OPERATIONS/PROCEDURES,1.  Insertion of right internal jugular Tessio catheter.,2.  Placement of left wrist primary submental arteriovenous fistula.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring lines were placed.  The right neck, chest and left arm were prepped and draped in a sterile fashion.  A small incision was made at the top of the anterior jugular triangle in the right neck.  Through this small incision, the right internal jugular vein was punctured and a guidewire was placed.  It was punctured a 2nd time, and a 2nd guidewire was placed.  The Tessio catheters were assembled.  They were measured for length.  Counter-incisions were made on the right chest.  They were then tunneled through these lateral chest wall incisions to the neck incision, burying the Dacron cuffs.  They were flushed with saline.  A suture was placed through the guidewire, and the guidewire and dilator were removed.  The arterial catheter was then placed through this, and the tear-away introducer was removed.  The catheter aspirated and bled easily.  It was flushed with saline and capped.  This was repeated with the venous line.  It also aspirated easily and was flushed with saline and capped.  The neck incision was closed with a 4-0 Tycron, and the catheters were sutured at the exit sites with 4-0 nylon.  Dressings were applied.  An incision was then made at the left wrist.  The basilic vein was dissected free, as was the radial artery.  Heparin was given, 50 mg.  The radial artery was clamped proximally and distally with a bulldog.  It was opened with a #11 blade and Potts scissors, and stay sutures of 5-0 Prolene were placed.  The vein was clipped distally, divided and spatulated for anastomosis.  It was sutured to the radial artery with a running 7-0 Prolene suture.  The clamps were removed.  Good flow was noted through the artery.  Protamine was given, and the wound was closed with interrupted 3-0 Dexon subcutaneous and a running 4-0 Dexon subcuticular on the skin.  The patient tolerated the procedure well.",37
"INDICATION: , Aortic stenosis.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION:  ,Procedure and complications explained to the patient in detail.  Informed consent was obtained.  The patient was anesthetized in the throat with lidocaine spray.  Subsequently, 3 mg of IV Versed was given for sedation.  The patient was positioned and transesophageal probe was introduced without any difficulty.  Images were taken.  The patient tolerated the procedure very well without any complications.  Findings as mentioned below.,FINDINGS:,1.  Left ventricle is in normal size and dimension.  Normal function.  Ejection fraction of 60%.,2.  Left atrium and right-sided chambers are of normal size and dimension.,3.  Mitral, tricuspid, and pulmonic valves are structurally normal.,4.  Aortic valve reveals annular calcification with fibrocalcific valve leaflets with decreased excursion.,5.  Left atrial appendage is clean without any clot or smoke effect.,6.  Atrial septum intact.  Study was negative.,7.  Doppler study essentially benign.,8.  Aorta essentially benign.,9.  Aortic valve planimetry valve area average about 1.3 cm2 consistent with moderate aortic stenosis.,SUMMARY:,1.  Normal left ventricular size and function.,2.  Benign Doppler flow pattern.,3.  Aortic valve area of 1.3 cm2 planimetry.,",3
"PREOPERATIVE DIAGNOSIS: , Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,POSTOPERATIVE DIAGNOSIS:,  Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,PROCEDURES:,1.  Removal of antibiotic spacer.,2.  Revision total hip arthroplasty.,IMPLANTS,1.  Hold the Zimmer trabecular metal 50 mm acetabular shell with two 6.5 x 30 mm screws.,2.  Zimmer femoral component, 13.5 x 220 mm with a size AA femoral body.,3.  A 32-mm femoral head with a +0 neck length.,ANESTHESIA:  ,Regional.,ESTIMATED BLOOD LOSS: , 500 cc.,COMPLICATIONS:,  None.,DRAINS: , Hemovac times one and incisional VAC times one.,INDICATIONS:,  The patient is a 66-year-old female with a history of previous right bipolar hemiarthroplasty for trauma.  This subsequently became infected.  She has undergone removal of this prosthesis and placement of antibiotic spacer.  She currently presents for stage II reconstruction with removal of antibiotic spacer and placement of a revision total hip.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room by anesthesia personnel.  She was placed supine on the operating table.  A Foley catheter was inserted.  A formal time out was obtained in identifying the correct patient, operative site.  Preoperative antibiotics were held for intraoperative cultures.  The patient was placed into the lateral decubitus position with the right side up.  The previous surgical incision was identified.  The right lower extremity was prepped and draped in standard fashion.  The old surgical incision was reopened along its proximal extent.  Immediately encountered was a large amount of fibrous scar tissue.  Dissection was carried sharply down through this scar tissue.  Soft tissue plains were extremely difficult to visualize due to all the scarring.  There was no native tissue to orient oneself with.  We carried our dissection down through the scar tissue to what seemed to be a fascial layer.  We incised through the fascial layer down to some scarred gluteus maximus muscle and down over what was initially felt to be the greater trochanter.  Dissection was carried down through soft tissue and the distal located antibiotic spacer was exposed.  This was used as a landmark to orient remainder of the dissection.  The antibiotic spacer was exposed and followed distally to expose the proximal femur.  Dissection was continued posteriorly and proximally to expose the acetabulum.  A cobra retractor was able to be inserted across the superior aspect of the acetabulum to enhance exposure.  Once improved visualization was obtained, the antibiotic spacer was removed from the femur.  This allowed further improved visualization of the acetabulum.  The acetabulum was filled with soft tissue debris and scar tissue.  This was removed with sharp excision with a knife as well as with a rongeur and a Bovie.  Once soft tissue was removed, the acetabulum was reamed.  Reaming was started with a 46-mm reamer and carried up sequentially to prepare for 50-mm shell.  The 50 mm shell was trialed and had good stability and fit.  Attention was then turned to continue preparation of the femur.  The canal was then debrided with femoral canal curettes.  Some fibrous tissue was removed from the canal.  The length of the femoral stem was then checked with this canal curette in place.  Following x-rays, we prepared to begin reaming the femur.  This femur was reamed over a guide rod using flexible reaming rods.  The canal was reamed up to 13.5 mm distally in preparation for 14 mm stem.  The stem was selected and initially size A body was placed in trial.  The body was too tight proximally to fit.  The proximal canal was then reamed for a size AA body.  A longer stem with an anterior bow was selected and a size AA trial was assembled.  This fit nicely in the canal and had good fit and fill.  Intraoperative radiographs were obtained to determine component position.  Intraoperative radiographs revealed satisfactory length of the component past the distal of fractures in the femur.  The remainder of the trial was then assembled and the hip was relocated and trialed.  Initially, it was found to be unstable posteriorly.  We changed from a 10 degree lip liner to 20 degree lip liner.  Again, the hip was trialed and found to be unstable posteriorly.  This was due to reversion of the femoral component.  As we attempted to seat the prosthesis, the stent continued to attempt to turn in retroversion.  The stem was extracted and retrialed.  Improved stability was obtained and we decided to proceed with the real components.  A 20 degree liner was inserted into the acetabular shell.  The real femoral components were assembled and inserted into the femoral canal.  Again, the hip was trialed.  The components were found to be in relative retroversion.  The real components were then backed down and the neck was placed in the more anteversion and reinserted.  Again, the stem attempted to follow in the relative retroversion.  Along with this time, however, it was improved from previous attempts.  The femoral head trial was placed back on the components and the hip relocated.  It was taken to a range of motion and found to have improved stability compared to previous trialing.  Decision was made to accept the component position.  The real femoral head was selected and implanted.  The hip was then taken again to a range of motion.  It was stable at 90 degrees of flexion with 20 degrees of adduction and 40 degrees of internal rotation.  The patient reached full extension and had no instability anteriorly.,The wound was then irrigated again with pulsatile lavage.  Six liters of pulsatile lavage was used during the procedure.,The wound was then closed in a layered fashion.  A Hemovac drain was placed deep to the fascial layer.  The subcutaneous tissues were closed with #1 PDS, 2-0 PDS, and staples in the skin.  An incisional VAC was then placed over the wound as well.  Sponge and needle counts were correct at the close of the case.,DISPOSITION:,  The patient will be weightbearing as tolerated with posterior hip precautions.",37
"CHIEF COMPLAINT:,  Status epilepticus.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 6-year-old male who is a former 27-week premature infant who suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis.  At baseline, he can put about 2 to 4 words together in brief sentences.  His speech is not always easily understood; however, he is in a special education classroom in kindergarten.  He ambulates independently, but falls often.  He has difficulty with his left side compared to the right, and prefers to use the right upper extremity more than the left.  Mother reports he postures the left upper extremity when running.  He is being followed by Medical Therapy Unit and has also been seen in the past by Dr. X.  He has not received Botox or any other interventions with regard to his cerebral palsy.,The patient did require one shunt revision, but since then his shunt has done well.,The patient developed seizures about 2 years ago.  These occurred periodically, but they are always in the same and with the involvement of the left side more than right and he had an eye deviation forcefully to the left side.  His events, however, always tend to be prolonged.  He has had seizures as long as an hour and a half.  He tends to require multiple medications to stop them.  He has been followed by Dr. Y and was started on Trileptal.  At one point, The patient was taken off his medication for presumed failure to prevent his seizures.  He was more recently placed on Topamax since March 2007.  His last seizures were in March and May respectively.  He is worked up to a dose of 25 mg capsules, 2 capsules twice a day or about 5 mg/kg/day at this point.,The patient was in his usual state of health until early this morning and was noted to be in seizure.  His seizure this morning was similar to the previous seizures with forced deviation of his head and eyes to the left side and convulsion more on the left side than the right.  Family administered Diastat 7.5 mg x1 dose.  They did not know they could repeat this dose.  EMS was called and he received lorazepam 2 mg and then in the emergency department, 15 mg/kg of fosphenytoin.  His seizures stopped thereafter, since that time, he had gradually become more alert and is eating, and is nearly back to baseline.  He is a bit off balance and tends to be a bit weaker on the left side compared to baseline postictally.,REVIEW OF SYSTEMS: , At this time, he is positive for a low-grade fever, he has had no signs of illness otherwise.  He does have some fevers after his prolonged seizures.  He denies any respiratory or cardiovascular complaints.  There is no numbness or loss of skills.  He has no rashes, arthritis or arthralgias.  He has no oropharyngeal complaints.  Visual or auditory complaints.,PAST MEDICAL HISTORY: , Also positive for some mild scoliosis.,SOCIAL HISTORY: , The patient lives at home with mother, father, and 2 other siblings.  There are no ill contacts.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-nourished, well-hydrated male, in no acute distress.,VITAL SIGNS:  His vital signs are stable and he is currently afebrile.,HEENT:  Atraumatic and normocephalic.  Oropharynx shows no lesions.,NECK:  Supple without adenopathy.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm, no murmurs.,ABDOMEN:  Benign without organomegaly.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  The patient is alert and will follow instructions.  His speech is very dysarthric and he tends to run his words together.  He is about 50% understandable at best.  He does put words and sentences together.  His cranial nerves reveal his pupils are equal, round, and reactive to light.  His extraocular movements are intact.  His visual fields are full.  Disks are sharp bilaterally.  His face shows left facial weakness postictally.  His palate elevates midline.  Vision is intact bilaterally.  Tongue protrudes midline.,Motor exam reveals clearly decreased strength on the left side at baseline.  His left thigh is abducted at the hip at rest with the right thigh and leg straight.  He has difficulty using the left arm and while reaching for objects, shows exaggerated tremor/dysmetria.  Right upper extremity is much more on target.  His sensations are intact to light touch bilaterally.  Deep tendon reflexes are 2+ and symmetric.  When sitting up, he shows some truncal instability and tendency towards decreased truncal tone and kyphosis.  He also shows some scoliotic curve of the spine, which is mild at this point.  Gait was not tested today.,IMPRESSION: , This is a 6-year-old male with recurrent status epilepticus, left hemiparesis, history of prematurity, and intraventricular hemorrhage.  He is on Topamax, which is at a moderate dose of 5 mg/kg a day or 50 mg twice a day.  At this point, it is not clear whether this medication will protect him or not, but the dose is clearly not at maximum, and he is tolerating the dose currently.  The plan will be to increase him up to 50 mg in the morning, and 75 mg at night for 2 weeks, and then 75 mg twice daily.  Reviewed the possible side effects of higher doses of Topamax, they will monitor him for language issues, cognitive problems or excessive somnolence.  I also discussed his imaging studies, which showed significant destruction of the cerebellum compared to other areas and despite this, the patient at baseline has a reasonable balance.  The plan from CT standpoint is to continue stretching program, continue with medical therapy unit.  He may benefit from Botox.,In addition, I reviewed the Diastat protocol with parents and given the patient tends to go into status epilepticus each time, they can administer Diastat immediately and not wait the standard 2 minutes or even 5 minutes that they were waiting before.  They are going to repeat the dose within 10 minutes and they can call EMS at any point during that time.  Hopefully at home, they need to start to abort these seizures or the higher dose of Topamax will prevent them.  Other medication options would include Keppra, Zonegran or Lamictal.,FOLLOWUP: , Followup has already been scheduled with Dr. Y in February and they will continue to keep that date for followup.",5
"PREOPERATIVE DIAGNOSIS:,  Diarrhea, suspected irritable bowel.,POSTOPERATIVE DIAGNOSIS:,  Normal colonoscopy., PREMEDICATIONS: , Versed 5 mg, Demerol 75 mg IV.,REPORTED PROCEDURE:,  The rectal exam revealed no external lesions.  The prostate was normal in size and consistency.,The colonoscope was inserted into the cecum with ease.  The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, and rectum were normal.  The scope was retroflexed in the rectum and no abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,  Normal colonoscopy - no evidence of inflammatory disease, polyp, or other neoplasm.  These findings are certainly consistent with irritable bowel syndrome.",14
"PREOPERATIVE DIAGNOSES:,1.  Right carpal tunnel syndrome.,2.  Right index finger and middle fingers tenosynovitis.,POSTOPERATIVE DIAGNOSES:,1.  Right carpal tunnel syndrome.,2.  Right index finger and middle fingers tenosynovitis.,PROCEDURES PERFORMED:,1.  Right carpal tunnel release.,2.  Right index and middle fingers release A1 pulley.,TOURNIQUET TIME:  ,70 minutes.,BLOOD LOSS: , Minimal.,GROSS INTRAOPERATIVE FINDINGS:,1.  A compressed median nerve at the carpal tunnel, which was flattened.,2.  A stenosing tenosynovitis of the A1 pulley of the right index as well as middle fingers.  After the A1 pulley was released, there was evidence of some synovitis as well as some fraying of the flexor digitorum profundus as well as flexor digitorum superficialis tendons.,HISTORY:  ,This is a 78-year-old male who is complaining of right hand pain and numbness with decreased range of the middle index finger and right middle finger complaining of catching and locking.  The patient was diagnosed with carpal tunnel syndrome on bilateral hands the right being worse than the left.  He had positive EMG findings as well as clinical findings.  The patient did undergo an injection, which only provided him with temporary relief and is for this reason, he has consented to undergo the above-named procedure.,All risks as well as complications were discussed with the patient and consent was obtained.,PROCEDURE:  ,The patient was wheeled back to the operating room #1 at ABCD General Hospital on 08/29/03.  He was placed supine on the operating room table.  Next, a non-sterile tourniquet was placed on the right forearm, but not inflated.  At this time, 8 cc of 0.25% Marcaine with epinephrine was instilled into the carpal tunnel region of the volar aspect of the wrist for anesthesia.  In addition, an additional 2 cc were used on the superficial skin of the volar palm over the A1 pulley of the right index and right middle fingers.  At this time, the extremity was then prepped and draped in usual sterile fashion for this procedure.  First, we went for release of the carpal tunnel.  Approximately 2.5 cm incision was made over the volar aspect of the wrist over the carpal tunnel region.  First, dissection through the skin in the superficial fascia was performed with a self-retractor placed in addition to Ragnells retracting proximally and distally.  The palmaris brevis muscle was then identified and sharply transected.  At this time, we identified the transverse carpal tunnel ligament and a #15 blade was used to sharply and carefully release that fascia.  Once the fascia of the transverse carpal ligament was transected, the identification of the median nerve was visualized.  The resection of the ligament was taken both proximally and distally to assure complete release and it was checked thoroughly.  At this time, a neurolysis was performed and no evidence of space-occupying lesions were identified within the carpal tunnel.  At this time, copious irrigation was used to irrigate the wound.  The wound was suctioned dry.  At this time, we proceeded to the release of the A1 pulleys.  Approximately, a 1.5 cm incision was made over the A1 pulley in the volar aspect of the palm of the right index and right middle fingers.  First, we went for the index finger.  Once the skin incision was made, Metzenbaum scissor was used to longitudinally dissect the subcutaneous tissue and with Ragnell retractors we identified the A1 pulley.  A #15 blade was used to make a longitudinal slit along with A1 pulley and the Littler scissors were used to release the A1 pulley proximally as well as distally.  Once this was performed, a tendon hook was then used to wrap the tendon and release the tendons both proximally and distally and they were removed from the wound in order to check their integrity.  There was some evidence of synovitis in addition to some fraying of the both the profundus as well as superficialis tendons.  Once a thorough release was performed, copious irrigation was used to irrigate that wound.  In the similar fashion, a 1.5 cm incision was made over the volar aspect of the A1 pulley of the right middle finger.  A Littler scissor was used to bluntly dissect in the longitudinal fashion.  With the Ragnell retractors, we identified the A1 pulley of the right middle finger.,Using a #15 blade, the A1 pulley was scored with the #15 blade and the Litter scissor was used to complete the release of the A1 pulley distally and proximally.  We again placed the tendon hook around both the superficialis and the profundus tendons and they were extruded from the wound to check their integrity.  Again, there was evidence of some synovitis as well as fraying of both tendons.  The girth of both tendons and both wounds were within normal limits.  At this time, copious irrigation was used to irrigate the wound.  The patient was then asked to intraoperatively flex and extend his fingers and he was able to fully flex his fingers to make a close fit which he was not able to do preoperatively.  In addition, he was able to abduct his thumb indicating that the recurrent branch of the median nerve was intact.  At this time, #5-0 nylon was used to approximate in a vertical mattress type fashion both the carpal tunnel incision as well as the both A1 pulley incisions of the right middle finger and right index finger.  The wound closure took place after the tourniquet was released and hemostasis was obtained with Bovie cautery.  At this time, a short-arm splint was placed on the volar aspect of the wrist after it was wrapped in a sterile dressing consisting of Adaptic and Kerlix roll.  The patient was then carefully taken off of the operating room table to Recovery in stable condition.",27
"PREOPERATIVE DIAGNOSIS:  ,Right ureteropelvic junction obstruction.,POSTOPERATIVE DIAGNOSES:,1.  Right ureteropelvic junction obstruction.,2.  Severe intraabdominal adhesions.,3.  Retroperitoneal fibrosis.,PROCEDURES PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Attempted laparoscopic pyeloplasty.,3.  Open laparoscopic pyeloplasty.,ANESTHESIA:,  General.,INDICATION FOR PROCEDURE:  ,This is a 62-year-old female with a history of right ureteropelvic junction obstruction with chronic indwelling double-J ureteral stent.  The patient presents for laparoscopic pyeloplasty.,PROCEDURE: , After informed consent was obtained, the patient was taken to the operative suite and administered general anesthetic.  The patient was sterilely prepped and draped in the supine fashion after building up the right side of the OR table to aid in the patient's positioning for bowel retraction.  Hassan technique was performed for the initial trocar placement in the periumbilical region.  Abdominal insufflation was performed.  There were significant adhesions noted.  A second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a Harmonic scalpel was placed through this and adhesiolysis was performed for approximately two-and-half hours, also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus, an additional 5 mm port in the right upper quadrant subcostal and midclavicular.  After adhesions were taken down, the ascending colon was mobilized by incising the white line of Toldt and mobilizing this medially.  The kidney was able to be palpated within Gerota's fascia.  The psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter.  The uterus was grasped with a Babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction.  The renal pelvis was also identified and dissected free.  There was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes.  We were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open.  An incision was made from the right upper quadrant port extending towards the midline.  This was carried down through the subcutaneous tissue, anterior fascia, muscle layers, posterior fascia, and peritoneum.  A Bookwalter retractor was placed.  The renal pelvis and the ureter were again identified.  Fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and Bovie cautery.  The tissue was sent down to Pathology for analysis.  Please note that upon entering the abdomen, all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted.  Ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place.  The renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue.  At this point, the indwelling double-J ureteral stent was removed.  At this time, the ureter was spatulated laterally and at the apex of this spatulation a #4-0 Vicryl suture was placed.  This was brought up to the deepened portion of the pyelotomy and cystic structures were approximated.  The back wall of the ureteropelvic anastomosis was then approximated with running #4-0 Vicryl suture.  At this point, a double-J stent was placed with a guidewire down into the bladder.  The anterior wall of the uteropelvic anastomosis was then closed again with a #4-0 running Vicryl suture.  Renal sinus fat was then placed around the anastomosis and sutured in place.  Please note in the inferior pole of the kidney, there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue.  This was repaired with horizontal mattress sutures #2-0 Vicryl.  FloSeal was placed over this and the renal capsule was placed over this.  A good hemostasis was noted.  A #10 Blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis.  The initial trocar incision was closed with #0 Vicryl suture.  The abdominal incision was also then closed with running #0 Vicryl suture incorporating all layers of muscle and fascia.  The Scarpa's fascia was then closed with interrupted #3-0 Vicryl suture.  The skin edges were then closed with staples.  Please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator.  We placed the patient on IV antibiotics and pain medications.  We will obtain KUB and x-rays for stent placement.  Further recommendations to follow.",38
"IDENTIFYING DATA:  ,The patient is a 35-year-old Caucasian female who speaks English.,CHIEF COMPLAINT:  ,The patient has a manic disorder, is presently psychotic with flight of ideas, believes, ""I can fly,"" tangential speech, rapid pressured speech and behavior, impulsive behavior.  Last night, she tried to turn on the garbage disposal and put her hand in it, in the apartment shared by her husband.  She then turned on the oven and put her head in the oven and then tried to climb over the second storied  balcony.  All of these behaviors were interrupted by her husband who called 911.  He reports that she has not slept in 3 to 5 days and has not taken her meds in at least that time period.,HISTORY OF PRESENT ILLNESS:  ,The patient was treated most recently at ABCD Hospital and decompensated during that admission resulting in her 90-day LR being revoked.  After leaving ABCD approximately 01/25/2010, she stopped taking her Abilify and lithium.  Her husband states that he restrained her from jumping, ""so she would not kill herself,"" and this was taken as a statement in his affidavit.  The patient was taken to X Hospital, medically cleared, given Ativan 2 mg p.o. and transferred on an involuntary status to XYZ Hospital.  She arrives here and is today pacing on the unit and in and out of the large TV room area.  She is friendly towards the patients although sometimes raises her voice and comes too close to other patients in a rapid manner.  She is highly tangential, delusional, and disorganized.  She refused to sign all admit papers and a considerable part of her immediate history is unknown.,PAST PSYCHIATRIC HISTORY:  ,The patient was last admitted to XYZ Hospital on January 14, 2009, and discharged on January 23, 2009.  Please see the excellent discharge summary of Dr. X regarding this admission for information, which the patient is unable to give at the present.  She is currently treated by Dr. Y.  She has been involuntarily detained at least 7 times and revoked at least 6 times.  She was on XYZ Inpatient in 2001 and in 01/2009.  She states that she ""feels invincible"" when she becomes manic and this is also the description given by her husband.,MEDICAL HISTORY:  ,The patient has a history of a herniated disc in 1999.,MEDICATIONS: , Current meds, which are her outpatient meds, which she is not taking at the moment are lithium 300 mg p.o.  AM and 600 mg p.o. q.p.m., Abilify 15 mg p.o. per day, Lyrica 100 mg p.o. per day, it is not clear if she is taking Geodon as the record is conflicting in this regard.  She is being given Vicodin, is not sure who the prescriber for that medication is and it is presumably due to her history of herniated disc.  Of note, she also has a history of abusing Vicodin.,ALLERGIES:  ,Said to be PENICILLIN, LAMICTAL, and ZYPREXA.,SOCIAL AND DEVELOPMENTAL HISTORY: , The patient lives with her husband.  There are no children.  She reportedly has a college education and has 2 brothers.,SUBSTANCE AND ALCOHOL HISTORY: , Per ABCD information, the patient has a history of abusing opiates, benzodiazepines, and Vicodin.  The X Hospital tox screen of last night was positive for opiates.  Her lithium level per last night at X Hospital was 0.42 mEq/L.  She smokes nicotine, the amount is not known although she has asked and received Nicorette gum.,LEGAL HISTORY: , She had a 90-day LR, which was revoked at ABCD Hospital, 12/ 25/2009, when she quickly deteriorated.,MENTAL STATUS EXAM:,ATTITUDE: ,The patient's attitude is agitated when asked questions, loud and evasive.,APPEARANCE:,  Disheveled and moderately well nourished.,PSYCHOMOTOR: , Restless with erratic sudden movements.,EPS:,  None.,AFFECT: , Hyperactive, hostile, and labile.,MOOD: , Her mood is agitated, suspicious, and angry.,SPEECH:  ,Circumstantial and sometimes intelligible when asked simple direct questions and at other points becomes completely tangential describing issues which are not real.,THOUGHT CONTENT: , Delusional, disorganized, psychotic, and paranoid.  Suicidal ideation, the patient refuses to answer the questions, but the record shows a past history of suicide attempt.,COGNITIVE ASSESSMENT:  ,The patient was said on her nursing admit to be oriented to place and person, but could not answer that question for me, and appeared to think that she may still be at ABCD Hospital.  Her recent, intermediate, and remote memory are impaired although there is a lack of cooperation in this testing.,JUDGMENT AND INSIGHT:,  Nil.  When asked, are there situations when you lose control, she refuses to answer.  When asked, are meds helpful, she refuses to answer.  She refuses to give her family information nor release of information to contact them.,ASSETS:,  The patient has an outpatient psychiatrist and she does better or is more stable when taking her medications.,LIMITATIONS:,  The patient goes off her medications routinely, behaves unsafely and in a potentially suicidal manner.,FORMULATION,:  The patient has bipolar affective disorder in a manic state at present.  She also may be depressed and is struggling with marital issues.,DIAGNOSES:",5
"REASON FOR FOLLOWUP:,  Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.,HISTORY OF PRESENT ILLNESS: , This is a 65-year-old patient originally admitted by me several weeks ago with profound hyponatremia and mental status changes.  Her history is also significant for likely recurrent aspiration pneumonia and intubation earlier on this admission as well.  Previously while treating this patient I had met with the family and discussed how aggressive the patient would wish her level of care to be given that there was evidence of possible ovarian malignancy with elevated CA-125 and a complex mass located in the ovary.  As the patient was showing signs of improvement with some speech and ability to follow commands, decision was made to continue to pursue an aggressive level of care, treat her dysphagia, hypertension, debilitation and this was being done.  However, last night the patient had apparently catastrophic event around 2:40 in the morning.  Rapid response was called and the patient was intubated, started on pressure support, and given CPR.  This morning I was called to the bedside by nursing stating the family had wished at this point not to continue this aggressive level of care.  The patient was seen and examined, she was intubated and sedated.  Limbs were cool.  Cardiovascular exam revealed tachycardia.  Lungs had coarse breath sounds.  Abdomen was soft.  Extremities were cool to the touch.  Pupils were 6 to 2 mm, doll's eyes were not intact.  They were not responsive to light.  Based on discussion with all family members involved including both sons, daughter and daughter-in-law, a decision was made to proceed with terminal wean and comfort care measures.  All pressure support was discontinued.  The patient was started on intravenous morphine and respiratory was requested to remove the ET tube.  Monitors were turned off and the patient was made as comfortable as possible.  Family is at the bedside at this time.  The patient appears comfortable and the family is in agreement that this would be her wishes per my understanding of the family and the patient dynamics over the past month, this is a very reasonable and appropriate approach given the patient's failure to turn around after over a month of aggressive treatment with likely terminal illness from ovarian cancer and associated comorbidities.,Total time spent at the bedside today in critical care services, medical decision making and explaining options to the family and proceeding with terminal weaning was excess of 37 minutes.",34
"ADMISSION DIAGNOSIS:  ,Adenocarcinoma of the prostate.,HISTORY:,  The patient is a 71-year-old male whose personal physician, Dr. X identified a change in the patient's PSA from 7/2008 (4.2) to 4/2009 (10.5).  The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base.  The patient also had Gleason 6 in the right lobe, midportion, as well as the left apical portion.  He underwent a bone scan which was normal and cystoscopy which was normal and renal ultrasound that was normal.,SURGICAL HISTORY: , Appendectomy.,MEDICAL HISTORY:,  Atrial fibrillation.,MEDICATIONS:,  Coumadin and lisinopril.,SOCIAL HISTORY:  ,Smokes none.  Alcohol none.,ALLERGIES:,  NONE.,REVIEW OF SYSTEMS: , The patient relates no recent weight gain, weight loss, night sweats, fevers or chills.  Eyes:  No change in vision or diplopia.  Ears:  No tinnitus or vertigo.  Mouth:  No dysphagia.  Pulmonary:  No chronic cough or shortness of breath.  Cardiac:  No angina or palpitations.  GI:  No nausea, vomiting, diarrhea or constipation.  Musculoskeletal:  No arthritides or myalgias.  Hematopoietic:  No easy bleeding or bruising.  Skin:  No chronic ulcers or persistent itch.,PHYSICAL EXAMINATION:,GENERAL:  The patient is well developed and well nourished.,HEENT:  Head is normocephalic.  Eyes, pupils are equal.  Conjunctivae are pink.  Sclerae are anicteric.,NECK:  There is no adenopathy.,PULMONARY:  Respirations are unlabored.,HEART:  Regular rhythm.,ABDOMEN:  Liver, spleen, kidney, and bladder are not palpable.  There are no discernible masses.  There are no peritoneal signs.,GENITALIA:  The penis has no plaques.  Meatus is on the glans.  Scrotal skin is healthy.  Testicles are fair consistency.  Epididymides are nontender.,RECTAL:  The prostate is +1 to 2/4.  There are no areas that are suspicious for tumor.  Consistency is even.  Sidewalls are sharp.  Seminal vesicles are not palpable.,MUSCULOSKELETAL:  The upper and lower extremities are symmetric bilaterally.,NEUROLOGIC:  There are no gross focal neurologic abnormalities.,IMPRESSION:,1.  Adenocarcinoma of the prostate.,2.  Atrial fibrillation.,PLAN: , The patient's wife and I have discussed his treatment options, which include primarily radiation and surgery.  He has _________ surviving prostate cancer by Dr. Y.  He is aware of incontinency, both total and partial.  We discussed erectile dysfunction.  We have discussed bleeding, infection, injury to the rectum, injury to vessels and nerves, deep vein thrombosis, pulmonary embolus, MI, stroke, and death.  He had no questions at the conclusion of the conversation and he does know that in his age group, though a nerve-sparing procedure will be performed, preserving any erectile function is highly unlikely.  He had no questions at the conclusion of our last conversation.",5
"PREOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,POSTOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,PROCEDURE PERFORMED: , Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,ANESTHESIA:,  LMA.,EBL: , Minimal.,FLUIDS: , Crystalloid.  The patient was given antibiotics, 1 g of Ancef and the patient was on oral antibiotics at home.,BRIEF HISTORY: , The patient is a 61-year-old female with history of recurrent uroseptic stones.  The patient had stones x2, 1 was already removed, second one came down, had recurrent episode of sepsis, stent was placed.  Options were given such as watchful waiting, laser lithotripsy, shockwave lithotripsy etc.  Risks of anesthesia, bleeding, infection, pain, need for stent, and removal of the stent were discussed.  The patient understood and wanted to proceed with the procedure.,DETAILS OF THE PROCEDURE: , The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A 0.035 glidewire was placed in the left system.  Using graspers, left-sided stent was removed.  A semirigid ureteroscopy was done.  A stone was visualized in the mid to upper ureter.  Using laser, the stone was broken into 5 to 6 small pieces.  Using basket extraction, all the pieces were removed.  Ureteroscopy all the way up to the UPJ was done, which was negative.  There were no further stones.  Using pyelograms, the rest of the system appeared normal.  The entire ureter on the left side was open and patent.  There were no further stones.  Due to the edema and the surgery, plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours.  Over the 0.035 glidewire, a 26 double-J stent was placed.  There was a nice curl in the kidney and one in the bladder.  The patient tolerated the procedure well.  Please note that the string was kept in place and the patient was to remove the stent the next day.  The patient's family was instructed how to do so.  The patient had antibiotics and pain medications at home.  The patient was brought to recovery room in a stable condition.",21
"PROCEDURES:, Cystourethroscopy and transurethral resection of prostate.,COMPLICATIONS:, None.,ADMITTING DIAGNOSIS:, Difficulty voiding.,HISTORY:, This 67-year old Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction.  Physical examination revealed normal heart and lungs.  Abdomen was negative for abnormal findings.  ,LABORATORY DATA:, BUN 19 and creatinine 1.1.  Blood group was A, Rh positive, Hemoglobin 13, Hematocrit 32.1, Prothrombin time 12.6 seconds, PTT 37.1.  Discharge  hemoglobin 11.4, and hematocrit 33.3.  Chest x-ray calcified old granulomatous disease, otherwise normal.  EKG was normal.  ,COURSE IN THE HOSPITAL:, The patient had a cysto and TUR of the prostate.  Postoperative course was uncomplicated. The pathology report is pending at the time of dictation.  He is being discharged in satisfactory condition with a good urinary stream, minimal hematuria, and on Bactrim DS one a day for ten days with a standard postprostatic surgery instruction sheet.  ,DISCHARGE DIAGNOSIS: , Enlarged prostate with benign bladder neck obstruction.  ,To be followed in my office in one week and by Dr. ABC next available as an outpatient.",38
"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.",0
"PREOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Hypermenorrhea.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Hypermenorrhea.,3.  Mild pelvic endometriosis.,PROCEDURE PERFORMED:,1.  Dilatation and curettage (D&C).,2.  Laparoscopic ablation of endometrial implants.,ANESTHESIA:  ,General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMEN: , Endometrial curettings.,INDICATIONS: , This is a 26-year-old female with a history of approximately one year of heavy painful menses.  She did complain of some dyspareunia and wants a definitive diagnosis.,FINDINGS: , On bimanual exam, the uterus is small and anteverted with mildly decreased mobility on the left side.  There are no adnexal masses appreciated.  On laparoscopic exam, the uterus is normal appearing but slightly compressible.  The bilateral tubes and ovaries appear normal.  There is evidence of endometriosis on the left pelvic sidewall in the posterior cul-de-sac.  There was no endometriosis in the right pelvic sidewall or along the bladder flap.,There were some adhesions on the right abdominal sidewall from the previous appendectomy.  The liver margin, gallbladder, and bowel appeared normal.  The uterus was sounded to 9 cm.,PROCEDURE: , After consent was obtained, the patient was taken to the operating room and general anesthetic was administered.  The patient was placed in dorsal lithotomy position and prepped and draped in normal sterile fashion.  Sterile speculum was placed in the patient's vagina.  The anterior lip of the cervix was grasped with vulsellum tenaculum.  The uterus was sounded to 9 cm.  The cervix was then serially dilated with Hank dilators.  A sharp curettage was performed until a gritty texture was noted in all aspects of the endometrium.  The moderate amount of tissue that was obtained was sent to Pathology.  The #20 Hank dilator was then replaced and the sterile speculum was removed.  Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made.  The Veress needle was placed into this incision and the gas was turned on.  When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate.  The #11 mm trocar was then placed through this incision and a camera was placed with the above findings noted.  A Bierman needle was placed 2 cm superior to the pubic bone and along the midline to allow a better visualization of the pelvic organs.  A 5 mm port was placed approximately 7 cm to 8 cm to the right of the umbilicus and approximately 3 cm inferior.  The harmonic scalpel was placed through this port and the areas of endometriosis were ablated using the harmonic scalpel.  A syringe was placed on to the Bierman needle and a small amount of fluid in the posterior cul-de-sac was removed to allow better visualization of the posterior cul-de-sac.  The lesions in the posterior cul-de-sac were then ablated using the Harmonic scalpel.  All instruments were then removed.  The Bierman needle and 5 mm port was removed under direct visualization with excellent hemostasis noted.  The camera was removed and the abdomen was allowed to desufflate.  The 11 mm trocar introducer was replaced and the trocar was removed.  The skin was closed with #4-0 undyed Vicryl in subcuticular fashion.  ,Approximately 10 cc of 0.25% Marcaine was placed in the incision sites.  The dilator and vulsellum tenaculum were removed from the patient's cervix with excellent hemostasis noted.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct at the end of procedure.  The patient was taken to the recovery room in satisfactory condition.  She will be discharged home with a prescription for Darvocet for pain and is instructed to follow up in the office in two weeks with further treatment will be discussed including approximately six months of continuous monophasic oral contraceptives.",37
"REASON FOR CONSULTATION: , Post-surgical medical management.,PROCEDURE DONE: , Right total knee replacement.,MEDICAL HISTORY:,1.  Arthritis of the right knee.,2.  Hypertension.,PAST SURGICAL HISTORY: , Hysterectomy, Cesarean section, left hip arthroplasty, and breast biopsy.,MEDICATIONS: , Hyzaar 12.5 mg p.o. daily, Femara 2.5 mg p.o. daily, Fosamax 70 mg p.o. every week, aspirin 81 mg p.o. daily, and vitamin.,ALLERGIES: , MORPHINE.,HISTORY OF PRESENT COMPLAINT: , This 84-year-old patient with history of arthritis underwent right total knee replacement yesterday.  The patient is admitted today to the surgical floor for postoperative management.  The patient tolerated the procedure well.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever, chills, or malaise.,ENT:  Unremarkable.,RESPIRATORY:  The patient denies shortness of breath, cough, or wheezing.,CARDIOVASCULAR:  No known heart problems.  No orthopnea, palpitations, syncopal episode, or pedal swelling.,GASTROINTESTINAL:  She denies nausea or vomiting.  No history of GI bleed.,GENITOURINARY:  No dysuria, no hematuria.,ENDOCRINE:  Negative for diabetes or thyroid problems.,NEUROLOGICAL:  No history of seizure or TIA.  Cognitive function is intact.,SOCIAL HISTORY:  ,The patient does not smoke.  She consumes alcohol moderately.,FAMILY HISTORY:  ,Positive for cancer.,PHYSICAL EXAMINATION:,GENERAL:  This is an 84-year-old lady who looks young for her age.,VITAL SIGNS:  Blood pressure of 138/53, pulse is 73, respiratory rate of 20, and O2 saturation is 95% on room air.  She is afebrile.,HEAD AND NECK:  Face is symmetrical.  Cranial nerves are intact.  No distended neck veins.  No palpable neck masses.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur is appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive.,EXTREMITIES:  There is no pedal swelling.,LABORATORY DATA:  ,Hemoglobin has dropped from 12.6 to 10.2.  Hematocrit is 30.  Glucose is 125.  BUN is 15.9, creatinine is 0.6, sodium is 134, and potassium is 3.8.,ASSESSMENT AND PLAN:,1.  Right knee arthritis status post right total knee replacement.  The patient tolerated the procedure well.,2.  Anemia due to stated operative blood loss, would not require transfusion at this point.,3.  Hypertension, under control.  Continue current home medications.,4.  Deep vein thrombosis risk, prophylaxis as per surgeon.,5.  Gastrointestinal prophylaxis.,6.  Debility.  Continue physical therapy and occupational therapy.",5
"EXAM: , Two views of the soft tissues of the neck.,HISTORY:,  Patient has swelling of the left side of his neck.,TECHNIQUE:,  Frontal and lateral views of the soft tissues of the neck were evaluated. There were no soft tissues of the neck radiographs for comparison. However, there was an ultrasound of the neck performed on the same day.,FINDINGS: , Frontal and lateral views of the soft tissues of the neck were evaluated and reveal there is an asymmetry seen to the left-sided soft tissues of the patient's neck which appear somewhat enlarged when compared to patient's right side. However the trachea appears to be normal caliber and contour.  Lateral views show a patent airway. The adenoids and tonsils appear normal caliber without evidence of hypertrophy. Airway appears patent. Osseous structures appear grossly normal.,IMPRESSION:,1. Patent airway. No evidence of any soft tissue swelling involving the patient's adenoids/tonsils, epiglottis or aryepiglottic folds. No evidence of any prevertebral soft tissue swelling.,2. Slight asymmetry seen to the soft tissues of the left side of the patient's neck which appears somewhat larger when compared to the right side.",33
"PREOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,POSTOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,PROCEDURES:,1. Repair of XXX upper lid laceration.,2. Repair of XXX upper lid canalicular laceration.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with XXX eye upper eyelid laceration involving the canaliculus.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient was brought to the operating room and placed in the supine position, where (s)he was prepped and draped in the routine fashion for general ophthalmic plastic reconstructive surgery, once the appropriate cardiac and respiratory monitoring was placed on him/her, and once general endotracheal anesthetic had been administered. The patient then had the wound freshened up with Westcott scissors and cotton-tip applications. Hemostasis was achieved with a high-temp disposable cautery. Once this had been done, the proximal end of the XXX upper lid canalicular system was intubated with a Monoka tube on a Prolene. The proximal end was then found and this was intubated with the same tubing system. Then, two 6-0 Vicryl sutures were used to reapproximate the medial canthal tendon. Once this had been done, the skin was reapproximated with interrupted 6-0 Vicryl sutures and interrupted 6-0 plain gut sutures. To ensure that the punctum was in the correct position and in the Monoka tube was seated with a seater, and the tube was cut short. The patient's nose was suctioned of blood, and (s)he was awakened from general endotracheal anesthesia and did well. (S)he left the operating room in good condition.",37
"REASON FOR VISIT: , This is a cosmetic consultation.,HISTORY OF PRESENT ILLNESS:,  The patient is a very pleasant 34-year-old white female who is a nurse in the operating room.  She knows me through the operating room and has asked me to possibly perform cosmetic surgery on her.  She is very bright and well informed about cosmetic surgery.  She has recently had some neck surgery for a re-fusion of her neck and is currently on methadone for chronic pain regarding this.  Her current desires are that she obtain a breast augmentation and liposuction of her abdomen, and she came to me mostly because I offer transumbilical breast augmentation.  Her breasts are reportedly healthy without any significant problems.  Her weight is currently stable.,PAST MEDICAL AND SURGICAL HISTORY: ,  Negative.  Past surgical history is significant for a second anterior cervical fusion and diskectomy in 02/05 and in 09/06.  She has had no previous cosmetic or aesthetic surgery.,FAMILY HISTORY AND SOCIAL HISTORY:,  Significant for Huntington disease in her mother and diabetes in her father.  Her brother has an aneurysm.  She does occasionally smoke and has been trying to quit recently.  She is currently smoking about a pack a day.  She drinks about once a week.  She is currently a registered nurse, circulator, and scrub technician in the operating room at Hopkins.  She has no children.,REVIEW OF SYSTEMS:  ,A 12-system review is significant for some musculoskeletal pain, mostly around her neck and thoracic region.  She does have occasional rash on her chest and problems with sleep and anxiety that are related to her chronic pain.  She has considered difficult airway due to anterior cervical disk fusion and instability.  Her last mammogram was in 2000.  She has a size 38C breast.,MEDICATIONS: , Current medications are 5 mg of methadone three times a day and amitriptyline at night as needed.,ALLERGIES: , None.,FINDINGS: , On exam today, the patient has good posture, good physique, good skin tone.  She is tanned.  Her lower abdomen has some excess adiposity.  There is some mild laxity of the lower abdominal skin.  Her umbilicus is oval shaped and of adequate caliber for a transumbilical breast augmentation.  There was no piercing in that region.  Her breasts are C shaped.  They are not ptotic.  They have good symmetry with no evidence of tubular breast deformity.  She has no masses or lesions noted.  The nipples are of appropriate size and shape for a woman of her age.  Her scar on her neck from her anterior cervical disk fusion is well healed.  Hopefully, our scars would be similar to this.,IMPRESSION AND PLAN: , Hypomastia.  I think her general physique and body habitus would accommodate about 300 to 350 cubic centimeter implant nicely.  This would make her fill out her clothes much better, and I think transumbilical technique in her is a good option.  I have discussed with her the other treatment options, and she does not want scars around her breasts if at all possible.  I think her lower abdominal skin is of good tone.  I think suction lipectomy in this region would bring down her size and accentuate her waist nicely.  I am a little concerned about the lower abdominal skin laxity, and I will discuss with her further that in the near future if this continues to be a problem, she may need a mini tummy tuck.  I do think that a liposuction is a reasonable alternative and we could see how much skin tightening she gets after the adiposity is removed.  I will try to set this up in the near future.  I will try to set this up to get the instrumentation from the instrumentation rep for the transumbilical breast augmentation procedure.  Due to her neck issues, we may not be able to perform her surgery but I will check with Dr. X to see if she is comfortable giving her deep sedation and no general anesthetic with her neck being fused.",6
"PROBLEM LIST:,1.  Generalized osteoarthritis and osteoporosis with very limited mobility.,2.  Adult failure to thrive with history of multiple falls, none recent.,3.  Degenerative arthritis of the knees with chronic bilateral knee pain.,4.  Chronic depression.,5.  Hypertension.,6.  Hyperthyroidism.,7.  Aortic stenosis with history of CHF and bilateral pleural effusions.,8.  Right breast mass, slowly enlarging.  Patient refusing workup.,9.  Status post ORIF of the right wrist, now healed.,10.  Anemia of chronic disease.,11.  Hypoalbuminemia.,12.  Chronic renal insufficiency.,CURRENT MEDICATIONS:,  Acetaminophen 325 mg 2 tablets twice daily, Coreg 6.25 mg twice daily, Docusate sodium 100 mg 1 cap twice daily, ibuprofen 600 mg twice daily with food, Lidoderm patch 5% to apply 1 patch to both knees every morning and off in the evening, one vitamin daily, ferrous sulfate 325 mg daily, furosemide 20 mg q.a.m., Tapazole 5 mg daily, potassium chloride 10 mEq daily, Zoloft 50 mg daily, Ensure t.i.d., and p.r.n. medications.,ALLERGIES:,  NKDA.,CODE STATUS:,  DNR, healthcare proxy, durable power of attorney.,DIET:,  Regular with regular consistency with thin liquids and ground meat.,RESTRAINTS: , None.  She does have a palm protector in her right hand.,INTERVAL HISTORY:,  No significant change over the past month has occurred.  The patient mainly complains about pain in her back.  On a scale from 1 to 10, it is 8 to 10, worse at night before she goes to bed.  She is requesting something more for the pain.  Other than that, she complains about her generalized pain.  There has been no significant change in her weight.  No fever or chills.  No complaint of headaches or visual changes, chest pain, shortness of breath, dyspnea on exertion, orthopnea, or PND.  No hemoptysis or night sweats.  No change in her bowels, abdominal pain, bright red rectal bleeding, or melena.  No nausea or vomiting.  Her appetite is fair.  She is a picky eater but definitely likes her candy.  There has been no change in her depression.  It seems to be stable on the Zoloft 50 mg daily, which she has been on since October 17, 2006.  She denies feeling depressed to me but complains of being bored, stating she just sits and watches TV or sometimes may go to activities but not very seldom due to her back pain.  No history of seizures.  She denies any tremors.  She is hyperthyroid and is on replacement.,PHYSICAL EXAMINATION: , An elderly female, sitting in a wheelchair, in no acute distress, very kyphotic.  She is very pleasant and alert.  Vital signs per chart.  Skin is normal in texture and turgor for her age.  She does have dry lips, which she picks at and was picking at her lips while I was talking with her.  HEENT:  Normocephalic, atraumatic.  She has nevi above her left eye, which she states she has had since birth and has not changed.  Pupils are equal, round and reactive to light and accommodation.  No exophthalmos or lid lag.  Anicteric sclerae.  Conjunctivae pink, nasal passages clear.  She is edentulous but does have her upper dentures in.  No mucosal ulcerations.  External ears normal.  Neck is supple.  No increased JVD, cervical or supraclavicular adenopathy.  No thyromegaly or masses.  Trachea is midline.  Her chest is very kyphotic, clear to A&P.  Heart:  Regular rate and rhythm with a 2-3/6 systolic murmur heard best at the left sternal border.  Abdomen:  Soft.  Good bowel sounds.  Nontender.  Unable to appreciate any organomegaly or masses as she is sitting in a wheelchair.  Extremities are without edema, cyanosis, clubbing, or tremor.  She does have Lidoderm patches over both of her knees and is wearing a brace in her right hand.,LABORATORY TESTS: , Albumin was 3.2 on 12/06/06.  Dietary is aware.  Electrolytes done 11/28/06, her sodium was 144, potassium 4.4, chloride 109, bicarbonate 26, anion gap 9, BUN 28, creatinine 1.2, GFR 44.  Digoxin was done and was less than 0.9, but she is not on digoxin.  CBC showed a white count of 7400, hemoglobin 11.1, hematocrit 35.9, MCV of 95.2, and platelet count of 252,000.  Her TSH was 1.52.  No changes were made in her Tapazole.,ASSESSMENT AND PLAN:,  We will continue present therapy except we will add Tylenol No.  3 to take 1 tablet before bed as needed for her back pain.  If she does develop drowsiness from this, then the CNS side effects will help her sleep.  During the day, her daughter likes the patient to remain alert and will use the ibuprofen at that time as long as she does not develop any GI symptoms.  We will make sure that she is taking the ibuprofen with food.  No further laboratory tests will be done at this time.",5
"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.",37
"REASON FOR VISIT:,  Syncope.,HISTORY:,  The patient is a 75-year-old lady who had a syncopal episode last night.  She went to her room with a bowl of cereal and then blacked out for a few seconds and then when she woke up, the cereal was on the floor.  She did not have any residual deficit.  She had a headache at that time.  She denies chest pains or palpitations.,PAST MEDICAL HISTORY: , Arthritis, first episode of high blood pressure today.  She had a normal stress test two years ago.,MEDICATIONS: , Her medication is one dose of hydrochlorothiazide today because her blood pressure was so high at 150/70.,SOCIAL HISTORY: , She does not smoke and she does not drink.  She lives with her daughter.,PHYSICAL EXAMINATION:,GENERAL:  Lady in no distress.,VITAL SIGNS:  Blood pressure 172/91, came down to 139/75, heart rate 91, and respirations 20.  Afebrile.,HEENT:  Head is normal.,NECK:  Supple.,LUNGS:  Clear to auscultation and percussion.,HEART:  No S3, no S4, and no murmurs.,ABDOMEN:  Soft.,EXTREMITIES:  Lower extremities, no edema.,DIAGNOSTIC DATA: , Her EKG shows sinus rhythm with nondiagnostic Q-waves in the inferior leads.,ASSESSMENT:  ,Syncope.,PLAN:  ,She had a CT scan of the brain that was negative today.  The blood pressure is high.  We will start Maxzide.  We will do an outpatient Holter and carotid Doppler study.  She has had an echocardiogram along with the stress test before and it was normal.  We will do an outpatient followup.",5
"FINAL DIAGNOSIS: ,I. Ligature strangulation.,A. Circumferential ligature with associated ligature furrow of neck.,B. Abrasions and petechial hemorrhages, neck.,C. Petechial hemorrhages, conjunctival surfaces of eyes and skin of face.,II. Craniocerebral injuries.,A. Scalp contusion.,B. Linear, comminuted fracture of right side of skull.,C. Linear pattern of contusions of right cerebral hemisphere.,D. subarachnoid and subdural hemorrhage.,E. Small contusions, tips of temporal lobes.,III. Abrasion of right cheek.,IV. Abrasion/contusion, posterior right shoulder.,V. Abrasions of left lower back and posterior left lower leg.,VI. Abrasion and vancular congestion of vaginal mucosa.,VII. Ligature of right wrist.,TOXICOLOGIC STUDIES ,Blood ethanol - none detected.,Blood drug screen - no drugs detected.,CLINOCOPATHOLIGICAL CORRELATION:, Cause of death of this six year old female is asphyxia by strangulation associated with craniocerebral trauma. ,The body of this six year old female was first seen by me after I was called to an address XYZ, on 12/26/96. I arrived at the scene approximately 8 PM on 12/26 and entered the house where the decedent's body was located at approximately 8:20 PM. ,A brief examination of the body disclosed a ligature around the neck and a ligature around the right wrist. Also noted was a small area of abrasion or contusion below the right ear on the lateral aspect of the right cheek. A prominent dried abrasion was present on the lower left neck. After examining the body, I left the residence at approximately 8:30 PM. ,EXTERNAL EVIDENCE OF INJURY:, Located just below the right ear at the right angle of the mandible, 1.5 inches below the right external auditory canal is a 3/8 x 1/4 inch area of rust colored abrasion. In the lateral aspect of the left lower eyelid on the inner conjunctival surface is a 1 mm in maximum dimension petechial hemorrhage. Very fine, less than 1 mm petechial hemorrhages are present on the skin of the upper eyelids bilaterally as well as on the lateral left cheek. On everything the left upper eyelid there are much smaller, less than 1 mm petechial hemorrhages located on the conjunctival surface. Possible petechial hemorrhages are also seen on the conjunctival surfaces of the right upper and lower eyelids, but liver mortis on this side of the face makes definite identification difficult. ,A deep ligature furrow encircles the entire neck. The width of the furrow varies from one- eight of an inch to five/sixteenths of an inch and is horizontal in orientation, with little upward deviation. The skin of the anterior neck above and below the ligature furrow contains areas of petechial hemorrhage and abrasion encompassing an area measuring approximately 3 x 2 inches. The ligature furrow crosses the anterior midline of the neck just below the laryngeal prominence, approximately at the level of the cricoid cartilage. It is almost completely horizontal with slight upward deviation from the horizontal towards the back of the neck. The midline of the furrow mark on the anterior neck is 8 inches below the top of the head. The midline of the furrow mark on the posterior neck is 6.75 inches below the top of the head. ,The area of abrasion and petechial hemorrhage of the skin of the anterior neck includes on the lower left neck, just to the left of the midline, a roughly triangular, parchment-like rust colored abrasion which measures 1.5 inches in length with a maximum width of 0.75 inches. This roughly triangular shaped abrasion is obliquely oriented with the apex superior and lateral. The remainder of the abrasions and petechial hemorrhages of the skin above and below the anterior projection of the ligature furrow are nonpatterned, purple to rust colored, and present in the midline, right, and left areas of the anterior neck. The skin just above the ligature furrow along the right side of the neck contains petechial hemorrhage composed of multiple confluent very small petechial hemorrhages as well as several larger petechial hemorrhages measuring up to one-sixteenth and one-eight of an inch in maximum dimension. Similar smaller petechial hemorrhages are present on the skin below the ligature furrow on the left lateral aspect of the neck. Located on the right side of the chin is a three-sixteenths by one-eight of an inch area of superficial abrasion. On the posterior aspect of the right shoulder is a poorly demarcated, very superficial focus of abrasion/contusion which is pale purple in color and measures up to three-quarters by one-half inch in maximum dimension. Several linear aggregates of petechial hemorrhages are present in the anterior left shoulder just above deltopectoral groove. These measure up to one inch in length by one-sixteenth to one-eight of an inch in width. On the left lateral aspect of the lower back, approximately sixteen and one-quarter inches and seventeen and one-half inches below the level of the top of the head are two dried rust colored to slightly purple abrasions. The more superior of the two measures one-eight by one-sixteenth of an inch and the more inferior measures three-sixteenths by one-eight of an inch. There is no surrounding contusion identified. On the posterior aspect of the left lower leg, almost in the midline, approximately 4 inches above the level of the heel are two small scratch-like abrasions which are dried and rust colored. They measure one-sixteenth by less than one- sixteenth of an inch and one-eight by less than one-sixteenth of an inch respectively. ,On the anterior aspect of the perineum, along the edges of closure of the labia majora, is a small amount of dried blood. A similar small amount of dried and semifluid blood is present on the skin of the fourchette and in the vestibule. Inside the vestibule of the vagina and along the distal vaginal wall is reddish hyperemia. This hyperemia is circumferential and perhaps more noticeable on the right side and posteriorly. The hyperemia also appears to extend just inside the vaginal orifice. A 1 cm red-purple area of abrasion is located on the right posterolateral area of the 1 x 1 cm hymeneal orifice. The hymen itself is represented by a rim of mucosal tissue extending clockwise between the 2 and 10:00 positions. The area of abrasion is present at approximately the 7:00 position and appears to involve the hymen and distal right lateral vaginal wall and possibly the area anterior to the hymen. On the right labia majora is a very faint area of violent discoloration measuring approximately one inch by three-eighths of an inch. Incision into the underlying subcutaneous tissue discloses no hemorrhage. A minimal amount of semiliquid thin watery red fluid is present in the vaginal vault. No recent or remote anal or other perineal trauma is identified. ,REMAINDER OF EXTERNAL EXAMINATION:, The unembalmed, well developed and well nourished Caucasian female body measures 47 inches in length and weighs an estimated 45 pounds. ,No scalp trauma is identified. The external auditory canals are patent and free of blood. The eyes are green and the pupils equally dilated. The sclerae are white. The nostrils are both patent and contain a small amount of tan mucous material. The teeth are native and in good repair. The tongue is smooth, pink-tan and granular. No buccal mucosal trauma is seen. The frenulum is intact. There is slight drying artifact of the tip of the tongue. On the right cheek is a pattern of dried saliva and mucous material which does not appear to be hemorrhagic. The neck contains no palpable adenopathy or masses and the trachea and larynx are midline. The chest is symmetrical. Breasts are prepubescent. The abdomen is flat and contains no scars. No palpable organomegaly or masses are identified. The external genitalia are that of a prepubescent female. No pubic hair is present. The anus is patent. Examination of the extremities is unremarkable. ,The fingernails of both hands are of sufficient length for clipping. Examination of the back is unremarkable. There is dorsal 3+ to 4+ livor mortis which is nonblanching. Livor mortis is also present on the right side of the face. At the time of the initiation of the autopsy there is mild 1 to 2+ rigor mortis of the elbows and shoulders with more advanced 2 to 3+ rigor mortis of the joints of the lower extremities. ,INTERNAL EXAM:, The anterior chest musculature is well developed. No sternal or rib fractures are identified. ,MEDIASTINUM: ,The mediastinal contents are normally distributed. The 21 gm thymus gland has a normal external appearance. The cut sections are finely lobular and pink-tan. No petechial hemorrhages are seen. The aorta and remainder of the mediastinal structures are unremarkable. ,BODY CAVITIES: ,The right and left thoracic cavities contain approximately 5 cc of straw colored fluid. The pleural surfaces are smooth and glistening. The pericardial sac contains 3-4 cc of straw colored fluid and the epicardium and pericardium are unremarkable. The abdominal contents are normally distributed and covered by a smooth glistening serosa. No intra-abdominal accumulation of fluid or blood is seen. ,LUNGS: ,The 200 gm right lung and 175 gm let lung have a normal lobar configuration. An occasional scattered subpleural petechial hemorrhage is seen on the surface of each lung. The cut sections of the lungs disclose an intact alveolar architecture with a small amount of watery fluid exuding from the cut surfaces with mild pressure. The intrapulmonary bronchi and vasculature are unremarkable. No evidence of consolidation is seen. ,HEART: ,The 100 gm heart has a normal external configuration. There are scattered subepicardial petechial hemorrhages over the anterior surface of the heart. The coronary arteries are normal in their distribution and contain no evidence of atherosclerosis. The tan- pink myocardium is homogeneous and contains no areas of fibrosis or infarction. The endocardium is unremarkable. The valve cusps are thin, delicate and pliable and contain no vegetation or thrombosis. The major vessels enter and leave the heart in the normal fashion. The foramen ovale is closed. ,AORTA AND VENA CAVA: ,The aorta is patent throughout its course as are its major branches. No atherosclerosis is seen. The Vena Cava is unremarkable. ,SPLEEN: ,The 61 gm spleen has a finely wrinkled purple capsule. Cut sections are homogeneous and disclose readily identifiable red and white pulp. No intrinsic abnormalities are identified. ,ADRENALS: ,The adrenal glands are of normal size and shape. A golden yellow cortex surmounts a thin brown-tan medullary area. No intrinsic abnormalities are identified. ",1
"PREOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,PROCEDURE PERFORMED:  ,Total hip arthroplasty on the left.,ANESTHESIA:  ,General.,BLOOD LOSS: , 800 cc.,The patient was positioned with the left hip exposed on the beanbag.,IMPLANT SPECIFICATION: , A 54 mm Trilogy cup with cluster holes 3 x 50 mm diameter with a appropriate liner, a 28 mm cobalt-chrome head with a zero neck length head, and a 12 mm porous proximal collared femoral component.,GROSS INTRAOPERATIVE FINDINGS:  ,Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes.  The patient also had a rent in the attachment of the hip abductors and a partial rent in the vastus lateralis.  This was revealed once we removed the trochanteric bursa.,HISTORY:  ,This is a 56-year-old obese female with a history of bilateral degenerative hip arthritis.  She underwent a right total hip arthroplasty by Dr. X in the year of 2000, and over the past three years, the symptoms in her left hip had increased tremendously especially in the past few months.,Because of the increased amount of pain as well as severe effect on her activities of daily living and uncontrollable pain with narcotic medication, the patient has elected to undergo the above-named procedure.  All risks as well complications were discussed with the patient including but not limited to infection, scar, dislocation, need for further surgery, risk of anesthesia, deep vein thrombosis, and implant failure.  The patient understood all these risks and was willing to continue further on with the procedure.,PROCEDURE: , The patient was wheeled back to the Operating Room #2 at ABCD General Hospital on 08/27/03.  The general anesthetic was first performed by the Department of Anesthesia.  The patient was then positioned with the left hip exposed on the beanbag in the lateral position.  Kidney rests were also used because of the patient's size.  An axillary roll was also inserted for comfort in addition to a Foley catheter, which was inserted by the OR nurse.  All her bony prominences were well padded.  At this time, the left hip and left lower extremity was then prepped and draped in the usual sterile fashion for this procedure.  At this time, an anterolateral approach was then performed, first incising through the skin in approximately 5 to 6 inches of subcutaneous fat.  The tensor fascia lata was then identified.  A self-retainer was then inserted to expose the operative field.  Bovie cautery was used for hemostasis.  At this time, a fresh blade was then used to incise the tensor fascia lata over the posterior one-third of the greater trochanter.  At this time, a blunt dissection was taken proximally.  The tensor fascia lata was occluded with a hip retractor.  At this time, after hemostasis was obtained, Bovie cautery was used to incise the proximal end of the vastus lateralis and removing the partial portion of the hip abductor, the gluteus medius.  At this time, a periosteal elevator was used to expose anterior hip capsule.  A ________ was then inserted over the femoral head purchasing of the acetabulum underneath the reflected head of the quadriceps muscle.  Once this was performed, Homan retractors were then inserted superiorly and inferiorly underneath the femoral neck.  At this time, a capsulotomy was then performed using a Bovie cautery and the capsulotomy was ________ and then edged over the acetabulum.  At this point, a large bone hook was then inserted over the neck and with gentle traction and external rotation, the femoral head was dislocated out of the acetabulum.  At this time, we had an exposure of the femoral head, which did reveal degenerative changes of the femoral head and once the acetabulum was visualized, we did see degenerative changes within the acetabulum as well as osteophyte formation around the rim of the acetabulum.  At this time, a femoral stem guide was then used to measure proximal femoral neck cut.  We made a cut approximately a fingerbreadth above the lesser trochanter.  At this time, with protection of the soft tissues an oscillating saw was used to make femoral neck cut.,The femoral head was then removed.  At this time, we removed the leg out of the bag and Homan retractors were then used to expose the acetabulum.  A long-handle knife was used to cut through the remainder of the capsule and remove the glenoid labrum around the rim of the acetabulum.  With better exposure of the acetabulum, we started reaming the acetabulum.  We started with a size #44 and progressively reamed to a size #50.  At the size #50 mm reamer, we obtained excellent bony bleeding with good remainder of bone stalk both anteriorly and posteriorly as well as superiorly within the acetabulum.  We then reamed up to size #52 in order to get bony bleeding around the rim as well as anterior and posterior within the acetabulum.  A size 54 mm Trilogy cup was then implanted with excellent approaches approximately 45 degrees of abduction and 10 to 15 degrees of anteversion dialed in.  Once the cup was impacted in place, we did visualize that the cup was well seated on to the internal portion of the acetabulum.  At this time, two screws were the placed within the superior table for better approaches securing the acetabular cup.  At this time, a plastic liner was then inserted for protection.  The leg was then placed back in the bag.  A Bennett retractor was used to retract the tensor fascia lata and femoral elevator was used to elevate the femur for better exposure and at this time, we began working on the femur.  A rongeur was used to lateralize over the greater trochanter.  A Box osteotome was used to remove the cancellous portion of the femoral neck.  A Charnley awl was then used to cannulate through the proximal femoral canal.  A power reamer was then used to ream the lateral aspect of the greater trochanter in order to provide maximal lateralization and prevent varus implantation of our stem.  At this time, we began broaching.  We started with a size #10 and progressively worked up to a size #12 mm broach.  Once the 12 mm broach was inserted in place, it was seated approximately 1 mm below the calcar.  A calcar reamer was then placed and the calcar was reamed smoothly.  A standard neck as well as a 28 mm plastic head was then placed and a trial reduction was then performed.  Once this was performed, the hip was taken to range of motion with external rotation, longitudinal traction as well as flexion and revealed good stability with no impingement or dislocation.  At this time, we removed 12 mm broach and proceeded with implanting our polyethylene liner within the acetabulum.  This was impacted and placed and checked to assure that it was well seated with no loosening.  Once this was performed, we then exposed the proximal femur one more time.  We copiously irrigated within the canal and then suctioned it dry.  At this time, a 12 mm porous proximal collared stem, a femoral component was then impacted in place.  Once it was well seated on the calcar, we double checked to assure that there was no evidence of calcar fractures, which there were none.  The 28 mm zero neck length cobalt-chrome femoral head was then impacted in place and the Morse taper assured that this was well fixed by ________.,Next, the hip was then reduced within the acetabulum and again we checked range of motion as well as ligamentous stability with gentle traction, external rotation, as well as hip flexion.  We were satisfied with components as well as the alignment of the components.  Copious irrigation was then used to irrigate the wound.  #1 Ethibond was then used to approximate the anterior hip capsule.  #1 Ethibond in interrupted fashion was used to approximate the vastus lateralis as well as the gluteus medius attachment over the partial gluteus medius attachment which was resected off the greater trochanter.  Next, a #1 Ethibond was then used to approximate the tensor fascia lata with figure-of-eight closure.  A tight closure was performed.  Since the patient did have a lot of subcutaneous fat, multiple #2-0 Vicryl sutures were then used to approximate the bed space and then #2-0 Vicryl for the subcutaneous skin.  Staples were then used for skin closure.  The patient's hip was then cleansed.  Sterile dressings consisting of Adaptic, 4 x 4, ABDs, and foam tape were then placed.  A drain was placed prior to wound closure for postoperative drainage.  After the dressing was applied, the patient was extubated safely and transferred to recovery in stable condition.  Prognosis is good.",37
"SUBJECTIVE:,  The patient is a 68-year-old white female who presents for complete physical, Pap and breast exam.  Her last Pap smear was 05/02/2002.  Her only complaint is that she has had some occasional episodes of some midchest pain that seems to go to her back, usually occurs at rest.  Has awakened her at night on occasion and only last about 15 to 20 minutes.  Denies nausea, vomiting, diaphoresis or shortness of breath with it.  This has not happened in almost two months.  She had a normal EKG one year ago.  Otherwise, has been doing quite well.  Did quite well with her foot surgery with Dr. Clayton.,PAST MEDICAL HISTORY:,  Reactive airway disease; rheumatoid arthritis, recent surgery on her hands and feet; gravida 4, para 5, with one set of twins, all vaginal deliveries; iron deficiency anemia; osteoporosis; and hypothyroidism.,MEDICATIONS:,  Methotrexate 2.5 mg five weekly, Fosamax 70 mg weekly, folic acid daily, amitriptyline 15 mg daily, Synthroid 0.088 mg daily, calcium two in the morning and two at noon, multivitamin daily, baby aspirin daily and Colace one to three b.i.d.,ALLERGIES:,  None.,SOCIAL HISTORY:,  She is married.  Denies tobacco, alcohol and drug use.  She is not employed outside the home.,FAMILY HISTORY: , Unremarkable.,REVIEW OF SYSTEMS:,  HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional and psychiatric are all negative except for HPI.,OBJECTIVE:,Vital Signs:  Weight 146.  Blood pressure 100/64.  Pulse 80.  Respirations 16.  Temperature 97.7.,General:  She is a well-developed, well-nourished white female in no acute distress.,HEENT:  Grossly within normal limits.,Neck:  Supple.  No lymphadenopathy.  No thyromegaly.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Positive bowel sounds, soft and nontender.  No hepatosplenomegaly.,Breasts:  No nipple discharge.  No lumps or masses palpated.  No dimpling of the skin.  No axillary lymph nodes palpated.  Self-breast exam discussed and encouraged.,Pelvic:  Normal female genitalia.  Atrophic vaginal mucosa.  No cervical lesions.  No cervical motion tenderness.  No adnexal tenderness or masses palpated.,Rectal:  Normal sphincter tone.  No stool present in the vault.  No rectal masses palpated.,Extremities:  No cyanosis, clubbing or edema.  She does have obvious rheumatoid arthritis of her hands.,Neurologic:  Grossly intact.,ASSESSMENT/PLAN:,1.  Chest pain.  The patient will evaluate when it happens next; what she has been eating, what activities she has been performing.  She had normal ECG one year ago.  In fact this does not sound cardiac in nature.  We will not do further cardiac workup at this time.  Did discuss with her she may be having some GI reflux type symptoms.,2.  Hypothyroidism.  We will recheck TSH to make sure she is on the right amount of medication at this time, making adjustments as needed.,3.  Rheumatoid arthritis.  Continue her methotrexate as prescribed by Dr. Mortensen, and follow up with Dr. XYZ as needed.,4.  Osteoporosis.  It is time for her to have a repeat DEXA at this time and that will be scheduled.,5.  Health care maintenance, Pap smear was obtained today.  The patient will be scheduled for mammogram.",24
"PROCEDURES: , Total knee replacement.,PROCEDURE DESCRIPTION:,  The patient was bought to the operating room and placed in the supine position.  After induction of anesthesia, a tourniquet was placed on the upper thigh.  Sterile prepping and draping proceeded.  The tourniquet was inflated to 300 mmHg.  A midline incision was made, centered over the patella.  Dissection was sharply carried down through the subcutaneous tissues.  A median parapatellar arthrotomy was performed.  The lateral patellar retinacular ligaments were released and the patella was retracted laterally.  Proximal medial tibia was denuded, with mild release of medial soft tissues.  The ACL and PCL were released.  The medial and lateral menisci and suprapatellar fat pad were removed.  These releases allowed for anterior subluxation of tibia.  An extramedullary tibial cutting jig was pinned to the proximal tibia in the appropriate alignment and flush cut was made along tibial plateau, perpendicular to the axis of the tibia.  Its alignment was checked with the rod and found to be adequate.  The tibia was then allowed to relocate under the femur.,An intramedullary hole was drilled into the femur and a femoral rod attached to the anterior cutting block was inserted, and the block was pinned in appropriate position, judging correct rotation using a variety of techniques.  An anterior rough cut was made.  The distal cutting jig was placed atop this cut surface and pinned to the distal femur, and the rod was removed.  The distal cut was performed.,A spacer block was placed, and adequate balance in extension was adjusted and confirmed, as was knee alignment.  Femoral sizing was performed with the sizer, and the appropriate size femoral 4-in-1 chamfer-cutting block was pinned in place and the cuts were made.  The notch-cutting block was pinned to the cut surface, slightly laterally, and the notch cut was then made.  The trial femoral component was impacted onto the distal femur and found to have an excellent fit.  A trial tibial plate and polyethylene were inserted, and stability was judged and found to be adequate in all planes.  Appropriate rotation of the tibial component was identified and marked.  The trials were removed and the tibia was brought forward again.  The tibial plate size was checked and the plate was pinned to plateau.  A keel guide was placed and the keel was then made.  The femoral intramedullary hole was plugged with bone from the tibia.  The trial tibial component and poly placed; and, after placement of the femoral component, range of motion and stability were checked and found to be adequate in various ranges of flexion and extension.,The patella was held in a slightly everted position with knee in extension.  Patellar width was checked with calipers.  A free-hand cut of the patellar articular surface was performed and checked to ensure symmetry with the calipers.  Sizing was then performed and 3 lug holes were drilled with the jig in place, taking care to medialize and superiorize the component as much as possible, given bony anatomy.  Any excess lateral patellar bone was recessed.  The trial patellar component was placed and found to have adequate tracking.  The trials were removed; and as the cement was mixed, all cut surfaces were thoroughly washed and dried.  The cement was applied to the components and the cut surfaces with digital pressurization, and then the components were impacted.  The excess cement was removed from the gutters and anterior and posterior parts of the knee.  The knee was brought into full extension with the trial polyethylene and further axially pressurized as cement hardened.  Once the cement had hardened, the tourniquet was deflated.  The knee was dislocated again, and any excess cement was removed with an osteotome.  Thorough irrigation and hemostasis were performed.  The real polyethylene component was placed and pinned.  Further vigorous power irrigation was performed, and adequate hemostasis was obtained and confirmed.  The arthrotomy was closed using 0 Ethibond and Vicryl sutures.  The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures.  The skin was sealed with staples.  Xeroform and a sterile dressing were applied followed by a cold-pack and Ace wrap.  The patient was transferred to the recovery room in stable condition, having tolerated the procedure well.",27
"PROCEDURE PERFORMED: , Endotracheal intubation.,INDICATION FOR PROCEDURE:  ,The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather.  PCO2 was 29 and pO2 was 66 on the 15 liters.,NARRATIVE OF PROCEDURE: , The patient was given a total of 5 mg of Versed, 20 mg of etomidate, and 10 mg of vecuronium.  He was intubated in a single attempt.  Cords were well visualized, and a #8 endotracheal tube was passed using a curved blade.  Fiberoptically, a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap A lavage with 100 mL of normal sterile saline for cytology, AFB, and fungal smear and culture.  A separate trap B was then lavaged for bacterial C&S and Gram stain and was sent for those purposes.  The patient tolerated the procedure well.",3
"DIAGNOSES ON ADMISSION,1.  Cerebrovascular accident (CVA) with right arm weakness.,2.  Bronchitis.,3.  Atherosclerotic cardiovascular disease.,4.  Hyperlipidemia.,5.  Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1.  Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2.  Old coronary infarct, anterior aspect of the right external capsule.,3.  Acute bronchitis with reactive airway disease.,4.  Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5.  Atherosclerotic cardiovascular disease.,6.  Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room.  Plavix was started  in addition to baby aspirin.  He was kept on oral Zithromax for his cough.  He was given Xopenex treatment, because of his respiratory distress.  Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid.  Dr. X saw him in consultation and recommended CT angiogram.  This showed no significant obstructive lesion other than what was known on the ultrasound.  Head MRI was done and revealed the above findings.  The patient was begun on PT and improved.  By discharge, he had much improved strength in his right arm.  He had no further progressions.  His cough improved with oral Zithromax and nebulizer treatments.  His platelets also improved as well.  By discharge, his platelets was up to 107,000.  His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential.  Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate.  Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1.  PT/INR on admission was 1.03, PTT 34.7.  At the time of discharge, the patient's cough was much improved.  His right arm weakness has much improved.  His lung examination has just occasional rhonchi.  He was changed to a metered dose inhaler with albuterol.  He is being discharged home.  An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation.  He will follow up in my office in 1 week.  He is to start PT and OT as an outpatient.  He is to avoid driving his car.  He is to notify, if further symptoms.  He has 2 more doses of Zithromax at home, he will complete.  His prognosis is good.",22
"PREOPERATIVE DIAGNOSIS: , Cholecystitis and cholelithiasis.,POSTOPERATIVE DIAGNOSIS:  ,Cholecystitis and cholelithiasis.,TITLE OF PROCEDURE,1.  Laparoscopic cholecystectomy.,2.  Intraoperative cholangiogram.,ANESTHESIA:  ,General.,PROCEDURE IN DETAIL:  ,The patient was taken to the operative suite and placed in the supine position under general endotracheal anesthetic.  The patient received 1 gm of IV Ancef intravenously piggyback.  The abdomen was prepared and draped in routine sterile fashion.,A 1-cm incision was made at the umbilicus and a Veress needle was inserted.  Saline test was performed.  Satisfactory pneumoperitoneum was achieved by insufflation of CO2 to a pressure of 14 mmHg.  The Veress needle was removed.  A 10- to 11-mm cannula was inserted.  Inspection of the peritoneal cavity revealed a gallbladder that was soft and without adhesions to it.  It was largely mobile.  The liver had a normal appearance as did the peritoneal cavity.  A 5-mm cannula was inserted in the right upper quadrant anterior axillary line.  A second 5-mm cannula was inserted in the subcostal space.  A 10- to 11-mm cannula was inserted into the upper midline.,The gallbladder was reflected in a cephalad direction.  The gallbladder was punctured with the aspirating needle, and under C-arm fluoroscopy was filled with contrast, filling the intra- and extrahepatic biliary trees, which appeared normal.  Extra contrast was aspirated and the aspirating needle was removed.  The ampulla was grasped with a second grasper, opening the triangle of Calot.  The cystic duct was dissected and exposed at its junction with the ampulla, was controlled with a hemoclip, digitally controlled with two clips and divided.  This was done while the common duct was in full visualization.  The cystic artery was similarly controlled and divided.  The gallbladder was dissected from its bed and separated from the liver, brought to the outside through the upper midline cannula and removed.,The subhepatic and subphrenic spaces were irrigated thoroughly with saline solution.  There was oozing and bleeding from the lateral 5-mm cannula site, but this stopped spontaneously with removal of the cannula.  The subphrenic and subhepatic spaces were again irrigated thoroughly with saline until clear.  Hemostasis was excellent.  CO2 was evacuated and the camera removed.  The umbilical fascia was closed with 2-0 Vicryl, the subcu with 3-0 Vicryl, and the skin was closed with 4-0 nylon.  Sterile dressings were applied.  Sponge and needle counts were correct.",14
"REASON FOR CONSULTATION:,  Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.  No symptoms of chest pain or shortness of breath.,His history from cardiac standpoint as mentioned below.,CORONARY RISK FACTORS: , History of hypertension, history of diabetes mellitus, nonsmoker.  Cholesterol elevated.  History of established coronary artery disease in the family and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.,MEDICATIONS:,1.  Metformin.,2.  Prilosec.,3.  Folic acid.,4.  Flomax.,5.  Metoprolol.,6.  Crestor.,7.  Claritin.,ALLERGIES:,  DEMEROL, SULFA.,PERSONAL HISTORY: , He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use.,PAST MEDICAL HISTORY:,  Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer.  Symptoms of shortness of breath, fatigue, and tiredness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills except for recent fever and rigors.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea and vomiting.  No hematemesis or melena.,UROLOGICAL:  Frequency, urgency.,MUSCULOSKELETAL:  No muscle weakness.,SKIN:  None significant.,NEUROLOGICAL:  No TIA or CVA.  No seizure disorder.,PSYCHOLOGICAL:  No anxiety or depression.,ENDOCRINE:  As above.,HEMATOLOGICAL:  None significant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic, normocephalic.,NECK:  Veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft, nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Benign.,EKG: ",15
"NERVE CONDUCTION STUDIES:,  Bilateral ulnar sensory responses are absent.  Bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude.  The left radial sensory response is normal and robust.  Left sural response is absent.  Left median motor distal latency is prolonged with attenuated evoked response amplitude.  Conduction velocity across the forearm is mildly slowed.  Right median motor distal latency is prolonged with a normal evoked response amplitude and conduction velocity.  The left ulnar motor distal latency is prolonged with a severely attenuated evoked response amplitude both below and above the elbow.  Conduction velocities across the forearm and across the elbow are prolonged.  Conduction velocity proximal to the elbow is normal.  The right median motor distal latency is normal with normal evoked response amplitudes at the wrist with a normal evoked response amplitude at the wrist.  There is mild diminution of response around the elbow.  Conduction velocity slows across the elbow.  The left common peroneal motor distal latency evoked response amplitude is normal with slowed conduction velocity across the calf and across the fibula head.  F-waves are prolonged.,NEEDLE EMG: , Needle EMG was performed on the left arm and lumbosacral and cervical paraspinal muscles as well as middle thoracic muscles using a disposable concentric needle.  It revealed spontaneous activity in lower cervical paraspinals, left abductor pollicis brevis, and first dorsal interosseous muscles.  There were signs of chronic reinnervation in triceps, extensor digitorum communis, flexor pollicis longus as well first dorsal interosseous and abductor pollicis brevis muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  A sensory motor length-dependent neuropathy consistent with diabetes.,2.  A severe left ulnar neuropathy.  This is probably at the elbow, although definitive localization cannot be made.,3.  Moderate-to-severe left median neuropathy.  This is also probably at the carpal tunnel, although definitive localization cannot be made.,4.  Right ulnar neuropathy at the elbow, mild.,5.  Right median neuropathy at the wrist consistent with carpal tunnel syndrome, moderate.,6.  A left C8 radiculopathy (double crush syndrome).,7.  There is no evidence for thoracic radiculitis.,The patient has made very good response with respect to his abdominal pain since starting Neurontin.  He still has mild allodynia and is waiting for authorization to get insurance coverage for his Lidoderm patch.  He is still scheduled for MRI of C-spine and T-spine.  I will see him in followup after the above scans.",33
"PREOPERATIVE DIAGNOSIS:,  Left pleural effusion.,POSTOPERATIVE DIAGNOSIS:,  Left hemothorax.,PROCEDURE: , Thoracentesis.,PROCEDURE IN DETAIL:,  After obtaining informed consent and having explained the procedure to the patient, he was sat at the side of a stretcher in the emergency department.  His left back was prepped and draped in the usual fashion.  Xylocaine 1% was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed, and then we proceed to draw by hand about 1200 mL blood.  This blood was nonclotting and it was tested twice.  Halfway during the procedure, the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s.  Therefore, we laid him off his right side while keeping the chest catheter in place.  At that time, I proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure.,Overall besides the described episode, the patient tolerated the procedure well and afterwards, we took another chest x-ray that showed much improvement in the pleural effusion and at that particular time, with all the history we proceeded to admit the patient for observation and with an idea to obtain a CT in the morning to see whether the patient would need an pigtail intrapleural catheter or not.",3
"TITLE OF OPERATION: , Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,INDICATION FOR SURGERY: , The patient with a large 3.5 cm acoustic neuroma.  The patient is having surgery for resection.  There was significant cerebellar peduncle compression.  The tumor was very difficult due to its size as well as its adherence to the brainstem and the nerve complex.  The case took 12 hours.  This was more difficult and took longer than the usual acoustic neuroma.,PREOP DIAGNOSIS: , Right acoustic neuroma.,POSTOP DIAGNOSIS: , Right acoustic neuroma.,PROCEDURE:,  The patient was brought to the operating room.  General anesthesia was induced in the usual fashion.  After appropriate lines were placed, the patient was placed in Mayfield 3-point head fixation, hold into a right park bench position to expose the right suboccipital area.  A time-out was settled with nursing and anesthesia, and the head was shaved, prescrubbed with chlorhexidine, prepped and draped in the usual fashion.  The incision was made and cautery was used to expose the suboccipital bone.  Once the suboccipital bone was exposed under the foramen magnum, the high speed drill was used to thin out the suboccipital bone and the craniectomy carried out with Leksell and insertion with Kerrison punches down to the rim of the foramen magnum as well as laterally to the edge of the sigmoid sinus and superiorly to the edge of the transverse sinus.  The dura was then opened in a cruciate fashion, the cisterna magna was drained, which nicely relaxed the cerebellum.  The dura leaves were held back with the 4-0 Nurolon.  The microscope was then brought into the field, and under the microscope, the cerebellar hemisphere was elevated.  Laterally, the arachnoid was very thick.  This was opened with bipolar and microscissors and this allowed for the cerebellum to be further mobilized until the tumor was identified.  The tumor was quite large and filled up the entire lateral aspect of the right posterior fossa.  Initially two retractors were used, one on the tentorium and one inferiorly.  The arachnoid was taken down off the tumor.  There were multiple blood vessels on the surface, which were bipolared.  The tumor surface was then opened with microscissors and the Cavitron was used to began debulking the lesion.  This was a very difficult resection due to the extreme stickiness and adherence to the cerebellar peduncle and the lateral cerebellum; however, as the tumor was able to be debulked, the edge began to be mobilized.  The redundant capsule was bipolared and cut out to get further access to the center of the tumor.  Working inferiorly and then superiorly, the tumor was taken down off the tentorium as well as out the 9th, 10th or 11th nerve complex.  It was very difficult to identify the 7th nerve complex.  The brainstem was identified above the complex.  Similarly, inferiorly the brainstem was able to be identified and cotton balls were placed to maintain this plain.  Attention was then taken to try identify the 7th nerve complex.  There were multitude of veins including the lateral pontine vein, which were coming right into this area.  The lateral pontine vein was maintained.  Microscissors and bipolar were used to develop the plain, and then working inferiorly, the 7th nerve was identified coming off the brainstem.  A number 1 and number 2 microinstruments were then used to began to develop the plane.  This then allowed for the further appropriate plane medially to be identified and cotton balls were then placed.  A number 11 and number 1 microinstrument continued to be used to free up the tumor from the widely spread out 7th nerve.  Cavitron was used to debulk the lesion and then further dissection was carried out.  The nerve stimulated beautifully at the brainstem level throughout this.  The tumor continued to be mobilized off the lateral pontine vein until it was completely off.  The Cavitron was used to debulk the lesion out back laterally towards the area of the porus.  The tumor was debulked and the capsule continued to be separated with number 11microinstrument as well as the number 1 microinstrument to roll the tumor laterally up towards the porus.  At this point, the capsule was so redundant, it was felt to isolate the nerve in the porus.  There was minimal bulk remaining intracranially.  All the cotton balls were removed and the nerve again stimulated beautifully at the brainstem.  Dr. X then came in and scrubbed into the case to drill out the porus and remove the piece of the tumor that was left in the porus and coming out of the porus.,I then scrubbed back into case once Dr. X had completed removing this portion of the tumor.  There was no tumor remaining at this point.  I placed some Norian in the porus to seal any air cells, although there were no palpated.  An intradural space was then irrigated thoroughly.  There was no bleeding.  The nerve was attempted to be stimulated at the brainstem level, but it did not stimulate at this time.  The dura was then closed with 4-0 Nurolons in interrupted fashion.  A muscle plug was used over one area.  Duragen was laid and strips over the suture line followed by Hemaseel.  Gelfoam was set over this and then a titanium cranioplasty was carried out.  The wound was then irrigated thoroughly.  O Vicryls were used to close the deep muscle and fascia, 3-0 Vicryl for subcutaneous tissue, and 3-0 nylon on the skin.,The patient was extubated and taken to the ICU in stable condition.",37
"CHIEF COMPLAINT: , Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter.,HISTORY OF PRESENT ILLNESS: , The patient was transferred here the evening of 02/23/2007 from Hospital with a new diagnosis of high-risk acute lymphoblastic leukemia based on confirmation by flow cytometry of peripheral blood lymphoblasts that afternoon.  History related to this illness probably dates back to October of 2006 when he had onset of swelling and discomfort in the left testicle with what he described as a residual ""lump"" posteriorly.  The left testicle has continued to be painful off and on since.  In early November, he developed pain in the posterior part of his upper right leg, which he initially thought was related to skateboarding and muscle strain.  Physical therapy was prescribed and the discomfort temporarily improved.  In December, he noted onset of increasing fatigue.  He used to work out regularly, lifting lifts, doing abdominal exercises, and playing basketball and found he did not have energy to pursue these activities.  He has lost 10 pounds since December and feels his appetite has decreased.  Night sweats and cough began in December, for which he was treated with a course of Augmentin.  However, both of these problems have continued.  He also began taking Accutane for persistent acne in December (this agent was stopped on 02/19/2007).  Despite increasing fatigue and lethargy, he continues his studies at University of Denver, has a biology major (he aspires to be an ophthalmologist).,The morning of 02/19/2007, he awakened with severe right inguinal and right lower quadrant pain.  He was seen in Emergency Room where it was noted that he had an elevated WBC of 18,000.  CT scan of the abdomen was obtained to rule out possible appendicitis and on that CT, a large clot in the inferior vena cava extending to the right iliac and femoral veins was found.  He promptly underwent appropriate treatment in interventional radiology with the above-noted angioplasty and placement of a vena caval filter followed by mechanical and pharmacologic thrombolysis.  Repeat ultrasound there on 02/20/2007 showed no evidence of deep venous thrombosis (DVT).  Continuous intravenous unfractionated heparin infusion was continued.  Because there was no obvious cause of this extensive thrombosis, occult malignancy was suspected.  Appropriate blood studies were obtained and he underwent a PET/CT scan as part of his diagnostic evaluation.  This study showed moderately increased diffuse bone marrow metabolic activity.  Because the WBC continued to rise and showed a preponderance of lymphocytes, the smear was reviewed by pathologist, Sheryl Asplund, M.D., and flow cytometry was performed on the peripheral blood.  These studies became available the afternoon of 02/23/2007, and confirmed the diagnosis of precursor-B acute lymphoblastic leukemia.  The patient was transferred here after stopping of the continuous infusion heparin and receiving a dose of Lovenox 60 mg subcutaneously for further diagnostic evaluation and management of the acute lymphoblastic leukemia (ALL).,ALLERGIES: , NO KNOWN DRUG ALLERGIES.  HE DOES SEEM TO REACT TO CERTAIN ADHESIVES.,CURRENT MEDICATIONS:  ,1.  Lovenox 60 mg subcutaneously q.12h. initiated.,2.  Coumadin 5 mg p.o., was administered on 02/19/2007 and 02/22/2007.,3.  Protonix 40 mg intravenous (IV) daily.,4.  Vicodin p.r.n.,5.  Levaquin 750 mg IV on 02/23/2007.,IMMUNIZATIONS: , Up-to-date.,PAST SURGICAL HISTORY:  ,The treatment of the thrombosis as noted above on 02/19/2007 and 02/20/2007.,FAMILY HISTORY:  ,Two half-brothers, ages 26 and 28, both in good health.  Parents are in good health.  A maternal great-grandmother had a deep venous thrombosis (DVT) of leg in her 40s.  A maternal great-uncle developed leukemia around age 50.  A maternal great-grandfather had bone cancer around age 80.  His paternal grandfather died of colon cancer at age 73, which he had had since age 68.  Adult-onset diabetes is present in distant relatives on both sides.,SOCIAL HISTORY:  ,The patient is a student at the University majoring in biology.  He lives in a dorm there.  His parents live in Breckenridge.  He admits to having smoked marijuana off and on with friends and drinking beer off and on as well.,REVIEW OF SYSTEMS: , He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication.  He has had acne for about two years, which he describes as mild to moderate.  He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain noted above.,PHYSICAL EXAMINATION:  ,GENERAL:  Alert, cooperative, moderately ill-appearing young man.,VITAL SIGNS:  At the time of admission, pulse was 94, respirations 20, blood pressure 120/62, temperature 98.7, height 171.5 cm, weight 63.04 kg, and pulse oximetry on room air 95%.,HAIR AND SKIN:  Mild facial acne.,HEENT:  Extraocular muscles (EOMs) intact.  Pupils equal, round, and reactive to light and accommodation (PERRLA), fundi normal.,CARDIOVASCULAR:  A 2/6 systolic ejection murmur (SEM), regular sinus rhythm (RSR).,LUNGS:  Clear to auscultation with an occasional productive cough.,ABDOMEN:  Soft with mild lower quadrant tenderness, right more so than left; liver and spleen each decreased 4 cm below their respective costal margins.,MUSCULOSKELETAL:  Mild swelling of the dorsal aspect of the right foot and distal right leg.  Mild tenderness over the prior catheter entrance site in the right popliteal fossa and mild tenderness over the right medial upper thigh.,GENITOURINARY:  Testicle exam disclosed no firm swelling with mild nondiscrete fullness in the posterior left testicle.,NEUROLOGIC:  Exam showed him to be oriented x4.  Normal fundi, intact cranial nerves II through XII with downgoing toes, symmetric muscle strength, and decreased patellar deep tendon reflexes (DTRs).,LABORATORY DATA:  ,White count 25,500 (26 neutrophils, 1 band, 7 lymphocytes, 1 monocyte, 1 myelocyte, 64 blasts), hemoglobin 13.3, hematocrit 38.8, and 312,000 platelets.  Electrolytes, BUN, creatinine, phosphorus, uric acid, AST, ALT, alkaline phosphatase, and magnesium were all normal.  LDH was elevated to 1925 units/L (upper normal 670), and total protein and albumin were both low at 6.2 and 3.4 g/dL respectively.  Calcium was also slightly low at 8.8 mg/dL.  Low molecular weight heparin test was low at 0.27 units/mL.  PT was 11.8, INR 1.2, and fibrinogen 374.  Urinalysis was normal.,ASSESSMENT: , 1.  Newly diagnosed high-risk acute lymphoblastic leukemia.,2.  Deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation.,3.  Probable chronic left epididymitis.,PLAN: , 1.  Proceed with diagnostic bone marrow aspirate/biopsy and lumbar puncture (using a #27-gauge pencil-tip needle for minimal trauma) as soon as these procedures can be safely done with regard to the anticoagulation status.,2.  Prompt reassessment of the status of the deep venous thrombosis with Doppler studies.,3.  Ultrasound/Doppler of the testicles.,4.  Maintain therapeutic anticoagulation as soon as the diagnostic procedures for ALL can be completed.,",16
"EXAM:,MRI-UP EXT JOINT LEFT SHOULDER,CLINICAL:,Left shoulder pain. Evaluate for rotator cuff tear.,FINDINGS:,  Multiple T1 and gradient echo axial images were obtained, as well as T1 and fat suppressed T2-weighted coronal images.,The rotator cuff appears intact and unremarkable. There is no significant effusion seen. Osseous structures are unremarkable. There is no significant downward spurring at the acromioclavicular joint. The glenoid labrum is intact and unremarkable.,IMPRESSION:,  Unremarkable MRI of the left shoulder.,",33
"MEDICATIONS: , Plavix, atenolol, Lipitor, and folic acid.,CLINICAL HISTORY:  ,This is a 41-year-old male patient who comes in with chest pain, had had a previous MI in 07/2003 and stents placement in 2003, who comes in for a stress myocardial perfusion scan.,With the patient at rest, 10.3 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.,PROCEDURE AND INTERPRETATION:  ,The patient exercised for a total of 12 minutes on the standard Bruce protocol.  The peak workload was 12.8 METS.  The resting heart rate was 57 beats per minute and the peak heart rate was 123 beats per minute, which was 69% of the age-predicted maximum heart rate response.  The blood pressure response was normal with a resting blood pressure of 130/100 and a peak blood pressure of 158/90.  The test was stopped due to fatigue and leg pain.  EKG at rest showed normal sinus rhythm.  The peak stress EKG did not reveal any ischemic ST-T wave abnormalities.  There was ventricular bigeminy seen during exercise, but no sustained tachycardia was seen.  At peak, there was no chest pain noted.  The test was stopped due to fatigue and left pain.  At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting myocardial perfusion imaging.,MYOCARDIAL PERFUSION IMAGING:,1.  The overall quality of the scan was good.,2.  There was no diagnostic abnormality on the rest and stress myocardial perfusion imaging.,3.  The left ventricular cavity appeared normal in size.,4.  Gated SPECT images revealed mild septal hypokinesis and mild apical hypokinesis.  Overall left ventricular systolic function was low normal with calculated ejection fraction of 46% at rest.,CONCLUSIONS:,1.  Good exercise tolerance.,2.  Less than adequate cardiac stress.  The patient was on beta-blocker therapy.,3.  No EKG evidence of stress induced ischemia.,4.  No chest pain with stress.,5.  Mild ventricular bigeminy with exercise.,6.  No diagnostic abnormality on the rest and stress myocardial perfusion imaging.,7.  Gated SPECT images revealed septal and apical hypokinesis with overall low normal left ventricular systolic function with calculated ejection fraction of 46% at rest.",33
"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.",10
"CHIEF COMPLAINT:  ,Penile cellulitis status post circumcision.,HISTORY OF PRESENT ILLNESS: , The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge.  The child initially had a newborn circumcision at about 1 week of life and then developed a concealed or buried penis with extra skin and tightness of the skin.  He underwent a second circumcision with a general anesthetic approximately 8 to 9 days ago.  The mother states that on Thursday, he developed fairly significant swelling, scrotum was also swollen, the suprapubic region was swollen, and he was having a purulent discharge and a fairly significant fever to 102 to 103.  He was seen at Hospital, transferred to Children's Hospital for further care.  Since being hospitalized, his cultures apparently have grown Staph but is unknown yet whether it is methicillin-resistant.  He has been placed on clindamycin, and he is now currently afebrile and with marked improvement according to the mother.  I was requested a consultation by Dr. X because of the appearance of penis.  The patient has been voiding without difficulty throughout.,PAST MEDICAL HISTORY: , The patient has no known allergies.  He was a term delivery via vaginal delivery.  Surgeries; he has had 2 circumcisions.  No other hospitalizations.  He has had no heart murmurs, seizures, asthma, or bronchitis.,REVIEW OF SYSTEMS: , A 14-point review of systems was negative with the exception of the penile and scrotal cellulitis and the surgeries as mentioned.  He also had an ear infection about 1 to 2 weeks before his circumcision.,SOCIAL HISTORY: , The patient lives with both parents and no siblings.  There are smokers at home.,MEDICATIONS: , Clindamycin and bacitracin ointment.  Also Bactrim.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight is 14.9 kg.,GENERAL:  The patient was sleepy but easily arousable.,HEAD AND NECK:  Grossly normal.  His neck and chest are without masses.,NARES:  He had some crusted nares; otherwise, no other discharge.,LUNGS:  Clear.,CARDIAC:  Without murmurs or gallops.,ABDOMEN:  Soft without masses or tenderness.,GU:  He has a fairly prominent suprapubic fat pad, and he is quite a large child in any event; however, there were no signs of erythema.  There was some induration around the penis; however, there were no signs of active infection.  He has a buried appearance of the penis after recent circumcision with a normal appearing glans.  The tissue itself, however, was quite dull and is soft or readily retractable at this time.  The scrotum was normal, and there was no erythema, there was no tenderness.  Both testes were descended without hydroceles.,EXTREMITIES:  He has full range of motion of all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,BACK:  Normal.,IMPRESSION/PLAN: , The patient had a recent circumcision with a fairly prominent suprapubic fat pad but also has a penile and suprapubic cellulitis.  This is being treated, but it is most likely Staph and pending sensitivities.  I talked to the mother and told her that at this point the swelling that is present is a mixture of the resolving cellulitis from a suprapubic fat pad.  I recommended that he be treated most likely with Bactrim for a 10-day course at home, bacitracin, or some antibiotics ointment to the penis with each diaper change for the next 2 to 3 weeks with sitz bath once or twice a day.  I told the mother that initially the tissues are going to be quite dull because of the infection and the recent surgery, but she ultimately will have to gently retract the skin to keep it from adhering again because of the prominent suprapubic fat pad, which makes it more likely.  Otherwise, it is a fairly healthy-appearing tissue at the present time and she knows the reasons that he cannot be discharged once the hospitalist service believes that it is appropriate to do so.  He has a scheduled followup appointment with his urologist  and he should keep that appointment or followup sooner if there is any other problem arising.",38
"ADMISSION DIAGNOSES:,1.  Menorrhagia.,2.  Uterus enlargement.,3.  Pelvic pain.,DISCHARGE DIAGNOSIS: , Status post vaginal hysterectomy.,COMPLICATIONS: , None.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 36-year-old, gravida 3, para 3 female who presented initially to the office with abnormal menstrual bleeding and increase in flow during her period.  She also had symptoms of back pain, dysmenorrhea, and dysuria.  The symptoms had been worsening over time.  The patient was noted also to have increasing pelvic pain over the past 8 months and she was noted to have uterine enlargement upon examination.,PROCEDURE:,  The patient underwent a total vaginal hysterectomy.,HOSPITAL COURSE:  ,The patient was admitted on 09/04/2007 to undergo total vaginal hysterectomy.  The procedure preceded as planned without complication.  Uterus was sent for pathologic analysis.  The patient was monitored in the hospital, 2 days postoperatively.  She recovered quite well and vitals remained stable.,Laboratory studies, H&H were followed and appeared stable on 09/05/2007 with hemoglobin of 11.2 and hematocrit of 31.8.,The patient was ready for discharge on Monday morning of 09/06/2007.,LABORATORY FINDINGS: , Please see chart for full studies during admission.,DISPOSITION:  ,The patient was discharged to home in stable condition.  She was instructed to follow up in the office postoperatively.",10
"PREOPERATIVE DIAGNOSIS:,  Open calcaneus fracture on the right.,POSTOPERATIVE DIAGNOSIS:,  Open calcaneus fracture on the right.,PROCEDURES:,  ,1.  Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture.,2.  Placement of antibiotic-impregnated beads.,ANESTHESIA:,  General.,BLOOD LOSS:,  Minimal.,COMPLICATIONS:,  None.,FINDINGS:,  Healing skin with no gross purulence identified, some fibrinous material around the beads.,SUMMARY:,  After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  After uneventful general anesthesia was obtained, her right leg was sterilely prepped and draped in a normal fashion.  The tourniquet was inflated and the previous wound was opened.  Dr. X came in to look at the wound and the beads were removed, all 25 beads were extracted, and pulsatile lavage, and curette, etc., were used to debride the wound.  The wound margins were healthy with the exception of very central triangular incision area.  The edges were debrided and then 19 antibiotic-impregnated beads with gentamicin and tobramycin were inserted and the wound was further closed today.,The skin edges were approximated under minimal tension.  The soft dressing was placed.  An Ace was placed.  She was awakened from the anesthesia and taken to recovery room in a stable condition.  Final needle, instrument, and sponge counts were correct.",37
"CC:, Right shoulder pain.,HX: ,This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck (Lhermitte's phenomena). She denied any history of neck/back/head trauma.,She had been taking Naprosyn with little relief.,PMH: ,1) Catamenial Headaches. 2) Allergy to Macrodantin.,SHX/FHX:, Smokes 2ppd cigarettes.,EXAM: ,Vital signs were unremarkable.,CN: unremarkable.,Motor: full strength throughout. Normal tone and muscle bulk.,Sensory: No deficits on LT/PP/VIB/TEMP/PROP testing.,Coord/Gait/Station: Unremarkable.,Reflexes: 2/2 in BUE except 2+ at left biceps. 1+/1+BLE except an absent right ankle reflex.,Plantar responses were flexor bilaterally. Rectal exam: normal tone.,IMPRESSION:, C-spine lesion.,COURSE: ,MRI C-spine revealed a central C5-6 disk herniation with compression of the spinal cord at that level. EMG/NCV showed normal NCV, but 1+ sharps and fibrillations in the right biceps (C5-6), brachioradialis (C5-6), triceps (C7-8) and teres major; and 2+ sharps and fibrillations in the right pronator terres. There was increased insertional activity in all muscles tested on the right side. The findings were consistent with a C6-7 radiculopathy.,The patient subsequently underwent C5-6 laminectomy and her symptoms resolved.",22
"HISTORY:,  The patient is 14 months old, comes in with a chief complaint of difficulty breathing.  Difficulty breathing began last night.  He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home.  They were home for about an hour when he began to get worse and they drove here to Children's Hospital.  He has a history of reactive airway disease.  He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing.  He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time.  He has been on albuterol off and on over that period.  He has had fever overnight.  No vomiting, no diarrhea.  Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department.  Normal urine output.  No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above.  No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:,  Up-to-date.,BIRTH HISTORY:,  The child was full term, no complications, home with mom.  No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home.  No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL:  The child is awake, alert, in moderate respiratory distress.,HEENT:  Pupils equal, round, reactive to light.  Extraocular movements are intact.  The TMs are clear.  The nares show some dry secretions.  Audible congestion and wheezing is noted.  Mucous membranes are dry.  Throat is clear.  No oral lesions noted.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Show inspiratory and expiratory wheezes in all fields.  Audible wheezes are noted.  There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART:  Shows tachycardia.  Regular rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding.  No rebound.  No hepatosplenomegaly.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed.  I felt the child was dehydrated on examination.  We gave 20 mL/kg bolus of normal saline over one hour.  The child was given Solu-Medrol 2 mg/kg IV.  He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally.  Normal heart size.  No evidence of pneumothorax.  No evidence of focal pneumonia.  After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time.  The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour.  The child's pulse ox on breathing treatments with 100% oxygen was 100%.  Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea.  The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time.  After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout.  After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia.  The child has a normal level of alertness; however, has not had any vomiting here.  I spoke with Dr. X, on call for hospitalist service.  She has come down and evaluated the patient.  We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family.  The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES:  ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT:  ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION:  ,Status asthmaticus, hypoxia.,PLAN:  ,Admitted to Pediatrics.",29
"HISTORY OF INJURY AND PRESENT COMPLAINTS: , The patient is a 59-year-old gentleman.  He is complaining chiefly of persistent lower back pain.  He states the pain is of a rather constant nature.  He describes it as a rather constant dull ache, sometimes rather sharp and stabbing in nature, most localized to the right side of his back more so than the left side of his lower back.  He states he has difficulty with prolonged standing or sitting.  He can only stand for about 5-10 minutes, then he has to sit down.  He can only sit for about 15-20 minutes, he has to get up and move about because it exacerbates his back pain.  He has difficulty with bending and stooping maneuvers.  He describes an intermittent radiating pain down his right leg, down from the right gluteal hip area to the back of the thigh to the calf and the foot.  He gets numbness along the lateral aspect of the foot itself.  He also describes chronic pain complaints with associated tension in the back of his neck.  He states the pain is of a constant nature in his neck.  He states he gets pain that radiates into the right shoulder girdle area and the right forearm.  He describes some numbness along the lateral aspect of the right forearm.  He states he has trouble trying to use his arm at or above shoulder height.  He has difficulty pushing, pulling, gripping, and grasping with the right upper extremity.  He describes pain at the anterior aspect of his shoulder, in particular.  He denies any headache complaints.  He is relating his above complaints to two industrial injuries that he sustained while employed with Frito Lay Company as a truck driver or delivery person.  He relates an initial injury that occurred on 06/29/1994, when apparently he was stepping out of the cab of his truck.  He lost his footing and fell.  He reached out to grab the hand railing.  He fell backwards on his back and his right shoulder.  He had immediate onset of shoulder pain, neck pain, and low back pain.  He had pain into his right leg.  He initially came under the care of Dr. H, an occupational physician in Modesto.  Initially, he did not obtain any MRIs or x-rays.  He did undergo some physical therapy and received some medications.  Dr. H referred him to Dr. Q, a chiropractor for three visits, which the patient was not certain was very helpful.  The patient advises he then changed treating physicians to Dr. N, D.C., whom he had seen previously for some back pain complaints back in 1990.  He felt that the chiropractic care was helping his back, neck, and shoulder pain complaints somewhat.  He continues with rather persistent pain in his right shoulder.  He underwent an MRI of the right shoulder performed on 08/16/1994 which revealed prominent impingement with biceps tenosynovitis as well as supraspinatus tendonitis superimposed by a small pinhole tear of the rotator cuff.  The patient was referred to Dr. P, an orthopedic surgeon who suggested some physical therapy for him and some antiinflammatories.  He felt that the patient might require a cortisone injection or possibly a surgical intervention.  The patient also underwent an MRI of the cervical spine on 08/03/1994, which again revealed multilevel degenerative disc disease in his neck.  There is some suggestion of bilateral neuroforaminal encroachment due to degenerative changes and disc bulges, particularly at C5-6 and C6-7 levels.  The patient was also seen by Dr. P, a neurologist for a Neurology consult.  It is unclear to me as to whether or not Dr. P had performed an EMG or nerve conduction studies of his upper or lower extremities.  The patient was off work for approximately six months following his initial injury date that occurred on 06/29/1994.  He returned back to regular duty.  Dr. N declared him permanent and stationary on 04/04/1995.  The patient then had a recurrence or flare-up or possibly new injury, again, particularly to his lower back while working for Frito Lay on 03/29/1997, when he was loading some pallets on the back of a trailer.  At that time, he returned to see Dr. N for chiropractic care, who is his primary treating physician.  Dr. N took him off work again.  He was off work again for approximately another six months, during which time, he was seen by Dr. M, M.D., a neurosurgeon.  He had a new MRI of his lumbar spine performed.  The MRI was performed on 05/20/1997.  It revealed L4-5 disc space narrowing with prominent disc bulge with some mild spinal stenosis.  The radiologist had noted he had a prior disc herniation at this level with some improvement from prior exam.  Dr. M saw him on 09/18/1997 and noted that there was some improvement in his disc herniation at the L4-5 level following a more recent MRI exam of 05/20/1997, from previous MRI exam of 1996 which revealed a rather prominent right-sided L4-5 disc herniation.  Dr. M felt that there was no indication for a lumbar spine surgery, but he mentioned with regards to his cervical spine, he felt that EMG studies of the right upper extremity should be obtained and he may require a repeat MRI of the cervical spine, if the study was positive.  The patient did undergo some nerve conduction studies of his lower extremities with Dr. K, M.D., which suggested a possible abnormal EMG with evidence of possible L5 radiculopathy, both right and left.  Unfortunately, I had no medical reports from Dr. P suggesting that he may have performed nerve conduction studies or EMGs of the upper and lower extremities.  The patient did see Dr. R for a neurosurgical consult.  Dr. R evaluated both his neck and lower back pain complaints on several occasions.  Dr. R suggested that the patient try some cervical epidural steroid injections and lumbar selective nerve root blocks.  The patient underwent these injections with Dr. K.  The patient reported only very slight relief temporarily with regards to his back and leg symptoms following the injections.  It is not clear from the medical record review whether the patient ever had a cervical epidural steroid injection; it appears that he had some selective nerve root blocks performed in the lumbar spine.  Dr. R on 12/15/2004 suggested that the patient had an MRI of the cervical spine revealing a right-sided C5-6 herniated nucleus pulposus which would explain his C-6 distribution numbness.  The patient also was noted to have a C4-5 with rather severe degenerative disc disease.  He felt the patient might be a candidate for a two-level ACDF at C4-5 and C5-6.  Dr. R in another report of 08/11/2004 suggested that the patient's MRI of 05/25/2004 of the lumbar spine reveals multilevel degenerative disc disease.  He had an L4-5 slight anterior spondylolisthesis, this may be a transitional vertebrae at the L6 level as well, with lumbarization of S1.  He felt that his examination suggested a possible right S1 radiculopathy with discogenic back pain.  He would suggest right-sided S1 selective nerve root blocks to see if this would be helpful; if not, he might be a candidate for a lumbar spine fusion, possibly a Dynesys or a fusion or some major spine surgery to help resolve his situation., ,The patient relates that he really prefers a more conservative approach of treatment regarding his neck, back, and right shoulder symptoms.  He continued to elect chiropractic care which he has found helpful, but apparently the insurance carrier is no longer authorizing chiropractic care for him.  He is currently taking no medications to manage his pain complaints.  He states regarding his work status, he was off work again for another six months following the 03/29/1997 injury.  He returned back to work and continued to work regular duty up until about a year ago, at which time, he was taken back off work again and placed on TTD status by Dr. N, his primary treating physician.  The patient states he has not been back to work since.  He has since applied for social security disability and now is receiving social security disability benefits.  The patient states he has tried some Myox therapy with Dr. H on 10 sessions, which he found somewhat helpful.  Overall, the patient does not feel that he could return back to his usual and customary work capacity as a delivery driver for Frito Lay.,",18
"CHIEF COMPLAINT: , Left breast cancer.,HISTORY:,  The patient is a 57-year-old female, who I initially saw in the office on 12/27/07, as a referral from the Tomball Breast Center.  On 12/21/07, the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o'clock position of the left breast (inferomedial).  The biopsy returned showing infiltrating ductal carcinoma high histologic grade.  The patient stated that she had recently felt and her physician had felt a palpable mass in that area prior to her breast imaging.  She prior to that area, denied any complaints.  She had no nipple discharge.  No trauma history.  She has had been on no estrogen supplementation.  She has had no other personal history of breast cancer.  Her family history is positive for her mother having breast cancer at age 48.  The patient has had no children and no pregnancies.  She denies any change in the right breast.  Subsequent to the office visit and tissue diagnosis of breast cancer, she has had medical oncology consultation with Dr. X and radiation oncology consultation with Dr. Y.  I have discussed the case with Dr. X and Dr. Y, who are both in agreement with proceeding with surgery prior to adjuvant therapy.  The patient's metastatic workup has otherwise been negative with MRI scan and CT scanning.  The MRI scan showed some close involvement possibly involving the left pectoralis muscle, although thought to also possibly represent biopsy artifact.  CT scan of the neck, chest, and abdomen is negative for metastatic disease.,PAST MEDICAL HISTORY:,  Previous surgery is history of benign breast biopsy in 1972, laparotomy in 1981, 1982, and 1984, right oophorectomy in 1984, and ganglion cyst removal of the hand in 1987.,MEDICATIONS:,  She is currently on omeprazole for reflux and indigestion.,ALLERGIES:,  SHE HAS NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:,  Negative for any recent febrile illnesses, chest pains or shortness of breath.  Positive for restless leg syndrome.  Negative for any unexplained weight loss and no change in bowel or bladder habits.,FAMILY HISTORY:,  Positive for breast cancer in her mother and also mesothelioma from possible asbestosis or asbestos exposure.,SOCIAL HISTORY:  ,The patient works as a school teacher and teaching high school.,PHYSICAL EXAMINATION,GENERAL:  The patient is a white female, alert and oriented x 3, appears her stated age of 57.,HEENT:  Head is atraumatic and normocephalic.  Sclerae are anicteric.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,BREASTS:  Exam reveals an approximately 1.5 cm relatively mobile focal palpable mass in the inferomedial left breast at the 7 o'clock position, which clinically is not fixed to the underlying pectoralis muscle.  There are no nipple retractions.  No skin dimpling.  There is some, at the time of the office visit, ecchymosis from recent biopsy.  There is no axillary adenopathy.  The remainder of the left breast is without abnormality.  The right breast is without abnormality.  The axillary areas are negative for adenopathy bilaterally.,ABDOMEN:  Soft, nontender without masses.  No gross organomegaly.  No CVA or flank tenderness.,EXTREMITIES:  Grossly neurovascularly intact.,IMPRESSION: , The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.,RECOMMENDATIONS: , I have discussed with the patient in detail about the diagnosis of breast cancer and the surgical options, and medical oncologist has discussed with her issues about adjuvant or neoadjuvant chemotherapy.  We have decided to recommend to the patient breast conservation surgery with left breast lumpectomy with preoperative sentinel lymph node injection and mapping and left axillary dissection.  The possibility of further surgery requiring wider lumpectomy or even completion mastectomy was explained to the patient.  The procedure and risks of the surgery were explained to include, but not limited to extra bleeding, infection, unsightly scar formation, the possibility of local recurrence, the possibility of left upper extremity lymphedema was explained.  Local numbness, paresthesias or chronic pain was explained.  The patient was given an educational brochure and several brochures about the diagnosis and treatment of breast cancers.  She was certainly encouraged to obtain further surgical medical opinions prior to proceeding.  I believe the patient has given full informed consent and desires to proceed with the above.",5
"REASON FOR CONSULTATION: , Possible free air under the diaphragm.,HISTORY OF PRESENT ILLNESS: , The patient is a 77-year-old female who is unable to give any information.  She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history.  On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.,PAST MEDICAL HISTORY: , Significant for alcohol abuse.  Unable to really gather any other information because she is so obtunded.,PAST SURGICAL HISTORY:  ,Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.,MEDICATIONS:,  Unable to evaluate.,ALLERGIES: , UNABLE TO EVALUATE.,SOCIAL HISTORY:  ,Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAM,VITAL SIGNS:  Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.,GENERAL:  She is a very obtunded female who upon arousal is not able to provide any information of any use.,HEENT:  Atraumatic.,NECK:  Soft and supple.,LUNGS:  Bilaterally diminished.,HEART:  Regular.,ABDOMEN:  Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.,LABORATORY STUDIES: , Show a normal white blood cell count with no shift.  Elevated AST at 138, with a normal ALT at 38.  Alkaline phosphatase of 96, bilirubin 0.8.  Sodium is 107, with 68 chloride and potassium of 2.8.,X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology.  The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.,ASSESSMENT: , No intra-abdominal pathology.,PLAN:,  Have her admitted to the medical service for treatment of her hyponatremia.",14
"CHIEF COMPLAINT: , I need refills.,HISTORY OF PRESENT ILLNESS:,  The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking.  She is a new patient today.  She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain.  She states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office.  She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try.,OBJECTIVE:  ,Well developed and well nourished.  She does not appear to be in any acute distress.  Cardiovascular:  Regular rhythm.  No murmurs, gallops, or rubs.  Capillary refill less than 3 seconds.  Peripheral pulses are 2+ bilaterally.  Respiratory:  Her lungs are clear to auscultation bilaterally with good effort.  No tenderness to palpation over chest wall.  Musculoskeletal:  She has full range of motion of all four extremities.  No tenderness to palpation over long bones.  Skin:  Warm and dry.  No rashes or lesions.  Neuro:  Alert and oriented x3.  Cranial nerves II-XII are grossly intact.  No focal deficits.,PLAN: , I did refill her medications.  I have requested that she have her primary doctor forward her records to me.  I have discussed Chantix and its use and success rate.  She was given a prescription, as well as a coupon.  She is to watch for any worsening signs or symptoms.  She verbalized understanding of discharge instructions and prescriptions.  I would like to see her back to proceed with her preventive health measures.",5
"PREOPERATIVE DIAGNOSIS: , Left patellar chondromalacia.,POSTOPERATIVE DIAGNOSIS:,  Left patellar chondromalacia with tight lateral structures.,PROCEDURE:,  Left knee arthroscopy with lateral capsular release.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME:  ,47 minutes.,MEDICATION:  ,The patient received 0.5% Marcaine local anesthetic 32 mL.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,HISTORY AND PHYSICAL:  ,The patient is a 14-year-old girl who started having left knee pain in the fall of 2007.  She was not seen in Orthopedic Clinic until November 2007.  The patient had an outside MRI performed that demonstrated left patellar chondromalacia only.  The patient was referred to physical therapy for patellar tracking exercises.  She was also given a brace.  The patient reported increasing pain with physical therapy and mother strongly desired other treatment.  It was explained to the mother in detail that this is a difficult problem to treat although majority of the patients get better with physical therapy.  Her failure with nonoperative treatment is below the standard 6-month trial; however, given her symptoms and severe pain, lateral capsular release was offered.  Risk and benefits of surgery were discussed.  Risks of surgery including risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling.  All questions were answered, and mother and daughter agreed to the above plans.,PROCEDURE NOTE: , The patient was taken to the operating room and placed on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A nonsterile tourniquet was placed on the upper aspect of left thigh.  The extremity was then prepped and draped in the standard surgical fashion.  A medial suprapatellar portal was marked on the skin as well as anteromedial and anterolateral joint line.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  Esmarch was then removed.  Incisions were then made.  Camera was initially inserted into the lateral joint line.  Visualization of patellofemoral joint revealed type 2 chondromalacia with slight lateral subluxation.  The patient did have congruent articulation about 30 degrees of knee flexion.  Visualization of the medial joint line revealed no loose bodies.  There was a small plica.  Visualization of the medial joint line revealed no significant chondromalacia.  Menisci was probed and tested with no signs of tears and instability.  ACL was noted to be intact.  The intercondylar notch and lateral joint line also revealed no significant chondromalacia or meniscal pathology.  Lateral gutter also demonstrated no loose bodies or plica.  The camera was then removed and inserted into the anteromedial portal using two 18-gauge needles.  The extent of lateral capsular release was marked using a monopolar coblator, lateral capsular release was performed.  The patient had significant improvement in anteromedial translation from 25% to 50%.  At the end of the case, all instruments were removed.  The knee was injected with 32 mL of 0.5% Marcaine with additional epinephrine.  Please note, the patient received 30 mL of 1:500,000 dilution epinephrine at the beginning of the case.  The portals were then closed using 4-0 Monocryl.  The wound was clean and dry, and dressed with Steri-Strips, Xeroform, and 4 x 4s.  The kneecap was translated medially under pressure and a bias placed.  The tourniquet was released at 47 minutes.  The patient was then placed in the knee immobilizer.  The patient tolerated the procedure well and was subsequently extubated and taken to the recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will weightbear as tolerated in the knee immobilizer.  She will start physical therapy within 1 to 2 weeks to work on patella mobilization as well as reconditioning and strengthening.  Intraoperative findings were relayed to the mother.  All questions were answered.",27
"PREOPERATIVE DIAGNOSES:,  ,1.  Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2.  Neck pain with left radiculopathy, progressive (723.1/723.4).,3.  Headaches, progressive (784.0).,POSTOPERATIVE DIAGNOSES:,  ,1.  Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2.  Neck pain with left radiculopathy, progressive (723.1/723.4).,3.  Headaches, progressive (784.0).,PROCEDURES:,  ,1.  Anterior cervical discectomy at C5-C6 for neural decompression (63075).,2.  Anterior interbody fusion C5-C6 (22554) utilizing Bengal cage (22851).,3.  Anterior cervical instrumentation at C5-C6 for stabilization by Uniplate construction at C5-C6 (22845); with intraoperative x-ray x2.,SERVICE:  ,  Neurosurgery,ANESTHESIA:,",27
"PROCEDURE:,  Belly button piercing for insertion of belly button ring.,DESCRIPTION OF PROCEDURE:,  The patient was prepped after informed consent was given of risk of infection and foreign body reaction.  The area was marked by the patient and then prepped.  The area was injected with 2% Xylocaine 1:100,000 epinephrine.,Then a #14-gauge needle was inserted above the belly button and inserted up to the skin just above the actual umbilical area and the ring was inserted into the #14-gauge needle and pulled through.  A small ball was placed over the end of the ring.  This terminated the procedure.,The patient tolerated the procedure well.  Postop instructions were given regarding maintenance.  Patient left the office in satisfactory condition.",6
"CHIEF COMPLAINT:  ,Blood in toilet.,HISTORY: , Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet.  They did not note any urine or stool in the toilet and the patient had no acute complaints.  The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events.  The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints.  There is no other history provided by the nursing staff from XYZ.  There apparently were no clots noted within there.  She does not have a history of being on anticoagulants.,PAST MEDICAL HISTORY: , Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.,PAST SURGICAL HISTORY:  ,Unknown.,SOCIAL HISTORY: , No tobacco or alcohol.,MEDICATIONS: , Listed in the medical records.,ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.,GENERAL:  This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress.,HEENT:  Visually normal.  Pupils are reactive.  TMs, canals, nasal mucosa, and oropharynx are intact.,NECK:  No lymphadenopathy or JVD.,HEART:  Regular rate and rhythm.  S1, S2.  No murmurs, gallops, or rubs.,LUNGS:  Clear to auscultation.  No wheeze, rales, or rhonchi.,ABDOMEN:  Benign, flat, soft, nontender, and nondistended.  Bowel sounds active.  No organomegaly or mass noted.,GU/RECTAL:  External rectum was normal.  No obvious blood internally.  There is no stool noted within the vault.  There is no gross amount of blood noted within the vault.  Guaiac was done and was trace positive.  Visual examination anteriorly during the rectal examination noted no blood within the vaginal region.,EXTREMITIES:  No significant abnormalities.,WORKUP: , CT abdomen and pelvis was negative.  CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%.  CMP also within normal limits.  PTT, PT, and INR were normal.  Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization.,ER COURSE:,  Uneventful.  I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient.  We have decided to send the patient back to XYZ with observation by the staff there.  She will have a CBC done daily for the next 3 days with results to Dr. X.  They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood.,ASSESSMENT: , Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",15
"PREOPERATIVE DIAGNOSIS:,  Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis, gangrenous.,PROCEDURE: , Appendectomy.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room under urgent conditions.  After having obtained an informed consent, he was placed in the operating room and under anesthesia.  Followed by a time-out process, his abdominal wall was prepped and draped in the usual fashion.  Antibiotics had been given prior to incision.  A McBurney incision was performed and it carried out through the peritoneal cavity.  Immediately there was  purulent material seen in the area.  Samples were taken for culture and sensitivity of aerobic and anaerobic sets.  The appendix was markedly swollen particularly in its distal three-fourth, where the distal appendix showed an abscess formation and devitalization of the wall.  There was quite a bit of local peritonitis.  The mesoappendix was clamped, divided and ligated, and then the appendix was ligated and divided, and the stump buried with a pursestring suture of Vicryl and then a Z stitch.  The area was abundantly irrigated with normal saline and also the pelvis.  The distal foot of small bowel had been explored and because it delivered itself __________ the incision and showed no pathology.,Then the peritoneal and internal fascia were approximated with a suture of 0 Vicryl and then the incision was closed in layers and after each layer the wound was irrigated with normal saline.  The skin was closed with a combination of a subcuticular suture of fine Monocryl followed by the application of Dermabond.  The patient tolerated the procedure well.  Estimated blood loss was minimal, and the patient was sent to the recovery room for recovery in satisfactory condition.,",14
"HISTORY:  ,We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic.  He was sent here with a chief complaint of joint pain in several joints for few months.  This is a 7-year-old white male who has no history of systemic disease, who until 2 months ago, was doing well and 2 months ago, he started to complain of pain in his fingers, elbows, and neck.  At this moment, this is better and is almost gone, but for several months, he was having pain to the point that he would cry at some point.  He is not a complainer according to his mom and he is a very active kid.  There is no history of previous illness to this or had gastrointestinal problems.  He has problems with allergies, especially seasonal allergies and he takes Claritin for it.  Other than that, he has not had any other problem.  Denies any swelling except for that doctor mentioned swelling on his elbow.  There is no history of rash, no stomach pain, no diarrhea, no fevers, no weight loss, no ulcers in his mouth except for canker sores.  No lymphadenopathy, no eye problems, and no urinary problems.,MEDICATIONS: , His medications consist only of Motrin only as needed and Claritin currently for seasonal allergies and rhinitis.,ALLERGIES: , He has no allergies to any drugs.,BIRTH HISTORY:  ,Pregnancy and delivery with no complications.  He has no history of hospitalizations or surgeries.,FAMILY HISTORY: , Positive for arthritis in his grandmother.  No history of pediatric arthritis.  There is history of psoriasis in his dad.,SOCIAL HISTORY: , He lives with mom, dad, brother, sister, and everybody is healthy.  They live in Easton.  They have 4 dogs, 3 cats, 3 mules and no deer.  At school, he is in second grade and he is doing PE without any limitation.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Temperature is 98.7, pulse is 96, respiratory rate is 24, height is 118.1 cm, weight is 22.1 kg, and blood pressure is 61/44.,GENERAL:  He is alert, active, in no distress, very cooperative.,HEENT:  He has no facial rash.  No lymphadenopathy.  Oral mucosa is clear.  No tonsillitis.  His ear canals are clear and pupils are reactive to light and accommodation.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm and no murmur.,ABDOMEN:  Soft, nontender with no visceromegaly.,MUSCULOSKELETAL:  Shows no limitation in any of his joints or active swelling today.  He has no tenderness either in any of his joints.  Muscle strength is 5/5 in proximal muscles.,LABORATORY DATA:,  Includes an arthritis panel.  It has normal uric acid, sedimentation rate of 2, rheumatoid factor of 6, and antinuclear antibody that is negative and C-reactive protein that is 7.1.  His mother stated that this was done while he was having symptoms.,ASSESSMENT AND PLAN: , This patient may have had reactive arthritis.  He is seen frequently and the patient has family history of psoriatic arthritis or psoriasis.  I do not see any problems at this moment on his laboratories or on his physical examination.  This may have been related to recent episode of viral infection or infection of some sort.  Mother was oriented about the finding and my recommendation is to observe him and if there is any recurrence of the symptoms or persistence of swelling or limitation in any of his joints, I will be glad to see him back.,If you have any question on further assessment and plan, please do no hesitate to contact us.",27
"INDICATIONS:  ,Chest pain.,STRESS TECHNIQUE:,",33
"CC:, Progressive lower extremity weakness.,HX: ,This 54 y/o RHF presented on 7/3/93 with a 2 month history of lower extremity weakness. She was admitted to a local hospital on 5/3/93 for a 3 day h/o of progressive BLE weakness associated with incontinence and BLE numbness. There was little symptom of upper extremity weakness at that time, according to the patient. Her evaluation was notable for a bilateral L1 sensory level and 4/4 strength in BLE. A T-L-S Spine MRI revealed a T4-6 lipomatosis with anterior displacement of the cord without cord compression. CSF analysis yielded: opening pressure of 14cm H20, protein 88, glucose 78, 3 lymphocytes and 160 RBC, no oligoclonal bands or elevated IgG index, and negative cytology. Bone marrow biopsy was negative. B12, Folate, and Ferritin levels were normal. CRP 5.2 (elevated). ANA was positive at 1:5,120 in speckled pattern. Her hospital course was complicated by deep venous thrombosis, which recurred after heparin was stopped to do the bone marrow biopsy. She was subsequently placed on Coumadin. EMG/NCV testing revealed "" lumbosacral polyradiculopathy with axonal degeneration and nerve conduction block."" She was diagnosed with atypical Guillain-Barre vs. polyradiculopathy and received a single course of Decadron; and no plasmapheresis or IV IgG. She was discharged home o 6/8/93.,She subsequently did not improve and after awaking from a nap on her couch the day of presentation, 7/3/93, she found she was paralyzed from the waist down. There was associated mild upper lumbar back pain without radiation. She had had no bowel movement or urination since that time. She had no recent trauma, fever, chills, changes in vision, dysphagia or upper extremity deficit.,MEDS:, Coumadin 7.5mg qd, Zoloft 50mg qd, Lithium 300mg bid.,PMH:, 1) Bi-polar Affective Disorder, dx 1979 2) C-section.,FHX:, Unremarkable.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM: ,BP118/64, HR103, RR18, Afebrile.,MS: ,A&O to person, place, time. Speech fluent without dysarthria. Lucid thought processes.,CN: ,Unremarkable.,MOTOR:, 5/5 strength in BUE. Plegic in BLE. Flaccid muscle tone.,SENSORY:, L1 sensory level (bilaterally) to PP and TEMP, without sacral sparing. Proprioception was lost in both feet.,CORD: ,Normal in BUE.,Reflexes were 2+/2+ in BUE. They were not elicited in BLE. Plantar responses were equivocal, bilaterally.,RECTAL: ,Poor rectal tone. stool guaiac negative. She had no perirectal sensation.,COURSE:, CRP 8.8 and ESR 76. FVC 2.17L. WBC 1.5 (150 bands, 555 neutrophils, 440 lymphocytes and 330 monocytes), Hct 33%, Hgb 11.0, Plt 220K, MCV 88, GS normal except for slightly low total protein (8.0). LFT were normal. Creatinine 1.0. PT and PTT were normal. ABCG 7.46/25/79/96% O2Sat. UA notable for 1+ proteinuria. EKG normal.,MRI L-spine, 7/3/93, revealed an area of abnormally increased T2 signal extending from T12 through L5. This area causes anterior displacement of the spinal cord and nerve roots. The cauda equina are pushed up against the posterior L1 vertebral body. There bilaterally pulmonary effusions. There is also abnormally increased T2 signal in the center of the spinal cord extending from the mid thoracic level through the conus. In addition, the Fila Terminale appear thickened. There is increased signal in the T3 vertebral body suggestion a hemangioma. The findings were felt consistent with a large epidural lipoma displacing the spinal cord anteriorly. there also appeared spinal cord swelling and increased signal within the spinal cord which suggests an intramedullary process.,CSF analysis revealed: protein 1,342, glucose 43, RBC 4,900, WBC 9. C3 and C$ complement levels were 94 and 18 respectively (normal) Anticardiolipin antibodies were negative. Serum Beta-2 microglobulin was elevated at 2.4 and 3.7 in the CSF and Serum, respectively. It was felt the patient had either a transverse myelitis associated with SLE vs. partial cord infarction related to lupus vasculopathy or hypercoagulable state. She was place on IV Decadron. Rheumatology felt that a diagnosis of SLE was likely. Pulmonary effusion analysis was consistent with an exudate. She was treated with plasma exchange and place on Cytoxan.,On 7/22/93 she developed fever with associated proptosis and sudden loss of vision, OD. MRI Brain, 7/22/93, revealed a 5mm thick area of intermediate signal adjacent to the posterior aspect of the right globe, possibly representing hematoma. Ophthalmology felt she had a central retinal vein occlusion; and it was surgically decompressed.,She was placed on prednisone on 8/11/93 and Cytoxan was started on 8/16/93. She developed a headache with meningismus on 8/20/93. CSF analysis revealed: protein 1,002, glucose2, WBC 8,925 (majority were neutrophils). Sinus CT scan negative. She was placed on IV Antibiotics for presumed bacterial meningitis. Cultures were subsequently negative. She spontaneously recovered. 8/25/93, cisternal tap CSF analysis revealed: protein 126, glucose 35, WBC 144 (neutrophils), RBC 95, Cultures negative, cytology negative. MRI Brain scan revealed diffuse leptomeningeal enhancement in both brain and spinal canal.,DSDNA negative. She developed leukopenia in 9/93, and she was switched from Cytoxan to Imuran. Her LFT's rose and the Imuran was stopped and she was placed back on prednisone.,She went on to have numerous deep venous thrombosis while on Coumadin. This required numerous hospital admissions for heparinization. Anticardiolipin antibodies and Protein C and S testing was negative.",27
"TITLE OF OPERATION: , Transnasal transsphenoidal approach in resection of pituitary tumor.,INDICATION FOR SURGERY: , The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.  She was started on Dostinex with increasing dosages.  The most recent MRI demonstrated an increased growth with hemorrhage.  This was then discontinued.  Most recent prolactin was at 70, although normalized, the recommendation was surgical resection given the size of the sellar lesion.  All the risks, benefits, and alternatives were explained in great detail via translator.,PREOP DIAGNOSIS: , Pituitary tumor.,POSTOP DIAGNOSIS: , Pituitary tumor.,PROCEDURE DETAIL:  ,The patient brought to the operating room, positioned on the horseshoe headrest in a neutral position supine.  The fluoroscope was then positioned.  The approach will be dictated by Dr. X. Once the operating microscope and the endoscope were then used to approach it through transnasal, this was complicated and complex secondary to the drilling within the sinus.  Once this was ensured, the tumor was identified, separated from the pituitary gland, it was isolated and then removed.  It appeared to be hemorrhagic and a necrotic pituitary, several sections were sent.  Once this was ensured and completed and hemostasis obtained, the wound was irrigated.  There might have been a small CSF leak with Valsalva, so the recommendation was for a reconstruction, Dr. X will dictate.  The fat graft was harvested from the left lower quadrant and closed primarily, this was soaked in fat and used to close the closure.  All sponge and needle counts were correct.  The patient was extubated and transported to the recovery room in stable condition.  Blood loss was minimal.",37
"1.  Pelvic tumor.,2.  Cystocele.,3.  Rectocele.,POSTOPERATIVE DIAGNOSES:,1.  Degenerated joint.,2.  Uterine fibroid.,3.  Cystocele.,4.  Rectocele.,PROCEDURE PERFORMED:  ,1.  Total abdominal hysterectomy.,2.  Bilateral salpingooophorectomy.,3.  Repair of bladder laceration.,4.  Appendectomy.,5.  Marshall-Marchetti-Krantz cystourethropexy.,6.  Posterior colpoperineoplasty.,GROSS FINDINGS:  The patient had a history of a rapidly growing mass on the abdomen, extending from the pelvis over the past two to three months.  She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus.  Curettings were negative for malignancy.  The patient did have a large cystocele and rectocele, and a collapsed anterior and posterior vaginal wall.,Upon laparotomy, there was a giant uterine tumor extending from the pelvis up to the above the umbilicus compatible with approximately four to five-month pregnancy.  The ovaries appeared to be within normal limits.  There was marked adherence between the bladder and the giant uterus and mass with edema and inflammation, and during dissection, a laceration inadvertently occurred and it was immediately recognized.  No other pathology noted from the abdominal cavity or adhesions.  The upper right quadrant of the abdomen compatible with a previous gallbladder surgery.  The appendix is in its normal anatomic position.  The ileum was within normal limits with no Meckel's diverticulum seen and no other gross pathology evident.  There was no evidence of metastasis or tumors in the left lobe of the liver.,Upon frozen section, diagnosis of initial and partial is that of a degenerating uterine fibroid rather than a malignancy.,OPERATIVE PROCEDURE:  The patient was taken to the Operating Room, prepped and draped in the low lithotomy position under general anesthesia.  A midline incision was made around the umbilicus down to the lower abdomen.  With a #10 Bard Parker blade knife, the incision was carried down through the fascia.  The fascia was incised in the midline, muscle fibers were splint in the midline, the peritoneum was grasped with hemostats and with a #10 Bard Parker blade after incision was made with Mayo scissors.  A Balfour retractor was placed into the wound.  This giant uterus was soft and compatible with a possible leiomyosarcoma or degenerating fibroid was handled with care.  The infundibular ligament on the right side was isolated and ligated with #0 Vicryl suture brought to an avascular area, doubly clamped and divided from the ovary and the ligament again re-ligated with #0 Vicryl suture.  The right round ligament was ligated with #0 Vicryl suture, brought to an avascular space within the broad ligament and divided from the uterus.  The infundibulopelvic ligament on the left side was treated in a similar fashion as well as the round ligament.  An attempt was made to dissect the bladder flap from the anterior surface of the uterus and this was remarkably edematous and difficult to do, and during dissection the bladder was inadvertently entered.  After this was immediately recognized, the bladder flap was wiped away from the anterior surface of the uterus.  The bladder was then repaired with a running locking stitch #0 Vicryl suture incorporating serosal muscularis mucosa and then the second layer of overlapping seromuscular sutures were used to make a two-layer closure of #0 Vicryl suture.  After removing the uterus, the bladder was tested with approximately 400 cc of sterile water and there appeared to be no leak.  Progressing and removing of the uterus was then carried out and the broad ligament was clamped bilaterally with a straight Ochsner forceps and divided from the uterus with Mayo scissors, and the straight Ochsner was placed by #0 Vicryl suture thus controlling the uterine blood supply.  The cardinal ligaments containing the cervical blood supply was serially clamped bilaterally with a curved Ochsner forceps, divided from the uterus with #10 Bard Parker blade knife and a curved Ochsner was placed by #0 Vicryl suture.  The cervix was again grasped with a Lahey tenaculum and pubovesicocervical ligament was entered and was divided using #10 Bard Parker blade knife and then the vaginal vault and with a double pointed sharp scissors.  A single-toothed tenaculum was placed on the cervix and then the uterus was removed from the vagina using hysterectomy scissors.  The vaginal cuff was then closed using a running #0 Vicryl suture in locking stitch incorporating all layers of the vagina, the cardinal ligaments of the lateral aspect and uterosacral ligaments on the posterior aspect.  The round ligaments were approximated to the vaginal cuff with #0 Vicryl suture and the bladder flap approximated to the round ligaments with #000 Vicryl suture.  The ______ was re-peritonealized with #000 Vicryl suture and then the cecum brought into the incision.  The pelvis was irrigated with approximately 500 cc of water.  The appendix was grasped with Babcock forceps.  The mesoappendix was doubly clamped with curved hemostats and divided with Metzenbaum scissors.  The curved hemostats were placed with #00 Vicryl suture.  The base of the appendix was ligated with #0 plain gut suture, doubly clamped and divided from the distal appendix with #10 Bard Parker blade knife, and the base inverted with a pursestring suture with #00 Vicryl.  No bleeding was noted.  Sponge, instrument, and needle counts were found to be correct.  All packs and retractors were removed.  The peritoneum muscle fascia was closed in single-layer closure using running looped #1 PDS, but prior to closure, a Marshall-Marchetti-Krantz cystourethropexy was carried out by dissecting the space of Retzius identifying the urethra in the vesical junction approximating the periurethral connective tissue to the symphysis pubis with interrupted #0 Vicryl suture.  Following this, the abdominal wall was closed as previously described and the skin was closed using skin staples.  Attention was then turned to the vagina, where the introitus of the vagina was grasped with an Allis forceps at the level of the Bartholin glands.  An incision was made between the mucous and the cutaneous junction and then a midline incision was made at the posterior vaginal mucosa in a tunneling fashion with Metzenbaum scissors.  The flaps were created bilaterally by making an incision in the posterior connective tissue of the vagina and wiping the rectum away from the posterior vaginal mucosa, and flaps were created bilaterally.  In this fashion, the rectocele was reduced and the levator ani muscles were approximated in the midline with interrupted #0 Vicryl suture.  Excess vaginal mucosa was excised and the vaginal mucosa closed with running #00 Vicryl suture.  The bulbocavernosus and transverse perinei muscles were approximated in the midline with interrupted #00 Vicryl suture.  The skin was closed with a running #000 plain gut subcuticular stitch.  The vaginal vault was packed with a Betadine-soaked Kling gauze sponge.  Sterile dressing was applied.  The patient was sent to recovery room in stable condition.",38
"IDENTIFICATION: , The patient is a 15-year-old female.,CHIEF COMPLAINT: , Right ankle pain.,HISTORY OF PRESENT ILLNESS:,  The patient was running and twisted her right ankle.  There were no other injuries.  She complains of right ankle pain on the lateral aspect.  She is brought in by her mother.  Her primary care physician is Dr. Brown.,REVIEW OF SYSTEMS:,  Otherwise negative except as stated above.,PAST MEDICAL HISTORY:,  None.,PAST SURGICAL HISTORY: , None.,MEDICATIONS:,  None.,SOCIAL HISTORY: , Mother appears loving and caring.  There is no evidence of abuse.,ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION: , General:  The patient is alert and oriented x4 in mild distress without diaphoresis.  She is nonlethargic and nontoxic.  Vitals:  Within normal limits.  The right ankle shows no significant swelling.  There is no ecchymosis.  There is no significant tenderness to palpation.  The ankle has good range of motion.  The foot is nontender.  Vascular:  +2/2 dorsalis pedis pulse.  All compartments are soft.  Capillary refill less than 2 seconds.,DIAGNOSTIC TEST:,  The patient had an x-ray of the right ankle, which interpreted by myself shows no acute fracture or dislocation.,MEDICAL DECISION MAKING: , Due to the fact this patient has no evidence of an ankle fracture, she can be safely discharged to home.  She is able to walk on it without significant pain, thus I recommend rest for 1 week and follow up with the doctor if she has persistent pain.  She may need to see a specialist, but at this time this is a very mild ankle injury.  There is no significant physical finding, and I foresee no complications.  I will give her 1 week off of PE.,MORBIDITY/MORTALITY:,  I expect no acute complications.  A full medical screening exam was done and no emergency medical condition exists upon discharge.,COMPLEXITY:,  Moderate.  The differential includes fracture, contusion, abrasion, laceration, and sprain.,ASSESSMENT:,  Right ankle sprain.,PLAN:,  Discharge the patient home and have her follow up with her doctor in 1 week if symptoms persist.  She is advised to return immediately p.r.n. severe pain, worsening, not better, etc.",5
"Her past medical history includes insulin requiring diabetes mellitus for the past 28 years.  She also has a history of gastritis and currently is being evaluated for inflammatory bowel disease.  She is scheduled to see a gastroenterologist in the near future.  She is taking Econopred 8 times a day to the right eye and Nevanac, OD, three times a day.  She is allergic to penicillin.,The visual acuity today was 20/50, pinholing, no improvement in the right eye.  In the left eye, the visual acuity was 20/80, pinholing, no improvement.  The intraocular pressure was 14, OD and 9, OS.  Anterior segment exam shows normal lids, OU.  The conjunctiva is quiet in the right eye.  In the left eye, she has an area of sectoral scleral hyperemia superonasally in the left eye.  The cornea on the right eye shows a paracentral area of mild corneal edema.  In the left eye, cornea is clear.  Anterior chamber in the right eye shows trace cell.  In the left eye, the anterior chamber is deep and quiet.  She has a posterior chamber intraocular lens, well centered and in sulcus of the left eye.  The lens in the left eye shows 3+ nuclear sclerosis.  Vitreous is clear in both eyes.  The optic nerves appear healthy in color and normal in size with cup-to-disc ratio of approximately 0.48.  The maculae are flat in both eyes.  The retinal periphery is flat in both eyes.,Ms. ABC is recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.  She will continue her current drops.  In the left eye, she has an area of what appears to be sectoral scleritis.  I did a comprehensive review of systems today and she reports no changes in her pulmonary, dermatologic, neurologic, gastroenterologic or musculoskeletal systems.  She is, however, being evaluated for inflammatory bowel disease.  The mild scleritis in the left eye may be a manifestation of this.  We will notify her gastroenterologist of this possibility of scleritis and will start Ms. ABC on a course of indomethacin 25 mg by mouth two times a day.  I will see her again in one week.  She will check with her primary physician prior to starting the Indocin.",34
"2-D STUDY,1. Mild aortic stenosis, widely calcified, minimally restricted.,2. Mild left ventricular hypertrophy but normal systolic function.,3. Moderate biatrial enlargement.,4. Normal right ventricle.,5. Normal appearance of the tricuspid and mitral valves.,6. Normal left ventricle and left ventricular systolic function.,DOPPLER,1. There is 1 to 2+ aortic regurgitation easily seen, but no aortic stenosis.,2. Mild tricuspid regurgitation with only mild increase in right heart pressures, 30-35 mmHg maximum.,SUMMARY,1. Normal left ventricle.,2. Moderate biatrial enlargement.,3. Mild tricuspid regurgitation, but only mild increase in right heart pressures.",33
"PREOPERATIVE DIAGNOSIS: , Bilateral renal mass.,POSTOPERATIVE DIAGNOSIS:,  Bilateral renal mass.,OPERATION: , Right hand-assisted laparoscopic cryoablation of renal lesions x2.  Lysis of adhesions and renal biopsy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  100 Ml.,FLUIDS: , Crystalloid.,The patient was bowel prepped and was given preoperative antibiotics.,BRIEF HISTORY: , The patient is a 73-year-old male, who presented to us with a referral from Dr. X's office with bilateral renal mass and renal insufficiency.  The patient's baseline creatinine was around 1.6 to 1.7.  The patient was found to have a 3 to 4-cm exophytic right renal mass, 1-cm renal mass inferior to that, and about 2-cm left renal mass.  Since the patient had bilateral renal disease and the patient had renal insufficiency, the best option at this time had been cryoprocedure for the kidney versus partial nephrectomy, one kidney at a time.  The patient understood all his options, had done some research on cryotherapy and wanted to proceed with the procedure.  The patient had a renal biopsy done, which showed a possibility of an oncocytoma, which also would indicate that if this is not truly a cancerous lesion, but there is an associated risk of renal cell carcinoma that the patient will benefit from a cryo of the kidney.,Risk of anesthesia, bleeding, infection, pain, hernia, bowel obstruction, ileus, injury to bowel, postoperative bleeding, etc., were discussed.  The patient understood the risk of delayed bleeding, the needing for nephrectomy, renal failure, renal insufficiency, etc., and wanted to proceed with the procedure.,DETAILS OF THE OR:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was given preoperative antibiotics.  The patient was bowel prepped.  The patient was placed in right side up, left side down, semiflank, with kidney rest up.  All the pressure points are very well padded using foam and towels.  The left knee was bent and the right knee was straight.  There was no tension on any of the joints.  All pressure points were well padded.  The patient was taped to the table using 2-inch wide tape all the way around.  A Foley catheter and OG tube were in place prior to prepping and draping the patient.  A periumbilical incision measuring about 6 cm was made.  The incision was carried through the subcutaneous tissue through the fascia using sharp dissection.  The peritoneum was open.  Abdomen was entered.  There were some adhesions on the right side of the abdomen, which were released using metz.  Two 12-mm ports were placed in the anteroaxillary line and one in the midclavicular line.  A gel porter was placed.  Pneumoperitoneum was obtained.  All ports were placed under direct vision, and the right colon was reflected medially.  Duodenum was cauterized.  Minimal dissection was done on the hilum and the Gerota's was opened laterally, and the renal masses were clearly visualized all the way around.  Pictures were taken.  Superficial biopsies were taken of 2 renal lesions using 3 different probes.  The 2 lesions were frozen.  The 2 probes were 2.4 mm and the other one was 3.1 mm in diameter.  So the R3.8 and R2.4 long probes were used.  Freezing/thawing, two cycles were done.  The temperatures were -131, -137, -150 and the freezing time was 5 and 10 minutes each and passive sign was done.  The exact times or exact temperatures are on the chart.  There was a nice ice ball with each freezing and with passive sign.  The probes were removed.,The probes were placed directly percutaneously through the skin into the renal lesions.,After freezing/thawing, the probes were removed and to seal with Surgicel were placed.  Pictures were taken after following total of 20 minutes were spent looking at the renal mass to make sure that there was no delayed bleeding.  From the time the probes were removed, until the time the laparoscope was removed, was total of 30 minutes.  So the masses were visualized for a total of 30 minutes without any pneumoperitoneum.  Pneumoperitoneum was obtained again.  Fibrin glue was placed over it just for precautionary measure.  There was about a total of 100 mL of blood loss overall with the entire procedure.  Please note that towels were used to prep off the colon and the liver to ensure there was no freezing of any other organ.  The kidney was kept in the left hand at all times.  Careful attention was drawn to make sure that the probe was deep enough, at least 3.5 to 4 cm in, to get the medial aspect of the tumors frozen.  The laparoscopic vacuum ultrasound showed that there was complete resolution of these lesions.  At the end of the procedure, after freezing/thawing and putting the fibrin glue, Surgicel, and EndoSeal, the colon was reflected medially.  Please note that the perirenal fat was placed over the lesion to ensure that the frozen area of the kidney was not exposed to the bowel.  Lap count was correct.  Please note that renal biopsy for permanent section was performed on the superficial aspect of the lesions.  No deeper biopsies were done to minimize the risk of bleeding.  The 12-mm ports were closed using 0-Vicryl and the middle incision.  The hand-port incision was closed using looped #1 PDS from both sides and was tied in the middle.  Please note that the pneumoperitoneum was closed using 0-Vicryl in running fashion.  After closing the abdomen, 4-0 Monocryl was used to close the skin and Dermabond was applied.,The patient was brought to recovery in a stable condition.",37
"PREOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,POSTOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,OPERATIONS PERFORMED,1.  Left hip arthroscopic debridement.,2.  Left hip arthroscopic femoral neck osteoplasty.,3.  Left hip arthroscopic labral repair.,ANESTHESIA: , General.,OPERATION IN DETAIL: , The patient was taken to the operating room, where he underwent general anesthetic.  His bilateral lower extremities were placed under traction on the Hana table.  His right leg was placed first.  The traction post was left line, and the left leg was placed in traction.  Sterile Hibiclens and alcohol prep and drape were then undertaken.  A fluoroscopic localization was undertaken.  Gentle traction was applied.  Narrow arthrographic effect was obtained.  Following this, the ProTrac portal was made under the fluoro visualization, and then, a direct anterolateral portal made and a femoral neck portal made under direct visualization.  The diagnostic arthroscopy showed the articular surface to be intact with a moderate anterior lip articular cartilage delamination injury that propagated into the acetabulum.  For this reason, the acetabular articular cartilage was taken down and stabilized.  This necessitated takedown of the anterior lip of the acetabulum and subsequent acetabular osteoplasty debridement with associated labral repair.  The labrum was repaired using absorbable Smith & Nephew anchors with a sliding SMC knot.  After stabilization of the labrum and the acetabulum, the ligamentum teres was assessed and noted to be stable.  The remnant articular surface of the femoral artery and acetabulum was stable.  The posterior leg was stable.  The traction was left half off, and the anterolateral aspect of the head and neck junction was identified.  A stable femoral neck decompression was accomplished starting laterally and proceeding anteriorly.  This terminated with the hip coming out of traction and indeterminable flexion.  A combination of burs and shavers was utilized to perform a stable femoral neck osteoplasty decompression.  The decompression was completed with thorough irrigation of the hip.  The cannula was removed, and the portals were closed using interrupted nylon.  The patient was placed into a sterile bandage and anesthetized intraarticularly with 10 mL of ropivacaine subcutaneously with 20 mL of ropivacaine and at this point was taken to the recovery room.  He tolerated the procedure very well with no signs of complications.",37
"CLINICAL INDICATION:  ,Normal stress test.,PROCEDURES PERFORMED:,1.  Left heart cath.,2.  Selective coronary angiography.,3.  LV gram.,4.  Right femoral arteriogram.,5.  Mynx closure device.,PROCEDURE IN DETAIL: , The patient was explained about all the risks, benefits, and alternatives of this procedure.  The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in the usual sterile fashion.  After local anesthesia with 2% lidocaine, a 6-French sheath was inserted in the right femoral artery.  Left and right coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheters.  Then, LV gram was performed using 6-French pigtail catheter.  Post LV gram, LV-to-aortic gradient was obtained.  Then, the right femoral arteriogram was performed.  Then, the Mynx closure device was used for hemostasis.  There were no complications.,HEMODYNAMICS: , LVEDP was 9.  There was no LV-to-aortic gradient.,CORONARY ANGIOGRAPHY:,1.  Left main is normal.  It bifurcates into LAD and left circumflex.,2.  Proximal LAD at the origin of big diagonal, there is 50% to 60% calcified lesion present.  Rest of the LAD free of disease.,3.  Left circumflex is a large vessel and with minor plaque.,4.  Right coronary is dominant and also has proximal 40% stenosis.,SUMMARY:,1.  Nonobstructive coronary artery disease, LAD proximal at the origin of big diagonal has 50% to 60% stenosis, which is calcified.,2.  RCA has 40% proximal stenosis.,3.  Normal LV systolic function with LV ejection fraction of 60%.,PLAN: , We will treat with medical therapy.  If the patient becomes symptomatic, we will repeat stress test.  If there is ischemic event, the patient will need surgery for the LAD lesion.  For the time being, we will continue with the medical therapy.,",37
"PREOPERATIVE DIAGNOSIS,Left breast ductal carcinoma in situ.,POSTOPERATIVE DIAGNOSIS,Left breast ductal carcinoma in situ.,PROCEDURES PERFORMED,1.  Sentinel lymph node biopsy.,2.  Ultrasound-guided lumpectomy with intraoperative ultrasound.,ANESTHESIA,General LMA anesthesia.,ESTIMATED BLOOD LOSS,Minimum.,IV FLUIDS,Per anesthesia record.,COMPLICATIONS,None.,FINDINGS,Clip well localized within the specimen.,INDICATION,This is a 65-year-old female who presents with abnormal mammogram who underwent stereotactic biopsy at an outside facility, which showed atypical ductal hyperplasia with central necrosis.  On reviewing this pathology, it is mostly likely DCIS.  The risks and benefits of the procedure were explained to the patient who appeared to understand and agreed to proceed.  The patient desired MammoSite Radiation Therapy; therefore, the sentinel lymph node biopsy was incorporated into the procedure.,PROCEDURE IN DETAIL,The patient was taken to the operating room, placed in supine position, and general LMA anesthesia was administered.  She was prepped and draped in the usual sterile fashion.  Prior to the procedure, she underwent nuclear medicine injection with technetium-99 and methylene blue.  Incision was made of the area of great uptake and the axilla and taken through the subcutaneous tissue with electric Bovie cautery.  Two sentinel lymph nodes were identified, one was blue and hot and the other was just hot.  These were sent to Pathology for touch prep.  Adequate hemostasis was obtained.  The wound was packed and attention was turned to the left breast.  Ultrasound was used to identify the marker and the mass within the breast and create an adequate anterior skin flap.  An elliptical incision was made roughly at approximately the 3 o'clock position secondary to subcutaneous tissues with electric Bovie cautery.  The mass was dissected off the surrounding tissue using Bovie cautery down to the level of the pectoralis fascia, which was incorporated within the specimen.  The specimen was completely removed and marked **** double deep, and a mini C-arm was used to confirm this.  The marker was well localized within the center of the specimen.  The fascia was then elevated off of the pectoralis muscle and closed loosely with the interrupted 2-0 Vicryl sutures to create a nice spherical cavity for the MammoSite radiation catheter.  The wound was then closed with a deep layer of interrupted 3-0 Vicryl followed by 3-0 Vicryl subcuticular stitch and 4-0 running Monocryl.  The axillary wound was closed with interrupted 3-0 Vicryl and a running 4-0 Monocryl.  Steri-Strips were applied.  The patient was awakened and extubated in the OR and taken to PACU in stable condition.  All counts were reported as correct.  I was present for the entire procedure.",37
"PREOPERATIVE DIAGNOSES:,  Menorrhagia and dysmenorrhea.,POSTOPERATIVE DIAGNOSES: , Menorrhagia and dysmenorrhea.,PROCEDURE: , Laparoscopic supracervical hysterectomy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 100 mL.,FINDINGS: , An 8-10 cm anteverted uterus, right ovary with a 2 cm x 2 cm x 2 cm simple cyst containing straw colored fluid, a normal-appearing left ovary, and normal-appearing tubes bilaterally.,SPECIMENS:  ,Uterine fragments.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , The patient was brought to the OR where general endotracheal anesthesia was obtained without difficulty.  The patient was placed in dorsal lithotomy position.  Examination under anesthesia revealed an anteverted uterus and no adnexal masses.  The patient was prepped and draped in normal sterile fashion.  A Foley catheter was placed in the patient's bladder.  The patient's cervix was visualized with speculum.  A single-tooth tenaculum was placed on the anterior lip of the cervix.  A HUMI uterine manipulator was placed through the internal os of the cervix and the balloon was inflated.  The tenaculum and speculum were then removed from the vagina.  Attention was then turned to the patient's abdomen where a small infraumbilical incision was made with scalpel.  Veress needle was placed through this incision and the patient's abdomen was inflated to a pressure of 15 mmHg.  Veress needle was removed and then 5-mm trocar was placed through the umbilical incision.  Laparoscope was placed through this incision and the patient's abdominal contents were visualized.  A 2nd trocar incision was placed in the midline 2 cm above the symphysis pubis and a 5-mm trocar was placed through this incision on direct visualization for laparoscope.  A trocar incision was made in the right lower quadrant.  A 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  A ___ trocar incision was made in the left lower quadrant and a 2nd 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  The patient's abdominal and pelvic anatomy were again visualized with the assistance of a blunt probe.  The Gyrus cautery was used to cauterize and cut the right and left round ligaments.  The anterior leaf of the broad ligament was bluntly dissected and cauterized and cut in an inferior fashion towards lower uterine segment.  The right uteroovarian ligament was cauterized and cut using the Gyrus.  The uterine vessels were then bluntly dissected.  The Gyrus was then used to cauterize the right uterine vessels.  Gyrus was then used on the left side to cauterize and cut the left round ligament.  The anterior leaf of the broad ligament on the left side was bluntly dissected, cauterized, and cut.  Using the Gyrus, the left uteroovarian ligament was cauterized and cut and the left uterine vessels were then bluntly dissected.  The left uterine vessels were then cauterized and cut using the Gyrus.  At this point, as the uterine vessels had been cauterized on both sides, the uterine body exhibited blanching.  At this point, the Harmonic scalpel hook was used to amputate the uterine body from the cervix at the level just below the uterine vessels.  The HUMI manipulator was removed prior to amputation of the uterine body.  After the uterine body was detached from the cervical stump, morcellation of the uterine body was performed using the uterine morcellator.  The uterus was removed in a piecemeal fashion through the right lower quadrant trocar incision.  Once, all fragments of the uterus were removed from the abdominal cavity, the pelvis was irrigated.  The Harmonic scalpel was used to cauterize the remaining endocervical canal.  The cervical stump was also cauterized with the Harmonic scalpel and good hemostasis was noted at the cervical stump and also at the sites of all pedicles.  The Harmonic scalpel was then used to incise the right ovarian simple cyst.  The right ovarian cyst was then drained yielding straw-colored fluid.  The site of right ovarian cystotomy was noted to be hemostatic.  The pelvis was again inspected and noted to be hemostatic.  The ureters were identified on both sides and noted to be intact throughout the visualized course.  All instruments were then removed from the patient's abdomen and the abdomen was deflated.  The fascial defects at the 10-mm trocar sites were closed using figure-of-8 sutures of 0-Vicryl and skin incisions were closed with a 4-0 Vicryl in subcuticular fashion.  The cervix was then visualized with the speculum.  Good hemostasis at the site of tenaculum insertion was obtained using silver nitrate sticks.  All instruments were removed from the patient's vagina and the patient was placed in normal supine position.,Sponge, lap, needle, and instrument counts were correct x2.  The patient was awoken from anesthesia and then transferred to the recovery room in stable condition.",24
"SUBJECTIVE:,  This is a followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome.  The patient reports that she has worked hard for a number of weeks following the meal plan prescribed, but felt like she was gaining weight and not losing weight on it.  She is not sure that she was following it accurately.  She is trying to walk 1-1/2 to 2 miles every other day, but is increasing her time in the garden and doing other yard work as well.  Once she started experiencing some weight gain, she went back to her old South Beach Diet and felt like she was able to take some of that weight off.  However she realizes that the South Beach Diet is not a healthy diet for her and so is coming back for better instruction on safe weight loss and low-fat eating.,OBJECTIVE:,  Weight is 275 pounds.  Food records were reviewed.,ASSESSMENT:,  The patient experienced a weight gain of 2 pounds since our last consultation which was two months ago.  I did carefully review her food records and evaluated calories consumed.  While she was carefully tracking the volume of protein and carbohydrates, she was getting some excess calories from the fatty proteins selected.  Thus we rearranged her meal plan a little bit and talked about how to track her fat calories as well.  She was more open to reducing the amount of protein from the previous meal plan and increasing slightly the amount of carbohydrates.  While this still is not as much carbohydrate as I would normally recommend, I am certainly willing to work with her on how she feels her body best handles weight reduction.  We also discussed a snack that could be eliminated in the morning because she really is not hungry at that time.,PLAN:,  A new 1500 calorie meal plan was developed based on 35% of the calories coming from protein, 40% of the calories from carbohydrate, and 25% of the calories from fat.  This translates in to 10 servings at 15 grams a piece of carbohydrates throughout the day dividing them in to groups of two servings per meal and per snack.  This also translates in to 2 ounces of protein at breakfast, 6 ounces at lunch, 2 ounces in the afternoon snack, 6 ounces at supper, and 2 ounces in the evening snack.  We have eliminated the morning snack.  The patient will now track the grams of fat in her meats as well as added fats.  Her goal for total fats over the course of the day is no more than 42 grams of fat per day.  This was a half hour consultation.  We will plan to see the patient back in one month for support.",34
"HX: ,This 46y/o RHM with HTN was well until 2 weeks prior to exam when he experienced sudden onset dizziness and RUE clumsiness. The symptoms resolved within 10 min. He did well until the afternoon of admission when while moving the lawn he experienced lightheadedness, RUE dysfunction and expressive aphasia (could not get the words out). His wife took him to his local MD, and on the way there his symptoms resolved. His aphasia recurred at his physician's office and a CT scan of the brain revealed a left temporal mass. He was transferred to UIHC.,PMH:, HTN for many years,MEDS:, Vasotec and Dyazide,SHX/FHX:, ETOH abuse (quit '92), 30pk-yr Cigarettes (quit '92),EXAM:, BP158/92, HR91, RR16,MS: Speech fluent without dysarthria,CN: no deficits noted,Motor: no weakness or abnormal tone noted,Sensory: no deficits noted,Coord: normal,Station: no drift,Gait ND,Reflexes: 3+ throughout. Plantars down-going bilaterally.,Gen exam: unremarkable,STUDIES:, WBC14.3K, Na 132, Cl 94, CO2 22, Glucose 129.,CT Brain without contrast: Calcified 2.5 x 2.5cm mass arising from left sylvian fissure/temporal lobe.,MRI Brain, 8/31/92: right temporo-parietal mass with mixed signal on T1 and T2 images. It has a peripheral dark rim on T1 and T2 with surrounding edema. This suggests a component of methemoglobin and hemosiderin within it. Slight peripheral enhancement was identified. There are two smaller foci of enhancement in the posterior parietal lobe on the right. There is nonspecific white matter foci within the pons and right thalamus. Impression: right temporoparietal hemorrhage, suggesting aneurysm or mass. The two smaller foci may suggest metastasis. The white matter changes probably reflect microvascular disease.,3 Vessel cerebroangiogram, 8/31/92: Lobulated fusiform aneurysm off a peripheral branch of the left middle cerebral artery with slow flow into the vessel distal to the aneurysm.,COURSE:, The aneurysm was felt to be inoperable and he was discharged home on Dilantin, ASA, and Diltiazem.",5
"OPERATIVE PROCEDURE,1.  Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.,2.  Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass,cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection, placement of temporary pacing wires.,DESCRIPTION:,  The patient was brought to the operating room, placed in supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring lines were placed.  The chest, abdomen and legs were prepped and draped in a sterile fashion.  The greater saphenous vein was harvested from the right upper leg through interrupted skin incisions and was prepared by ligating all branches with 4-0 silk and flushing with vein solution.  The leg was closed with running 3-0 Dexon subcu, and running 4-0 Dexon subcuticular on the skin, and later wrapped.  A median sternotomy incision was made and the left internal mammary artery was dissected free from its takeoff at the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The sternum was closed.  A right carotid incision was made along the anterior border of the sternocleidomastoid muscle and carried down to and through the platysma.  The deep fascia was divided.  The facial vein was divided between clamps and tied with 2-0 silk.  The common carotid artery, takeoff of the external and internal carotid arteries were dissected free, with care taken to identify and preserve the hypoglossal and vagus nerves.  The common carotid artery was double-looped with umbilical tape, takeoff of the external was looped with a heavy silk, distal internal was double-looped with a heavy silk.  Shunts were prepared.  A patch was prepared.  Heparin 50 mg was given IV.  Clamp was placed on the beginning of the takeoff of the external and the proximal common carotid artery.  Distal internal was held with a forceps.  Internal carotid artery was opened with 11-blade.  Potts scissors were then used to extend the aortotomy through the lesion into good internal carotid artery beyond.  The shunt was placed and proximal and distal snares were tightened.  Endarterectomy was carried out under direct vision in the common carotid artery and the internal reaching a fine, feathery distal edge using eversion on the external.  All loose debris was removed and Dacron patch was then sutured in place with running 6-0 Prolene suture, removing the shunt just prior to completing the suture line.  Suture line was completed and the neck was packed.,The pericardium was opened.  A pericardial cradle was created.  The patient was heparinized for cardiopulmonary bypass, cannulated with a single aortic and single venous cannula.  A retrograde cardioplegia cannula was placed with a pursestring of 4-0 Prolene into the coronary sinus, and secured to a Rumel tourniquet.  An antegrade cardioplegia needle sump was placed in the ascending aorta and cardiopulmonary bypass was instituted.  The ascending aorta was cross-clamped and cold blood potassium cardioplegia was given antegrade, a total of 5 cc per kg.  This was followed sumping of the ascending aorta and retrograde cardioplegia, a total of 5 cc per kg to the coronary sinus.  The obtuse marginal 1 coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture.  The vein was cut to length.  Antegrade and retrograde cold blood potassium cardioplegia was given.  The obtuse marginal 2 was not felt to be suitable for bypass, therefore, the posterior descending of the right coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture to reverse autogenous saphenous vein.  The vein was cut to length.  The mammary was clipped distally, divided and spatulated for anastomosis.  Antegrade and retrograde cold blood potassium cardioplegia was given.  The anterior descending was identified and opened. the mammary was then sutured to this with running 8-0 Prolene suture.  Warm blood potassium cardioplegia was given, and the cross-clamp was removed.  A partial-occlusion clamp was placed.  Two aortotomies were made.  The veins were cut to fit these and sutured in place with running 5-0 Prolene suture.  The partial- occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Atrial and ventricular pacing wires were placed.  Ventilation was commenced.  The patient was fully warmed.  The patient was weaned from cardiopulmonary bypass and de-cannulated in a routine fashion.  Protamine was given.  Good hemostasis was noted.  A single mediastinal chest tube and bilateral pleural Blake drains were placed.  The sternum was closed with figure-of-eight stainless steel wire, the linea alba with figure-of-eight #1 Vicryl, the sternal fascia with running #1 Vicryl, the subcu with running 2-0 Dexon and the skin with a running 4-0 Dexon subcuticular stitch.",3
"PREOPERATIVE DIAGNOSIS: , Inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct inguinal hernia.,PROCEDURE PERFORMED:,  Rutkow direct inguinal herniorrhaphy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF 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.  Preoperative antibiotics were given for prophylaxis against surgical infection.  The patient was prepped and draped in the usual sterile fashion.,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 no sac was found.  The hernia was found coming from the floor of the inguinal canal medial to the inferior epigastric vessels.  This was dissected back to the hernia opening.  The hernia was inverted back into the abdominal cavity and a large PerFix plug inserted into the ring.  The plug was secured to the ring by interrupted 2-0 Prolene sutures.,The PerFix onlay patch was then placed on the floor of the inguinal canal and secured in place using interrupted 2-0 Prolene sutures.  By reinforcing the floor with the onlay patch, a new internal ring was thus formed.,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 2-0 Vicryl in a running fashion, thus reforming the external ring.  The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.",37
"PREOPERATIVE DIAGNOSIS: , Endometrial cancer.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:,  Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.,ANESTHESIA:,  General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology, uterus with attached tubes and ovaries, right and left pelvic lymph nodes, para-aortic nodes.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding and was found to have a Grade II endometrial carcinoma on biopsy.  She was counseled to undergo staging laparotomy.,FINDINGS:,  Examination under anesthesia revealed a small uterus with no nodularity.  During the laparotomy, the uterus was small, mobile, and did not show any evidence of extrauterine spread of disease.  Other abdominal viscera, including the diaphragm, liver, spleen, omentum, small and large bowel, and peritoneal surfaces, were palpably normal.  There was no evidence of residual neoplasm after removal of the uterus.  The uterus itself showed no serosal abnormalities and the tubes and ovaries were unremarkable in appearance.,PROCEDURE: , The patient was brought to the Operating Room with an IV in place.  Anesthesia was induced, after which she was examined, prepped and draped.,A vertical midline incision was made and fascia was divided.  The peritoneum was entered without difficulty and washings were obtained.  The abdomen was explored with findings as noted.  A Bookwalter retractor was placed and bowel was packed.  Clamps were placed on the broad ligament for traction.  The retroperitoneal spaces were opened by incising lateral and parallel to the infundibulopelvic ligament.  The round ligaments were isolated, divided, and ligated.  The peritoneum overlying the vesicouterine fold was incised to mobilize the bladder.,Retroperitoneal spaces were then opened, allowing exposure of pelvic vessels and ureters.  The infundibulopelvic ligaments were isolated, divided, and doubly ligated.  The uterine artery pedicles were skeletonized, clamped, divided, and suture ligated.  Additional pedicles were developed on each side of the cervix, after which tissue was divided and suture ligated.  When the base of the cervix was reached, the vagina was cross-clamped and divided, allowing removal of the uterus with attached tubes and ovaries.  Angle stitches of o-Vicryl were placed, incorporating the uterosacral ligaments and the vaginal vault was closed with interrupted figure-of-eight stitches.  The pelvis was irrigated and excellent hemostasis was noted.,Retractors were repositioned to allow exposure for lymphadenectomy.  Metzenbaum scissors were used to incise lymphatic tissues.  Borders of the pelvic node dissection included the common iliac bifurcation superiorly, the psoas muscle laterally, the cross-over of the deep circumflex iliac vein over the external iliac artery inferiorly, and the anterior division of the hypogastric artery medially.  The posterior border of dissection was the obturator nerve, which was carefully identified and preserved bilaterally.  Ligaclips were applied where necessary.  After the lymphadenectomy was performed bilaterally, excellent hemostasis was noted.,Retractors were again repositioned to allow exposure of para-aortic nodes.  Lymph node tissue was mobilized, Ligaclips were applied, and the tissue was excised.  The pelvis was again irrigated and excellent hemostasis was noted.  The bowel was run and no evidence of disease was seen.,All packs and retractors were removed and the abdominal wall was closed using a running Smead-Jones closure with #1 permanent monofilament suture.  Subcutaneous tissues were irrigated and a Jackson-Pratt drain was placed.  Scarpa's fascia was closed with a running stitch and skin was closed with a running subcuticular stitch.  The final sponge, needle and instrument counts were correct at the completion of the procedure. ,The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.",24
"REASON FOR CONSULTATION: , Management of blood pressure.,HISTORY OF PRESENT ILLNESS: , The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.  She is on multiple medications, unable to control the blood pressure.  From cardiac standpoint, the patient denies any symptoms of chest pain, or shortness of breath.  She complains of fatigue and tiredness.  The child had some congenital anomaly, was transferred to Hospital, where the child has had surgery.  The patient is in intensive care unit.,CORONARY RISK FACTORS:,  History of hypertension, history of gestational diabetes mellitus, nonsmoker, and cholesterol is normal.  No history of established coronary artery disease and family history noncontributory for coronary disease.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY:  ,No major surgery except for C-section.,MEDICATIONS:,  Presently on Cardizem and metoprolol were discontinued.  Started on hydralazine 50 mg t.i.d., and labetalol 200 mg b.i.d., hydrochlorothiazide, and insulin supplementation.,ALLERGIES: , None.,PERSONAL HISTORY: , Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,  Hypertension, gestational diabetes mellitus, pre-eclampsia, this is her third child with one miscarriage.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR:  No congestive heart.  No arrhythmia.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis, or melena.,UROLOGIC:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGICAL:  No TIA.  No CVA.  No seizure disorder.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 86, blood pressure 175/86, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.,LUNGS:  Clear.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.,LABORATORY DATA: , EKG shows sinus tachycardia with nonspecific ST-T changes.  Labs were noted.  BUN and creatinine within normal limits.,IMPRESSION:,1.  Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.,2.  No prior history of cardiac disease except for borderline gestational diabetes mellitus.,RECOMMENDATIONS:,1.  We will get an echocardiogram for assessment left ventricular function.,2.  The patient will start on labetalol and hydralazine to see how see fairs.,3.  Based on response to medication, we will make further adjustments.  Discussed with the patient regarding plan of care, fully understands and consents for the same.  All the questions answered in detail.",5
"CC: ,Fall with subsequent nausea and vomiting.,HX: ,This 52 y/o RHM initailly presented in 10/94 with a two year hisotry of gradual progressive difficulty with speech. He ""knew what he wanted to say, but could not say it."",His speech was slurred and he found it difficult to control his tongue. Examination at that time was notable for phonemic paraphasic errors, fair repetition of short phrases with decreased fluency, and slurred nasal speech. He could read, but could not write. He exhibited facial-limb apraxia, decreased gag reflex and positive grasp reflex. He was thougth to have possible Pick's disease vs. Cortical Basal Ganglia Degeneration.,On 11/18/94, he fell and was seen in Neurology clinic on 11/23/94. EEG showed borderline background slowing and no other abnormalities. An MRI on 11/8/94, revealed mild atrophy of the left temporal lobe. Neuropsychological evaluations were obtained on 10/25/94 and 11/8/94. These were consistent with progressive aphasia and apraxia with relative sparing of nonverbal reasoning.,He reported consuming 8 beers on the evening of 1/1/95. On 1/2/95, at 9:30AM, he fell forward while stading in his kitchen and struck his forehead on the counter top, and then struck his occiput on the floor. He subsequently developed nausea and vomiting, tinnitus, vertigo, headache and mild shortness of breath. He was taken to the ETC at UIHC. Skull films were negative and he was treated with IV Compazine and IV fluid hydration and sent home. His nausea and vomiting persisted and he became generally weak. He returned to the ETC at UIHC on 1/5/95. HCT scan revealed a right frontal SDH containing signs of both chronic and acute bleeding.,MEDS:, None.,PMH:, 1)fell in 1990 from 15 feet up and landed on his feet sustaining crush injury to both feet and ankles. He reportedly had brief loss of consciousness with no reported head injury.,2)Progressive aphasia. In 10/93, he was able to draw blue prints and write checks for his family business, 3) Left frontoparietal headache for 1.5 years prior to 10/94. Headaches continue to occur once a week, 4)right ankle fusion 4/94, right ankle fusion pending at present.,FHX:, No neurologic disease in family.,SHX:, Divorced and lives with girlfriend. One child by current girlfriend. He has 3 children with former wife. Smoked more than 15 years ago. Drinks 1-2 beers/day. Former Iron worker.,EXAM: ,BP128/83, HR68, RR18, 36.5C. Supine: BP142/71, HR64; Sitting: BP127/73, HR91 and lightheaded.,MS: Appeared moderately distressed and persistently held his forehead. A&O to person, place and time. Dysarthric and dysphagic. Non-fluent speech and able to say single syllable words such as ""up"" or ""down"". He comprehended speech, but could not repeat or write.,CN: Pupils 4/3.5 decreasing to 2/2 on exposure to light. EOM were full and smooth. Optic disks were flat and without sign of hemorrhage. Moderate facial apraxia, but had intact facial sensation.,Motor: 5/5 strength with normal muscle bulk and tone.,Sensory: no abnormalities noted.,Coord: Decreased RAM in the RUE. He had difficulty mmicking movements and postures with his RUE,Gait: ND.,Station: No truncal ataxia, but he had a slight RUE upward drift.,Reflexes 2/2 BUE, 2+/2+ patellae, 2/2 archilles, and plantar responses were flexor, bilaterally.,Rectal exam was unremarkable. The rest of the General Physical exam was unremarkable.,HEENT: atraumatic normocephalic skull. No carotid bruitts.,COURSE:, PT, PTT, CBC, GS, UA and Skull XR were negative. HCT brain, revealed a left frontal SDH with acute and cronic componenets.,He was markedly orthostatic during the first few days of his hospital stay. He was given a 3 day trial of Florinef, which showed mild to moderate improvement of his symptoms of lightheadedness. This improved still further with a trial of Sigvaris pressure stockings. A second HCT was obtained on 12/10/94 and revealed decreased intensity and sized of the left frontal SDH. He was discharged home.,His ideomotor apraxia worsened by 1/96. He developed seizures and was treated with CBZ. He progressively worsened and his overall condition was marked by aphasia, dysphagia, apraxia, and rigidity. He was last seen in 10/96 and the working diagnosis was CBGD vs. Pick's Disease.",22
"PREOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE:  ,Open carpal tunnel release.,COMPLICATIONS:  ,None.,PROCEDURE IN DETAIL:  ,After administering appropriate antibiotics and general anesthesia the Left upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the 4th ray.  The dissection was carried down to the superficial aponeurosis, which was cut.  The distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with scissors.,After irrigating the wound with copious amounts of normal saline, the skin was repaired with 4-0 nylon interrupted stitches.,Marcaine with epinephrine was injected into the wound, which was then dressed and splinted.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.",37
"HISTORY:,  Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.  Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient.  Over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value.  He also underwent EGD earlier today with Dr. X.  I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding.  Dr. X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future.  The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the ICU.  He is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure is 100/54, heart rate 80 and temperature 98.8.  Is and Os negative fluid balance of 1.4 liters in the last 24 hours.,GENERAL:  This is a somnolent 68-year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough.  Pallor is improved.,EYES:  Conjunctivae are now pink.,ENT:  Oropharynx is clear.,CARDIOVASCULAR:  Reveals distant heart tones with regular rate and rhythm.,LUNGS:  Have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases.,ABDOMEN:  Soft and nontender with no organomegaly appreciated.,EXTREMITIES:  Showed no clubbing, cyanosis or edema.  Capillary refill time is now normal in the fingertips.,NEUROLOGICAL:  Cranial nerves II through XII are grossly intact with no focal neurological deficits.,LABORATORY DATA:,  Laboratories drawn at 1449 today, WBC 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000.  This is up from 8.6 and 24.7.  Platelets are stable.  Sodium is 134, potassium 4.0, chloride 101, bicarb 26, BUN 19, creatinine 1.0, glucose 73, calcium 8.4, INR 0.96, iron 13%, saturations 4%, TIBC 312, TSH 0.74, CEA elevated at 8.6, ferritin 27.5 and occult blood positive.  EGD, final results pending per Dr. X's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time.,IMPRESSION/PLAN,1.  Melena secondary to ulcerative esophagitis.  We will continue to monitor the patient overnight to ensure there is no further bleeding.  If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.,2.  Chronic obstructive pulmonary disease exacerbation.  The patient is doing well, taking PO.  We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments.  We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions.  This does appear to be improving.  His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.,3.  Elevated CEA.  The patient will need colonoscopy on an outpatient basis.  He has refused this today.  We would like to encourage him to do so.  Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion.  Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors.,4.  Anemia, normochromic normocytic with low total iron binding capacity.  This appears to be anemia of chronic disease.  However, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding.  Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes.",14
"IDENTIFYING DATA:  ,Mr. T is a 45-year-old white male.,CHIEF COMPLAINT: , Mr. T presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.  His confidence and self-esteem are significantly low.  He stated he has excessive somnolence, his energy level is extremely low, motivation is low, and he has a lack for personal interests.  He has had suicidal ideation, but this is currently in remission.  Furthermore, he continues to have hopeless thoughts and crying spells.  Mr. T stated these symptoms appeared approximately two months ago.,HISTORY OF PRESENT ILLNESS: , On March 25, 2003, Mr. T was fired from his job secondary, to an event at which he stated he was first being harassed by another employee."" This other, employee had confronted Mr. T with a very aggressive, verbal style, where this employee had placed his face directly in front of Mr. T was spitting on him, and called him ""bitch."" Mr. T then retaliated, and went to hit the other employee.  Due to this event, Mr. T was fired.  It should be noted that Mr. T stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to ""deal with it."",There are no other apparent stressors in Mr. T's life at this time or in recent months.  Mr. T stated that work was his entire life and he based his entire identity on his work ethic.  It should be noted that Mr. T was a process engineer for Plum Industries for the past 14 years.,PAST PSYCHIATRIC HISTORY:,  There is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to Mr. T's family physician, Dr. B at which point Mr. T was placed on Lexapro with an unknown dose at this time.  Mr. T is currently seeing Dr. J for psychotherapy where he has been in treatment since April, 2003.,PAST PSYCHIATRIC REVIEW OF SYSTEMS:,  Mr. T denied any history throughout his childhood, adolescence, and early adulthood for depressive, anxiety, or psychotic disorders.  He denied any suicide attempts, or profound suicidal or homicidal ideation.  Mr. T furthermore stated that his family psychiatric history is unremarkable.,SUBSTANCE ABUSE HISTORY:,  Mr. T stated he used alcohol following his divorce in 1993, but has not used it for the last two years.  No other substance abuse was noted.,LEGAL HISTORY: , Currently, charges are pending over the above described incident.,MEDICAL HISTORY: , Mr. T denied any hospitalizations, surgeries, or current medications use for any heart disease, lung disease, liver disease, kidney disease, gastrointestinal disease, neurological disease, closed head injury, endocrine disease, infectious, blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia.,PERSONAL AND SOCIAL HISTORY: , Mr. T was born in Dwyne, Missouri, with no complications associated with his birth.  Originally, he was raised by both parents, but they separated at an early age.  When he was about seven years old, he was raised by his mother and stepfather.  He did not sustain a relationship with his biological father from that time on.  He stated his parents moved a lot, and because this many times he was picked on in his new environments, Mr. T stated he was, at times, a rebellious teenager, but he denied any significant inability to socialize, and denied any learning disabilities or the need for special education.,Mr. T stated his stepfather was somewhat verbally abusive, and that he committed suicide when Mr. T was 18 years old.  He graduated from high school and began work at Dana Corporation for two to three years, after which he worked as an energy, auditor for a gas company.  He then became a homemaker while his wife worked for Chrysler for approximately two years.  Mr. T was married for eleven years, and divorced in 1993.  He has a son who is currently 20 years old.  After being a home maker, Mr. T worked for his mother in a restaurant, and moved on from there to work for Borg-Warner corporation for one to two years before beginning at Plum Industries, where he worked for 14 years and worked his way up to lead engineer.,Mental Status Exam:  Mr. T presented with a hyper vigilant appearance, his eye contact was appropriate to the interview, and his motor behavior was tense.  At times he showed some involuntary movements that would be more akin to a resting tremor.  There was no psychomotor retardation, but there was some mild psychomotor excitement.  His speech was clear, concise, but pressured.  His attitude was overly negative and his mood was significant for moderate depression, anxiety, anhedonia and loneliness, and mild evidence of anger.  There was no evidence of euphoria or diurnal mood variation.  His affective expression was restricted range, but there was no evidence of lability.  At times, his affective tone and facial expressions were inappropriate to the interview.  There was no evidence of auditory, visual, olfactory, gustatory, tactile or visceral hallucinations.  There was no evidence of illusions, depersonalizations, or derealizations.  Mr. T presented with a sequential and goal directed stream of thought.  There was no evidence of incoherence, irrelevance, evasiveness, circumstantiality, loose associations, or concrete thinking.  There was no evidence of delusions; however, there was some ambivalence, guilt, and self-derogatory thoughts.  There was evidence of concreteness for similarities and proverbs.  His intelligence was average.  His concentration was mildly impaired, and there was no evidence of distractibility.  He was oriented to time, place, person and situation.  There was no evidence of clouded consciousness or dissociation.  His memory was intact for immediate, recent, and remote events.,He presented with poor appetite, easily fatigued, and decreased libidinal drive, as well as excessive somnolence.  There was a moderate preoccupation with his physical health pertaining to his headaches.  His judgment was poor for finances, family relations, social relations, employment, and, at this time, he had no future plans.  Mr. T's insight is somewhat moderate as he is aware of his contribution to the problem.  His motivation for getting well is good as he accepts offered treatment, complies with recommended treatment, and seeks effective treatments.  He has a well-developed empathy for others and capacity for affection.,There was no evidence of entitlement, egocentricity, controllingness, intimidation, or manipulation.  His credibility seemed good.  There was no evidence for potential self-injury, suicide, or violence.  The reliability and completeness of information was very good, and there were no barriers to communication.  The information gathered was based on the patient's self-report and objective testing and observation.  His attitude toward the examiner was neutral and his attitude toward the examination process was neutral.  There was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings, and there was no lack of cooperation with the evaluation or poor compliance with treatment, and no evidence of antisocial personality disorder.,IMPRESSIONS: , Major Depressive Disorder, single episode,RECOMMENDATIONS AND PLAN: , I recommend Mr. T continue with psychopharmacologic care as well as psychotherapy.  At this time, the excessive amount of psychiatric symptoms would impede Mr. T from seeking employment.  Furthermore, it appears that the primary precipitating event had occurred on March 25, 2003, when Mr. T was fired from his job after being harassed for over a year.  As Mr. T placed his entire identity and sense of survival on his work, this was a deafening blow to his psychological functioning.  Furthermore, it only appears logical that this would precipitate a major depressive episode.",5
"TITLE OF OPERATION: , Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.,PREOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,POSTOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,ANESTHESIA:,  Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,ESTIMATED BLOOD LOSS:,  Less than 10 mL.,HEMOSTASIS:,  Right ankle tourniquet set at 250 mmHg for 35 minutes.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, and two partially threaded cannulated screws from 3.0 OsteoMed System for internal fixation.,INJECTABLES:  ,Ancef 1 g IV 30 minutes preoperatively.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical site.  The right ankle was then covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set at 250 mmHg.  The right ankle tourniquet was then inflated.  The right foot was prepped, scrubbed, and draped in normal sterile technique.  Attention was then directed on the dorsal aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed just parallel and medial to the course of the extensor hallucis longus to the right great toe.  The incision was deepened through the subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, all the capsular and periosteal attachments were mobilized from the base of the proximal phalanx of the right great toe and head of the first right metatarsal.  Once the base of the proximal phalanx of the right great toe and the first right metatarsal head were adequately exposed, multiple osteophytes were encountered.  Gouty tophi were encountered both intraarticularly and periarticularly for the first right metatarsophalangeal joint, which were consistent with a medical history that is positive for gout for this patient.,Using sharp and dull dissection, all the ligamentous and soft tissue attachments were mobilized and the right first metatarsophalangeal joint was freed from all adhesions.  Using the sagittal saw, all the osteophytes were removed from the dorsal, medial, and lateral aspect of the first right metatarsal head as well as the dorsal, medial, and lateral aspect of the base of the proximal phalanx of the right great toe.  Although some improvement of the range of motion was encountered after the removal of the osteophytes, some tightness and restriction was still present.  The decision was thus made to perform a Youngswick-type osteotomy on the head of the first right metatarsal.  The osteotomy consistent of two dorsal cuts and a plantar cut in a V-pattern with the apex of the osteotomy distal and the base of the osteotomy proximal.  The two dorsal cuts were longer than the plantar cut in order to accommodate for the future internal fixation.  The wedge of bone that was formed between the two dorsal cuts was resected and passed off to Pathology for further examination.  The head of the first right metatarsal was then impacted on the shaft of the first right metatarsal and provisionally stabilized with two wires from the OsteoMed System.  The wires were inserted from a dorsal distal to plantar proximal direction through the dorsal osteotomy.  The wires were also used as guidewires for the insertion of two 16-mm proximally threaded cannulated screws from the OsteoMed System.  The 2 screws were inserted using AO technique.  Upon insertion of the screws, the two wires were removed.  Fixation of the osteotomy on the table was found to be excellent.  The area was copiously flushed with saline and range of motion was reevaluated and was found to be much improved from the preoperative levels without any significant restriction.  The cartilaginous surfaces on the base of the first right metatarsal and the base of the proximal phalanx were also fenestrated in order to induce some cartilaginous formation.  The capsule and periosteal tissues were then reapproximated with 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues.  Steri-Strips were used to approximate and reinforce the skin edges.  At this time, the right ankle tourniquet was deflated.  Immediate hyperemia was noted in the entire right lower extremity upon deflation of the cuff.  The patient's surgical site was then covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's right foot was placed in a surgical shoe and the patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and neurovascular status at appropriate levels.  The patient was given instructions and education on how to continue caring for her right foot surgery at home.  The patient was also given pain medication instructions on how to control her postoperative pain.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.",37
"PRINCIPAL DIAGNOSES:,1.  A 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with BEAM regimen in 04/02 followed by relapse.,2.  Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,3.  Graft versus host disease involving GI tracts, skin, and liver presently off immunosuppression.,4.  Diabetes.,5.  Bipolar disorder.,6.  Chronic muscle aches.,7.  Chronic lower extremity edema.,8.  ECOG performance status 1.,INTERIM HISTORY: , The patient comes to the clinic today for followup.  I am seeing him once every 4 to 8 weeks.  He is off of all immunosuppression.  He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant.,He has multiple complaints.  He has had hematochezia.  I referred him to gastroenterology.  They did an upper and lower endoscopy.  No evidence of ulcers or any abnormality was found.  Some polyps were removed.  They were benign.  He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity.,CURRENT MEDICATIONS:,1.  Paxil 40 mg once daily.,2.  Cozaar.,3.  Xanax 1 mg four times a day.,4.  Prozac 20 mg a day.,5.  Lasix 40 mg a day.,6.  Potassium 10 mEq a day.,7.  Mirapex two tablets every night.,8.  Allegra 60 mg twice a day.,9.  Avandamet 4/1000 mg daily.,10.  Nexium 20 mg a day.,11.  NovoLog 25/50.,REVIEW OF SYSTEMS:,  Fatigue, occasional rectal bleeding, and obesity.  Other systems were reviewed and were found to be unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Today revealed that temperature 35.8, blood pressure 120/49, pulse 85, and respirations 18.  HEENT:  Oral cavity, no mucositis.  NECK:  No nodes.  AXILLA:  No nodes.  LUNGS:  Clear.  CARDIAC:  Regular rate and rhythm without murmurs.  ABDOMEN:  No palpable masses.  Morbid obesity.  EXTREMITIES:  Mild lower extremity edema.  SKIN:  Mild dryness.  CNS:  Grossly intact.,LABORATORY DATA:,  White count 4.4, hemoglobin 10.1, platelet count 132,000, sodium 135, potassium 3.9, chloride 105, bicarbonate 24, BUN 15, and creatinine 0.9.  Normal alkaline phosphatase 203, AST 58, and ALT 31.,ASSESSMENT AND PLAN:,1.  The patient with mantle cell lymphoma who is 4-1/2 years post allotransplant.  He is without evidence of disease at the present time.  Since he is 4-1/2 years posttransplant, I do not plan to scan him or obtain chimerisms unless there is reason to.,2.  He is slightly anemic, may be iron deficient.  He has had recurrent rectal bleeding.  I told him to take multivitamin with iron and see how that helps the anemia.,3.  Regarding the hematochezia, he had an endoscopy.  I reviewed the results from the previous endoscopy.  It appears that he has polyps, but there is no evidence of graft versus host disease.,4.  Regarding the fatigue, I just reassured him that he should increase his activity level, but I am not sure how realistic that is going to be.,5.  He is followed for his diabetes by his internist.,6.  If he should have any fever or anything suggestive of infection, I advised him to call me.  I will see him back in about 2 months from now.",16
"EXAM: , Bilateral renal ultrasound.,CLINICAL INDICATION: , UTI.,TECHNIQUE: , Transverse and longitudinal sonograms of the kidneys were obtained.,FINDINGS:  ,The right kidney is of normal size and echotexture and measures 5.7 x 2.2 x 3.8 cm.  The left kidney is of normal size and echotexture and measures 6.2 x 2.8 x 3.0 cm.  There is no evidence for ,HYDRONEPHROSIS, or ,PERINEPHRIC ,fluid collections.  The bladder is of normal size and contour.  The bladder contains approximately 13 mL of urine after recent voiding.  This is a small postvoid residual.,IMPRESSION: , Normal renal ultrasound.  Small postvoid residual.",33
"CHIEF COMPLAINT:,  Well-child check.,HISTORY OF PRESENT ILLNESS:,  This is a 12-month-old female here with her mother for a well-child check.  Mother states she has been doing well.  She is concerned about drainage from her left eye.  Mother states she was diagnosed with a blocked tear duct on that side shortly after birth, and normally she has crusted secretions every morning.  She states it is worse when the child gets a cold.  She has been using massaging when she can remember to do so.  The patient is drinking whole milk without problems.  She is using solid foods three times a day.  She sleeps well without problems.  Her bowel movements are regular without problems.  She does not attend daycare.,DEVELOPMENTAL ASSESSMENT:,  Social:  She can feed herself with fingers.  She is comforted by parent’s touch.  She is able to separate and explore.  Fine motor:  She scribbles.  She has a pincer grasp.  She can drink from a cup.  Language:  She says dada.  She says one to two other words and she indicates her wants.  Gross motor:  She can stand alone.  She cruises.  She walks alone.  She stoops and recovers.,PHYSICAL EXAMINATION:,General:  She is alert, in no distress.,Vital signs:  Weight:  25th percentile.  Height:  25th percentile.  Head circumference:  50th percentile.,HEENT:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light.  Left eye with watery secretions and crusted lashes.  Conjunctiva is clear.  TMs are clear bilaterally.  Nares are patent.  Mild nasal congestion present.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Female external genitalia.,Extremities:  Symmetrical.  Femoral pulses are 2+ bilaterally.  Full range of motion of all extremities.,Neurologic:  Grossly intact.,Skin:  Normal turgor.,Testing:  Hearing and vision assessments grossly normal.,ASSESSMENT:,1.  Well child.,2.  Left lacrimal duct stenosis.,PLAN:,  MMR #1 and Varivax #1 today.  VIS statements given to Mother after discussion.  Evaluation and treatment as needed with Dr. XYZ with respect to the blocked tear duct.  Anticipatory guidance for age.  She is to return to the office in three months.",29
"PREOPERATIVE DIAGNOSIS:,  Critical left carotid stenosis.,POSTOPERATIVE DIAGNOSIS: , Critical left carotid stenosis.,PROCEDURE PERFORMED:,  Left carotid endarterectomy with endovascular patch angioplasty.,ANESTHESIA:,  Cervical block.,GROSS FINDINGS:  ,The patient is a 57-year-old black female with chronic renal failure.  She does have known critical carotid artery stenosis.  She wishes to undergo bilateral carotid endarterectomy, however, it was felt necessary by Dr. X to perform cardiac catheterization.  She was admitted to the hospital yesterday with chest pain.  She has been considered for coronary artery bypass grafting.  I have been asked to address the carotid stenosis, left being more severe, this was addressed first.  Intraoperatively, an atherosclerotic plaque was noted in the common carotid artery extending into the internal carotid artery.  The internal carotid artery is quite torturous.  The external carotid artery was occluded at its origin.  When the endarterectomy was performed, the external carotid artery back-bled nicely.  The internal carotid artery had good backflow bleeding noted.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite and placed in the supine position.  Then neck, shoulder, and chest wall were prepped and draped in appropriate manner.  Longitudinal incision was created along the anterior border of the left sternocleidal mastoid muscle and this was taken through the subcutaneous tissue and platysmal muscle utilizing electrocautery.,Utilizing both blunt and sharp dissections, the common carotid artery, the internal carotid artery beyond the atherosclerotic back, the external carotid artery, and the superior thyroid artery were isolated and encircled with a umbilical tape.  During the dissection, facial veins were ligated with #4-0 silk ligature prior to dividing them.  Also during the dissection, ansa cervicalis, hypoglossal, and vagus nerve identified and preserved.  There was some inflammation above the carotid bulb, but this was not problematic.,The patient had been administered 5000 units of aqueous heparin after allowing adequate circulating time.  The internal carotid artery is controlled with Heifitz clip followed by the external carotid artery and the superior thyroid artery being controlled with Heifitz clips.  The common carotid artery was controlled with profunda clamp.  The patient remained neurologically intact.  A longitudinal arteriotomy was created along the posterior lateral border of the common carotid artery.  This was extended across the lobe on to the internal carotid artery.  An endarterectomy was then performed.  The ________ intima was cleared of all debris and the ________ was flushed with copious amounts of heparinized saline.  As mentioned before, the internal carotid artery is quite torturous.  This was shortened by imbricating the internal carotid artery with horizontal mattress stitches of #7-0 Prolene suture.,The wound was copiously irrigated, rather an endovascular patch was then brought on to the field.  This was cut to shape and length.  This was sutured in place with continuous running #6-0 Prolene suture.  The suture line began at both sites.  The suture was tied in the center along the anterior and posterior walls.  Prior to completing the closure, the common carotid artery was flushed.  The internal carotid artery permitted to back bleed.  The clamp was placed after completing the closure.  The clamp was placed at the origin of the internal carotid artery.  Flow was first directed into the external carotid artery then into the internal carotid artery.  The patient remained neurologically intact.  Topical ________ Gelfoam was utilized.  Of note, during the endarterectomy, the patient did receive an additional 7000 units of aqueous heparin.  The wound was copiously irrigated with antibiotic solution.  Sponge, needle, and all counts were correct.  All surgical sites were inspected.  Good hemostasis noted.  The incision was closed in layers with absorbable suture.  Stainless steel staples approximated skin.  Sterile dressings were applied.  The patient tolerated the procedure well, grossly neurologically intact.",3
"PREOPERATIVE DIAGNOSIS:,1.  Left chronic anterior and posterior ethmoiditis.,2.  Left chronic maxillary sinusitis with polyps.,3.  Left inferior turbinate hypertrophy.,4.  Right anterior and posterior chronic ethmoiditis.,5.  Right chronic maxillary sinusitis with polyps.,6.  Right chronic inferior turbinate hypertrophic.,7.  Intranasal deformity causing nasal obstruction due to septal deviation.,POSTOPERATIVE DIAGNOSIS:,1.  Left chronic anterior and posterior ethmoiditis.,2.  Left chronic maxillary sinusitis with polyps.,3.  Left inferior turbinate hypertrophy.,4.  Right anterior and posterior chronic ethmoiditis.,5.  Right chronic maxillary sinusitis with polyps.,6.  Right chronic inferior turbinate hypertrophic.,7.  Intranasal deformity causing nasal obstruction due to septal deviation.,NAME OF OPERATION: , Bilateral endoscopic sinus surgery, including left anterior and posterior ethmoidectomy, left maxillary antrostomy with polyp removal, left inferior partial turbinectomy, right anterior and posterior ethmoidectomy, right maxillary antrostomy and polyp removal, right partial inferior turbinectomy, and septoplasty.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 20 cc.,HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old female who has had chronic nasal obstruction secondary to nasal polyps and chronic sinusitis.  She also has a septal deviation mid posterior to the left compromising greater than 70% of her nasal airway.,PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  After adequate endotracheal anesthesia was obtained, the skin was prepped and draped in sterile fashion.  Lidocaine 1% with 1:100,000 epinephrine was injected into the region of the anterior portion of the nasal septum.  Approximately 10 cc total was used.,A #15 blade and the Freer elevator were used to help make a standard hemitransfixion incision.  A mucoperichondrial flap was carefully elevated, and the junction with the cartilaginous bony septum was separated with the Freer elevator.  The bony deflection was removed using Jansen-Middleton forceps.  The cartilaginous deflection was created by freeing up the inferior attachments to the cartilaginous septum, placing it more on the midline maxillary crest.  The initial incision was placed in its anatomical position and secured with a 4-0 nylon suture for stabilization effect.,Attention then was directed toward the left side.  Lidocaine 1% with 1:100,000 epinephrine was injected in the region of the anterior portion of the left middle turbinate and uncinate process and polyps.  Approximately 10 cc total was used.  The polyps were removed using the Richards essential shaver to help identify the middle turbinate and uncinate process better.  The uncinate process was removed systematically superiorly to inferiorly with back-biting forceps.  Next, the maxillary antrostomy was identified and expanded with the back-biting forceps and showed polypoid accumulation in the mucosal disease on its opening site.  The sinus linings were edematous but did not have any polyps in the inferior, lateral, or superior aspects.,The anterior and posterior ethmoid air cells were entered primarily and dissected with the Richards essential shaver followed by the use of a 30-degree endoscope and up-biting forceps for the superior and lateral dissection.  Bright mucosal disease and small polypoid accumulations were noted through the sinuses also.  The inferior turbinates had some polypoid changes on them also and showed marked mucosal irritation and hypertrophy.  The mucosal polypoid accumulations were cleared using the Richards essential shaver.  The turbinate was partially resected from mucosally but with good shape to it.  It was not desirable to remove it in its entirety.  Any obvious bleeding points along the edge were controlled with the suction Bovie apparatus.,The same procedure and findings were noted on the right side with 1% lidocaine with 1:100,000 epinephrine injected into the anterior portion of the right middle turbinate, polyps, and uncinate process; 10 cc total were used.  The polyps were removed.  The Richards essential shaver was used to allow better exposure of the uncinate process.  The uncinate process was removed superiorly to inferiorly with back-biting side-biting forceps.,Next, a maxillary antrostomy was identified and expanded with the back-biting and side-biting forceps and showed all plate accumulations there also.  The anterior and posterior ethmoid air cells were then entered primarily and dissected with Richards essential shaver followed by the use of the 30-degree scope and up-biting forceps for the superior and lateral resection.  The inferior turbinates showed mucosal disease, polypoid accumulations, and changes.  These were removed using the Richards essential shaver followed by a submucosal resection of the hypertrophied portion of the turbinate.,Any obvious bleeding points were controlled with the suction Bovie apparatus.  A thorough irrigation was then carried out in the nasal cavity, and Gelfilm packing was used to coat the linings in the middle meatal regions.  The patient tolerated the procedure well and returned to the recovery room in stable condition.",37
"HISTORY:,  I had the pleasure of meeting and evaluating the patient referred today for evaluation and treatment of chronic sinusitis.  As you are well aware, she is a pleasant 50-year-old female who states she started having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.  She states she really has sinus problems, but this infection has been rather severe and she notes she has not had much improvement with antibiotics.  She had a CT of her paranasal sinuses identifying mild mucosal thickening of right paranasal sinuses with occlusion of the ostiomeatal complex on the right and turbinate hypertrophy was also noted when I reviewed the films and there is some minimal nasal septum deviation to the left.  She currently is not taking any medication for her sinuses.  She also has noted that she is having some problems with her balance and possible hearing loss or at least ear popping and fullness.  Her audiogram today demonstrated mild high frequency sensorineural hearing loss, normal tympanometry, and normal speech discrimination.  She has tried topical nasal corticosteroid therapy without much improvement.  She tried Allegra without much improvement and she believes the Allegra may have caused problems with balance to worsen.  She notes her dizziness to be much worse if she does quick positional changes such as head turning or sudden movements, no ear fullness, pressure, humming, buzzing or roaring noted in her ears.  She denies any previous history of sinus surgery or nasal injury.  She believes she has some degree of allergy symptoms.,PAST MEDICAL HISTORY:  ,Seasonal allergies, possible food allergies, chronic sinusitis, hypertension and history of weight change.  She is currently 180 pounds.,PAST SURGICAL HISTORY:,  Lower extremity vein stripping, tonsillectomy and adenoidectomy.,FAMILY HISTORY: , Strong for heart disease and alcoholism.,CURRENT MEDICATIONS: , DynaCirc.,ALLERGIES: , Egg-based products cause hives.,SOCIAL HISTORY:  ,The patient used to smoke cigarettes for about 20 years, one-half pack a day.  She currently does not, which was encouraged to continue.  She rarely drinks any alcohol-containing beverages.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Age 50, blood pressure is 136/74, pulse 84, temperature is 98.4, weight is 180 pounds, and height is 5 feet 3 inches.,GENERAL:  The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,HEAD:  Normocephalic.  No masses or lesions noted.,FACE:  No facial tenderness or asymmetry noted.,EYES:  Pupils are equal, round and reactive to light and accommodation bilaterally.  Extraocular movements are intact bilaterally.  No nystagmus.,EARS:  During Hallpike examination, the patient did not become dizzy until she would be placed back into sitting in the upright position.  No nystagmus was appreciated; however, the patient did subjectively report dizziness, which was repeated twice.  No evidence of any orthostatic hypotension was noted during the exam.  Tympanic membranes were noted to be intact.  No signs of middle ear effusion or ear canal inflammation.,NOSE:  The patient appears congested.  Turbinate hypertrophy is noted.  There are no signs of any acute sinusitis.  Septum is midline, slightly deviated to the left.,THROAT:  There is clear postnasal drip.  Oral hygiene is good.  No masses or lesions noted.  Both vocal cords move well to midline.,NECK:  The neck is supple with no adenopathy or masses palpated.  The trachea is midline.  The thyroid gland is of normal size with no nodules.,LUNGS:  Clear to auscultation bilaterally.  No wheeze noted.,HEART:  Regular rate and rhythm.  No murmur noted.,NEUROLOGIC:  Facial nerve is intact bilaterally.  The remaining cranial nerves are intact without focal deficit.,PROCEDURE: , Fiberoptic nasopharyngoscopy identifying turbinate hypertrophy and nasal septum deviation to the left, more significant posteriorly.,IMPRESSION:  ,1.  Probable increasing problems with allergic rhinitis and chronic sinusitis, both contributing to the patient's symptoms.,2.  Subjective dizziness, etiology uncertain; however, consider positional vertigo versus vestibular neuronitis as possible ear causes of dizziness, cannot rule out systemic, central or medication or causes at this time.,3.  Inferior turbinate hypertrophy.,4.  Nasal septum deformity.,RECOMMENDATIONS:,  An ENG was ordered to evaluate vestibular function.  She was placed on Veramyst nasal spray two sprays each nostril daily and even twice daily if symptoms are worsening.  A Medrol Dosepak was prescribed as directed.  The patient was given instruction on use of nasal saline irrigation to be used twice daily and Clarinex 5 mg daily was recommended.  After the patients' ENG examination, we will see the patient back for further evaluation and treatment recommendations.  In light of the patient's atypical dizziness symptoms, I cannot rule out other pathology at this time, and I informed her if there are any acute changes or problems with regards to her balance or any other acute changes, which she attributes associated with her dizziness, she most likely should pursue an emergent visit to the emergency room.,Thank you for allowing me to participate with the care of your patient.",0
"PAST MEDICAL/SURGICAL HISTORY: , Briefly, his past medical history is significant for hypertension of more than 5 years, asthma, and he has been on Advair and albuterol.  He was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008.  His past surgical history is only significant for left AV fistula on the wrist done in 04/2008.  He still has urine output.  He has no history of blood transfusion.,PERSONAL AND SOCIAL HISTORY: , He is a nonsmoker.  He denies any alcohol.  No illicit drugs.  He used to work as the custodian at the nursing home, but now on disability since 03/2008.  He is married with 2 sons, ages 5 and 17 years old.,FAMILY HISTORY:,  No similar illness in the family, except for hypertension in his one sister and his mom, who died at 61 years old of congestive heart failure.  His father is 67 years old, currently alive with asthma.  He also has one sister who has hypertension.  The rest of the 6 siblings are alive and well.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Singulair 10 mg once daily, Cardizem 365 mg once daily, Coreg 25 mg once daily, hydralazine 100 mg three times a day, Lanoxin 0.125 mg once daily, Crestor 10 mg once daily, lisinopril 10 mg once daily, Phoslo 3 tablets with meals, and Advair 250 mg inhaler b.i.d.,REVIEW OF SYSTEMS: , Significant only for asthma.  No history of chest pain normal MI.  He has hypertension.  He occasionally will develop colds especially with weather changes.  GI:  Negative.  GU:  Still making urine about 1-3 times per day.  Musculoskeletal:  Negative.  Skin:  He complains of dry skin.  Neurologic:  Negative.  Psychiatry:  Negative.  Endocrine:  Negative.  Hematology:  Negative.,PHYSICAL EXAMINATION: , A pleasant 41-year-old African-American male who stands 5 feet 6 inches and weighs about 193 pounds.  HEENT:  Anicteric sclera, pink conjunctiva, no cervical lymphadenopathy.  Chest:  Equal chest expansion.  Clear breath sounds.  Heart:  Distinct heart sounds, regular rhythm with no murmur.  Abdomen:  Soft, nontender, flabby, no organomegaly.  Extremities:  Poor peripheral pulses.  No cyanosis and no edema.,ASSESSMENT AND PLAN:,  This is a 49-year old African-American male who was diagnosed with end-stage renal disease secondary to hypertension.  He is on hemodialysis since 02/2008.  Overall, I think that he is a reasonable candidate for a kidney transplantation and should undergo a complete pretransplant workup with pulmonary clearance because of his chronic asthma.  Other than that, I think that he is a reasonable candidate for transplant.,I would like to thank you for allowing me to participate in the care of your patient.  Please feel free to contact me if there are any questions regarding his case.",5
"PREOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Laryngeal edema.,POSTOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Laryngeal edema.,PROCEDURE PERFORMED: , Tracheostomy change.  A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.,INDICATIONS: , The patient is a 60-year-old Caucasian female who presented to ABCD General Hospital with exacerbation of COPD and CHF.  The patient had subsequently been taken to the operating room by Department of Otolaryngology and a direct laryngoscope was performed.  The patient was noted at that time to have transglottic edema.  Biopsies were taken.  At the time of surgery, it was decided that the patient required a tracheostomy for maintenance of continued ventilation and airway protection.  The patient is currently postop day #6 and appears to be unable to be weaned from ventilator at this time and may require prolonged ventricular support.  A decision was made to perform tracheostomy change.,DESCRIPTION OF PROCEDURE: , The patient was seen in the Intensive Care Unit.  The patient was placed in a supine position.  The neck was then extended.  The sutures that were previously in place in the #6 Shiley with proximal extension were removed.  The patient was preoxygenated to 100%.  After several minutes, the patient was noted to have a pulse oximetry of 100%.  The IV tubing that was supporting the patient's trache was then cut.  The tracheostomy tube was then suctioned.,The inner cannula was then removed from the tracheostomy and a nasogastric tube was placed down the lumen of the tracheostomy tube as a guidewire.  The tracheostomy tube was then removed over the nasogastric tube and the operative field was suctioned.  With the guidewire in place and with adequate visualization, a new #6 Shiley with proximal extension was then passed over the nasogastric tube guidewire and carefully inserted into the trachea.  The guidewire was then removed and the inner cannula was then placed into the tracheostomy.  The patient was then reconnected to the ventilator and was noted to have normal tidal volumes.  The patient had a tidal volume of 500 and was returning 500 cc to 510 cc.  The patient continued to saturate well with saturations 99%.  The patient appeared comfortable and her vital signs were stable.  A soft trache collar was then connected to the trachesotomy.  A drain sponge was then inserted underneath the new trache site.  The patient was observed for several minutes and was found to be in no distress and continued to maintain adequate saturations and continued to return normal tidal volumes.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well.  0.25% acetic acid soaks were ordered to the drain sponge every shift.",3
"PROCEDURE PERFORMED: , Nissen fundoplication.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained detailing the risks of infection, bleeding, esophageal perforation and death, the patient was brought to the operative suite and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was then placed in a modified lithotomy position taking great care to pad all extremities.  TEDs and Venodynes were placed as prophylaxis against deep venous thrombosis.  Antibiotics were given for prophylaxis against surgical infection.,A 52-French bougie was placed in the proximal esophagus by Anesthesia, above the cardioesophageal junction.  A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp.  A 1-2 cm incision was then made in the fascia gaining entry into the abdominal cavity without incident.  Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adaptor in order to occlude the fascial opening.  Pneumoperitoneum was then established using carbon dioxide insufflation to a steady state of pressure of 16 mmHg.  A 30-degree laparoscope was inserted through this port and used to guide the remaining trocars.,The remaining trocars were then placed into the abdomen taking care to make the incisions along Langer's line, spreading the subcutaneous tissue with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar.  A total of 4 other 10/11 mm trocars were placed.  Under direct vision 1 was inserted in the right upper quadrant at the midclavicular line, at a right supraumbilical position; another at the left upper quadrant at the midclavicular line, at a left supraumbilical position; 1 under the right costal margin in the anterior axillary line; and another laterally under the left costal margin on the anterior axillary line.  All of the trocars were placed without difficulty.  The patient was then placed in reverse Trendelenburg position.,The triangular ligament was taken down sharply, and the left lobe of the liver was retracted superolaterally using a fan retractor placed through the right lateral cannula.  The gastrohepatic ligament was then identified and incised in an avascular plane.  The dissection was carried anteromedially onto the phrenoesophageal membrane.  The phrenoesophageal membrane was divided on the anterior aspect of the hiatal orifice.  This incision was extended to the right to allow identification of the right crus.  Then along the inner side of the crus, the right esophageal wall was freed by dissecting the cleavage plane.,The liberation of the posterior aspect of the esophagus was started by extending the dissection the length of the right diaphragmatic crus.  The pars flaccida of the lesser omentum was opened, preserving the hepatic branches of the vagus nerve.  This allowed free access to the crura, left and right, and the right posterior aspect of the esophagus, and the posterior vagus nerve.,Attention was next turned to the left anterolateral aspect of the esophagus.  At its left border, the left crus was identified.  The dissection plane between it and the left aspect of the esophagus was freed.  The gastrophrenic ligament was incised, beginning the mobilization of the gastric pouch.  By dissecting the intramediastinal portion of the esophagus, we elongated the intra-abdominal segment of the esophagus and reduced the hiatal hernia.,The next step consisted of mobilization of the gastric pouch.  This required ligation and division of the gastrosplenic ligament and several short gastric vessels using the harmonic scalpel.  This dissection started on the stomach at the point where the vessels of the greater curvature turned towards the spleen, away from the gastroepiploic arcade.  The esophagus was lifted by a Babcock inserted through the left upper quadrant port.  Careful dissection of the mesoesophagus and the left crus revealed a cleavage plane between the crus and the posterior gastric wall.  Confirmation of having opened the correct plane was obtained by visualizing the spleen behind the esophagus.  A one-half inch Penrose drain was inserted around the esophagus and sewn to itself in order to facilitate retraction of the distal esophagus.  The retroesophageal channel was enlarged to allow easy passage of the antireflux valve.,The 52-French bougie was then carefully lowered into the proximal stomach, and the hiatal orifice was repaired.  Two interrupted 0 silk sutures were placed in the diaphragmatic crura to close the orifice.,The last part of the operation consisted of the passage and fixation of the antireflux valve.  With anterior retraction on the esophagus using the Penrose drain, a Babcock was passed behind the esophagus, from right to left.  It was used to grab the gastric pouch to the left of the esophagus and to pull it behind, forming the wrap.  The,52-French bougie was used to calibrate the external ring.  Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior superior iliac spine and around the wound for postanesthetic pain control.  The skin incision was approximated with skin staples.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.",37
"CHIEF COMPLAINT:,  Back pain and right leg pain.  The patient has a three-year history of small cell lung cancer with metastases.,HISTORY OF PRESENT ILLNESS:,  The patient is on my schedule today to explore treatment of the above complaints.  She has a two-year history of small cell lung cancer, which she says has spread to metastasis in both femurs, her lower lumbar spine, and her pelvis.  She states she has had numerous chemotherapy and radiation treatments and told me that she has lost count.  She says she has just finished a series of 10 radiation treatments for pain relief.  She states she continues to have significant pain symptoms.  Most of her pain seems to be in her low back on the right side, radiating down the back of her right leg to her knee.  She has also some numbness in the bottom of her left foot, and some sharp pain in the left foot at times.  She complains of some diffuse, mid back pain.  She describes the pain as sharp, dull, and aching in nature.  She rates her back pain as 10, her right leg pain as 10, with 0 being no pain and 10 being the worst possible pain.  She states that it seems to be worse while sitting in the car with prolonged sitting, standing, or walking.  She is on significant doses of narcotics.  She has had multiple CT scans looking for metastasis.,PAST MEDICAL HISTORY:,  Significant for cancer as above.  She also has a depression.,PAST SURGICAL HISTORY:,  Significant for a chest port placement.,CURRENT MEDICATIONS:,  Consist of Duragesic patch 250 mcg total, Celebrex 200 mg once daily, iron 240 mg twice daily, Paxil 20 mg daily, and Percocet.  She does not know of what strength up to eight daily.  She also is on warfarin 1 mg daily, which she states is just to keep her chest port patent.  She is on Neurontin 300 mg three times daily.,HABITS:,  She smokes one pack a day for last 30 years.  She drinks beer approximately twice daily.  She denies use of recreational drugs.,SOCIAL HISTORY:,  She is married.  She lives with her spouse.,FAMILY HISTORY: , Significant for two brothers and father who have cancer.,REVIEW OF SYSTEMS:,  Significant mainly for her pain complaints.  For other review of systems the patient seems stable.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant somewhat emaciated Caucasian female.,Vital Signs:  Height is 5 feet 2 inches.  Weight is 130 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Chest:  Clear to auscultation.,Heart:  Regular rate and rhythm.,Abdomen:  Soft, regular bowel sounds.,Musculoskeletal:  Examination shows functional range of joint movements.  No focal muscle weakness.  She is deconditioned.,Neurologic:  She is alert and oriented with appropriate mood and affect.  The patient has normal tone and coordination.  Reflexes are 2+ in both knees and absent at both ankles.  Sensations are decreased distally in the left foot, otherwise intact to pinprick.,Spine:  Examination of her lumbar spine shows normal lumbar lordosis with fairly functional range of movement.  The patient had significant tenderness at her lower lumbar facet and sacroiliac joints, which seems to reproduce a lot of her low back and right leg complaints.,FUNCTIONAL EXAMINATION: , Gait has a normal stance and swing phase with no antalgic component to it.,INVESTIGATION: , She has had again multiple scans including a whole body bone scan, which showed abnormal uptake involving the femurs bilaterally.  She has had increased uptake in the sacroiliac joint regions bilaterally.  CT of the chest showed no evidence of recurrent metastatic disease.  CT of the abdomen showed no evidence of metastatic disease.  MRI of the lower hip joints showed heterogenous bone marrow signal in both proximal femurs.  CT of the pelvis showed a trabecular pattern with healed metastases.  CT of the orbits showed small amount of fluid in the mastoid air cells on the right, otherwise normal CT scan.  MR of the brain showed no acute intracranial abnormalities and no significant interval changes.,IMPRESSION:,1.  Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs.,2.  Symptomatic facet and sacroiliac joint syndrome on the right.,3.  Chronic pain syndrome.,RECOMMENDATIONS:,  Dr. XYZ and I discussed with the patient her pathology.  Dr. XYZ explained her although she does have lung cancer metastasis, she seems to be symptomatic with primarily pain at her lower lumbar facet and sacroiliac joints on the right.  Secondary to the patient's significant pain complaints today, Dr. XYZ will plan on injecting her right sacroiliac and facet joints under fluoroscopy today.  I explained the rationale for the procedure, possible complications, and she voiced understanding and wished to proceed.  She understands that she is on warfarin therapy and that we generally do not perform injections while they are on this.  We have asked for stat protime today.  She is on a very small dose, she states she has had previous biopsies while on this before, and did not have any complications.  She is on significant dose of narcotics already, however, she continues to have pain symptoms.  Dr. XYZ advised that if she continues to have pain, even after this injection, she could put on an extra 50 mcg patch and take a couple of extra Percocet if needed.  I will plan on evaluating her in the Clinic on Tuesday.  I have also asked that she stop her Paxil, and we plan on starting her on Cymbalta instead.  She voiced understanding and is in agreement with this plan.  I have also asked her to get an x-ray of the lumbar spine for further evaluation.  Physical exam, findings, history of present illness, and recommendations were performed with and in agreement with Dr. G's findings.  Peripheral neuropathy of her left foot is most likely secondary to her chemo and radiation treatments.",5
"PREOPERATIVE DIAGNOSIS:,  Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Left inguinal hernia, direct.,PROCEDURE: , Left inguinal herniorrhaphy, modified Bassini.,DESCRIPTION OF PROCEDURE:  ,The patient was electively taken to the operating room.  In same day surgery, Dr. X applied a magnet to the pacemaker defibrillator that the patient has to change it into a fixed mode and to protect the device from the action of the cautery.  Informed consent was obtained, and the patient was transferred to the operating room where a time-out process was followed and the patient under general endotracheal anesthesia was prepped and draped in the usual fashion.  Local anesthesia was used as a field block and then an incision was made in the left inguinal area and carried down to the external oblique aponeurosis, which was opened.  The cord was isolated and protected.  It was dissected out.  The lipoma of the cord was removed and the sac was high ligated.  The main hernia was a direct hernia due to weakness of the floor.  A Bassini repair was performed.  We used a number of interrupted sutures of 2-0 Tevdek __________ in the conjoint tendon and the ilioinguinal ligament.,The external oblique muscle was approximated same as the soft tissue with Vicryl and then the skin was closed with subcuticular suture of Monocryl.  The dressing was applied and the patient tolerated the procedure well, estimated blood loss was minimal, was transferred to recovery room in satisfactory condition.",38
"HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging.  She was doing well until about 2 days ago, when she developed gagging.  No vomiting.  No fever.  She has history of constipation.  She normally passes stool every two days after giving an enema.  No rectal bleeding.  She was brought to the Hospital with some loose stool.  She was found to be dehydrated.  She was given IV fluid bolus, but then she started bleeding from G-tube site.  There was some fresh blood coming out of the G-tube site.  She was transferred to PICU.  She is hypertensive.  Intensivist Dr. X requested me to come and look at her, and do upper endoscopy to find the site of bleeding.,PAST MEDICAL HISTORY: , PEHO syndrome, infantile spasm, right above knee amputation, developmental delay, G-tube fundoplication.,PAST SURGICAL HISTORY: , G-tube fundoplication on 05/25/2007.  Right above knee amputation.,ALLERGIES:,  None.,DIET: , She is NPO now, but at home she is on PediaSure 4 ounces 3 times a day through G-tube, 12 ounces of water per day.,MEDICATIONS: , Albuterol, Pulmicort, MiraLax 17 g once a week, carnitine, phenobarbital, Depakene and Reglan.,FAMILY HISTORY:,  Positive for cancer.,PAST LABORATORY EVALUATION: , On 12/27/2007; WBC 9.3, hemoglobin 7.6, hematocrit 22.1, platelet 132,000.  KUB showed large stool with dilated small and large bowel loops.  Sodium 140, potassium 4.4, chloride 89, CO2 21, BUN 61, creatinine 2, AST 92 increased, ALT 62 increased, albumin 5.3, total bilirubin 0.1.  Earlier this morning, she had hemoglobin of 14.5, hematocrit 41.3, platelets 491,000.  PT 58 increased, INR 6.6 increased, PTT 75.9 increased.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99 degrees Fahrenheit, pulse 142 per minute, respirations 34 per minute, weight 8.6 kg.,GENERAL:  She is intubated.,HEENT:  Atraumatic.  She is intubated.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Distended.  Decreased bowel sounds.,GENITALIA:  Grossly normal female.,CNS:  She is sedated.,IMPRESSION: , A 3-year-old female patient with history of passage of blood through G-tube site with coagulopathy.  She has a history of G-tube fundoplication, developmental delay, PEHO syndrome, which is progressive encephalopathy optic atrophy.,PLAN:  ,Plan is to give vitamin K, FFP, blood transfusion.  Consider upper endoscopy.  Procedure and informed consent discussed with the family.",5
"REASON FOR ADMISSION: , A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.,PAST MEDICAL HISTORY:,1.  Diabetes type II.,2.  High blood pressure.,3.  High cholesterol.,4.  Acid reflux disease.,5.  Chronic back pain.,PAST SURGICAL HISTORY:,1.  Lap-Band done today.,2.  Right foot surgery.,MEDICATIONS:,1.  Percocet on a p.r.n. basis.,2.  Keflex 500 mg p.o. t.i.d.,3.  Clonidine 0.2 mg p.o. b.i.d.,4.  Prempro, dose is unknown.,5.  Diclofenac 75 mg p.o. daily.,6.  Enalapril 10 mg p.o. b.i.d.,7.  Amaryl 2 mg p.o. daily.,8.  Hydrochlorothiazide 25 mg p.o. daily.,9.  Glucophage 100 mg p.o. b.i.d.,10.  Nifedipine extended release 60 mg p.o. b.i.d.,11.  Omeprazole 20 mg p.o. daily.,12.  Zocor 20 mg p.o. at bedtime.,ALLERGIES: , No known allergies.,HISTORY OF PRESENT COMPLAINT: , This 54-year-old patient had had Lap-Band at Tempe St Luke this morning.  She woke up at home this evening with massive swelling of the left side of the tongue.  The patient therefore came to the emergency room for evaluation.  The patient was almost intubated on clinical grounds.  Anesthesia was called to see the patient and they decided to give a trial of conservative management of Decadron and racemic epinephrine.,REVIEW OF SYSTEMS:,GENERAL:  The patient denies any itching of the skin or urticaria.  She has not noticed any new rashes.  She denies fever, chill, or malaise.,HEENT:  The patient denies vision difficulty.,RESPIRATORY:  No cough or wheezing.,CARDIOVASCULAR:  No palpitations or syncopal episodes.,GASTROINTESTINAL:  The patient denies swallowing difficulty.,Rest of the review of systems not remarkable.,SOCIAL HISTORY:  ,The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  Obese 54-year-old lady, not in acute distress at this time.,VITAL SIGNS:  On arrival in the emergency room, blood pressure was 194/122, pulse was 94, respiratory rate of 20, and temperature was 96.6.  O2 saturation was 95% on room air.,HEAD AND NECK:  Face is symmetrical.  Tongue is still swollen, especially on the left side.  The floor of the mouth is also indurated.  There is no cervical lymphadenopathy.  There is no stridor.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  There is no swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.",5
"EXAM: , Ultrasound of pelvis.,HISTORY:, Menorrhagia.,FINDINGS: , Uterus is enlarged measuring 11.0 x 7.5 x 11.0 cm.  It appears to be completely replaced by multiple ill-defined fibroids.  The endometrial echo complex was not visualized due to the contents of replacement of the uterus with fibroids.  The right ovary measures 3.9 x 1.9 x 2.3 cm.  The left ovary is not seen.  No complex cystic adnexal masses are identified.,IMPRESSION:  ,Essential replacement of the uterus by fibroids.  It is difficult to measure given their heterogenous and diffuse nature.  MRI of the pelvis could be performed for further evaluation to evaluate for possible uterine fibroid embolization.",33
"PREOPERATIVE DIAGNOSES:,1.  Left facial cellulitis.,2.  Possible odontogenic abscess of the #18, #19, and #20.,POSTOPERATIVE DIAGNOSES:,1.  Left facial cellulitis.,2.  Possible odontogenic abscess of the #18, #19, and #20.,PROCEDURE PERFORMED: , Attempted incision and drainage (I&D) of odontogenic abscess.,ANESTHESIA:  ,1% lidocaine plain approximately 5 cc total.,COMPLICATIONS: , The patient is very noncompliant with attempted procedure refusing further exam and treatment after localization and attempted FNA.  The attempted FNA was without any purulent aspirate although limited in the area of attempted examination.,INDICATIONS FOR THE PROCEDURE: , The patient is a 39-year-old Caucasian female who was admitted to ABCD General Hospital on 08/21/03 secondary to acute left facial cellulitis suspected to be secondary to odontogenic etiology.  The patient states that this was started approximately 24 hours ago.  The patient subsequently presented to ABCD General Hospital Emergency Room secondary to worsening of left face swelling and increasing in pain.  The patient admits to poor dental hygiene.  Denies any recent or dental abscesses in the past.  The patient is a substance abuser, does admit to smoking cocaine approximately three days ago.  The patient did have a CT scan of the face obtained with contrast demonstrated no signs of any acute abscess although a profuse amount of cellulitis was noted.  After risks, complications, consequences, and questions were discussed with the patient, a written consent was obtained for an I&D of a possible odontogenic abscess ________ on the CT scan.,PROCEDURE:  ,The patient was brought in upright and supine position.  Approximately 5 cc of 1% lidocaine without epinephrine was injected in the localized area along the buccogingival sulcus of the left side.  This was done at the base of #18, #19, and #20 teeth.  After this, the patient did have approximately 2 more mg of morphine given through the IV for pain control.  After this, the #18 gauge needle on a ________ syringe was then utilized to attempt a FNA at the base of #18 tooth and #19 with one stick placed.  There were no signs of any purulent drainage, although at this time the patient became very irate and noncompliant and refusing further examination.  The patient understood consequences of her actions.  Does state that she does not care at this time and just wants to be left alone.  At this time, the bed was actually placed back in its normal position and the patient will be continued on clindamycin 900 mg IV q.6h. along with pain control utilizing Toradol, morphine, and Vicodin.  The patient will also be started on Peridex oral rinse of 10 cc p.o. swish and spit t.i.d. and a K-pad to the left face.",37
"PREOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,POSTOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,PROCEDURE PERFORMED: , Excision of soft tissue mass on the right flank.,ANESTHESIA: , Sedation with local.,INDICATIONS FOR PROCEDURE:,  This 54-year-old male was evaluated in the office with a large right flank mass.  He would like to have this removed.,DESCRIPTION OF PROCEDURE:,  Consent was obtained after all risks and benefits were described.  The patient was brought back into the operating room.  The aforementioned anesthesia was given.  Once the patient was properly anesthetized, the area was prepped and draped in the sterile fashion.  With the area properly prepped and draped, a needle was used to localize the area directly above the mass on the patient's right flank.  Then a #10 blade scalpel was used to make the incision approximately 4 cm to 5 cm in length just above the mass.  The incision was extended down using electrocautery.  The excision then had a Allis clamp placed on it and was retracted using sharp dissection and electrocautery was used to dissect the mass off the muscle.  The mass was sent off to Pathology for investigation.  Hemostasis maintained with electrocautery and then the subcutaneous fascia was closed using a #3-0 Vicryl suture in interrupted fashion and the skin was reapproximated using a #4-0 undyed Vicryl suture in a running subcuticular fashion.  The patient's wound was cleaned.  Steri-Strips were placed and sterile dressings were placed on top of this.  The patient tolerated the procedure well and will reevaluate in the office in one week's time.",37
"CHIEF COMPLAINT:  ,Penile cellulitis status post circumcision.,HISTORY OF PRESENT ILLNESS: , The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge.  The child initially had a newborn circumcision at about 1 week of life and then developed a concealed or buried penis with extra skin and tightness of the skin.  He underwent a second circumcision with a general anesthetic approximately 8 to 9 days ago.  The mother states that on Thursday, he developed fairly significant swelling, scrotum was also swollen, the suprapubic region was swollen, and he was having a purulent discharge and a fairly significant fever to 102 to 103.  He was seen at Hospital, transferred to Children's Hospital for further care.  Since being hospitalized, his cultures apparently have grown Staph but is unknown yet whether it is methicillin-resistant.  He has been placed on clindamycin, and he is now currently afebrile and with marked improvement according to the mother.  I was requested a consultation by Dr. X because of the appearance of penis.  The patient has been voiding without difficulty throughout.,PAST MEDICAL HISTORY: , The patient has no known allergies.  He was a term delivery via vaginal delivery.  Surgeries; he has had 2 circumcisions.  No other hospitalizations.  He has had no heart murmurs, seizures, asthma, or bronchitis.,REVIEW OF SYSTEMS: , A 14-point review of systems was negative with the exception of the penile and scrotal cellulitis and the surgeries as mentioned.  He also had an ear infection about 1 to 2 weeks before his circumcision.,SOCIAL HISTORY: , The patient lives with both parents and no siblings.  There are smokers at home.,MEDICATIONS: , Clindamycin and bacitracin ointment.  Also Bactrim.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight is 14.9 kg.,GENERAL:  The patient was sleepy but easily arousable.,HEAD AND NECK:  Grossly normal.  His neck and chest are without masses.,NARES:  He had some crusted nares; otherwise, no other discharge.,LUNGS:  Clear.,CARDIAC:  Without murmurs or gallops.,ABDOMEN:  Soft without masses or tenderness.,GU:  He has a fairly prominent suprapubic fat pad, and he is quite a large child in any event; however, there were no signs of erythema.  There was some induration around the penis; however, there were no signs of active infection.  He has a buried appearance of the penis after recent circumcision with a normal appearing glans.  The tissue itself, however, was quite dull and is soft or readily retractable at this time.  The scrotum was normal, and there was no erythema, there was no tenderness.  Both testes were descended without hydroceles.,EXTREMITIES:  He has full range of motion of all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,BACK:  Normal.,IMPRESSION/PLAN: , The patient had a recent circumcision with a fairly prominent suprapubic fat pad but also has a penile and suprapubic cellulitis.  This is being treated, but it is most likely Staph and pending sensitivities.  I talked to the mother and told her that at this point the swelling that is present is a mixture of the resolving cellulitis from a suprapubic fat pad.  I recommended that he be treated most likely with Bactrim for a 10-day course at home, bacitracin, or some antibiotics ointment to the penis with each diaper change for the next 2 to 3 weeks with sitz bath once or twice a day.  I told the mother that initially the tissues are going to be quite dull because of the infection and the recent surgery, but she ultimately will have to gently retract the skin to keep it from adhering again because of the prominent suprapubic fat pad, which makes it more likely.  Otherwise, it is a fairly healthy-appearing tissue at the present time and she knows the reasons that he cannot be discharged once the hospitalist service believes that it is appropriate to do so.  He has a scheduled followup appointment with his urologist  and he should keep that appointment or followup sooner if there is any other problem arising.",5
"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.",10
"PROCEDURE:,  Colonoscopy.,PREOPERATIVE DIAGNOSES: , Change in bowel habits and rectal prolapse.,POSTOPERATIVE DIAGNOSIS: , Normal colonoscopy.,PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice.  The preparation was poor, but mucosa was visible after lavage and suction.  Small lesions might have been missed in certain places, but no large lesions are likely to have been missed.  The mucosa was normal, was visualized.  In particular, there was no mucosal abnormality in the rectum and distal sigmoid, which is reported to be prolapsing.  Biopsies were taken from the rectal wall to look for microscopic changes.  The anal sphincter was considerably relaxed, with no tone and a gaping opening.  The patient tolerated the procedure well and was sent to recovery room.,FINAL DIAGNOSIS: , Normal colonic mucosa to the cecum.  No contraindications to consideration of a repair of the prolapse.",14
"POSTOPERATIVE DIAGNOSIS:  Fever.,PROCEDURES:  Bronchoalveolar lavage.,INDICATIONS FOR PROCEDURE:  The patient is a 28-year-old male, status post abdominal trauma, splenic laceration, and splenectomy performed at the outside hospital, who was admitted to the Trauma Intensive Care Unit on the evening of August 4, 2008.  Greater than 24 hours postoperative, the patient began to run a fever in excess of 102.  Therefore, evaluation of his airway for possible bacterial infection was performed using bronchoalveolar lavage.,DESCRIPTION OF PROCEDURE:  The patient was preoxygenated with 100% FIO2 for approximately 5 to 10 minutes prior to the procedure.  The correct patient and procedure was identified by time out by all members of the team.  The patient was prepped and draped in a sterile fashion and sterile technique was used to connect the BAL lavage catheter to Lukens trap suction.  A catheter was introduced into the endotracheal tube through a T connector and five successive 20 mL aliquots of normal saline were flushed through the catheter, each time suctioning out the sample into the Lukens trap.  A total volume of 30 to 40 mL was collected in the trap and sent to the lab for quantitative bacteriology.  The patient tolerated the procedure well and had no episodes of desaturation, apnea, or cardiac arrhythmia.  A postoperative chest x-ray was obtained.",37
"EXAM:,  CT Abdomen & Pelvis W&WO Contrast, ,REASON FOR EXAM: , Status post aortobiiliac graft repair. , ,TECHNIQUE: , 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement.  No oral or rectal contrast was utilized.  Comparison is made with the prior CT abdomen and pelvis dated 10/20/05.  There has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3.7 cm transversely x 3.4 AP.  Just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips.  The size of the native aneurysm component at this level is stable at 5.5 cm in diameter with mural thrombus surrounding the enhancing endolumen.  There is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak.  Further distally, there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either.  No exoluminal leakage is identified at any level.  There is no retroperitoneal hematoma present.  The findings are unchanged from the prior exam.  ,The liver, spleen, pancreas, adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present.  There is advanced atrophy of the left kidney.  No hydronephrosis is present.  No acute findings are identified elsewhere in the abdomen. ,The lung bases are clear. ,Concerning the remainder of the pelvis, no acute pathology is identified.  There is prominent streak artifact from the left total hip replacement.  There is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis.  The bladder grossly appears normal.  A hysterectomy has been performed.  ,IMPRESSION:,1.  No complications identified regarding endoluminal aortoiliac graft repair as described.  The findings are stable compared to the study of 10/20/04.  ,2.  Stable mild aneurysm of aortic aneurysm, centered roughly at renal artery level.  ,3.  No other acute findings noted. ,4.  Advanced left renal atrophy.",33
"PREOPERATIVE DIAGNOSIS:,  Medial meniscal tear of the right knee.,POSTOPERATIVE DIAGNOSES:,1.  Medial meniscal tear, right knee.,2.  Lateral meniscal tear, right knee.,3.  Osteochondral lesion, medial femoral condyle, right knee.,4.  Degenerative joint disease, right knee.,5.  Patella grade-II chondromalacia.,6.  Lateral femoral condyle grade II-III chondromalacia.,PROCEDURE PERFORMED:,1.  Arthroscopy, right knee.,2.  Medial meniscoplasty, right knee.,3.  Lateral meniscoplasty, right knee.,4.  Medial femoral chondroplasty, right knee.,5.  Medical femoral microfracture, right knee.,6.  Patellar chondroplasty.,7.  Lateral femoral chondroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,BRIEF HISTORY AND INDICATION FOR PROCEDURE: , The patient is a 47-year-old female who has knee pain since 03/10/03 after falling on ice.  The patient states she has had inability to bear significant weight and had swelling, popping, and giving away, failing conservative treatment and underwent an operative procedure.,PROCEDURE:,  The patient was taken to the Operative Suite at ABCD General Hospital on 09/08/03, placed on the operative table in supine position.  Department of Anesthesia administered general anesthetic.  Once adequately anesthetized, the right lower extremity was placed in a Johnson knee holder.  Care was ensured that all bony prominences were well padded and she was positioned and secured.  After adequately positioned, the right lower extremity was prepped and draped in the usual sterile fashion.  Attention was then directed to creation of the arthroscopic portals, both medial and lateral portal were made for arthroscope and instrumentation respectively.  The arthroscope was advanced through the inferolateral portal taking in a suprapatellar pouch.  All compartments were then examined in sequential order with photodocumentation of each compartment.  The patella was noted to have grade-II changes of the inferior surface, otherwise appeared to track within the trochlear groove.  There was mild grooving of the trochlear cartilage.  The medial gutter was visualized.  There was no evidence of loose body.  The medial compartment was then entered.  There was noted to be a large defect on the medial femoral condyle grade III-IV chondromalacia changes with exposed bone in evidence of osteochondral displaced fragment.  There was also noted to be a degenerative meniscal tear of the posterior horn of the medial meniscus.  The arthroscopic probe was then introduced and the meniscus and chondral surfaces were probed throughout its entirety and photos were taken.  At this point, a meniscal shaver was then introduced and the chondral surfaces were debrided as well as any loose bodies removed.  This gave a smooth shoulder to the chondral lesion.  After this, the meniscus was debrided until it had been smooth over the frayed edges.  At this point, the shaver was removed.  The meniscal binder was then introduced and the meniscus was further debrided until the tear was adequately contained at this point.  The shaver was reintroduced and all particles were again removed and the meniscus was smoothed over the edge.  The probe was then reintroduced and the shaver removed, the meniscus was probed ___________ and now found to be stable.  At this point, attention was directed to the rest of the knee.  The ACL was examined.  It was intact and stable.  The lateral compartment was then entered.  There was noted to be a grade II-III changes of the lateral femoral condyle.  Again, with the edge of some friability at the shoulder of this cartilage lesion.  There was noted to be some mild degenerative fraying of the posterior horn of the lateral meniscus.  The probe was introduced and the remaining meniscus appeared stable.  This was then removed and the stapler was introduced.  A chondroplasty and meniscoplasty were then performed until adequately debrided and smoothed over.  The lateral gutter was then visualized.  There was no evidence of loose bodies.  Attention was then redirected back to the medial and femoral condyles.,At this point, a 0.62 K-wire was then placed in through the initial portal, medial portal, as well as an additional poke hole, so we can gain access and proper orientation to the medial femoral lesion.  Microfacial technique was then used to introduce the K-wire into the subchondral bone in multiple areas until we had evidence of some bleeding to allow ___________ of this lesion.  After this was performed, the shaver was then reintroduced and the loose bodies and loose fragments were further debrided.  At this point, the shaver was then moved to the suprapatellar pouch and the patellar chondroplasty was then performed until adequately debrided.  Again, all compartments were then re-visualized and there was no further evidence of other pathology or loose bodies.  The knee was then copiously irrigated and suctioned dry.  All instrumentation was removed.  Approximately 20 cc of 0.25% plain Marcaine was injected into the portal site and the remaining portion intraarticular.  Sterile dressings of Adaptic, 4x4s, ABDs, and Webril were then applied.  The patient was then transferred back to the gurney in supine position.,DISPOSITION:  The patient tolerated the procedure well with no complications.  The patient was transferred to PACU in satisfactory condition.",37
"HISTORY OF PRESENT ILLNESS:,  A 14-day-old was seen by private doctor because of blister.  On Friday, she was noted to have a small blister near her umbilicus.  They went to their doctor on Saturday, culture was drawn.  It came back today, growing MRSA.  She has been doing well.  They put her on bacitracin ointment near the umbilicus.  That has about healed up.  However today, they noticed a small blister on her left temporal area.  They called the private doctor.  They direct called the Infectious Disease doctor here and was asked that they come into the hospital.  Mom states she has been diagnosed with MRSA on her buttocks as well and is on some medications.  The child has not had any fever.  She has not been lethargic or irritable.  She has been eating well up to 2 ounces every feed.  Eating well and sleeping well.  No other changes have been noted.,PAST MEDICAL HISTORY:,  She was born full term.  No complications.  Home with mom.  No hospitalization, surgeries, allergies.,MEDICATIONS: , As noted.,IMMUNIZATIONS: , Up-to-date.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No ill contacts.  No travel or changes in living condition.,REVIEW OF SYSTEMS:  ,Ten systems were asked, all of them were negative except as noted above.,PHYSICAL EXAMINATION:  ,GENERAL:  Awake, alert female, no acute distress at this time.,HEENT:  Fontanelle soft and flat.  PERRLA.  EOMI.  Conjunctivae are clear.  TMS are clear.  Nares are clear.  Mucous membranes pinks and moist.  Throat clear.  No oral lesions.,NECK:  Supple.,LUNGS:  Clear.,HEART:  Regular rate and rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding, no rebound.  No rashes seen.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  5/5 strength in all extremities.,SKIN:  Her umbilicus looks completely clear.  There is no evidence of erythema.  The area that the parents point where the blister was, appears to be well healed.  There is no evidence of lesion noted, at this time.  On her left temple area and just inside her hairline, there is a small vesicle.  It is not a pustule.  It is almost flat and it has minimal fluid underneath that.  There is no surrounding erythema, tenderness.  I have inspected the body, head to toe.  No other areas of lesions seen.,EMERGENCY DEPARTMENT COURSE: , I spoke with Infectious Disease, Dr. X.  He states, we should treat for MRSA with Bactrim p.o.  There has been no evidence of jaundice with this little girl.  Hibiclens and Bactroban.  I spoke with Dr. X's associate to call back after Dr. X recommended a Herpes culture be done, just for completeness and that was done.  Blood culture was done here to make sure she did not have MRSA in her blood, which clinically, she does not appear to have.  She was discharged in stable condition.,IMPRESSION: , Methicillin-resistant Staphylococcus aureus infection.,PLAN: ,  MRSA Instructions were given as above and antibiotics were prescribed.  To follow up with their doctor.",8
"PROCEDURE: , Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,PATIENT PROFILE:,  This is a 42-year-old female.  Refer to note in patient chart for documentation of history and physical.  Due to the nature of the patient's increasing pain, surgery is recommended.  The alternatives, risks and benefits of surgery were discussed with the patient.  The patient verbalized understanding of the risks as well as the alternatives to surgery.  The patient wished to proceed with operative intervention.  A signed and witnessed informed consent was placed on the chart.  Prior to initiation of the procedure, patient identification and proposed procedure were verified by the surgeon in the pre-op area, and the operative site was marked by the patient and verified by the surgeon.,PRE-OP DIAGNOSIS: , Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,POST-OP DIAGNOSIS:,  Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,ANESTHESIA: , General - Endotracheal.,FINDINGS:,ACROMION:,1.  There was a medium-sized (5 - 10 mm) anterior acromial spur.,2.  The subacromial bursa was inflamed.,3.  The subacromial bursa was thickened.,4.  There was thickening of the coracoacromial ligament.,LIGAMENTS / CAPSULE: , Joint capsule within normal limits.,LABRUM: , The labrum is within normal limits.,ROTATOR CUFF: , Full thickness tear of the supraspinatus tendon, 5 mm anterior to posterior, by 10 mm medial to lateral.  Muscles and Tendons:  The biceps tendon is within normal limits.,JOINT:,  Normal appearance of the glenoid and humeral surfaces.,DESCRIPTION OF PROCEDURE:,PATIENT POSITIONING: , Following induction of anesthesia, the patient was placed in the beach-chair position on the standard operating table.  All body parts were well padded and protected to make sure there were no pressure points.  Subsequently, the surgical area was prepped and draped in the appropriate sterile fashion with Betadine.,INCISION TYPE:,1.  Scope Ports:  Anterior Portal.,2.  Scope Ports:  Posterior Portal.,3.  Scope Ports:  Accessory Anterior Portal.,INSTRUMENTS AND METHODS:,1.  The arthroscope and instruments were introduced into the shoulder joint through the arthroscopic portals.,2.  The subacromial space and bursa, biceps tendon, coracoacromial and glenohumeral ligaments, biceps tendon, rotator cuff, supraspinatus, subscapularis, infraspinatus, teres minor, capsulo-labral complex, capsule, glenoid labrum, humeral head, and glenoid, including the inner and outer surfaces of the rotator cuff, were visualized and probed.,3.  The subacromial bursa, subacromial soft tissues and frayed rotator cuff tissue were resected and debrided using a motorized resector and 4.5 Synovial Resector.,4.  The anterior portion of the acromion and acromial spur were resected with the 5.5 acromionizer burr.  Approximately 5 mm of bone was removed.  The coracoacromial ligament was released with the bony resection.  The shoulder joint was thoroughly irrigated.,5.  The edges of the cuff tissue were prepared, prior to the fixation, using the motorized resector.,6.  The supraspinatus tendon was reattached and sutured using the arthroscopic knot pusher and Mitek knotless anchor system and curved pointed suture passer and large bore cannula (to pass the sutures).  The repair was accomplished in a side-to-side and a tendon-to-bone fashion using three double loaded Mitek G IV suture anchors with 1 PDS suture.,7.  The repair was stable to palpation with the probe and watertight.,8.  The arthroscope and instruments were removed from the shoulder.,PATHOLOGY SPECIMEN: , No pathology specimens.,WOUND CLOSURE:,  The joint was thoroughly irrigated with 7 L of sterile saline.  The portal sites were infiltrated with 1% Xylocaine.  The skin was closed with 4-0 Vicryl using interrupted subcuticular technique.,DRAINS / DRESSING:,  Applied sterile dressing including gauze, iodoform gauze and Elastoplast.,SPONGE / INSTRUMENT / NEEDLE COUNTS:,  Final counts were correct.",27
"PREOPERATIVE DIAGNOSIS: , Recurrent re-infected sebaceous cyst of abdomen.,POSTOPERATIVE DIAGNOSES:,1.  Abscess secondary to retained foreign body.,2.  Incisional hernia.,PROCEDURES,1.  Excision of abscess, removal of foreign body.,2.  Repair of incisional hernia.,ANESTHESIA: , LMA.,INDICATIONS: , Patient is a pleasant 37-year-old gentleman who has had multiple procedures including a laparotomy related to trauma.  The patient has had a recurrently infected cyst of his mass at the superior aspect of his incision, which he says gets larger and then it drains internally, causing him to be quite ill.  He presented to my office and I recommended that he undergo exploration of this area and removal.  The procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him and he was agreeable to surgery.,FINDINGS:,  The patient was found upon excision of the cyst that it contained a large Prolene suture, which is multiply knotted as it always is; beneath this was a very small incisional hernia, the hernia cavity, which contained omentum; the hernia was easily repaired.,DESCRIPTION OF PROCEDURE: , The patient was identified, then taken into the operating room, where after induction of an LMA anesthetic, his abdomen was prepped with Betadine solution and draped in sterile fashion.  The puncta of the wound lesion was infiltrated with methylene blue and peroxide.  The lesion was excised and the existing scar was excised using an ellipse and using a tenotomy scissors, the cyst was excised down to its base.  In doing so, we identified a large Prolene suture within the wound and followed this cyst down to its base at which time we found that it contained omentum and was in fact overlying a small incisional hernia.  The cyst was removed in its entirety, divided from the omentum using a Metzenbaum and tying with 2-0 silk ties.  The hernia repair was undertaken with interrupted 0 Vicryl suture with simple sutures.  The wound was then irrigated and closed with 3-0 Vicryl subcutaneous and 4-0 Vicryl subcuticular and Steri-Strips.  Patient tolerated the procedure well.  Dressings were applied and he was taken to recovery room in stable condition.",14
"DIAGNOSES:,1.  Cervical dystonia.,2.  Post cervical laminectomy pain syndrome.,Ms. XYZ states that the pain has now shifted to the left side.  She has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago.  She did not have any side effects on the Botox injection and she feels that her activities of daily living are increased, but she is still on the oxycodone and methadone.  The patient's husband confirms the fact that she is doing a lot better, that she is more active, but there are still issues yet regarding anxiety, depression, and frustration regarding the pain in her neck.,PHYSICAL EXAMINATION:,  The patient is appropriate.  She is well dressed and oriented x3.  She still smells of some cigarette smoke.  Examination of the neck shows excellent reduction in muscle spasm on the right paraspinals, trapezius and splenius capitis muscles.  There are no trigger points felt and her range of motion of the neck is still somewhat guarded, but much improved.  On the left side, however, there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding.  This extends down into the trapezius muscle, but the splenius capitis seems to be not involved.,TREATMENT PLAN:,  After a long discussion with the patient and the husband, we have decided to go ahead and do botulinum toxin injection into the left multifidus/trapezius muscles.  A total of 400 units of Botox is anticipated.  The procedure is being scheduled.  The patient's medications are refilled.  She will continue to see Dr. Berry and continue her therapy with Mary Hotchkinson in Victoria.",27
"BILATERAL SCROTAL ORCHECTOMY,PROCEDURE:,:  The patient is placed in the supine position, prepped and draped in the usual manner.  Under satisfactory general anesthesia, the scrotum was approached and through a transverse mid scrotal incision, the right testicle was delivered through the incision.  Hemostasis was obtained with the Bovie and the spermatic cord was identified.  It was clamped, suture ligated with 0 chromic catgut and the cord above was infiltrated with 0.25% Marcaine for postoperative pain relief.  The left testicle was delivered through the same incision.  The spermatic cord was identified, clamped, suture ligated and that cord was also injected with 0.25% percent Marcaine.  The incision was injected with the same material and then closed in two layers using 4-0 chromic catgut continuous for the dartos and interrupted for the skin.  A dry sterile dressing fluff and scrotal support applied over that.  The patient was sent to the Recovery Room in stable condition.",37
"REASON FOR CONSULTATION:,  Renal failure evaluation for possible dialysis therapy.,HISTORY OF PRESENT ILLNESS:,  This is a 47-year-old gentleman, who works offshore as a cook, who about 4 days ago noted that he was having some swelling in his ankles and it progressively got worse over the past 3 to 4 days, until he was swelling all the way up to his mid thigh bilaterally.  He also felt like he could not make much urine, and his wife, who is a nurse instructed him to force fluids.  While he was there, he was drinking cranberry juice, some Powerade, but he also has a history of weightlifting and had been taking on a creatine protein drink on a daily basis for some time now.  He presented here with very decreased urine output until a Foley catheter was placed and about 500 mL was noted in his bladder.  He did have a CPK level of about 234 while his BUN and creatinine on admission were 109 and 6.9.  Despite IV hydration fluids, his potassium has gone up from 5.4 to 6.1.  He did not put out any significant urine and his weight was documented at 103 kg.  He was given a dose of Kayexalate.  His potassium came down to like about 5.9 and urine studies were ordered.  His urinalysis did show that he had microscopic hematuria and proteinuria and his protein-creatinine ratio was about 9 gm of protein consistent with nephrotic range proteinuria.  He did have a low albumin of 1.9.  He denied any nonsteroidal usage, any recreational drug abuse, and his urine drug screen was unremarkable, and he denied any history of hypertension or any other medical problems.  He has not had any blood work except for drug screens that are required by work and no work up by any primary care physician because he has not seen one for primary care.  He is very concerned because his mother and father were both on dialysis, which he thinks were due to diabetes and both parents have expired.  He denied any hemoptysis, gross hematuria, melena, hematochezia, hemoptysis, hematemesis, no seizures, no palpitations, no pruritus, no chest pain.  He did have a decrease in his appetite, which all started about Thursday.  We were asked to see this patient in consultation by Dr. X because of his renal failure and the need for possible dialysis therapy.  He was significantly hypertensive on admission with a blood pressure of 162/80.,PAST MEDICAL HISTORY: , Unremarkable.,PAST SURGICAL HISTORY: , Unremarkable.,FAMILY HISTORY: , Both mother and father were on dialysis of end-stage renal disease.,SOCIAL HISTORY: , He is married.  He does smoke despite understanding the risks associated with smoking a pack every 6 days.  Does not drink alcohol or use any recreational drug use.  He was on no prescribed medications.  He did have a fairly normal PSA of about 119 and I had ordered a renal ultrasound which showed fairly normal-sized kidneys and no evidence of hydronephrosis or mass, but it was consistent with increased echogenicity in the cortex, findings representative of medical renal disease.,PHYSICAL EXAMINATION:,Vital signs:  Blood pressure is 153/77, pulse 66, respiration 18, temperature 98.5.,General:  He was alert and oriented x 3, in no apparent distress, well-developed male.,HEENT:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light.  Extraocular muscles intact.,Neck:  Supple.  No JVD, adenopathy, or bruit.,Chest:  Clear to auscultation.,Heart:  Regular rate and rhythm without a rub.,Abdomen:  Soft, nontender, nondistended.  Positive bowel sounds.,Extremities:  Showed no clubbing, cyanosis.  He did have 2+ pretibial edema in both lower extremities.,Neurologic:  No gross focal findings.,Skin:  Showed no active skin lesions.,LABORATORY DATA: , Sodium 138, potassium 6.1, chloride 108, CO2 22, glucose 116, BUN 111, creatinine 7.29, estimated GFR 10 mL/minute.  Calcium 7.4 with an albumin of 1.9.  Mag normal at 2.2.  Urine culture negative at 12 hours.  His Random urine sodium was low at 12.  Random urine protein was 4756, and creatinine in the urine was 538.  Urine drug screen was unremarkable.  Troponin was within normal limits.  Phosphorus slightly elevated at 5.7.  CPK level was 234, white blood cells 6.5, hemoglobin 12.2, platelet count 188,000 with 75% segs.  PT 10.0, INR 1.0, PTT at 27.3.  B-natriuretic peptide 718.  Urinalysis showed 3+ protein, 4+ blood, negative nitrites, and trace leukocytes, 5 to 10 wbc's, greater than 100 rbc's, occasional fine granular casts, and moderate transitional cells.,IMPRESSION:,1.  Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.,2.  Hyperkalemia due to renal failure, slowly improving with Kayexalate.,3.  Microscopic hematuria with nephrotic range proteinuria, more consistent with a glomerulonephropathy nephritis.,4.  Hypertension.,PLAN: , I will give him Kayexalate 15 gm p.o. q.6h. x 2 more doses since he is responding and his potassium is already down to 5.2.  I will also recheck a urinalysis, consult the surgeon in the morning for temporary hemodialysis catheter placement, and consult case managers to start work on a transfer to ABCD Center per the patient and his wife's request, which will occur after his second dialysis treatment if he remains stable.  We will get a BMP, phosphorus, mag, CBC in the morning since he was given 80 mg of Lasix for fluid retention.  We will also give him 10 mg of Zaroxolyn p.o.  Discontinue all IV fluids.  Check an ANCA hepatitis profile, C3 and C4 complement levels along with CH 50 level.  I did discuss with the patient and his wife the need for kidney biopsy and they would like the kidney biopsy to be performed closer to home at Ochsner where his family is, since he only showed up here because of the nearest hospital located to his offshore job.  I do agree with getting him transferred once he is stable from his hyperkalemia and he starts his dialysis.,I appreciate consult.  I did discuss with him the importance of the kidney biopsies to direct treatment, finding the underlying etiology of his acute renal failure and to also give him prognostic factors of renal recovery.",5
"REASON FOR EXAM: , Dynamic ST-T changes with angina.,PROCEDURE:,1.  Selective coronary angiography.,2.  Left heart catheterization with hemodynamics.,3.  LV gram with power injection.,4.  Right femoral artery angiogram.,5.  Closure of the right femoral artery using 6-French AngioSeal.,Procedure explained to the patient, with risks and benefits.  The patient agreed and signed the consent form.,The patient received a total of 2 mg of Versed and 25 mcg of fentanyl for conscious sedation.  The patient was draped and dressed in the usual sterile fashion.  The right groin area infiltrated with lidocaine solution.  Access to the right femoral artery was successful, okayed with one attempt with anterior wall stick.  Over a J-wire, 6-French sheath was introduced using modified Seldinger technique.,Over the J-wire, a JL4 catheter was passed over the aortic arch.  The wire was removed.  Catheter was engaged into the left main.  Multiple pictures with RAO caudal, AP cranial, LAO cranial, shallow RAO, and LAO caudal views were all obtained.  Catheter disengaged and exchanged over J-wire into a JR4 catheter, the wire was removed.  Catheter with counter-clock was rotating to the RCA one shot with LAO, position was obtained.  The cath disengaged and exchanged over J-wire into a pigtail catheter.  Pigtail catheter across the aortic valve.  Hemodynamics obtained.  LV gram with power injection of 36 mL of contrast was obtained.,The LV gram assessed followed by pullback hemodynamics.,The catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6-French AngioSeal with no hematoma.  The patient tolerated the procedure well with no immediate postprocedure complication.,HEMODYNAMICS:  ,The aortic pressure was 117/61 with a mean pressure of 83.  The left ventricular pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmHg.  The pullback across the aortic valve reveals zero gradient.,ANATOMY:  ,The left main showed minimal calcification as well as the proximal LAD.  No stenosis in the left main seen, the left main bifurcates in to the LAD and left circumflex.,The LAD was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was TIMI 3 flow in the LAD.  The LAD gave off two early diagonal branches.  The second was the largest of the two and showed minimal lumen irregularities, but no focal stenosis.,Left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the PDA.  The left circumflex was large and patent, 6.0 mm in diameter.  All three obtuse marginal branches appeared to be with no significant stenosis.,The obtuse marginal branch, the third OM3 showed at the origin about 30 to 40% minimal narrowing, but no significant stenosis.  The PDA was wide, patent, with no focal stenosis.,The RCA was a small nondominant system with no focal stenosis and supplying the RV marginal.,LV gram showed that the LV EF is preserved with EF of 60%.  No mitral regurgitation identified.,IMPRESSION:,1.  Patent coronary arteries with normal left anterior descending, left circumflex, and dominant left circumflex system.,2.  Nondominant right, which is free of atheromatous plaque.,3.  Minimal plaque in the diagonal branch II, and the obtuse,marginal branch III, with no focal stenosis.,4.  Normal left ventricular function.,5.  Evaluation for noncardiac chest pain would be recommended.",3
"EXAM:,MRI/LOW EX NOT JNT RT W/O CONTRAST,CLINICAL:,Pain and swelling in the right foot, peroneal tendon tear.,FINDINGS:,  Contours of marrow signal patterns of the regional bones are within normal range treating there is increased T2 signal within the soft tissues at the lateral margin of the cuboid bone. A small effusion is noted within the peroneal tendon sheath. There is a 3mm slight separation of the distal tip of the peroneus longus tendon from the lateral margin of the cuboid bone, consistent with an avulsion. There is no sign of cuboid fracture. The fifth metatarsal base appears intact. The calcaneus is also normal in appearance.,IMPRESSION:  ,Findings consistent with an avulsion of the peroneus longus tendon from the insertion on the lateral aspect of cuboid bone.,",33
"OPERATIONS,1.  Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.,2.  Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.,3.  Posterior leaflet abscess resection.,ANESTHESIA:  ,General endotracheal anesthesia,TIMES:  ,Aortic cross-clamp time was ** minutes.  Cardiopulmonary bypass time total was ** minutes.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Next, the patient's chest and legs were prepped and draped in standard surgical fashion.  A #10-blade scalpel was used to make a midline median sternotomy incision.  Dissection was carried down to the level of the sternum using Bovie electrocautery.  The sternum was opened with a sternal saw, and full-dose heparinization was given.  Next, the chest retractor was positioned.  The pericardium was opened with Bovie electrocautery and pericardial stay sutures were positioned.  We then prepared to place the patient on cardiopulmonary bypass.  A 2-0 Ethibond double pursestring was placed in the ascending aorta.  Through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine.  Next, double cannulation with venous cannulas was instituted.  A 3-0 Prolene pursestring was placed in the right atrial appendage.  Through this was passed our SEC cannula.  This was connected to the venous portion of the cardiopulmonary bypass machine in a Y-shaped circuit.  Next, a 3-0 Prolene pursestring was placed in the lower border of the right atrium.  Through this was passed our inferior vena cava cannula.  This was likewise connected to the Y connection of our venous cannula portion.  We then used a 4-0 U-stitch in the right atrium for our retrograde cardioplegia catheter, which was inserted.  Cardiopulmonary bypass was instituted.  Metzenbaum scissors were used to dissect out the SVC and IVC, which were subsequently encircled with umbilical tape.  Sondergaard's groove was taken down.  Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta.  This was connected appropriately as was the retrograde cardioplegia catheter.  Next, the aorta was cross-clamped, and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole.  Next a #15-blade scalpel was used to open the left atrium.  The left atrium was decompressed with pump sucker.  Next, our self-retaining retractor was positioned so as to bring the mitral valve up into view.  Of note was the fact that the mitral valve P2 segment of the posterior leaflet had an abscess associated with it.  The borders of the P2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4-0 silk.  After doing so, the P2 segment of the posterior leaflet was excised with a #11-blade scalpel.  Given the laxity of the posterior leaflet, it was decided to reconstruct it with a 2-0 Ethibond pledgeted suture.  This was done so as to reconstruct the posterior annular portion.  Prior to doing so, care was taken to remove any debris and abscess-type material.  The pledgeted stitch was lowered into place and tied.  Next, the more anterior portion of the P2 segment was reconstructed by running a 4-0 Prolene stitch so as to reconstruct it.  This was done without difficulty.  The apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle.  There was noted to be a small amount of central regurgitation.  It was felt that this would be corrected with our annuloplasty portion of the procedure.  Next, 2-0 non-pledgeted Ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion.  Care was taken to go from trigone to trigone.  Prior to placing these sutures, the annulus was sized and noted to be a *** size for the Cosgrove-Galloway suture band ring from Medtronic.  After, as mentioned, we placed our interrupted sutures in the annulus, and they were passed through the CG suture band.  The suture band was lowered into position and tied in place.  We then tested our repair and noted that there was very mild regurgitation.  We subsequently removed our self-retaining retractor.  We closed our left atriotomy using 4-0 Prolene in a running fashion.  This was done without difficulty.  We de-aired the heart.  We then gave another round of antegrade and retrograde cardioplegia in warm fashion.  The aortic cross-clamp was removed, and the heart gradually resumed electromechanical activity.  We then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5-0 Prolene.  We placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin.  The patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed.  We then gave full-dose protamine; and after noting that there was no evidence of a protamine reaction, we removed our aortic cannula.  This site was buttressed with a 4-0 Prolene on an SH needle.  The patient tolerated the procedure well.  We placed a mediastinal #32-French chest tube as well as a right chest Blake drain.  The mediastinum was inspected for any signs of bleeding.  There were none.  We closed the sternum with #7 sternal wires in interrupted figure-of-eight fashion.  The fascia was closed with a #1 Vicryl followed by a 2-0 Vicryl, followed by 3-0 Vicryl in a running subcuticular fashion.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the intensive care unit in good condition.",37
"CHIEF COMPLAINT: , Chest pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 40-year-old white male who presents with a chief complaint of ""chest pain"".,The patient is diabetic and has a prior history of coronary artery disease.  The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent.  The severity of the pain has progressively increased.  He describes the pain as a sharp and heavy pain which radiates to his neck & left arm.  He ranks the pain a 7 on a scale of 1-10.  He admits some shortness of breath & diaphoresis.  He states that he has had nausea & 3 episodes of vomiting tonight.  He denies any fever or chills.  He admits prior episodes of similar pain prior to his PTCA in 1995.  He states the pain is somewhat worse with walking and seems to be relieved with rest.  There is no change in pain with positioning.  He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain.  The patient ranks his present pain a 4 on a scale of 1-10.  The most recent episode of pain has lasted one-hour.,The patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed.,REVIEW OF SYSTEMS:,  All other systems reviewed & are negative.,PAST MEDICAL HISTORY:,  Diabetes mellitus type II, hypertension, coronary artery disease, atrial fibrillation, status post PTCA in 1995 by Dr. ABC.,SOCIAL HISTORY: , Denies alcohol or drugs.  Smokes 2 packs of cigarettes per day.  Works as a banker.,FAMILY HISTORY: , Positive for coronary artery disease (father & brother).,MEDICATIONS: , Aspirin 81 milligrams QDay.  Humulin N. insulin 50 units in a.m.  HCTZ 50 mg QDay.  Nitroglycerin 1/150 sublingually PRN chest pain.,ALLERGIES: , Penicillin.,PHYSICAL EXAM: , The patient is a 40-year-old white male.,General:  The patient is moderately obese but he is otherwise well developed & well nourished.  He appears in moderate discomfort but there is no evidence of distress.  He is alert, and oriented to person place and circumstance.  There is no evidence of respiratory distress.  The patient ambulates",5
"CHIEF COMPLAINT: , Increased work of breathing.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-month-old female with a 9-day history of illness.  Per mom's report, the illness started 9 days ago with a dry cough.  The patient was eating normal up until approximately three days ago.  Mom was using a vaporizer at night, which she feels to have helped.  The patient's cough gradually worsened and three days ago, the patient had a significant increasing cough.  At that time, the patient also had significant increasing congestion.  Two days ago the patient was taken to the primary care physician's office and the patient was given Xopenex 2 puffs every 4 to 6 hours for home regimen, but this per mom's report, did not help the patient's symptoms.  On Wednesday evening, the patient's congestion and work of breathing increased and the patient was gagging after feedings.  The patient was brought to Children's Hospital Emergency Room at which time the patient was evaluated.  A chest x-ray was obtained and was noted to be normal.  The patient's saturations were noted to be normal and the patient was discharged home.  Last night, the patient was having multiple episodes of emesis after feedings with coughing and today was noted to have decreasing activity.  The patient had a 101 temperature on Wednesday evening, but has had no true fevers.  The patient has had a mild decrease in urine output today and secondary to the persistent increased work of breathing, coughing, and posttussive emesis, the patient was brought to Children's Hospital for reevaluation.,REVIEW OF SYSTEMS: , The remainder of the review of system is otherwise negative, all systems being reviewed, outside of pertinent positives as stated above.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS:  ,As above.,IMMUNIZATIONS:,  None.,PAST MEDICAL HISTORY:  ,No hospitalizations.  No surgeries.,BIRTH HISTORY: , The patient was born to a G8, P2, A6 mom via normal spontaneous vaginal delivery.  Birth weight 6 pounds 12 ounces.  Mom stated she had a uterine infection during her pregnancy and at the time of delivery, but the patient was only in the hospital for 24 hours with mom after delivery.  The patient was full term and mom was noted to have gestational diabetes controlled with diet during her pregnancy.,FAMILY HISTORY: , Brother, mother, and father all have asthma.  Mom was noted to have gestational diabetes.,SOCIAL HISTORY: , The patient lives with mother, father, and a brother.  There is one bird.  There are smokers in the household.  There are sick contacts.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 97.7 and pulse is 181, but the patient is fussy.  Respiratory rate ranged between 36 and 44.  The patient is saturating 100% on one-half liter and 89% on room air.,GENERAL APPEARANCE:  Nontoxic child, but with increased work of breathing.  No respiratory distress.,HEENT:  Head is normocephalic and atraumatic.  Anterior fontanelle flat.  Pupils are equal, round, and reactive to light bilaterally.  Tympanic membranes are clear bilaterally.  Nares are congested.  Mucous membranes are moist without erythema.,NECK:  Supple.  No lymphadenopathy.,CHEST:  Exhibits symmetric expansion and retractions.,LUNGS:  The patient has diffuse crackles bilaterally, but no wheezes, rales, or rhonchi.,CARDIOVASCULAR:  Heart has a 2/6 vibratory systolic ejection murmur, best heard over the left sternal boarder.,ABDOMEN:  Soft, nondistended, and nondistended.  Good bowel sounds noted in all 4 quadrants.,GU:  Normal female.  No discharge or erythema.,BACK:  Normal with a normal curvature.,EXTREMITIES:  A 2+ pulses in the bilateral upper lower extremities.  No evidence of clubbing, cyanosis, or edema.  Capillary refill less than 3 seconds.,LABORATORY DATA: , Labs in the emergency room include a CBC, which showed a white blood cell count of 20.8 with a hemoglobin of 10.7, hematocrit of 31.3 with platelet count of 715,000 with 40% neutrophils, 2 bands, and 70% monocytes.  A urinalysis obtained in the emergency room was noted to be negative.  CRP was noted to be 2.0.  The chest x-ray, reviewed by myself in the emergency room, showed no significant change from previous x-ray, but the patient does has some bronchial wall thickening.,ASSESSMENT AND PLAN: , This is a 2-month-old female who presents to Children's Hospital with examination consistent with bronchiolitis.  At this time, the patient will be placed on the bronchiolitis pathway providing this patient with aggressive suctioning and supplemental oxygen as needed.  Currently, at this time, I feel no respiratory treatments are indicated in this patient.  I hear no evidence of wheezing or reactive airway disease.  We will continue to monitor and reassess this patient closely for this as there is a strong family history of reactive airway disease; however, at this time, the patient will be monitored without any medications and the remainder of the clinical course will be determined by her presentation during the course of this illness.",12
"EXAM: , Five views of the right knee.,HISTORY: , Pain.  The patient is status-post surgery, he could not straighten his leg, pain in the back of the knee.,TECHNIQUE:,  Five views of the right knee were evaluated.  There are no priors for comparison.,FINDINGS: , Five views of the right knee were evaluated and they reveal there is no evidence of any displaced fractures, dislocations, or subluxations.  There are multiple areas of growth arrest lines seen in the distal aspect of the femur and proximal aspect of the tibia.  There is also appearance of a high-riding patella suggestive of patella alta.,IMPRESSION:,1.  No evidence of any displaced fractures, dislocations, or subluxations.,2.  Growth arrest lines seen in the distal femur and proximal tibia.,3.  Questionable appearance of a slightly high-riding patella, possibly suggesting patella alta.",27
"PREOPERATIVE DIAGNOSIS:,  Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS:  ,Rule out temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsy.,ANESTHESIA:,  Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:,  I was consulted by Dr. X for this patient with bilateral temporal headaches to rule out temporal arteritis.  I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way.  After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery.  The temporal artery was identified and was grossly normal on both sides.  Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult.  The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm.  They were sent as separate specimens, right and left labeled.  The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond.  She tolerated the procedure well.",22
"DISCHARGE DATE:  MM/DD/YYYY,HISTORY OF PRESENT ILLNESS:  Mr. ABC is a 60-year-old white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital.  He underwent a resection there.  He was to be admitted to the Day Hospital for cystectomy.  He was seen in Urology Clinic and Radiology Clinic on MM/DD/YYYY.,HOSPITAL COURSE:  Mr. ABC presented to the Day Hospital in anticipation for Urology surgery.  On evaluation, EKG, echocardiogram was abnormal, a Cardiology consult was obtained.  A cardiac adenosine stress MRI was then proceeded, same was positive for inducible ischemia, mild-to-moderate inferolateral subendocardial infarction with peri-infarct ischemia.  In addition, inducible ischemia seen in the inferior lateral septum.  Mr. ABC underwent a left heart catheterization, which revealed two vessel coronary artery disease.  The RCA, proximal was 95% stenosed and the distal 80% stenosed.  The mid LAD was 85% stenosed and the distal LAD was 85% stenosed.  There was four Multi-Link Vision bare metal stents placed to decrease all four lesions to 0%.  Following intervention, Mr. ABC was admitted to 7 Ardmore Tower under Cardiology Service under the direction of Dr. XYZ.  Mr. ABC had a noncomplicated post-intervention hospital course.  He was stable for discharge home on MM/DD/YYYY with instructions to take Plavix daily for one month and Urology is aware of the same.,DISCHARGE EXAM:,VITAL SIGNS:  Temperature 97.4, heart rate 68, respirations 18, blood pressure 133/70.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  Obese, soft, nontender.  Lower abdomen tender when touched due to bladder cancer.,RIGHT GROIN:  Dry and intact, no bruit, no ecchymosis, no hematoma.  Distal pulses are intact.,DISCHARGE LABS:  CBC:  White count 5.4, hemoglobin 10.3, hematocrit 30, platelet count 132, hemoglobin A1c 9.1.  BMP:  Sodium 142, potassium 4.4, BUN 13, creatinine 1.1, glucose 211.  Lipid profile:  Cholesterol 157, triglycerides 146, HDL 22, LDL 106.,PROCEDURES:,1.  On MM/DD/YYYY, cardiac MRI adenosine stress.,2.  On MM/DD/YYYY, left heart catheterization, coronary angiogram, left ventriculogram, coronary angioplasty with four Multi-Link Vision bare metal stents, two placed to the LAD in two placed to the RCA.,DISCHARGE INSTRUCTIONS:  Mr. ABC is discharged home.  He should follow a low-fat, low-salt, low-cholesterol, and heart healthy diabetic diet.  He should follow post-coronary artery intervention restrictions.  He should not lift greater than 10 pounds for seven days.  He should not drive for two days.  He should not immerse in water for two weeks.  Groin site care reviewed with patient prior to being discharged home.  He should check groin for bleeding, edema, and signs of infection.  Mr. ABC is to see his primary care physician within one to two weeks, return to Dr. XYZ's clinic in four to six weeks, appointment card to be mailed him.  He is to follow up with Urology in their clinic on MM/DD/YYYY at 10 o'clock and then to scheduled CT scan at that time.,DISCHARGE DIAGNOSES:,1.  Coronary artery disease status post percutaneous coronary artery intervention to the right coronary artery and to the LAD.,2.  Bladder cancer.,3.  Diabetes.,4.  Dyslipidemia.,5.  Hypertension.,6.  Carotid artery stenosis, status post right carotid endarterectomy in 2004.,7.  Multiple resections of the bladder tumor.,8.  Distant history of appendectomy.,9.  Distant history of ankle surgery.",15
"DELIVERY NOTE:,  This G1, P0 with EDC 12/23/08 presented with SROM about 7.30 this morning.  Her prenatal care complicated by GBS screen positive and a transfer of care at 34 weeks from Idaho.  Exam upon arrival 2 to 3 cm, 100% effaced, -1 station and by report pool of fluid was positive for Nitrazine and positive ferning.,She required augmentation with Pitocin to achieve a good active phase.  She achieved complete cervical dilation at 1900  At this time, a bulging bag was noted, which ruptured and thick meconium was present.  At 1937 hours, she delivered a viable male infant, left occiput, anterior.  Mouth and nares suctioned well with a DeLee on the perineum.  No nuchal cord present.  Shoulders and body followed easily.  Infant re-suctioned with the bulb and cord clamped x2 and cut and was taken to the warmer where the RN and RT were in attendance.  Apgars 9 and 9.  Pitocin 15 units infused via pump protocol.  Placenta followed complete and intact with fundal massage and general traction on the cord.  Three vessels are noted.  She sustained a bilateral periurethral lax on the left side, this extended down to the labia minora, became a second degree in the inferior portion and did have some significant bleeding in this area.  Therefore, this was repaired with #3-0 Vicryl after 1% lidocaine infiltrated approximately 5 mL.  The remainder of the lacerations was not at all bleeding and no other lacerations present.  Fundus required bimanual massage in a couple of occasions for recurrent atony with several larger clots; however, as the Pitocin infused and massage continued, this improved significantly.  EBL was about 500 mL.  Bleeding appears much better; however, Cytotec 400 mcg was placed per rectum apparently prophylactically.  Mom and baby currently doing very well.",37
"SUBJECTIVE:,  The patient is a 75-year-old female who comes in today with concerns of having a stroke.  She states she feels like she has something in her throat.  She started with some dizziness this morning and some left hand and left jaw numbness.  She said that she apparently had something about three weeks ago where she was dizzy and ended up falling down and she saw Dr. XYZ for that who gave her some Antivert.  She said that today though she woke up in the middle of the night and her left hand was numb and she was having numbness on the left side of her face, as well as the left side of her neck.  She said she had an earache a day or so ago.  She has not had any cold symptoms.,ALLERGIES:,  Demerol and codeine.,MEDICATIONS: , Lotensin, Lopid, metoprolol, and Darvocet.,REVIEW OF SYSTEMS:,  The patient says that she feels little bit nauseated at times.  She denies chest pain or shortness of breath and again feels like she has something in her throat.  She has been able to swallow liquids okay.  She said that she did brush her teeth this morning and did not have any fluid dripping out of her mouth.  She does say that she occasionally has numbness in her left hand prior to today.,PHYSICAL EXAMINATION:,General:  She is awake and alert, no acute distress.,Vital Signs:  Blood pressure:  175/86.  Temperature:  She is afebrile.  Pulse:  78.  Respiratory rate:  20.  O2 sat:  93% on room air.,HEENT:  Her TMs are normal bilaterally.  Posterior pharynx is unremarkable.  It should be noted that her uvula did not deviate and neither did her tongue.  When she smiles though she has some drooping of the left side of her face, as well as some mild nasolabial fold flattening.,Neck:  Without adenopathy or thyromegaly.  Carotids pulses are brisk without bruits.,Lungs:  Clear to auscultation.,Heart:  Regular rate and rhythm without murmur.,Extremities:  Her muscle strength is symmetrical and intact bilaterally.  DTRs are 2+/4+ bilaterally and muscle strength is intact in the upper extremities.  She has a positive Tinel’s sign on her left wrist.,Neurological:  I also took monofilament and she could sense it easily when testing her sensation on her face.,ASSESSMENT:,  Bell’s Palsy.,PLAN:,  We did get an EKG showed some ST segment changes anterolaterally.  The only EKG I have here is from 1998 and she actually had bypass in 1999, but there certainly does not appear to be anything acute on his EKG.  I assured her that it does not look like she has a stroke.  If she wants to prevent a stroke, obviously quitting her smoking would help.  It should be noted she also takes Synthroid and Zocor.  We are going to give her Valtrex 1 g t.i.d. for seven days and then if she starts noticing any other drooping or worsening of her symptoms on the left side of her face, she needs to come back, but I will not start her on steroids at this time, which she agreed with.",22
"HISTORY OF PRESENT ILLNESS:, This is the initial clinic visit for a 41-year-old worker who is seen for a foreign body to his left eye.  He states that he was doing his normal job when he felt a foreign body sensation.  He attempted to flush this at work, but has had persistent pain which has progressively worsened throughout the course of the day.  He has no significant blurriness of vision or photophobia.",15
"PREOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology.,POSTOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology with pathology pending.,PROCEDURE:  ,Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.,ANESTHESIA: , General endotracheal.,SPECIMEN:,  Left chest wall with tumor and left lower lobe lung wedge resection to pathology.,INDICATIONS FOR PROCEDURE:,  The patient is a 79-year-old male who began to experience back pain approximately 2 years ago, which increased.  Chest x-ray and CT scan revealed a 3 cm x 4 cm mass abutting the left chest wall inferior to the left scapula with pleural thickening.  A biopsy was performed at an outside hospital (Kaiser) and pathology was consistent with mesothelioma.  The patient had a metastatic workup, which was negative including a brain MRI and bone scan.  The bone scan showed only signal positivity in the left 9th rib near the tumor.  The patient has a significant past medical history consisting of coronary artery disease, hypertension, non-insulin dependent diabetes, longstanding atrial fibrillation, anemia, and hypercholesterolemia.  He and his family were apprised of the high-risk nature of this surgery preoperatively and informed consent was obtained.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  The patient was intubated with a double-lumen endotracheal tube.  Intravenous antibiotics were given.  A Foley catheter was placed.  The patient was placed in the right lateral decubitus position and the left chest was prepped and draped in the usual sterile fashion.  An incision approximately 8 inches long was made centered over the mass and extending slightly obliquely over the mass.  The skin and subcutaneous tissues were dissected sharply with the electrocautery.  Good hemostasis was obtained.  The tumor was easily palpable and clearly involving the 8th to 9th rib.  A thoracotomy was initially made above the mass in approximately the 7th intercostal space.  Inspection of the pleural cavity revealed multiple adhesions, which were taken down with a combination of blunt and sharp dissection.  The thoracotomy was extended anteriorly and posteriorly.  It was clear that in order to obtain an adequate resection of the tumor, approximately 4 rib segment of the chest wall would need to be resected.  The ribs of the chest wall were first cut at their anterior aspect.  The ribs 7, 8, 9, and 10 were serially transected after the interspaces were dissected with electrocautery.  Hemostasis was obtained with both electrocautery and clips.  The chest wall segment to be resected was retracted laterally and posteriorly.  It was clear that there were at least 2 areas where the tumor was invading the lung and a lengthy area of diaphragmatic involvement.  Inferiorly, the diaphragm was divided to provide a margin of at least 1 to 2 cm around the areas of tumor.  The spleen and the stomach were identified and were protected.  Inferiorly, the resection of the chest wall was continued in the 10th interspace.  The dissection was then carried posteriorly to the level of the spine.  The left lung at this point was further dissected out and multiple firings of the GIA 75 were used to perform a wedge resection of the left lower lobe, which provided a complete resection of all palpable and visible tumor in the lung.  A 2-0 silk tie was used to ligate the last remaining corner of lung parenchyma at the corner of the wedge resection.  Posteriorly, the chest wall segment was noted to have an area at the level of approximately T8 and T9, where the tumor involved the vertebral bodies.  The ribs were disarticulated, closed to or at their articulations with the spine.  Bleeding from the intercostal vessels was controlled with a combination of clips and electrocautery.  There was no disease grossly involving or encasing the aorta.,The posterior transection of the ribs was completed and the specimen was passed off of the field as a specimen to pathology for permanent section.  The specimen was oriented for the pathologist who came to the room.  Hemostasis was obtained.  The vent in the diaphragm was then closed primarily with a series of figure-of-8 #1 Ethibond sutures.  This produced a satisfactory diaphragmatic repair without undue tension.  A single 32-French chest tube was placed in the pleural cavity exiting the left hemithorax anteriorly.  This was secured with a #1 silk suture.  The Gore-Tex mesh was brought on to the field and was noted to be of adequate size to patch the resulting chest wall defect.  A series of #1 Prolene were placed in an interrupted horizontal mattress fashion circumferentially and tied down individually.  The resulting mesh closure was snug and deemed adequate.  The serratus muscle was reapproximated with figure-of-8 0 Vicryl.  The latissimus was reapproximated with a two #1 Vicryl placed in running fashion.  Of note, two #10 JP drains were placed over the mesh repair of the chest wall.  The subcutaneous tissues were closed with a running 3-0 Vicryl suture and the skin was closed with a 4-0 Monocryl.  The wounds were dressed.  The patient was brought from the operating room directly to the North ICU, intubated in stable condition.  All counts were correct.,",37
"PREOPERATIVE DIAGNOSES:,1.  Chronic otitis media with effusion.,2.  Conductive hearing loss.,POSTOPERATIVE DIAGNOSES:,1.  Chronic otitis media with effusion.,2.  Conductive hearing loss.,PROCEDURE PERFORMED: , Bilateral tympanostomy with myringotomy tube placement _______ split tube 1.0 mm.,ANESTHESIA:  ,Total IV general mask airway.,ESTIMATED BLOOD LOSS:  ,None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:,  The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy.  After risks, complications, consequences, and questions were addressed with the family, a written consent was obtained for the procedure.,PROCEDURE:,  The patient was brought to the operative suite by Anesthesia.  The patient was placed on the operating table in supine position.  After this, the patient was then placed under general mask airway and the patient's head was then turned to the left.,The Zeiss operative microscope and medium-sized ear speculum were placed and the cerumen from the external auditory canals were removed with a cerumen loop to #5 suction.  After this, the tympanic membrane is then brought into direct visualization with no signs of any gross retracted pockets or cholesteatoma.  A myringotomy incision was then made within the posterior inferior quadrant and the middle ear was then suctioned with a #5 suction demonstrating dry contents.  A _____ split tube 1.0 mm was then placed in the myringotomy incision utilizing a alligator forcep.  Cortisporin Otic drops were placed followed by cotton balls.  Attention was then drawn to the left ear with the head turned to the right and the medium sized ear speculum placed.  The external auditory canal was removed off of its cerumen with a #5 suction which led to the direct visualization of the tympanic membrane.  The tympanic membrane appeared with no signs of retraction pockets, cholesteatoma or air fluid levels.  A myringotomy incision was then made within the posterior inferior quadrant with a myringotomy blade after which a _________ split tube 1.0 mm was then placed with an alligator forcep.  After this, the patient had Cortisporin Otic drops followed by cotton balls placed.  The patient was then turned back to Anesthesia and transferred to recovery room in stable condition and tolerated the procedure very well.  The patient will be followed up approximately in one week and was sent home with a prescription for Ciloxan ear drops to be used as directed and with instructions not to get any water in the ears.",11
"CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD WITHOUT CONTRAST,TECHNIQUE:,  Noncontrast axial CT images of the head were obtained.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection.  The ventricles and cortical sulci are normal in shape and configuration.  The gray/white matter junctions are well preserved.  There is no calvarial fracture.  The visualized paranasal sinuses and mastoid air cells are clear.,IMPRESSION: , Negative for acute intracranial disease.,CT CERVICAL SPINE,TECHNIQUE:  ,Noncontrast axial CT images of the cervical spine were obtained.  Sagittal and coronal images were obtained.,FINDINGS:,  Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms.  No fracture or subluxation is seen.  Anterior and posterior osteophyte formation is seen at C5-C6.  No abnormal anterior cervical soft tissue swelling is seen.  No spinal compression is noted.  The atlanto-dens interval is normal.  There is a large retention cyst versus polyp within the right maxillary sinus.,IMPRESSION:,1.  Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms.,2.  Degenerative disk and joint disease at C5-C6.,3.  Retention cyst versus polyp of the right maxillary sinus.",22
"GENERAL: , Well developed, well nourished, alert, in no acute distress.  GCS 50, nontoxic.,VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature * degrees F.  Pulse oximetry *%.,HEENT: , Eyes: Lids and conjunctiva.  No lesions.  Pupils equal, round, reactive to light and accommodation.  Irises symmetrical, undilated.  Funduscopic exam reveals no hemorrhages or discopathy.  Ears, Nose, Mouth, and throat:  External ears without lesions.  Nares patent.  Septum midline.  Tympanic membranes without erythema, bulging or retraction.  Canals without lesion.  Hearing is grossly intact.  Lips, teeth, gums, palate without lesion.  Posterior oropharynx:  No erythema.  No tonsillar enlargement, crypt formation or abscess.,NECK:  ,Supple and symmetric.  No masses. Thyroid midline, non enlarged.  No JVD.  Neck is nontender.  Full range of motion without pain.,RESPIRATORY: , Good respiratory effort.  Clear to auscultation.  Clear to percussion.  Chest:  Symmetrical rise and fall.  Symmetrical expansion.  No egophony or tactile fremitus.,CARDIOVASCULAR:,  Regular rate and rhythm.  No murmur, gallops, clicks, heaves or rub.  Cardiac palpation within normal limits.  Pulses equal at carotid.  Femoral and pedal pulses:  No peripheral edema.,GASTROINTESTINAL:  ,No tenderness or mass.  No hepatosplenomegaly.  No hernia.  Bowel sounds equal times four quadrants.  Abdomen is nondistended.  No rebound, guarding, rigidity or ecchymosis.,MUSCULOSKELETAL: , Normal gait and station.  No pathology to digits or nails.  Extremities move times four.  No tenderness or effusion.  Range of motion adequate.  Strength and tone equal bilaterally, stable.,BACK: , Nontender on midline.  Full range of motion with flexion, extension and sidebending.,SKIN:,  Inspection within normal limits.  Well hydrated.  No diaphoresis.  No obvious wound.,LYMPH:,  Cervical lymph nodes.  No lymphadenopathy.,NEUROLOGICAL:  ,Cranial nerves II-XII grossly intact.  DTRs symmetric 2 out of 4 bilateral upper and lower extremity, elbow, patella and ankle.  Motor strength 4/4 bilateral upper and lower extremity.  Straight leg raise is negative bilaterally.,PSYCHIATRIC: , Judgment and insight adequate.  Alert and oriented times three.  Memory and mood within normal limits.  No delusions, hallucinations.  No suicidal or homicidal ideation.",5
"PREOPERATIVE DIAGNOSES:,1.  Radiation cystitis.,2.  Refractory voiding dysfunction.,3.  Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,POSTOPERATIVE DIAGNOSES:,1.  Radiation cystitis.,2.  Refractory voiding dysfunction.,3.  Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,TITLE OF OPERATION: , Salvage cystectomy (very difficult due to postradical prostatectomy and postradiation therapy to the pelvis), Indiana pouch continent cutaneous diversion, and omental pedicle flap to the pelvis.,ANESTHESIA: , General endotracheal with epidural.,INDICATIONS:  ,This patient is a 65-year-old white male who in 1998 had a radical prostatectomy.  He was initially dry without pads and then underwent salvage radiation therapy for rising PSA.  After that he began with episodes of incontinence as well as urinary retention requiring catheterization.  One year ago, he was unable to catheterize and was taken to the operative room and had cystoscopy.  He had retained staple removed and a diverticulum identified.  There were also bladder stones that were lasered and removed, and he had been incontinent ever since that time.  He wears 8 to 10 pads per day, and this has affected his quality of life significantly.  I took him to the operating room on January 16, 2008, and found diffuse radiation changes with a small capacity bladder and wide-open bladder neck.  We both felt that his lower urinary tract was not rehabilitatable and that a continent cutaneous diversion would solve the number of problems facing him.  I felt like if we could remove the bladder safely, then this would also provide a benefit.,FINDINGS: , At exploration, there were no gross lesions of the smaller or large bowel.  The bladder was predictably sucked into the pelvic sidewall both inferiorly and laterally.  The opened bladder, which we were able to remove completely, had a wide-open capacious diverticulum in its very distal segment.  Because of the previous radiation therapy and a dissection down to the pelvis, I elected to place an omental pedicle flap to provide additional blood supply for healing as well in the pelvis and also under the pubic bone which was exposed inferiorly due to previous surgery and treatment.,PROCEDURE IN DETAIL:  ,The patient was brought to the operative suite and after adequate general endotracheal and epidural anesthesia obtained, placed in the supine position, flexed over the anterosuperior iliac spine, and his abdomen and genitalia were sterilely prepped and draped in the usual fashion.  A nasogastric tube was placed as well as radial arterial line.  He was given intravenous antibiotics for prophylaxis.  A generous midline skin incision was made from the midepigastrium down to the symphysis pubis, deep into the rectus fascia, the rectus muscle separated in the midline, and exploration carried out with the findings described.  Moist wound towels and a Bookwalter retractor were placed for exposure.  We began by retracting the bowels by mobilizing the cecum and ascending colon and hepatic flexure and elevating the terminal ileum up to the second and third portion of the duodenum.  The ureter was identified as a crisis over the iliac vessels and dissected deep into pelvis and subsequently divided between clips.  An identical procedure was performed in the left side with similar findings and the bowels were packed cephalad.,We began then dissecting the bladder away from the pelvic side walls staying medial to both epigastric arteries.  This was quite challenging because of the previous radiation therapy and radical prostatectomy.  We essentially carved the bladder off of the pelvic sidewall inferiorly as best we could and then we were able to have enough freedom to identify the lateral pedicles, and these were taken between double clips approximately and clipped distally.  We then approached things posteriorly and carefully dissected between the __________ and posterior bladder.  There was some remnant seminal vesicle on the right as well as both remnant ejaculatory duct and we used this to dissect the longus safe plane anterior to the rectum.  We then entered the bladder anteriorly as distal as we could and remove the bladder and what we thought was a bladder neck and this appeared to end in a diverticulum.  We then peeled it off the remaining rectum and passed the specimen off the operative field.  Bladder was irrigated with warm sterile water and a meticulous inspection was made for hemostasis.,We then completely mobilized the omentum off of the proximal transverse colon.  This allowed a generous flap to be able to be laid into the pelvis without tension.,We then turned our attention to forming the Indiana pouch.  I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon.  The colon was divided proximal to the middle colic using a GIA-80 stapler.  I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum.  The mesentery was then sealed with a LigaSure device and divided, and the bowel was divided with a GIA-60 stapler.  We then performed a side-to-side ileo-transverse colostomy using a GIA-80 stapler, closing the open end with a TA 60.  The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,We then removed the staple line along the terminal ileum, passed a 12-French Robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the GIA-60 stapler.  The ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by Rowland, et al, and following this, passage of an 18-French Robinson catheter was associated with the characteristic ""pop,"" indicating that we had adequately plicated the ileocecal valve.,As the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy.  We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 Vicryl sutures.  The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb-75.  Between the staple lines, Vicryl sutures were placed and the defects closed with 3-0 Vicryl suture ligatures.,We then turned our attention to forming the ileocolonic anastomosis.  The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 Vicryl sutures, and this was stented with a Cook 8.4-French ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture.  The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis.  We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture.  A 24-French Malecot catheter was placed through the cecum and secured with a chromic suture.  The staple lines were then buried with a running 3-0 Vicryl two-layer suture and the open end of the pouch closed with a TA 60 Polysorb suture.  The pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,We then made a final inspection for hemostasis.  The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures.  We then matured our stoma through the umbilicus.  We removed the plug of skin through the umbilicus and delivered the ileal segment through this.  A portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures.  We left an 18-French Robinson through the stomag and secured this to the skin with silk sutures.  The Malecot and stents were also secured in a similar fashion.,We matured the stoma to the umbilicus with interrupted chromic stitches.  The stitch was brought out to the right upper quadrant and the Malecot to the left lower quadrant.  A Large JP drain was placed in the pelvis dependent to the omentum pedicle flap as well as the Indiana pouch.,The rectus fascia was closed with a buried #2 Prolene running stitch, tying a new figure-of-eight proximally and distally and meeting in the middle and tying it underneath the fascia.  Subcutaneous tissue was irrigated with saline and skin was closed with surgical clips.  The estimated blood loss was 450 mL, and the patient received no packed red blood cells.  The final sponge and needle count were reported to be correct.  The patient was awakened and extubated, and taken on stretcher to the recovery room in satisfactory condition.",38
"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.",27
"PREOPERATIVE DIAGNOSIS: , Blighted ovum, severe cramping.,POSTOPERATIVE DIAGNOSIS:,  Blighted ovum, severe cramping.,OPERATION PERFORMED: , Vacuum D&C.,DRAINS: , None.,ANESTHESIA: , General.,HISTORY: , This 21-year-old white female gravida 1, para 0 who was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.  Due to the severe cramping, a decision to undergo vacuum D&C was made.  At the time of the procedure, moderate amount of tissue was obtained.,PROCEDURE:  ,The patient was taken to the operating room and placed in a supine position, at which time a general form of anesthesia was administered by the anesthesia department.  The patient was then repositioned in a modified dorsal lithotomy position and then prepped and draped in the usual fashion.  A weighted vaginal speculum was placed in the posterior vaginal vault.  Anterior lip of the cervix was grasped with single tooth tenaculum, and the cervix was dilated to approximately 8 mm straight.  Plastic curette was placed into the uterine cavity and suction was applied at 60 mmHg to remove the tissue.  This was followed by gentle curetting of the lining as well as followed by suction curetting and then another gentle curetting and a final suction.  Methargen 0.2 mg was given IM and Pitocin 40 units and a 1000 was also started at the time of the procedure.  Once the procedure was completed, the single tooth tenaculum was removed from the vaginal vault with some _____ remaining blood and the weighted speculum was also removed.  The patient was repositioned to supine position and taken to recovery room in stable condition.",37
"TITLE OF OPERATION:,1.  Repair of total anomalous pulmonary venous connection.,2.  Ligation of patent ductus arteriosus.,3.  Repair secundum type atrial septal defect (autologous pericardial patch).,4.  Subtotal thymectomy.,5.  Insertion of peritoneal dialysis catheter.,INDICATION FOR SURGERY: , This neonatal was diagnosed postnatally with total anomalous pulmonary venous connection.  Following initial stabilization, she was transferred to the Hospital for complete correction.,PREOP DIAGNOSIS:  ,1.  Total anomalous pulmonary venous connection.,2.  Atrial septal defect.,3.  Patent ductus arteriosus.,4.  Operative weight less than 4 kilograms (3.2 kilograms).,COMPLICATIONS: , None.,CROSS-CLAMP TIME: , 63 minutes.,CARDIOPULMONARY BYPASS TIME MONITOR:,  35 minutes, profound hypothermic circulatory arrest time (4 plus 19) equals 23 minutes.  Low flow perfusion 32 minutes.,FINDINGS:,  Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left-sided veins.  Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence.  Nonobstructed ascending vein ligated.  Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin.  At completion of the procedure, right ventricular pressure approximating one-half of systemic, normal sinus rhythm, good biventricular function by visual inspection.,PROCEDURE: , After the informed consent, the patient was brought to the operating room and placed on the operating room table in supine position.  Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines.  The patient was prepped and draped in the usual sterile fashion from chin to groins.  A median sternotomy incision was performed.  Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw.  A subtotal thymectomy was performed.  Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle.  A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure.  Pursestrings were deployed on the ascending aorta on the right.  Atrial appendage.  The aorta was then cannulated with an 8-French aorta cannula and the right atrium with an 18-French Polystan right-angle cannula.  With an ACT greater than 400, greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2-0 silk tie.  Systemic cooling was started and the head was packed  and iced and systemic steroids were administered.  During cooling, traction suture was placed in the apex of the left ventricle.  After 25 minutes of cooling, the aorta was cross-clamped and the heart arrested by administration of 30 cubic centimeter/kilogram of cold-blood cardioplegia delivered directly within the aortic root following the aorta cross-clamping.  Following successful cardioplegic arrest, a period of low flow perfusion was started and a 10-French catheter was inserted into the right atrial appendage substituting the 18-French Polystan venous cannula.  The heart was then rotated to the right side and the venous confluence was exposed.  It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed.  The two openings were then anastomosed in an end-to-side fashion with several interlocking sutures to avoid pursestring effect with a running 7-0 PDS suture.  Following completion of the anastomosis, the heart was returned into the chest and the patient's blood volume was drained into the reservoir.  A right atriotomy was then performed during the period of circulatory arrest.  The atrial septal defect was very difficult to expose, but it was sealed with an autologous pericardial patch was secured in place with a running 6-0 Prolene suture.  The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6-0 Prolene sutures.  The venous cannula was reinserted.  Cardiopulmonary bypass restarted and the aorta cross-clamp was released.  The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which, following a prolonged period of rewarming, allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm.  Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15-French Blake drains.  Venous decannulation was followed by aortic decannulation and administration of protamine sulfate.  All cannulation sites were oversewn with 6-0 Prolene sutures and the anastomotic sites noticed to be hemostatic.  With good hemodynamics and hemostasis, the sternum was then smeared with vancomycin, placing closure with stainless steel wires.  The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was transferred in very stable condition to the pediatric intensive care unit .,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.  Given the magnitude of the operation, the unavailability of an appropriate level, cardiac surgical resident, Mrs. X (attending pediatric cardiac surgery at the Hospital) participated during the cross-clamp time of the procedure in quality of first assistant.",37
"PREOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Left subclavian vein occlusion.,3.  Status post chronic tracheostomy.,4.  Status post coronary artery bypass grafting.,5.  Right subclavian vein stenosis.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Left subclavian vein occlusion.,3.  Status post chronic tracheostomy.,4.  Status post coronary artery bypass grafting.,5.  Right subclavian vein stenosis.,OPERATIVE PROCEDURE,Creation of autologous right brachiobasilic arteriovenous fistula - first stage.,INDICATIONS FOR THE PROCEDURE,This patient has a known left subclavian vein occlusion.  The right subclavian vein has an estimated 50% stenosis.  The patient has a catheter traversed in the right innominate vein.  The right basilic vein was judged to be suitable for usage on vein mapping.,OPERATIVE FINDINGS,The basilic vein was of an adequate size, but somewhat sclerotic.  A first stage autologous right brachiobasilic arteriovenous fistula was created.  A grade 2 was felt at completion.,OPERATIVE PROCEDURE IN DETAIL,After informed consent was obtained, the patient was taken to the operating room.  The patient was placed in the supine position.  The patient received regional nerve block.  The patient also received intravenous sedation.  The right arm was prepped and draped in the usual sterile fashion.  We used ultrasound to locate the basilic vein at the cubital fossa.,A small transverse incision was made slightly above the basilic vein.  The basilic vein was identified and immobilized.  The basilic vein was of a good size, but somewhat sclerotic.  The underlying fascia was incised and the brachial artery was identified and immobilized.  The brachial artery was normal.  We then divided the basilic vein distally.  The distal end was ligated using silk suture.  The brachial artery was clamped proximally and distally.  A small longitudinal arteriotomy was made in the brachial artery.  We did not give heparin.  The end of the basilic vein was then sewn end-to-side to the brachial artery using a running 7-0 Prolene suture.  ,Just prior to completion of the anastomosis, it was flushed and anastomosis was completed.  Flow was then established.  A grade 2 was felt in the outflow basilic fistula.  Hemostasis was secured.  The wound was then closed in layers using interrupted PDS sutures for the fascia and a running 4-0 Monocryl subcuticular suture for the skin.  A sterile dry dressing was applied.,The patient tolerated the procedure well.  There were no operative complications.  The sponge, instrument, and needle counts were correct at the end of the case.  I was present and participated in all aspects of the procedure.  The patient was transferred to the recovery room in satisfactory condition.",21
"PROCEDURE: , Colonoscopy.,INDICATIONS: , Hematochezia, Personal history of colonic polyps.,MEDICATIONS:,  Midazolam 2 mg IV, Fentanyl 100 mcg IV,PROCEDURE:,  A History and Physical has been performed, and patient medication allergies have been reviewed.  The patient's tolerance of previous anesthesia has been reviewed.  The risks and benefits of the procedure and the sedation options and risks were discussed with the patient.  All questions were answered and informed consent was obtained.  Mental Status Examination:  alert and oriented.  Airway Examination:  normal oropharyngeal airway and neck mobility.  Respiratory Examination:  clear to auscultation.  CV Examination:  RRR, no murmurs, no S3 or S4.  ASA Grade Assessment:  P1 A normal healthy patient.  After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.  The anesthesia plan was to use conscious sedation.  Immediately prior to administration of medications, the patient was re-assessed for adequacy to receive sedatives.  The heart rate, respiratory rate, oxygen saturations, blood pressure, adequacy of pulmonary ventilation, and response to care were monitored throughout the procedure.  The physical status of the patient was re-assessed after the procedure.  After I obtained informed consent, the scope was passed under direct vision.  Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.  The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & IC valve.  The quality of the prep was good.  The patient tolerated the procedure well.,FINDINGS:,1.  A sessile, non-bleeding polyp was found in the rectum.  The polyp was 5 mm in size.  Polypectomy was performed with a saline injection-lift technique using the snare.  Resection and retrieval were complete.  Estimated blood loss was minimal.,2.  One pedunculated, non-bleeding polyp was found in the sigmoid colon.  The polyp was 7 mm in size.  Polypectomy was performed with a hot forceps.  Resection and retrieval were complete.  Estimated blood loss was minimal.,3.  Multiple large-mouthed diverticula were found in the descending colon.,4.  Internal, non-bleeding, prolapsed with spontaneous reduction (grade II) hemorrhoids were found on retroflexion.,IMPRESSION:,1.  One 5 mm benign appearing polyp in the rectum.  Resected and retrieved.,2.  One 7 mm polyp in the sigmoid colon.  Resected and retrieved.,3.  Diverticulosis.,4.  Internal hemorrhoids were found.,RECOMMENDATION:,1.  High fiber diet.,2.  Await pathology results.,3.  Repeat colonoscopy for surveillance in 3 years.,4.  The findings and recommendations were discussed with the patient.,CPT CODE(S):,45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare,technique.,45384, 59, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot,biopsy forceps or bipolar cautery.,45381, 59, Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.,ICD9 CODE(S):,211.4, Benign neoplasm of rectum and anal canal.,211.3, Benign neoplasm of colon.,562.10, Diverticulosis of colon (without mention of hemorrhage).,455.2, Internal hemorrhoids with other complication,578.1, Blood in stool.,v12.72, Personal history of colonic polyps.",14
"PREOPERATIVE DIAGNOSIS:, Chronic abdominal pain and heme positive stool.,POSTOPERATIVE DIAGNOSES:,1.  Antral gastritis.,2.  Duodenal polyp.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with photos and antral biopsy.,ANESTHESIA: , Demerol and Versed.,DESCRIPTION OF PROCEDURE: , Consent was obtained after all risks and benefits were described.  The patient was brought back into the Endoscopy Suite.  The aforementioned anesthesia was given.  Once the patient was properly anesthetized, bite block was placed in the patient's mouth.  Then, the patient was given the aforementioned anesthesia.  Once he was properly anesthetized, the endoscope was placed in the patient's mouth that was brought down to the cricopharyngeus muscle into the esophagus and from the esophagus to his stomach.  The air was insufflated down.  The scope was passed down to the level of the antrum where there was some evidence of gastritis seen.  The scope was passed into the duodenum and then duodenal sweep where there was a polyp seen.  The scope was pulled back into the stomach in order to flex upon itself and straightened out.  Biopsies were taken for CLO and histology of the antrum.  The scope was pulled back.  The junction was visualized.  No other masses or lesions were seen.  The scope was removed.  The patient tolerated the procedure well.  We will recommend the patient be on some type of a H2 blocker.  Further recommendations to follow.",14
"PREOPERATIVE DIAGNOSIS:,  Obstructive sleep apnea.,POSTOPERATIVE DIAGNOSIS:  ,Obstructive sleep apnea.,PROCEDURE PERFORMED:,1.  Tonsillectomy.,2.  Uvulopalatopharyngoplasty.,ANESTHESIA:,  General endotracheal tube.,BLOOD LOSS: , Approximately 50 cc.,INDICATIONS: , The patient is a 41-year-old gentleman with a history of obstructive sleep apnea who has been using CPAP, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea.,PROCEDURE: , After all risks, benefits, and alternatives have been discussed with the patient, informed consent was obtained.  The patient was brought to the operative suite where he was placed in supine position and general endotracheal tube intubation was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away and a shoulder roll was placed and a McIvor mouthgag was inserted into the oral cavity.  Correct inspection and palpation did not reveal evidence of a bifid uvula or submucosal clots.  Attention was directed first to the right tonsil in which a curved Allis forceps was applied to the superior pole.  The needle-tip Bovie cautery was used to incise the mucosa of the anterior tonsillar pillar.  Once the tonsillar pillar was identified and the superior pole was released, the curved forceps with a straight Allis forceps and the dissection was carried down inferiorly, dissecting the tonsil free from all fascial attachments.  Once the tonsil was delivered from the oral cavity, hemostasis was obtained within the tonsillar fossa utilizing suction cautery.,Attention was then directed over to the left tonsil in which a similar procedure was performed.  Once all bleeding was controlled, the mucosa of both the hard and soft palate was anesthetized with a mixture of 1% lidocaine and 1:50000 epinephrine solution.  Now attention was directed to the posterior pillars.  A hemostat was used to clamp the posterior pillar, which was then taken down with Metzenbaum scissors.  The posterior pillar was then approximated to the anterior pillar with the use of #3-0 PDS suture so as to create a box shaped soft palate.  Now, the uvula was reflected onto the soft palate and #12 blade scalpel was used to incise the mucosa of the soft palate extending down onto the uvula.  The mucosa was dissected off with the use of Potts scissors.  Now the uvula was reflected onto the soft palate and sutured down in place with use of #3-0 PDS suture approximated with deep muscle layers.  Now the mucosa of the soft palate and the uvula were approximated with interrupted #3-0 PDS sutures.  Finally, #4-0 Vicryl sutures were placed intermittently between the PDS to further secure the uvula, which had been reflected onto the soft palate.  A final #3-0 PDS suture was used to further approximate the anterior and posterior tonsil pillars.  Final inspection did not reveal any further bleeding.  The mouth was then irrigated with saline and suctioned.  At this point, the procedure was complete.  He was awakened and taken to recovery room in stable condition.  He will be admitted as an observation patient to the Telemetry Floor for routine postoperative management.  Of note, IV Decadron was administered during the procedure.",11
"PREOPERATIVE DIAGNOSIS:,  A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,POSTOPERATIVE DIAGNOSIS:,  A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,PROCEDURES PERFORMED:,1.  Epidermal autograft on Integra to the back (3520 cm2).,2.  Application of allograft to areas of the lost Integra, not grafted on the back (970 cm2).,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  Approximately 50 cc.,BLOOD PRODUCTS RECEIVED:,  One unit of packed red blood cells.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 26-year-old male, who sustained a 60% total body surface area flame burn involving the head, face, neck, chest, abdomen, back, bilateral upper extremities, hands, and bilateral lower extremities.  He has previously undergone total burn excision with placement of Integra and an initial round of epidermal autografting to the bilateral upper extremities and hands.  His donor sites have healed particularly over his buttocks and he returns for a second round of epidermal autografting over the Integra on his back utilizing the buttock donor sites, the extent they will provide coverage.,OPERATIVE FINDINGS:,1.  Variable take of Integra, particularly centrally and inferiorly on the back.  A fair amount of lost Integra over the upper back and shoulders.,2.  No evidence of infection.,3.  Healthy viable wound beds prior to grafting.,PROCEDURE IN DETAIL:,  The patient was brought to the operating room and positioned supine.  General endotracheal anesthesia was uneventfully induced and an appropriate time out was performed.  He was then repositioned prone and perioperative IV antibiotics were administered.  He was prepped and draped in the usual sterile manner.  All staples were removed from the Integra and the adherent areas of Silastic were removed.  The entire wound bed was further prepped with scrub brushes and more Betadine followed by a sulfamylon solution.  Hemostasis of the wound bed was ensured using epinephrine-soaked Telfa pads.  Following dermal tumescence of the buttocks, epidermal autografts were harvested 8 one-thousandths of an inch using the air Zimmer dermatome.  These grafts were passed to the back table where they were meshed 3:1.  The donor sites were hemostased using epinephrine-soaked Telfa and lap pads.  Once all the  grafts were meshed, we brought them back up onto the field, positioned them over the wounds beginning inferiorly and moving cephalad where we had best areas of Integra engraftment.  We were happy with the lie of the grafts and they were stapled into place.  The grafts were then overlaid with Conformant 2, which was also stapled into place.  Utilizing all of his buttocks skin, we did not have enough to cover his entire back, so we elected to apply allograft to the cephalad and a few areas on his flanks where we had had poor Integra engraftment.  Allograft was thawed and meshed 1:1.  It was then brought up onto the field, trimmed to fit and stapled into place over the wound.  Once the entirety of the posterior wounds on his back were covered out with epidermal autograft or allograft sulfamylon soaked dressings were applied.  Donor sites on his buttocks were dressed in Acticoat and secured with staples.  He was then repositioned supine and extubated in the operating room having tolerated the procedure without any apparent complications.  He was transported to PACU in stable condition.",37
"PREOPERATIVE DIAGNOSIS:,  Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip - donor site, abdomen.,INDICATION:  ,This is a 62-year-old female for the above-planned procedure.  She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied.  Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,PROCEDURE: , The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table.  Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen.  This included the neck accordingly.,Two platysmal sling application and operating headlight were utilized.  Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.,The first procedure was performed was that of a quadrilateral blepharoplasty.  Markers were applied to both upper lids in symmetrical fashion.  The skin was excised from the right upper lid first followed by appropriate muscle resection.  Minimal fat removed from the medial upper portion of the eyelid.  Hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture.  Attention was then turned to the lower lid.  A classic skin muscle flap was created accordingly.  Fat was resected from the middle, medial, and lateral quadrant.  The fat was allowed to open drain the arcus marginalis for appropriate contour.  Hemostasis was controlled with the pinpoint cautery accordingly.  Skin was redraped with a conservative amount resected.  Running closure with 7-0 nylon was accomplished without difficulty.  The exact same procedure was repeated on the left upper and lower lid.,After completion of this portion of the procedure, the lag lid was again placed in the eyes.  Eye mass was likewise clamped.  Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure.  The right face was first operated.  It was injected with a 0.25% Marcaine 1:200,000 adrenaline.  A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula.  She had minimal subcutaneous extra fat as noted.  Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline.  The flap was elevated without difficulty with various facelift scissors.  Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.,The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision.  Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery.  The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.,Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication.  The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene.  The skin was draped appropriately and appropriate tissue was resected.  A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface.  Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon.  The hairline temporal incision was closed with running 5-0 nylon.  The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.,The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.,The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described.  Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly.  Approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly.  Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure.  The incision site was closed with 7-0 nylon.,The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.,The patient will be admitted for overnight short stay through the cosmetic package procedure.  She will be discharged in the morning.,Estimated blood loss was less than 75 cc.  No complications noted, and the patient tolerated the procedure well.",37
"FINAL DIAGNOSES:,1.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2.  Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and ""tension headaches.""  In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right.  He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful.  More recently he saw Dr. Y and went through some physical therapy without much relief.,Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7.  In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief.  The procedure and its risk were fully discussed and he decided to proceed with the operation.,HOSPITAL COURSE: , Following admission, the procedure was carried out without difficulty.  Blood loss was about 125 cc.  Postop x-ray showed good alignment and positioning of the cages, plate, and screws.  After surgery, he was able to slowly increase his activity level with assistance from physical therapy.  He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck.  He also had some nausea with the PCA.  He had a low-grade fever to 100.2 and was started on incentive spirometry.  Over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,By 06/27/07, he was ready to go home.  He has been counseled regarding wound care and has received a neck sheet for instruction.  He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks.  He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg.  He is to call if there are any problems.",27
"TITLE OF OPERATION: , Ligation (clip interruption) of patent ductus arteriosus.,INDICATION FOR SURGERY: , This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.  She has now been put forward for operative intervention.,PREOP DIAGNOSIS:  ,1.  Patent ductus arteriosus.,2.  Severe prematurity.,3.  Operative weight less than 4 kg (600 grams).,COMPLICATIONS: , None.,FINDINGS: , Large patent ductus arteriosus with evidence of pulmonary over circulation.  After completion of the procedure, left recurrent laryngeal nerve visualized and preserved.  Substantial rise in diastolic blood pressure.,DETAILS OF THE PROCEDURE: , After obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced.  The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed.  Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma.  The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus.  The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion.  It was then test occluded and then interrupted with a medium titanium clip.  There was preserved pulsatile flow in the descending aorta.  The left recurrent laryngeal nerve was identified and preserved.  With excellent hemostasis, the intercostal space was closed with 4-0 Vicryl sutures and the muscular planes were reapproximated with 5-0 Caprosyn running suture in two layers.  The skin was closed with a running 6-0 Caprosyn suture.  A sterile dressing was placed.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was returned to the supine position in which palpable bilateral femoral pulses were noted.,I was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case.",29
"POSTOPERATIVE DIAGNOSIS:,  Chronic adenotonsillitis.,PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA:  ,General endotracheal tube.,ESTIMATED BLOOD LOSS:,  Minimum, less than 5 cc.,SPECIMENS:,  Right and left tonsils 2+, adenoid pad 1+.  There was no adenoid specimen.,COMPLICATIONS: , None.,HISTORY: , The patient is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy.  The patient has had approximately four to five episodes of adenotonsillitis per year for the last three to four years.,PROCEDURE: , Informed consent was properly obtained from the patient's parents and the patient was taken to the operating room #3 and was placed in a supine position.  He was placed under general endotracheal tube anesthesia by the Department of Anesthesia.  The bed was then rolled away from Department of Anesthesia.  A shoulder roll was then placed beneath the shoulder blades and a blue towel was then fashioned as a turban wrap.  The McIvor mouth gag was carefully positioned into the patient's mouth with attention to avoid the teeth.,The retractor was then opened and the oropharynx was visualized.  The adenoid pad was then visualized with a laryngeal mirror.  The adenoids appeared to be 1+ and non-obstructing.  There was no evidence of submucosal cleft palate palpable.  There was no evidence of bifid uvula.  A curved Allis clamp was then used to grasp the superior pole of the right tonsil.  The tonsil was then retracted inferiorly and medially.  Bovie cautery was used to make an incision on the mucosa of the right anterior tonsillar pillar to find the appropriate plane of dissection.  The tonsil was then dissected out within this plane using a Bovie.  Tonsillar sponge was re-applied to the tonsillar fossa.  Suction cautery was then used to adequately obtain hemostasis with the tonsillar fossa.  Attention was then directed to the left tonsil.  The curved Allis was used to grasp the superior pole of the left tonsil and it was retracted inferiorly and medially.  Bovie cautery was used to make an incision in the mucosa of the left anterior tonsillar pillar and define the appropriate plane of dissection.  The tonsil was then dissected out within this plane using the Bovie.  Next, complete hemostasis was achieved within the tonsillar fossae using suction cautery.  After adequate hemostasis was obtained, attention was directed towards the adenoid pad.  The adenoid pad was again visualized and appeared 1+ and was non-obstructing.  Decision was made to use suction cautery to cauterize the adenoids.  Using a laryngeal mirror under direct visualization, the adenoid pad was then cauterized with care to avoid the eustachian tube orifices as well as the soft palate and inferior turbinates.  After cauterization was complete, the nasopharynx was again visualized and tonsillar sponge was applied.  Adequate hemostasis was achieved.  The tonsillar fossae were again visualized and no evidence of bleeding was evident.  The throat pack was removed from the oropharynx and the oropharynx was suctioned.  There was no evidence of any further bleeding.  A flexible suction catheter was then used to suction out the nasopharynx to the oropharynx.  The suction catheter was also used to suction up the stomach.  Final look revealed no evidence of further bleeding and 10 mg of Decadron was given intraoperatively.,DISPOSITION:  ,The patient tolerated the procedure well and the patient was transported to the recovery room in stable condition.",11
"EXAM: , Transvaginal ultrasound.,HISTORY: , Pelvic pain.,FINDINGS: , The right ovary measures 1.6 x 3.4 x 2.0 cm.  There are several simple-appearing probable follicular cysts. There is no abnormal flow to suggest torsion on the right.  Left ovary is enlarged, demonstrating a 6.0 x 3.5 x 3.7 cm complex cystic mass of uncertain etiology.  This could represent a large hemorrhagic cyst versus abscess.  There is no evidence for left ovarian torsion.  There is a small amount of fluid in the cul-de-sac likely physiologic.,The uterus measures 7.7 x 5.0 cm.  The endometrial echo is normal at 6 mm.,IMPRESSION:,1.  No evidence for torsion.,2.  Large, complex cystic left ovarian mass as described.  This could represent a large hemorrhagic cyst; however, an abscess/neoplasm cannot be excluded.  Recommend either short interval followup versus laparoscopic evaluation given the large size and complex nature.",33
"INDICATION: , Paroxysmal atrial fibrillation.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 55-year-old white female with multiple myeloma.  She is status post chemotherapy and autologous stem cell transplant.  Latter occurred on 02/05/2007.  At that time, she was on telemetry monitor and noticed to be in normal sinus rhythm.,As part of study protocol for investigational drug for prophylaxis against mucositis, she had electrocardiogram performed on 02/06/2007.  This demonstrated underlying rhythm of atrial fibrillation with rapid ventricular response at 125 beats per minute.  She was subsequently transferred to telemetry for observation.  Cardiology consultation was requested.  Prior to formal consultation, the patient did have an echocardiogram performed on 02/06/2007, which showed a structurally normal heart with normal left ventricular (LV) systolic function, ejection fraction of 60%, aortic sclerosis without stenosis, a trivial pericardial effusion with no evidence for immunocompromise and mild tricuspid regurgitation with normal pulmonary atrial pressures.  Overall, essentially normal heart.,At the time of my evaluation, the patient felt somewhat jittery and nervous, but otherwise asymptomatic.,PAST MEDICAL HISTORY:,  Multiple myeloma, diagnosed in June of 2006, status post treatment with thalidomide and Coumadin.  Subsequently, with high-dose chemotherapy followed by autologous stem cell transplant.,PAST SURGICAL HISTORY: , Cosmetic surgery of the nose and forehead.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,CURRENT MEDICATIONS,1.  Acyclovir 400 mg p.o. b.i.d.,2.  Filgrastim 300 mcg subcutaneous daily.,3.  Fluconazole 200 mg daily.,4.  Levofloxacin 250 mg p.o. daily.,5.  Pantoprazole 40 mg daily.,6.  Ursodiol 300 mg p.o. b.i.d.,7.  Investigational drug is directed ondansetron 24 mg p.r.n.,FAMILY HISTORY: , Unremarkable.  Father and mother both alive in their mid 70s.  Father has an unspecified heart problem and diabetes.  Mother has no significant medical problems.  She has one sibling, a 53-year-old sister, who has a pacemaker implanted for unknown reasons.,SOCIAL HISTORY: , The patient is married.  Has four adult children.  Good health.  She is a lifetime nonsmoker, social alcohol drinker.,REVIEW OF SYSTEMS: , Prior to treatment for her multiple myeloma, she was able to walk four miles nonstop.  Currently, she has dyspnea on exertion on the order of one block.  She denies any orthopnea or paroxysmal nocturnal dyspnea.  She denies any lower extremity edema.  She has no symptomatic palpitations or tachycardia.  She has never had presyncope or syncope.  She denies any chest pain whatsoever.  She denies any history of coagulopathy or bleeding diathesis.  Her oncologic disorder is multiple myeloma.  Pulmonary review of systems is negative for recurrent pneumonias, bronchitis, reactive airway disease, exposure to asbestos or tuberculosis.  Gastrointestinal (GI) review of systems is negative for known gastroesophageal reflux disease, GI bleed, and hepatobiliary disease.  Genitourinary review of systems is negative for nephrolithiasis or hematuria.  Musculoskeletal review of systems is negative for significant arthralgias or myalgias.  Central nervous system (CNS) review of systems is negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.  Psychiatric review of systems is negative for known affective or cognitive disorders.,PHYSICAL EXAMINATION,GENERAL:  This is a well-nourished, well-developed white female who appears her stated age and somewhat anxious.,VITAL SIGNS:  She is afebrile at 97.4 degrees Fahrenheit with a heart rate ranging from 115 to 150 beats per minute, irregularly irregular.  Respirations are 20 breaths per minute and blood pressure ranges from 90/59 to 107/68 mmHg.  Oxygen saturation on room air is 94%.,HEENT:  Benign being normocephalic and atraumatic.  Extraocular motions are intact.  Her sclerae are anicteric and conjunctivae are noninjected.  Oral mucosa is pink and moist.,NECK:  Jugular venous pulsations are normal.  Carotid upstrokes are palpable bilaterally.  There is no audible bruit.  There is no lymphadenopathy or thyromegaly at the base of the neck.,CHEST:  Cardiothoracic contour is normal.  Lungs, clear to auscultation in all lung fields.,CARDIAC:  Irregularly irregular rhythm and rate.  S1, S2 without a significant murmur, rub, or gallop appreciated.  Point of maximal impulse is normal, no right ventricular heave.,ABDOMEN:  Soft with active bowel sounds.  No organomegaly.  No audible bruit.  Nontender.,LOWER EXTREMITIES:  Nonedematous.  Femoral pulses were deferred.,LABORATORY DATA: , EKG, electrocardiogram showed underlying rhythm of atrial fibrillation with a rate of 125 beats per minute.  Nonspecific ST-T wave abnormality is seen in the inferior leads only.,White blood cell count is 9.8, hematocrit of 30 and platelets 395.  INR is 0.9.  Sodium 136, potassium 4.2, BUN 43 with a creatinine of 2.0, and magnesium 2.9.  AST and ALT 60 and 50.  Lipase 343 and amylase 109.  BNP 908.  Troponin was less than 0.02.,IMPRESSION: , A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.,Currently enrolled in a blinded study, where she may receive a drug for prophylaxis against mucositis, which has at least one reported incident of acceleration of preexisting tachycardia.,RECOMMENDATIONS,1.  Atrial fibrillation.  The patient is currently hemodynamically stable, tolerating her dysrhythmia.  However, given the risk of thromboembolic complications, would like to convert to normal sinus rhythm if possible.  Given that she was in normal sinus rhythm approximately 24 hours ago, this is relatively acute onset within the last 24 hours.  We will initiate therapy with amiodarone 150 mg intravenous (IV) bolus followed by mg/minute at this juncture.  If she does not have spontaneous cardioversion, we will consider either electrical cardioversion or anticoagulation with heparin within 24 hours from initiation of amiodarone.,As part of amiodarone protocol, please check TSH.  Given her preexisting mild elevation of transaminases, we will follow LFTs closely, while on amiodarone.,2.  Thromboembolic risk prophylaxis, as discussed above.  No immediate indication for anticoagulation.  If however she does not have spontaneous conversion within the next 24 hours, we will need to initiate therapy.  This was discussed with Dr. X.  Preference would be to run intravenous heparin with PTT of 45 during her thrombocytopenic nadir and initiation of full-dose anticoagulation once nadir is resolved.,3.  Congestive heart failure.  The patient is clinically euvolemic.  Elevated BNP possibly secondary to infarct or renal insufficiency.  Follow volume status closely.  Follow serial BNPs.,4.  Followup.  The patient will be followed while in-house, recommendations made as clinically appropriate.",5
"PREPROCEDURE DIAGNOSIS:,  Left leg claudication.,POSTPROCEDURE DIAGNOSIS: ,  Left leg claudication.,OPERATION PERFORMED: , Aortogram with bilateral, segmental lower extremity run off.,ANESTHESIA: , Conscious sedation.,INDICATION FOR PROCEDURE:  ,The patient presents with lower extremity claudication.  She is a 68-year-old woman, who is very fearful of the aforementioned procedures.  Risks and benefits of the procedure were explained to her to include bleeding, infection, arterial trauma requiring surgery, access issues and recurrence.  She appears to understand and agrees to proceed.,DESCRIPTION OF PROCEDURE: , The patient was taken to the Angio Suite, placed in a supine position.  After adequate conscious sedation, both groins were prepped with Chloraseptic prep.  Cloth towels and paper drapes were placed.  Local anesthesia was administered in the common femoral artery and using ultrasound guidance, the common femoral artery was accessed.  Guidewire was threaded followed by a ,4-French sheath.  Through the 4-French sheath a 4-French Omni flush catheter was placed.  The glidewire was removed and contrast administered to identify the level of the renal artery.  Using power injector an aortogram proceeded.,The catheter was then pulled down to the aortic bifurcation.  A timed run-off view of both legs was performed and due to a very abnormal and delayed run-off in the left, I opted to perform an angiogram of the left lower extremity with an isolated approach.  The catheter was pulled down to the aortic bifurcation and using a glidewire, I obtained access to the contralateral left external iliac artery.  The Omni flush catheter was advanced to the left distal external iliac artery.  The glidewire rather exchanged for an Amplatz stiff wire.  This was left in place and the 4-French sheath removed and replaced with a 6-French destination 45-cm sheath.  This was advanced into the proximal superficial femoral artery and an angiogram performed.  I identified a functionally occluded distal superficial femoral artery and after obtaining views of the run off made plans for angioplasty.,The patient was given 5000 units of heparin and this was allowed to circulate.  A glidewire was carefully advanced using Roadmapping techniques through the functionally occluded blood vessels.  A 4-mm x 4-cm angioplasty balloon was used to dilate the area in question.,Final views after dilatation revealed a dissection.  A search for a 5-mm stent was performed, but none of this was available.  For this reason, I used a 6-mm x 80-mm marked stent and placed this at the distal superficial femoral artery.  Post dilatation was performed with a 4-mm angioplasty balloon.  Further views of the left lower extremity showed irregular change in the popliteal artery.  No significant stenosis could be identified in the left popliteal artery and noninvasive scan.  For this reason, I chose not to treat any further areas in the left leg.,I then performed closure of the right femoral artery with a 6-French Angio-Seal device.  Attention was turned to the left femoral artery and local anesthesia administered.  Access was obtained with the ultrasound and the femoral artery identified.  Guidewire was threaded followed by a 4-French sheath.  This was immediately exchanged for the 6-French destination sheath after the glidewire was used to access the distal external iliac artery.  The glidewire was exchanged for the Amplatz stiff wire to place the destination sheath.  The destination was placed in the proximal superficial femoral artery and angiogram obtained.  Initial views had been obtained from the right femoral sheath before removal.,Views of the right superficial femoral artery demonstrated significant stenosis with accelerated velocities in the popliteal and superficial femoral artery.  For this reason, I performed the angioplasty of the superficial femoral artery using the 4-mm balloon.  A minimal dissection plane measuring less than 1 cm was identified at the proximal area of dilatation.  No further significant abnormality was identified.  To avoid placing a stent in the small vessel I left it alone and approached the popliteal artery.  A 3-mm balloon was chosen to dilate a 50 to 79% popliteal artery stenosis.  Reasonable use were obtained and possibly a 4-mm balloon could have been used.  However, due to her propensity for dissection I opted not to.  I then exchanged the glidewire for an O1 for Thruway guidewire using an exchange length.  This was placed into the left posterior tibial artery.  A 2-mm balloon was used to dilate the orifice of the posterior tibial artery.  I then moved the wire to the perineal artery and dilated the proximal aspect of this vessel.  Final images showed improved run-off to the right calf.  The destination sheath was pulled back into the left external iliac artery and an Angio-Seal deployed.,FINDINGS: , Aortogram demonstrates a dual right renal artery with the inferior renal artery supplying the lower one third of the right renal parenchyma.  No evidence of renal artery stenosis is noted bilaterally.  There is a single left renal artery.  The infrarenal aorta, both common iliac and the external iliac arteries are normal.  On the right, a superficial femoral artery is widely patent and normal proximally.  At the distal third of the thigh there is diffuse disease with moderate stenosis noted.  Moderate stenosis is also noted in the popliteal artery and single vessel run-off through the posterior tibial artery is noted.  The perineal artery is functionally occluded at the midcalf.  The dorsal pedal artery filled by collateral at the high ankle level.,On the left, the proximal superficial femoral artery is patent.  Again, at the distal third of the thigh, there is a functional occlusion of the superficial femoral artery with poor collateralization to the high popliteal artery.  This was successfully treated with angioplasty and a stent placement.  The popliteal artery is diffusely diseased without focal stenosis.  The tibioperoneal trunk is patent and the anterior tibial artery occluded at its orifice.,IMPRESSION,1.  Normal bilateral renal arteries with a small accessory right renal artery.,2.  Normal infrarenal aorta as well as normal bilateral common and external iliac arteries.,3.  The proximal right renal artery is normal with moderately severe stenosis in the superficial femoral popliteal and tibial arteries.  Successful angioplasty with reasonable results in the distal superficial femoral, popliteal and proximal posterior tibial artery as described.,4.  Normal proximal left superficial femoral artery with functional occlusion of the distal left superficial femoral artery successfully treated with angioplasty and stent placement.  Run-off to the left lower extremity is via a patent perineal and posterior tibial artery.",37
"PREOPERATIVE DIAGNOSES,1.  Dyspnea on exertion with abnormal stress echocardiography.,2.  Frequent PVCs.,3.  Metabolic syndrome.,POSTOPERATIVE DIAGNOSES,1.  A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.,2.  Frequent PVCs.,3.  Metabolic syndrome.,PROCEDURES,1.  Left heart catheterization with left ventriculography.,2.  Selective coronary angiography.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory in fasting state.  Both groins were prepped and draped in the usual sterile fashion.  Xylocaine 1% was used as local anesthetic.  Versed and fentanyl were used for conscious sedation.  Next, a #6-French sheath was placed in the right femoral artery using modified Seldinger technique.  Next, selective angiography of the left coronary artery was performed in multiple views using #6-French JL4 catheter.  Next, selective angiography of the right coronary artery was performed in multiple views using #6-French 3DRC catheter.  Next, a #6-French angle pigtail catheter was advanced into the left ventricle.  The left ventricular pressure was then recorded.  Left ventriculography was the performed using 36 mL of contrast injected over 3 seconds.  The left heart pull back was then performed.  The catheter was then removed.,Angiography of the right femoral artery was performed.  Hemostasis was obtained by Angio-Seal closure device.  The patient left the Cardiac Catheterization Laboratory in stable condition.,HEMODYNAMICS,1.  LV pressure was 163/0 with end-diastolic pressure of 17.  There was no significant gradient across the aortic valve.,2.  Left ventriculography showed old inferior wall hypokinesis.  Global left ventricular systolic function is normal.  Estimated ejection fraction was 58%.  There is no significant mitral regurgitation.,3.  Significant coronary artery disease.,4.  The left main is approximately 7 or 8 mm proximally.  It trifurcates into left anterior descending artery, ramus intermedius artery, and left circumflex artery.  The distal portion of the left main has an ulcerated excentric plaque, up to about 50% in severity.,5.  The left anterior descending artery is around 4 mm proximally.  It extends slightly beyond the apex into the inferior wall.  It gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators.  At the ostium of the left anterior descending artery, there was an eccentric plaque up to 70% to 80%, best seen in the shallow LAO with caudal angulation.,There was no other flow-limiting disease noted in the rest of the left anterior descending artery or its major branches.,The ramus intermedius artery is around 3 mm proximally, but shortly after its origin, it bifurcates into two medium size branches.  There was no significant disease noted in the ramus intermedius artery however.,The left circumflex artery is around 2.5 mm proximally.  It gave off a recurrent atrial branch and a small AV groove branch prior to terminating into a bifurcating medium size obtuse marginal branch.  The mid to distal circumflex has a moderate disease, which is relatively diffuse up to about 40% to 50%.,The right coronary artery is around 4 mm in diameter.  It gives off conus branch, two medium size acute marginal branches, relatively large posterior descending artery and a posterior lateral branch.  In the mid portion of the right coronary artery at the origin of the first acute marginal branch, there is a relatively discrete stenosis of about 80% to 90%.  Proximally, there is an area of eccentric plaque, but seem to be non-flow limiting, at best around 20% to 30%.  Additionally, there is what appears to be like a shell-like lesion in the proximal segment of the right coronary artery as well.  The posterior descending artery has an eccentric plaque of about 40% to 50% in its mid segment.,PLAN:  ,Plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery.  Continue risk factor modification, aspirin, and beta blocker.",37
"PREOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,POSTOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,PROCEDURE PERFORMED:,  Arthroscopy of the left knee with medial meniscoplasty.,ANESTHESIA:  ,LMA.,GROSS FINDINGS: , Displaced bucket-handle tear of medial meniscus, left knee.,PROCEDURE: , After informed consent was obtained, the patient was taken to ABCD General Hospital Operating Room #1 where anesthesia was administered by the Department of Anesthesiology.  The patient was then transferred to the operating room table in supine position with Johnson knee holder well-padded.  Tourniquet was placed around the left upper thigh.  The limb was then prepped and draped in usual sterile fashion.  Standard anteromedial and anterolateral arthroscopy portals were obtained and a systematic examination of the knee was then performed.  Patellofemoral joint showed frequent chondromalacia.  Examination of the medial compartment showed a displaced bucket-handle tear of the medial meniscus involving the entire posterior, parietal, and portion of his anterior portion of the medial meniscus.  The medial femoral condyle and medial tibial plateau were unaffected.  Intercondylar notch examination revealed an intact ACL and PCL stable to drawer testing and probing and the lateral compartment showed an intact lateral meniscus.  The femoral condyle and tibial plateau were all stable to probing.  Attention was then directed back to the medial compartment where the detached portion of the meniscus was excised using arthroscopy scissors.  A shaver was then used to smooth all the edges until the margins were stable to probing.,The knee was then flushed with normal saline and suctioned dry.  20 cc of 0.25% Marcaine was injected into the knee and into the arthroscopy portals.  A dressing consisting of Adaptic, 4x4s, ABDs, and Webril were applied followed by a TED hose.  The patient was then transferred to the recovery room in stable condition.",37
"SUBJECTIVE: , I am following the patient today for multiple issues.  He once again developed gross hematuria, which was unprovoked.  His Coumadin has been held.  The patient has known BPH and is on Flomax.  He is being treated with Coumadin because of atrial fibrillation and stroke.  This is the second time he has had significant gross hematuria this month.  He also fell about a week ago and is complaining of buttock pain and leg pain.  We did get x-rays of hips, knees, and ankles.  Clearly, he has significant degenerative disease in all these areas.  No fractures noted however.  He felt that the pain is pretty severe and particularly worse in the morning.  His sinuses are bothering him.  He wonders about getting some nasal saline spray.  We talked about Coumadin, stroke risk, etc. in the setting of atrial fibrillation.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is alert, pleasant, and cooperative.  He is not in any apparent distress.  He is comfortable in a seated position.  I did not examine him further today.,ASSESSMENT AND PLAN:,1.  Hematuria.  Coumadin needs to be stopped, so we will evaluate what is going on, which is probably just some BPH.  We will also obtain a repeat UA as he did describe to me some dysuria.  However, I do not think this would account for the gross hematuria.  He will be started on an aspirin 81 mg p.o. daily.,2.  For the pain we will try him on Lortab.  He will get a Lortab everyday in the morning 5/500 prior to getting out of bed, and then he will have the option of having a few more throughout the day if he requires it.,3.  We will see about getting him set up with massage therapy and/or physical therapy as well for his back pain.,4.  For his sinuses, we will arrange for him to have saline nasal spray at the bedside for p.r.n. use.",34
"EXAM: , MRI orbit/face/neck with and without contrast; MR angiography of the head,CLINICAL HISTORY: , 1-day-old female with facial mass.,TECHNIQUE:,1.  Multisequence, multiplanar images of the orbits/face/neck were obtained with and without contrast.  0.5 ml Magnevist was used as the intravenous contrast agent.,2.  MR angiography of the head was obtained using a time-of-flight technique.,3.  The patient was under general anesthesia during the exam.,FINDINGS:,  MRI orbits/face/neck:  There is a pedunculated mass measuring 5.7 x 4.4 x 6.7 cm arising from the patient's lip on the right side.  The mass demonstrates a heterogeneous signal.  There is also heterogeneous enhancement which may relate to a high vascular tumor given the small amount of contrast for the exam.  The origin of the mass from the upper lip demonstrates intact soft tissue planes.,Limited evaluation of the head demonstrates normal appearing midline structures.  Incidental note is made of a small arachnoid cyst within the anterior left middle cranial fossa.  The mastoid air cells on the right are opacified; while the left demonstrates appropriate aeration.,MR angiography of the head:  Angiography is limited such that the vessel feeding the mass cannot be identified with certainty.  The right external carotid artery is noted to be asymmetrically larger than the left, the phenomenon likely related to provision of feeding vessels to the mass.  There is no carotid stenosis.,IMPRESSION:,1.  The mass arising from the right upper lip measures 5.7 x 4.4 x 6.7 cm with a heterogeneous appearance and enhancement pattern.  Hemangioma should be considered in the differential diagnosis as well as other mesenchymal neoplasms.,2.  MR angiography is suboptimal such that feeding vessels to the mass cannot be identified with certainty.",33
"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:",5
"CHIEF COMPLAINT:,  The patient is a 49-year-old Caucasian male transported to the emergency room by his wife, complaining of shortness of breath.,HISTORY OF PRESENT ILLNESS:, The patient is known by the nursing staff here to have a long history of chronic obstructive pulmonary disease and emphysema. He has made multiple visits in the past. Today, the patient presents himself in severe respiratory distress. His wife states that since his recent admission of three weeks ago for treatment of pneumonia, he has not seemed to be able to recuperate, and has persistent complaints of shortness of breath.,Today, his symptoms worsened and she brought him to the emergency room. To the best of her knowledge, there has been no fever. He has persistent chronic cough, as always. More complete history cannot be taken because of the patient’s acute respiratory decompensation.,PAST MEDICAL HISTORY:,  Hypertension and emphysema.,MEDICATIONS:,  Lotensin and some water pill as well as, presumably, an Atrovent inhaler.,ALLERGIES:,  None are known.,HABITS:,  The patient is unable to cooperate with the history.,SOCIAL HISTORY:,  The patient lives in the local area with his wife.,REVIEW OF BODY SYSTEMS:,  Unable, secondary to the patient’s condition.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 96 degrees, axillary. Pulse 128. Respirations 48. Blood pressure 156/100. Initial oxygen saturations on room air are 80.,GENERAL: Reveals a very anxious, haggard and exhausted-appearing male, tripoding, with labored breathing.,HEENT: Head is normocephalic and atraumatic.,NECK: The neck is supple without obvious jugular venous distention.,LUNGS: Auscultation of the chest reveals very distant and faint breath sounds, bilaterally, without obvious rales.,HEART: Cardiac examination reveals sinus tachycardia, without pronounced murmur.,ABDOMEN: Soft to palpation.,Extremities: Without edema.,DIAGNOSTIC DATA:,  White blood count 25.5, hemoglobin 14, hematocrit 42.4, 89 polys, 1 band, 4 lymphocytes. Chemistry panel within normal limits, with the exception of sodium of 124, chloride 81, CO2 44, BUN 6, creatinine 0.7, glucose 182, albumin 3.3 and globulin 4.1. Troponin is 0.11. Urinalysis reveals yellow clear urine. Specific gravity greater than 1.030 with 2+ ketones, 1+ blood and 3+ protein. No white cells and 0-2 red cells.,Chest x-ray suboptimal in quality, but without obvious infiltrates, consolidation or pneumothorax.,CRITICAL CARE NOTE:,  Critical care one hour.,Shortly after the patient’s initial assessment, the patient apparently began to complain of chest pain and appeared to the nurse to have mounting exhaustion and respiratory distress. Although O2 had been placed, elevating his oxygen saturations to the mid to upper 90s, he continued to complain of symptoms, as noted above. He became progressively more rapidly obtunded. The patient did receive one gram of magnesium sulfate shortly after his arrival, and the BiPAP apparatus was being readied for his use. However, the patient, at this point, became unresponsive, unable to answer questions, and preparations were begun for intubation. The BiPAP apparatus was briefly placed while supplies and medications were assembled for intubation. It was noted that even with the BiPAP apparatus, in the duration of time which was required for transfer of oxygen tubing to the BiPAP mask, the patient’s O2 saturations rapidly dropped to the upper 60 range.,All preparations for intubation having been undertaken, Succinylcholine was ordered, but was apparently unavailable in the department. As the patient was quite obtunded, and while the Dacuronium was being sought, an initial trial of intubation was carried out using a straight blade and a cupped 7.9 endotracheal tube. However, the patient had enough residual muscle tension to make this impractical and further efforts were held pending administration of Dacuronium 10 mg. After approximately two minutes, another attempt at intubation was successful. The cords were noted to be covered with purulent exudates at the time of intubation.,The endotracheal tube, having been placed atraumatically, the patient was initially then nebulated on 100% oxygen, and his O2 saturations rapidly rose to the 90-100% range.,Chest x-ray demonstrated proper placement of the tube. The patient was given 1 mg of Versed, with decrease of his pulse from the 140-180 range to the 120 range, with satisfactory maintenance of his blood pressure.,Because of a complaint of chest pain, which I myself did not hear, during the patient’s initial triage elevation, a trial of Tridil was begun. As the patient’s pressures held in the slightly elevated range, it was possible to push this to 30 mcg per minute. However, after administration of the Dacuronium and Versed, the patient’s blood pressure fell somewhat, and this medication was discontinued when the systolic pressure briefly reached 98.,Because of concern regarding pneumonia or sepsis, the patient received one gram of Rocephin intravenously shortly after the intubation. A nasogastric and Foley were placed, and an arterial blood gas was drawn by respiratory therapy. Dr. X was contacted at this point regarding further orders as the patient was transferred to the Intensive Care Unit to be placed on the ventilator there. The doctor’s call was transferred to the Intensive Care Unit so he could leave appropriate orders for the patient in addition to my initial orders, which included Albuterol or Atrovent q. 2h. and Levaquin 500 mg IV, as well as Solu-Medrol.,Critical care note terminates at this time.,EMERGENCY DEPARTMENT COURSE:,  See the critical care note.,MEDICAL DECISION MAKING (DIFFERENTIAL DIAGNOSIS):,  This patient has an acute severe decompensation with respiratory failure. Given the patient’s white count and recent history of pneumonia, the possibility of recurrence of pneumonia is certainly there. Similarly, it would be difficult to rule out sepsis. Myocardial infarction cannot be excluded.,COORDINATION OF CARE:,  Dr. X was contacted from the emergency room and asked to assume the patient’s care in the Intensive Care Unit.,FINAL DIAGNOSIS:,  Respiratory failure secondary to severe chronic obstructive pulmonary disease.,DISCHARGE INSTRUCTIONS:, The patient is to be transferred to the Intensive Care Unit for further management.",12
"REASON FOR VISIT: , This is a new patient evaluation for Mr. A. There is a malignant meningioma.  He is referred by Dr. X.,HISTORY OF PRESENT ILLNESS: , He said he has had two surgeries in 07/06 followed by radiation and then again in 08/07.  He then had a problem with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently.  He is unable to stand at the moment.  He is unable to care for himself. ,I reviewed the information that was sent down with him from the nursing home which includes his medical history.,MEDICATIONS:  ,Keppra 1500 twice a day and Decadron 6 mg four times a day.  His other medicines include oxycodone, an aspirin a day, Prilosec, Dilantin 300 a day, and Flagyl.,FINDINGS:,  On examination, he is lying on the stretcher.  He has oxygen on and has periods of spontaneous hyperventilation.  He is unable to lift his right arm or right leg.  He has an expressive dysphasia and confusion.,I reviewed the imaging studies from summer from the beginning of 10/07, end of 10/07 as well as the current MRI he had last week.  This shows that he has had progression of disease with recurrence along the surface of the brain and there is significant brain edema.  This is a malignant meningioma by diagnosis.,ASSESSMENT/PLAN: , In summary, Mr. A has significant disability and is not independent currently.  I believe that because of this that the likelihood of benefit from surgery is small and there is a very good chance that he would not be able to recover from surgery.  I do not think that surgery will help his quality of life and a need to control the tumor would be dependent on another therapy impacting the tumor.  Given that there are not good therapies and chemotherapy would be the option at the moment, and he certainly is not in a condition where chemotherapy would be given, I believe that surgery would not be in his best interest.  I discussed this both with him, although it is not clear to me how much he understood, as well as his family.",5
"OPERATIVE DIAGNOSES: , Chronic sinusitis with deviated nasal septum and nasal obstruction and hypertrophied turbinates.,OPERATIONS PERFORMED: , Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.,OPERATION: , The patient was taken to the operating room.  After adequate anesthesia via endotracheal intubation, the nose was prepped with Afrin nasal spray.  After this was done, 1% Xylocaine with 100,000 epinephrine was infiltrated in both sides of the septum and the mucoperichondrium.  After this, the sinus endoscope at 25-degrees was then used to examine the nasal cavity in the left nasal cavity and staying lateral to the middle turbinate.  A 45-degree forceps then used to open up the maxillary sinus.  There was some prominent tissue and just superior to this, the anterior ethmoid was opened.  The 45-degree forceps was then used to open the maxillary sinus ostium.  This was enlarged with backbiting rongeur.  After this was done, the tissue found in the ethmoid and maxillary sinus were removed and sent to pathology and labeled as left maxillary sinus mucosa.  After this was done, attention was then turned to the right nasal cavity staying laterally to the middle turbinate.  There was noted to have prominence in the anterior ethmoidal area.  This was then opened with 45-degree forceps.  This mucosa was then removed from the anterior area.  The maxillary sinus ostium was then opened with 45-degree forceps.  Tissue was removed from this area.  This was sent as right maxillary mucosa.  After this, the backbiting rongeur was then used to open up the ostium and enlarge the ostium on the right maxillary sinus.  Protecting the eyes with wet gauze and using KTP laser at 10 watts, the sinus endoscope was used for observation and the submucosal resection was done of both inferior turbinates as well as anterior portion of the middle turbinates bilaterally.  This was to open up to expose the maxillary ostium as well as other sinus ostium to minimize swelling and obstruction.  After this was completed, a septoplasty was performed.  The incision was made with a #15 blade Bard-Parker knife.  The flap was then elevated, overlying the spur that was protruding into the right nasal cavity.  This was excised with a #15 blade Bard-Parker knife.  The tissue was then laid back in position.  After this was laid back in position, the nasal cavity was irrigated with saline solution, suctioned well as well as the oropharynx.  , ,Surgicel with antibiotic ointment was placed in each nostril and sutured outside the nose with 3-0 nylon.  The patient was then awakened and taken to recovery room in good condition.",11
"PREOPERATIVE DIAGNOSES: , Malnutrition and dysphagia.,POSTOPERATIVE DIAGNOSES: , Malnutrition and dysphagia with two antral polyps and large hiatal hernia.,PROCEDURES: , Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement.,ANESTHESIA: , IV sedation, 1% Xylocaine locally.,CONDITION:,  Stable.,OPERATIVE NOTE IN DETAIL: , After risk of operation was explained to this patient's family, consent was obtained for surgery.  The patient was brought to the GI lab.  There, she was placed in partial left lateral decubitus position.  She was given IV sedation by Anesthesia.  Her abdomen was prepped with alcohol and then Betadine.  Flexible gastroscope was passed down the esophagus, through the stomach into the duodenum.  No lesions were noted in the duodenum.  There appeared to be a few polyps in the antral area, two in the antrum.  Actually, one appeared to be almost covering the pylorus.  The scope was withdrawn back into the antrum.  On retroflexion, we could see a large hiatal hernia.  No other lesions were noted.  Biopsy was taken of one of the polyps.  The scope was left in position.  Anterior abdominal wall was prepped with Betadine, 1% Xylocaine was injected in the left epigastric area.  A small stab incision was made and a large bore Angiocath was placed directly into the anterior abdominal wall, into the stomach, followed by a thread, was grasped with a snare using the gastroscope, brought out through the patient's mouth.  Tied to the gastrostomy tube, which was then pulled down and up through the anterior abdominal wall.  It was held in position with a dressing and a stent.  A connector was applied to the cut gastrostomy tube, held in place with a 2-0 silk ligature.  The patient tolerated the procedure well.  She was returned to the floor in stable condition.",14
"SUBJECTIVE:,  This is a 12-year-old male who comes in for healthy checkups and sports physical.  No major concerns today.  He is little bit congested at times.  He has been told he is allergic to grasses.  They have done over-the-counter Claritin and that seems to help but he is always sniffling mother reports.  He has also got some dryness on his face as far as the skin and was wondering what cream he could put on.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Very healthy.,CURRENT MEDICATIONS:,  Claritin p.r.n.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home currently.,DIETARY:,  He is on whole milk and does a variety of foods.  Growth chart is reviewed with mother.  Voids and stools well.,DEVELOPMENTAL:,  He is in seventh grade and going out for cross-country and track.  He is supposed to be wearing glasses, is not today.  We did not test his vision because he recently saw the eye doctor though we did discuss the need for him to wear glasses with mother.  His hearing was normal today and no concerns with speech.,PHYSICAL EXAMINATION:,General:  A well-developed, well-nourished male in no acute distress.,Dermatologic:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes are present bilaterally.  Optic discs are sharp with normal vasculature.  Ears:  Tympanic membranes are gray, translucent with normal light reflex.  Nares are very congested.  Turbinates swollen and boggy.,Neck:  Supple without masses.,Chest:  Clear to auscultation and percussion, easy respirations.  No accessory muscle use.,Cardiovascular:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,Back:  Symmetric with no scoliosis or kyphosis noted.  Normal flexibility.  Femoral pulses 2+ and symmetric.,Abdomen:  Soft, nontender, nondistended without hepatosplenomegaly.,GU Exam:  Normal Tanner III male.  Testes descended bilaterally.  No abnormal rash, discharge, or scars.,Extremities:  Pink and warm.  Moves all extremities well with normal function and strength in the arms and legs.  Normal balance, station, and gait.  Normal speech.,Neurologic:  Nonfocal with normal speech, station, gait, and balance.,ASSESSMENT:,  Healthy Tanner III male, developing normally.,PLAN:,1.  Diet, growth, safety, drugs, violence, and social competence all discussed.,2.  Immunizations reviewed.,3.  We will place him on Clarinex 5 mg once daily, some Rhinocort-AQ nasal spray one spray each nostril once daily and otherwise discussed the importance of him wearing glasses.,4.  Return to clinic p.r.n. and at two to three years for a physical, otherwise return p.r.n.",29
"CHIEF COMPLAINT: , Foot pain.,HISTORY OF PRESENT ILLNESS: , This is a 17-year-old high school athlete who swims for the swimming team.  He was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet.  He was barefoot at that time.  He had been in the pool practicing an hour prior to this injury.  Because of the contusions and abrasions to his feet, his athletic trainer brought in him to the urgent care.  He is able to bear weight; however, complains of pain in his toes.  The patient did have some avulsion of the skin across the second and third toes of the left foot with contusions across the second, third, and fourth toes and dorsum of the foot.  According to the patient, he was at his baseline state of health prior to this acute event.,PAST MEDICAL HISTORY: , Significant for attention deficit hyperactivity disorder.,PAST SURGICAL HISTORY:  ,Positive for wisdom tooth extraction.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,He does not use alcohol, tobacco or illicit drugs.  He plays water polo for the school team.,IMMUNIZATION HISTORY: , All immunizations are up-to-date for age.,REVIEW OF SYSTEMS: , The pertinent review of systems is as noted above; the remaining review of systems was reviewed and is noted to be negative.,PRESENT MEDICATIONS: , Provigil, Accutane and Rozerem.,ALLERGIES:  ,None.,PHYSICAL EXAMINATION:,GENERAL:  This is a pleasant white male in no acute distress.,VITAL SIGNS:  He is afebrile.  Vitals are stable and within normal limits.,HEENT:  Negative for acute evidence of trauma, injury or infection.,LUNGS:  Clear.,HEART:  Regular rate and rhythm with S1 and S2.,ABDOMEN:  Soft.,EXTREMITIES:  There are some abrasions across the dorsum of the right foot including the second, third and fourth toes.  There is some mild tenderness to palpation.  However, there are no clinical fractures.  Distal pulses are intact.  The left foot notes superficial avulsion lacerations to the third and fourth digit.  There are no subungual hematomas.  Range of motion is decreased secondary to pain.  No obvious fractures identified.,BACK EXAM:  Nontender.,NEUROLOGIC EXAM:  He is alert, awake and appropriate without deficit.,RADIOLOGY: , AP, lateral, and oblique views of the feet were conducted per Radiology, which were negative for acute fractures and significant soft tissue swelling or bony injuries.,On reevaluation, the patient was resting comfortably.  He was informed of the x-ray findings.  The patient was discharged in the care of his mother with a preliminary diagnosis of bilateral foot contusions with superficial avulsion lacerations, not requiring surgical repair.,DISCHARGE MEDICATIONS: , Darvocet.,The patient's condition at discharge was stable.  All medications, discharge instructions and follow-up appointments were reviewed with the patient/family prior to discharge.  The patient/family understood the instructions and was discharged without further incident.",12
"DIAGNOSES,1.  Term pregnancy.,2.  Possible rupture of membranes, prolonged.,PROCEDURE:,  Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:,  The patient is a 20-year-old female, gravida 4, para 0, who presented to the office.  She had small amount of leaking since last night.  On exam, she was positive Nitrazine, no ferning was noted.  On ultrasound, her AFI was about 4.7 cm.  Because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,She was brought to the hospital and begun on Pitocin.  Once she was in her regular pattern, we ruptured her bag of water; fluid was clear.  She went rapidly to completion over the next hour and a half.  She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation.  Upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications.  The baby was vigorous, moving all extremities.  The cord was clamped and cut.  The baby was handed off to mom with nurse present.  Apgars were 8 and 9.  Placenta was delivered spontaneously, intact.  Three-vessel cord with no retained placenta.  Estimated blood loss was about 150 mL.  There were no tears.",24
"CHIEF COMPLAINT:,  A 74-year-old female patient admitted here with altered mental status.,HISTORY OF PRESENT ILLNESS:,  The patient started the last 3-4 days to do poorly.  She was more confused, had garbled speech, significantly worse from her baseline.  She has also had decreased level of consciousness since yesterday.  She has had aphasia which is baseline but her aphasia has gotten significantly worse.  She eventually became unresponsive and paramedics were called.  Her blood sugar was found to be 40 because of poor p.o. intake.  She was given some D50 but that did not improve her mental status, and she was brought to the emergency department.  By the time she came to the emergency department, she started having some garbled speech.  She was able to express her husband's name and also recognize some family members, but she continued to be more somnolent when she was in the emergency department.  When seen on the floor, she is more awake, alert.,PAST MEDICAL HISTORY: , Significant for recurrent UTIs as she was recently to the hospital about 3 weeks ago for urinary tract infection.  She has chronic incontinence and bladder atony, for which eventually it was decided for the care of the patient to put a Foley catheter and leave it in place.  She has had right-sided CVA.  She has had atrial fibrillation status post pacemaker.  She is a type 2 diabetic with significant neuropathy.  She has also had significant pain on the right side from her stroke.  She has a history of hypothyroidism.  Past surgical history is significant for cholecystectomy, colon cancer surgery in 1998.  She has had a pacemaker placement.  ,REVIEW OF SYSTEMS:,GENERAL:  No recent fever, chills.  No recent weight loss.,PULMONARY:  No cough, chest congestion.,CARDIAC:  No chest pain, shortness of breath.,GI:  No abdominal pain, nausea, vomiting.  No constipation.  No bleeding per rectum or melena.,GENITOURINARY:  She has had frequent urinary tract infection but does not have any symptoms with it.  ENDOCRINE:  Unable to assess because of patient's bed-bound status.,MEDICATIONS:  ,Percocet 2 tablets 4 times a day, Neurontin 1 tablet b.i.d.  600 mg, Cipro recently started 500 b.i.d., Humulin N 30 units twice a day.  The patient had recently reduced that to 24 units.  MiraLax 1 scoop nightly, Avandia 4 mg b.i.d., Flexeril 1 tablet t.i.d., Synthroid 125 mcg daily, Coumadin 5 mg.  On the medical records, it shows she is also on ibuprofen, Lasix 40 mg b.i.d., Lipitor 20 mg nightly, Reglan t.i.d.  5 mg, Nystatin powder.  She is on oxygen chronically.,SOCIAL/FAMILY HISTORY: , She is married, lives with her husband, has 2 children that passed away and 4 surviving children.  No history of tobacco use.  No history of alcohol use.  Family history is noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  She is awake, alert, appears to be comfortable.,VITAL SIGNS:  Blood pressure 111/43, pulse 60 per minute, temperature 37.2.  Weight is 98 kg.  Urine output is so far 1000 mL.  Her intake has been fairly similar.  Blood sugars are 99 fasting this morning.  ,HEENT:  Moist mucous membranes.  No pallor,NECK:  Supple.  She has a rash on her neck.  ,HEART:  Regular rhythm, pacemaker could be palpated.,CHEST:  Clear to auscultation.,ABDOMEN:  Soft, obese, nontender.,EXTREMITIES:  Bilateral lower extremities edema present.  She is able to move the left side more efficiently than the right.  The power is about 5 x 5 on the left and about 3-4 x 5 on the right.  She has some mild aphasia.,DIAGNOSTIC STUDIES: , BUN 48, creatinine 2.8.  LFTs normal.  She is anemic with a hemoglobin of 9.6, hematocrit 29.  INR 1.1, pro time 14.  Urine done in the emergency department showed 20 white cells.  It was initially cloudy but on the floor it has cleared up.  Cultures from the one done today are pending.  The last culture done on August 20 showed guaiac negative status and prior to that she has had mixed cultures.  There is a question of her being allergic to Septra that was used for her last UTI.,IMPRESSION/PLAN:,1.  Cerebrovascular accident as evidenced by change in mental status and speech.  She seems to have recovered at this point.  We will continue Coumadin.  The patient's family is reluctant in discontinuing Coumadin but they do express the patient since has overall poor quality of life and had progressively declined over the last 6 years, the family has expressed the need for her to be on hospice and just continue comfort care at home.,2.  Recurrent urinary tract infection.  Will await culture at this time, continue Cipro.,3.  Diabetes with episode of hypoglycemia.  Monitor blood sugar closely, decrease the dose of Humulin N to 15 units twice a day since intake is poor.  At this point, there is no clear evidence of any benefit from Avandia but will continue that for now.,4.  Neuropathy, continue Neurontin 600 mg b.i.d., for pain continue the Percocet that she has been on.,5.  Hypothyroidism, continue Synthroid.,6.  Hyperlipidemia, continue Lipitor.,7.  The patient is not to be resuscitated.  Further management based on the hospital course.",15
"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Arrest of dilation. ,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Arrest of dilation.,PROCEDURE PERFORMED:,  Primary low-transverse cesarean section.,ANESTHESIA: , Epidural.,ESTIMATED BLOOD LOSS: , 1000 mL.,COMPLICATIONS: , None.,FINDINGS:  ,Female infant in cephalic presentation, OP position, weight 9 pounds 8 ounces.  Apgars were 9 at 1 minute and 9 at 5 minutes.  Normal uterus, tubes, and ovaries were noted.,INDICATIONS:  ,The patient is a 20-year-old gravida 1, para 0 female, who presented to labor and delivery in early active labor at 40 and 6/7 weeks gestation.  The patient progressed to 8 cm, at which time, Pitocin was started.  She subsequently progressed to 9 cm, but despite adequate contractions, arrested dilation at 9 cm.  A decision was made to proceed with a primary low transverse cesarean section.,The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and possible need for further surgery.  Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where epidural anesthesia was found to be adequate.  The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a left-ward tilt.  A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie.  The fascia was incised in the midline and extended laterally using Mayo scissors.  Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors.  Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors.  The rectus muscles were dissected in the midline.,The peritoneum was bluntly dissected, entered, and extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was inserted.  The vesicouterine peritoneum was identified with pickups and entered sharply using Metzenbaum scissors.  This incision was extended laterally and the bladder flap was created digitally.  The bladder blade was reinserted.  The lower uterine segment was incised in a transverse fashion using the scalpel and extended using manual traction.  Clear fluid was noted.  The infant was subsequently delivered atraumatically.  The nose and mouth were bulb suctioned.  The cord was clamped and cut.  The infant was subsequently handed to the awaiting nursery nurse.  Next, cord blood was obtained per the patient's request for cord blood donation, which took several minutes to perform.  Subsequent to the collection of this blood, the placenta was removed spontaneously intact with a 3-vessel cord noted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was repaired in 2 layers using 0 chromic suture.  Hemostasis was visualized.  The uterus was returned to the abdomen.,The pelvis was copiously irrigated.  The uterine incision was reexamined and was noted to be hemostatic.  The rectus muscles were reapproximated in the midline using 3-0 Vicryl.  The fascia was closed with 0 Vicryl, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples.  Sponge, lap, and instrument counts were correct x2.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.",37
"CHIEF COMPLAINT:,  Arm and leg jerking.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.  Mom denies any apnea, perioral cyanosis, or color changes.  These movements are without any back arching.  They mainly occur during sleep, so mom is unaware of any eye rolling.  Mom is able to wake the patient up during this periods and stop the patient's extremity movements.,Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast.  She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours.  She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day.,REVIEW OF SYSTEMS:,  Negative fever, negative fussiness, tracks with her eyes, some sneezing and hiccups.  This patient has developed some upper airway congestion in the past day.  She has not had any vomiting or diarrhea.  Per mom, she does not spit up, and mom is also unable to notice any relationship between these movements and feeds.  This patient has not had any rashes.  Mom was notified by the nurses at birth that her temperature may be low of approximately 97.5 degrees Fahrenheit.  Otherwise, the above history of present illness and other review of systems negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pound 11 ounce baby, ex-41-weeker born via vaginal delivery without vacuum assist or forceps.  There were no complications during pregnancy such as diabetes or hypertension.  Prenatal care started at approximately 3 weeks, and mom maintained all visits.  She also denies any smoking, alcohol, or drug use during the pregnancy.  Mom was GBS status positive, but denies any other infections such as urinary tract infections.  She did not have any fever during labor and received inadequate intrapartum antibiotics prophylaxis.  After delivery, this patient did not receive antibiotics secondary to ""borderline labs.""  She was jaundiced after birth and received photo treatments.  Her discharge bilirubin level was approximately 11.  Mom and child stayed in the hospital for approximately 3-1/2 days.,Mom denies any history of sexually transmitted disease in her or dad.  She specifically denies any blistering, herpetic genital lesions.  She does have a history though of human papillomavirus warts (vaginal), removed 20 years ago.,PAST SURGICAL HISTORY:,  Negative.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , None.,SOCIAL HISTORY: , At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister.  All the residents at home are sick currently with cold, cough, runny nose, except for mom.  At home also live 2 dogs and 2 outside cats.  Mom denies any recent travel history, especially during the recent holidays and no smoke exposures.,FAMILY HISTORY:,  Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently.  The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia.  The maternal grandmother is notable for hypertension and diabetes.  There are no other children in the family who see a specialist or no child death less than 1 year of age.,PHYSICAL EXAMINATION:",29
"CHIEF COMPLAINT:,  Right ear pain with drainage.,HISTORY OF PRESENT ILLNESS:,  This is a 12-year-old white male here with his mother for complaints of his right ear hurting.  Mother states he has been complaining for several days.  A couple of days ago she noticed drainage from the right ear.  The patient states it has been draining for several days and it has a foul smell to it.  He has had some low-grade fever.  The patient was seen in the office about a week ago with complaints of a sore throat, headache and fever.  The patient was evaluated for Strep throat which was negative and just had been doing supportive care.  He did have a recent airplane ride a couple of weeks ago also.  There has been no cough, shortness of breath or wheezing.  No vomiting or diarrhea.,PHYSICAL EXAM:,General:  He is alert in no distress.,Vital Signs:  Temperature:  99.1 degrees.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  The left TM is clear.  The right TM is poorly visualized secondary to purulent secretions in the right ear canal.  There is no erythema of the ear canals.  Nares is patent.  Oropharynx is clear.  The patient does wear braces.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,ASSESSMENT:,1.  Right otitis media.,2.  Right otorrhea.,PLAN:,  Ceftin 250 mg by mouth twice a day for 10 days.  Ciprodex four drops to the right ear twice a day.  The patient is to return to the office in two weeks for followup.",5
"PREOPERATIVE DIAGNOSIS:  ,Left communicating hydrocele.,POSTOPERATIVE DIAGNOSIS: , Left communicating hydrocele.,ANESTHESIA: , General.,PROCEDURE:  ,Left inguinal hernia and hydrocele repair.,INDICATIONS: , The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele.  The fluid size tends to fluctuate with time but has been relatively persistent for the past year.  I met with the patient's mom and also spoke with his father by phone in the past couple of months and explained the diagnosis of patent processus vaginalis for communicating hydrocele and talked to them about the surgical treatment and options.  All their questions have been answered and the patient is fit for operation today.,OPERATIVE FINDINGS:  ,The patient had a very thin patent processus vaginalis leading to a rather sizeable hydrocele sac in the left hemiscrotum.  We probably drained around 10 to 15 mL of fluid from the hydrocele sac.  The processus vaginalis was clearly seen back to the peritoneal reflection where a high ligation was successfully performed.  There were no other abnormalities noted in the inguinal scrotal region.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had an uneventful induction of inhalation anesthetic.  A peripheral IV was placed, and we conducted a surgical time-out to reiterate all of The patient's important identifying information and to confirm that we were indeed going to perform a left inguinal hernia and hydrocele repair.  After preparation and draping was done with chlorhexidine based prep solution, a local infiltration block as well as an ilioinguinal and iliohypogastric nerve block was performed with 0.25% Marcaine with dilute epinephrine.  A curvilinear incision was made low in the left inguinal area along one of prominent skin folds.  Soft tissue dissection was carried down through Scarpa's layer to the external oblique fascia, which was then opened to expose the underlying spermatic cord structures.  The processus vaginalis was dissected free from the spermatic cord structures, and the distal hydrocele sac was widely opened and drained of its fluid contents.  The processus vaginalis was cleared back to peritoneal reflection at the deep inguinal ring and a high ligation was performed there using both the transfixing and a mass ligature of 3-0 Vicryl.  After the excess hydrocele and processus vaginalis tissue was excised, the spermatic cord structures were replaced and the external oblique and Scarpa's layers were closed with interrupted 3-0 Vicryl sutures.  Subcuticular 5-0 Monocryl and Steri-Strips were used for the final skin closure.  The patient tolerated the operation well.  He was awakened and taken to the recovery room in good condition.  Blood loss was minimal.  No specimen was submitted.,",38
"PREOPERATIVE DIAGNOSIS: , Lumbar stenosis.,POSTOPERATIVE DIAGNOSES:,  Lumbar stenosis and cerebrospinal fluid fistula.,TITLE OF THE OPERATION,1.  Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques.,2.  Repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.,INDICATIONS:,  The patient is an 82-year-old woman who has about a four-month history now of urinary incontinence and numbness in her legs and hands, and difficulty ambulating.  She was evaluated with an MRI scan, which showed a very high-grade stenosis in her lumbar spine, and subsequent evaluation included a myelogram, which demonstrated cervical stenosis at C4-C5, C5-C6, and C6-C7 as well as a complete block of the contrast at L4-L5 and no contrast at L5-S1 either and stenosis at L3-L4 and all the way up, but worse at L3-L4, L4-L5, and L5-S1.  Yesterday, she underwent an anterior cervical discectomy and fusions C4-C5, C5-C6, C6-C7 and had some improvement of her symptoms and increased strength, even in the recovery room.  She was kept in the ICU because of her age and the need to bring her back to the operating room today for decompressive lumbar laminectomy.  The rationale for putting the surgery is close together that she is normally on Coumadin for atrial fibrillation, though she has been cardioverted.  She and her son understand the nature, indications, and risks of the surgery, and agreed to go ahead.,PROCEDURE: , The patient was brought from the Neuro ICU to the operating room, where general endotracheal anesthesia was obtained.  She was rolled in a prone position on the Wilson frame.  The back was prepared in the usual manner with Betadine soak, followed by Betadine paint.  Markings were applied.  Sterile drapes were applied.  Using the usual anatomical landmarks, linear midline incision was made presumed over L4-L5 and L5-S1.  Sharp dissection was carried down into subcutaneous tissue, then Bovie electrocautery was used to isolate the spinous processes.  A Kocher clamp was placed in the anterior spinous ligament and this turned out to be L5-S1.  The incision was extended rostrally and deep Gelpi's were inserted to expose the spinous processes and lamina of L3, L4, L5, and S1.  Using the Leksell rongeur, the spinous processes of L4 and L5 were removed completely, and the caudal part of L3.  A high-speed drill was then used to thin the caudal lamina of L3, all of the lamina of L4 and of L5.  Then using various Kerrison punches, I proceeded to perform a laminectomy.  Removing the L5 lamina, there was a dural band attached to the ligamentum flavum and this caused about a 3-mm tear in the dura.  There was CSF leak.  The lamina removal was continued, ligamentum flavum was removed to expose all the dura.  Then using 4-0 Nurolon suture, a running-locking suture was used to close the approximate 3-mm long dural fistula.  There was no CSF leak with Valsalva.,I then continued the laminectomy removing all of the lamina of L5 and of L4, removing the ligamentum flavum between L3-L4, L4-L5 and L5-S1.  Foraminotomies were accomplished bilaterally.  The caudal aspect of the lamina of L3 also was removed.  The dura came up quite nicely.  I explored out along the L4, L5, and S1 nerve roots after completing the foraminotomies, the roots were quite free.  Further more, the thecal sac came up quite nicely.  In order to ensure no CSF leak, we would follow the patient out of the operating room.  The dural closure was covered with a small piece of fat.  This was all then covered with DuraSeal glue.  Gelfoam was placed on top of this, then the muscle was closed with interrupted 0 Ethibond.  The lumbodorsal fascia was closed with multiple sutures of interrupted 0 Ethibond in a watertight fashion.  Scarpa's fascia was closed with a running 0 Vicryl, and finally the skin was closed with a running-locking 3-0 nylon.  The wound was blocked with 0.5% plain Marcaine.,ESTIMATED BLOOD LOSS:  Estimated blood loss for the case was about 100 mL.,SPONGE AND NEEDLE COUNTS:  Correct.,FINDINGS:  A very tight high-grade stenosis at L3-L4, L4-L5, and L5-S1.  There were adhesions between the dura and the ligamentum flavum owing to the severity and length of the stenosis.,The patient tolerated the procedure well with stable vitals throughout.",27
"EXAM: , Transesophageal echocardiogram and direct current cardioversion.,REASON FOR EXAM:  ,1.  Atrial fibrillation with rapid ventricular rate.,2.  Shortness of breath.,PROCEDURE: , After informed consent was obtained, the patient was then sedated using a total of 4 mg of Versed and 50 mcg of fentanyl.  Following this, transesophageal probe was placed in the esophagus.  Transesophageal views of the heart were then obtained.,FINDINGS:,1.  Left ventricle is of normal size.  Overall LV systolic function is preserved.  Estimated ejection fraction is 60% to 65%.  No wall motion abnormalities are noted.,2.  Left atrium is dilated.,3.  Left atrial appendage is free of clots.,4.  Right atrium is of normal size.,5.  Right ventricle is of normal size.,6.  Mitral valve shows evidence of mild MAC.,7.  Aortic valve is sclerotic without significant restriction of leaflet motion.,8.  Tricuspid valve appears normal.,9.  Pulmonic valve appears normal.,10.  Pacer wires are noted in the right atrium and in the right ventricle.,11.  Doppler interrogation of moderate mitral regurgitation is present.,12.  Mild-to-moderate AI is seen.,13.  No significant TR is noted.,14.  No significant TI is noted.,15.  No pericardial disease seen.,IMPRESSION:,1.  Preserved left ventricular systolic function.,2.  Dilated left atrium.,3.  Moderate mitral regurgitation.,4.  Aortic valve sclerosis with mild-to-moderate aortic insufficiency.,5.  Left atrial appendage is free of clots.,Following these, direct current cardioversion was performed.  Three biphasic shock waves of 150 and two of 200 joules were then applied to the patient's chest in anteroposterior direction without success in conversion to sinus rhythm.  The patient remained in atrial fibrillation.,PLAN: , Plan will be to continue medical therapy.  We will consider using beta-blocker, calcium channel blockers for better ventricular rate control.",3
"REASON FOR CONSULTATION:  ,Abnormal echocardiogram findings and followup.  Shortness of breath, congestive heart failure, and valvular insufficiency.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 86-year-old female admitted for evaluation of abdominal pain and bloody stools.  The patient has colitis and also diverticulitis, undergoing treatment.  During the hospitalization, the patient complains of shortness of breath, which is worsening.  The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion.  This consultation is for further evaluation in this regard.  As per the patient, she is an 86-year-old female, has limited activity level.  She has been having shortness of breath for many years.  She also was told that she has a heart murmur, which was not followed through on a regular basis.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, nonsmoker, cholesterol status unclear, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY:  ,Nonsignificant.,PAST SURGICAL HISTORY: , No major surgery.,MEDICATIONS: , Presently on Lasix, potassium supplementation, Levaquin, hydralazine 10 mg b.i.d., antibiotic treatments, and thyroid supplementation.,ALLERGIES:  ,AMBIEN, CARDIZEM, AND IBUPROFEN.,PERSONAL HISTORY:,  She is a nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:  ,Basically GI pathology with diverticulitis, colitis, hypothyroidism, arthritis, questionable hypertension, no prior history of coronary artery disease, and heart murmur.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  History of cataract, blurred vision, and hearing impairment.,CARDIOVASCULAR:  Shortness of breath and heart murmur.  No coronary artery disease.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  No nausea, vomiting, hematemesis, or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Arthritis and severe muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGICAL:  No TIA or CVA.  No seizure disorder.,ENDOCRINE/HEMATOLOGICAL:  As above.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 84, blood pressure of 168/74, afebrile, and respiratory rate 16 per minute.,HEENT/NECK:  Head is atraumatic and normocephalic.  Neck veins flat.  No significant carotid bruits appreciated.,LUNGS:  Air entry bilaterally fair.  No obvious rales or wheezes.,HEART:  PMI displaced.  S1, S2 with systolic murmur at the precordium, grade 2/6.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  Chronic skin changes.  Feeble pulses distally.  No clubbing or cyanosis.,DIAGNOSTIC DATA: , EKG:  Normal sinus rhythm.  No acute ST-T changes.,Echocardiogram report was reviewed.,LABORATORY DATA:,  H&H 13 and 39.  BUN and creatinine within normal limits.  Potassium within normal limits.  BNP 9290.,IMPRESSION:,1.  The patient admitted for gastrointestinal pathology, under working treatment.,2.  History of prior heart murmur with echocardiogram findings as above.  Basically revealed normal left ventricular function with left atrial enlargement, large pleural effusion, and severe mitral regurgitation and tricuspid regurgitation.,RECOMMENDATIONS:,1.  From cardiac standpoint, conservative treatment.  Possibility of a transesophageal echocardiogram to assess valvular insufficiency adequately well discussed extensively.,2.  After extensive discussion, given her age 86, limited activity level, and no intention of undergoing any treatment in this regard from a surgical standpoint, the patient does not wish to proceed with a transesophageal echocardiogram.,3.  Based on the above findings, we will treat her medically with ACE inhibitors and diuretics and see how she fares.  She has a normal LV function.",3
"PREOPERATIVE DIAGNOSIS: , Achilles tendon rupture, left lower extremity.,POSTOPERATIVE DIAGNOSIS: , Achilles tendon rupture, left lower extremity.,PROCEDURE PERFORMED:,  Primary repair left Achilles tendon.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME:  ,40 minutes at 325 mmHg.,POSITION:,  Prone.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 26-year-old African-American male who states that he was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg.  The patient was placed in posterior splint and followed up at ABC orthopedics for further care.,PROCEDURE:,  After all potential complications, risks, as well as anticipated benefits of the above-named procedure were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the patient, the operative surgeon, Department Of Anesthesia, and nursing staff.  While in this hospital, the Department Of Anesthesia administered general anesthetic to the patient.  The patient was then transferred to the operative table and placed in the prone position.  All bony prominences were well padded at this time.,A nonsterile tourniquet was placed on the left upper thigh of the patient, but not inflated at this time.  Left lower extremity was sterilely prepped and draped in the usual sterile fashion.  Once this was done, the left lower extremity was elevated and exsanguinated using an Esmarch and the tourniquet was inflated to 325 mmHg and kept up for a total of 40 minutes.  After all bony and soft tissue land marks were identified, a 6 cm longitudinal incision was made paramedial to the Achilles tendon from its insertion proximal.  Careful dissection was then taken down to the level of the peritenon.  Once this was reached, full thickness flaps were performed medially and laterally.  Next, retractor was placed.  All neurovascular structures were protected.  A longitudinal incision was then made in the peritenon and opened up exposing the tendon.  There was noted to be complete rupture of the tendon approximately 4 cm proximal to the insertion point.  The plantar tendon was noted to be intact.  The tendon was debrided at this time of hematoma as well as frayed tendon.  Wound was copiously irrigated and dried.  Most of the ankle appeared that there was sufficient tendon links in order to do a primary repair.  Next #0 PDS on a taper needle was selected and a Krackow stitch was then performed.  Two sutures were then used and tied individually ________ from the tendon.  The tendon came together very well and with a tight connection.  Next, a #2-0 Vicryl suture was then used to close the peritenon over the Achilles tendon.  The wound was once again copiously irrigated and dried.  A #2-0 Vicryl sutures were then used to close the skin and subcutaneous fashion followed by #4-0 suture in the subcuticular closure on the skin.  Steri-Strips were then placed over the wound and the sterile dressing was applied consisting of 4x4s, Kerlix roll, sterile Kerlix and a short length fiberglass cast in a plantar position.  At this time, the Department of anesthesia reversed the anesthetic.  The patient was transferred back to hospital gurney to the Postanesthesia Care Unit.  The patient tolerated the procedure well.  There were no complications.",27
"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.,",15
"CHIEF COMPLAINT: , ""Bloody bump on penis."",HISTORY OF PRESENT ILLNESS: , This is a 29-year-old African-American male who presents to the Emergency Department today with complaint of a bleeding bump on his penis.  The patient states that he has had a large bump on the end of his penis for approximately a year and a half.  He states that it has never bled before.  It has never caused him any pain or has never been itchy.  The patient states that he is sexually active, but has been monogamous with the same person for the past 13 years.  He states that he believes that his sexual partner is monogamous as well and reciprocates in this practice.  The patient does state that last night he was ""trying to get some,"" meaning that he was engaging in sexual intercourse, at which time this bump bent backwards and ripped a portion of the skin on the tip of his penis.  The patient said that there is a large amount of blood from this injury.  This happened last night, but he was embarrassed to come to the Emergency Department yesterday when it was bleeding.  The patient has been able to get the bleeding to stop, but the large bump is still located on the end of his penis, and he is concerned that it will rip off, and does want it removed.  The patient denies any drainage or discharge from his penis.  He denies fevers or chills recently.  He also denies nausea or vomiting.  The patient has not had any discharge from his penis.  He has not had any other skin lesions on his penis that are new to him.  He states that he has had numerous bumps along the head of his penis and on the shaft of his penis for many years.  The patient has never had these checked out.  He denies fevers, chills, or night sweats.  He denies unintentional weight gain or loss.  He denies any other bumps, rashes, or lesions throughout the skin on his body.,PAST MEDICAL HISTORY:  ,No significant medical problems.,PAST SURGICAL HISTORY: , Surgery for excision of a bullet after being shot in the back.,SOCIAL HABITS: , The patient denies illicit drug usage.  He occasionally smokes tobacco and drinks alcohol.,MEDICATIONS: , None.,ALLERGIES: , No known medical allergies.,PHYSICAL EXAMINATION:  ,GENERAL:  This is an African-American male who appears his stated age of 29 years.  He is well nourished, well developed, in no acute distress.  The patient is pleasant.  He is sitting on a Emergency Department gurney.,VITAL SIGNS:  Temperature 98.4 degrees Fahrenheit, blood pressure of 139/78, pulse of 83, respiratory rate of 18, and pulse oximetry of 98% on room air.,HEART:  Regular rate and rhythm.  Clear S1, S2.  No murmur, rub, or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales, or rhonchi.,ABDOMEN:  Soft, nontender, nondistended, and positive bowel sounds throughout.,GENITOURINARY:  The patient's external genitalia is markedly abnormal.  There is a large pedunculated mass dangling from the glans of the penis at approximately the urethral meatus.  This pedunculated mass is approximately 1.5 x 2 cm in size and pedunculated by a stalk that is approximately 2 mm in diameter.  The patient appears to have condylomatous changes along the glans of the penis and on the shaft of the penis as well.  There are no open lesions at this point.  There is a small tear of the skin where the mass attaches to the glans near the urethral meatus.  Bleeding is currently stanch, and there is no sign of secondary infection at this time.  Bilateral testicles are descended and normal without pain or mass bilaterally.  There is no inguinal adenopathy.,EXTREMITIES:  No edema.,SKIN:  Warm, dry, and intact.  No rash or lesion.,DIAGNOSTIC STUDIES:  ,Non-emergency department courses.  It is thought that this patient should proceed directly with a referral to Urology for excision and biopsy of this mass.,ASSESSMENT AND PLAN: , Penile mass.  The patient does have a large pedunculated penile mass.  He will be referred to the urologist who is on-call today.  The patient will need this mass excised and biopsied.  The patient verbalized understanding the plan of followup and is discharged in satisfactory condition from the ER.,",38
"FINDINGS:,There is a large intrasellar mass lesion producing diffuse expansion of the sella turcica. This mass lesions measures approximately 16 x 18 x 18mm (craniocaudal x AP x mediolateral) in size.",33
"SUBJECTIVE:,  The patient is a 49-year-old white female, established patient to Dermatology, last seen in the office on 08/10/2004.  She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and back.  On examination, this is a flaring of her acne with small folliculitis lesions.  The patient has been taking amoxicillin 500 mg b.i.d. and using Tazorac cream 0.1, and her face is doing well, but she has been out of her medicine now for three days also.  She has also been getting photofacials at Healing Waters and was wondering about what we could offer as far as cosmetic procedures and skin care products, etc.  The patient is married.  She is a secretary.,FAMILY, SOCIAL, AND ALLERGY HISTORY:,  She has hay fever, eczema, sinus, and hives.  She has no melanoma or skin cancers or psoriasis.  Her mother had oral cancer.  The patient is a nonsmoker.  No blood tests.  Had some sunburn in the past.  She is on benzoyl peroxide and Daypro.,CURRENT MEDICATIONS:,  Lexapro, Effexor, Ditropan, aspirin, vitamins.,PHYSICAL EXAMINATION:,  The patient is well developed, appears stated age.  Overall health is good.  She has a couple of acne lesions, one on her face and neck but there are a lot of small folliculitis-like lesions on her abdomen, chest, and back.,IMPRESSION:,  Acne with folliculitis.,TREATMENT:,1.  Discussed condition and treatment with the patient.,2.  Continue the amoxicillin 500 mg two at bedtime.,3.  Add Septra DS every morning with extra water.,4.  Continue the Tazorac cream 0.1; it is okay to use on back and chest also.,5.  Referred to ABC clinic for an aesthetic consult.  Return in two months for followup evaluation of her acne.",34
"Chief Complaint:, Back and hip pain.,History of Present Illness:, The patient is a 73 year old Caucasian male with a history of hypertension, end-stage renal disease secondary to reflux nephropathy / restriction of bladder neck requiring hemodialysis and eventual cadaveric renal transplant now on chronic immunosuppression, peripheral vascular disease with non-healing ulcer of right great toe, and peripheral neuropathy who initially presented to his primary care physician in May 2001 with complaints of low back pain and bilateral hip pain. The pain was described as a constant pain in the middle to lower back and hips. The pain was exacerbated by climbing stairs and in the morning after sleeping. He reported occasional radiation of pain from back into buttocks (greatest on the right side). He has history of chronic feet and leg numbness and paraesthesias related to his neuropathy, but he denied any recent changes in these symptoms in relation to the back pain. He denied any history of trauma. He was treated symptomatically with Acetaminophen with only some relief. He continued to complain intermittently of pain in his back and hips, and occasionally even in his elbows during the next 8 months. In January 2002, plain pelvic films showed no fracture or dislocation of the hips. Elbow films also showed no acute injury, but there were some erosions along the posterior aspect of the olecranon. An MRI was performed of his lumbar spine which showed degenerative disk disease, spondylosis, and annular bulging/herniation at L4-L5 with resultant encroachment on the neural foramen. He was evaluated by neurosurgery, who felt he should not have surgery at this time. His pain continued and progressively worsened, becoming unresponsive to medical therapy including narcotics,In May 2002, as part of a vascular work-up for the patient’s non-healing right toe, an MRA showed extensive vascular disease in the vessels of both legs below the knees and evidence of bilateral trochanteric bursitis. It also revealed an abnormal enhancing lesion in the left proximal femur, the left iliac bone, the right iliac bone, and possibly the right tibia.,Past Medical History:,End stade renal disease secondary to reflux nephropathy,a. numerous related urinary tract infections,b. hemodialysis (1983-1988),c. s/p cadaveric renal transplant (1988),d. baseline creatinine about 2.3.,Hypertension,Peripheral vascular disease,a. history of right foot infected toenail and non-healing ulcer since 2000; receiving hyperbaric oxygen therapy; recent surgery on infected toe in March, 2002,Peripheral Neuropathy,Chronic anemia (on Epogen injections),History of several partial small bowel obstructions - six times during the last 10 years,Past Surgical History:,1. Tonsillectomy and adenoidectomy (1943),2. Left ureter re-implantation (1960),3. Repair of splenic artery aneurysm (1968),4. Left arm AV fistula graft placement and numerous procedures for dialysis access (1983-1988),5. Cadaveric renal transplant (1988),6. Cataract surgery in bilateral eyes,Medications:,1. Imuran 100mg po QD,2. Prednisone 7.5mg po QD,3. Aspirin 81mg po QD,4. Trental 400mg po TID,5. Norvasc 5mg po BID,6. Prinivil 20mg po BID,7. Hydralazine 50mg po Q6H,8. Clonidine TTS III on Thursdays,9. Terasozin 5mg po BID,10. Elavil 30mg po QHS,11. Vicodin 1-2tabs po Q6H prn,12. Epoetin SR 10,000Units SQ QM and F,13. Sodium bicarbonate 648mg po QD,14. Calcium carbonate 2gm po QID,15. Docusate sodium 100mg po QD,16. Chocolate Ensure one can po QID,17. Multivitamin,18. Vitamin E,Social History:, The patient is married with five children and lives with his wife. He is a retired engineer and real estate broker. He denies tobacco use. He drinks alcohol occasionally with up to three drinks a week. No history of drug abuse.,Allergies:, No known drug allergies.,Family History:",5
"PREOPERATIVE DIAGNOSIS: , A 39-week intrauterine pregnancy with complete breech presentation.,POSTOPERATIVE DIAGNOSIS:,  A 39-week intrauterine pregnancy in vertex presentation, status post successful external cephalic version.,PROCEDURE: , External cephalic version.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:  ,The patient was brought to Labor and Delivery where a reactive fetal heart tracing was obtained.  The patient was noted to have irregular contractions.  She was given 1 dose of subcutaneous terbutaline which resolved her contraction.  A bedside ultrasound was performed which revealed single intrauterine pregnancy and complete breech presentation.  There was noted to be adequate fluid.  Using manual pressure, the breech was manipulated in a forward roll fashion until a vertex presentation was obtained.  Fetal heart tones were checked intermittently during the procedure and were noted to be reassuring.  Following successful external cephalic version, the patient was placed on continuous external fetal monitoring.  She was noted to have a reassuring and reactive tracing for 1 hour following the external cephalic version.  She did not have regular contractions and therefore she was felt to be stable for discharge to home.  She was given appropriate labor instructions.",24
"CHIEF COMPLAINT: , Vaginal discharge with a foul odor.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old African-American female who states that for the past week she has been having thin vaginal discharge which she states is gray in coloration.  The patient states that she has also had frequency of urination.  The patient denies any burning with urination.  She states that she is sexually active and does not use condoms.  She does have three sexual partners.  The patient states that she has had multiple yeast infections in the past and is concerned that she may have one again.  The patient also states that she has had sexually transmitted diseases in her teens, but has not had one in many years.  The patient does state that she has never had HIV testing.  The patient states that she has not had any vaginal bleeding and does not have any abdominal pain.  The patient denies fevers or chills, nausea or vomiting, headaches or head trauma.  The patient also denies skin rashes or lesions.  She does state, however, there is one area of roughened skin on her right forearm that she is concerned it may be an infection of the skin.  The patient is G2 P2.  She has had some irregular Pap smears in the past.  Her last Pap smear was approximately 6 to 12 months ago.  The patient has had frequent urinary tract infections in the past.,PAST MEDICAL HISTORY:,1.  Bronchitis.,2.  Urinary tract infections.,3.  Vaginal candidiasis.,PAST SURGICAL HISTORY: , Cyst removal of the right breast.,SOCIAL HISTORY: , The patient does smoke approximately half a pack of cigarettes per day.  She denies alcohol or illicit drug use.,MEDICATIONS: , None.,ALLERGIES:,  No known medical allergies.,PHYSICAL EXAMINATION:,GENERAL:  This is an African-American female who appears her stated age of 25 years.  She is well nourished, well developed, and in no acute distress.  The patient is pleasant.,VITAL SIGNS:  Afebrile.  Blood pressure is mildly over 96/68, pulse is 68, respiratory rate 12, and pulse oximetry of 98% on room air.,HEART:  Regular rate and rhythm.  Clear S1 and S2.  No murmur, rub or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales or rhonchi.,ABDOMEN:  Soft, nontender, nondistended.  Positive bowel sounds throughout.,SKIN:  Warm, dry and intact.  No rash or lesion.,PSYCH:  Alert and oriented to person, place, and time.,NEUROLOGIC:  Cranial nerves II through XII are intact bilaterally.  No focal deficits are appreciated.,GENITOURINARY:  The pelvic exam done shows external genitalia without abnormalities or lesions.  There is a white-to-yellow discharge.  Transformation zone is identified.  The cervix is mildly friable.  Vaginal vault is without lesions.  There is no adnexal tenderness.  No adnexal masses.  No cervical motion tenderness.  Cervical swabs and vaginal cultures are obtained.,DIAGNOSTIC STUDIES: , Urinalysis shows 3+ bacteria, however, there are no wbc's.  No squamous epithelial cells and no other signs of infection.  There is no glucose.  The patient's cervical swabs and cultures are obtained and there are positive clue cells.  Negative Trichomonas.  Negative fungal elements and Chlamydia and gonorrhea are pending at this time.  Urinalysis is sent for culture and sensitivity.,ASSESSMENT:,: Gardnerella bacterial vaginosis.,PLAN: , The patient will be treated with metronidazole 500 mg p.o. twice a day x7 days.  The patient will follow up with her primary care provider.,",12
"ADMITTING DIAGNOSES:,1. Hematuria.,2. Benign prostatic hyperplasia.,3. Osteoarthritis.,DISCHARGE DIAGNOSES:,1. Hematuria, resolved.,2. Benign prostatic hyperplasia.,3. Complex renal cyst versus renal cell carcinoma or other tumor.,4. Osteoarthritis.,HOSPITAL COURSE:, This is a 77-year-old African-American male who was previously well until he began having gross hematuria and clots passing through his urethra on the day of admission. He stated that he never had blood in his urine before, however, he does have a past history of BPH and he had a transurethral resection of prostate more than 10 years ago. He was admitted to a regular bed. Dr. G of Urology was consulted for evaluation of his hematuria. During the workup for this, he had a CT of the abdomen and pelvis with and without contrast with early and late-phase imaging for evaluation of the kidneys and collecting system. At that time, he was shown to have multiple bilateral renal cysts with one that did not meet classification as a simple cyst and ultrasound was recommended.,He had an ultrasound done of the cyst which showed a 2.1 x 2.7 cm mass arising from the right kidney which, again, did not fit ultrasound criteria for a simple cyst and they recommended further evaluation by an MRI as this could be a hemorrhagic cyst or a solid mass or tumor, so an MRI was scheduled on the day of discharge for further evaluation of this. The report was not back at discharge. The patient had a cystoscopy and transurethral resection of prostate as well with entire resection of the prostate gland. Pathology on this specimen showed multiple portions of prostatic tissue which was primarily fibromuscular, and he was diagnosed with nonprostatic hyperplasia. His urine slowly cleared. He tolerated a regular diet with no difficulties in his activities of daily living, and his Foley was removed on the day of discharge.,He was started on ciprofloxacin, Colace, and Lasix after the transurethral resection and continued these for a short course. He is asked to continue the Colace as an outpatient for stool softening for comfort.,DISCHARGE MEDICATIONS:, Colace 100 mg 1 b.i.d.,DISCHARGE FOLLOWUP PLANNING:, The patient is to follow up with his primary care physician at ABCD, Dr. B or Dr. J, the patient is unsure of which, in the next couple weeks. He is to follow up with Dr. G of  Urology in the next week by phone in regards to the patient's MRI and plans for a laparoscopic partial renal resection biopsy. This is scheduled for the week after discharge potentially by Dr. G, and the patient will discuss the exact time later this week. The patient is to return to the emergency room or to our clinic if he has worsening hematuria again or no urine output.",10
"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.",33
"CLINICAL INDICATION:,  Chest pain.,INTERPRETATION: , The patient received 14.9 mCi of Cardiolite for the rest portion of the study and 11.5 mCi of Cardiolite for the stress portion of the study.,The patient's baseline EKG was normal sinus rhythm.  The patient was stressed according to Bruce protocol by Dr. X.  Exercise test was supervised and interpreted by Dr. X.  Please see the separate report for stress portion of the study.,The myocardial perfusion SPECT study shows there is mild anteroseptal fixed defect seen, which is most likely secondary to soft tissue attenuation artifact.  There is, however, mild partially reversible perfusion defect seen, which is more pronounced in the stress images and short-axis view suggestive of minimal ischemia in the inferolateral wall.,The gated SPECT study shows normal wall motion and wall thickening with calculated left ventricular ejection fraction of 59%.,CONCLUSION:,1.  The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall.,2.  Normal LV systolic function with LV ejection fraction of 59%.",33
"PREOPERATIVE DIAGNOSIS: , Term pregnancy at 40 and 3/7th weeks.,PROCEDURE PERFORMED: , Spontaneous vaginal delivery.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 36-year-old African-American female who is a G-2, P-2-0-0-2 with an EDC of 08/30/2003.  She is blood type AB -ve with antibody screen negative and is also rubella immune, VDRL nonreactive, hepatitis B surface antigen negative, and HIV nonreactive.  She does have a history of sickle cell trait.  She presented to Labor and Delivery Triage at 40 and 3/7th weeks gestation with complaint of contractions every ten minutes.  She also stated that she has lost her mucous plug.  She did have fetal movement, noted no leak of fluid, did have some spotting.  On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.  She was evaluated by sterile vaginal exam and was noted to be 4 cm dilated, 70% effaced, and -3 station.  This was a change from her last office exam, at which she was 1 cm to 2 cm dilated.,PROCEDURE DETAILS:,  The patient was admitted to Labor and Delivery for expected management of labor and AROM was performed and the amniotic fluid was noted to be meconium stained.  After her membranes were ruptured, contractions did increase to every two to three minutes as well as the intensity increased.  She was given Nubain for discomfort with good result.,She had a spontaneous vaginal delivery of a live born female at 11:37 with meconium stained fluid as noted from ROA position.  After controlled delivery of the head, tight nuchal cord was noted, which was quickly double clamped and cut and the shoulders and body were delivered without difficulty.  The infant was taken to the awaiting pediatrician.  Weight was 2870 gm, length was 51 cm.  The Apgars were 6 at 1 minute and 9 at 5 minutes.  There was initial neonatal depression, which was treated by positive pressure ventilation and the administration of Narcan.,Spontaneous delivery of an intact placenta with a three-vessel cord was noted at 11:45.  On examination, there were no noted perineal abrasions or lacerations.  On vaginal exam, there were no noted cervical or vaginal sidewall lacerations.  Estimated blood loss was less than 250 cc.  Mother and infant are in recovery doing well at this time.",37
"ATHLETE'S FOOT, TINEA PEDIS,, is a very common fungal skin infection of the foot.  It often first appears between the toes.  It can be a one-time occurrence or it can be chronic.  The fungus, known as Trichophyton, thrives under warm, damp conditions so people whose feet sweat a great deal are more susceptible.  It is easily transmitted in showers and pool walkways.  Those people with immunosuppressive conditions, such as diabetes mellitus, are also more susceptible to athlete's foot.,SIGNS AND SYMPTOMS:,*  Itchy feet.,*  White or red and soft scaling on feet, usually in between toes.,*  Small blisters may be present.,*  Bad foot odor.,*  Very rare involvement of hands and simultaneously (called an Id reaction).,TREATMENT:,*  Diagnosis is via symptoms or sometimes by examining skin scrapings under a microscope..  A bacterial infection may also be suspected in which case a skin culture will confirm this.,*  Try a non-prescription antifungal powder or cream available in drugstores; your doctor can prescribe a stronger topical antifungal medication if necessary.,*  Oral antibiotics may be prescribed for a possible bacterial infection.,*  Keep feet as dry as possible! Change socks twice a day if necessary and wear those made of natural fibers, such as cotton.  Go barefoot when you have a chance or wear sandals.  Dry thoroughly in between toes after swimming or bathing.,*  A special powder to absorb moisture on feet is also available in drugstores.  Ask the pharmacist about this.,*  Spray your shower at home with a 10% bleach solution after bathing.  This may help decrease the chance that other family members will be infected.,*  Wear sandals or thongs in public showers and around pools.,*  Keep in mind that it may take up to a month or more to get rid of your athlete's foot.  Be diligent in using the antifungal medication.  Unfortunately, recurrence of athlete's foot is common.  Luckily, the condition does not cause serious problems for the majority of people who have it.,*  Call the office if your athlete's foot spreads or worsens despite treatment.,PLANTAR FASCIAL STRETCHES,1.  Raise toes toward you while bending your ankle as high as you can.,2.  Hold this position for 15 seconds.,3.  Alternate doing this with the opposite foot 10 times.,4.  Perform this exercise 2- 3 times a day.,WOUND CARE INSTRUCTIONS,1.  Clean the area daily with soap and water.,2.  Every day apply a thin coat of polysporin ointment.,3.  Change the dressing daily and keep the area covered with an adhesive bandage until completely healed.,4.  Notify the office if you have any increasing wound pain or any evidence of infection.",31
"SUBJECTIVE:,  The patient is well-known to me.  He comes in today for a comprehensive evaluation.  Really, again he borders on health crises with high blood pressure, diabetes, and obesity.  He states that he has reached a critical decision in the last week that he understands that he cannot continue with his health decisions as they have been made, specifically the lack of exercise, the obesity, the poor eating habits, etc.  He knows better and has been through some diabetes training.  In fact, interestingly enough, with his current medications which include the Lantus at 30 units along with Actos, glyburide, and metformin, he achieved ideal blood sugar control back in August 2004.  Since that time he has gone off of his regimen of appropriate eating, and has had sugars that are running on average too high at about 178 over the last 14 days.  He has had elevated blood pressure.  His other concerns include allergic symptoms.  He has had irritable bowel syndrome with some cramping.  He has had some rectal bleeding in recent days.  Also once he wakes up he has significant difficulty in getting back to sleep.  He has had no rectal pain, just the bleeding associated with that.,MEDICATIONS/ALLERGIES:,  As above.,PAST MEDICAL/SURGICAL HISTORY: , Reviewed and updated - see Health Summary Form for details.,FAMILY AND SOCIAL HISTORY:,  Reviewed and updated - see Health Summary Form for details.,REVIEW OF SYSTEMS:,  Constitutional, Eyes, ENT/Mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin/Breasts, Neurologic, Psychiatric, Endocrine, Heme/Lymph, Allergies/Immune all negative with the following exceptions:  None.,PHYSICAL EXAMINATION:,VITAL SIGNS:  As above.,GENERAL:  The patient is alert, oriented, well-developed, obese male who is in no acute distress.,HEENT:  PERRLA.  EOMI.  TMs clear bilaterally.  Nose and throat clear.,NECK:  Supple without adenopathy or thyromegaly.  Carotid pulses palpably normal without bruit.,CHEST:  No chest wall tenderness or breast enlargement.,HEART:  Regular rate and rhythm without murmur, clicks, or rubs.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Significantly obese without any discernible organomegaly.  GU:  Normal male genitalia without testicular abnormalities, inguinal adenopathy, or hernia.,RECTAL:  Smooth, nonenlarged prostate with just some irritation around the rectum itself.  No hemorrhoids are noted.,EXTREMITIES:  Some slow healing over the tibia.  Without clubbing, cyanosis, or edema.  Peripheral pulses within normal limits.,NEUROLOGIC:  Cranial nerves II-XII intact.  Strength, sensation, coordination, and reflexes all within normal limits.,SKIN:  Noted to be normal.  No subcutaneous masses noted.,LYMPH SYSTEM:  No lymphadenopathy noted.,BACK:  He has pain in his back in general.,ASSESSMENT/PLAN:,1.  Diabetes and hypertension, both under less than appropriate control.  In fact, we discussed increasing the Lantus.  He appears genuine in his desire to embark on a substantial weight-lowering regime, and is going to do that through dietary control.  He knows what needs to be done with the absence of carbohydrates, and especially simple sugar.  He will also check a hemoglobin A1c, lipid profile, urine for microalbuminuria and a chem profile.  I will need to recheck him in a month to verify that his sugars and blood pressure have come into the ideal range.  He has allergic rhinitis for which Zyrtec can be used.,2.  He has irritable bowel syndrome.  We will use Metamucil for that which also should help stabilize the stools so that the irritation of the rectum is lessened.  For the bleeding I would like to obtain a sigmoidoscopy.  It is bright red blood.,3.  For his insomnia, I found there is very little in the way of medications that are going to fix that, however I have encouraged him in good sleep hygiene.  I will look forward to seeing him back in a month.  I will call him with the results of his lab.  His medications were made out.  We will use some Elocon cream for his seborrheic dermatitis of the face.  Zyrtec and Flonase for his allergic rhinitis.",15
"CC:, BLE weakness.,HX:, This 82y/o RHM was referred to the Neurology service by the Neurosurgery service for evaluation of acute onset paraplegia. He was in his usual state of health until 5:30PM on 4/6/95, when he developed sudden ""pressure-like"" epigastric discomfort associated with bilateral lower extremity weakness, SOB, lightheadedness and diaphoresis. He knelt down to the floor and ""went to sleep."" The Emergency Medical Service was alert and arrived within minutes, at which time he was easily aroused though unable to move or feel his lower extremities. No associated upper extremity or bulbar dysfunction was noted. He was taken to a local hospital where an INR was found to be 9.1. He was given vitamin K 15mg, and transferred to UIHC to rule out spinal epidural hemorrhage. An MRI scan of the T-spine was obtained and the preliminary reading was ""normal."" The Neurology service was then asked to evaluate the patient.,MEDS:, Coumadin 2mg qd, Digoxin 0.25mg qd, Prazosin 2mg qd.,PMH:, 1)HTN. 2)A-Fib on coumadin. 3)Peripheral vascular disease:s/p left Femoral-popliteal bypass (8/94) and graft thrombosis-thrombolisis (9/94). 4)Adenocarcinoma of the prostate: s/p TURP (1992).,FHX: ,unremarkable.,SHX:, Farmer, Married, no Tobacco/ETOH/illicit drug use.,EXAM:, BP165/60 HR86 RR18 34.2C SAO2 98% on room air.,MS: A&O to person, place, time. In no acute distress. Lucid.,CN: unremarkable.,MOTOR: 5/5 strength in BUE. Flaccid paraplegia in BLE,Sensory: T6 sensory level to LT/PP, bilaterally. Decreased vibratory sense in BLE in a stocking distribution, distally.,Coord: Intact FNF and RAM in BUE. Unable to do HKS.,Station: no pronator drift.,Gait: not done.,Reflexes: 2/2 BUE, Absent in BLE, plantar responses were flexor, bilaterally.,Rectal: decreased rectal tone.,GEN EXAM: No carotid bruitts. Lungs: bibasilar crackles. CV: Irregular rate and rhythm with soft diastolic murmur at the left sternal border. Abdomen: flat, soft, non-tender without bruitt or pulsatile mass. Distal pulses were strong in all extremities.,COURSE:, Hgb 12.6, Hct 40%, WBC 11.7, Plt 154k, INR 7.6, PTT 50, CK 41, the GS was normal. EKG showed A-Fib at 75BPM with competing junctional pacemaker, essentially unchanged from 9/12/94.,It was suspected that the patient sustained an anterior-cervico-thoracic spinal cord infarction with resultant paraplegia and T6 sensory level. A CXR was done in the ER prior to admission. This revealed cardiomegaly and a widened mediastinum. He returned from the x-ray suite and suddenly became unresponsive and went into cardiopulmonary arrest. Resuscitative measures failed. Pericardiocentesis was unremarkable. Autopsy revealed a massive aortic dissection extending from the aortic root to the origin of the iliac arteries with extensive pericardial hematoma. The dissection was seen in retrospect on the MRI T-spine.",33
"PROCEDURE PERFORMED:,1.  Right femoral artery access.,2.  Selective right and left coronary angiogram.,3.  Left heart catheterization.,4.  Left ventriculogram.,INDICATIONS FOR PROCEDURE:,  A 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents with symptoms of shortness of breath.  The resting echocardiogram showed a severe decrease in her left ventricular systolic function with a reported LVEF of 20% to 25%.  This was a sharp decline from a previous LVEF of 50% to 55%.  We therefore, decided to proceed with coronary angiography.,TECHNIQUE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in post-absorptive and non-sedated state.  The right groin was prepped and draped in the usual sterile manner.  2% Lidocaine was used for infiltration anesthesia.  Using modified Seldinger technique, a 6-French sheath was introduced into the right femoral artery.  6-French JL4 and JR4 diagnostic catheters were used to perform the left and right coronary angiogram.  A 6-French pigtail catheter was used to perform the LV-gram in the RAO projection.,HEMODYNAMIC DATA: , LVEDP of 11.  There was no gradient across the aortic valve upon pullback.,ANGIOGRAPHIC FINDINGS:,1.  The left main coronary artery is a very short vessel and immediately bifurcates into the left anterior descending artery and the left circumflex coronary artery.,2.  The left main coronary artery is free of any disease.,3.  The left circumflex coronary artery which is a nondominant vessel gives off 2 marginal branches.  The first marginal branch is very small in caliber and runs a fairly long course and is free of any disease.,4.  The second marginal branch which is actually a continuation of the left circumflex coronary artery gives off several secondary branches.  One of its secondary branches which is a small caliber has an ostial 70% stenosis.,5.  The left anterior descending artery has a patent stent in the proximal LAD.  The second stent which is overlapping the junction of the mid and distal left anterior descending artery has mild late luminal loss.  There appears to be 30% narrowing involving the distal cuff segment of the stent in the distal left anterior descending artery.  The diagonal branches are free of any disease.,6.  The right coronary artery is a dominant vessel and has mild luminal irregularities.  Its midsegment has a focal area of 30% narrowing as well.  The rest of the right coronary artery is free of any disease.,7.  The LV-gram performed in the RAO projection shows well preserved left ventricular systolic function with an estimated LVEF of 55%.,RECOMMENDATION: , Continue with optimum medical therapy.  Because of the discrepancy between the left ventriculogram EF assessment and the echocardiographic EF assessment, I have discussed this matter with Dr. XYZ and we have decided to proceed with a repeat 2D echocardiogram.  The mild disease in the distal left anterior descending artery with mild in-stent re-stenosis should be managed medically with optimum control of hypertension and hypercholesterolemia.",37
"FINDINGS:,There is a lobulated mass lesion of the epiglottis measuring approximately 22 x 16 x 30 mm (mediolateral x AP x craniocaudal) in size. There is slightly greater involvement on the right side however there is bilateral involvement of the aryepiglottic folds. There is marked enlargement of the bilateral aryepiglottic folds (left greater than right). There is thickening of the glossoepiglottic fold. There is an infiltrative mass like lesion extending into the pre-epiglottic space.,There is no demonstrated effacement of the piriform sinuses. The mass obliterates the right vallecula. The paraglottic spaces are normal. The true and false cords appear normal. Normal thyroid, cricoid and arytenoid cartilages.,There is lobulated thickening of the right side of the tongue base, for which invasion of the tongue cannot be excluded. A MRI examination would be of benefit for further evaluation of this finding.,There is a 14 x 5 x 12 mm node involving the left submental region (Level I).,There is borderline enlargement of the bilateral jugulodigastric nodes (Level II). The left jugulodigastric node,measures 14 x 11 x 8 mm while the right jugulodigastric node measures 15 x 12 x 8 mm.,There is an enlarged second left high deep cervical node measuring 19 x 14 x 15 mm also consistent with a left Level II node, with a probable necrotic center.,There is an enlarged second right high deep cervical node measuring 12 x 10 x 10 mm but no demonstrated central necrosis.,There is an enlarged left mid level deep cervical node measuring 9 x 16 x 6 mm, located inferior to the hyoid bone but cephalad to the cricoid consistent with a Level III node.,There are two enlarged matted nodes involving the right mid level deep cervical chain consistent with a right Level III nodal disease, producing a conglomerate nodal mass measuring approximately 26 x 12 x 10 mm.,There is a left low level deep cervical node lying along the inferior edge of the cricoid cartilage measuring approximately 18 x 11 x 14 mm consistent with left Level IV nodal disease.,There is no demonstrated pretracheal, prelaryngeal or superior mediastinal nodes. There is no demonstrated retropharyngeal adenopathy.,There is thickening of the adenoidal pad without a mass lesion of the nasopharynx. The torus tubarius and fossa of Rosenmuller appear normal.,IMPRESSION:,Epiglottic mass lesion with probable invasion of the glossoepiglottic fold and pre-epiglottic space with invasion of the bilateral aryepiglottic folds.,Lobulated tongue base for which tongue invasion cannot be excluded. An MRI may be of benefit for further assessment of this finding.,Borderline enlargement of a submental node suggesting Level I adenopathy.,Bilateral deep cervical nodal disease involving bilateral Level II, Level III and left Level IV.",33
"HISTORY OF PRESENT ILLNESS: , In short, the patient is a 55-year-old gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7 with comorbidities of hypertension, atrial fibrillation, hyperlipidemia, possible sleep apnea, and also osteoarthritis of the lower extremities.  He is also an ex-smoker.  He is currently smoking and he is planning to quit and at least he should do this six to eight days before for multiple reasons including decreasing the DVT, PE rates and marginal ulcer problems after surgery, which will be discussed later on. ,PHYSICAL EXAMINATION: , On physical examination today, he weighs 514.8 pounds, he has gained 21 pounds since the last visit with us.  His pulse is 78, temperature is 97.5, blood pressure is 132/74.  Lungs are clear.  He is a pleasant gentleman with stigmata of supermorbid obesity expected of his size.  Abdomen is soft, nontender.  No incisions.  No umbilical hernia, no groin hernia, has a large abdominal pannus.  No hepatosplenomegaly.  Lower extremities; no pedal edema.  No calf tenderness.  Deep tendon reflexes are normal.  Lungs are clear.  S1, S2 is heard.  Regular rate and rhythm. ,DISCUSSION:,  I had a long talk with the patient about laparoscopic gastric bypass possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines.  I also explained to him complications including rare cases of death secondary to DVT, PE, leak, peritonitis, sepsis shock, multisystem organ failure, need for reoperations, need for endoscopy for bleeding or leak, operations which could be diagnostic laparoscopy, exploratory laparotomy, drainage procedure, gastrostomy, jejunostomy for feeding, bleeding requiring blood transfusion, myocardial infarction, pneumonia, atelectasis, respiratory failure requiring mechanical ventilation, rarely tracheostomy, rare cases of renal failure requiring dialysis, etc., were all discussed. ,All these are going to be at high risk for this patient secondary to his supermorbid obese condition. ,I also explained to him specific gastric bypass related complications including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or antiinflammatory drug intake, which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which are described, so the patient could alert us for earlier intervention, symptomatic gallstone formation during rapid weight loss, how to avoid it by taking ursodiol, which will be prescribed in the postoperative period. ,Long-term complication of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, psychosocial and marital issues, addiction transfer, etc., were all discussed with the patient.  The patient is at higher risk than usual set of patients secondary to his supermorbid obesity of BMI nearing 70 and also major cardiopulmonary and metabolic comorbidities.  Smoking of course does not help and increase the risk for cardiopulmonary complications and is at increased risk for cardiac risk.  He will be seen by cardiologist, pulmonologist.  He will also undergo long Medifast dieting under our guidance, which is a very low-calorie diet to decrease the size of the liver and also to optimize his cardiopulmonary and metabolic comorbidities.  He will also see a psychologist, nutritionist, and exercise physiologist in preparation for surgery for a multidisciplinary approach for short and long-term success. ,Especially for him in view of his restricted mobility, supermorbid obesity status, and possibility of a pulmonary hypertension secondary to sleep apnea, he has been advised to have retrievable IVC filter and also will go home on Lovenox.  He also needs to start exercising to increase his flexibility and muscle tone before surgery and also to start getting the habit of doing so.  All these were discussed with the patient.  The patient understands.  He wants to go to surgery.  All questions were answered.  I will see him in few weeks before the planned date of surgery.",5
"REASON FOR CONSULTATION:,  Breast reconstruction post mastectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old lady, who had gone many years without a mammogram when she discovered a lump in her right breast early in February of this year.  She brought this to the attention of her primary care doctor and she soon underwent ultrasound and mammogram followed by needle biopsy, which revealed that there was breast cancer.  This apparently was positive in two separate locations within the suspicious area.  She also underwent MRI, which suggested that there was significant size to the area involved.  Her contralateral left breast appeared to be uninvolved.  She has had consultation with Dr. ABC and they are currently in place to perform a right mastectomy.,PAST MEDICAL HISTORY: , Positive for hypertension, which is controlled on medications.  She is a nonsmoker and engages in alcohol only moderately.,PAST SURGICAL HISTORY: , Surgical history includes uterine fibroids, some kind of cyst excision on her foot, and cataract surgery.,ALLERGIES: , None known.,MEDICATIONS: , Lipitor, ramipril, Lasix, and potassium.,PHYSICAL EXAMINATION: , On examination, the patient is a healthy looking 51-year-old lady, who is moderately overweight.  Breast exam reveals significant breast hypertrophy bilaterally with a double D breast size and significant shoulder grooving from her bra straps.  There are no any significant scars on the right breast as she has only undergone needle biopsy at this point.  Exam also reveals abdomen where there is moderate excessive fat, but what I consider a good morphology for a potential TRAM flap.,IMPRESSION:,  A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.  We discussed the breast reconstruction options in some detail including immediate versus delayed reconstruction and autologous tissue versus implant reconstruction.  I think for a lady of this physical size and breast morphology that the likelihood of getting a good result with a tissue expander reconstruction is rather slim.  A further complicating factor is the fact that she may well be undergoing radiation after her mastectomy.  I would think this would make a simple tissue expander reconstruction virtually beyond the balance of consideration.  I have occasionally gotten away with tissue expanders with reasonable results in irradiated patients when they are thinner and smaller breasted, but in a heavier lady with large breasts, I think it virtually deemed to failure.  We therefore, mostly confine our discussion to the relative merits of TRAM flap breast reconstruction and latissimus dorsi reconstruction with implant.  In either case, the contralateral breast reduction would be part of the overall plan., ,The patient understands that the TRAM flap although not much more lengthy of a procedure is a little comfortable recovery.  Since we are sacrificing a rectus abdominus muscle that can be more discomfort and difficulties in healing both due to it being a respiratory muscle and to its importance in sitting up and getting out of bed.  In any case, she does prefer this option in order to avoid the need for an implant.  We discussed pros and cons of the surgery, including the risks such as infection, bleeding, scarring, hernia, or bulging of the donor site, seroma of the abdomen, and fat necrosis or even the skin slough in the abdomen.  We also discussed some of the potential flap complications including partial or complete necrosis of the TRAM flap itself.,PLAN: , The patient is definitely interested in undergoing TRAM flap reconstruction.  At the moment, we are planning to do it as an immediate reconstruction at the time of the mastectomy.  For this reason, I have made arrangements to do initial vascular delay procedure within the next couple of days.  We may cancel this if the chance of postoperative irradiation is high.  If this is the case, I think we can do a better job on the reconstruction if we defer it.  The patient understands this and will proceed according to the recommendations from Dr. ABC and from the oncologist.",5
"CHIEF COMPLAINT:,1.  Infection.,2.  Pelvic pain.,3.  Mood swings.,4.  Painful sex.,HISTORY OF PRESENT ILLNESS:,  The patient is a 29-year-old female who is here today with the above-noted complaints.  She states that she has been having a lot of swelling and infection in her inner thigh area with the folliculitis she has had in the past.  She is requesting antibiotics.  She has been squeezing them and some of them are very bruised and irritated.  She also states that she is having significant pelvic pain and would like to go back and see Dr. XYZ again.  She also states that she took herself off of lithium, but she has been having significant mood swings, anger outbursts and not dealing with the situation well at all.  She also has had some psychiatric evaluation, but she states that she did not feel like herself on the medication, so she took herself off.  She states she does not wish to be on any medication at the current time.  She otherwise states that sex is so painful that she is unable to have sex with her husband, even though she ""wants to."",PAST MEDICAL HISTORY:,  Significant for cleft palate.,ALLERGIES:,  She is allergic to Lortab.,CURRENT MEDICATIONS:,  None.,REVIEW OF SYSTEMS:,  Please see history of present illness.,Psychiatric:  She has had some suicidal thoughts, but no plans.  She denies being suicidal at the current time.,Cardiopulmonary:  She has not had any chest pain or shortness of breath.,GI:  Denies any nausea or vomiting.,Neurological:  No numbness, weakness or tingling.,PHYSICAL EXAMINATION:,General:  The patient is a well-developed, well-nourished, 29-year-old female who is in no acute distress.,Vital signs:  Weight:  160 pounds.  Blood pressure:  100/60.  Pulse:  62.,Psychiatric:  I did spend over 25 minutes face-to-face with the patient talking about the situation she was in and the medication and her discontinuing use of that.,Extremities:  Her inner thighs are covered with multiple areas of folliculitis and mild abscesses.  They are bruised from her squeezing them.  We talked about that in detail.,ASSESSMENT:,1.  Folliculitis.,2.  Pelvic pain.,3.  Mood swings.,4.  Dyspareunia.,PLAN:,1.  I would like her to go to the lab and get a CBC, chem-12, TSH and UA.,2.  We will put her on cephalexin 500 mg three times a day.,3.  We will send her back to see Dr. XYZ regarding the pelvic pain per her request.,4.  We will get her an appointment with a psychiatrist for evaluation and treatment.,5.  She is to call if she has any further problems or concerns.  Otherwise I will see her back for her routine care or sooner if there are any further issues.",5
"FLEXIBLE BRONCHOSCOPY,The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit.  I explained to the parents that the possible risks include:  irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax.  A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back.  The sample will then be sent for testing.  The flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.,The parents seem to understand, had the opportunity to ask questions and were satisfied with the information.  A booklet containing the description of the procedure and other information was provided.",3
"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.",21
"PREOPERATIVE DIAGNOSIS: , Cataract, left eye.,POSTOPERATIVE DIAGNOSIS:  ,Cataract, left eye.,PROCEDURE PERFORMED:  ,Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE: , After the induction of topical anesthesia with 4% Xylocaine drops, the left eye was prepped and draped in the usual fashion.  A speculum was inserted, and the microscope was moved into position.,A 3.2-mm incision was made in clear cornea at the limbus with a diamond keratome at the 3 o'clock position, and 0.1 cc of 1% Xylocaine without preservative was instilled into the anterior chamber.  It was then filled with viscoelastic.  A stab incision was made into the anterior chamber at the limbus at 5 o'clock position with a microblade.,A cystitome was used to make a capsulotomy, and the capsulorrhexis forceps were used to complete a circular capsulorrhexis.  The nucleus was hydrodelineated and hydrodissected with balanced salt solution on a 26-gauge cannula, and the phacoemulsifier was used to phacoemulsify the nucleus using a bimanual technique with the nucleus rotator inserted through the keratotomy incision.  The irrigation-aspiration handpiece was used to systematically aspirate cortex 360 degrees.  The posterior capsule was vacuumed; it was clear and intact.,The capsular bag and the anterior chamber were filled with viscoelastic.  A model MA30AC lens, power 21.5 diopters, serial number 864414.095, was folded, grasped with the lens insertion forceps and inserted into the capsular bag.  The trailing loop was placed inside the bag.  The viscoelastic was removed with the irrigation-aspiration handpiece.  The lens centered well.  A single 10-0 nylon suture was placed to close the wound.  It was checked and ascertained to be watertight.  Decadron 0.25 cc, 0.25 cc of antibiotic and 0.25 cc of Xylocaine were injected subconjunctivally.  Dexacidin ointment was placed in the eye, and the procedure was terminated.,The procedure was well tolerated by the patient who was returned to the recovery room in good condition.",37
"ADMISSION DIAGNOSIS: , Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.,SECONDARY DIAGNOSIS:,  Chronic pain syndrome.,PRINCIPAL PROCEDURE: , L5 Gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morphogenic protein, and pedicle fixation.  This was performed by Dr. X on 01/08/08.,BRIEF HISTORY OF HOSPITAL COURSE: , The patient is a man with a history of longstanding back, buttock, and bilateral leg pain.  He was evaluated and found to have bilateral pars defects at L5-S1 with spondylolysis and instability.  He was admitted and underwent an uncomplicated surgical procedure as noted above.  In the postoperative period, he was up and ambulatory.  He was taking p.o. fluids and diet well.  He was afebrile.  His wounds were healing well.  Subsequently, the patient was discharged home.,DISCHARGE MEDICATIONS: , Discharge medications included his usual preoperative pain medication as well as other medications.,FOLLOWUP:  ,At this time, the patient will follow up with me in the office in six weeks' time.  The patient understands discharge plans and is in agreement with the discharge plan.  He will follow up as noted",27
"PHYSICAL EXAMINATION:,  Patient is a 46-year-old white male seen for annual physical exam and had an incidental PSA elevation of 4.0.  All other systems were normal.,PROCEDURES:  ,Sextant biopsy of the prostate.,Radical prostatectomy:  Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.,PATHOLOGY:,Prostate biopsy:  Right lobe, negative.  Left lobe, small focus of adenocarcinoma, Gleason's 3 + 3 in approximately 5% of the tissue.,Radical prostatectomy:  Negative lymph nodes.  Prostate gland showing moderately differentiated infiltrating adenocarcinoma, Gleason 3 + 2 extending to the apex involving both lobes of the prostate, mainly right.  Tumor overall involved less than 5% of the tissue.  Surgical margin was reported and involved at the apex.  The capsule and seminal vesicles were free.,DISCHARGE NOTE:,  Patient has made good post-op recovery other than mild urgency incontinence.  His post-op PSA is 0.1 mg/ml.",34
"MEDICATIONS: , Plavix, atenolol, Lipitor, and folic acid.,CLINICAL HISTORY:  ,This is a 41-year-old male patient who comes in with chest pain, had had a previous MI in 07/2003 and stents placement in 2003, who comes in for a stress myocardial perfusion scan.,With the patient at rest, 10.3 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.,PROCEDURE AND INTERPRETATION:  ,The patient exercised for a total of 12 minutes on the standard Bruce protocol.  The peak workload was 12.8 METS.  The resting heart rate was 57 beats per minute and the peak heart rate was 123 beats per minute, which was 69% of the age-predicted maximum heart rate response.  The blood pressure response was normal with a resting blood pressure of 130/100 and a peak blood pressure of 158/90.  The test was stopped due to fatigue and leg pain.  EKG at rest showed normal sinus rhythm.  The peak stress EKG did not reveal any ischemic ST-T wave abnormalities.  There was ventricular bigeminy seen during exercise, but no sustained tachycardia was seen.  At peak, there was no chest pain noted.  The test was stopped due to fatigue and left pain.  At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting myocardial perfusion imaging.,MYOCARDIAL PERFUSION IMAGING:,1.  The overall quality of the scan was good.,2.  There was no diagnostic abnormality on the rest and stress myocardial perfusion imaging.,3.  The left ventricular cavity appeared normal in size.,4.  Gated SPECT images revealed mild septal hypokinesis and mild apical hypokinesis.  Overall left ventricular systolic function was low normal with calculated ejection fraction of 46% at rest.,CONCLUSIONS:,1.  Good exercise tolerance.,2.  Less than adequate cardiac stress.  The patient was on beta-blocker therapy.,3.  No EKG evidence of stress induced ischemia.,4.  No chest pain with stress.,5.  Mild ventricular bigeminy with exercise.,6.  No diagnostic abnormality on the rest and stress myocardial perfusion imaging.,7.  Gated SPECT images revealed septal and apical hypokinesis with overall low normal left ventricular systolic function with calculated ejection fraction of 46% at rest.",3
"CC:, Right sided numbness.,HX:, 28 y/o male presented with a 3 month history of progressive right sided numbness; now anesthetic to pain. In addition, he experienced worsening balance, and episodes of aspiration while eating.,PMH:, 1) Born prematurely and weighed 3#2oz., 2) Multiple episodes of aspiration pneumonia as an infant and child, 3) ASD repair age 14, 4) Left ptosis repair age 11, 5) Scoliosis, 6) Gait abnormality, 7) Poor pharyngeal reflexes.,SHX/FHX: ,Mainstream high school education, no mental retardation, ambulatory, works at cardboard shop for the disabled.,EXAM:, Short stature. Head tilt to right.,CN: Left ptosis, decreased left nasolabial fold, decreased gag reflex bilaterally.,Motor: Full strength,Sensory: Marked hypesthesia on entire right side.,Coord: Slowed RAM on left.,Station: No drift,Gait: ND,Reflexes: 3+ throughout; Babinski signs bilaterally. 8 beat ankle clonus on right and 3 beat ankle clonus on left.,MRI:, Arnold Chiari II with syrinx: Severe basilar invagination, marked compression of ventral pontomedullary junction, downward descension of cerebellar tonsils and vermis.,COURSE:, Patient underwent transpalatal/pharyngeal ventral decompression of pons/medulla with resection of clivus/odontoid and tracheostomy placement. on 9/29/92. Halo vest and ring were removed 6/18/93. 6 months later his Philadelphia collar was removed. He was last seen 4/8/94 and he had mildly spastic gait with good strength and hyperreflexia throughout. His gag response had returned and he was eating without difficulty. Sensation had returned to his extremities.",22
"PROCEDURE:  ,Laparoscopic tubal sterilization, tubal coagulation.,PREOPERATIVE DIAGNOSIS: , Request tubal coagulation.,POSTOPERATIVE DIAGNOSIS: , Request tubal coagulation.,PROCEDURE:  ,Under general anesthesia, the patient was prepped and draped in the usual manner.  Manipulating probe placed on the cervix, changed gloves.  Small cervical stab incision was made, Veress needle was inserted without problem.  A 3 L of carbon dioxide was insufflated.  The incision was enlarged.  A 5-mm trocar placed through the incision without problem.  Laparoscope placed through the trocar.  Pelvic contents visualized.  A 2nd puncture was made 2 fingerbreadths above the symphysis pubis in the midline.  Under direct vision, the trocar was placed in the abdominal cavity.  Uterus, tubes, and ovaries were all normal.  There were no pelvic adhesions, no evidence of endometriosis.  Uterus was anteverted and the right adnexa was placed on a stretch.  The tube was grasped 1 cm from the cornual region, care being taken to have the bipolar forceps completely across the tube and the tube was coagulated using amp meter for total desiccation.  The tube was grasped again and the procedure was repeated for a separate coagulation, so that 1.5 cm of the tube was coagulated.  The structure was confirmed to be tube by looking at fimbriated end.  The left adnexa was then placed on a stretch and the procedure was repeated again grasping the tube 1 cm from the cornual region and coagulating it.  Under traction, the amp meter was grasped 3 more times so that a total of 1.5 cm of tube was coagulated again.  Tube was confirmed by fimbriated end.  Gas was lend out of the abdomen.  Both punctures repaired with 4-0 Vicryl and punctures were injected with 0.5% Marcaine 10 mL.  The patient went to the recovery room in good condition.",37
"OPERATION PERFORMED:,  Full mouth dental rehabilitation in the operating room under general anesthesia.,PREOPERATIVE DIAGNOSES:  ,1.  Severe dental caries.,2.  Hemophilia.,POSTOPERATIVE DIAGNOSES:  ,1.  Severe dental caries.,2.  Hemophilia.,3.  Nonrestorable teeth.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY:  ,1 hour and 22 minutes.,BRIEF HISTORY:  ,The patient was first seen by me on 08/23/2007, who is 4-year-old with hemophilia, who received infusion on Tuesdays and Thursdays and he has a MediPort.  Mom reported history of high fever after surgery and he has one seizure previously.  He has history of trauma to his front teeth and physician put him on antibiotics.  He was only cooperative for having me do a visual examination on his anterior teeth.  Visual examination revealed severe dental caries and dental abscess from tooth #E and his maxillary anterior teeth needed to be extracted.  Due to his young age and hemophilia, I felt that he would be best served to be taken to the hospital operating room.,OTHER PREPARATION:  ,The child was brought to the Hospital Day Surgery accompanied by his mother.  There, I met with her and discussed the needs of the child, types of restoration to be performed, and the risks, and benefits of the treatment as well as the options and alternatives of the treatment.  After all her questions and concerns were addressed, she gave her informed consent to proceed with treatment.  The patient's history and physical examination was reviewed.  He was given factor for appropriately for his hemophilia prior to being taken back to the operating room.  Once he was cleared by Anesthesia, the child was taken back to the operating room.,OPERATIVE PROCEDURE:  ,The patient was placed on the surgical table in the usual supine position with all extremities protected.  Anesthesia was induced by mask.  The patient was then intubated with an oral tube and the tube was stabilized.  The head was wrapped and IV was started.  The head and neck were draped with sterile towels and the body was covered with a lead apron and sterile sheath.  A moist continuous throat pack was placed beyond tonsillar pillars.  Plastic lip and cheek retractors were then placed.  Preoperative clinical photographs were taken.  Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiograph.  After the radiographs were taken, the lead shield was removed.,Prophylaxis was then performed using a prophy cup and fluoridated prophy paste.  The patient's teeth were rinsed well.  The patient's oral cavity was suctioned clean.  Clinical and radiographic examination followed and areas of decay were noted.  During the restorative phase, these areas of decay were incidentally removed.  Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it.  Final caries removal was confirmed upon reaching hard, firm and sound dentin.,Teeth restored with composite ___________  bonded with a one-step bonding agent.  Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement.  Non-restorable primary teeth would be extracted.  The caries were extensive and invaded the pulp tissues, pulp therapy was initiated using ViscoStat and then IRM pulpotomies.  Teeth treated in such a manner would then be crowned with stainless steel crowns.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  The original treatment plan was verified with the actual treatment provided.  Postoperative clinical photographs were then taken.  The continuous gauze throat pack was removed with continuous suction with visualization.  Topical fluoride was then placed on the teeth.  At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, was taken to the recovery room, breathing spontaneously with stable vital signs.,FINDINGS: , This young patient presented with mild generalized marginal gingivitis, secondary to light generalized plaque accumulation and fair oral hygiene.  All primary teeth were present.  Dental carries were present on the following teeth:  Tooth B, OL caries, tooth C, M, L, S caries, tooth B, caries on all surfaces, tooth E caries on all surfaces, tooth F caries on all surfaces, tooth T caries on all surfaces, tooth H, lingual and facial caries, tooth I, caries on all surfaces, tooth L caries on all surfaces, and tooth S, all caries.  The remainder of his teeth and soft tissues were within normal limits.  The following restoration and procedures were performed.  Tooth B, OL amalgam, tooth C, M, L, S composite, tooth D, E, F, and G were extracted, tooth H, and L and separate F composite.  Tooth I is stainless steel crown, tooth L pulpotomy and stainless steel crown and tooth S no amalgam.  Sutures were also placed at extraction site D, E, S, and G.,CONCLUSION:  ,The mother was informed of the completion of the procedure.  She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care.  She is to contact to myself with an event of immediate postoperative complications and after full recovery, he was discharged from recovery room in the care of his mother.  She was also given prescription for Tylenol with Codeine Elixir for postoperative pain control.,",37
"PREOPERATIVE DIAGNOSIS:,  Left pleural effusion.,POSTOPERATIVE DIAGNOSIS:,  Left hemothorax.,PROCEDURE: , Thoracentesis.,PROCEDURE IN DETAIL:,  After obtaining informed consent and having explained the procedure to the patient, he was sat at the side of a stretcher in the emergency department.  His left back was prepped and draped in the usual fashion.  Xylocaine 1% was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed, and then we proceed to draw by hand about 1200 mL blood.  This blood was nonclotting and it was tested twice.  Halfway during the procedure, the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s.  Therefore, we laid him off his right side while keeping the chest catheter in place.  At that time, I proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure.,Overall besides the described episode, the patient tolerated the procedure well and afterwards, we took another chest x-ray that showed much improvement in the pleural effusion and at that particular time, with all the history we proceeded to admit the patient for observation and with an idea to obtain a CT in the morning to see whether the patient would need an pigtail intrapleural catheter or not.",37
"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.",24
"PREOPERATIVE DIAGNOSIS:,  Dural tear, postoperative laminectomy, L4-L5.,POSTOPERATIVE DIAGNOSES,1.  Dural tear, postoperative laminectomy, L4-L5.,2.  Laterolisthesis, L4-L5.,3.  Spinal instability, L4-L5.,OPERATIONS PERFORMED,1.  Complete laminectomy, L4.,2.  Complete laminectomy plus facetectomy, L3-L4 level.,3.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.,4.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.,5.  Posterior spinal fusion, L4 to S1.,6.  Insertion of morselized autograft, L4 to S1.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,DRAINS:  ,Hemovac x1.,DISPOSITION: , Vital signs stable, taken to the recovery room in a satisfactory condition, extubated.,INDICATIONS FOR OPERATION: , The patient is a 48-year-old gentleman who has had a prior decompression several weeks ago.  He presented several days later with headaches as well as a draining wound.  He was subsequently taken back for a dural repair.  For the last 10 to 11 days, he has been okay except for the last two days he has had increasing headaches, has nausea, vomiting, as well as positional migraines.  He has fullness in the back of his wound.  The patient's risks and benefits have been conferred him due to the fact that he does have persistent spinal leak.  The patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively.,PROCEDURE IN DETAIL:,  After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #7.  The patient was placed in the usual supine position and intubated under general anesthesia without any difficulties.  The patient was given intraoperative antibiotics.  The patient was rolled onto the OSI table in usual prone position and prepped and draped in usual sterile fashion.,Initially, a midline incision was made from the cephalad to caudad level.  Full-thickness skin flaps were developed.  It was seen immediately that there was large amount of copious fluid emanating from the wound, clear-like fluid, which was the cerebrospinal fluid.  Cultures were taken, aerobic, anaerobic, AFB, fungal.  Once this was done, the paraspinal muscles were affected from the posterior elements.  It was seen that there were no facet complexes on the right side at L4-L5 and L5-S1.  It was seen that the spine was listhesed at L5 and that the dural sac was pinched at the L4-5 level from the listhesis.  Once this was done; however, the fluid emanating from the dura could not be seen appropriately.  Complete laminectomy at L4 was performed as well extending the L5 laminectomy more to the left.  Complete laminectomy at L3 was done.  Once this was done within the subarticular recess on the right side at the L4 pedicle level, a rent in the dura was seen.  Once this was appropriately cleaned, the dural edges were approximated using a running 6-0 Prolene suture.  A Valsalva confirmed no significant lead after the repair was made.  There was a significant laterolisthesis at L4-L5 and due to the fact that there were no facet complexes at L5-S1 and L4-L5 on the right side as well as there was a significant concavity on the right L4-L5 disk space which was demonstrated from intraoperative x-rays and compared to preoperative x-rays, it was decided from an instrumentation.  The lateral pedicle screws were placed at L4, L5, and S1 using the standard technique of Magerl.  After this the standard starting point was made.  Trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall.  Once this was done, this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall.  The screws were subsequently placed.  Tricortical purchase was obtained at S1 ________ appropriate size screws.  Precontoured titanium rod was then appropriately planned and placed between the screws at L4, L5, and S1.  This was done on the right side first.  The screw was torqued at S1 appropriately and subsequently at L5.  Minimal compression was then placed between L5 and L4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at L4.  Neutral compression distraction was obtained on the left side.  Screws were torqued at L4, L5, and S1 appropriately.  Good placement was seen both in AP and lateral planes using fluoroscopy.  Laterolisthesis corrected appropriately at L4 and L5.,Posterior spinal fusion was completed by decorticating the posterior elements at L4-L5 and the sacral ala with a curette.  Once good bleeding subchondral bone was appreciated, the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix.  This was placed in the posterior lateral gutters.  DuraGen was then placed over the dural repair, and after this, fibrin glue was placed appropriately.  Deep retractors then removed from the confines of the wound.  Fascia was closed using interrupted Prolene running suture #1.  Once this was done, suprafascial drain was placed appropriately.  Subcutaneous tissues were opposed using a 2-0 Prolene suture.  The dermal edges were approximated using staples.  Wound was dressed sterilely using bacitracin ointment, Xeroform, 4 x 4's, and tape.  The drain was connected appropriately.  The patient was rolled on stretcher in usual supine position, extubated uneventfully, and taken back to the recovery room in a satisfactory stable condition.  No complications arose.",37
"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.",37
"CHIEF COMPLAINT:,  Followup on diabetes mellitus, status post cerebrovascular accident.,SUBJECTIVE:,  This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side.  We have done EMG studies.  He has noticed it since his stroke about five years ago.  He has been to see a neurologist.  We have tried different medications and it just does not seem to help.  He checks his blood sugars at home two to three times a day.  He kind of adjusts his own insulin himself.  Re-evaluation of symptoms is essentially negative.  He has a past history of heavy tobacco and alcohol usage.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt; 118 lbs, B/P; 108/72, T; 96.5, P; 80 and regular.  ,General:  A 70-year-old male who does not appear to be in acute distress but does look older than his stated age.  He has some missing dentition.,Skin:  Dry and flaky. ,CV:  Heart tones are okay, adequate carotid pulsations.  He has 2+ pedal pulse on the left and 1+ on the right.,Lungs: Diminished but clear.,Abdomen:  Scaphoid.,Rectal:  His prostate check was normal per Dr. Gill.,Neuro:  Sensation with monofilament testing is better on the left than it is on the right.,IMPRESSION:,1.  Diabetes mellitus.,2.  Neuropathy.,3.  Status post cerebrovascular accident.,PLAN:,  Refill his medications x 3 months.  We will check an A1c and BMP.  I have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood.  We will check a PSA.  Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in three months and p.r.n.",34
"HISTORY OF PRESENT ILLNESS: , The patient is a 71-year-old woman with history of coronary artery disease for which she has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1.  She also has a significant history of chronic renal insufficiency and severe COPD.  The patient and her husband live in ABC but they have family in XYZ.  She came to our office today as she is in the area visiting her family.  She complains of having shortness of breath for the past month that has been increasingly getting worse.  She developed a frequent nonproductive cough about 2 weeks ago.  She has also had episodes of paroxysmal nocturnal dyspnea, awaking in the middle of the night, panicking from dyspnea and shortness of breath.  She has also gained about 15 pounds in the past few months and has significant peripheral edema.  In the office, she is obviously dyspnea and speaking in 2 to 3 word sentences.,PAST MEDICAL HISTORY: , Coronary artery disease, anemia secondary to chronic renal insufficiency, stage IV chronic kidney disease, diabetic nephropathy, hypertension, hyperlipidemia, COPD, insulin-dependent diabetes, mild mitral valve regurgitation, severe tricuspid valve regurgitation, sick sinus syndrome, gastritis, and heparin-induced thrombocytopenia.,PAST SURGICAL HISTORY: , Status post pacemaker implantation, status post CABG x4 in 1999 and status post CABG x2 in 2003, status post PCA stenting x1 to the left anterior descending artery, cholecystectomy, back surgery, bladder surgery, and colonic polypectomies.,SOCIAL HISTORY:  ,The patient is married.  Lives with her husband.  They are retired from ABC.,MEDICATIONS:,1.  Plavix 75 mg p.o. daily.,2.  Aspirin 81 mg p.o. daily.,3.  Isosorbide mononitrate 60 mg p.o. daily.,4.  Colace 100 mg p.o. b.i.d.,5.  Atenolol 50 mg p.o. daily.,6.  Lantus insulin 15 units subcutaneously every evening.,7.  Protonix 40 mg p.o. daily.,8.  Furosemide 40 mg p.o. daily.,9.  Norvasc 5 mg p.o. daily.,ALLERGIES: , SHE IS ALLERGIC TO HEPARIN AGENTS, WHICH CAUSE HEPARIN-INDUCED THROMBOCYTOPENIA.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Positive for generalized fatigue and malaise.,HEAD AND NECK:  Negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions.,CARDIOVASCULAR:  Positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain.,RESPIRATORY:  Positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough.  Negative for wheezing.,ABDOMEN:  Negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis.,GENITOURINARY:  Negative for dysuria, polyuria, hematuria, or incontinence.,MUSCULOSKELETAL:  Negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy.,SKIN:  Negative for rashes, petechiae, and hair or nail changes.  Positive for easy bruising on forearms.,NEUROLOGIC:  Negative for paralysis, paresthesias, dysphagia, or dysarthria.,PSYCHIATRIC:  Negative for depression, anxiety, or mood swings.,All other systems reviewed are negative.,PHYSICAL EXAMINATION,VITAL SIGNS:  Her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air.  Her height is 63 inches.  She is weighs 195 pounds and her BMI is 34.6.,CONSTITUTIONAL:  A 71-year-old woman in significant distress from shortness of breath and dyspnea at rest.,HEENT:  Eyes:  Pupils are reactive.  Sclera is nonicteric.  Ears, nose, mouth, and throat.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.  Swallow is intact.,CARDIOVASCULAR:  Positive JVD at 45 degrees.  Heart tones are distant.  S1 and S2.  No murmurs.,EXTREMITIES:  Have 3+ edema in the feet and ankles bilaterally that extends up to her knees.  Femoral pulses are weakly palpable.  Posterior tibial pulses are not palpable.  Capillary refill is somewhat sluggish.,RESPIRATORY:  Breath sounds are clear with some bilateral basilar diminishment.  No rales and no wheezing.  Speaking in 2 to 3 word sentences.  Diaphragmatic excursions are limited.  AP diameter is expanded.,ABDOMEN:  Soft and nontender.  Active bowel sounds x4 quadrants.  No hepatosplenomegaly.  No masses are appreciated.,GENITOURINARY:  Deferred.,MUSCULOSKELETAL:  Adequate range of motion along with extremities.,SKIN:  Warm and dry.  No lesions or ulcerations are noted.,NEUROLOGIC:  Alert and oriented x3.  Head is normocephalic and atraumatic.  No focal, motor, or sensory deficits.,PSYCHIATRIC:  Normal affect.,IMPRESSION,1.  Coronary artery disease.",5
"PREOPERATIVE DIAGNOSIS:,1.  Acute bowel obstruction.,2.  Umbilical hernia.,POSTOPERATIVE DIAGNOSIS:,1.  Acute small bowel obstruction.,2.  Incarcerated umbilical Hernia.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Release of small bowel obstruction.,3.  Repair of periumbilical hernia.,ANESTHESIA: , General with endotracheal intubation.,COMPLICATIONS:,  None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN: , Hernia sac.,HISTORY:  ,The patient is a 98-year-old female who presents from nursing home extended care facility with an incarcerated umbilical hernia, intractable nausea and vomiting and a bowel obstruction.  Upon seeing the patient and discussing in extent with the family, it was decided the patient needed to go to the operating room for this nonreducible umbilical hernia and bowel obstruction and the family agreed with surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have an incarcerated umbilical hernia.  There was a loop of small bowel incarcerated within the hernia sac.  It showed signs of ecchymosis, however no signs of any ischemia or necrosis.  It was easily reduced once opening the abdomen and the rest of the small bowel was ran without any other defects or abnormalities.,PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and the patient's family.  The patient was brought to the operating suite.  After general endotracheal intubation, prepped and draped in normal sterile fashion.  A midline incision was made around the umbilical hernia defect with a #10 blade scalpel.  Dissection was then carried down to the fascia.  Using a sharp dissection, an incision was made above the defect superior to the defect entering the fascia.  The abdomen was entered under direct visualization.  The small bowel that was entrapped within the hernia sac was easily reduced and observed and appeared to be ecchymotic, however, no signs of ischemia were noted or necrosis.  The remaining of the fascia was then extended using Metzenbaum scissors.  The hernia sac was removed using Mayo scissors and sent off as specimen.  Next, the bowel was run from the ligament of Treitz to the ileocecal valve with no evidence of any other abnormalities.  The small bowel was then milked down removing all the fluid.  The bowel was decompressed distal to the obstruction.  Once returning the abdominal contents to the abdomen, attention was next made in closing the abdomen and using #1 Vicryl suture in the figure-of-eight fashion the fascia was closed.  The umbilicus was then reapproximated to its anatomical position with a #1 Vicryl suture.  A #3-0 Vicryl suture was then used to reapproximate the deep dermal layers and skin staples were used on the skin.  Sterile dressings were applied.  The patient tolerated the procedure well and was transferred to recovery in stable condition.",37
"HISTORY OF PRESENT ILLNESS: , The patient presents today for followup, history of erectile dysfunction, last visit started on Cialis 10 mg.  He indicates that he has noticed some mild improvement of his symptoms, with no side effect.  On this dose, he is having firm erection, able to penetrate, lasting for about 10 or so minutes.  No chest pain, no nitroglycerin usage, no fever, no chills.  No dysuria, gross hematuria, fever, chills.  Daytime frequency every three hours, nocturia times 0, good stream.  He does have a history of elevated PSA and biopsy June of this year was noted for high grade PIN, mid left biopsy, with two specimens being too small to evaluate.  PSA 11.6.  Dr. X's notes are reviewed.,IMPRESSION:  ,1.  Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects.  The patient has multiple risk factors, but denies using any nitroglycerin or any cardiac issues at this time.  We reviewed options of increasing the medication, versus trying other medications, options of penile prosthesis, Caverject injection use as well as working pump is reviewed.,2.  Elevated PSA in a patient with a recent biopsy showing high-grade PIN, as well as two specimens not being large enough to evaluate.  The patient tells me he has met with his primary care physician and after discussion, he is in consideration of repeating a prostate ultrasound and biopsy.  However, he would like to meet with Dr. X to discuss these prior to biopsy.,PLAN: , Following detailed discussion, the patient wishes to proceed with Cialis 20 mg, samples are provided as well as Levitra 10 mg, may increase this to 20 mg and understand administration of each and contraindication as well as potential side effects are reviewed.  The patient not to use them at the same time.  Will call if any other concern.  In the meantime, he is scheduled to meet with Dr. X, with a prior PSA in consideration of a possible repeating prostate ultrasound and biopsy.  He declined scheduling this at this time.  All questions answered.",38
"PREOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,NAME OF OPERATION: , Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft.  Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.,ANESTHESIA: , General.,PROCEDURE DETAILS: , The patient was brought to the operating room and placed in the supine position upon the table.  After adequate general anesthesia, the patient was prepped with Betadine soap and solution in the usual sterile manner.  Elbows were protected to avoid ulnar neuropathy, chest wall expansion avoided to avoid ulnar neuropathy, phrenic nerve protectors used to protect the phrenic nerve and removed at the end of the case.,A midline sternal skin incision was made and carried down through the sternum which was divided with the saw.  Pericardial and thymus fat pad was divided.  The left internal mammary artery was harvested and spatulated for anastomosis.  Heparin was given.,Vein resected from the thigh, side branches secured using 4-0 silk and Hemoclips.  The thigh was closed multilayer Vicryl and Dexon technique.  A Pulsavac wash was done, drain was placed.,The left internal mammary artery is sewn to the left anterior descending using 7-0 running Prolene technique with the Medtronic off-pump retractors.  After this was done, the patient was fully heparinized, cannulated with a 6.5 atrial cannula and a 2-stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia.  Medtronic retractors used to expose the circumflex.  Prior to going on pump, we stapled the vein graft in place to the aorta.,Then, on pump, we did the distal anastomosis with a 7-0 running Prolene technique.  The right side graft was brought to the posterior descending artery using running 7-0 Prolene technique.  Deairing procedure was carried out.  The bulldogs were removed.  The patient maintained good normal sinus rhythm with good mean perfusion.  The patient was weaned from cardiopulmonary bypass.  The arterial and venous lines were removed and doubly secured.  Protamine was delivered.  Meticulous hemostasis was present.  Platelets were given for coagulopathy.  Chest tube was placed and meticulous hemostasis was present.  The anatomy and the flow in the grafts was excellent.  Closure was begun.,The sternum was closed with wire, followed by linea alba and pectus fascia closure with running 0 Vicryl sutures in double-layer technique.  The skin was closed with subcuticular 4-0 Dexon suture technique.  The patient tolerated the procedure well and was transferred to the intensive care unit in stable condition.,We minimized the pump time to 16 minutes for just the distal anastomosis of the circumflex in order to lessen the insult to the kidneys as the patient already has kidney failure with a creatinine of 3.0.",3
"REASON FOR VISIT:  ,The patient is a 76-year-old man referred for neurological consultation by Dr. X.  The patient is companied to clinic today by his wife and daughter.  He provides a small portion of his history; however, his family provides virtually all of it.,HISTORY OF PRESENT ILLNESS: , He has trouble with walking and balance, with bladder control, and with thinking and memory.  When I asked him to provide me detail, he could not tell me much more than the fact that he has trouble with his walking and that he has trouble with his bladder.  He is vaguely aware that he has trouble with his memory.,According to his family, he has had difficulty with his gait for at least three or four years.  At first, they thought it was weakness and because of he was on the ground (for example, gardening) he was not able to get up by himself.  They did try stopping the statin that he was taking at that time, but because there was no improvement over two weeks, they resumed the statin.  As time progressed, he developed more and more difficulty.  He started to shuffle.  He started using a cane about two and a half years ago and has used a walker with wheels in the front since July of 2006.  At this point, he frequently if not always has trouble getting in or out of the seat.  He frequently tends to lean backwards or sideways when sitting.  He frequently if not always has trouble getting in or out a car, always shuffles or scuffs his feet, always has trouble turning or changing direction, always has trouble with uneven surfaces or curbs, and always has to hold on to someone or something when walking.  He has not fallen in the last month.  He did fall earlier, but there seemed to be fewer opportunities for him to fall.  His family has recently purchased a lightweight wheelchair to use if he is traveling long distances.  He has no stairs in his home, however, his family indicates that he would not be able to take stairs.  His handwriting has become smaller and shakier.,In regard to the bladder, he states, ""I wet the bed.""  In talking with his family, it seems as if he has no warning that he needs to empty his bladder.  He was diagnosed with a small bladder tumor in 2005.  This was treated by Dr. Y.  Dr. X does not think that the bladder tumor has anything to do with the patient's urinary incontinence.  The patient has worn a pad or undergarment for at least one to one and a half years.  His wife states that they go through two or three of them per day.  He has been placed on medications; however, they have not helped.,He has no headaches or sensation of head fullness.,In regard to the thinking and memory, at first he seemed forgetful and had trouble with dates.  Now he seems less spontaneous and his family states he seems to have trouble expressing himself.  His wife took over his medications about two years ago.  She stopped his driving about three years ago.  She discovered that his license had been expired for about a year and she was concerned enough at that time that she told him he could drive no more.  Apparently, he did not object.  At this point, he frequently has trouble with memory, orientation, and everyday problems solving at home.  He needs coaching for his daily activities such as reminders to brush his teeth, put on his clothes, and so forth.  He is a retired office machine repairman.  He is currently up and active about 12 hours a day and sleeping or lying down about 12 hours per day.,He has not had PT or OT and has not been treated with medications for Parkinson's disease or Alzheimer's disease.  He has been treated for the bladder.  He has not had lumbar puncture.,Past medical history and review of all 14 systems from the form they completed for this visit that I reviewed with them is negative with the exception that he has had hypertension since 1985, hypercholesterolemia since 1997, and diabetes since 1998.  The bladder tumor was discovered in 2005 and was treated noninvasively.  He has lost weight from about 200 pounds to 180 pounds over the last two or three years.  He had a period of depression in 1999 and was on Prozac for a while, but this was then stopped.  He used to drink a significant amount of alcohol.  This was problematic enough that his wife was concerned.  She states he stopped when she retired and she was at home all day.,SOCIAL HISTORY:  ,He quit smoking in 1968.  His current weight is 183 pounds.  His tallest height is 5 feet 10 inches.,FAMILY HISTORY:  ,His grandfather had arthritis.  His father had Parkinson's disease.  His mother had heart disease and a sister has diabetes.,He does not have a Living Will and indicates he would wish his wife to make decisions for him if he could not make them for himself.,REVIEW OF HYDROCEPHALUS RISK FACTORS: , None.,ALLERGIES: , None.,MEDICATIONS: , Metformin 500 mg three times a day, Lipitor 10 mg per day, lisinopril 20 mg per day, metoprolol 50 mg per day, Uroxatral 10 mg per day, Detrol LA 4 mg per day, and aspirin 81 mg per day.,PHYSICAL EXAM: , On examination today, this is a pleasant 76-year-old man who is guided back from the clinic waiting area walking with his walker.  He is well developed, well nourished, and kempt.,Vital Signs:  His weight is 180 pounds.,Head:  The head is normocephalic and atraumatic.  The head circumference is 59 cm, which is the ,75-90th percentile for an adult man whose height is 178 cm.,Spine:  The spine is straight and not tender.  I can easily palpate the spinous processes.  There is no scoliosis.,Skin:  No neurocutaneous stigmata.,Cardiovascular Examination:  No carotid or vertebral bruits.,Mental Status:  Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  The Mini-Mental State Exam score was 17/30.  He did not know the year, season, or day of the week nor did he know the building or specialty or the floor.  There was a tendency for perseveration during the evaluation.  He could not copy the diagram of intersecting pentagons.,Cranial Nerve Exam:  No evidence of papilledema.  The pupillary light reflex is intact as are extraocular movements without nystagmus, facial expression and sensation, hearing, head turning, tongue, and palate movement.,Motor Exam:  Normal bulk and strength, but the tone is marked by significant paratonia.  There is no atrophy, fasciculations, or drift.  There is tremulousness of the outstretched hands.,Sensory Exam:  Is difficult to interpret.  Either he does not understand the test or he is mostly guessing.,Cerebellar Exam:  Is intact for finger-to-nose, heel-to-knee, and rapid alternating movement tests.  There is no dysarthria.,Reflexes:  Trace in the arms, 2+ at the knees, and 0 at the ankles.  It is not certain whether there is a Babinski sign or simply withdrawal.,Gait:  Assessed using the Tinetti assessment tool that shows a balance score of 7-10/16 and a gait score of 2-5/12 for a total score of 9-15/28, which is significantly impaired.,REVIEW OF X-RAYS: , I personally reviewed the MRI scan of the brain from December 11, 2007 at Advanced Radiology.  It shows the ventricles are enlarged with a frontal horn span of 5.0 cm.  The 3rd ventricle contour is flat.  The span is enlarged at 12 mm.  The sylvian aqueduct is patent.  There is a pulsation artifact.  The corpus callosum is effaced.  There are extensive T2 signal abnormalities that are confluent in the corona radiata.  There are also scattered T2 abnormalities in the basal ganglia.  There is a suggestion of hippocampal atrophy.  There is also a suggestion of vermian atrophy.,ASSESSMENT: , The patient has a clinical syndrome that raises the question of idiopathic normal pressure hydrocephalus.  His examination today is notable for moderate-to-severe dementia and moderate-to-severe gait impairment.  His MRI scan raises the question of hydrocephalus, however, is also consistent with cerebral small vessel disease.,PROBLEMS/DIAGNOSES:,1.  Possible idiopathic normal pressure hydrocephalus (331.5).,2.  Probable cerebral small-vessel disease (290.40 & 438).,3.  Gait impairment (781.2).,4.  Urinary urgency and incontinence (788.33).,5.  Dementia.,6.  Hypertension.,7.  Hypercholesterolemia.",5
"PREOPERATIVE DIAGNOSES: , Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,POSTOPERATIVE DIAGNOSES:,  Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,PROCEDURE:  ,Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.,ANESTHESIA:  ,General endotracheal anesthetic with a caudal block x2.,FLUIDS RECEIVED:  ,1000 mL crystalloid.,ESTIMATED BLOOD LOSS:  ,Less than 10 mL.,SPECIMENS: , Tissue sent to pathology is a renal biopsy.,ABNORMAL FINDINGS: , A stenotic scarred ureteropelvic junction with dilated ureter and dilated renal pelvis.,TUBES AND DRAINS:  ,A 10-French silicone Foley catheter with 3 mL in balloon and a 4.7-French ureteral double J-stent multilength.,INDICATIONS FOR OPERATION:  ,The patient is a 3-1/2-year-old boy, who has a solitary left kidney with renal insufficiency with creatinine of 1.2, who has had a ureteropelvic junction repair performed by Dr. Chang.  It was subsequently obstructed with multiple episodes of pyelonephritis, two percutaneous tube placements, ureteroscopy with balloon dilation of the system, and continued obstruction.  Plan is for co surgeons due to the complexity of the situation and the solitary kidney to do surgical procedure to correct the obstruction.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operative room.  Surgical consent, operative site, and patient identification were verified.  Dr. X and Dr. Y both agreed upon the procedures in advance.  Dr. Y then, once the patient was anesthetized, requested IV antibiotics with Fortaz, the patient had a caudal block placed, and he was then placed in lithotomy position.  Dr. Y then calibrated the urethra with the bougie a boule to 8, 10, and up to 12 French.  The 9.5-French cystoscope sheath was then placed within the patient's bladder with the offset scope, and his bladder had no evidence of cystitis.  I was able to locate the ureteral orifice bilaterally, although no urine coming from the right.  We then placed a 4-French ureteral catheter into the ureter as far as we could go.  An antegrade nephrostogram was then performed, which shows that the contrast filled the dilated pelvis, but did not go into the ureter.  A retrograde was performed, and it was found that there was a narrowed band across the two.  Upon draining the ureter allowing to drain to gravity, the pelvis which had been clamped and its nephrostomy tube did not drain at all.  Dr. Y then placed a 0.035 guidewire into the ureter after removing the 4-French catheter and then placed a 4.7-French double-J catheter into the ureter as far as it would go allowing it to coil in the bladder.  Once this was completed, we then removed the cystoscope and sheath, placed a 10-French Foley catheter, and the patient was positioned by Dr. X and Dr. Y into the flank position with the left flank up after adequate padding on the arms and legs as well as a brachial plexus roll.  He was then sterilely prepped and draped.  Dr. Y then incised the skin with a 15-blade knife through the old incision and then extended the incision with curved mosquito clamp and Dr. X performed cautery of the areas advanced to be excised.  Once this was then dissected, Dr. Y and Dr. X divided the lumbosacral fascia; at the latissimus dorsi fascia, posterior dorsal lumbotomy maneuver using the electrocautery; and then using curved mosquito clamps __________.  At this point, Dr. X used the cautery to enter the posterior retroperitoneal space through the posterior abdominal fascia.  Dr. Y then used the curved right angle clamp and dissected around towards the ureter, which was markedly adherent to the base of the retroperitoneum.  Dr. X and Dr. Y also needed dissection on the medial and lateral aspects with Dr. Y being on the lateral aspect of the area and Dr. X on the medial to get an adequate length of this.  The tissue was markedly inflamed and had significant adhesions noted.  The patient's spermatic vessels were also in the region as well as the renal vessels markedly scarred close to the ureteropelvic junction.  Ultimately, Dr. Y and Dr. X both with alternating dissection were able to dissect the renal pelvis to a position where Dr. Y put stay sutures and a 4-0 chromic to isolate the four quadrant area where we replaced the ureter.  Dr. X then divided the ureter and suture ligated the base, which was obstructed with a 3-0 chromic suture.  Dr. Y then spatulated the ureter for about 1.5 cm, and the stent was gently delivered in a normal location out of the ureter at the proximal and left alone in the bladder.  Dr. Y then incised the renal pelvis and dissected and opened it enough to allow the new ureteropelvic junction repair to be performed.  Dr. Y then placed interrupted sutures of 5-0 Monocryl at the apex to repair the most dependent portion of the renal pelvis, entered the lateral aspect, interrupted sutures of the repair.  Dr. X then was able to without much difficulty do interrupted sutures on the medial aspect.  The stent was then placed into the bladder in the proper orientation and alternating sutures by Dr. Y and Dr. X closed the ureteropelvic junction without any evidence of leakage.  Once this was complete, we removed the extra stay stitches and watched the ureter lay back into the retroperitoneum in a normal position without any kinking in apparently good position.  This opening was at least 1.5 cm wide.  Dr. Y then placed 2 stay sutures of 2-0 chromic in the lower pole of the kidney and then incised wedge biopsy and excised the biopsy with a 15-blade knife and curved iris scissors for renal biopsy for determination of renal tissue health.  Electrocautery was used on the base.  There was no bleeding, however, and the tissue was quite soft.  Dermabond and Gelfoam were placed, and then Dr. Y closed the biopsy site over with thrombin-Gelfoam using the 2-0 chromic stay sutures.  Dr. X then closed the fascial layers with running suture of 3-0 Vicryl in 3 layers.  Dr. Y closed the Scarpa fascia and the skin with 4-0 Vicryl and 4-0 Rapide respectively.  A 4-0 nylon suture was then placed by Dr. Y around the previous nephrostomy tube, which was again left clamped.  Dermabond tissue adhesive was placed over the incision and then a dry sterile dressing was placed by Dr. Y over the nephrostomy tube site, which was left clamped, and the patient then had a Foley catheter placed in the bladder.  The Foley catheter was then taped to his leg.  A second caudal block was placed for anesthesia, and he is in stable condition upon transfer to recovery room.",38
"FINDINGS:,There is diffuse subcutis space edema extending along the posteromedial aspect of the elbow adjacent to the medial epicondyle, extending to the olecranon process and along the superficial aspect of the epicondylo-olecranon ligament. There is no demonstrated solid, cystic or lipomatous mass lesion. There is enlargement with hyperintense signal of the ulnar nerve within the cubital tunnel. There is inflammation with mild laxity of the epicondylo-olecranon ligament. The combined findings are most consistent with a ulnar nerve neuritis possibly secondary to a subluxing ulnar nerve however the ulnar nerve at this time is within the cubital tunnel. There is no accessory muscle within the cubital tunnel. The common flexor tendon origin is normal.,Normal ulnar collateral ligamentous complex.,There is mild epimysial sheath edema of the pronator teres muscle consistent with a mild epimysial sheath sprain but no muscular tear.,There is minimal intratendinous inflammation of the common extensor tendon origin consistent with a mild tendinitis. There is no demonstrated common extensor tendon tear. Normal radial collateral ligamentous complex.,Normal radiocapitellum and ulnotrochlear articulations.,Normal triceps and biceps tendon insertions.,There is peritendinous inflammation of the brachialis tendon insertion but an intrinsically normal tendon.,IMPRESSION:,Edema of the subcutis adipose space overlying the posteromedial aspect of the elbow with interstitial inflammation of the epicondylo-olecranon ligament.,Enlarged edematous ulnar nerve most compatible with ulnar nerve neuritis.,The above combined findings suggest a subluxing ulnar nerve.,Mild epimysial sheath strain of the pronator teres muscle but no muscular tear.,Mild lateral epicondylitis with focal tendinitis of the origin of the common extensor tendon.,Peritendinous edema of the brachialis tendon insertion.,No solid, cystic or lipomatous mass lesion.,",33
"CC:, Confusion and slurred speech.,HX , (primarily obtained from boyfriend): This 31 y/o RHF experienced a ""flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found ""passed out"" in bed, and when awoken appeared confused, and lethargic. She apparently recovered within 24 hours. For two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). She left a stove on.,She began slurring her speech 2 days prior to admission. On the day of presentation she developed right facial weakness and began stumbling to the right. She denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. There was no history of illicit drug/ETOH use or head trauma.,PMH:, Migraine Headache.,FHX: , Unremarkable.,SHX: ,Divorced. Lives with boyfriend. 3 children alive and well. Denied tobacco/illicit drug use. Rarely consumes ETOH.,ROS:, Irregular menses.,EXAM: ,BP118/66.  HR83. RR 20. T36.8C.,MS: Alert and oriented to name only. Perseverative thought processes. Utilized only one or two word answers/phrases. Non-fluent. Rarely followed commands. Impaired writing of name.,CN: Flattened right nasolabial fold only.,Motor: Mild weakness in RUE manifested by pronator drift. Other extremities were full strength.,Sensory: withdrew to noxious stimulation in all 4 extremities.,Coordination: difficult to assess.,Station: Right pronator drift.,Gait: unremarkable.,Reflexes: 2/2BUE, 3/3BLE, Plantars were flexor bilaterally.,General Exam: unremarkable.,INITIAL STUDIES:, CBC, GS, UA, PT, PTT, ESR, CRP, EKG were all unremarkable. Outside HCT showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified).,COURSE: ,MRI Brian Scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left MCA distribution suggesting slow flow. The latter suggested a vasculopathy such as Moya Moya, or fibromuscular dysplasia. HIV, ANA, Anti-cardiolipin Antibody titer, Cardiac enzymes, TFTs, B12, and cholesterol studies were unremarkable.,She underwent a cerebral angiogram on 2/12/92. This revealed an occlusion of the left MCA just distal to its origin. The distal distribution of the left MCA filled on later films through collaterals from the left ACA. There was also an occlusion of the right MCA just distal to the temporal branch. Distal branches of the right MCA filled through collaterals from the right ACA. No other vascular abnormalities were noted. These findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as Moya Moya disease. She was subsequently given this diagnosis. Neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. She had long latencies responding and understood only simple questions. Affect was blunted and there was distinct lack of concern regarding her condition. She was subsequently discharged home on no medications.,In 9/92 she was admitted for sudden onset right hemiparesis and mental status change. Exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. OB/GYN exam including cervical biopsy, and abdominal/pelvic CT scanning revealed stage IV squamous cell cancer of the cervix. She died 9/24/92 of cervical cancer.",33
"PREOPERATIVE DIAGNOSIS: , Left tibial tubercle avulsion fracture.,POSTOPERATIVE DIAGNOSIS:,  Comminuted left tibial tubercle avulsion fracture with intraarticular extension.,PROCEDURE:,  Open reduction and internal fixation of left tibia.,ANESTHESIA: , General.  The patient received 10 ml of 0.5% Marcaine local anesthetic.,TOURNIQUET TIME: , 80 minutes.,ESTIMATED BLOOD LOSS:,  Minimal.,DRAINS: , One JP drain was placed.,COMPLICATIONS: , No intraoperative complications or specimens.  Hardware consisted of two 4-5 K-wires, One 6.5, 60 mm partially threaded cancellous screw and one 45, 60 mm partially threaded cortical screw and 2 washers.,HISTORY AND PHYSICAL:,  The patient is a 14-year-old male who reported having knee pain for 1 month.  Apparently while he was playing basketball on 12/22/2007 when he had gone up for a jump, he felt a pop in his knee.  The patient was seen at an outside facility where he was splinted and subsequently referred to Children's for definitive care.  Radiographs confirmed comminuted tibial tubercle avulsion fracture with patella alta.  Surgery is recommended to the grandmother and subsequently to the father by phone.  Surgery would consist of open reduction and internal fixation with subsequent need for later hardware removal.  Risks of surgery include the risks of  anesthesia, infection, bleeding, changes on sensation in most of the extremity, hardware failure, need for later hardware removal, failure to restore extensor mechanism tension, and need for postoperative rehab.  All questions were answered, and father and grandmother agreed to the above plan.,PROCEDURE: , The patient was taken to the operating and placed supine on the operating table.  General anesthesia was then administered.  The patient was given Ancef preoperatively.  A nonsterile tourniquet was placed on the upper aspect of the patient's left thigh.  The patient's extremity was then prepped and draped in the standard surgical fashion.  Midline incision was marked on the skin extending from the tibial tubercle proximally and extremities wrapped in Esmarch.  Finally, the patient had tourniquet that turned in 75 mmHg.  Esmarch was then removed.  The incision was then made.  The patient had significant  tearing of the posterior retinaculum medially with proximal migration of the tibial tubercle which was located in the joint there was a significant comminution and intraarticular involvement.  We were able to see the underside of the anterior horn of both medial and lateral meniscus.  The intraarticular cartilage was restored using two 45 K-wires.  Final position was checked via fluoroscopy and the corners were buried in the cartilage.  There was a large free floating metaphyseal piece that included parts of proximal tibial physis.  This was placed back in an anatomic location and fixed using a 45 cortical screw with a washer.  The avulsed fragment with the patellar tendon was then fixed distally to this area using a 6.5, 60 mm cancellous screw with a washer.  The cortical screw did not provide good compression and fixation at this distal fragment.  Retinaculum was repaired using 0 Vicryl suture as best as possible.  The hematoma was evacuated at the beginning of the case as well as the end.  The knee was copiously irrigated with normal saline.  The subcutaneous tissue was re-approximated using 2-0 Vicryl and the skin with 4-0 Monocryl.  The wound was cleaned, dried, and dressed with Steri-Strips, Xeroform, and 4 x4s.  Tourniquet was released at 80 minutes.  JP drain was placed on the medium gutter.  The extremity was then wrapped in Ace wrap from the proximal thigh down to the toes.  The patient was then placed in a knee mobilizer.  The patient tolerated the procedure well.  Subsequently extubated and taken to the recovery in stable condition.,POSTOP PLAN:  ,The patient hospitalized overnight to decrease swelling and as well as manage his pain.  He may weightbear as tolerated using knee mobilizer.  Postoperative findings relayed to the grandmother.  The patient will need subsequent hardware removal.  The patient also was given local anesthetic at the end of the case.",27
"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.",33
"PROCEDURES PERFORMED:,1. Left heart catheterization with coronary angiography and left ventricular pressure measurement.,2. Left ventricular angiography was not performed.,3. Right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting.,4. Right femoral artery angiography.,5. Perclose to seal the right femoral arteriotomy.,INDICATIONS FOR PROCEDURE:, Patient presenting with a history of coronary artery disease in the past with coronary angiography in the early 1990s. The patient presented with what appeared to be a COPD exacerbation and had mildly positive cardiac enzyme markers suggestive of a non-ST elevation myocardial infarction. He was subsequently dispositioned to the cardiac catheterization lab for further evaluation.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, the patient was taken to the cardiac catheterization lab, where his procedure was performed. The patient was appropriately prepped and prepared on the table, after which his right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery. Over a standard 0.035 guidewire, coronary angiography and left ventricular pressure measurements were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery, a 6-French JR4 diagnostic catheter to image the right coronary artery, a 6-French angled pigtail catheter to measure left ventricular pressure. At the conclusion of the diagnostic study, the case was progressed to percutaneous coronary intervention, which will be described below. Subsequently, right femoral artery angiography was performed which showed right femoral artery which was free of significant atherosclerotic plaque, and an arteriotomy that was suitable for a closure device. Then, a Perclose was used to seal the right femoral arteriotomy.,HEMODYNAMIC DATA:, The opening aortic pressure was 91/63. The left ventricular pressure was 94/13 with an end-diastolic pressure of 24. Left ventricular ejection fraction was not assessed, as ventriculogram was not performed. The patient did have some elevated creatinine earlier in this hospital course which warranted limitation of contrast where possible.,CORONARY ANGIOGRAM:, The left main coronary artery was angiographically okay. The LAD had mild diffuse disease. There appeared to be distal tapering of the LAD. The left circumflex had mild diffuse disease. In the very distal aspect of the circumflex after OM-3 and OM-4 type branch, there was a long, severely diseased segment that appeared to be chronic and subtotal in one area. The runoff from this area appeared to be a very small PLOM type branch and continuation of a circ which did not appear to supply much territory, and there was not much to salvage by approaching this lesion. The right coronary artery had mild diffuse disease. The PLV branch was 100% occluded at its ostium at the crux. The PDA at the ostium had an 80% stenosis. The PDA was a fairly sizeable vessel with a long course. The right coronary is dominant.,CONCLUSION:, Mild diffuse coronary artery disease with severe distal left circumflex lesion with not much runoff beyond this lesion. This circumflex appears to be chronically diseased and has areas that appear to be subtotal. There is a 100% PLV branch which is also chronic and reported in his angiogram in the 1990s. There is an ostial 80% right PDA lesion. The plan is to proceed with percutaneous intervention to the right PDA.,The case was then progressed to percutaneous intervention of the right PDA. A 6-French JR4 guide catheter with side holes was selected and used to engage the right coronary artery ostium. The lesion was crossed with a long BMW 0.014 guidewire. Then, we ballooned the lesion with a 2.5 x 9 mm Maverick balloon. Subsequently, we stented the lesion with a 2.5 x 16 mm Taxus drug-eluting stent with a nice angiographic result. The patient tolerated the procedure very well, without complications.,ANGIOPLASTY CONCLUSION:, Successful percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.,RECOMMENDATIONS:, Aspirin indefinitely, and Plavix 75 mg p.o. daily for no less than six months. The patient will be dispositioned back to telemetry for further monitoring.,TOTAL MEDICATIONS DURING PROCEDURE:, Versed 1 mg and fentanyl 25 mcg for conscious sedation. Heparin 8400 units IV was given for anticoagulation. Ancef 1 g IV was given for closure device prophylaxis.,CONTRAST ADMINISTERED:, 200 mL.,FLUOROSCOPY TIME:, 12.4 minutes.",3
"CHIEF COMPLAINT:,  Right ankle sprain.,HISTORY OF PRESENT ILLNESS: , This is a 56-year-old female who fell on November 26, 2007 at 11:30 a.m. while at work.  She did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle.  She describes no other injury at this time.,PAST MEDICAL HISTORY: , Hypertension and anxiety.,PAST SURGICAL HISTORY: , None.,MEDICATIONS: , She takes Lexapro and a blood pressure pill, but does not know anything more about the names and the doses.,ALLERGIES:,  No known drug allergies.,SOCIAL HISTORY: , The patient lives here locally.  She does not report any significant alcohol or illicit drug use.  She works full time.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS:,Pulm:  No cough, No wheezing, No shortness of breath,CV:  No chest pain or palpitations,GI:  No abdominal pain.  No nausea, vomiting, or diarrhea.,PHYSICAL EXAM:,GENERAL APPEARANCE:  No acute distress,VITAL SIGNS:  Temperature 97.8, blood pressure 122/74, heart rate 76, respirations 24, weight 250 lbs, O2 sat 95% on R.A.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.,CHEST:  Clear to auscultation bilaterally.,HEART:  Regular rate and rhythm.  No murmurs.,ABDOMEN:  Non-distended, nontender, normal active bowel sounds.,EXTREMITIES:  No Clubbing, No Cyanosis, No edema.,MUSCULOSKELETAL:  The spine is straight and there is no significant muscle spasm or tenderness there.  Both knees appear to be non-traumatic with no deformity or significant tenderness.  The right ankle has some swelling just below the right lateral malleolus and the dorsum of the foot is tender.  There is decreased range of motion and some mild ecchymosis noted around the ankle.,DIAGNOSTIC DATA: , X-ray of the right ankle reveals no acute fracture by my observation.  Radiologic interpretation is pending., ,IMPRESSION:,  Right ankle sprain.,PLAN:,1.  Motrin 800 mg t.i.d.,2.  Tylenol 1 gm q.i.d. as needed.,3.  Walking cast is prescribed.,4.  I told the patient to call back if any problems.  The next morning she called back complaining of worsening pain and I called in some Vicodin ES 1-2 p.o. q.  8 hours p.r.n. pain #60 with no refills.",5
"PREOPERATIVE DIAGNOSIS:  ,Urinary hesitancy and weak stream.,POSTOPERATIVE DIAGNOSES:,1.  Urinary hesitancy and weak stream.,2.  Urethral narrowing.,3.  Mild posterior wall erythema.,PROCEDURE PERFORMED:,1.  Cystourethroscopy.,2.  Urethral dilation.,3.  Bladder biopsy and fulguration.,ANESTHESIA:  ,General.,SPECIMEN:  ,Urine culture sensitivity and cytology and bladder biopsy x1.,DISPOSITION: , To PACU in stable condition.,INDICATIONS AND FINDINGS:  ,This is a 76-year-old female with history of weak stream and history of intermittent catheterization secondary to hypotonic bladder in the past, last cystoscopy approximately two years ago.,FINDINGS AT TIME OF SURGERY:,  Cystourethroscopy revealed some mild narrowing of the urethra, which was easily dilated to #23 French.  A midureteral polyp was noted.  Cystoscopy revealed multiple cellules and mild trabeculation of the bladder.  Posterior wall revealed some mild erythema with some distorted architecture of the bladder mucosa.  No obvious raised bladder tumor was noted.  No foreign bodies were noted.  The ureteral orifices were noted on the trigone just proximal to the bladder neck.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to the operating room, general anesthesia was induced by the Department of Anesthesia.  The patient was prepped and draped in normal sterile fashion and urethral sounds used to dilate the urethra to accommodate #23 French cystoscope.  Cystoscopy was performed in its entirety with the above findings.  The small area of erythema on the posterior wall was biopsied using a flexible biopsy forceps and Bovie cautery was used to cauterize and fulgurate this area.  The bladder was drained, cystoscope was removed, scope was reinserted and bladder was again reexamined.  No evidence of active bleeding noted.  The bladder was drained, cystoscope was removed, and the patient was cleaned and sent to recovery room in stable condition to followup with Dr. X in two weeks.  She is given prescription for Levaquin and Pyridium and given discharge instructions.",37
"INDICATIONS:,  Ischemic cardiomyopathy, status post inferior wall myocardial infarction, status post left anterior descending PTCA and stenting.,PROCEDURE DONE:,  Adenosine Myoview stress test.,STRESS ECG RESULTS:,  The patient was stressed by intravenous adenosine, 140 mcg/kg/minute infused over four minutes.  The baseline resting electrocardiogram revealed an electronic pacemaker depolarizing the ventricles regularly at a rate of 70 beats per minute.  Underlying atrial fibrillation noted, very wide QRS complexes.  The heart rate remained unchanged at 70 beats per minute as the blood pressure decreased from 140/80 to 110/70 with adenosine infusion.",3
"PROCEDURE:,1.  Implantation, dual chamber ICD.,2.  Fluoroscopy.,3.  Defibrillation threshold testing.,4.  Venography.,PROCEDURE NOTE: , After informed consent was obtained, the patient was taken to the operating room.  The patient was prepped and draped in a sterile fashion.  Using modified Seldinger technique, the left subclavian vein was attempted to be punctured but unsuccessfully.  Approximately 10 cc of intravenous contrast was injected into the left upper extremity peripheral vein.  Venogram was then performed.  Under fluoroscopy via modified Seldinger technique, the left subclavian vein was punctured and a guidewire was passed through the vein into the superior vena cava, then the right atrium and then into the inferior vena cava.  A second guidewire was placed in a similar fashion.  Approximately a 5 cm incision was made in the left upper anterior chest.  The skin and subcutaneous tissue was dissected out of the prepectoral fascia.  Both guide wires were brought into the pocket area.  A sheath was placed over the lateral guidewire and fluoroscopically guided to the vena cava.  The dilator and guidewire were removed.  A Fixation ventricular lead, under fluoroscopic guidance, was placed through the sheath into the superior vena cava, right atrium and then right ventricle.  Using straight and curved stylettes, it was placed in position and screwed into the right ventricular apex.  After pacing and sensing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscle with Ethibond suture.  A guide sheath was placed over the guidewire and fluoroscopically placed in the superior vena cava.  The dilator and guidewire were removed.  An Active Fixation atrial lead was fluoroscopically passed through the sheath, into the superior vena cava and then the right atrium.  Using straight and J-shaped stylettes, it was placed in the appropriate position and screwed in the right atrial appendage area.  After significant pacing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscles with Ethibond suture.  The tract was flushed with saline solution.  A Medtronic pulse generator was attached to both the leads and fixed to the pectoral muscle with Ethibond suture.  Deep and superficial layers were closed with 3-0 Vicryl in a running fashion.  Steri-strips were placed over the incision.  Tegaderm was placed over the Steri-strips.  Pressure dressing was applied to the pocket area.",3
"EXAM: , MRI of the brain without contrast.,HISTORY: , Daily headaches for 6 months in a 57-year-old.,TECHNIQUE:  ,Noncontrast axial and sagittal images were acquired through the brain in varying degrees of fat and water weighting.,FINDINGS: , The brain is normal in signal intensity and morphology for age.  There are no extraaxial fluid collections.  There is no hydrocephalus/midline shift.  Posterior fossa, 7th and 8th nerve complexes and intraorbital contents are within normal limits.  The normal vascular flow volumes are maintained.  The paranasal sinuses are clear.,Diffusion images demonstrate no area of abnormally restricted diffusion that suggests acute infarct.,IMPRESSION: , Normal MRI brain.  Specifically, no findings to explain the patient's headaches are identified.",22
"EXAM: , CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.,REASON FOR EXAM:,  A 68-year-old status post fall with multifocal pain.,COMPARISONS: , None.,TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast.  Additional high-resolution sagittal and/or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures.,INTERPRETATIONS:,HEAD:,There is mild generalized atrophy.  Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes.  There are subtle areas of increased attenuation seen within the frontal lobes bilaterally.  Given the patient's clinical presentation, these likely represent small hemorrhagic contusions.  Other differential considerations include cortical calcifications, which are less likely.  The brain parenchyma is otherwise normal in attenuation without evidence of mass, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  The visualized paranasal sinuses and mastoid air cells are clear.  The bony calvarium and skull base are unremarkable.,FACIAL BONES:,The osseous structures about the face are grossly intact without acute fracture or dislocation.  The orbits and extra-ocular muscles are within normal limits.  There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses.  The remaining visualized paranasal sinuses and mastoid air cells are clear.  Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture.,CERVICAL SPINE:,There is mild generalized osteopenia.  There are diffuse multilevel degenerative changes identified extending from C4-C7 with disk space narrowing, sclerosis, and marginal osteophyte formation.  The remaining cervical vertebral body heights are maintained without acute fracture, dislocation, or spondylolisthesis.  The central canal is grossly patent.  The pedicles and posterior elements appear intact with multifocal facet degenerative changes.  There is no prevertebral or paravertebral soft tissue masses identified.  The atlanto-dens interval and dens are maintained.,IMPRESSION:,1.Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions.  There is no associated shift or mass effect at this time.  Less likely, this finding could be secondary to cortical calcifications.  The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated.,2.Atrophy and chronic small vessel ischemic changes in the brain.,3.Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture.,4.Osteopenia and multilevel degenerative changes in the cervical spine as described above.,5.Findings were discussed with Dr. X from the emergency department at the time of interpretation.",33
"PROCEDURES PERFORMED: , C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.,ESTIMATED BLOOD LOSS: , 10 mL.,CLINICAL NOTE: , This is a 57-year-old gentleman with refractory neck pain with single-level degeneration of the cervical spine and there was also some arm pain.  We decided go ahead with anterior cervical discectomy at C5-C6 and fusion.  The risks of lack of pain relief, paralysis, hoarse voice, nerve injuries, and infection were explained and the patient agreed to proceed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room where a general endotracheal anesthesia was induced without complication.  The patient was placed in the slightly extended position with the neck and the head was restrained in a doughnut and the occiput was restrained by the doughnut.  He had tape placed over the shoulders during intraoperative x-rays and his elbows were well padded.  The tape was placed and his arms were well padded.  He was prepped and draped in a sterile fashion.  A linear incision was fashioned at the cricothyroid level from near the midline to over the sternocleidomastoid muscle.  We separated the platysma from the subcutaneous tissue and then opened the platysma along the medial border of the sternocleidomastoid muscle.  We then dissected sharply medial to carotid artery, which we palpated to the prevertebral region.  We placed Caspar retractors for medial and lateral exposure over the C5-C6 disc space, which we confirmed with the lateral cervical spine x-ray including 18-gauge needle in the disc space.  We then marked the disc space.  We then drilled off ventral osteophyte as well as osteophyte creating concavity within the disc space.  We then under magnification removed all the disc material, we could possibly see down to bleeding bone and both the endplates.  We took down posterior longitudinal ligament as well.  We incised the 6-mm cornerstone bone.  We placed a 6-mm parallel medium bone nicely into the disc space.  We then sized a 23-mm plate.  We inserted the screws nicely above and below.  We tightened down the lock-nuts.  We irrigated the wound.  We assured hemostasis using bone wax prior to placing the plate.  We then assured hemostasis once again.  We reapproximated the platysma using 3-0 Vicryl in a simple interrupted fashion.  The subcutaneous level was closed using 3-0 Vicryl in a simple buried fashion.  The skin was closed with 3-0 Monocryl in a running subcuticular stitch.  Steri-Strips were applied.  Dry sterile dressing with Telfa was applied over this.  We obtained an intraoperative x-ray to confirm the proper level and good position of both plates and screw construct on the lateral x-ray and the patient was transferred to the recovery room, moving all four extremities with stable vital signs.  I was present as a primary surgeon throughout the entire case.",37
"TITLE OF OPERATION: , Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,INDICATION FOR SURGERY: , The patient with a large 3.5 cm acoustic neuroma.  The patient is having surgery for resection.  There was significant cerebellar peduncle compression.  The tumor was very difficult due to its size as well as its adherence to the brainstem and the nerve complex.  The case took 12 hours.  This was more difficult and took longer than the usual acoustic neuroma.,PREOP DIAGNOSIS: , Right acoustic neuroma.,POSTOP DIAGNOSIS: , Right acoustic neuroma.,PROCEDURE:,  The patient was brought to the operating room.  General anesthesia was induced in the usual fashion.  After appropriate lines were placed, the patient was placed in Mayfield 3-point head fixation, hold into a right park bench position to expose the right suboccipital area.  A time-out was settled with nursing and anesthesia, and the head was shaved, prescrubbed with chlorhexidine, prepped and draped in the usual fashion.  The incision was made and cautery was used to expose the suboccipital bone.  Once the suboccipital bone was exposed under the foramen magnum, the high speed drill was used to thin out the suboccipital bone and the craniectomy carried out with Leksell and insertion with Kerrison punches down to the rim of the foramen magnum as well as laterally to the edge of the sigmoid sinus and superiorly to the edge of the transverse sinus.  The dura was then opened in a cruciate fashion, the cisterna magna was drained, which nicely relaxed the cerebellum.  The dura leaves were held back with the 4-0 Nurolon.  The microscope was then brought into the field, and under the microscope, the cerebellar hemisphere was elevated.  Laterally, the arachnoid was very thick.  This was opened with bipolar and microscissors and this allowed for the cerebellum to be further mobilized until the tumor was identified.  The tumor was quite large and filled up the entire lateral aspect of the right posterior fossa.  Initially two retractors were used, one on the tentorium and one inferiorly.  The arachnoid was taken down off the tumor.  There were multiple blood vessels on the surface, which were bipolared.  The tumor surface was then opened with microscissors and the Cavitron was used to began debulking the lesion.  This was a very difficult resection due to the extreme stickiness and adherence to the cerebellar peduncle and the lateral cerebellum; however, as the tumor was able to be debulked, the edge began to be mobilized.  The redundant capsule was bipolared and cut out to get further access to the center of the tumor.  Working inferiorly and then superiorly, the tumor was taken down off the tentorium as well as out the 9th, 10th or 11th nerve complex.  It was very difficult to identify the 7th nerve complex.  The brainstem was identified above the complex.  Similarly, inferiorly the brainstem was able to be identified and cotton balls were placed to maintain this plain.  Attention was then taken to try identify the 7th nerve complex.  There were multitude of veins including the lateral pontine vein, which were coming right into this area.  The lateral pontine vein was maintained.  Microscissors and bipolar were used to develop the plain, and then working inferiorly, the 7th nerve was identified coming off the brainstem.  A number 1 and number 2 microinstruments were then used to began to develop the plane.  This then allowed for the further appropriate plane medially to be identified and cotton balls were then placed.  A number 11 and number 1 microinstrument continued to be used to free up the tumor from the widely spread out 7th nerve.  Cavitron was used to debulk the lesion and then further dissection was carried out.  The nerve stimulated beautifully at the brainstem level throughout this.  The tumor continued to be mobilized off the lateral pontine vein until it was completely off.  The Cavitron was used to debulk the lesion out back laterally towards the area of the porus.  The tumor was debulked and the capsule continued to be separated with number 11microinstrument as well as the number 1 microinstrument to roll the tumor laterally up towards the porus.  At this point, the capsule was so redundant, it was felt to isolate the nerve in the porus.  There was minimal bulk remaining intracranially.  All the cotton balls were removed and the nerve again stimulated beautifully at the brainstem.  Dr. X then came in and scrubbed into the case to drill out the porus and remove the piece of the tumor that was left in the porus and coming out of the porus.,I then scrubbed back into case once Dr. X had completed removing this portion of the tumor.  There was no tumor remaining at this point.  I placed some Norian in the porus to seal any air cells, although there were no palpated.  An intradural space was then irrigated thoroughly.  There was no bleeding.  The nerve was attempted to be stimulated at the brainstem level, but it did not stimulate at this time.  The dura was then closed with 4-0 Nurolons in interrupted fashion.  A muscle plug was used over one area.  Duragen was laid and strips over the suture line followed by Hemaseel.  Gelfoam was set over this and then a titanium cranioplasty was carried out.  The wound was then irrigated thoroughly.  O Vicryls were used to close the deep muscle and fascia, 3-0 Vicryl for subcutaneous tissue, and 3-0 nylon on the skin.,The patient was extubated and taken to the ICU in stable condition.",23
"PROCEDURES:,1.  Chest x-ray on admission, no acute finding, no interval change.,2.  CT angiography, negative for pulmonary arterial embolism.,3.  Nuclear myocardial perfusion scan, abnormal.  Reversible defect suggestive of ischemia, ejection fraction of 55%.,DIAGNOSES ON DISCHARGE:,1.  Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.,2.  Coronary artery disease, abnormal nuclear scan, discussed with Cardiology Dr. X, who recommended to discharge the patient and follow up in the clinic.,3.  Diabetes mellitus type 2.,4.  Anemia, hemoglobin and hematocrit stable.,5.  Hypokalemia, replaced.,6.  History of coronary artery disease status post stent placement 2006-2008.,7.  Bronchitis.,HOSPITAL COURSE:  ,The patient is a 65-year-old American-native Indian male, past medical history of heavy tobacco use, history of diabetes mellitus type 2, chronic anemia, COPD, coronary artery disease status post stent placement, who presented in the emergency room with increasing shortness of breath, cough productive for sputum, and orthopnea.  The patient started on IV steroid, bronchodilator as well as antibiotics.,He also complained of chest pain that appears to be more pleuritic with history of coronary artery disease and orthopnea.  He was evaluated by Cardiology Dr. X, who proceeded with stress test.  Stress test reported positive for reversible ischemia, but Cardiology decided to follow up the patient in the clinic.  The patient's last cardiac cath was in 2008.,The patient clinically significantly improved and wants to go home.  His hemoglobin on admission was 8.8, and has remained stable.  He is afebrile, hemodynamically stable.,ALLERGIES: , LISINOPRIL AND PENICILLIN.,MEDICATIONS ON DISCHARGE:,1.  Prednisone tapering dose 40 mg p.o. daily for three days, then 30 mg p.o. daily for three days, then 20 mg p.o. daily for three days, then 10 mg p.o. daily for three days, and 5 mg p.o. daily for two days.,2.  Levaquin 750 mg p.o. daily for 5 more days.,3.  Protonix 40 mg p.o. daily.,4.  The patient can continue other current home medications at home.,FOLLOWUP APPOINTMENTS:,1.  Recommend to follow up with Cardiology Dr. X's office in a week.,2.  The patient is recommended to see Hematology Dr. Y in the office for workup of anemia.,3.  Follow up with primary care physician's office tomorrow.,SPECIAL INSTRUCTIONS:,1.  If increasing shortness of breath, chest pain, fever, any acute symptoms to return to emergency room.,2.  Discussed about discharge plan, instructions with the patient by bedside.  He understands and agreed.  Also discussed discharge plan instructions with the patient's nurse.",10
"CHIEF COMPLAINT: , Polycythemia rubra vera.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old female with a history of polycythemia vera.  She comes in to clinic today for followup.  She has not required phlebotomies for several months.  The patient comes to clinic unaccompanied.,CURRENT MEDICATIONS: , Levothyroxine 200 mcg q.d., Nexium 40 mg q.d., Celebrex 200 mg q.d., vitamin D3 2000 IU q.d., aspirin 81 mg q.d., selenium 200 mg q.d., Aricept 10 mg q.d., Skelaxin 800 mg q.d., ropinirole 1 mg q.d., vitamin E 1000 IU q.d., vitamin C 500 mg q.d., flaxseed oil 100 mg daily, fish oil 100 units q.d., Vicodin q.h.s., and stool softener q.d.,ALLERGIES:  ,Penicillin.,REVIEW OF SYSTEMS:  ,The patient's chief complaint is her weight.  She brings in a packet of information on HCZ Diovan and also metabolic assessment that was done at the key.  She has questions as to whether or not there would be any contra indications to her going on the diet.  Otherwise, she feels great.  She had family reunion in Iowa once in four days out there.  She continues to volunteer Hospital and is walking and enjoying her summer.  She denies any fevers, chills, or night sweats.  She has some mild constipation problem but has had under control.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:",16
"PREOPERATIVE DIAGNOSIS:,  Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Right inguinal hernia.,ANESTHESIA: , General.,PROCEDURE:  ,Right inguinal hernia repair.,INDICATIONS: , The patient is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.  He had an inguinal hernia on physical exam in the Pediatric Surgery Clinic and is here now for elective repair.  We met with his parents and explained the surgical technique, risks, and talked to them about trying to perform a diagnostic laparoscopic look at the contralateral side to rule out an occult hernia.  All their questions have been answered and they agreed with the plan.,OPERATIVE FINDINGS:  ,The patient had a well developed, but rather thin walled hernia sac on the right.  The thinness of hernia sac made it difficult to safely cannulate through the sac for the laparoscopy.  Therefore, high ligation was performed, and we aborted the plan for laparoscopic view of the left side.,DESCRIPTION OF PROCEDURE: , The patient came to operating room and had an uneventful induction of general anesthesia.  Surgical time-out was conducted while we were preparing and draping his abdomen with chlorhexidine based prep solution.  During our time-out, we reiterated the patient's name, medical record number, weight, allergies status, and planned operative procedure.  I then infiltrated 0.25% Marcaine with dilute epinephrine in the soft tissues around the inguinal crease in the right lower abdomen chosen for hernia incision.  An additional aliquot of Marcaine was injected deep to the external oblique fascia performing the ilioinguinal and iliohypogastric nerve block.  A curvilinear incision was made with a scalpel and a combination of electrocautery and some blunt dissection and scissor dissection was used to clear the tissue layers through Scarpa fascia and expose the external oblique.  After the oblique layers were opened, the cord structure were identified and elevated.  The hernia sac was carefully separated from the spermatic cord structures and control of the sac was obtained.  Dissection of the hernia sac back to the peritoneal reflection at the level of deep inguinal ring was performed.  I attempted to gently pass a 3-mm trocar through the hernia sac, but it was rather difficult and I became fearful that the sac would be torn in proximal control and mass ligation would be less effective.  I aborted the laparoscopic approach and performed a high ligation using transfixing and a simple mass ligature of 3-0 Vicryl.  The excess sac was trimmed and the spermatic cord structures were replaced.  The external oblique fascia and Scarpa layers were closed with interrupted 3-0 Vicryl and skin was closed with subcuticular 5-0 Monocryl and Steri-Strips.  The patient tolerated the operation well.  Blood loss was less than 5 mL.  The hernia sac was submitted for specimen, and he was then taken to the recovery room in good condition.",37
"DISCHARGE DIAGNOSES:,1.  Bilateral lower extremity cellulitis secondary to bilateral tinea pedis.,2.  Prostatic hypertrophy with bladder outlet obstruction.,3.  Cerebral palsy.,DISCHARGE INSTRUCTIONS: , The patient would be discharged on his usual Valium 10-20 mg at bedtime for spasticity, Flomax 0.4 mg daily, cefazolin 500 mg q.i.d., and Lotrimin cream between toes b.i.d. for an additional two weeks.  He will be followed in the office.,HISTORY OF PRESENT ILLNESS:,  This is a pleasant 62-year-old male with cerebral palsy.  The patient was recently admitted to Hospital with lower extremity cellulitis.  This resolved, however, recurred in both legs.  Examination at the time of this admission demonstrated peeling of the skin and excoriation between all of his toes on both feet consistent with tinea pedis.,PAST MEDICAL/FAMILY/SOCIAL HISTORY:,  As per the admission record.,REVIEW OF SYSTEMS: , As per the admission record.,PHYSICAL EXAMINATION:  ,As per the admission record.,LABORATORY STUDIES: , At the time of admission, his white blood cell count was 8200 with a normal differential, hemoglobin 13.6, hematocrit 40.6 with normal indices, and platelet count was 250,000.  Comprehensive metabolic profile was unremarkable, except for a nonfasting blood sugar of 137, lactic acid was 0.8.  Urine demonstrated 4-9 red blood cells per high-powered field with 2+ bacteria.  Blood culture and wound cultures were unremarkable.  Chest x-ray was unremarkable.,HOSPITAL COURSE: , The patient was admitted to the General Medical floor and treated with intravenous ceftriaxone and topical Lotrimin.  On this regimen, his lower extremity edema and erythema resolved quite rapidly.,Because of urinary frequency, a bladder scan was done suggesting about 600 cc of residual urine.  A Foley catheter was inserted and was productive of approximately 500 cc of urine.  The patient was prescribed Flomax 0.4 mg daily.  24 hours later, the Foley catheter was removed and a bladder scan demonstrated 60 cc of residual urine after approximately eight hours.,At the time of this dictation, the patient was ambulating minimally, however, not sufficiently to resume independent living.",10
"CHIEF COMPLAINT AND IDENTIFICATION:,  A is a 23-month-old girl, who has a history of reactive airway disease who is being treated on an outpatient basis for pneumonia who presents with cough and fever.,HISTORY OF PRESENT ILLNESS: , The patient is to known to have reactive airway disease and uses Pulmicort daily and albuterol up to 4 times a day via nebulization.,She has no hospitalizations.,The patient has had a 1 week or so history of cough.  She was seen by the primary care provider and given amoxicillin for yellow nasal discharge according to mom.  She has been taking 1 teaspoon every 6 hours.  She originally was having some low-grade fever with a maximum of 100.4 degrees Fahrenheit; however, on the day prior to admission, she had a 104.4 degrees Fahrenheit temperature, and was having posttussive emesis.  She is using her nebulizer, but the child was in respiratory distress, and this was not alleviated by the nebulizer, so she was brought to Children's Hospital Central California.,At Children's Hospital, the patient was originally treated as an asthmatic and was receiving nebulized treatments; however, a chest x-ray did show right-sided pneumonia, and the patient was hypoxemic after resolution of her respiratory distress, so the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,REVIEW OF SYSTEMS: , Negative except that indicated in the history of present illness.  All systems were checked.,PAST MEDICAL HISTORY: , As stated in the history of present illness, no hospitalizations, no surgeries.,IMMUNIZATIONS: , The patient is up-to-date on her shots.  She has a schedule for her 2-year-old shot soon.,ALLERGIES: , No known drug allergies.,DEVELOPMENT HISTORY: , Developmentally, she is within normal limits.,FAMILY HISTORY:,  Her maternal uncles have asthma.  There are multiple family members on the maternal side that have diabetes mellitus, otherwise the family history is negative for other chronic medical conditions.,SOCIAL HISTORY: , Her sister has a runny nose, but no other sick contacts.  The family lives in Delano.  She lives with her mom and sister.  The dad is involved, but the parents are separated.  There is no smoking exposure.,PHYSICAL EXAMINATION:,  ,GENERAL:  The child was in no acute distress.,VITAL SIGNS:  Temperature 99.8 degrees Fahrenheit, heart rate 144, respiratory rate 28.  Oxygen saturations 98% on continuous.  Off of oxygen shows 85% laying down on room air.  The T-max in the ER was 101.3 degrees Fahrenheit.,SKIN:  Clear.,HEENT:  Pupils were equal, round, react to light.  No conjunctival injection or discharge.  Tympanic membranes were clear.  No nasal discharge.  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly, or masses.,CHEST:  Clear to auscultation bilaterally; no tachypnea, wheezing, or retractions.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds are present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses, nontender to palpation.,GENITOURINARY:  No inguinal lymphadenopathy.  Tanner stage I female.,EXTREMITIES:  Symmetric in length.  No joint effusions.  She moves all extremities well.,BACK:  Straight.  No spinous defects.,NEUROLOGIC:  The patient has a normal neurologic exam.  She is sitting up solo in bed, gets on her knees, stands up, is playful, smiles, is interactive.  She has no focal neurologic deficits.,LABORATORY DATA: , Chest x-ray by my reading shows a right lower lobe infiltrate.  Metabolic panel:  Sodium 139, potassium 3.5, chloride 106, total CO2 22, BUN and creatinine are 5 and 0.3 respectively, glucose 84, CRP 4.3.  White blood cell count 13.7, hemoglobin and hematocrit 9.6 and 29.9 respectively, and platelets 294,000.  Differential of the white count 34% lymphocytes, 55% neutrophils.,ASSESSMENT AND PLAN: , This is a 22-month-old girl, who has an infiltrate on the x-ray, hypoxemia, and presented in respiratory distress.  I believe, she has bacterial pneumonia, which is partially treated by her amoxicillin, which is a failure of her outpatient treatment.  She will be placed on the pneumonia pathway and started on cefuroxime to broaden her coverage.  She is being admitted for hypoxemia.  I hope that this will resolve overnight, and she will be discharged in the morning.  I will start her home medications of Pulmicort twice daily and albuterol on a p.r.n. basis; however, at this point, she has no wheezing, so no systemic steroids will be instituted.,Further interventions will depend on the clinical course.",3
"INDICATIONS FOR PROCEDURE:, A 51-year-old, obese, white female with positive family history of coronary disease and history of chest radiation for Hodgkin disease 20 years ago with no other identifiable risk factors who presents with an acute myocardial infarction with elevated enzymes. The chest pain occurred early Tuesday morning. She was treated with Plavix, Lovenox, etc., and transferred for coronary angiography and possible PCI. The plan was discussed with the patient and all questions answered.,PROCEDURE NOTE:, Following sterile prep and drape, the right groin and instillation of 1% Xylocaine anesthesia, the right femoral artery was percutaneously entered with a single wall puncture. A 6-French sheath inserted. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricle pressures, and a left ventriculography. The left pullback pressure. The catheters withdrawn. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. She tolerated the procedure well.,Left ventricular end-diastolic pressure equals 25 mmHg post A wave. No aortic valve or systolic gradient on pullback.,ANGIOGRAPHIC FINDINGS:,I. Left coronary artery: The left main coronary artery is,normal. The left anterior descending extends to the apex and has only minor luminal irregularities within the midportion of the vessel. Normal diagonal branches. Normal septal perforator branches. The left circumflex is a nondominant vessel with only minor irregularities with normal obtuse marginal branches.,II. Right coronary artery: The proximal right coronary artery has a focal calcification. There is minor plaque with luminal irregularity in the proximal and midportion of the vessel with no narrowing greater than 10 to 20% at most. The right coronary artery is a dominant system which gives off normal posterior,descending and posterior lateral branches. TIMI 3 flow is present.,III. Left ventriculogram: The left ventricle is slightly enlarged with normal contraction of the base, but, with wall motion abnormality involving the anteroapical and inferoapical left ventricle with hypokinesis within the apical portion. Ejection fraction estimated 40%, 1+ mitral regurgitation (echocardiogram ordered).,DISCUSSION:, Recent inferoapical mild myocardial infarction by left ventriculography and cardiac enzymes with elevated left ventricular end-diastolic pressure post A wave, but, only minor residual coronary artery plaque with calcification proximal right coronary artery.,PLAN:, Medical treatment is contemplated, including ACE inhibitor, a beta blocker, aspirin, Plavix, nitrates. An echocardiogram is ordered to exclude apical left ventricular thrombus and to further assess ejection fraction.",3
"PREPROCEDURE DIAGNOSIS:,  Left leg claudication.,POSTPROCEDURE DIAGNOSIS: ,  Left leg claudication.,OPERATION PERFORMED: , Aortogram with bilateral, segmental lower extremity run off.,ANESTHESIA: , Conscious sedation.,INDICATION FOR PROCEDURE:  ,The patient presents with lower extremity claudication.  She is a 68-year-old woman, who is very fearful of the aforementioned procedures.  Risks and benefits of the procedure were explained to her to include bleeding, infection, arterial trauma requiring surgery, access issues and recurrence.  She appears to understand and agrees to proceed.,DESCRIPTION OF PROCEDURE: , The patient was taken to the Angio Suite, placed in a supine position.  After adequate conscious sedation, both groins were prepped with Chloraseptic prep.  Cloth towels and paper drapes were placed.  Local anesthesia was administered in the common femoral artery and using ultrasound guidance, the common femoral artery was accessed.  Guidewire was threaded followed by a ,4-French sheath.  Through the 4-French sheath a 4-French Omni flush catheter was placed.  The glidewire was removed and contrast administered to identify the level of the renal artery.  Using power injector an aortogram proceeded.,The catheter was then pulled down to the aortic bifurcation.  A timed run-off view of both legs was performed and due to a very abnormal and delayed run-off in the left, I opted to perform an angiogram of the left lower extremity with an isolated approach.  The catheter was pulled down to the aortic bifurcation and using a glidewire, I obtained access to the contralateral left external iliac artery.  The Omni flush catheter was advanced to the left distal external iliac artery.  The glidewire rather exchanged for an Amplatz stiff wire.  This was left in place and the 4-French sheath removed and replaced with a 6-French destination 45-cm sheath.  This was advanced into the proximal superficial femoral artery and an angiogram performed.  I identified a functionally occluded distal superficial femoral artery and after obtaining views of the run off made plans for angioplasty.,The patient was given 5000 units of heparin and this was allowed to circulate.  A glidewire was carefully advanced using Roadmapping techniques through the functionally occluded blood vessels.  A 4-mm x 4-cm angioplasty balloon was used to dilate the area in question.,Final views after dilatation revealed a dissection.  A search for a 5-mm stent was performed, but none of this was available.  For this reason, I used a 6-mm x 80-mm marked stent and placed this at the distal superficial femoral artery.  Post dilatation was performed with a 4-mm angioplasty balloon.  Further views of the left lower extremity showed irregular change in the popliteal artery.  No significant stenosis could be identified in the left popliteal artery and noninvasive scan.  For this reason, I chose not to treat any further areas in the left leg.,I then performed closure of the right femoral artery with a 6-French Angio-Seal device.  Attention was turned to the left femoral artery and local anesthesia administered.  Access was obtained with the ultrasound and the femoral artery identified.  Guidewire was threaded followed by a 4-French sheath.  This was immediately exchanged for the 6-French destination sheath after the glidewire was used to access the distal external iliac artery.  The glidewire was exchanged for the Amplatz stiff wire to place the destination sheath.  The destination was placed in the proximal superficial femoral artery and angiogram obtained.  Initial views had been obtained from the right femoral sheath before removal.,Views of the right superficial femoral artery demonstrated significant stenosis with accelerated velocities in the popliteal and superficial femoral artery.  For this reason, I performed the angioplasty of the superficial femoral artery using the 4-mm balloon.  A minimal dissection plane measuring less than 1 cm was identified at the proximal area of dilatation.  No further significant abnormality was identified.  To avoid placing a stent in the small vessel I left it alone and approached the popliteal artery.  A 3-mm balloon was chosen to dilate a 50 to 79% popliteal artery stenosis.  Reasonable use were obtained and possibly a 4-mm balloon could have been used.  However, due to her propensity for dissection I opted not to.  I then exchanged the glidewire for an O1 for Thruway guidewire using an exchange length.  This was placed into the left posterior tibial artery.  A 2-mm balloon was used to dilate the orifice of the posterior tibial artery.  I then moved the wire to the perineal artery and dilated the proximal aspect of this vessel.  Final images showed improved run-off to the right calf.  The destination sheath was pulled back into the left external iliac artery and an Angio-Seal deployed.,FINDINGS: , Aortogram demonstrates a dual right renal artery with the inferior renal artery supplying the lower one third of the right renal parenchyma.  No evidence of renal artery stenosis is noted bilaterally.  There is a single left renal artery.  The infrarenal aorta, both common iliac and the external iliac arteries are normal.  On the right, a superficial femoral artery is widely patent and normal proximally.  At the distal third of the thigh there is diffuse disease with moderate stenosis noted.  Moderate stenosis is also noted in the popliteal artery and single vessel run-off through the posterior tibial artery is noted.  The perineal artery is functionally occluded at the midcalf.  The dorsal pedal artery filled by collateral at the high ankle level.,On the left, the proximal superficial femoral artery is patent.  Again, at the distal third of the thigh, there is a functional occlusion of the superficial femoral artery with poor collateralization to the high popliteal artery.  This was successfully treated with angioplasty and a stent placement.  The popliteal artery is diffusely diseased without focal stenosis.  The tibioperoneal trunk is patent and the anterior tibial artery occluded at its orifice.,IMPRESSION,1.  Normal bilateral renal arteries with a small accessory right renal artery.,2.  Normal infrarenal aorta as well as normal bilateral common and external iliac arteries.,3.  The proximal right renal artery is normal with moderately severe stenosis in the superficial femoral popliteal and tibial arteries.  Successful angioplasty with reasonable results in the distal superficial femoral, popliteal and proximal posterior tibial artery as described.,4.  Normal proximal left superficial femoral artery with functional occlusion of the distal left superficial femoral artery successfully treated with angioplasty and stent placement.  Run-off to the left lower extremity is via a patent perineal and posterior tibial artery.",3
"SUBJECTIVE:,  The patient comes in today for a comprehensive evaluation.  She is well-known to me.  I have seen her in the past multiple times.,PAST MEDICAL HISTORY/SOCIAL HISTORY/FAMILY HISTORY: , Noted and reviewed today.  They are on the health care flow sheet.  She has significant anxiety which has been under fair control recently.  She has a lot of stress associated with a son that has some challenges.  There is a family history of hypertension and strokes.,CURRENT MEDICATIONS:,  Currently taking Toprol and Avalide for hypertension and anxiety as I mentioned.,REVIEW OF SYSTEMS:,  Significant for occasional tiredness.  This is intermittent and currently not severe.  She is concerned about the possibly of glucose abnormalities such diabetes.  We will check a glucose, lipid profile and a Hemoccult test also and a mammogram.  Her review of systems is otherwise negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  As above.,GENERAL:  The patient is alert, oriented, in no acute distress.,HEENT:  PERRLA.  EOMI.  TMs clear bilaterally.  Nose and throat clear.,NECK:  Supple without adenopathy or thyromegaly.  Carotid pulses palpably normal without bruit.,CHEST:  No chest wall tenderness.,BREAST EXAM:  No asymmetry, skin changes, dominant masses, nipple discharge, or axillary adenopathy.,HEART:  Regular rate and rhythm without murmur, clicks, or rubs.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Soft, nontender, bowel sounds normoactive.  No masses or organomegaly.,GU:  External genitalia without lesions.  BUS normal.  Vulva and vagina show just mild atrophy without any lesions.  Her cervix and uterus are within normal limits.  Ovaries are not really palpable.  No pelvic masses are appreciated.,RECTAL:  Negative.,BREASTS:  No significant abnormalities.,EXTREMITIES:  Without clubbing, cyanosis, or edema.  Pulses within normal limits.,NEUROLOGIC:  Cranial nerves II-XII intact.  Strength, sensation, coordination, and reflexes all within normal limits.,SKIN:  Noted to be normal.  No subcutaneous masses noted.,LYMPH SYSTEM:  No lymphadenopathy.,ASSESSMENT:,  Generalized anxiety and hypertension, both under fair control.,PLAN:,  We will not make any changes in her medications.  I will have her check a lipid profile as mentioned, and I will call her with that.  Screening mammogram will be undertaken.  She declined a sigmoidoscopy at this time.  I look forward to seeing her back in a year and as needed.",15
"REASON FOR EXAM: , Aortic valve replacement.  Assessment of stenotic valve.  Evaluation for thrombus on the valve.,PREOPERATIVE DIAGNOSIS:  ,Atrial valve replacement.,POSTOPERATIVE DIAGNOSES:,  Moderate stenosis of aortic valve replacement.  Mild mitral regurgitation.  Normal left ventricular function.,PROCEDURES IN DETAIL: , The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient received a total of 3 mg of Versed and 50 mcg of fentanyl for conscious sedation and pain control.  The oropharynx anesthetized with benzocaine spray and lidocaine solution.,Esophageal intubation was done with no difficulty with the second attempt.  In a semi-Fowler position, the probe was passed to transthoracic views at about 40 to 42 cm.  Multiple pictures obtained.  Assessment of the peak velocity was done later.,The probe was pulled to the mid esophageal level.  Different pictures including short-axis views of the aortic valve was done.  Extubation done with no problems and no blood on the probe.  The patient tolerated the procedure well with no immediate postprocedure complications.,INTERPRETATION: , The left atrium was mildly dilated.  No masses or thrombi were seen.  The left atrial appendage was free of thrombus.  Pulse wave interrogation showed peak velocities of 60 cm per second.,The left ventricle was normal in size and contractility with mild LVH.  EF is normal and preserved.,The right atrium and right ventricle were both normal in size.,Mitral valve showed no vegetations or prolapse.  There was mild-to-moderate regurgitation on color flow interrogation.  Aortic valve was well-seated mechanical valve, bileaflet with acoustic shadowing beyond the valve noticed.  No perivalvular leak was noticed.  There was increased velocity across the valve with peak velocity of 3.2 m/sec with calculated aortic valve area by continuity equation at 1.2 cm2 indicative of moderate aortic valve stenosis based on criteria for native heart valves.,No AIC.,Pulmonic valve was somewhat difficult to see because of acoustic shadowing from the aortic valve.  Overall showed no abnormalities.  The tricuspid valve was structurally normal.,Interatrial septum appeared to be intact, confirmed by color flow interrogation as well as agitated saline contrast study.,The aorta and aortic arch were unremarkable.  No dissection.,IMPRESSION:,1.  Mildly dilated left atrium.,2.  Mild-to-moderate regurgitation.,3.  Well-seated mechanical aortic valve with peak velocity of 3.2 m/sec and calculated valve area of 1.2 cm2 consistent with moderate aortic stenosis.  Reevaluation in two to three years with transthoracic echocardiogram will be recommended.",3
"CHIEF COMPLAINT:, ""Trouble breathing."",HISTORY OF PRESENT ILLNESS:, A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. Approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. Approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. On the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. On arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. She denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. She denied any history of IVDA, tattoos, or high risk sexual behavior. She did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an IVC filter had been placed in Germany . She had been living in the United States for years, and had had no recent travel. She denied any occupational exposures. Before the onset of her shortness of breath she had been very active and had exercised regularly.,PAST MEDICAL HISTORY:,  Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis.  Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed.  Psoriasis.  She denied any history of miscarriage.,PAST SURGICAL HISTORY:,  IVC filter placement 1999.",15
"EXAM:,  Single frontal view of the chest.,HISTORY:,  Respiratory distress.  The patient has a history of malrotation.  The patient is back for a re-anastomosis of the bowel with no acute distress.,TECHNIQUE:,  Single frontal view of the chest was evaluated and correlated with the prior film dated MM/DD/YY.,FINDINGS:,  A single frontal view of the chest was evaluated.  It reveals interval placement of an ET tube and an NG tube.  ET tube is midway between the patient's thoracic inlet and carina.  NG tube courses with the distal tip in the left upper quadrant beneath the left hemidiaphragm.  There is no evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions.  The mediastinum seen was slightly prominent; however, this may be secondary to thymus and/or technique.  There is a slight increase seen with regards to the central pulmonary vessels.  Again, this may represent a minimal amount of pulmonary vascular congestion.  There is paucity of bowel gas seen in the upper abdomen.  The osseous thorax appears to be grossly intact and symmetrical.  Slightly low lung volumes, however, this may be secondary to the film being taken on the expiratory phase of respiration.,IMPRESSION:,1.  No evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions.,2.  Slight prominence to the mediastinum which may be secondary to thymus and/or technique.,3.  Slight prominence of some of the central pulmonary vasculature which may represent a minimal amount of vascular congestion.",33
"MULTISYSTEM EXAM,CONSTITUTIONAL:  ,The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  The patient appeared alert.,EYES:  ,The conjunctiva was clear.  The pupil was equal and reactive.  There was no ptosis.  The irides appeared normal.,EARS, NOSE AND THROAT:  ,The ears and the nose appeared normal in appearance.  Hearing was grossly intact.  The oropharynx showed that the mucosa was moist.  There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK:  ,The neck was supple.  The thyroid gland was not enlarged by palpation.,RESPIRATORY:  ,The patient's respiratory effort was normal.  Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR:  ,Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted.  The extremities showed no edema.,GASTROINTESTINAL: , The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  Bowel sounds were present.,GU: , The scrotal elements were normal.  The testes were without discrete mass.  The penis showed no lesion, no discharge.,LYMPHATIC:  ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL:  ,The head and neck by inspection showed no obvious deformity.  Again, the extremities showed no obvious deformity.  Range of motion appeared to be normal for the upper and lower extremities.,SKIN: , Inspection of the skin and subcutaneous tissues appeared to be normal.  The skin was pink, warm and dry to touch.,NEUROLOGIC:  ,Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.,PSYCHIATRIC: , The patient was oriented to time, place and person.  The patient's judgment and insight appeared to be normal.",25
"PROCEDURE:  ,Laparoscopic tubal sterilization, tubal coagulation.,PREOPERATIVE DIAGNOSIS: , Request tubal coagulation.,POSTOPERATIVE DIAGNOSIS: , Request tubal coagulation.,PROCEDURE:  ,Under general anesthesia, the patient was prepped and draped in the usual manner.  Manipulating probe placed on the cervix, changed gloves.  Small cervical stab incision was made, Veress needle was inserted without problem.  A 3 L of carbon dioxide was insufflated.  The incision was enlarged.  A 5-mm trocar placed through the incision without problem.  Laparoscope placed through the trocar.  Pelvic contents visualized.  A 2nd puncture was made 2 fingerbreadths above the symphysis pubis in the midline.  Under direct vision, the trocar was placed in the abdominal cavity.  Uterus, tubes, and ovaries were all normal.  There were no pelvic adhesions, no evidence of endometriosis.  Uterus was anteverted and the right adnexa was placed on a stretch.  The tube was grasped 1 cm from the cornual region, care being taken to have the bipolar forceps completely across the tube and the tube was coagulated using amp meter for total desiccation.  The tube was grasped again and the procedure was repeated for a separate coagulation, so that 1.5 cm of the tube was coagulated.  The structure was confirmed to be tube by looking at fimbriated end.  The left adnexa was then placed on a stretch and the procedure was repeated again grasping the tube 1 cm from the cornual region and coagulating it.  Under traction, the amp meter was grasped 3 more times so that a total of 1.5 cm of tube was coagulated again.  Tube was confirmed by fimbriated end.  Gas was lend out of the abdomen.  Both punctures repaired with 4-0 Vicryl and punctures were injected with 0.5% Marcaine 10 mL.  The patient went to the recovery room in good condition.",24
"PREOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1.  Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS:  ,Approximately 1000 cc.,CELL SAVER RETURNED:  ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain.  He had previous lumbar laminectomy at L4-L5.  He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable.  He is suffering from neurogenic claudication.  He was unresponsive to extensive conservative treatment.  He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia.  He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded.  His lumbar spine was then sterilely prepped and draped in the usual fashion.  A previous midline incision was extended from approximate level of L3 to S1.  This was in the midline.  Skin and subcutaneous tissue were debrided sharply.  Electrocautery provided hemostasis.  ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia.  The lumbar fascia was identified and split in the midline.  Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1.  Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4.  Once this was completed, a self-retaining retractor was then placed.  With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable.  These were readily mobile with digital palpation.  A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1.  This bone was morcellized and placed on the back table for utilization for bone grafting.  The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1.  Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained.  Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1.  The microscope was utilized during this portion of procedure for visualization.  There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure.  Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5.  Once this was identified, foraminotomies were created to allow additional mobility.  The wound was then copiously irrigated with antibiotic solution and suctioned dry.  Working type screws, provisional titanium screws were then placed at L4-l5.  This was to allow distraction and reduction of the spondylolisthesis.  These were placed in the pedicles of L4 and L5 under direct intensification.  The position of the screws were visualized, both AP and lateral images.  They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5.  This allowed for additional decompression of the L5 and L4 nerve roots.  Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed.  Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval.  This was taken in sequence up to a 13 mm space.  This was then reduced to a 11 mm as it was much more anatomic in nature.  Once this was completed, the spacers were then placed on the left side and distraction obtained.  Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally.  Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried.  A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft.  There were impacted at the interspace of L4-L5 under direct image intensification.  Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried.  The provisional screws and plates were removed.  This allowed for additional compression along L4-L5 with the cage instrumentation.  Permanent screws were then placed at L4, L5, and S1 bilaterally.  This was performed under direct image intensification.  The position was verified in both AP and lateral images.  Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally.  A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1.  Appropriate cross connecters were applied and the construct was placed over the pedicle screws.  They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra.  Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory.  All connections were tightened and retightened in Torque 2 specifications.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The dura was inspected and noted to be free of tension.  At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors.  An 8-inch Hemovac drain was placed exiting the wound.  The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin.  The remainder of the Hemovac was assembled.  Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape.  He was turned and taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded.",27
"REASON FOR CONSULTATION:,  Thrombocytopenia.,HISTORY OF PRESENT ILLNESS:,  Mrs. XXX is a 17-year-old lady who is going to be 18 in about 3 weeks.  She has been referred for the further evaluation of her thrombocytopenia.  This thrombocytopenia was detected on a routine blood test performed on the 10th of June 2006.  Her hemoglobin was 13.3 with white count of 11.8 at that time.  Her lymphocyte count was 6.7.  The patient, subsequently, had a CBC repeated on the 10th at Hospital where her hemoglobin was 12.4 with a platelet count of 26,000.  She had a repeat of her CBC again on the 12th of June 2006 with hemoglobin of 14, white count of 11.6 with an increase in the number of lymphocytes.  Platelet count was 38.  Her rapid strep screen was negative but the infectious mononucleosis screen is positive.  The patient had a normal platelet count prior too and she is being evaluated for this low platelet count.,The patient gives a history of feeling generally unwell for a couple of days towards the end of May.  She was fine for a few days after that but then she had sore throat and fever 2-3 days subsequent to that.  The patient continues to have sore throat.,She denies any history of epistaxis.  Denies any history of gum bleeding.  The patient denies any history of petechiae.  She denies any history of abnormal bleeding.  Denies any history of nausea, vomiting, neck pain, or any headaches at the present time.,The patient was accompanied by her parents.,PAST MEDICAL HISTORY: , Asthma.,CURRENT MEDICATIONS: , Birth control pills, Albuterol, QVAR and Rhinocort.,DRUG ALLERGIES: , None.,PERSONAL HISTORY: , She lives with her parents.,SOCIAL HISTORY:,  Denies the use of alcohol or tobacco.,FAMILY HISTORY: , Noncontributory.,OCCUPATION: , The patient is currently in school.,REVIEW OF SYSTEMS:,Constitutional:  The history of fever about 2 weeks ago.,HEENT:  Complains of some difficulty in swallowing.,Cardiovascular:  Negative.,Respiratory:  Negative.,Gastrointestinal:  No nausea, vomiting, or abdominal pain.,Genitourinary:  No dysuria or hematuria.,Musculoskeletal:  Complains of generalized body aches.,Psychiatric:  No anxiety or depression.,Neurologic:  Complains of episode of headaches about 2-3 weeks ago.,PHYSICAL EXAMINATION:  ,She was not in any distress.  She appears her stated age.  Temperature 97.9.  Pulse 84.  Blood pressure was 110/60.  Weighs 162 pounds.  Height of 61 inches.  Lungs - Normal effort.  Clear.  No wheezing.  Heart - Rate and rhythm regular.  No S3, no S4.  Abdomen - Soft.  Bowel sounds are present.  No palpable hepatosplenomegaly.  Extremities - Without any edema, pallor, or cyanosis.  Neurological:  Alert and oriented x 3.  No focal deficit.  Lymph Nodes - No palpable lymphadenopathy in the neck or the axilla.  Skin examination reveals few petechiae along the lateral aspect of the left thigh but otherwise there were no ecchymotic patches.,DIAGNOSTIC DATA: , The patient's CBC results from before were reviewed.  Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000.,IMPRESSION: , ITP, the patient has a normal platelet count.,PLAN:,1.  I had a long discussion with family regarding the treatment of ITP.  In view of the fact that the patient's platelet count is 26,000 and she is asymptomatic, we will continue to monitor the counts.,2.  An ultrasound of the abdomen will be performed tomorrow.,3.  I have given her a requisition to obtain some blood work tomorrow.",16
"DIAGNOSIS:,  Polycythemia vera with secondary myelofibrosis.,REASON FOR VISIT:, Followup of the above condition.,CHIEF COMPLAINT: , Left shin pain.,HISTORY OF PRESENT ILLNESS: , A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis.  Diagnosis was made some time in 2005/2006.  Initially, he underwent phlebotomy.  He subsequently transferred his care here.  In the past, he has been on hydroxyurea and interferon but did not tolerate both of them.  He is JAK-2 positive.  He does not have any siblings for a match-related transplant.  He was seen for consideration of a MUD transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health.,At our institution, the patient received a trial of lenalidomide and prednisone for a short period.  He did well with the combination.  Subsequently, he developed intolerance to lenalidomide.  He complained of severe fatigue and diarrhea.  This was subsequently stopped.,The patient reports some injury to his left leg last week.  His left leg apparently was swollen.  He took steroids for about 3 days and stopped.  Left leg swelling has disappeared.  The patient denies any other complaints at this point in time.  He admits to smoking marijuana.  He says this gives him a great appetite and he has actually gained some weight.  Performance status in the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS:  He is afebrile.  Blood pressure 144/85, pulse 86, weight 61.8 kg, and respiratory rate 18 per minute.  GENERAL:  He is in no acute distress.  HEENT:  There is no pallor, icterus or cervical adenopathy that is noted.  Oral cavity is normal to exam.  CHEST:  Clear to auscultation.  CARDIOVASCULAR:  S1 and S2 normal with regular rate and rhythm.  ABDOMEN:  Soft and nontender with no hepatomegaly.  Spleen is palpable 4 fingerbreadths below the left costal margin.  There is no guarding, tenderness, rebound or rigidity noted.  Bowel sounds are present.  EXTREMITIES:  Reveal no edema.  Palpation of the left tibia revealed some mild tenderness.  However, I do not palpate any bony abnormalities.  There is no history of deep venous thrombosis.,LABORATORY DATA: , CBC from today is significant for a white count of 41,900 with an absolute neutrophil count of 34,400, hemoglobin 14.8 with an MCV of 56.7, and platelet count 235,000.,ASSESSMENT AND PLAN:,1.  JAK-2 positive myeloproliferative disorder.  The patient has failed pretty much all available options.  He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.  I have e-mailed Dr. X to see whether he will be a candidate for the LBH trial.  Hopefully, we can get a JAK-2 inhibitor trial quickly on board.,2.  I am concerned about the risk of thrombosis with his elevated white count.  He is on aspirin prophylaxis.  The patient has been told to call me with any complaints.,3.  Left shin pain.  I have ordered x-rays of the left tibia and knee today.  The patient will return to the clinic in 3 weeks.  He is to call me in the interim for any problems.",16
"PREOPERATIVE DIAGNOSIS (ES):, Left supracondylar, intercondylar distal femur fracture.,POSTOPERATIVE DIAGNOSIS (ES):, Left supracondylar, intercondylar distal femur fracture.,PROCEDURE:, Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture (27513).,OPERATIVE FINDINGS:, He had intercondylar split, and then he had a medial Hoffa fracture. He also had some comminution of the medial femoral condyle which prohibited an anatomic key between the two segments of the medial condyle.,IMPLANTS:, We used 2.4 and 3.5 cortical screws, as well as a LISS Synthes femoral locking plate.,COMPLICATIONS:, None.,IV FLUIDS:, 2000,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, 40 mL,URINE OUTPUT:, 650,HISTORY: ,This 45-year-old male had a ground-level fall, sustaining this injury. He was admitted for definitive operative fixation. Risks and benefits were discussed, he agreed to go ahead with the procedure.,DESCRIPTION OF THE OPERATION:, The patient was identified in preop holding, then taken to the operating room. Once adequate anesthesia was obtained, his left lower extremity was prepped and draped in a routine sterile fashion. He was given antibiotics. He placed a traction pin through his proximal tibia, and pulled weight off the end of the bed. I made a midline approach and then did the lateral parapatellar arthrotomy. We excised some of the fat pad to give us better visibility into the notch. We excised a good bit of his synovium and synovial pouch. At this time we were able to identify the fracture fragments. Again, there was an intercondylar split and then two free pieces of the medial condyle. The femur fracture was very distal through the metaphysis. At this time we thoroughly cleaned out all the clot between all the fracture fragments and cleaned the cortical margins.,Next we began the reduction. There was no reduction key between the two segments of the Hoffa fracture. Therefore, we reduced the anterior portion of the medial condyle to the lateral condyle, held it with point-of-reduction clamp and K-wires, and then secured it with 2.4 mini fragment lag screws. Next, with this medial anterior piece in place, we had some contour over the notch with which we were able to reduce the posterior medial Hoffa fragment. This gave us a nice notch contour. Again, there was some comminution laterally so that the fracture between the Hoffa segments did not have a perfect key. Once we had it reduced, based on the notch reduction, we then held it with K-wires. We secured it with two 3.5 cortical screws from the lateral condyle into this posterior segment. We then secured it with 2.4 cortical screws from the anterior medial to the posterior medial segment just subchondral. Then, finally, we secured it with a 3.5 cortical screw from the anterior medial to the posterior medial piece. All screws ran between and out of the notch.,With the condyle now well reduced, we reduced it to the metaphysis. We slid a 13-hole LISS plate submuscularly. We checked on AP and lateral views that showed we had good reduction of the fracture and appropriate plate placement. We placed the tip threaded guidewire through the A-hole of the plate jig and got it parallel to the joint. We then clamped the plate down to the bone. Proximally, we made a stab incision for the trocar at the 13-hole position, placed our tip threaded guidewire in the lateral aspect of the femur, checked it on lateral view, and had it in good position.,With the jig in appropriate position and clamped, we then proceeded to fill the distal locking screws to get purchase into the condyles. We then placed multiple unicortical locking screws in the shaft and metaphyseal segment. Our most proximal screw was proximal to the tip of the prosthesis.,At this time we took the jig off and put the final screw into the A-hole of the plate. We then took final C-arm views which showed we had a good reduction on AP and lateral views, the plate was in good position, we had full range of motion of the knee, and good reduction clinically and radiographically. We then pulse lavaged the knee with 3 liters of fluid. We closed the quad tendon and lateral retinaculum with interrupted 0 Vicryl over a Hemovac drain. Subdermal tissue was closed with 2-0 Vicryl, skin with staples. Sterile dressing and a hinged knee brace were applied. The patient was awakened from anesthesia and taken to Recovery in stable condition.,PLAN:,1. Nonweightbearing for 3 months.,2. CPM for 0 to 90 degrees as tolerated.",27
"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.",27
"PROCEDURE:,  Esophagogastroduodenoscopy with biopsy.,REASON FOR PROCEDURE:,  The child with history of irritability and diarrhea with gastroesophageal reflux.  Rule out reflux esophagitis, allergic enteritis, and ulcer disease, as well as celiac disease.  He has been on Prevacid 7.5 mg p.o. b.i.d. with suboptimal control of this irritability.,Consent history and physical examinations were performed.  The procedure, indications, alternatives available, and complications i.e. bleeding, perforation, infection, adverse medication reactions, possible need for blood transfusion, and surgery associated complication occur were discussed with the mother who understood and indicated this.  Opportunity for questions was provided and informed consent was obtained.,MEDICATIONS:  ,General anesthesia.,INSTRUMENT: , Olympus GIF-XQ 160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FINDINGS: , With the patient in the supine position intubated under general anesthesia, the endoscope was inserted without difficulty into the hypopharynx.  The proximal, mid, and distal esophagus had normal mucosal coloration and vascular pattern.  Lower esophageal sphincter appeared normal and was located at 25 cm from the central incisors.  A Z-line was identified within the lower esophageal sphincter.  The endoscope was advanced into the stomach, which was distended with excess air.  The rugal folds flattened completely.  The gastric mucosa was entirely normal.  No hiatal hernia was seen and the pyloric valve appeared normal.  The endoscope was advanced into first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  Ampule of Vater was identified and found to be normal.  Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology.  Additional two antral biopsies were obtained for CLO testing.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated the procedure well.  The patient was taken to recovery room in satisfactory condition.,IMPRESSION:,  Normal esophagus, stomach, and duodenum.,PLAN:,  Histologic evaluation and CLO testing.  Continue Prevacid 7.5 mg p.o. b.i.d.  I will contact the parents next week with biopsy results and further management plans will be discussed at that time.",37
"REASON FOR CONSULT:  ,I was asked to see the patient for C. diff colitis.,HISTORY OF PRESENTING ILLNESS: , Briefly, the patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff for which she was admitted here in 5/2009, who presents to the hospital on 6/18/2009 with abdominal pain, cramping, and persistent diarrhea.  After admission, she had a CT of the abdomen done, which showed evidence of diffuse colitis and she was started on IV Flagyl and also on IV Levaquin.  She was also placed on IV Reglan because of nausea and vomiting.  In spite of the above, her white count still continues to be elevated today.  On questioning the patient, she states the nausea and vomiting has resolved, but the diarrhea still present, but otherwise denies any other specific complaints except for some weakness.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, recent C. diff colitis, which had resolved based on speaking to Dr. X.  Two weeks ago, he had seen the patient and she was clinically well.,PAST SURGICAL HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,No history of smoking, alcohol, or drug use.  She lives at home.,HOME MEDICATIONS:  ,She is on atenolol and Mevacor.,ALLERGIES:  NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:  ,Positive for diarrhea and abdominal pain, otherwise main other complaints are weakness.  She denies any cough, sputum production, or dysuria at this time.  Otherwise, a 10-system review is essentially negative.,PHYSICAL EXAM:,GENERAL:  She is awake and alert, currently in no apparent distress.,VITAL SIGNS:  She has been afebrile since admission, temperature today 96.5, heart rate 80, respirations 18, blood pressure 125/60, and O2 sat is 98% on 2 L.,HEENT:  Pupils are round and reactive to light and accommodation.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  S1 and S2 are present.  No rales appreciated.,ABDOMEN:  She does have tenderness to palpation all over with some mild rebound tenderness also.  No guarding noted.  Bowel sounds present.,EXTREMITIES:  No clubbing, cyanosis, or edema.,CT of the abdomen and pelvis is also reviewed on the computer, which showed evidence of diffuse colitis.,LABORATORY: , White blood cell count today 21.5, hemoglobin 12.4, platelet count 284,000, and neutrophils 89.  UA on 6/18/2009 showed no evidence of UTI.  Sodium today 130, potassium 2.7, and creatinine 0.4.  AST and ALT on 6/20/2009 were normal.  Blood cultures from admission were negative.  Urine culture on admission was negative.  C. diff was positive.  Stool culture was negative.,ASSESSMENT:,1.  A 72-year-old female with Clostridium difficile colitis.,2.  Diarrhea secondary to above and also could be related Reglan, which was discontinued today.,3.  Leukocytosis secondary to above, mild improvement today though.,4.  Bilateral pleural effusion by CT of the chest, although could represent thickening.,5.  New requirement for oxygen, rule out pneumonia.,6.  Hypertension.,PLAN:,1.  Treat the C. diff aggressively especially given CT appearance and her continued leukocytosis and because of the Levaquin, which could have added additional antibiotic pressure, so I will restart the IV Flagyl.,2.  Continue p.o. vancomycin.  Add Florastor to help replenish the gut flora.,3.  Monitor WBCs closely and follow clinically and if there is any deterioration in her clinical status, I would recommend getting surgical evaluation immediately for surgery if needed.,4.  We will check a chest x-ray especially given her new requirement for oxygen.",15
"XYZ, M.D. ,Suite 123, ABC Avenue ,City, STATE 12345 ,RE:  XXXX, XXXX ,MR#:  0000000,Dear Dr. XYZ: ,XXXX was seen in followup in the Pediatric Urology Clinic.  I appreciate you speaking with me while he was in clinic.  He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ,When I examined him, he seems to indicate that his pain is essentially in the lower abdomen in the suprapubic region; however, on actual physical examination, he seems to complain of pain through his entire right side.  His parents have brought up the question of whether this could be gastrointestinal in origin and that is certainly an appropriate consideration.  They also feel that since he has been on Detrol, his pain levels have been somewhat worse, and so, I have given them the option of stopping the Detrol initially.  I think he should stay on MiraLax for management of his bowels.  I would also suggest that he be referred to Pediatric Gastroenterology for evaluation.  If they do not find any abnormalities from a gastrointestinal perspective, then the next step would be to endoscope his bladder and then make sure that he does not have any evidence of bladder anatomic abnormalities that is leading to this pain. ,Thank you for following XXXX along with us in Pediatric Urology Clinic.  If you have any questions, please feel free to contact me. ,Sincerely yours,",38
"XYZ, S.,RE:  ABC,Dear Dr. XYZ,On your kind referral, I had the pleasure of meeting and consulting with ABC on MM/DD/YYYY for evaluation regarding extraction of his mandibular left second molar tooth #18.  This previously root-canaled tooth, now failed, is scheduled for removal.  As per your request, I agree that placement of an implant in the #20 and #19 positions would allow for immediate functional replacement of the bridge which has recently been lost in this area.,I have given Mr. ABC an estimate for the surgical aspects of this case and suggested he combine this with your prosthetic or restorative fees in order to have a full understanding of the costs involved with this process.,We will plan to place two Straumann implants as per our normal protocol, one each in the #19 and 20 positions, with the #19 implant being a wide-neck, larger diameter implant.  I will plan on providing the prosthetic abutments, the lab analogue, and temporary healing cap at the end of the four-month integration period.  If you have any additional suggestions or concerns, please give me a call.,Best regards,,",7
"The patient and his wife had the opportunity to ask questions, all of which were answered for them and the patient stated in a clear, competent and coherent fashion that he wished to go forward with cardiac catheterization which I felt was appropriate.,PROCEDURE NOTE:  ,The patient was brought to the Cardiac Catheterization Lab in a fasting state.  All appropriate labs had been reviewed.  Bilateral groins were prepped and draped in the usual fashion for sterile conditions.  The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff.  He received a total of 2 mg of Versed and 50 mcg of Fentanyl utilizing titrated concentration with good effect.  Bilateral groins had been prepped and draped in the usual fashion.  Right femoral inguinal fossa was anesthetized with 1% topical lidocaine and a 6-French vascular sheath was put into place percutaneously via guide-wire exchanger with a finder needle.  All catheters were passed using a J-tipped guide-wire.  Left heart catheterization and left ventriculography performed using a 6-French pigtail catheter.  Left system coronary angiography performed using a 6-French JL4 catheter.  Right system coronary angiography performed using a 6-French CDRC catheter.  Following the procedure, all catheters were removed.  Manual pressure was held with the Neptune pad and the patient was discharged back to his room.  I inspected the femoral arteriotomy site after the procedure was complete and it was benign without evidence of hematoma nor bruit with intact distal pulses.  There were no apparent complications.  A total of 77 cc of Isovue dye and 1.4 minutes of fluoroscopy time were utilized during the case.,FINDINGS:,HEMODYNAMICS: , LV pressure is 120, EDP is 20, aortic pressure 120/62, mean of 82.,LV function is normal, EF 60%, no wall motion abnormalities.,CORONARY ANATOMY:,1.  Left main demonstrates 30-40% distal left main lesion which is tapering, not felt significantly obstructive.,2.  The LAD demonstrates proximal moderate 50% lesion and a severe mid-LAD lesion immediately after the take-off of this large diagonal of 99% which is quite severe with TIMI-3 flow throughout the LAD and the left main.,3.  The left circumflex demonstrates mid-90% severe lesion with TIMI-3 flow.,4.  The right coronary artery was the dominant artery giving rise to right posterior descending artery demonstrates mild luminal irregularity.  There is a moderate distal PDA lesion of 60% seen.,IMPRESSION:,1.  Mild to moderate left main stenosis.,2.  Very severe mid-LAD stenosis with severe mid-left circumflex stenosis and moderate prox-LAD CAD.,We are going to continue the patient's aspirin, beta blocker as heart rate tolerates as he tends to run on the bradycardic side and add statin.  We will check a fasting lipid profile and ALT and titrate statin therapy to keep LDL of 70 mg/deciliter or less but in the past the patient's LDL had been higher or high.",37
"PREOPERATIVE DIAGNOSIS:,  Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Left inguinal hernia, direct.,PROCEDURE: , Left inguinal herniorrhaphy, modified Bassini.,DESCRIPTION OF PROCEDURE:  ,The patient was electively taken to the operating room.  In same day surgery, Dr. X applied a magnet to the pacemaker defibrillator that the patient has to change it into a fixed mode and to protect the device from the action of the cautery.  Informed consent was obtained, and the patient was transferred to the operating room where a time-out process was followed and the patient under general endotracheal anesthesia was prepped and draped in the usual fashion.  Local anesthesia was used as a field block and then an incision was made in the left inguinal area and carried down to the external oblique aponeurosis, which was opened.  The cord was isolated and protected.  It was dissected out.  The lipoma of the cord was removed and the sac was high ligated.  The main hernia was a direct hernia due to weakness of the floor.  A Bassini repair was performed.  We used a number of interrupted sutures of 2-0 Tevdek __________ in the conjoint tendon and the ilioinguinal ligament.,The external oblique muscle was approximated same as the soft tissue with Vicryl and then the skin was closed with subcuticular suture of Monocryl.  The dressing was applied and the patient tolerated the procedure well, estimated blood loss was minimal, was transferred to recovery room in satisfactory condition.",37
"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:",15
"PREOPERATIVE DIAGNOSES:,1.  Right carotid stenosis.,2.  Prior cerebrovascular accident.,POSTOPERATIVE DIAGNOSES:,1.  Right carotid stenosis.,2.  Prior cerebrovascular accident.,PROCEDURE PERFORMED:  ,Right carotid endarterectomy with patch angioplasty.,ESTIMATED BLOOD LOSS:  ,250 cc.,OPERATIVE FINDINGS: , The common and internal carotid arteries were opened.  A high-grade narrowing was present at the proximal internal carotid and this tapered well to a slightly small diameter internal carotid.  This was repaired with a Dacron patch and the patient tolerated this well under regional anesthetic without need for shunting.,PROCEDURE:  ,The patient was taken to the operating room, placed in supine position, prepped and draped in the usual sterile manner with Betadine solution.  Longitudinal incisions were made along the anterior border of the sternocleidomastoid, carried down through subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The platysmal muscle was divided.  The carotid sheath was identified and opened.  The vagus nerve, ansa cervicalis, and hypoglossal nerves were identified and avoided.  The common internal and external carotids were then freed from the surrounding tissue.  At this point, 10,000 units of aqueous heparin were administered and allowed to take effect.  The external and common carotids were then clamped.  The patient's neurological status was evaluated and found to be unchanged from preoperative levels.,Once sufficient time had lapsed, we proceeded with the procedure.  The carotid bulb was opened with a #11 blade and extended with Potts scissors through the very tight lesion into normal internal carotid.  The plaque was then sharply excised proximally and an eversion endarterectomy was performed successfully at the external.  The plaque tapered nicely on the internal and no tacking sutures were necessary.  Heparinized saline was injected and no evidence of flapping or other debris was noted.  The remaining carotid was examined under magnification, which showed no debris of flaps present.  At this point, a Dacron patch was brought on to the field, cut to appropriate length and size, and anastomosed to the artery using #6-0 Prolene in a running fashion.  Prior to the time of last stitch, the internal carotid was back-bled through this.  The last stitch was tied.  Hemostasis was excellent.  The internal was again gently occluded while flow was restored to the common and external carotids for several moments and then flow was restored to the entire system.  At this point, a total of 50 mg of Protamine was administered and allowed to take effect.  Hemostasis was excellent.  The wound was irrigated with antibiotic solution and closed in layers using #3-0 Vicryl and #4-0 undyed Vicryl.  The patient was then taken to the recovery room in satisfactory condition after tolerating the procedure well.  Sponge, needles, and instrument count were correct.  Estimated blood loss was 250 cc.",3
"Grade II:  Atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.,Grade III:  Atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.,Grade IV:  The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.,RIGHT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease.  The internal carotid artery shows intimal thickening with some mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  The external carotid artery shows no disease.  The vertebral was present and was antegrade.,LEFT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening, but no increase in velocity and no evidence for any significant obstructive disease. the internal carotid artery shows some intimal thickening with mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  The external carotid artery shows no disease.  The vertebral was present and was antegrade.,IMPRESSION:,  Bilateral atherosclerotic changes with no evidence for any significant obstructive disease.",3
"HISTORY: , The patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.  She was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain, which radiates down into her buttocks and down to posterior aspect of her thigh into her knee.  This has required large amounts of opioid analgesics to control.  She has been basically bedridden because of this.  She was brought into hospital for further investigations.,PHYSICAL EXAMINATION: , On examination, she has positive straight leg rising on the right with severe shooting, radicular type pain with right leg movement.  Difficult to assess individual muscles, but strength is largely intact.  Sensory examination is symmetric.  Deep tendon reflexes reveal hyporeflexia in both patellae, which probably represents a cervical myelopathy from prior cord compression.  She has slightly decreased right versus left ankle reflexes.  The Babinski's are positive.  On nerve conduction studies, motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in lower extremities.,NEEDLE EMG: , Needle EMG was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle.  It reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles.  There is evidence of denervation in right gastrocnemius medialis muscle.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  Inactive right S1 (L5) radiculopathy.,2.  There is no evidence of left lower extremity radiculopathy, peripheral neuropathy or entrapment neuropathy.,Results were discussed with the patient and she is scheduled for imaging studies in the next day.",30
"REASON FOR REFERRAL:,  Evaluation for right L4 selective nerve root block.,CHIEF COMPLAINT:,",28
"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. ",12
"EXAM:,MRI LEFT FOOT,CLINICAL:, A 49-year-old female with ankle pain times one month, without a specific injury. Patient complains of moderate to severe pain, worse with standing or walking on hard surfaces, with tenderness to palpation at the plantar aspect of the foot and midfoot region and tenderness over the course of the posterior tibialis tendon.,FINDINGS:,Received for second opinion interpretations is an MRI examination performed on 05/27/2005.,There is edema of the subcutis adipose space extending along the medial and lateral aspects of the ankle.,There is edema of the subcutis adipose space posterior to the Achilles tendon. Findings suggest altered biomechanics with crural fascial strains.,There is tendinosis of the posterior tibialis tendon as it rounds the tip of the medial malleolus with mild tendon thickening. There is possible partial surface tearing of the anterior aspect of the tendon immediately distal to the tip of the medial malleolus (axial inversion recovery image #16) which is a possible hypertrophic tear less than 50% in cross sectional diameter. The study has been performed with the foot in neutral position. Confirmation of this possible partial tendon tear would require additional imaging with the foot in a plantar flexed position with transaxial images of the posterior tibialis tendon as it rounds the tip of the medial malleolus oriented perpendicular to the course of the posterior tibialis tendon.,There is minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting but intrinsically normal tendons.,Normal peroneal tendons.,There is tendinosis of the tibialis anterior tendon with thickening but no demonstrated tendon tear. Normal extensor hallucis longus and extensor digitorum tendons.,Normal Achilles tendon. There is a low-lying soleus muscle that extends to within 2cm of the teno-osseous insertion of the Achilles tendon.,Normal distal tibiofibular syndesmotic ligamentous complex.,Normal lateral, subtalar and deltoid ligamentous complexes.,There are no erosions of the inferior neck of the talus and there are no secondary findings of a midfoot pronating force.,Normal plantar fascia. There is no plantar calcaneal spur.,There is venous engorgement of the plantar veins of the foot extending along the medial and lateral plantar cutaneous nerves which may be acting as intermittent entrapping lesions upon the medial and lateral plantar cutaneous nerves.,Normal tibiotalar, subtalar, talonavicular and calcaneocuboid articulations.,The metatarsophalangeal joint of the hallux was partially excluded from the field-of-view of this examination.,IMPRESSION:,Tendinosis of the posterior tibialis tendon with tendon thickening and possible surface fraying / tearing of the tendon immediately distal to the tip of the medial malleolus, however, confirmation of this finding would require additional imaging.,Minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths, consistent with flexor splinting.,Edema of the subcutis adipose space along the medial and lateral aspects of the ankle suggesting altered biomechanics and crural fascial strain.,Mild tendinosis of the tibialis anterior tendon with mild tendon thickening.,Normal plantar fascia and no plantar fasciitis.,Venous engorgement of the plantar veins of the foot which may be acting as entrapping lesions upon the medial and lateral plantar cutaneous nerves.",31
"PREOPERATIVE DIAGNOSES:  ,1.  Congenital chylous ascites and chylothorax.,2.  Rule out infradiaphragmatic lymphatic leak.,POSTOPERATIVE DIAGNOSES: , Diffuse intestinal and mesenteric lymphangiectasia.,ANESTHESIA: , General.,INDICATION:  ,The patient is an unfortunate 6-month-old baby boy, who has been hospitalized most of his life with recurrent chylothoraces and chylous ascites.  The patient has been treated somewhat successfully with TPN and voluntary restriction of enteral nutrition, but he had repeated chylothoraces.  Last week, Dr. X took the patient to the operating room in hopes that with thoracotomy, a thoracic duct leak could be found, which would be successfully closed surgically.  However at the time of his thoracotomy exploration what was discovered was a large amount of transdiaphragmatic transition of chylous ascites coming from the abdomen.  Dr. X opened the diaphragm and could literally see a fountain of chylous fluid exiting through the diaphragmatic hole.  This was closed, and we decided that perhaps an abdominal exploration as a last stage effort would allow us to find an area of lymphatic leak that could potentially help the patient from this dismal prognostic disease.  We met with his parents and talked to them about this, and he is here today for that attempt.,OPERATIVE FINDINGS:  ,The patient's abdomen was relatively soft, minimally distended.  Exploration through supraumbilical transverse incision immediately revealed a large amount of chylous ascites upon entering into the peritoneal cavity.  What we found which explains the chronic chylous ascites and chylothorax was a diffuse lymphangiectatic picture involving the small bowel mesentery approximately two thirds to three quarters of the distal small bowel including all of the ileum, the cecum, and the portion of the ascending colon.  It appeared that any attempt to resect this area would have been met with failure because of the extensive lymphatic dilatation all the way down towards the root of the supramesenteric artery.  There was about one quarter to one third of the jejunum that did not appear to be grossly involved, but I did not think that resection of three quarters of the patient's small bowel would be viable surgical option.  Instead, we opted to close his abdomen and refer for potential small intestine transplantation procedure in the future if he is a candidate for that.,The lymphatic abnormality was extensive.  They were linear dilated lymphatic channels on the serosal surface of the bowel in the mesentery.  They were small aneurysm-like pockets of chyle all along the course of the mesenteric structures and in the mesentery medially adjacent to the bowel as well.  No other major retroperitoneal structure or correctable structure was identified.  Both indirect inguinal hernias were wide open and could be palpated from an internal aspect as well.,DESCRIPTION OF OPERATION:  ,The patient was brought from the Pediatric Intensive Care Unit to the operating room within an endotracheal tube im place and with enteral feeds established at full flow to provide maximum fat content and maximum lymphatic flow.  We conducted a surgical time-out and reiterated all of the patient's important identifying information and confirmed the operative plan as described above.  Preparation and draping of his abdomen was done with chlorhexidine based prep solution and then we opened his peritoneal cavity through a transverse supraumbilical incision dividing both rectus muscles and all layers of the abdominal wall fascia.  As the peritoneal cavity was entered, we divided the umbilical vein ligamentum teres remnant between Vicryl ties, and we were able to readily identify a large amount of chylous ascites that had been previously described.  The bowel was eviscerated, and then with careful inspection, we were able to identify this extensive area of intestinal and mesenteric lymphangiectasia that was a source of the patient's chylous ascites.  The small bowel from the ligament of Treitz to the proximal to mid jejunum was largely unaffected, but did not appear that resection of 75% of the small intestine and colon would be a satisfactory tradeoff for The patient, but would likely render him with significant short bowel and nutritional and metabolic problems.  Furthermore, it might burn bridges necessary for consideration of intestinal transplantation in the future if that becomes an option.  We suctioned free all of the chylous accumulations, replaced the intestines to their peritoneal cavity, and then closed the patient's abdominal incision with 4-0 PDS on the posterior sheath and 3-0 PDS on the anterior rectus sheath.  Subcuticular 5-0 Monocryl and Steri-Strips were used for skin closure.,The patient tolerated the procedure well.  He lost minimal blood, but did lose approximately 100 mL of chylous fluid from the abdomen that was suctioned free as part of the chylous ascitic leak.  The patient was returned to the Pediatric Intensive Care Unit with his endotracheal tube in place and to consider the next stage of management, which might be an attempted additional type of feeding or referral to an Intestinal Transplantation Center to see if that is an option for the patient because he has no universally satisfactory medical or surgical treatment for this at this time.",37
"CC: ,BLE weakness and numbness.,HX:, This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,PMH:, 1)CAD with chronic CP, 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13), 4)Anxiety D/O, 5)DJD, 6)Developed confusion with metoprolol use, 7)HTN.,MEDS:, Benadryl, ECASA, Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI, Ipratropium MDI, Folic Acid, Thiamine.,SHX:, 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: ,unremarkable except for ETOH abuse,EXAM:,  T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress.,MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact.,CN: unremarkable.,Motor: Full strength in both upper extremities.,HF HE HAdd HAbd KF KE AF AE,RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout.,SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally.,Gait: unable to walk. Stands with support only.,Station: no pronator drift or truncal ataxia.,Reflexes: 2+/2+ in BUE, 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent.,CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT, ND, NBS, but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole.,COURSE: ,Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine.,He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation.",22
"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.",11
"PREOPERATIVE DIAGNOSIS:,  Refractory priapism.,POSTOPERATIVE DIAGNOSIS:,  Refractory priapism.,PROCEDURE PERFORMED: , Cavernosaphenous shunt.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS:  ,400 cc.,FLUIDS: , IV fluids 1600 crystalloids, one liter packed red blood cells.,INDICATIONS FOR PROCEDURE:  ,This is a 34-year-old African-American male who is known to our service with a history of recurrent priapism.  The patient presented with priapism x48 hours on this visit.  The patient underwent corporal aspiration and Winter's shunt both of which failed and then subsequently underwent _______ procedure.  The patient's priapism did return following this and he was scheduled for cavernosaphenous shunt.,PROCEDURE:,  Informed written consent was obtained.  The patient was taken to the operative suite and administered anesthetic.  The patient was sterilely prepped and draped in the supine fashion.  A #15 French Foley catheter was inserted under sterile conditions.  Incision was made in the left base of the penile shaft on the lateral aspect, approximately 3 cm in length.  Tissue was dissected down to the level of the corpora cavernosum and corpora spongiosum.  The fascia was incised in elliptical fashion for approximately 2 cm.  A #14 gauge Angiocath was inserted into the corpora cavernosum to the glans of the penis and the corpora was irrigated copiously until all of the old clotted blood was removed and fresher irrigation was noted.,Attention was then turned to the left groin and the superficial saphenous vein was harvested.  Due to incisions brought up into the initial incision after gauging enough length, this was then spatulated with Potts scissors for approximately 2 cm.  Vein was irrigated.  One branching vessel was noted to be leaking, this was tied off and repeat injection with heparinized saline showed no additional leaks.  Tunnel was then created from the superior most groin region to the incision in the penile shaft.  Saphenous vein was then passed through this tunnel with the aid of a hemostat.  Anastomosis was performed using #5-0 Prolene suture in a running fashion from proximal to distal.  There were no leaks noted.  There was good flow noted within the saphenous vein graft.  Penis was noted to be in a flaccid state.  All incisions were irrigated copiously and closed in several layers.  Sterile dressings were applied.  The patient was cleaned, transferred to recovery room in stable condition.,PLAN:  ,We will continue with antibiotics for pain control, maintain Foley catheter.  Further recommendations to follow.",37
"PREOPERATIVE DIAGNOSES,1.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2.  Tonsillitis with hypertrophy.,3.  Edema to the uvula and soft palate.,POSTOPERATIVE DIAGNOSES,1.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2.  Tonsillitis with hypertrophy.,3.  Edema to the uvula and soft palate.,OPERATION PERFORMED,1.  Nasal septoplasty.,2.  Bilateral submucous resection of the inferior turbinates.,3.  Tonsillectomy and resection of soft palate.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Chris is a very nice 38-year-old male with nasal septal deviation and bilateral inferior turbinate hypertrophy causing nasal obstruction.  He also has persistent tonsillitis with hypertrophy and tonsillolith and halitosis.  He also has developed tremendous edema to his posterior palate and uvula, which is causing choking.  Correction of these mechanical abnormalities is indicated.,DESCRIPTION OF OPERATION:  ,The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, the right and left nasal septal mucosa and right and left inferior turbinates were anesthetized with 1% lidocaine with 1:100,000 epinephrine using approximately 10 mL.  Afrin-soaked pledgets were placed in the nasal cavity bilaterally.  The face was prepped with pHisoHex and draped in a sterile fashion.  A hemitransfixion incision was performed on the left with a #15 blade and submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator.  Anterior to the septal deflection, the septal cartilage was incised and an opposite-sided submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator.  The deviated portion of the nasal septal cartilage and bone was removed with a Takahashi forceps, and a large inferior septal spur was removed with a V-chisel.  Once the septum was reduced in the midline, the hemitransfixion incision was closed with a 4-0 Vicryl in an interrupted fashion.  The right and left inferior turbinates were trimmed in a submucous fashion using straight and curved turbinate scissors under direct visualization with a 4 mm 0 degree Storz endoscope.  Hemostasis was acquired by using suction electrocautery.  The turbinates were then covered with bacitracin ointment after cauterizing them and bacitracin ointment soaked Doyle splints were placed in the right and left nares and secured anteriorly to the columella with a 3-0 nylon suture.  The table was then turned.  A shoulder roll placed under the shoulders and the face was draped in a clean fashion.  A McIvor mouth gag was applied.  The tongue was retracted and the McIvor was gently suspended from the Mayo stand.  The left tonsil was grasped with a curved Allis forceps, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole to inferior pole using a Bovie electrocautery in its entirety in a subcapsular fashion.  The right tonsil was grasped in a similar fashion, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole to inferior pole using Bovie electrocautery in its entirety in a subcapsular fashion.  The inferior, middle, and superior pole vessels were further cauterized with suction electrocautery.  The extremely edematous portion of soft palate was resected using a right angle clamp and right angle scissor and was closed with 3-0 Vicryl in a figure-of-eight interrupted fashion.  Copious saline irrigation of the oral cavity was then performed.  There was no further identifiable bleeding at the termination of the procedure.  The estimated blood loss was less than 10 mL.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.",11
"HEENT:,  No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.,GASTROINTESTINAL:,  No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems.,GENITOURINARY: , No dysuria, hematuria, frequency, incontinence or colic.,NERVOUS SYSTEM: , No gait problems, strokes, numbness or muscle weakness.,PSYCHIATRIC: , No history of emotional lability, depression or sleep disturbances.,ONCOLOGIC:,  No history of any cancer, change in moles or rashes.  No history of weight loss.  The patient has a good energy level.,ALLERGIC/LYMPH: , No history of systemic allergy, abnormal lymph nodes or swelling.,MUSCULOSKELETAL: , No fractures, motor weakness, arthritis or other joint pains.",25
"INDICATION: , Syncope.,HOLTER MONITOR SUMMARY ANALYSIS: , Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds.  Total beats of 108,489, heart rate minimum of approximately 54 beats per minutes at 7 a.m. and maximum of 106 beats per minute at approximately 4 p.m.  Average heart rate is approximately 75 beats per minute, total of 31 to bradycardia, longest being 225 beats at approximately 7 in the morning, minimum rate of 43 beats per minute at approximately 01:40 a.m.  Total ventricular events of 64, primarily premature ventricular contraction and supraventricular events total beats of 9 atrial premature contractions.  No significant ST elevation noted and ST depression noted only in one channel for approximately three minutes for a maximum of 2.7 mm.,IMPRESSION OF THE FINDINGS: , Predominant sinus rhythm with occasional premature ventricular contraction, occasional atrial premature contractions and Mobitz type 1 Wenckebach, several episodes, Mobitz type II, 3 to 2 AV conduction disease noted as well approximately two episodes and one episode of atrial bigeminy noted.  No significant pauses noted.",3
"PREOPERATIVE DIAGNOSIS:,  Cholelithiasis; possible choledocholithiasis.",14
"PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,NAME OF OPERATION: , Re-excision of squamous cell carcinoma site, right hand.,ANESTHESIA:,  Local with monitored anesthesia care.,INDICATIONS:,  Patient, 72,  status post excision of squamous cell carcinoma on the dorsum of the right hand at the base of the thumb.  The deep margin was positive.  Other margins were clear.  He was brought back for re-excision.,PROCEDURE:,  The patient was brought to the operating room and placed in the supine position.  He was given intravenous sedation.  The right hand was prepped and draped in the usual sterile fashion.  Three cubic centimeters of 1% Xylocaine mixed 50/50 with 0.5% Marcaine with epinephrine was instilled with local anesthetic around the site of the excision, and the site of the cancer was re-excised with an elliptical incision down to the extensor tendon sheath.  The tissue was passed off the field as a specimen.,The wound was irrigated with warm normal saline.  Hemostasis was assured with the electrocautery.  The wound was closed with running 3-0 nylon without complication.  The patient tolerated the procedure well and was taken to the recovery room in stable condition after a sterile dressing was applied.",37
"REASON FOR ADMISSION:,  Intraperitoneal chemotherapy.,HISTORY: , A very pleasant 63-year-old hypertensive, nondiabetic, African-American female with a history of peritoneal mesothelioma.  The patient has received prior intravenous chemotherapy.  Due to some increasing renal insufficiency and difficulties with hydration, it was elected to change her to intraperitoneal therapy.  She had her first course with intraperitoneal cisplatin, which was very difficultly tolerated by her.  Therefore, on the last hospitalization for IP chemo, she was switched to Taxol.  The patient since her last visit has done relatively well.  She had no acute problems and has basically only chronic difficulties.  She has had some decrease in her appetite, although her weight has been stable.  She has had no fever, chills, or sweats.  Activity remains good and she has continued difficulty with depression associated with type 1 bipolar disease.  She had a recent CT scan of the chest and abdomen.  The report showed the following findings.  In the chest, there was a small hiatal hernia and a calcification in the region of the mitral valve.  There was one mildly enlarged mediastinal lymph node.  Several areas of ground-glass opacity were noted in the lower lungs, which were subtle and nonspecific.  No pulmonary masses were noted.  In the abdomen, there were no abnormalities of the liver, pancreas, spleen, and left adrenal gland.  On the right adrenal gland, a 17 x 13 mm right adrenal adenoma was noted.  There were some bilateral renal masses present, which were not optimally evaluated due to noncontrast study.  A hyperdense focus in the lower pole of the left kidney was felt to most probably represent a hemorrhagic renal cyst.  It was unchanged from February and measured 9 mm.  There was again minimal left pelvic/iliac _______ with right and left peritoneal catheters noted and were unremarkable.  Mesenteric nodes were seen, which were similar in appearance to the previous study that was felt somewhat more conspicuous due to opacified bowel adjacent to them.  There was a conglomerate omental mass, which had decreased in volume when compared to previous study, now measuring 8.4 x 1.6 cm.  In the pelvis, there was a small amount of ascites in the right pelvis extending from the inferior right paracolic gutter.  No suspicious osseous lesions were noted.,CURRENT MEDICATIONS: , Norco 10 per 325 one to two p.o. q.4h. p.r.n. pain, atenolol 50 mg p.o. b.i.d., Levoxyl 75 mcg p.o. daily, Phenergan 25 mg p.o. q.4-6h. p.r.n. nausea, lorazepam 0.5 mg every 8 hours as needed for anxiety, Ventolin HFA 2 puffs q.6h. p.r.n., Plavix 75 mg p.o. daily, Norvasc 10 mg p.o. daily, Cymbalta 60 mg p.o. daily, and Restoril 30 mg at bedtime as needed for sleep.,ALLERGIES: , THE PATIENT STATES THAT ON OCCASION LORAZEPAM DOSE PRODUCE HALLUCINATIONS, AND SHE HAD DIFFICULTY TOLERATING ATIVAN.,PHYSICAL EXAMINATION,VITAL SIGNS:  The patient's height is 165 cm, weight is 77 kg.  BSA is 1.8 sq m.  The vital signs reveal blood pressure to be 158/75, heart rate 61 per minute with a regular sinus rhythm, temperature of 96.6 degrees, respiratory rate 18 with an SpO2 of 100% on room air.,GENERAL:  She is normally developed; well nourished; very cooperative; oriented to person, place, and time; and in no distress at this time.  She is anicteric.,HEENT:  EOM is full.  Pupils are equal, round, reactive to light and accommodation.  Disc margins are unremarkable as are the ocular fields.  Mouth and pharynx within normal limits.  The TMs are glistening bilaterally.  External auditory canals are unremarkable.,NECK:  Supple, nontender without adenopathy.  Trachea is midline.  There are no bruits nor is there jugular venous distention.,CHEST:  Clear to percussion and auscultation bilaterally.,HEART:  Regular rate and rhythm without murmur, gallop, or rub.,BREASTS:  Unremarkable.,ABDOMEN:  Slightly protuberant.  Bowel tones are present and normal.  She has no palpable mass, and there is no hepatosplenomegaly.,EXTREMITIES:  Within normal limits.,NEUROLOGICAL:  Nonfocal.,DIAGNOSTIC IMPRESSION,1.  Intraperitoneal mesothelioma, partial remission, as noted by CT scan of the abdomen.,2.  Presumed left lower pole kidney hemorrhagic cyst.,3.  History of hypertension.,4.  Type 1 bipolar disease.,PLAN: , The patient will have appropriate laboratory studies done.  A left renal ultrasound is requested to further delineate the possible hemorrhagic cyst in the lower left pole of the left kidney.  Interventional radiology will access for ports in the abdomen.  She will receive chemotherapy intraperitoneally.  The plan will be to use intraperitoneal Taxol.",16
"REVIEW OF SYSTEMS,GENERAL:  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY:  Negative rash, negative jaundice.,HEMATOPOIETIC:  Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC:  Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS:  Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  Negative postnasal drip, negative sore throat.,CARDIOVASCULAR:  Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL:  Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY:  Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.  **No history of OB/GYN problems.,MUSCULOSKELETAL:  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC:  See psychiatric evaluation.,ENDOCRINE:  No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.",25
"LEFT LOWER EXTREMITY VENOUS DOPPLER ULTRASOUND,REASON FOR EXAM: , Status post delivery five weeks ago presenting with left calf pain.,INTERPRETATIONS: , There was normal flow, compression and augmentation within the right common femoral, superficial femoral and popliteal veins.  Lymph nodes within the left inguinal region measure up to 1 cm in short-axis.,IMPRESSION: , Lymph nodes within the left inguinal region measure up to 1 cm in short-axis, otherwise no evidence for left lower extremity venous thrombosis.",3
"PREOPERATIVE DIAGNOSIS: , Incidental right adnexal mass on ultrasound.,POSTOPERATIVE DIAGNOSES:,1.  Complex left ovarian cyst.,2.  Bilateral complex adnexae.,3.  Bilateral hydrosalpinx.,4.  Chronic pelvic inflammatory disease.,5.  Massive pelvic adhesions.,PROCEDURE PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Enterolysis.,4.  Lysis of the pelvic adhesions.,5.  Left salpingo-oophorectomy.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,SPECIMENS: , Endometrial curettings and left ovarian mass.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,DRAINS:,  None.,FINDINGS: , On bimanual exam, the patient has a slightly enlarged, anteverted, freely mobile uterus with an enlarged left adnexa.  Laparoscopically, the patient has massive pelvic adhesions with completely obliterated posterior cul-de-sac and adnexa.,No adnexal structures were initially able to be visualized until after the lysis of adhesions.  Eventually we found a normal appearing right ovary, severely scarred right and left fallopian tubes, and a enlarged complex cystic left ovary.  There was a normal-appearing appendix and liver, and the vesicouterine junction appeared within normal limits.  There were significant adhesions from the small bowel to the bilateral adnexa in the posterior surface of the uterus.,PROCEDURE:  ,The patient was taken to the operating room where a general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  Next, a weighted speculum was placed in the vagina and anterior wall of the vagina was elevated with the uterine sound and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterus was then sounded to 12 cm.  The cervix was then serially dilated with Hank dilators to a size #20 Hank.  Next a Telfa pad was placed on the weighted speculum and a short curettage was performed obtaining a large amount of endometrial tissue.  Next, the uterine manipulator was placed in the cervix and attached to the anterior lip of the cervix.  At this point, the vulsellum tenaculum and weighted speculum were removed.  Next, attention was turned to the abdomen where an approximately 2 cm incision was made immediately inferior to the umbilicus.  The superior aspect of the umbilicus was grasped with a towel clamp and Veress needle was inserted through this incision.  Small amount of normal saline was injected into Veress needle and seemed to drop freely.  So, the Veress needle was connected to he CO2 gas, which was started at the lower setting.  It was seen to flow freely with a normal resistance so the gas was advanced to the higher setting.  The abdomen was then insufflated to an adequate distention.  Next, the Veress needle was removed and a size #11 step trocar was inserted.  Next, the introducer was removed from the trocar and the laparoscope was inserted through this port and the port was also connected to the CO2 gas.  At this point, the initial operative findings were seen.  Next, a size #5 step trocar was inserted approximately two fingerbreadths above the pubic symphysis in the midline.  This was done by making a 1 cm incision with the skin knife, introducing a Veress needle with Ethicon sheet, and the Veress needle was then removed and the #5 port was introduced under direct visualization.  A size #5 port was also placed approximately six fingerbreadths to the right of the umbilicus in a similar manner also under direct visualization.  A blunt probe was inserted suprapubically along with a grasper in the right upper quadrant.  These were used to see the above operative findings.  Next, a size #12 mm port was introduced approximately seven fingerbreadths to the left of the umbilicus under direct visualization.  Through this, a Harmonic scalpel was inserted.,The Harmonic scalpel along with the grasper was used to meticulously address the adhesions along the right adnexa in the posterior cul-de-sac.  Care was taken at all times to avoid the bowel and the ureters.  The fallopian tubes appeared massively scarred and completely obliterated from disease.  After the right adnexa had been freed to the point where we could visualize the ovary and the posterior cul-de-sac was clearing off then we could visualize the uterosacral ligaments.  Attention was turned to the left adnexa, which appeared to contain a cystic structure, but it was unclear at the beginning of the procedure what the structure was.  Adhesions were carefully taken down from the bowel to the left fallopian tube and ovary, and sidewall.  The adhesions were then carefully removed from the inferior aspect of the ovary also with the Harmonic scalpel.  At intermittent points throughout the procedure, the suction irrigator was used to irrigate and suck blood and irrigation out of the pelvis to watch for any bleeding.  At this point, the Harmonic scalpel was removed and another laparoscopic needle with a 60 cc syringe was inserted and this was used to aspirate approximately 30 cc of serosanguineous fluid from the cystic structure.  Next, the needle was removed and the ligature device was inserted.  This was used to clamp across the fallopian tube initially and then after the fallopian tube was ligated, the uterovarian ligament was clamped and ligated with the ligature device.  Next, the fallopian tube was removed from the ovary with the ligature device in approximately 3 clamping and ligations.  Then, the attention was turned to the inferior aspect of the ovary.  First the infundibulopelvic ligament was identified, clamped with a ligature device, and ligated.  Next, the ovary was bluntly dissected from the ovarian fossa with attention to the left ureter.  Next, the ligature device was used to clamp and ligate the broad ligament immediately inferior to the ovary across.  Then the ovary was completely bluntly dissected out of the ovarian fossa and completely separated from the pelvis.  This was grasped with a clamp.  The ligature device was removed from the #12 and a EndoCatch bag was inserted to the size #12 port.  The left ovary was placed in this EndoCatch bag, which was then removed along with the whole port from the left upper quadrant.  Next, the pelvis was copiously irrigated and suctioned of all blood and extra fluid.  At this point, the remaining two size #5 ports were removed under direct visualization.  The camera was removed and the abdomen was desufflated.  Next, an introducer was replaced on a #11 port.  The #11 port was removed.  Next, the fascia in the left upper quadrant port was identified and grasped with Ochsner clamps, tented up, and closed with a single interrupted suture of #0 Vicryl on a UR-6 needle.  Next, all skin incisions were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion.  The incisions were cleaned, injected with 0.25% Marcaine, and then adjusted with Steri-Strips and bandage appropriately.,The patient was taken from the operating room in stable condition and should be observed overnight in the hospital.",24
"SUBJECTIVE:,  This is a 12-year-old male who comes in for healthy checkups and sports physical.  No major concerns today.  He is little bit congested at times.  He has been told he is allergic to grasses.  They have done over-the-counter Claritin and that seems to help but he is always sniffling mother reports.  He has also got some dryness on his face as far as the skin and was wondering what cream he could put on.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Very healthy.,CURRENT MEDICATIONS:,  Claritin p.r.n.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home currently.,DIETARY:,  He is on whole milk and does a variety of foods.  Growth chart is reviewed with mother.  Voids and stools well.,DEVELOPMENTAL:,  He is in seventh grade and going out for cross-country and track.  He is supposed to be wearing glasses, is not today.  We did not test his vision because he recently saw the eye doctor though we did discuss the need for him to wear glasses with mother.  His hearing was normal today and no concerns with speech.,PHYSICAL EXAMINATION:,General:  A well-developed, well-nourished male in no acute distress.,Dermatologic:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes are present bilaterally.  Optic discs are sharp with normal vasculature.  Ears:  Tympanic membranes are gray, translucent with normal light reflex.  Nares are very congested.  Turbinates swollen and boggy.,Neck:  Supple without masses.,Chest:  Clear to auscultation and percussion, easy respirations.  No accessory muscle use.,Cardiovascular:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,Back:  Symmetric with no scoliosis or kyphosis noted.  Normal flexibility.  Femoral pulses 2+ and symmetric.,Abdomen:  Soft, nontender, nondistended without hepatosplenomegaly.,GU Exam:  Normal Tanner III male.  Testes descended bilaterally.  No abnormal rash, discharge, or scars.,Extremities:  Pink and warm.  Moves all extremities well with normal function and strength in the arms and legs.  Normal balance, station, and gait.  Normal speech.,Neurologic:  Nonfocal with normal speech, station, gait, and balance.,ASSESSMENT:,  Healthy Tanner III male, developing normally.,PLAN:,1.  Diet, growth, safety, drugs, violence, and social competence all discussed.,2.  Immunizations reviewed.,3.  We will place him on Clarinex 5 mg once daily, some Rhinocort-AQ nasal spray one spray each nostril once daily and otherwise discussed the importance of him wearing glasses.,4.  Return to clinic p.r.n. and at two to three years for a physical, otherwise return p.r.n.",5
"CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY,PROCEDURE: , Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time.  Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV.  Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.,Retrospective ECG gating was performed.  The patient received 0.4 milligrams of sublingual nitroglycerin prior to the to the scan.  The average heart rate was 62 beats/min.,The patient had no adverse reaction to the contrast.  Multiphase retrospective reconstructions were performed.  Small field of view cardiac and coronary images were analyzed on a 3D work station.  Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease.,CORONARY CTA:,1.  The technical quality of the scan is adequate.,2.  The coronary ostia are in their normal position.  The coronary anatomy is right dominant.,3.  LEFT MAIN:  The left main coronary artery is patent without angiographic stenosis.,4.  LEFT ANTERIOR DESCENDING ARTERY:  The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30% in stenosis severity.  Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities.,5.  The ramus intermedius is a small vessel with minor irregularities.,6.  LEFT CIRCUMFLEX:  The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis.,7.  RIGHT CORONARY ARTERY:  The right coronary artery is a large and dominant vessel.  It demonstrates within its mid-segment calcified atherosclerosis, less than 50% stenosis severity.  Left ventricular ejection fraction is calculated to be 69%.  There are no wall motion abnormalities.,8.  Coronary calcium score was calculated to be 79, indicating at least mild atherosclerosis within the coronary vessels.,ANCILLARY FINDINGS: , None.,FINAL IMPRESSION:,1.  Mild coronary artery disease with a preserved left ventricular ejection fraction of 69%.,2.  Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy.,Thank you for referring this patient to us.",3
"CHIEF COMPLAINT:,1.  Extensive stage small cell lung cancer.,2.  Chemotherapy with carboplatin and etoposide.,3.  Left scapular pain status post CT scan of the thorax.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old female with extensive stage small cell lung cancer.  She is currently receiving treatment with carboplatin and etoposide.  She completed her fifth cycle on 08/12/10.  She has had ongoing back pain and was sent for a CT scan of the thorax.  She comes into clinic today accompanied by her daughters to review the results.,CURRENT MEDICATIONS: , Levothyroxine 88 mcg daily, Soriatane 25 mg daily, Timoptic 0.5% solution b.i.d., Vicodin 5/500 mg one to two tablets q.6 hours p.r.n.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:  ,The patient continues to have back pain some time she also take two pain pill.  She received platelet transfusion the other day and reported mild fever.  She denies any chills, night sweats, chest pain, or shortness of breath.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:",34
"CC:, Dysarthria,HX: ,This 52y/o RHF was transferred from a local hospital to UIHC on 10/28/94 with a history of progressive worsening of vision, dysarthria, headache, and incoordination beginning since 2/94. Her husband recalled her first difficulties became noticeable after a motor vehicle accident in 2/94. She was a belted passenger in a car struck at a stop. There was no reported head or neck injury or alteration of consciousness. She was treated and released from a local ER the same day. Her husband noted the development of mild dysarthria, incoordination, headache and exacerbation of preexisting lower back pain within 2 week of the accident. In 4/94 she developed stress urinary incontinence which spontaneously resolved in June. In 8/94, her HA changed from a dull constant aching in the bitemporal region to a sharper constant pain in the nuchal/occipital area. She also began experiencing increased blurred vision, worsening dysarthria and difficulty hand writing. In 9/94 she was evaluated by a local physician. Examination then revealed incoordination, generalized fatigue, and dysarthria. Soon after this she became poorly arousable and increasingly somnolent. She had difficulty walking and generalized weakness. On 10/14/94, she lost the ability to walk by herself. Evaluation at a local hospital revealed: 1)Normal electronystagmography, 2)two lumbar punctures which revealed some atypical mononuclear cells suggestive of ""tumor or reactive lymphocytosis."" One of these CSF analysis showed: Glucose 16, Protein 99, WBC 14, RBC 114. Echocardiogram was normal. Bone marrow biopsy was normal except for decreased iron. Abdominal-Pelvic CT scan, CXR, Mammogram, PPD, ANA, TFT, and RPR were unremarkable. A 10/31/94 MRI brain scan a 5x10mm area of increased signal on T2 weighted images in the right remporal lobe lateral to the anterior aspect of the temporal horn, right posterolateral aspect of the midbrain, pons, and bilateral inferior surface of the cerebellum involving gray and white matter. These areas did not enhance with gadolinium contrast on T1 weighted images.,MEDS: ,none.,PMH:, 1)G3P3, 2)last menses one year ago.,FHX:, Mother suffered stroke in her 70's. DM and Htn in family.,SHX:, Married, Secretary, No h/o tobacco/ETOH/illicit drug use.,ROS:, no weight loss, fever, chills, nightsweats, cough, dysphagia.,EXAM:, BP139/74, HR 90, RR20, 36.8C,MS: Drowsy to somnolent, occasionally ""giddy."" Oriented to person, place, time. Minimal dysarthric speech, but appropriate. MMSE 27/30 (copy of exam not in chart).,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. Optic disks were flat and without sign of papilledema. VFFTC. EOM intact. No nystagmus. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout. Normal muscle tone and bulk.,Sensory: No deficit to LT/PP/VIB/PROP.,Coord: difficulty with RAM in BUE, and ataxia on FNF and HKS in all extremities.,Station: Romberg sign present.,Gait: unsteady, wide-based, with notable difficulty on TW, TT and HW.,Reflexes: 2/2 BUE, 0/1 patellae, trace at both archilles, Plantars responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CSF analysis by lumbar puncture, 10/31/94: Protein 131mg/dl (normal 15-45), Albumin 68 (normal 14-20), IgG10mg/dl (normal <6.2), IgG index -O.1mg/24hr (normal),,No oligoclonal bands seen, WBC 33 (19lymphocytes, 1 neutrophil), RBC 29, Glucose 13, Cultures (bacteria, fungal, AFB) were negative, crytococcal Ag negative. The elevated CSF total protein, IgG, and albumin suggested breakdown of the blood brain barrier or blockage of CSF flow. The normal IgG synthesis rate and lack of oligoclonal banding did not suggest demylination. A second CSF analysis on 11/2/94 revealed similar findings; and in addition Anti-purkinje cell and Anti-neuronal antibodies (Yo and Ho) were not found; Beta-2 microglobulin was 1.8 (normal); histoplasmosis Ag negative. Serum ACE, SPEP, Urine histoplasmin were negative.,Neuropsychologic assessment, 10/28/94, raised a question of a demential syndrome, but given her response style on the MMPI (marked defensiveness, with unwillingness to admit to even very common human faults) prevented such a diagnosis. Severe defects in memory, fine motor skills, and constructional praxis were noted.,Chest-Abdominal-Pelvic CT scans were negative. 11/4/94 cerebral angiogram noted variable caliber in the RMCA, LACA and Left AICA distributions. It was intially thought that thismight be suggestive of a vasculopathy and she was treated with a short course of IV steroids. Temporal artery biopsy was unremarkable.,She underwent multiple MRI brain scans at UIHC: 11/4/94, 11/9/94, 11/16/94. All scans consistently showed increase in T2 signal in the brainstem, cerebellar peduncles and temporal lobes bilaterally. These areas did not enhance with gadolinium contrast. These findings were felt most suggestive of glioma.,She underwent left temporal lobe brain biopsy on 11/10/94: This study was inconclusive and showed evidence of atypical mononuclear cells and lymphocytes in the perivascular and subarachnoid spaces. Despite cytologic atypia the cells were felt to be reactive in nature, since immunohistochemical stains failed to disclose lymphoid clonality or non-leukocytic phenomena. Little sign of vasculopathy or tumor was found. Bacterial, fungal , HSV, CMV and AFB cultures were negative. HSV, and VZV antigen was negative.,Her neurological state progressively worsened throughout her hospital stay. By time of discharge, 12/2/94, she was very somnolent and difficult to arouse and required NGT feeding and 24hour supportive care. She was made DNR after family request prior to transfer to a care facility.",22
"PREOPERATIVE DIAGNOSES,1.  Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.,2.  Documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery, last procedure in 2005.,3.  Primary malignant ventricular arrhythmia and necessitated ventricular fibrillation.  He is intubated and ventilated.,POSTOPERATIVE DIAGNOSES:,  Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.  Primary ventricular arrhythmia.  Occluded left anterior descending artery, successfully re-canalized with angioplasty and implantation of the drug-eluting stent.  Previously stented circumflex with mild stenosis and previously documented occlusion of the right coronary artery, well collateralized.,PROCEDURES:,  Left heart catheterization, selective bilateral coronary angiography and left ventriculography.  Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent.  Right heart catheterization and Swan-Ganz catheter placement for monitoring.,DESCRIPTION OF PROCEDURE:  ,The patient arrived from the emergency room intubated and ventilated.  He is hemodynamically stable on heparin and Integrilin bolus and infusion was initiated.  The right femoral area was prepped and draped in usual sterile fashion.  Lidocaine 2 mL was then filled locally.  The right femoral artery was cannulated with an 18-guage needle followed by a 6-French vascular sheath.  A guiding catheter XB 3.5 was advanced in manipulated to cannulate the left coronary artery and angiography was obtained.  A confirmed occlusion of the left anterior descending artery with minimal collaterals and also occlusion of the right coronary artery, which is well collateralized.  An angioplasty wire with present wire was advanced into the left anterior descending artery, and could cross the area of occlusion within the stent.  An angioplasty balloon measuring 2.0 x 15 was advanced and three inflations were obtained.  It successfully re-canalized the artery.  There is evidence of residual stenosis within the distal aspect of the previous stents.  A drug-eluting stent Xience 2.75 x 15 was advanced and positioned within the area of stenosis with its distal marker adjacent to bifurcation with a diagonal branch and was deployed at 12 and 18 atmospheres.  The intermittent result was improved.  An additional inflation was obtained more proximally.  His blood pressure fluctuated and dropped in the 70s, correlating with additional sedation.  There is patency of the left anterior descending artery and good antegrade flow.  The guiding catheter was replaced with a 5-French Judkins right catheter manipulated to cannulate the right coronary artery and selective angiography was obtained.  The catheter was then advanced into the left ventricle and pressure measurement was obtained including pullback across the aortic valve.  The right femoral vein was cannulated with an 18-guage needle followed by an 8-French vascular sheath.  A 8-French Swan-Ganz catheter was then advanced under fluoroscopic and hemodynamic control and pressure stenting was obtained from the right ventricle, pulmonary artery, and pulmonary capillary wedge position.  Cardiac catheter was determined by thermal dilution.  The procedure was then concluded, well tolerated and without complications.  The vascular sheath was in secured in place and the patient return to the coronary care unit for further monitoring.  Fluoroscopy time was 8.2 minutes.  Total amount of contrast was 113 mL.,HEMODYNAMICS:,  The patient remained in sinus rhythm with intermittent ventricular bigeminy post revascularization.  His initial blood pressure was 96/70 with a mean of 83 and the left ventricular pressure was 17 mmHg.  There was no gradient across the aortic valve.  Closing pressure was 97/68 with a mean of 82.,Right heart catheterization with right atrial pressure at 13, right ventricle 31/9, pulmonary artery 33/19 with a mean of 25, and capillary wedge pressure of 19.  Cardiac output was 5.87 by thermal dilution.,CORONARIES:,  On fluoroscopy, there was evidence of previous coronary stent in the left anterior descending artery and circumflex distribution.,A.  Left main coronary:  The left main coronary artery is of good caliber and has no evidence of obstructive lesions.,B.  Left anterior descending artery:  The left anterior descending artery was initially occluded within the previously stented proximal-to-mid segment.  There is minimal collateral flow.,C.  Circumflex:  Circumflex is a nondominant circulation.  It supplies a first obtuse marginal branch on good caliber.  There is an outline of the stent in the midportion, which has mild 30% stenosis.  The rest of the vessel has no significant obstructive lesions.  It also supplies significant collaterals supplying the occluded right coronary artery.,D.  Right coronary artery:  The right coronary artery is a weekly dominant circulation.  The vessel is occluded in intermittent portion and has a minimal collateral flow distally.,ANGIOPLASTY: , The left anterior descending artery was the site of re-canalization by angioplasty and implantation of a drug-eluting stent (Xience 15 mm length deployed at 2.9 mm) final result is good with patency of the left anterior descending artery, good antegrade flow and no evidence of dissection.  The stent was deployed proximal to the bifurcation with a second diagonal branch, which has remained patent.  There is a septal branch overlapped by the stent, which is also patent, although presenting a proximal stenosis.  The distal left anterior descending artery trifurcates with two diagonal branches and apical left anterior descending artery.  There is good antegrade flow and no evidence of distal embolization.,CONCLUSION: , Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution, complicated with primary ventricular malignant arrhythmia and required defibrillation along intubation and ventilatory support.,Previously documented coronary artery disease with remote angioplasty and stents in the left anterior descending artery and circumflex artery.,Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution related to in-stent thrombosis of the left anterior descending artery, successfully re-canalized with angioplasty and a drug-eluting stent.  There is mild-to-moderate disease of the previously stented circumflex and clinic occlusion of the right coronary artery, well collateralized.,Right femoral arterial and venous vascular access.,RECOMMENDATION:,  Integrilin infusion is maintained until tomorrow.  He received aspirin and Plavix per nasogastric tube.  Titrated doses of beta-blockers and ACE inhibitors are initiated.  Additional revascularization therapy will be adjusted according to the clinical evaluation.",37
"PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1.  Lumbar discogram L2-3.,2.  Lumbar discogram L3-4.,3.  Lumbar discogram L4-5.,4.  Lumbar discogram L5-S1.,ANESTHESIA:  ,IV sedation.,PROCEDURE IN DETAIL:  ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table.  The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained.  We then proceeded to prepare the low back with a Betadine solution and draped sterile.  Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space.  A metallic marker was then placed laterally and a needle entrance point was determined.  A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections.  A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus.  We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.",33
"OPERATION: , Left lower lobectomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  After general endotracheal anesthesia was induced, the appropriate monitoring devices were placed.  The patient was placed in the right lateral decubitus position.  The left chest and back were prepped and draped in a sterile fashion.  A right lateral thoracotomy incision was made.  Subcutaneous flaps were raised.  The anterior border of the latissimus dorsi was freed up, and the muscle was retracted posteriorly.  The posterior border of the pectoralis was freed up and it was retracted anteriorly.  The 5th intercostal space was entered.,The inferior pulmonary ligament was then taken down with electrocautery.  The major fissure was then taken down and arteries identified.  The artery was dissected free and it was divided with an Endo GIA stapler.  The vein was then dissected free and divided with an Endo GIA stapler.  The bronchus was then cleaned of all nodal tissue.  A TA-30 green loaded stapler was then placed across this, fired, and main bronchus divided distal to the stapler.,Then the lobe was removed and sent to pathology where margins were found to be free of tumor.  Level 9, level 13, level 11, and level 6 nodes were taken for permanent cell specimen.  Hemostasis noted.  Posterior 28-French and anterior 24-French chest tubes were placed.,The wounds were closed with #2 Vicryl.  A subcutaneous drain was placed.  Subcutaneous tissue was closed with running 3-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.",37
"The patient's home regimen includes Duragesic patch at 125 mcg every 3 days.  She is currently on a Dilaudid PCA of 1 mg every 10 minutes lockout, Dilaudid boluses 2 mg q.3 h. p.r.n., Ativan 2 mg q.4 h., Tylenol per rectum.  The patient was offered multiple procedures to help with her abdominal pain including a thoracic epidural placement for sympathetic block for pain control and a celiac plexuses/neurolytic block.  The patient's family and she will continue to think about these pain procedures and let us know if they are interested in either.  For the moment, we will not make any further recommendations on her current medical management.  We did ask Dr. X, a psychiatrist, who works for the Pain Service to come in and see Ms. A as anxiety is a large component of her suffering at this time.,",34
"PREOPERATIVE DIAGNOSES:,  Chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.,POSTOPERATIVE DIAGNOSES:,  Chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.,OPERATION: , Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.,ANESTHESIA:  ,General via facemask.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS: , None.,INDICATIONS:  ,The patient is a one-year-old with history of chronic and recurrent episodes of otitis media with persistent middle ear effusions resistant to medical therapy.,PROCEDURE: , The patient was brought to the operating room, was placed in supine position.  General anesthesia was begun via face mask technique.  Once an adequate level of anesthesia was obtained, the operating microscope was brought, positioned and visualized the right ear canal.  A small amount of wax was removed with a loop.  A 4-mm operating speculum was then introduced.  An anteroinferior quadrant radial myringotomy was then performed.  A large amount of mucoid middle ear effusion was aspirated from the middle ear cleft.  Reuter bobbin PE tube was then inserted, followed by Floxin otic drops and a cotton ball in the external meatus.  Head was then turned to the opposite side, where similar procedure was performed.  Once again, the middle ear cleft had a mucoid effusion.  A tube was inserted to an anteroinferior quadrant radial myringotomy.,Anesthesia was then reversed and the patient was transported to the recovery room having tolerated the procedure well with stable signs.",11
"PREOPERATIVE DIAGNOSES:  ,1.  Posttraumatic nasal deformity.,2.  Nasal obstruction.,3.  Nasal valve collapse.,4.  Request for cosmetic change with excellent appearance of nose.,POSTOPERATIVE DIAGNOSES:,1.  Posttraumatic nasal deformity.,2.  Nasal obstruction.,3.  Nasal valve collapse.,4.  Request for cosmetic change with excellent appearance of nose.,OPERATIVE PROCEDURES:,1.  Left ear cartilage graft.,2.  Repair of nasal vestibular stenosis using an ear cartilage graft.,3.  Cosmetic rhinoplasty.,4.  Left inferior turbinectomy.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is with symptomatic nasal obstruction and fixed nasal valve collapse following a previous nasal fracture and attempted repair.  We discussed with the patient the indications, risks, benefits, alternatives, and complications of the proposed surgical procedure, she had her questions asked and answered.  Preoperative imaging was performed in consultation with regard to aesthetic results and communicated via the computerized imager.  The patient had questions asked and answered.  Informed consent was obtained.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed in supine position.  The appropriate level of general endotracheal anesthesia was induced.  The patient was converted to the lounge chair position, and the nose was anesthetized and vasoconstricted in the usual fashion.  Procedure began with an inverted going incision and elevation of the skin of the nose in the submucoperichondrial plane over the medial crural footplates and lower lateral cartilages and up over the dorsum.  The septal angle was approached and submucoperichondrial flaps were elevated.  Severe nasal septal deviation to the right hand side and evidence of an old fracture with a separate alignment of the cartilaginous nose from the bony nose was encountered.  The upper laterals were divided and medial and lateral osteotomies were carried out.  Inadequate septal cartilage was noted to be present for use as spreader graft; therefore, left postauricular incision was made, and the conchal bowl cartilage graft was harvested, and it was closed with 3-0 running locking chromic with a sterile cotton ball pressure dressing applied.  Ear cartilage graft was then placed to put two spreader grafts on the left and one the right.  The two on the left extended all the way up to the caudal tip, the one on the right just primarily the medial wall.  It was placed in such a way to correct a caudal dorsal deviation of the nasal tip septum.  The upper lateral cartilage was noted to be of the same width and length in size.  Yet, the left lower cartilage was scarred and adherent to the upper lateral cartilage.  The upper lateral cartilages were noted to be excessive of uneven length with the right being much taller than the left and that was shortened to the same length.  The scar bands were released in the lower lateral cartilages to the upper lateral cartilages to allow free mobilization of the lower lateral cartilages.  A middle crus stitch was used to unite the domes, and then the nose was projected by suturing the medial crural footplates of the caudal septum in deep projected fashion.  Crushed ear cartilage was then placed in the pockets above the spreader grafts in the area of the deficient dorsal nasal height and the lateral nasal sidewall height.  The spreader brought an excellent aesthetic appearance to the nose.  We left more than 1 cm of dorsal and caudal support for the nasal tip and dorsum height.  Mucoperichondrial flaps were closed with 4-0 plain gut suture.  The skin was closed with 5-0 chromic and 6-0 fast absorbing gut.  Doyle splints were placed on each side of nasal septum and secured with 3-0 nylon and a Denver splint was applied.  The patient was awakened in the operating room and taken to the recovery room in good condition.",11
"PREOPERATIVE DIAGNOSIS: , Need for intravenous access.,POSTOPERATIVE DIAGNOSIS: , Need for intravenous access.,PROCEDURE PERFORMED:  ,Insertion of a right femoral triple lumen catheter.,ANESTHESIA: , Includes 4 cc of 1% lidocaine locally.,ESTIMATED BLOOD LOSS: , Minimum.,INDICATIONS:,  The patient is an 86-year-old Caucasian female who presented to ABCD General Hospital secondary to drainage of an old percutaneous endoscopic gastrostomy site.  The patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.,PROCEDURE:,  The patient's legal guardian was talked to.  All questions were answered and consent was obtained.  The patient was sterilely prepped and draped.  Approximately 4 cc of 1% lidocaine was injected into the inguinal site.  A strong femoral artery pulse was felt and triple lumen catheter Angiocath was inserted at 30-degree angle cephalad and aspirated until a dark venous blood was aspirated.  A guidewire was then placed through the needle.  The needle was then removed.  The skin was ________ at the base of the wire and a dilator was placed over the wire.  The triple lumen catheters were then flushed with bacteriostatic saline.  The dilator was then removed from the guidewire and a triple lumen catheter was then inserted over the guidewire with the guidewire held at all times.,The wire was then carefully removed.  Each port of the lumen catheter was aspirated with 10 cc syringe with normal saline till dark red blood was expressed and then flushed with bacteriostatic normal saline and repeated on the remaining two ports.  Each port was closed off and also kept off.  Straight needle suture was then used to suture the triple lumen catheter down to the skin.  Peristatic agent was then placed at the site of the lumen catheter insertion and a Tegaderm was then placed over the site.  The surgical site was then sterilely cleaned.  The patient tolerated the full procedure well.  There were no complications.  The nurse was then contacted to allow for access of the triple lumen catheter.",37
"REASON FOR CONSULTATION: , Azotemia.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 36-year-old gentleman admitted to the hospital because he passed out at home.,Over the past week, he has been noticing increasing shortness of breath.  He also started having some abdominal pain; however, he continued about his regular activity until the other day when he passed out at home.  His wife called paramedics and he was brought to the emergency room.,The patient has had a workup at this time which shows bilateral pulmonary infarcts.  He has been started on heparin and we are asked to see him because of increasing BUN and creatinine.,The patient has no past history of any renal problems.  He feels that he has been in good health until this current episode.  His appetite has been good.  He denies swelling in his feet or ankles.  He denies chest pain.  He denies any problems with bowel habits.  He denies any unexplained weight loss.  He denies any recent change in bowel habits or recent change in urinary habits.,PHYSICAL EXAMINATION:,GENERAL:  A gentleman seen who appears his stated age.,VITAL SIGNS:  Blood pressure is 130/70.,CHEST:  Chest expands equally bilaterally.  Breath sounds are heard bilaterally.,HEART:  Had a regular rhythm, no gallops or rubs.,ABDOMEN:  Obese.  There is no organomegaly.  There are no bruits.  There is no peripheral edema.  He has good pulse in all 4 extremities.  He has good muscle mass.,LABORATORY DATA: , The patient's current chemistries include a hemoglobin of 14.8, white count of 16.3, his sodium 133, potassium 5.1, chloride 104, CO2 of 19, a BUN of 26, and a creatinine of 3.5.  On admission to the hospital, his creatinine on 6/27/2009 was 0.9.,The patient has had several studies including a CAT scan of his abdomen, which shows poor perfusion to his right kidney.,IMPRESSION:,1.  Acute renal failure, probable renal vein thrombosis.,2.  Hypercoagulable state.,3.  Deep venous thromboses with pulmonary embolism.,DISCUSSION: , We are presented with a 36-year-old gentleman who has been in good health until this current event.  He most likely has a hypercoagulable state and has bilateral pulmonary emboli.  Most likely, the patient has also had emboli to his renal veins and it is causing renal vein thrombosis.,Interestingly, the urine protein was obtained which is not that elevated and I would suspect that it would have been higher.  Unfortunately, the patient has been exposed to IV dye and my anxiety is that this too is contributing to his current problem.,The patient's urine output is about 30 to 40 mL per hour.,Several chemistries have been ordered.  A triple renal scan has been ordered.,I reviewed all of this with the patient and his wife.  Hopefully under his current anticoagulation, there will be some resolution of his renal vein thrombosis.  If not and his renal failure progresses, we are looking at dialytic intervention.  Both he and his wife were aware of this.  ,Thank you very much for asking to see this acutely ill gentleman in consultation with you.",5
"GENERAL:  Negative for any nausea, vomiting, fevers, chills, or weight loss.,NEUROLOGIC:  Negative for any blurry vision, blind spots, double vision, facial asymmetry, dysphagia, dysarthria, hemiparesis, hemisensory deficits, vertigo, ataxia.,HEENT:  Negative for any head trauma, neck trauma, neck stiffness, photophobia, phonophobia, sinusitis, rhinitis.,CARDIAC:  Negative for any chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema.,PULMONARY:  Negative for any shortness of breath, wheezing, COPD, or TB exposure.,GASTROINTESTINAL:  Negative for any abdominal pain, nausea, vomiting, bright red blood per rectum, melena.,GENITOURINARY:  Negative for any dysuria, hematuria, incontinence.,INTEGUMENTARY:  Negative for any rashes, cuts, insect bites.,RHEUMATOLOGIC:  Negative for any joint pains, photosensitive rashes, history of vasculitis or kidney problems.,HEMATOLOGIC:  Negative for any abnormal bruising, frequent infections or bleeding.",25
"PREOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.,POSTOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion, and potentially unstable cervical spine.,OPERATIVE PROCEDURE:  ,Application of PMT large halo crown and vest.,ESTIMATED BLOOD LOSS: , None.,ANESTHESIA:  ,Local, conscious sedation with Morphine and Versed.,COMPLICATIONS: , None.  Post-fixation x-rays, nonalignment, no new changes.  Post-fixation neurologic examination normal.,CLINICAL HISTORY:  ,The patient is a 41-year-old female who presented to me with severe cervical spondylosis and myelopathy.  She was referred to me by Dr. X.  The patient underwent a complicated anterior cervical discectomy, 2-level corpectomy, spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate.  Surgery had gone well, and the patient has done well in the last 2 days.  She is neurologically improved and is moving all four extremities.  No airway issues.  It was felt that the patient was now a candidate for a halo vest placement given that chance of going to the OR were much smaller.  She was consented for the procedure, and I sought the help of ABC and felt that a PMT halo would be preferable to a Bremer halo vest.  The patient had this procedure done at the bedside, in the SICU room #1.  I used a combination of some morphine 1 mg and Versed 2 mg for this procedure.  I also used local anesthetic, with 1% Xylocaine and epinephrine a total of 15 to 20 cc.,PROCEDURE DETAILS:,  The patient's head was positioned on some towels, the retroauricular region was shaved, and the forehead and the posterolateral periauricular regions were prepped with Betadine.  A large PMT crown was brought in and fixed to the skull with pins under local anesthetic.  Excellent fixation achieved.  It was lateral to the supraorbital nerves and 1 fingerbreadth above the brows and the ear pinnae.,I then put the vest on, by sitting the patient up, stabilizing her neck.  The vest was brought in from the front as well and connected.  Head was tilted appropriately, slightly extended, and in the midline.  All connections were secured and pins were torqued and tightened.,During the procedure, the patient did fine with no significant pain.,Post-procedure, she is neurologically intact and she remained intact throughout.  X-rays of the cervical spine AP, lateral, and swimmer views showed excellent alignment of the hardware construct in the graft with no new changes.,The patient will be subjected to a CT scan to further define the alignment, and barring any problems, she will be ambulating with the halo on.,The patient will undergo pin site care as per protocol, and likely she will go in the next 2 to 3 days.  Her prognosis indeed is excellent, and she is already about 90% or so better from her surgery.  She is also on a short course of Decadron, which we will wean off in due course.,The matter was discussed with the patient and the patient's family.",37
"CHIEF COMPLAINT:,  A 5-month-old boy with cough.,HISTORY OF PRESENT ILLNESS:,  A 5-month-old boy brought by his parents because of 2 days of cough.  Mother took him when cough started 2 days go to Clinic where they told the mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and he also started having fever.  Mother did not measure it.,REVIEW OF SYSTEMS:,  No vomiting.  No diarrhea.  He had runny nose started with the cough two days ago.  No skin rash.  No cyanosis.  Pulling on his right ear.  Feeding, he is bottle-fed 2 ounces every 2 hours.  Mother states he urinates like 5 to 6 times a day, stools 1 time a day.  He is still feeding good to mom.,IMMUNIZATIONS: , He received first set of shot and due for the second set on 01/17/2008.,BIRTH HISTORY:,  He was premature at 33 weeks born at Hospital kept in NICU for 2 weeks for feeding problem as the mother said.  Mother had good prenatal care at 4 weeks for more than 12 visits.  No complications during pregnancy.  Rupture of membranes happened two days before the labor.  Mother received the antibiotics, but she is not sure, if she received steroids also or not.,FAMILY HISTORY: , No history of asthma or lung disease.,SOCIAL HISTORY: , Lives with parents and with two siblings, one 18-year-old and the other is 14-year-old in house, in Corrales.  They have animals, but outside the house and father smokes outside house.  No sick contacts as the mother said.,PAST MEDICAL HISTORY:,  No hospitalizations.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , No medications.,History of 2 previous ear infection, last one was in last November treated with ear drops, because there was pus coming from the right ear as the mother said.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 100.1, heart rate 184, respiratory rate 48.  Weight 7 kg.,GENERAL:  In no acute distress.,HEAD:  Normocephalic and atraumatic.  Open, soft, and flat anterior fontanelle.,NECK:  Supple.,NOSE:  Dry secretions.,EAR:  Right ear full of yellowish material most probably pus and necrotic tissue.  Tympanic membrane bilaterally visualized.,MOUTH:  No pharyngitis.  No ulcers.  Moist mucous membranes.,CHEST:  Bilateral audible breath sound.  No wheezes.  No palpitation.,HEART:  Regular rate and rhythm with no murmur.,ABDOMEN:  Soft, nontender, and nondistended.,GENITOURINARY:  Tanner I male with descended testes.,EXTREMITIES:  Capillary refill less than 2 seconds.,LABS:,  White blood cell 8.1, hemoglobin 10.5, hematocrit 30.9, and platelets 380,000.  CRP 6, segments 41, and bands 41.  RSV positive.  Chest x-ray evidenced bronchiolitis with hyperinflation and bronchial wall thickening in the central hilar region.  Subsegmental atelectasis in the right upper lobe and left lung base.,ASSESSMENT:,  A 5-month-old male with 2 days of cough and 1 day of fever.  Chest x-ray shows bronchiolitis with atelectasis, and RSV antigen is positive.,DIAGNOSES: , Respiratory syncytial virus bronchiolitis with right otitis externa.,PLAN: , Plan was to admit to bronchiolitis pathway, and ciprofloxacin for right otitis externa eardrops twice daily.,",5
"OPERATION PERFORMED:,  Ligament reconstruction and tendon interposition arthroplasty of right wrist.,DESCRIPTION OF PROCEDURE: , With the patient under adequate anesthesia, the right upper extremity was prepped and draped in a sterile manner.,Attention was turned to the base of the thumb where a longitudinal incision was made over the anatomic snuffbox and extended out onto the carpometacarpal joint.  Using blunt dissection radial sensory nerve was dissected and retracted out of the operative field.  Further blunt dissection exposed the radial artery, which was dissected and retracted off the trapezium.  An incision was then made across the scaphotrapezial joint distally onto the trapezium and out onto the carpometacarpal joint.  Sharp dissection exposed the trapezium, which was then morselized and removed in toto with care taken to protect the underlying flexor carpi radialis tendon.  The radial beak of the trapezoid was then osteotomized off the head of the scaphoid.  The proximal metacarpal was then fenestrated with a 4.5-mm drill bit.  Four fingers proximal to the flexion crease of the wrist a small incision was made over the FCR tendon and blunt dissection delivered the FCR tendon into this incision.  The FCR tendon was divided and this incision was closed with 4-0 nylon sutures.  Attention was returned to the trapezial wound where longitudinal traction on the FCR tendon delivered the FCR tendon into the wound.,The FCR tendon was then threaded through the fenestration in the metacarpal.  A bone anchor was then placed distal to the metacarpal fenestration.  The FCR tendon was then pulled distally and the metacarpal reduced to an anatomic position.  The FCR tendon was then sutured to the metacarpal using the previously placed bone anchor.  Remaining FCR tendon was then anchovied and placed into the scaphotrapezoidal and trapezial defect.  The MP joint was brought into extension and the capsule closed using interrupted 3-0 Tycron sutures.,Attention was turned to the MCP joint where the MP joint was brought in to 15 degrees of flexion and pinned with a single 0.035 Kirschner wire.  The pin was cut at the level of the skin.,All incisions were closed with running 3-0 Prolene subcuticular stitch.,Sterile dressings were then applied.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.",37
"PROCEDURE PERFORMED: , EGD with biopsy.,INDICATION: , Mrs. ABC is a pleasant 45-year-old female with a history of severe diabetic gastroparesis, who had a gastrojejunal feeding tube placed radiologically approximately 2 months ago.  She was admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.  A CT scan done yesterday revealed evidence of feeding tube remnant still seen within the stomach.  The endoscopy is done to confirm this and remove it, as well as determine if there are any other causes to account for her symptoms.  Physical examination done prior to the procedure was unremarkable, apart from upper abdominal tenderness.,MEDICATIONS: , Fentanyl 25 mcg, Versed 2 mg, 2% lidocaine spray to the pharynx.,INSTRUMENT: , GIF 160.,PROCEDURE REPORT:,  Informed consent was obtained from Mrs. ABC's sister, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications.  Consent was not obtained from Mrs. Morales due to her recent narcotic administration.  Conscious sedation was achieved with the patient lying in the left lateral decubitus position.  The endoscope was then passed through the mouth, into the esophagus, the stomach, where retroflexion was performed, and it was advanced into the second portion of the duodenum.,FINDINGS:,1.  ESOPHAGUS:  There was evidence of grade C esophagitis, with multiple white-based ulcers seen from the distal to the proximal esophagus, at 12 cm in length.  Multiple biopsies were obtained from this region and placed in jar #1.,2.  STOMACH:  Small hiatal hernia was noted within the cardia of the stomach.  There was an indentation/scar from the placement of the previous PEG tube and there was suture material noted within the body and antrum of the stomach.  The remainder of the stomach examination was normal.  There was no feeding tube remnant seen within the stomach.,3.  DUODENUM:  This was normal.,COMPLICATIONS:,  None.,ASSESSMENT:,1.  Grade C esophagitis seen within the distal, mid, and proximal esophagus.,2.  Small hiatal hernia.,3.  Evidence of scarring at the site of the previous feeding tube, as well as suture line material seen in the body and antrum of the stomach.,PLAN: , Followup results of the biopsies and will have radiology replace her gastrojejunal feeding tube.",37
"REASON FOR VISIT:,  Lap band adjustment.,HISTORY OF PRESENT ILLNESS:,  Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment.  Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress.  She was in a car accident a couple of weeks ago and she has problems, she does not feel full.  She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.,PHYSICAL EXAMINATION: , On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit.  She was alert and oriented in no apparent distress.  ,PROCEDURE:  ,I was able to access her port.  She does have an AP standard low profile.  I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her band, she did tolerate water postprocedure.,ASSESSMENT:,  The patient is status post lap band adjustments, doing well, has a total of 7 mL within her band, tolerated water postprocedure.  She will come back in two weeks for another adjustment as needed.,",2
"EXAM: , CT stone protocol.,REASON FOR EXAM:,  History of stones, rule out stones.,TECHNIQUE: , Noncontrast CT abdomen and pelvis per renal stone protocol.,FINDINGS: , Correlation is made with a prior examination dated 01/20/09.,Again identified are small intrarenal stones bilaterally.  These are unchanged.  There is no hydronephrosis or significant ureteral dilatation.  There is no stone along the expected course of the ureters or within the bladder.  There is a calcification in the low left pelvis not in line with ureter, this finding is stable and is compatible with a phlebolith.  There is no asymmetric renal enlargement or perinephric stranding.,The appendix is normal.  There is no evidence of a pericolonic inflammatory process or small bowel obstruction.,Scans through the pelvis disclose no free fluid or adenopathy.,Lung bases aside from very mild dependent atelectasis appear clear.,Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas are grossly unremarkable.  The gallbladder is present.  There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. Bilateral intrarenal stones, no obstruction.,2. Normal appendix.",33
"CHIEF COMPLAINT: , ""I have had trouble breathing for the past 3 days"",HISTORY: , 69-year-old Caucasian male complaining of difficulty breathing for 3 days.  He also states that he has been coughing accompanying with low-grade type fever.  He also admits to having intermittent headaches and bilateral chest pain that does not radiate to upper extremities and jaws but worse with coughing.  Patient initially had this type of episodes about 10 months ago but has intermittently getting worse since.,PMH: , DM, HTN, COPD, CAD,PSH:  ,CABG, appendectomy, tonsillectomy,FH:,  Non-contributory,SOCH: , Divorce and live alone, retired postal worker, has 3 children, 7 grandchildren.  He smokes 1 pack a day of Newport for 30 years and is a social drinker.  He denies any illicit drug use.,TRAVEL HISTORY: , Denies any recent travel overseas,ALLERGIES: , Denies any drug allergies,HOME MEDICATIONS:,  Advair 1 puff bid Lisinopril 10 mg qd Lopressor 50 mg bid Aspirin 81 mg qd Plavix 75 mg qd Multivitamins Feso4 1 tab qd Colace 100 mg qd,REVIEW OF SYSTEMS REVEALS:,  Same as above,PHYSICAL EXAM:,Vital signs are:  Temp.  99.3 F / BP 138/92, Resp.  22, P 88,General:  Patient is in mild acute respiratory distress,HEENT:,Head:  Atraumatic, normocephalic,,Eyes:",15
"PREOPERATIVE DIAGNOSES,1.  Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2.  Bilateral breast asymmetry.,3.  Right breast macromastia.,4.  Right abdominal scar deformity.,5.  Left abdominal scar deformity.,6.  A 1.3 cm lesion right inferior breast.,7.  Lesion measuring 0.5 cm right inferior breast lateral.,POSTOPERATIVE DIAGNOSES,1.  Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2.  Bilateral breast asymmetry.,3.  Right breast macromastia.,4.  Right abdominal scar deformity.,5.  Left abdominal scar deformity.,6.  A 1.3 cm lesion right inferior breast.,7.  Lesion measuring 0.5 cm right inferior breast lateral.,PROCEDURES,1.  Left breast flap revision.,2.  Right breast flap revision.,3.  Right breast reduction mammoplasty.,4.  Right nipple reconstruction.,5.  Left abdominal scar deformity.,6.  Right abdominal scar deformity.,7.  Excision of right breast medial lesion enclosure.,8.  Excision of right breast lateral lesion enclosure.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,DRAINS:,  None.,SPECIMENS:,  Right breast skin and lesions x2.,COMPLICATIONS:, None.,INDICATIONS:,  This patient is a 54-year-old white female who presents for a revision of her previous bilateral breast reconstruction.  The patient had asymmetry as well as right breast hypertrophy, and therefore, the procedures named above were indicated.  The patient was informed about the possible risks and complications of the above procedures and gave an informed consent.,PROCEDURE:,  The patient was brought to the operating room, placed supine on the operative table.  After adequate endotracheal anesthesia was established and IV prophylactic antibiotics were given, the chest and abdomen were prepped and draped in standard surgical fashion.,Attention was first turned to the left breast where liposuction was performed laterally to allow for better contour and minimize the outer quadrant.  The incision was made for this and was then closed with 5-0 Prolene interrupted suture.,Attention was then turned to the right breast where liposuction was also performed to reduce the medial superior and lateral quadrants.  Once this was performed, the vertical reduction mammoplasty was outlined.  Prior to that, the nipple reconstruction was performed with a keyhole pattern flap.  The flap was elevated with 15-blade and hemostasis was then obtained with the Bovie.  The flap was then sutured onto itself and secured with 5-0 Prolene interrupted sutures.  Then the lateral and medial limbs were undermined to close the defect and this was performed with 3-0 Monocryl interrupted sutures.  Subsequently, the reduction mastectomy skin was then excised sharply and passed up the table marked and sent to Pathology. ,Hemostasis was then obtained with the Bovie and then undermining was performed in the medial, superior, and lateral skin to allow for closure of the reduction incisions.  Once this was performed, a 3-0 Monocryl interrupted sutures were used to close the inferior limb.  Subsequently 2-0 PDS continuous suture was then placed in the periareolar area to close the defect, with a diameter that equaled the new nipple areolar complex.  Once this was performed, the remaining incision was then closed with 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures.  Subsequently, the 2 lesions were excised, the larger one which was medial and the lateral one that was smaller that were excised sharply, passed up the table and sent to Pathology.  They were closed in 2 layers using 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the abdominal scars where liposuction and tumescent solution of diluted epinephrine were used to minimize the amount of excision that was required.  Subsequently the extra skin was excised sharply in an elliptical fashion on the right side measuring approximately 10 x 3 cm, this was the superior and inferior skin, was when undermined and closure was performed after hemostasis was obtained with 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the contralateral left side where there was a larger defect.  There was a larger excision required measuring approximately 15 x 3 cm.  The superior and inferior edges of skin were undermined and closed primarily using 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures.  Steri-Strips were placed on all incisions followed by surgical bra.,The patient tolerated the procedure well and was extubated without complications and transferred to the recovery room in stable condition.  All instruments, needle counts, and sponges were correct at the end of the case.",6
"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.",3
"PREOPERATIVE DIAGNOSES,Breast hypoplasia, melasma to the face, and varicose veins to the posterior aspect of the right distal thigh/popliteal fossa area.,PROCEDURES,1.  Bilateral augmentation mammoplasty, subglandular with a mammary gel silicone breast implant, 435 cc each.,2.  TCA peel to two lesions of the face and vein stripping to the right posterior thigh and popliteal fossa area.,ANESTHESIA,General endotracheal.,EBL,100 cc.,IV FLUIDS,2L.,URINE OUTPUT,Per Anesthesia.,INDICATION FOR SURGERY,The patient is a 48-year-old female who was seen in clinic by Dr. W and where she was evaluated for her small breasts as well as dark areas on her face and varicose veins to the back and posterior aspect of her right lower extremity.  She requested that surgical procedures to be performed for correction of these abnormalities.  As such, complications were explained to the patient including infection, bleeding, poor wound healing, and need for additional surgery.  The patient subsequently signed the consent and requested that Dr. W and associates to perform the procedure.,TECHNIQUE,The patient was brought to the operating room in supine position.  General anesthesia was induced and then the patient was placed on the operating table in a prone position.  The posterior thigh of the right lower extremity was prepped and draped in a sterile fashion.  First, multiple serial small incisions less than 1 cm in length were made to the posterior aspect of the right thigh and sequential stripping of the varicose veins was performed.  Once these varicose veins had been completely stripped and avulsed, then next the wounds were then irrigated and were cleaned with wet and dry, and all the incisions were closed with the use of 5-0 Monocryl buried interrupted sutures.  The incisions were then dressed with Mastisol, Steri-Strips, ABDs and a TED hose.  Next, the patient was then flipped back over onto the stretcher and placed on the operating table in a supine position.  The anterior chest was then prepped and draped in a sterile fashion.  Next, a 10 blade was placed through previous circumareolar incisions from a previous augmentation mammoplasty.  Dissection was carried out with a 10 blade and Bovie cautery until the pectoralis fascia was identified to both breasts.  Once the pectoralis muscle and fascia were identified, then a surgical plane was created in a subglandular layer.  The hemostasis was obtained to both breast pockets with the Bovie cautery and suction and irrigation was performed to bilateral breast pockets as well.  A sizer was used to identify the appropriate size of the silicone implant to be used.  This was determined to be approximately 435 cc bilaterally.  As such, two mammary gel silicone breast implants were placed in a subglandular muscle.  Additional dissection of the breast pockets were performed bilaterally and the patient was sequentially placed in the upright sitting position for evaluation of appropriate placement of the mammary gel silicone implants.  Once it was determined that the implants were appropriately selected and placed with the 435 cc silicon gel implant, the circumareolar incisions were closed in approximately 4-layered fashion closing the fascia, subcutaneous tissue, deep dermis, and a running dermal subcuticular for final skin closure.  This was performed with 3-0 Monocryl and then 4-0 Monocryl for running subcuticular.  The incisions were then dressed with Mastisol, Steri-Strips, and Xeroform and dressed with sample Kerlix.  Next, our attention was paid to the face where 25% TCA solution was applied to two locations; one on the left cheek and the other one on the right cheek, where a hyperpigmentation/melasma.  Several applications of the TCA peel was performed, and at the end of this, the frosting was noted to both spots.  At the end of the case, needle and instrument counts were correct.  Dr. W was present and scrubbed for the entire procedure.  The patient was extubated in the operating room and taken to the PACU in stable condition.",6
"PREOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,OPERATIONS PERFORMED:,1.  Bilateral carotid cerebral angiogram.,2.  Right femoral-popliteal angiogram.,FINDINGS: , The right carotid cerebral system was selectively catheterized and visualized.  The right internal carotid artery was found to be very tortuous with kinking in its cervical portions, but no focal stenosis was noted.  Likewise, the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery.,The left carotid cerebral system was selectively catheterized and visualized.  The cervical portion of the left internal carotid artery showed a 30 to 40% stenosis with small ulcer crater present.  The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery.,Visualization of the right lower extremity showed no significant disease.,PROCEDURE: , With the patient in supine position under local anesthesia plus intravenous sedation, the groin areas were prepped and draped in a sterile fashion.,The common femoral artery was punctured in a routine retrograde fashion and a 5-French introducer sheath was advanced under fluoroscopic guidance.  A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above.,Following completion of the above, the catheter and introducer sheath were removed.  Heparin had been initially given, which was reversed with protamine.  Firm pressure was held over the puncture site for 20 minutes, followed by application of a sterile Coverlet dressing and sandbag compression.,The patient tolerated the procedure well throughout.",23
"PREOPERATIVE DIAGNOSIS: , Right ureteral calculus.,POSTOPERATIVE DIAGNOSIS: , Right ureteropelvic junction calculus.,PROCEDURE PERFORMED:,1.  Cystourethroscopy.,2.  Right retrograde pyelogram.,3.  Right double-J stent placement 22 x 4.5 mm.,FIRST SECOND ANESTHESIA: , General.,SPECIMEN:,  Urine for culture and sensitivity.,DRAINS: , 22 x 4.5 mm right double-J ureteral stent.,PROCEDURE: , After consent was obtained, the patient was brought to operating room and placed in the supine position.  She was given general anesthesia and then placed in the dorsal lithotomy position.  A #21 French cystoscope was then passed through the urethra into the bladder.  There was noted to be some tightness of the urethra on passage.  On visualization of the bladder, there were no stones or any other debris within the bladder.  There were no abnormalities seen.  No masses, diverticuli, or other abnormal findings.  Attention was then turned to the right ureteral orifice and attempts to pass to a cone tip catheter, however, the ureteral orifice was noted to be also tight and we were unable to pass the cone tip catheter.  The cone tip catheter was removed and a glidewire was then passed without difficulty up into the renal pelvis.  An open-end ureteral catheter was then passed ________ into the distal right ureter.  Retrograde pyelogram was then performed.,There was noted to be an UPJ calculus with no noted hydronephrosis.  The wire was then passed back through the ureteral catheter.  The catheter was removed and a 22 x 4.5 mm double-J ureteral stent was then passed over the glidewire under fluoroscopic and cystoscopic guidance.  The stent was clear within the kidney as well as within the bladder.  The bladder was drained and the cystoscope was removed.  The patient tolerated the procedure well.  She will be discharged home.  She is to follow up with Dr. X for ESWL procedure.  She will be given prescription for Darvocet and will be asked to have a KUB x-ray done prior to her followup and to bring them with her to her appointment.",37
"REASON FOR CONSULTATION:,  Acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.,HISTORY OF PRESENTING ILLNESS:  ,Briefly, this is a 36-year-old robust Caucasian gentleman with no significant past medical or surgical history, who works as a sales representative, doing a lot of traveling by plane and car and attending several sales shows, developed acute shortness of breath with an episode of syncope this weekend and was brought in by paramedics to Hospital.  A V/Q scan revealed multiple pulmonary perfusion defects consistent with high probability pulmonary embolism.  A Doppler venous study of the lower extremity also revealed nonocclusive right popliteal vein thrombosis.  A CT of the abdomen and pelvis revealed normal-appearing liver, spleen, and pancreas; however, the right kidney appeared smaller compared to left and suggesting possibility of renal infarct.  Renal function on admission was within normal range; however, serial renal function showed rapid increase in creatinine to 5 today.  He has been on intravenous heparin and hemodialysis is being planned for tomorrow.  Reviewing his history, there is no family members with hypercoagulable state or prior history of any thrombotic complication.  He denies any recent injury to his lower extremity and in fact denied any calf pain or swelling.,PAST MEDICAL AND SURGICAL HISTORY:  ,Unremarkable.,SOCIAL HISTORY: , He is married and has 1 son.  He has a brother who is healthy.  There is no history of tobacco use or alcohol use.,FAMILY HISTORY:,  No family history of hypercoagulable condition.,MEDICATIONS:  ,Advil p.r.n.,ALLERGIES: , NONE.,REVIEW OF SYSTEMS: , Essentially unremarkable except for sudden onset dyspnea on easy exertion complicated with episode of syncope.  He denied any hemoptysis.  He denied any calf swelling or pain.  Lately, he has been traveling and has been sitting behind a desk for a long period of time.,PHYSICAL EXAMINATION:,GENERAL:  He is a robust young gentleman, awake, alert, and hemodynamically stable.,HEENT:  Sclerae anicteric.  Conjunctivae normal.  Oropharynx normal.,NECK:  No adenopathy or thyromegaly.  No jugular venous distention.,HEART:  Regular.,LUNGS:  Bilateral air entry.,ABDOMEN:  Obese and benign.,EXTREMITIES:  No calf swelling or calf tenderness appreciated.,SKIN:  No petechiae or ecchymosis.,NEUROLOGIC:  Nonfocal.,LABORATORY FINDINGS:,  Blood count obtained showed a white count of 16.8, hemoglobin 14.8 g percent, hematocrit 44.6%, MCV 94, and platelet count 209,000.  Liver profile normal.  Thyroid study revealed a TSH of 1.3.  Prothrombin time/INR 1.5, partial thromboplastin time 78.6 seconds.  Renal function, BUN 44 and creatinine 5.7.  Echocardiogram revealed left ventricular hypertrophy with ejection fraction of 65%, no intramural thrombus noted.,IMPRESSION:,1.  Bilateral pulmonary embolism, most consistent with emboli from right lower extremity, on intravenous heparin, rule out hereditary hypercoagulable state.,2.  Leukocytosis, most likely leukemoid reaction secondary to acute pulmonary embolism/renal infarction, doubt presence of myeloproliferative disorder.,3.  Acute renal failure secondary to embolic right renal infarction.,4.  Obesity.,PLAN: , From hematologic standpoint, we will await hypercoagulable studies, which have all been sent on admission to see if a hereditary component is at play.  For now, we will continue intravenous heparin and subsequent oral anticoagulation with Coumadin.  In view of worsening renal function, may need temporary hemodialysis until renal function improves.  I discussed at length with the patient's wife at the bedside.",16
"PREOPERATIVE DIAGNOSIS: , Respiratory failure.,POSTOPERATIVE DIAGNOSIS:  ,Respiratory failure.,OPERATIVE PROCEDURE: , Tracheotomy.,ANESTHESIA:  ,General inhalational.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  General inhalational anesthesia was administered through the patient's existing 4.0 endotracheal tube.  The neck was extended and secured with tape and incision in the midline of the neck approximately 2 fingerbreadths above the sternal notch was outlined.  The incision measured approximately 1 cm and was just below the palpable cricoid cartilage and first tracheal ring.  The incision area was infiltrated with 1% Xylocaine with epinephrine 1:100,000.  A #67 blade was used to perform the incision.  Electrocautery was used to remove excess fat tissue to expose the strap muscles.  The strap muscles were grasped and divided in the midline with a cutting electrocautery.  Sharp dissection was used to expose the anterior trachea and cricoid cartilage.  The thyroid isthmus was identified crossing just below the cricoid cartilage.  This was divided in the midline with electrocautery.  Blunt dissection was used to expose adequate cartilaginous rings.  A 4.0 silk was used for stay sutures to the midline of the cricoid.  Additional stay sutures were placed on each side of the third tracheal ring.  Thin DuoDerm was placed around the stoma.  The tracheal incision was performed with a #11 blade through the second, third, and fourth tracheal rings.  The cartilaginous edges were secured to the skin edges with interrupted #4-0 Monocryl.  A 4.5 PED tight-to-shaft cuffed Bivona tube was placed and secured with Velcro ties.  A flexible scope was passed through the tracheotomy tube.  The carina was visualized approximately 1.5 cm distal to the distal end of the tracheotomy tube.  Ventilation was confirmed.  There was good chest rise and no appreciable leak.  The procedure was terminated.  The patient was in stable condition.  Bleeding was negligible and she was transferred back to the Pediatric intensive care unit in stable condition.",37
"FEMALE REVIEW OF SYSTEMS:,Constitutional:  Patient denies fevers, chills, sweats and weight changes.,Eyes:  Patient denies any visual symptoms.,Ears, Nose, and Throat:  No difficulties with hearing.  No symptoms of rhinitis or sore throat.,Cardiovascular:  Patient denies chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.,Respiratory:  No dyspnea on exertion, no wheezing or cough.,GI:  No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia or melena.,GU:  No dysuria, frequency or incontinence.  No difficulties with vaginal discharge.,Musculoskeletal:  No myalgias or arthralgias.,Breasts:  Patient performs self-breast examinations and has noticed no abnormalities or nipple discharge.,Neurologic:  No chronic headaches, no seizures.  Patient denies numbness, tingling or weakness.,Psychiatric:  Patient denies problems with mood disturbance.  No problems with anxiety.,Endocrine:  No excessive urination or excessive thirst.,Dermatologic:  Patient denies any rashes or skin changes.",15
"PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS:  ,Tailor's bunion, right foot.,PROCEDURE PERFORMED: , Removal of bone, right fifth metatarsal head.,ANESTHESIA:  ,TIVA/local.,HISTORY: , This 60-year-old male presents to ABCD Preoperative Holding Area after keeping himself n.p.o., since mid night for surgery on his painful right Tailor's bunion.  The patient has a history of chronic ulceration to the right foot which has been treated on an outpatient basis with conservative methods Dr. X.  At this time, he desires surgical correction as the ulcer has been refractory to conservative treatment.  Incidentally, the ulcer is noninfective and practically healed at this date.  The consent is available on the chart for review and Dr. X has discussed the risks versus benefits of this procedure to the patient in detail.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room, placed on the operating table in supine position and a safety strap was placed across his waist for his protection.  A pneumatic ankle tourniquet was applied about the right foot over copious amount of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 1:1 mixture of 1% lidocaine and 0.5% Marcaine plain were administered into the right fifth metatarsal using a Mayo type block technique.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered in the operating field and a sterile stockinet was reflected.  The Betadine was cleansed with saline-soaked gauze and dried.  Anesthesia was tested with a one tooth pickup and found to be adequate.  A #10 blade was used to make 3.5 cm linear incision over the fifth metatarsophalangeal joint.  A #15 blade was used to deepen the incision to the subcutaneous layer.  Care was taken to retract the extensor digitorum longus tendon medially and the abductor digiti minimi tendon laterally.  Using a combination of sharp and blunt dissection, the medial and lateral edges of the wound were undermined down to the level of the capsule and deep fascia.  A linear capsular incision was made with a #15 blade down to the bone.  The capsular periosteal tissues were elevated off the bone with a #15 blade.  Metatarsal head was delivered into the wound.  There was hypertrophic exostosis noted laterally as well as a large bursa in the subcuteneous tissue layer.  The ulcer on the skin was approximately 2 x 2 mm, it was partial skin thickness and did not probe.  A sagittal saw was used to resect the hypertrophic lateral eminence.  The hypertrophic bone was split in half and one half was sent to Pathology and the other half was sent to Microbiology for culture and sensitivity.  Next, a reciprocating rasp was used to smoothen all bony surfaces.  The bone stock had an excellent healthy appearance and did not appear to be infected.  Copious amount of sterile gentamicin impregnated saline were used to flush the wound.  The capsuloperiosteal tissues were reapproximated with #3-0 Vicryl in simple interrupted technique.  The subcutaneous layer was closed with #4-0 Vicryl in simple interrupted technique.  Next, the skin was closed with #4-0 nylon in a horizontal mattress suture technique.  A standard postoperative dressing was applied consisting of Betadine-soaked Owen silk, 4x4s, Kerlix, and Kling.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted at the digits.  The patient tolerated the above anesthesia and procedure without complications.  He was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  He was given a postop shoe and will be full weightbearing.  He has prescription already at home for hydrocodone and does not need to refill.  He is to follow up with Dr. X and was given emergency contact numbers.  He was discharged in stable condition.",31
"CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with ""pins & needles"" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.",33
"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",22
"CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with ""pins & needles"" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.",22
"PREOPERATIVE DIAGNOSES:,1.  Pathologic insufficiency.,2.  Fracture of the T8 vertebrae and T9 vertebrae.,POSTOPERATIVE DIAGNOSES:,1.  Pathologic insufficiency.,2.  Fracture of the T8 vertebra and T9 vertebra.,PROCEDURE PERFORMED:,1.  Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty.,2.  Vertebroplasties at T7 and T9 with insertion of prosthetic device.,ANESTHESIA: , Local with sedation.,SPECIMEN: , Bone from the T8 vertebra.,COMPLICATIONS:,  None.,SURGICAL INDICATIONS:,  The patient is an 80-year-old female who had previous history of compression fractures.  She had recently undergone an additional compression fracture of the T8 vertebrae.  She was in extreme pain.  This pain interfered with activities of daily living and was unimproved with conservative treatment modalities.  She is understanding the risks, benefits, and potential complications as well as all treatment alternatives.  The patient provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #2 where she was placed prone on the Jackson spinal table.  She was given sedative.  The thoracodorsal spine was then sterilely prepped and draped in the usual fashion.  Biplanar image intensification was utilized to localize the T8, T7, and T9 vertebrae.  Local anesthetic of 1% Marcaine with epinephrine and lidocaine were 50:50 mixed.,Approximately 7 cc was instilled on the left side.  This was directly over the posterior aspect of the pedicle on the left.  Once this was localized, the right side was localized as well.  Stab incisions were then created over the pedicles of T8 bilaterally.  Jamshidi needles were then placed percutaneously.  Their position was verified in both AP and lateral images.  They were advanced slowly under direct image intensification in biplanar fashion.  Once these were satisfactorily placed, the inner trocar was removed and a guidewire was inserted into the depths of the T7 vertebrae.  The Jamshidi needles were then removed.  A biopsy was then harvested with a biopsy trocar placed into the T8 vertebrae.  This bone was then removed and sent to the lab.  The injection cannulas were then placed over the guidewires and their position was verified in both AP and lateral images.  Once this was completed, a second Jamshidi needle was placed at the T7 vertebrae on the left at the entrance of the pedicle.  This was advanced under direct image intensification in a biplanar fashion.  Once this was deemed satisfactory, it was impacted.  The inner trocar was removed and a guidewire was then placed.  An injection cannula was then placed over the guidewire into the body of T7.  In a similar fashion, T9 was dressed on the left side as well.  A guidewire was then placed through the Jamshidi needle, which was verified in both AP and lateral images.  The cement injection cannula was then placed over this entering the T9 vertebrae body.  Attention was then turned to the kyphoplasty portion of the procedure at the T8 vertebrae.  The balloons were inserted bilaterally.  The balloons were then inflated under direct image intensification and pressurized to approximately 200 mmHg.  These were allowed to expand and reduce the fracture.  Once this was completed, the balloons were deflated and removed.  The inner cannulas of all four entrance holes were removed and approximately 1.5 cc of cement was injected in each of the cannulas.  This was done directly under image intensification.  Once this was completed, additional cement was injected into T9 as there was a larger vertebra.  The cement was allowed to cure.  The cannula was removed and final radiographs were obtained.  The stab incisions were then cleansed with water and antibiotic irrigation.  The wounds were then approximated with #4-0 Nylon in interrupted fashion.  Compression dressings were applied and fixed with tape.  She was aroused and moved to her inpatient bed.  She was moving all four extremities without deficit.  She had no significant pain.",27
"CHIEF COMPLAINT:  ,Severe tonsillitis, palatal cellulitis, and inability to swallow.,HISTORY OF PRESENT ILLNESS: , This patient started having sore throat approximately one week ago; however, yesterday it became much worse.  He was unable to swallow.  He complained to his parent.  He was taken to Med Care and did not get any better, and therefore presented this morning to ER, where seen and evaluated by Dr. X and concerned as whether he had an abscess either pharyngeal, palatal, or peritonsillar.  He was noted to have extreme tonsillitis with kissing tonsils, marked exudates especially right side and right palatal cellulitis.  A CT scan at ER did not show abscess.  He has not had airway compromise, but he has had difficulty swallowing.  He may have had a low-grade fever, but nothing marked at home.  His records from Hospital are reviewed as well as the pediatric notes by Dr. X. He did have some equivalent leukocytosis.  He had a negative monospot and negative strep screen.,PAST MEDICAL HISTORY:  ,The patient takes no medications, has had no illnesses or surgeries and he is generally in good health other than being significantly overweight.  He is a sophomore at High School.,FAMILY HISTORY:  ,Noncontributory to this illness.,SURGERIES: , None.,HABITS: , Nonsmoker, nondrinker.  Denies illicit drug use.,REVIEW OF SYSTEMS:,ENT:  The patient other than having dysphagia, the patient denies other associated ENT symptomatology.,GU:  Denies dysuria.,Orthopedic:  Denies joint pain, difficulty walking, etc.,Neuro:  Denies headache, blurry vision, etc.,Eyes:  Says vision is intact.,Lungs:  Denies shortness of breath, cough, etc.,Skin:  He states he has a rash, which occurred from penicillin that he was given IM yesterday at Covington Med Care.  Mildly itchy.  Mother has penicillin allergy.,Endocrine:  The patient denies any weight loss, weight gain, skin changes, fatigue, etc, essentially no symptoms of hyper or hypothyroidism.,Physical Exam:,General:  This is a morbidly obese white male adolescent, in no acute disease, alert and oriented x 4.  Voice is normal.  He is handling his secretions.  There is no stridor.,Vital Signs:  See vital signs in nurses notes.,Ears:  TM and EACs are normal.  External, normal.,Nose:  Opening clear.  External nose is normal.,Mouth:  Has bilateral marked exudates, tonsillitis, right greater than left.  Uvula is midline.  Tonsils are touching.  There is some redness of the right palatal area, but is not consistent with peritonsillar abscess.  Tongue is normal.  Dentition intact.  No mucosal lesions other than as noted.,Neck:  No thyromegaly, masses, or adenopathy except for some small minimally enlarged high jugular nodes.,Chest:  Clear to auscultation.,Heart:  No murmurs, rubs, or gallops.,Abdomen:  Obese.  Complete exam deferred.,Skin:  Visualized skin dry and intact, except for rash on his inner thighs and upper legs, which is red maculopapular and consistent with possible allergic reaction.,Neuro:  Cranial nerves II through XII are intact.  Eyes, pupils are equal, round, and reactive to light and accommodation, full range.,IMPRESSION: , Marked exudative tonsillitis, non-strep, non-mono, probably mixed anaerobic infection.  No significant prior history of tonsillitis.  Possible rash to PENICILLIN.,RECOMMENDATIONS: , I concur with IV clindamycin and IV Solu-Medrol as per Dr. X. I anticipate this patient may need several days of IV antibiotics and then be able to switch over to oral.  I do not insist that this patient will need surgical intervention since there is no evidence of abscess.  This one episode of severe tonsillitis does not mean the patient needs tonsillectomy, but if he continues to have significant tonsil problems after this he should be referred for ENT evaluation as an outpatient.  The patient's parents in the room had expressed good understanding, have a chance to ask questions.  At this time, I will see the patient back on an as needed basis.",5
"CHIEF COMPLAINT: , Buttock abscess.,HISTORY OF PRESENT ILLNESS: , This patient is a 24-year-old African-American female who presented to the hospital with buttock pain.  She started off with a little pimple on the buttock.  She was soaking it at home without any improvement.  She came to the hospital on the first.  The patient underwent incision and drainage in the emergency department.  She was admitted to the hospitalist service with elevated blood sugars.  She has had positive blood cultures.  Surgery is consulted today for evaluation.,PAST MEDICAL HISTORY:  ,Diabetes type II, poorly controlled, high cholesterol.,PAST SURGICAL HISTORY: , C-section and D&C.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , Insulin, metformin, Glucotrol, and Lipitor.,FAMILY HISTORY: , Diabetes, hypertension, stroke, Parkinson disease, and heart disease.,REVIEW OF SYSTEMS: , Significant for pain in the buttock.  Otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  This is an overweight African-American female not in any distress.,VITAL SIGNS:  She has been afebrile since admission.  Vital signs have been stable.  Blood sugars have been in the 200 range.,HEENT:  Normal to inspection.,NECK:  No bruits or adenopathy.,LUNGS:  Clear to auscultation.,CV:  Regular rate and rhythm.,ABDOMEN:  Protuberant, soft, and nontender.,EXTREMITIES:  No clubbing, cyanosis or edema.,RECTAL EXAM:  The patient has a drained abscess on the buttock cheek.  There is some serosanguineous drainage.  There is no longer any purulent drainage.  The wound appears relatively clean.  I do not see a lot of erythema.,ASSESSMENT AND PLAN: , Left buttock abscess, status post incision and drainage.  I do not believe surgical intervention is warranted.  I have recommended some local wound care.  Please see orders for details.",15
"CHIEF COMPLAINT:,  Worker’s compensation injury.,HISTORY OF PRESENT ILLNESS:,  The patient is a 21-year-old Hispanic female.  She comes in today with her boyfriend.  The patient speaks English fairly well, but her primary language is Spanish.  Her boyfriend does help to make sure that she understands what we are talking about.  The patient seems to understand our conversation fairly well.  She works at Norcraft and injured her right thumb on 09/10/2004 at 12:15 a.m.  She was pushing a cart and mashed her thumb between the cart and the wall.  This was at the finishing room in Norcraft.  She went ahead and went to work yesterday, which was the 14th, but was not able to work on the 13th.  She has swelling in her thumb.  It hurt only if it is pushed on.  It was the distal end of her thumb that was mashed.  She has not noticed any numbness or tingling or weakness.  She has not sought any treatment for this, is not taking any pain medications.  She did try soaking it in warm salt water and did not notice any improvement.,MEDICATIONS: , None.,ALLERGIES: , None.,PAST MEDICAL HISTORY:,  Possible history of chicken pox, otherwise no other medical illnesses.  She has never had any surgery.,FAMILY HISTORY: , Parents and two siblings are healthy.  She has had no children.,SOCIAL HISTORY:,  The patient is single.  She lives with her boyfriend and his father.  She works at Norcraft.  She wears seatbelt 30% of the time.  I encouraged her to use them all of the time.  She is a nonsmoker, nondrinker.,VACCINATIONS: , She thinks she got a tetanus vaccine in childhood, but does not know for sure.  She does not think she has had a tetanus booster recently.,REVIEW OF SYSTEMS:,Constitutional:  No fevers, chills, or sweats.,Neurologic:  She has had no numbness, tingling, or weakness.,Musculoskeletal:  As above in HPI.  No other difficulties.,PHYSICAL EXAMINATION:,General:  This is a well-developed, well-nourished, very pleasant Hispanic female, in no acute distress.,Vital Signs:  Weight:  121.4.  Blood pressure:  106/78.  Pulse:  64.  Respirations:  20.  Temperature:  96.,Extremities:  Examination of the right hand reveals the distal end of the thumb to be swollen especially just proximal to the nail bed.  The nail bed is pushed up.  I can see hematoma below the nail bed, although it does appear to be intact.  She has some blue fingernail polish on her nail also, but that is starting to come off.  She is able to bend her thumb normally at the DIP joint.  She has no discomfort doing that.  Sensation is intact over the entire thumb.  She has normal capillary refill.  There is some erythema and swelling noted especially over the posterior thumb just proximal to the nail bed.  I am not feeling any fluctuance.  I do not think it is a collection of pus.  There is no drainage.  She does have some small fissures in the skin where I think she did injure it with this smashing injury, but no deep lacerations at all.  It looks like there may be some mild cellulitis at the site of her injury.,LABORATORY:,  X-ray of the thumb was obtained and I do not see any sign of fracture or foreign body.,ASSESSMENT:,  Blunt trauma to the distal right thumb without fracture.  I think there is some mild cellulitis developing there.,PLAN:,1.  We will give a tetanus diphtheria booster.,2.  We will start Keflex 500 mg one p.o. q.i.d. x 7 days.  I would recommend that she can return to work, but she is not to do any work that requires the use of her right thumb.  I would like to see her back on Monday, the 20th in the morning and we can see how her thumb is doing at that time.  If she is noticing any difficulties with increased redness, increased warmth, increased pain, pus-like drainage, or any other difficulties, she is to go ahead and give us a call.  Otherwise I will be seeing her back on Monday.",18
"CC:, BLE weakness.,HX:, This 82y/o RHM was referred to the Neurology service by the Neurosurgery service for evaluation of acute onset paraplegia. He was in his usual state of health until 5:30PM on 4/6/95, when he developed sudden ""pressure-like"" epigastric discomfort associated with bilateral lower extremity weakness, SOB, lightheadedness and diaphoresis. He knelt down to the floor and ""went to sleep."" The Emergency Medical Service was alert and arrived within minutes, at which time he was easily aroused though unable to move or feel his lower extremities. No associated upper extremity or bulbar dysfunction was noted. He was taken to a local hospital where an INR was found to be 9.1. He was given vitamin K 15mg, and transferred to UIHC to rule out spinal epidural hemorrhage. An MRI scan of the T-spine was obtained and the preliminary reading was ""normal."" The Neurology service was then asked to evaluate the patient.,MEDS:, Coumadin 2mg qd, Digoxin 0.25mg qd, Prazosin 2mg qd.,PMH:, 1)HTN. 2)A-Fib on coumadin. 3)Peripheral vascular disease:s/p left Femoral-popliteal bypass (8/94) and graft thrombosis-thrombolisis (9/94). 4)Adenocarcinoma of the prostate: s/p TURP (1992).,FHX: ,unremarkable.,SHX:, Farmer, Married, no Tobacco/ETOH/illicit drug use.,EXAM:, BP165/60 HR86 RR18 34.2C SAO2 98% on room air.,MS: A&O to person, place, time. In no acute distress. Lucid.,CN: unremarkable.,MOTOR: 5/5 strength in BUE. Flaccid paraplegia in BLE,Sensory: T6 sensory level to LT/PP, bilaterally. Decreased vibratory sense in BLE in a stocking distribution, distally.,Coord: Intact FNF and RAM in BUE. Unable to do HKS.,Station: no pronator drift.,Gait: not done.,Reflexes: 2/2 BUE, Absent in BLE, plantar responses were flexor, bilaterally.,Rectal: decreased rectal tone.,GEN EXAM: No carotid bruitts. Lungs: bibasilar crackles. CV: Irregular rate and rhythm with soft diastolic murmur at the left sternal border. Abdomen: flat, soft, non-tender without bruitt or pulsatile mass. Distal pulses were strong in all extremities.,COURSE:, Hgb 12.6, Hct 40%, WBC 11.7, Plt 154k, INR 7.6, PTT 50, CK 41, the GS was normal. EKG showed A-Fib at 75BPM with competing junctional pacemaker, essentially unchanged from 9/12/94.,It was suspected that the patient sustained an anterior-cervico-thoracic spinal cord infarction with resultant paraplegia and T6 sensory level. A CXR was done in the ER prior to admission. This revealed cardiomegaly and a widened mediastinum. He returned from the x-ray suite and suddenly became unresponsive and went into cardiopulmonary arrest. Resuscitative measures failed. Pericardiocentesis was unremarkable. Autopsy revealed a massive aortic dissection extending from the aortic root to the origin of the iliac arteries with extensive pericardial hematoma. The dissection was seen in retrospect on the MRI T-spine.",27
"The patient was told that the injection may cause more pain for two to three days afterwards and if this occurred they would best be served by icing the area 15-20 minutes every 6 hours.  The patient was advised to protect the knee by limiting repetitive bending, squatting , kneeling and excessive heavy use for a week.  Also, they were asked to follow up in two weeks p.r.n.",28
"GENERAL EVALUATION: ,Twin B,Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Longitudinal, to the maternal right.,Fetal Presentation: Cephalic.,Placenta: Fused, posterior placenta, Grade I to II.,Uterus: Normal,Cervix: Closed.,Adnexa: Not seen,Amniotic Fluid: AFI 5.5cm in a single AP pocket.,BIOMETRY:,BPD: 7.9cm consistent with 31weeks, 5 days gestation,HC: 31.1cm consistent with 33 weeks, 3 days gestation,AC: 30.0cm consistent with 34 weeks, 0 days gestation,FL:",33
"PREOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,POSTOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,3.Severe adhesions.,TYPE OF ANESTHESIA: , General endotracheal tube.,TECHNICAL PROCEDURE: , Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.,INDICATION FOR PROCEDURE: , The patient is a 42-year-old parous female who had a longstanding history of severe endometriosis unresponsive to hormonal medical therapy and pain medication.  She had severe dyspareunia and chronic suprapelvic pain.  The patient had had a prior left salpingoophorectomy laparoscopically in 2004 for same disease process.  Now, she presented with a recurrent right ovarian endometrioma and severe pelvic pain.  She desired surgical treatment.  She accepted risk of a complete hysterectomy and salpingoophorectomy, risk of injury to underlying organs.  The risks, benefits, and alternatives were clearly discussed with the patient as documented in the medical record.,DESCRIPTION OF FINDINGS: , Absent left adnexa.  Right ovary about 6 cm with chocolate cyst and severely adherent to the right pelvic side wall, uterus, and colon.  Careful dissection to free right ovary and remove it although it is likely that some ovarian tissue remains behind.  Ureter visualized and palpated on right and appears normal.  Indigo carmine given IV with no leaks intraperitoneally noted.  Sigmoid colon dissected free from back of uterus and from cul-de-sac.  Bowel free of lacerations or denudation.  Upon inspection, right tube with hydrosalpinx, appendix absent.  Omental adhesions to ensure abdominal wall was lysed.,TECHNICAL PROCEDURE: , After informed consent was obtained, the patient was taken to the operating room where she underwent smooth induction of general anesthesia.  She was placed in a supine position with a transurethral Foley in place and compression stockings in place.  The abdomen and vagina were thoroughly prepped and draped in the usual sterile fashion.,A Pfannenstiel skin incision was made with the scalpel and carried down sharply to the underlying layer of fascia and peritoneum.  The peritoneum was bluntly entered and the incision extended caudally and cephaladly with good visualization of underlying organs.  Next, exploration of the abdominal and pelvic organs revealed the above noted findings.  The uterus was enlarged and probably contained adenomyosis.  There were dense adhesions, and a large right endometrioma with a chocolate cyst-like material contained within.  The sigmoid colon was densely adhered to the cul-de-sac into the posterior aspect of the uterus.  A Bookwalter retractor was placed into the incision, and the bowel was packed away with moist laparotomy sponges.  Next, a sharp and blunt dissection was used to free the extensive adhesions, and enterolysis was performed with very careful attention not to injure or denude the bowel.  Next, the left round ligament and cornual region was divided, transected, and suture-ligated with 0 Polysorb.  The anterior and posterior leafs of the broad ligament were dissected and opened anteriorly to the level of the bladder.  The uterine arteries were skeletonized on the left, and these were suture-clamped and transected with 0 Polysorb with good hemostasis noted.  Next, the bladder flap was developed anteriorly, and the bladder peritoneum was sharply and bluntly dissected off of the lower uterus.,On the right, a similar procedure was performed.  The right round ligament was suture-ligated with 0 Polysorb.  It was transected and divided with electrocautery.  The anterior and posterior leafs of the broad ligament were dissected and developed anteriorly and posteriorly, and this area was relatively avascular.  The left infundibulopelvic ligament was identified.  It was cross-clamped and transected, suture-ligated with 0 Polysorb with good hemostasis noted.  Next, the uterine arteries were skeletonized on the right.  They were transected and suture-ligated with 0 Polysorb.  The uterosacral ligaments were taken bilaterally and transected and suture-ligated with 0 Polysorb.  The cardinal ligaments were taken near their insertion into the cervical and uterine tissue.  Pedicles were sharply developed and suture-ligated with 0 Polysorb.  Next, the electrocautery was used to dissect the cervix anteriorly from the underlying vagina.  Once entry into the vagina was made, the cervix and uterus were amputated with Jorgensen scissors.  The vaginal cuff angles were suture-ligated with 0 Polysorb and transfixed to the ipsilateral, cardinal, and uterosacral ligaments for vaginal support.  The remainder of the vagina was closed with figure-of-eight sutures in an interrupted fashion with good hemostasis noted.,Next, the right ovarian tissue was densely adherent to the colon.  It was sharply and bluntly dissected, and most of the right ovary and endometrioma was removed and dissected off completely; however, there is a quite possibility that small remnants of ovarian tissue were left behind.  The right ureter was seen and palpated.  It did not appear to be dilated and had good peristalsis noted.  Next, the retractors were removed.  The laparotomy sponges were removed from the abdomen.  The rectus fascia was closed with 0 Polysorb in a continuous running fashion with 2 sutures meeting in the midline.  The subcutaneous tissue was closed with 0 plain gut in an interrupted fashion.  The skin was closed with 4-0 Polysorb in a subcuticular fashion.  A thin layer of Dermabond was placed.,The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x 2.  Cefoxitin 2 g was given preoperatively.,INTRAOPERATIVE COMPLICATIONS:,  None.,DESCRIPTION OF SPECIMEN: , Uterus and right adnexa.,ESTIMATED BLOOD LOSS: , 1000 mL.,POSTOPERATIVE CONDITION: , Stable.,",24
"REASON FOR REFERRAL:,  The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the ""early stages of a likely dementia"" and was thereafter terminated from her position as a psychiatric nurse.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.  Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning.  The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION:  ,Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  The patient reported that she had worked as a nurse supervisor for Hospital Center for four years.  She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work.  She continues to receive some compensation through FMLA hours.  She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services.  She said that these 90 days are up around the end of November.  She said the reason for her dismissal was performance complaints.  She said that they began ""as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off.  She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays.  She described it as a very chaotic and hectic work environment in which she was often putting in extra time.  She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time.  Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D.  He completed a Comprehensive Independent Medical Evaluation on 08/14/2009.  She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore.  Please note that we do not have copies of any of her work-related correspondence.  The patient never received a copy of the neuropsychological evaluation because she was told that it was ""too derogatory.""  A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation.  To summarize, the results indicated ""diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history.  This suggests that her intellectual functioning has declined.""  It concluded that ""results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy…  The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing.  The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other.  Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits.  His neurological examination on 09/23/2009 was unremarkable.  The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting.  A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions.  Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING:  ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her.  When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills.  She also denied any problems with attention and concentration or forgetfulness or memory problems.  She continues to independently perform all activities of daily living.  She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning.  She reported that if her children had noticed anything they definitely would have brought it to her attention.  She said that she does not currently have a lawyer and does not intend to return to her previous physician.  She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application.  Other current symptoms include excessive fatigue.  She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia.  She also reported having fallen approximately five times within the past year.  She said that this typically occurs when she is climbing up steps and is usually related to her right foot ""like dragging.""  Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis.  She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body.  Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal.  She denied any significant medical conditions during childhood.  As mentioned, she now has a history of fibromyalgia.  She also experiences some restriction in the range of motion with her right arm.  MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7.  MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon.  As mentioned, she was diagnosed with chronic fatigue syndrome in 1991.  She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control.  She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974.  Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007.  She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night.  She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:,  NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs.  She drinks two to four cups of coffee per day.,SOCIAL HISTORY:  ,The patient was born and raised in North Carolina.  She was the sixth of nine siblings.  Her father was a chef.  He completed third grade and died at 60 due to complications of diabetes.  Her mother is 93 years old.  Her last job was as a janitor.  She completed fourth grade.  She reported that she has no cognitive problems at this time.  Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression.  The patient completed a Bachelor of Science in Nursing through State University in 1979.  She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems.  She was married for two years.  Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse.  She has two children ages 43 and 30.  Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York.  In school, the patient reported obtaining primarily A's and B's.  She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling.  The patient worked for Hospital Center for four years.  Prior to that, she worked for an outpatient mental health center for 2-1/2 years.  She was reportedly either terminated or laid off and was unsure of the reason for that.  Prior to that, she worked for Walter P. Carter Center reportedly for 21 years.  She has also worked as an OB nurse in the past.  She reported that other than the two instances reported above, she had never been terminated or fired from a job.  In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue.  She was also taking Prozac during that time.  She then began taking Prozac again when she started working at secondary to stress with the work situation.  She reported a chronic history of mild sadness or depression, which was relatively stable.  When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things.  She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",5
"Chief Complaint:, Abdominal pain, nausea, vomiting, fever, altered mental status.,History of Present Illness:, 55 yo WM with reactive airways disease, allergic rhinitis who was in his usual state of health until he underwent a dental extraction with administration of cephalexin 1 week prior to admission. Approximately one day after the dental procedure, he began having nausea, and abdominal pain along with fatigue. The abdominal pain was described as pressure-like and was located in the epigastrium and periumbilical regions. He initially attributed the symptoms to a side effect of the antibiotic he was taking. However, with worsening of his symptoms, he presented to the ER 5 days after dental extraction.,At that time his vitals were T 99.9 ° HR 115 RR 18 BP 182/101. His exam was notable for mild tenderness in the central abdomen. Laboratory evaluation was notable for WBC 15.6, Hgb 13.1, Plt 189, 16% bands, 68% PMNs. Na 127, K4.7, Cl 88, CO2 29, BUN 19, Cr 1.5, Glucose 155, Ca 9.6, alk phos 125, t bili 0.7, ALT 29, nl amylase and lipase. UA with 100 protein, lg blood, 53 RBC, 2 WBC. Plain films done at that time revealed dilation of small bowel loops in mid-abdomen up to 3.5cm in diameter, thought to be most consistent with a paralytic ileus. The patient was discharged home with diagnosis of medication-induced gastroenteritis vs. UTI. He was instructed to stop his current antibiotic but start Levaquin, and he was given Vicodin, and phenergan for symptomatic relief.,Over the next 2 days, the patient began having fevers, non-bloody emesis, diarrhea, and confusion in addition to his persistent nausea, and abdominal pain. On the night of presentation, the patient was found by a cousin in his bathroom lethargic and disoriented. EMS was called and patient was taken to the ER. In the ER, the pt was diaphoretic, unable to answer questions appropriately, hypotensive, and febrile, with some response of bp to multiple IVF boluses (4L). He received acetaminophen, and ceftriaxone 2g IV after blood cultures were obtained and an LP was performed in the ER. He was then admitted to the ICU for further evaluation and management.,Past Medical History:,Asthma,Allergic Rhinitis,Medications:,loratadine,beclomethasone nasal,fluticasone/salmeterol inhaled,Montelukast,cephalexin,hydrocodone,Allergies:, PCN, but has tolerated cephalosporins in the past.,Social History:, No tobacco use, occasional EtOH, no known drug use, works as a real estate agent.,Family History:, HTN, father with SLE, uncle with Addison’s Disease.,Physical Exam:,T 102.9 ° HR 145 RR 22 BP 99/50 98% on room air, (orthostatics were not performed due to patient’s mental status),I/O: minimal urine output after Foley insertion,Gen: lethargic, mild tachypnea,HEENT: no evidence of trauma, sclerae anicteric, pupils are equal round and reactive to light, oropharynx clear, MM dry.,Neck: supple, without increased JVP, lymphadenopathy or bruits. No thyromegaly,Chest: coarse rhonchi bilaterally,CV: tachycardia, regular, no murmurs, gallops, rubs,Abd: hypoactive bowel sounds, soft, slightly distended, mild tenderness throughout. No rebound, no masses or hepatosplenomegaly.,Ext: no cyanosis, clubbing, or edema. 2+ pulses bilateral distal extremities, no petechiae or splinter hemorrhages.,Neuro: lethargic, but arousable, oriented to person, but not to place, or time. He was not able to answer questions appropriately. Moved all extremities equally but was uncooperative with exam. 2+ DTRs bilaterally, no Babinski reflex.,Skin: no rash, ecchymosis, or petechiae,STUDIES:,EKG: sinus tachycardia, normal axis, isolated Q in III, no TWI or ST elevations or depressions,CXR: Heart normal in size, pulmonary vasculature unremarkable, subsegmental atelectasis in the lower lobes. Acromioclavicular osteoarthritis bilaterally. Lucent lesion in the subchondral bone of the R humeral head, likely a degenerative subchondral cyst.,AXR: Minimal dilation of the small bowel loops in the mid abdomen measuring up to 3cm, no mass lesion or free air visible.,MRI brain pre and post gadolinium: No evidence of hemorrhage, abnormal enhancement, mass lesions, mass effect or edema. The ventricles, sulci, and cisterns are age appropriate in size and configuration. There is no evidence for restricted diffusion. There is mucosal thickening lining the walls of the left maxillary sinus, also containing an air fluid level with two different levels within it, most likely from proteinaceous differences. There is mucosal thickening along the posterior wall of the right maxillary sinus. Mucosal thickening is identified along the walls of the sphenoid sinus, ethmoid sinuses and frontal sinus. Sinusitis with chronic and acute features.,Echo: EF 50%, mild LV concentric hypertrophy, otherwise normal chamber sizes and function,TEE: Normal valves, no thrombi, PFO with R to L shunt, trivial MR, trivial TR,RLE Ultrasound with Dopplers – total deep venous obstruction in distal external iliac, common femoral, profunda femoral, and femoral vein, partial DVT in popliteal and posterior tibial veins, and total DVT greater saphenous vein. No venous obstruction on the L LE. R calf 34cm, R thigh 42 cm, L calf 31cm, L thigh 39cm.,CT Abdomen (initial ER visit): Trace bilateral pleural fluid, findings in liver compatible with diffuse fatty infiltration, 3.5cm non calcified R adrenal mass was noted, along with an edematous L adrenal with no discrete mass. There was retroperitoneal edema around the lower abdominal aorta with perinephric stranding, no stone or obstruction. Moderate fullness of small bowel loops was noted, most consistent with a paralytic ileus.,Hospital Course:, The patient developed right lower extremity swelling and was diagnosed with deep venous thrombosis. Diagnostic studies were performed.",5
"PREOPERATIVE DIAGNOSIS:,  Complex Regional Pain Syndrome, right upper extremity.,POSTOPERATIVE DIAGNOSIS:,  Same.,OPERATION:,",28
"PREOPERATIVE DIAGNOSIS:,  Dorsal ganglion, right wrist.,POSTOPERATIVE DIAGNOSIS:,  Dorsal ganglion, right wrist.,OPERATIONS PERFORMED:,  Excision dorsal ganglion, right wrist.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME:,  minutes.,DESCRIPTION OF PROCEDURE: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated and the tourniquet was elevated to 290 mm/Hg.  A transverse incision was made over the dorsal ganglion.  Using blunt dissection the dorsal ulnar sensory nerve branches and radial sensory nerve branches were dissected and retracted out of the operative field.  The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field.  The ganglion was then further dissected to its origin from the dorsal distal scapholunate interosseus ligament and excised in toto.  Care was taken to protect ligament integrity.  Reactive synovium was then removed using soft tissue rongeur technique.  The wound was then infiltrated with 0.25% Marcaine.  The tendons were allowed to resume their normal anatomical position.  The skin was closed with 3-0 Prolene subcuticular stitch.  Sterile dressings were applied.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.",37
"ADMITTING DIAGNOSES:,  Hiatal hernia, gastroesophageal reflux disease reflux.,DISCHARGE DIAGNOSES:,  Hiatal hernia, gastroesophageal reflux disease reflux.,SECONDARY DIAGNOSIS: , Postoperative ileus.,PROCEDURES DONE: , Hiatal hernia repair and Nissen fundoplication revision.,BRIEF HISTORY: , The patient is an 18-year-old male who has had a history of a Nissen fundoplication performed six years ago for gastric reflux.  Approximately one year ago, he was involved in a motor vehicle accident and CT scan at that time showed that he had a hiatal hernia.  Over the past year, this has caused him an increasing number of problems, including chest pain when he eats, and shortness of breath after large meals.  He is also having reflux symptoms again.  He presents to us for repair of the hiatal hernia and revision of the Nissen fundoplication.,HOSPITAL COURSE: , Mr. A was admitted to the adolescent floor by Brenner Children's Hospital after his procedure.  He was stable at that time.  He did complain of some nausea.  However, he did not have any vomiting at that time.  He had an NG tube in and was n.p.o.  He also had a PCA for pain management as well as Toradol.  On postoperative day #1, he complained of not being able to urinate, so a Foley catheter was placed.  Over the next several days, his hospital course proceeded as follows.  He continued to complain of some nausea; however, he did not ever have any vomiting.  Eventually, the Foley catheter was discontinued and he had excellent urine output without any complications.  He ambulated frequently.  He remained n.p.o. for three days.  He also had the NG tube in during that time.  On postoperative day #4, he began to have some flatus, and the NG tube was discontinued.  He was advanced to a liquid diet and tolerated this without any complications.  At this time, he was still using the PCA for pain control.  However, he was using it much less frequently than on days #1 and #2 postoperatively.  After tolerating the full liquid diet without any complications, he was advanced to a soft diet and his pain medications were transitioned to p.o. medications rather than the PCA.  The PCA was discontinued.  He tolerated the soft diet without any complications and continued to have flatus frequently.  On postoperative day #6, it was determined that he was stable for discharge to home as he was taking p.o. without any complications.  His pain was well controlled with p.o. pain medications.  He was passing gas frequently, had excellent urine output, and was ambulating frequently without any issues.,DISCHARGE CONDITION:,  Stable.,DISPOSITION: , Discharged to home.,DISCHARGE INSTRUCTIONS: , The patient was discharged to home with instructions for maintaining a soft diet.  It was also recommended that he does not drink any soda postoperatively.  He is instructed to keep his incision site clean and dry and it was also recommended that he avoid any heavy lifting.  He will be able to attend school when it starts in a few weeks.  However, he is not going to be able to play football in the near future.  He was given prescription for pain medication upon discharge.  He is instructed to contact Pediatric Surgery if he has any fevers, any nausea and vomiting, any chest pain, any constipation, or any other concerns.",14
"PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Endometriosis.,3.  Prior right salpingo-oophorectomy.,4.  History of intrauterine device perforation and exploratory surgery.,POSTOPERATIVE DIAGNOSES:,1.  Endometriosis.,2.  Interloop bowel adhesions.,PROCEDURE PERFORMED:,1.  Total abdominal hysterectomy (TAH).,2.  Left salpingo-oophorectomy.,3.  Lysis of interloop bowel adhesions.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS:  ,400 cc.,FLUIDS: , 2300 cc of lactated Ringers, as well as lactated Ringers for intraoperative irrigation.,URINE: , 500 cc of clear urine output.,INTRAOPERATIVE FINDINGS: , The vulva and perineum are without lesions.  On bimanual exam, the uterus was enlarged, movable, and anteverted.  The intraabdominal findings revealed normal liver margin, kidneys, and stomach upon palpation.  The uterus was found to be normal in size with evidence of endometriosis on the uterus.  The right ovary and fallopian tube were absent.  The left fallopian tube and ovary appeared normal with evidence of a small functional cyst.  There was evidence of left adnexal adhesion to the pelvic side wall which was filmy, unable to be bluntly dissected.  There were multiple interloop bowel adhesions that were filmy in nature noted.,The appendix was absent.  There did appear to be old suture in a portion of the bowel most likely from a prior procedure.,INDICATIONS: , This patient is a 45-year-old African-American gravida7, para3-0-0-3, who is here for definitive treatment of chronic pelvic pain with a history of endometriosis.  She did have a laparoscopic ablation of endometriosis on a laparoscopy and also has a history of right salpingo-oophorectomy.  She has tried Lupron and did stop secondary to the side effects.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the Operating Suite and placed under general anesthesia.  She was then prepped and draped in the sterile fashion and placed in the dorsal supine position.  An indwelling Foley catheter was placed.  With the skin knife, an incision was made removing the old cicatrix.  A Bovie was used to carry the tissue through to the underlying layer of the fascia which was incised in the midline and extended with the Bovie.  The rectus muscle was then sharply and bluntly dissected off the superior aspect of the rectus fascia in the superior as well as the inferior aspect using the Bovie.  The rectus muscle was then separated in the midline using a hemostat and the peritoneum was entered bluntly.  The peritoneal incision was then extended superiorly and inferiorly with Metzenbaum scissors with careful visualization of the bladder.  At this point, the intraabdominal cavity was manually explored and the above findings were noted.  A Lahey clamp was then placed on the fundus of the uterus and the uterus was brought to the surgical field.  The bowel was then packed with moist laparotomy sponges.  Prior to this, the filmy adhesions leftover were taken down.  At this point, the left round ligament was identified, grasped with two hemostats, transected, and suture ligated with #0 Vicryl.  At this point, the broad ligament was dissected down and the lost portion of the bladder flap was created.  The posterior aspect of the peritoneum was also dissected.  At this point, the infundibulopelvic ligament was isolated and three tie of #0 Vicryl was used to isolate the pedicle.  Two hemostats were then placed across the pedicle and this was transected with the scalpel.  This was then suture ligated in Heaney fashion.  The right round ligament was then identified and in the similar fashion, two hemostats were placed across the round ligament and using the Mayo scissors the round ligament was transected and dissected down the broad ligament to create the bladder flap anteriorly as well as dissect the posterior peritoneum and isolate the round ligament.  This was then ligated with three tie of #0 Vicryl.  Also incorporated in this was the remnant from the previous right salpingo-oophorectomy.  At this point, the bladder flap was further created with sharp dissection as well as the moist Ray-Tech to push the bladder down off the anterior portion of the cervix.,The left uterine artery was then skeletonized and a straight Heaney was placed.  In a similar fashion, the contralateral uterine artery was skeletonized and straight Heaney clamp was placed.  These ligaments bilaterally were transected and suture ligated in a left Heaney stitch.  At this point, curved Masterson was used to incorporate the cardinal ligament complex, thus was transected and suture ligated.  Straight Masterson was then used to incorporate the uterosacrals bilaterally and this was also transected and suture ligated.  Prior to ligating the uterine arteries, the uterosacral arteries were tagged bilaterally with #0 Vicryl.  At this point, the roticulator was placed across the vaginal cuff and snug underneath the entire cervix.  The roticulator was then clamped and removed and the staple line was in place.  This was found to be hemostatic.  A suture was then placed through each cuff angle bilaterally and cardinal ligament complex was found to be fixed to each apex bilaterally.  At this point, McCall culdoplasty was performed with an #0 Vicryl incorporating each uterosacral as well as the posterior peritoneum.  There did appear to be good support on palpation.  Prior to this, the specimen was handed off and sent to pathology.  At this point, there did appear to be small amount of oozing at the right peritoneum.  Hemostasis was obtained using a #0 Vicryl in two single stitches.  Good hemostasis was then obtained on the cuff as well as the pedicles.  Copious irrigation was performed at this point with lactate Ringers.  The round ligaments were then incorporated into the cuff bilaterally.  Again, copious amount of irrigation was performed and good hemostasis was obtained.  At this point, the peritoneum was reapproximated in a single interrupted stitch on the left and right lateral aspects to cover each pedicle bilaterally.  At this point, the bowel packing as well as moist Ray-Tech was removed and while re-approximating the bowel it was noted that there were multiple interloop bowel adhesions which were taken down using the Metzenbaum scissors with good visualization of the underlying bowel.  Good hemostasis was obtained of these sites as well.  The sigmoid colon was then returned to its anatomic position and the omentum as well.  The rectus muscle was then reapproximated with two interrupted sutures of #2-0 Vicryl.  The fascia was then reapproximated with #0 Vicryl in a running fashion from lateral to medial meeting in the midline.  The Scarpa's fascia was then closed with #3-0 plain in a running suture.  The skin was then re-approximated with #4-0 undyed Vicryl in a subcuticular closure.  This was dressed with an Op-Site.  The patient tolerated the procedure well.  The sponge, lap, and needle were correct x2.  After the procedure, the patient was extubated and brought out of general anesthesia.  She will go to the floor where she will be followed postoperatively in the hospital.",24
"SUBJECTIVE: , The patient was seen and examined.  He feels much better today, improved weakness and decreased muscular pain.  No other complaints.,PHYSICAL EXAMINATION:,GENERAL:  Not in acute distress, awake, alert and oriented x3.,VITAL SIGNS:  Blood pressure 147/68, heart rate 82, respiratory rate 20, temperature 97.7, O2 saturation 99% on 3 L.,HEENT:  NC/T, PERRLA, EOMI.,NECK:  Supple.,HEART: Regular rate and rhythm.,RESPIRATORY:  Clear bilateral.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses present bilateral.,LABORATORY DATA: , Total CK coming down 70,142 from 25,573, total CK is 200, troponin is 2.3 from 1.9 yesterday.,BNP, blood sugar 93, BUN of 55.7, creatinine 2.7, sodium 137, potassium 3.9, chloride 108, and CO2 of 22.,Liver function test, AST 704, ALT 298, alkaline phosphatase 67, total bilirubin 0.3.  CBC, WBC count 9.1, hemoglobin 9.9, hematocrit 29.2, and platelet count 204.  Blood cultures are still pending.,Ultrasound of abdomen, negative abdomen, both kidneys were echogenic, cortices suggesting chronic medical renal disease.  Doppler of lower extremities negative for DVT., ,ASSESSMENT AND PLAN:,1.  Rhabdomyolysis, most likely secondary to statins, gemfibrozil, discontinue it on admission.  Continue IV fluids.  We will monitor.,2.  Acute on chronic renal failure.  We will follow up with Nephrology recommendation.,3.  Anemia, drop in hemoglobin most likely hemodilutional.  Repeat CBC in a.m.,4.  Leukocytosis, improving.,5.  Elevated liver enzyme, most likely secondary to rhabdomyolysis.  The patient denies any abdominal pain and ultrasound is unremarkable.,6.  Hypertension.  Blood pressure controlled.,7.  Elevated cardiac enzyme, follow up with Cardiology recommendation.,8.  Obesity.,9.  Deep venous thrombosis prophylaxis.  Continue Lovenox 40 mg subcu daily.",34
"PROCEDURE: , Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,INDICATIONS FOR PROCEDURE: , A 17-year-old with history of 40-pound weight loss, abdominal pain, status post appendectomy with recurrent abscess formation and drainage.  Currently, he has a fistula from his anterior abdominal wall out.  It does not appear to connect to the gastrointestinal tract, but merely connect from the ventral surface of the rectus muscles out the abdominal wall.  CT scans show thickened terminal ileum, which suggest that we are dealing with Crohn's disease.  Endoscopy is being done to evaluate for Crohn's disease.,MEDICATIONS:  ,General anesthesia.,INSTRUMENT:,  Olympus GIF-160 and PCF-160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FINDINGS: , With the patient in the supine position, intubated under general anesthesia.  The endoscope was inserted without difficulty into the hypopharynx.  The scope was advanced down the esophagus, which had normal mucosal coloration and vascular pattern.  Lower esophageal sphincter was located at 40 cm from the central incisors.  It appeared normal and appeared to function normally.  The endoscope was advanced into the stomach, which was distended with excess air.  Rugal folds were flattened completely.  There were multiple superficial erosions scattered throughout the fundus, body, and antral portions consistent with Crohn's involvement of the stomach.  The endoscope was advanced through normal-appearing pyloric valve into the first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  Biopsies were obtained x2 in the second portion of the duodenum, antrum, body, and distal esophagus at 37 cm from the central incisors for histology.  Two additional biopsies were obtained in the antrum for CLO testing.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated that part of the procedure well.,The patient was turned and scope was changed for colonoscopy.  Prior to colonoscopy, it was noted that there was a perianal fistula at 7 o'clock.  The colonoscope was then inserted into the anal verge.  The colonic clean out was excellent.  The scope was advanced without difficulty to the cecum.  The cecal area had multiple ulcers with exudate.  The ileocecal valve was markedly distorted.  Biopsies were obtained x2 in the cecal area and then the scope was withdrawn through the ascending, transverse, descending, sigmoid, and rectum.  The colonic mucosa in these areas was well seen and there were a few scattered aphthous ulcers in the ascending and descending colon.  Biopsies were obtained in the cecum at 65 cm, transverse colon 50 cm, rectosigmoid 20 cm, and rectum at 5 cm.  No fistulas were noted in the colon.  Excess air was evacuated from the colon.  The scope was removed.  The patient tolerated the procedure well and was taken to recovery in satisfactory condition.,IMPRESSION: , Normal esophagus and duodenum.  There were multiple superficial erosions or aphthous ulcers in the stomach along with a very few scattered aphthous ulcers in the colon with marked cecal involvement with large ulcers and a very irregular ileocecal valve.  All these findings are consistent with Crohn's disease.,PLAN:  ,Begin prednisone 30 mg p.o. daily.  Await PPD results and chest x-ray results, as well as cocci serology results.  If these are normal, then we would recommend Remicade 5 mg/kg IV infusion.  We would start Modulon 50 mL/h for 20 hours to reverse the malnutrition state of this boy.  Check CMP and phosphate every Monday, Wednesday, and Friday for receding syndrome noted by following potassium and phosphate.  We will discuss with Dr. X possibly repeating the CT fistulogram if the findings on the previous ones are inconclusive as far as the noting whether we can rule in or out an enterocutaneous fistula.  He will need an upper GI to rule out small intestinal strictures and involvement of the small intestine that cannot be seen with upper and lower endoscopy.  If he has no stricture formation in the small bowel, we would then recommend a video endoscopy capsule to further evaluate any mucosal lesions consistent with Crohn's in the small intestine that we cannot visualize with endoscopy.",14
"REASON FOR CONSULTATION:,  Abnormal cardiac enzyme profile.,HISTORY OF PRESENT ILLNESS:,  The patient is a 66-year-old gentleman, was brought into emergency room with obtundation.  The patient was mechanically ventilated originally.  His initial diagnosis was septic shock.  His labs showed elevated cardiac enzyme profile.  This is a consultation for evaluation of the same.  The patient is unable to give history.  History obtained through the family members.  As per the patient's son, he does not have history of cardiac disease.  He lives in Utah, presently spending few months in Arizona.  As I understand, he has been followed by a physician back in Utah and believes that he had some workup done from cardiac standpoint which has been negative so far.  No prior history of chest pain, shortness of breath as per the family members.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status borderline elevated, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Foot surgery as per the family members.,MEDICATIONS:,1.  Vitamin supplementation.,2.  Prednisone.,3.  Cyclobenzaprine.,4.  Losartan 50 mg daily.,5.  Nifedipine 90 mg daily.,6.  Lasix.,7.  Potassium supplementation.,ALLERGIES:,  SULFA.,PERSONAL HISTORY:,  He is an ex-smoker.  Does not consume alcohol.,PAST MEDICAL HISTORY: , Pulmonary fibrosis, on prednisone, oxygen-dependent cellulitis status post foot surgery with infection recuperating from the same.  Presentation today with respiratory acidosis, septicemia and septic shock, presently on mechanical ventilation.  No prior cardiac history.  Elevated cardiac enzyme profile.,REVIEW OF SYSTEMS: , Limited.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 94, blood pressure 98/57, respiratory rate as per setting.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.,LUNGS:  Air entry bilaterally clear, rales are scattered.,HEART:  PMI displaced.  S1, S2 regular.  Systolic murmur, grade 2/6.,ABDOMEN:  Soft, nontender.,EXTREMITIES:  Chronic skin changes, markings in the lower extremities noted.  Pulses found palpable.  Dressing also noted.,LABORATORY AND DIAGNOSTIC DATA: , EKG, normal sinus rhythm with wide complex.  Labs, white count of 20,000, H&H 10 and 33, platelets of 163, INR 1.36, BUN of 158, creatinine 8.7, potassium 7.3, of bicarbonate is 11.  Cardiac enzyme profile, troponin 0.05, total CK 312, myoglobin 1423.  Chest x-ray, no acute changes.,IMPRESSION:,1.  The patient is a 66-year-old gentleman with pulmonary fibrosis, on prednisone, oxygen dependent with respiratory acidosis.,2.  Septicemia, septic shock secondary to cellulitis of the leg.,3.  Acute renal shutdown.,4.  Elevated cardiac enzyme profile without prior cardiac history possibly due to sepsis and also acute renal failure.,RECOMMENDATIONS:,1.  Echocardiogram to assess LV function to rule out any cardiac valvular involvement.,2.  Aggressive medical management including dialysis.,3.  From cardiac standpoint, conservative treatment at this juncture.  His cardiac enzyme profile could be elevated secondary to sepsis and also underlying renal failure.,4.  Explained to patient's family in detail regarding condition which is critical which they are aware of.",3
"SUBJECTIVE:,  Patient presents with Mom and Dad for her 5-year 3-month well-child check.  Family has not concerns stating patient has been doing well overall since last visit.  Taking in a well-balanced diet consisting of milk and dairy products, fruits, vegetables, proteins and grains with minimal junk food and snack food.  No behavioral concerns.  Gets along well with peers as well as adults.  Is excited to start kindergarten this upcoming school year.  Does attend daycare.  Normal voiding and stooling pattern.  No concerns with hearing or vision.  Sees the dentist regularly.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development.  See Denver II form in the chart.,ALLERGIES:,  None.,MEDICATIONS: , None.,FAMILY SOCIAL HISTORY:,  Unchanged since last checkup.  Lives at home with mother, father and sibling.  No smoking in the home.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs:  Weight 43 pounds.  Height 42-1/4 inches.  Temperature 97.7.  Blood pressure 90/64.,General:  Well-developed, well-nourished, cooperative, alert and interactive 5-year -3month-old white female in no acute distress.,HEENT:  Atraumatic, normocephalic.  Pupils equal, round and reactive.  Sclerae clear.  Red reflex present bilaterally.  Extraocular muscles intact.  TMs clear bilaterally.  Oropharynx:  Mucous membranes moist and pink.  Good dentition.,Neck:  Supple, no lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze or crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No masses or organomegaly.,GU:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.,Back:  Straight.  No scoliosis.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.  Cranial nerves II-XII grossly intact.  DTRs 2+/4+ bilaterally.,ASSESSMENT/PLAN:,1. Well 5-year 3-month-old white female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations.  Will receive MMR, DTaP and IPV today.  Discussed risks and benefits as well as possible side effects and symptomatic treatment.  Gave 5-year well-child check handout to mom.  Completed school pre-participation physical.  Copy in the chart.  Completed vision and hearing screening.  Reviewed results with family.,3. Follow up in one year for next well-child check or as needed for acute care.",5
"PROCEDURES:,1.  Right frontal craniotomy with resection of right medial frontal brain tumor.,2.  Stereotactic image-guided neuronavigation for resection of tumor.,3.  Microdissection and micro-magnification for resection of brain tumor.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR THE PROCEDURE:  ,The patient is a 71-year-old female with a history of left-sided weakness and headaches.  She has a previous history of non-small cell carcinoma of the lung, treated 2 years ago.  An MRI was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor.  After informed consent was obtained, the patient was brought to the operating room for surgery.,PREOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift.,POSTOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift, probable metastatic lung carcinoma.,DESCRIPTION OF THE PROCEDURE: , The patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube.  She was positioned on the operating room table in the Sugita frame with the head secured.,Using the preoperative image-guided MRI, we carefully registered the fiducials and then obtained the stereotactic image-guided localization to guide us towards the tumor.  We marked external landmarks.  Then we shaved the head over the right medial frontal area.  This area was then sterilely prepped and draped.,Evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted.,A horseshoe shaped flap was based on the right and then brought across to the midline.  This was opened and hemostasis obtained using Raney clips.  The skin flap was retracted medially.  Two burr holes were made and were carefully connected.  One was placed right over the sinus and we carefully then removed a rectangular shaped bone flap.  Hemostasis was obtained.  Using the neuronavigation, we identified where the tumor was.  The dura was then opened based on a horseshoe flap based on the medial sinus.  We retracted this medially and carefully identified the brain.  The brain surface was discolored and obviously irritated consistent with the tumor.,We used the stereotactic neuronavigation to identify the tumor margins.,Then we used a bipolar to coagulate a thin layer of brain over the tumor.  Subsequently, we entered the tumor.  The tumor itself was extremely hard.  Specimens were taken and send for frozen section analysis, which showed probable metastatic carcinoma.,We then carefully dissected around the tumor margins.,Using the microscope, we then brought microscopic magnification and dissection into the case.  We used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly, medially, inferiorly, and laterally.,Then using the Cavitron, we cored out the central part of the tumor.  Then we collapsed the tumor on itself and removed it entirely.  In this fashion, microdissection and magnification resection of the tumor was carried out.  We resected the entire tumor.  Neuronavigation was used to confirm that no further tumor residual was remained.,Hemostasis was obtained using bipolar coagulation and Gelfoam.  We also lined the cavity with Surgicel.  The cavity was nicely dry and excellent hemostasis was obtained.,The dura was closed using multiple interrupted 4-0 Nurolon sutures in a watertight fashion.  Surgicel was placed over the dural closure.  The bone flap was repositioned and held in place using CranioFIX cranial fixators.  The galea was re-approximated and the skin was closed with staples.  The wound was dressed.  The patient was returned to the intensive care unit.  She was awake and moving extremities well.  No apparent complications were noted.  Needle and sponge counts were listed as correct at the end of the procedure.  Estimated intraoperative blood loss was approximately 150 mL and none was replaced.",37
"PREOPERATIVE DIAGNOSES:,1.  Chronic nasal obstruction secondary to deviated nasal septum.,2.  Inferior turbinate hypertrophy.,POSTOPERATIVE DIAGNOSES:,1.  Chronic nasal obstruction secondary to deviated nasal septum.,2.  Inferior turbinate hypertrophy.,PROCEDURE PERFORMED:,1.  Nasal septal reconstruction.,2.  Bilateral submucous resection of the inferior turbinates.,3.  Bilateral outfracture of the inferior turbinates.,ANESTHESIA:,  General endotracheal tube.,BLOOD LOSS: , Minimal less than 25 cc.,INDICATIONS: , The patient is a 51-year-old female with a history of chronic nasal obstruction.  On physical examination, she was derived to have a severely deviated septum with an S-shape deformity as well as turbinate hypertrophy present along the inferior turbinates contributing to the obstruction.,PROCEDURE:  ,After all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained.  The patient was brought to the Operating Suite where she was placed in the supine position and general endotracheal intubation was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away.  Nasal pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavities.  These were then removed and the nasal septum as well as the turbinates were localized with the mixture of 1% lidocaine with 1:100000 epinephrine solution.  The nasal pledgets were then reinserted as the patient was prepped in the usual fashion.  The nasal pledgets were again removed and the turbinates as well as an infraorbital nerve block was performed with 0.25% Marcaine solution.  The nasal vestibules were then cleansed with a pHisoHex solution.  A #15 blade scalpel was then used to make an incision along the length of the caudal septum.  The mucoperichondrial junction was then identified with the aid of cotton-tipped applicator as well as the stitch scissor.  Once the plane was identified, the mucosal flap on the left side of the septum was elevated with the aid of a Cottle.  At this point it should be mentioned that the patient's septum was significantly deviated with a large S-shape deformity obstructing both the right and left nasal cavity with the convex portion present in the left nasal cavity.  Again, the Cottle elevator was used to raise the mucosal flap down to the level of the septal spur.  At this point, the septal knife was used to make a crossover incision through the cartilage just anterior to the septal spur.  Again, the mucosal flap was elevated in the right nasal septum.  Now Knight scissors were used to remove the ascending portion of the nasal cartilage, which was then removed with a Takahashi forceps.  A Cottle elevator was used to further elevate the mucosal flap off the septal spur on the left side.  Removal of the spur was performed with the aid of the septal knife as well as a 3 mm straight chisel.  Once all ascending cartilage has been removed, inspection of the nasal cavity revealed patent passages with the exception of inferior turbinates that were very hypertrophied and was felt to be contributing to the patient's symptoms.  Therefore, the turbinates were again localized and a #15 blade scalpel was used to make a vertical incision dissected down to the chondral bone.  The XPS microdebrider with the inferior turbinate blade was then inserted through the incision and a submucous resection was performed by passing the microdebrider along the length of the bone.  Once the submucosal tissue had been resected, an outfracture procedure was performed so as to fully open the nasal passages.  Inspection revealed very patent and nonobstructive nasal passages.  Now the caudal incision was reapproximated with #4-0 chromic suture.  Finally, a #4-0 fast absorbing plain gut suture was used to approximate the mucosal surface of the septum in a running whipstitch fashion.  Finally, Merocel packing was placed and the patient was retuned to the Department of Anesthesia for awakening and taken to the recovery room without incident.",11
"PREOPERATIVE DIAGNOSIS:,  Residual stone, status post right percutaneous nephrolithotomy.,POSTOPERATIVE DIAGNOSES: , Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.,ANESTHESIA:,  General via endotracheal tube.,BLOOD LOSS:,  Minimal.,DRAINS: , 16-French Foley, 6-French variable length double-J stent.,INTRAOPERATIVE COMPLICATIONS: , Unable to re-access the collecting system.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room and laid supine.  General anesthesia was accomplished.  A 16-French Foley was placed using aseptic technique.  The patient was then placed on the operating table prone.  His right flank was prepped and draped in a sterile fashion.  At this point, contrast was injected through his existing nephrostomy tube and there was no continuity with the collecting system and it was removed.  The 5-French Pollack catheter was used to pass a 0.38 super-stiff Amplatz wire.  The wire would not go down the ureter.  Multiple attempts were made using Pollack catheters and Cobra catheters and attempts were made to dilate the track, both with rigid dilator and the balloon dilator and access could not be obtained.  After multiple attempts, access was lost.  At this point, the tubes were left out of the kidney and sterile dressings were applied.  The patient was then placed on another operating table supine.  His genitalia were prepped and draped after removing his Foley catheter.  Flexible cystoscopy was performed and the right orifice identified, which was edematous and erythematous.  The wire was passed up to kidney and a 5-French Pollack catheter was then passed over to after the removing the scope.  The wire was removed.  Contrast injection with good placement in the collecting system.  The wire was replaced.  The Pollack catheter removed and 6-French variable length double-J stent was inserted using fluoroscopic guidance.  The wire was removed leaving the double-J stent in good position.  _______ 16-French Foley was reinserted and connected to close drains.,Procedure was terminated at this point and had been well tolerated.  The patient was awakened and taken to recovery room in satisfactory condition having tolerated the procedure well.",21
"PREOPERATIVE DIAGNOSIS:  ,Prostate cancer.,POSTOPERATIVE DIAGNOSIS:,  Prostate cancer.,OPERATION PERFORMED:,  Radical retropubic nerve-sparing prostatectomy without lymph node dissection.,ESTIMATED BLOOD LOSS: , 450 mL.,REPLACEMENT:,  250 mL of Cell Saver and crystalloid.,COMPLICATIONS: , None.,INDICATIONS OF SURGERY: , This is a 67-year-old man with needle biopsy proven to be Gleason 6 adenocarcinoma in one solitary place on the right side of the prostate.  Due to him being healthy with no comorbid conditions, he has elected to undergo surgical treatment with radical retropubic prostatectomy.  Potential complications include, but are not limited to:,1.  Infection.,2.  Bleeding.,3.  Incontinence.,4.  Impotence.,5.  Injury to the adjacent viscera.,6.  Deep venous thrombosis.,PROCEDURE IN DETAIL: , Prophylactic antibiotic was given in the preoperative holding area, after which the patient was transferred to the operating room.  Epidural anesthesia and general endotracheal anesthesia were administered by Dr. A without any difficulty.  The patient was shaved, prepped, and draped using the usual sterile technique.  A sterile 16-French Foley catheter was then placed with clear urine drained.  A midline infraumbilical incision was performed by using a #10 scalpel blade.  The rectus fascia and the subcutaneous space were opened by using the Bovie.  Transversalis fascia was opened in the midline and the retropubic space and the paravesical space were developed bluntly.  A Bookwalter retractor was then placed.  The area of the obturator lymph nodes were carefully inspected and no suspicious adenopathy was detected.  Given this patient's low Gleason score and low PSA with a solitary core biopsy positive, the decision was made to not perform bilateral lymphadenectomy.  The endopelvic fascia was opened bilaterally by using the Metzenbaum scissors.  Opening was enlarged by using sharp dissection.  Small perforating veins from the prostate into the lateral pelvic wall were controlled by using bipolar coagulation device.  The dorsal aspect of the prostate was bunched up by using 2-0 silk sutures.  The deep dorsal vein complex was bunched up by using Allis also and ligated by using 0 Vicryl suture in a figure-of-eight fashion.  With the prostate retracted cephalad, the deep dorsal vein complex was transected superficially using the Bovie.  Deeper near the urethra, the dorsal vein complex was transected by using Metzenbaum scissors.  The urethra could then be easily identified.  Nearly two-third of the urethra from anteriorly to posteriorly was opened by using Metzenbaum scissors.  This exposed the blue Foley catheter.  Anastomotic sutures were then placed on to the urethral stump using 2-0 Monocryl suture.  Six of these were placed evenly spaced out anteriorly to posteriorly.  The Foley catheter was then removed.  This allowed for better traction of the prostate laterally.  Lateral pelvic fascia was opened bilaterally.  This effectively released the neurovascular bundle from the apex to the base of the prostate.  Continued dissection from the lateral pelvic fascia deeply opened up the plane into the perirectal fat.  The prostate was then dissected from laterally to medially from this opening in the perirectal fat.  The floor of the urethra posteriorly and the rectourethralis muscle was then transected just distal to the prostate.  Maximal length of ureteral stump was preserved.  The prostate was carefully lifted cephalad by using gentle traction with fine forceps.  The prostate was easily dissected off the perirectal fat using sharp dissection only.  Absolutely, no traction to the neurovascular bundle was evident at any point in time.  The dissection was carried out easily until the seminal vesicles could be visualized.  The prostate pedicles were controlled easily by using multiple medium clips in 4 to 5 separate small bundles on each side.  The bladder neck was then dissected out by using a bladder neck dissection method.  Unfortunately, most of the bladder neck fiber could not be preserved due to the patient's anatomy.  Once the prostate had been separated from the bladder in the area with the bladder neck, dissection was carried out posteriorly to develop a plane between the bladder and the seminal vesicles.  This was developed without any difficulty.  Both vas deferens were identified, hemoclipped and transected.  The seminal vesicles on both sides were quite large and a decision was made to not completely dissect the tip off, as it extended quite deeply into the pelvis.  About two-thirds of the seminal vesicles were able to be removed.  The tip was left behind.  Using the bipolar Gyrus coagulation device, the seminal vesicles were clamped at the tip sealed by cautery and then transected.  This was performed on the left side and then the right side.  This completely freed the prostate.  The prostate was sent for permanent section.  The opening in the bladder neck was reduced by using two separate 2-0 Vicryl sutures.  The mucosa of the bladder neck was everted by using 4-0 chromic sutures.  Small amount of bleeding around the area of the posterior bladder wall was controlled by using suture ligature.  The ureteral orifice could be seen easily from the bladder neck opening and was completely away from the everting sutures.  The previously placed anastomotic suture on the urethral stump was then placed on the corresponding position on the bladder neck.  This was performed by using a French ***** needle.  A 20-French Foley catheter was then inserted and the sutures were sequentially tied down.  A 15 mL of sterile water was inflated to balloon.  The bladder anastomosis to the urethra was performed without any difficulty.  A 19-French Blake Drain was placed in the left pelvis exiting the right inguinal region.  All instrument counts, lap counts, and latex were verified twice prior to the closure.  The rectus fascia was closed in running fashion using #1 PDS.  Subcutaneous space was closed by using 2-0 Vicryl sutures.  The skin was reapproximated by using metallic clips.  The patient tolerated the procedure well and was transferred to the recovery room in stable condition.",38
"INDICATION: , Iron deficiency anemia.,PROCEDURE:  ,Colonoscopy with terminal ileum examination.,POSTOPERATIVE DIAGNOSIS:,  Normal examination.,WITHDRAWAL TIME: , 15 minutes.,SCOPE: , CF-H180AL.,MEDICATIONS: , Fentanyl 100 mcg and versed 10 mg.,PROCEDURE DETAIL:  ,Following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation, missed polyp rate as well as side effects of medications and alternatives were reviewed.  Questions were answered.  Pause preprocedure was performed.,Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty.  The ileocecal valve looked normal.  Preparation was fair allowing examination of 85% of mucosa after washing and cleaning with tap water through the scope.  The terminal ileum was intubated through the ileocecal valve for a 5 cm extent.  Terminal ileum mucosa looked normal.,Then the scope was withdrawn while examining the mucosa carefully including the retroflexed views of the rectum.  No polyp, no diverticulum and no bleeding source was identified.,The patient was assessed upon completion of the procedure.  Okay to discharge once criteria met.  ,RECOMMENDATIONS:,  Follow up with primary care physician.",14
"PRINCIPAL DIAGNOSIS: , Buttock abscess, ICD code 682.5.,PROCEDURE PERFORMED:,  Incision and drainage (I&D) of buttock abscess.,CPT CODE: , 10061.,DESCRIPTION OF PROCEDURE:  ,Under general anesthesia, skin was prepped and draped in usual fashion.  Two incisions were made along the right buttock approximately 5 mm diameter.  Purulent material was drained and irrigated with copious amounts of saline flush.  A Penrose drain was placed.  Penrose drain was ultimately sutured forming a circular drain.  The patient's drain will be kept in place for a period of 1 week and to be taken as an outpatient basis.  Anesthesia, general endotracheal anesthesia.  Estimated blood loss approximately 5 mL.  Intravenous fluids 100 mL.  Tissue collected.  Purulent material from buttock abscess sent for usual cultures and chemistries.  Culture and sensitivity Gram stain.  A single Penrose drain was placed and left in the patient.  Dr. X attending surgeon was present throughout the entire procedure.",37
"CC: ,Vertigo.,HX: ,This 61y/o RHF experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. In 11/92, while eating breakfast, she suddenly experienced vertigo. This was immediately followed by nausea and several episodes of vomiting. The vertigo lasted 2-3minutes. She retired to her room for a 2 hour nap after vomiting. When she awoke, the symptoms had resolved. On 1/13/93 she had an episode of right arm numbness lasting 4-5hours. There was no associated weakness, HA, dysarthria, dysphagia, visual change, vertigo or lightheadedness.,OUTSIDE RECORDS:, 12/16/92 Carotid Doppler (RICA 30-40%, LICA 10-20%). 12/4/92, brain MRI revealed a right cerebellar hypodensity consistent with infarct.,MEDS:, Zantac 150mg bid, Proventil MDI bid, Azmacort MDI bid, Doxycycline 100mg bid, Premarin 0.625mg qd, Provera 2.5mg qd. ASA 325mg qd.,PMH:, 1)MDD off antidepressants since 6/92. 2)asthma. 3)allergic rhinitis. 4)chronic sinusitis. 5)s/p Caldwell-Luc 1978, and nasal polypectomy. 6) GERD. 7)h/o elevated TSH. 8)hypercholesterolemia 287 on 11/20/93. 9)h/o heme positive stool: BE 11/24/92 and UGI 11/25/92 negative.,FHX: ,Father died of a thoracic aortic aneurysm, age 71. Mother died of stroke, age 81.,SHX:, Married. One son deceased. Salesperson. Denied tobacco/ETOH/illicit drug use.,EXAM,: BP (RUE)132/72 LUE (136/76). HR67 RR16 Afebrile. 59.2kg.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Thought lucid.,CN: unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits appreciated.,Coord: unremarkable.,Station: no pronator drift, truncal ataxia, or Romberg sign.,Gait: not done.,Reflexes: 2/2 throughout BUE and at patellae. 1/1 at Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese.,COURSE: ,CBC, GS, PT/PTT, UA were unremarkable. The patient was admitted with a working diagnosis of posterior circulation TIA and history of cerebellar stroke. She was placed on Ticlid 250mg bid. HCT,1/15/93: low density focus in the right medial and posterior cerebellar hemisphere. MRI and MRA, 1/18/93, revealed a well circumscribed lesion within the posterior aspect of the right cerebellar hemisphere suggestive of vascular malformation (e.g. cavernous angioma. An abnormal vascular blush was seen on the MRA. This area appeared to be supplied by one of the external carotid arteries (which one is was not specified). this finding maybe suggestive of a vascular malformation. 1/20/93 Cerebral Angiogram: The right cerebellar hemisphere lesion seen on MRI as a possible cavernous angioma was not seen on angiography. Upon review of the MRI and HCT the lesion was felt to probably represent an old infarction with hemosiderin deposition. The ""vascular blush"" seen on MRA was no visualized on angiography. The patient was discharged home on 1/25/93.",5
"PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:,  Basal Cell CA.,LOCATION:  ,Medial right inferior helix.,PREOP SIZE:,  1.4 x 1 cm,POSTOP SIZE: , 2.7 x 2 cm,INDICATION: , Poorly defined borders.,COMPLICATIONS: , None.,HEMOSTASIS: , Electrodessication.,PLANNED RECONSTRUCTION: , Wedge resection advancement flap.,DESCRIPTION OF PROCEDURE: , Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.,The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision.  With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique.  A map was prepared to correspond to the area of skin from which it was excised.  The tissue was prepared for the cryostat and sectioned.  Each section was coded, cut and stained for microscopic examination.  The entire base and margins of the excised piece of tissue were examined by the surgeon.  Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.,No tumor was identified after the final stage of microscopically controlled surgery.  The patient tolerated the procedure well without any complication.  After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.",37
"PRELIMINARY DIAGNOSES:,1.  Contusion of the frontal lobe of the brain.,2.  Closed head injury and history of fall.,3.  Headache, probably secondary to contusion.,FINAL DIAGNOSES:,1.  Contusion of the orbital surface of the frontal lobes bilaterally.,2.  Closed head injury.,3.  History of fall.,COURSE IN THE HOSPITAL: , This is a 29-year-old male, who fell at home.  He was seen in the emergency room due to headache.  CT of the brain revealed contusion of the frontal lobe near the falx.  The patient did not have any focal signs.  He was admitted to ABCD.  Neurology consultation was obtained.  Neuro checks were done.  The patient continued to remain stable, although he had some frontal headache.  He underwent an MRI to rule out extension of the contusion or the possibility of a bleed and the MRI of the brain without contrast revealed findings consistent with contusion of the orbital surface of the frontal lobes bilaterally near the interhemispheric fissure.  The patient remained clinically stable and his headache resolved.  He was discharged home on 11/6/2008.,PLAN: , Discharge the patient to home.,ACTIVITY:  ,As tolerated.,The patient has been advised to call if the headache is recurrent and Tylenol 650 mg 1 p.o. q.6 h. p.r.n. headache.  The patient has been advised to follow up with me as well as the neurologist in about 1 week.",10
"PREOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,INDICATIONS:,  Mr. ABC is a 10-year-old boy who suffered a fall resulting in a right distal both-bone forearm fracture.  Upon evaluation by Orthopedic Surgery team in the emergency department, it was determined that a closed reduction under conscious sedation and application of a splint was warranted.  This was discussed with the parents who expressed verbal and written consent.,PROCEDURE:,  Conscious sedation was achieved via propofol via the emergency department staff.  Afterwards, traction with re-creation of the injury pattern was utilized to achieve reduction of the patient's fracture.  This was confirmed with image intensifier.  Subsequently, the patient was placed into a splint.  The patient was aroused from conscious sedation and at this time it was noted that he had full sensation throughout radial, median, and ulnar nerve distributions and positive extensor pollicis longus, flexor pollicis longus, dorsal and palmar interossei.,DISPOSITION:  ,Post-reduction x-rays revealed good alignment in the AP x-rays.  The lateral x-rays also revealed adequate reduction.  At this time, we will allow the patient to be discharged home and have him follow up with Dr. XYZ in one week.",27
"PREOPERATIVE DIAGNOSIS:,  Visually significant nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with posterior chamber intraocular lens implantation, right eye.,ANESTHESIA:,  Monitored anesthesia care with retrobulbar block consisting of 2% lidocaine in an equal mixture with 0.75% Marcaine and Amphadase.,INDICATIONS FOR SURGERY:,  This patient has been experiencing difficulty with eyesight regarding activities of daily living.  There has been a progressive and gradual decline in the visual acuity.  The cataract was believed related to her decline in vision.  The risks, benefits, and alternatives (including with observation or spectacles) were discussed in detail.  The risks as explained included, but are not limited to pain, bleeding, infection, decreased or loss of vision/loss of eye, retinal detachment requiring further surgery, and possible consultation out of town, swelling of the back part of the eye/retina, need for prolonged eye drop use or injections, instability of the lens, and loss of corneal clarity necessitating long-term drop use or further surgery.  The possibility of needing intraocular lens exchange or incorrect lens power was discussed.  Anesthesia option and risks associated with anesthesia and retrobulbar anesthesia were discussed.  It was explained that some or all of these complications might arise at the time of or months to years after surgery.  The patient had a good understanding of the risks with the proposed, elective eye surgery.  The patient accepted these risks and elected to proceed with cataract surgery.  All questions were answered and informed consent was signed and placed in the chart.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified.  The pupil was dilated per protocol.  The patient was taken to the operating room and placed in the supine position.  After intravenous sedation, the retrobulbar block was injected followed by several minutes of digital massage.  No signs of orbital tenseness or retrobulbar hemorrhage were present.,The patient was prepped and draped in the usual ophthalmic sterile fashion.  An eyelid speculum was used to separate the eyelids.  A crescent blade was used to make a clear corneal temporally located incision.  A 1-mm Dual-Bevel blade was used to make a paracentesis site.  The anterior chamber was filled with viscoelastic (Viscoat).  The crescent blade was then used to make an approximate 2-mm long clear corneal tunnel through the temporal incision.  A 2.85-mm keratome blade was then used to penetrate into the anterior chamber through the temporal tunneled incision.  A 25-gauge pre-bent cystotome used to begin a capsulorrhexis.  The capsulorrhexis was completed with the Utrata forceps.  A 27-guage needle was used for hydrodissection and three full and complete fluid waves were noted.  The lens was able to be freely rotated within the capsular bag.  Divide-and-conquer ultrasound was used for phacoemulsification.  After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment.  Each of the four nuclear quadrants was phacoemulsified.  Aspiration was used to remove all remaining cortex.  Viscoelastic was used to re-inflate the capsular bag.  An AMO model SI40NB posterior chamber intraocular lens with power *** diopters and serial number *** was injected into the capsular bag.  The trailing haptic was placed with the Sinskey hook.  The lens was made well centered and stable.  Viscoelastic was aspirated.  BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure.  A Weck-Cel sponge was used to check both incision sites for leaks and none were identified.  The incision sites remained well approximated and dry with a well-formed anterior chamber and eccentric posterior chamber intraocular lens.  The eyelid speculum was removed and the patient was cleaned free of Betadine.  Vigamox and Econopred drops were applied.  A soft eye patch followed by a firm eye shield was taped over the operative eye.  The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed.  All questions were answered.  The discharge instructions were also reviewed with the patient by the discharging nurse.  The patient was comfortable and was discharged with followup in 24 hours.  Complications none.",37
"CHIEF COMPLAINT:, ""Trouble breathing."",HISTORY OF PRESENT ILLNESS:, A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. Approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. Approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. On the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. On arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. She denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. She denied any history of IVDA, tattoos, or high risk sexual behavior. She did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an IVC filter had been placed in Germany . She had been living in the United States for years, and had had no recent travel. She denied any occupational exposures. Before the onset of her shortness of breath she had been very active and had exercised regularly.,PAST MEDICAL HISTORY:,  Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis.  Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed.  Psoriasis.  She denied any history of miscarriage.,PAST SURGICAL HISTORY:,  IVC filter placement 1999.",3
"PREOPERATIVE DIAGNOSIS:,  Desire for sterility.,POSTOPERATIVE DIAGNOSIS:,  Desire for sterility.,OPERATIVE PROCEDURES: , Vasectomy.,DESCRIPTION OF PROCEDURE: , The patient was brought to the suite, where after oral sedation, the scrotum was prepped and draped.  Then, 1% lidocaine was used for anesthesia.  The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas.  A segment about 3 cm in length was dissected out.  It was clipped proximally and distally, and then the ends were cauterized after excising the segment.  Minimal bleeding was encountered and the scrotal skin was closed with 3-0 chromic.  The identical procedure was performed on the contralateral side.  He tolerated it well.  He was discharged from the surgical center in good condition with Tylenol with Codeine for pain.  He will use other forms of birth control until he has confirmed azoospermia with two consecutive semen analyses in the month ahead.  Call if there are questions or problems prior to that time.",37
"EXAM: , AP abdomen and ultrasound of kidney.,HISTORY:,  Ureteral stricture.,AP ABDOMEN ,FINDINGS:,  Comparison is made to study from Month DD, YYYY.  There is a left lower quadrant ostomy.  There are no dilated bowel loops suggesting obstruction.  There is a double-J right ureteral stent, which appears in place.  There are several pelvic calcifications, which are likely vascular.  No definite pathologic calcifications are seen overlying the regions of the kidneys or obstructing course of the ureters.  Overall findings are stable versus most recent exam.,IMPRESSION: , Properly positioned double-J right ureteral stent.  No evidence for calcified renal or ureteral stones.,ULTRASOUND KIDNEYS,FINDINGS:,  The right kidney is normal in cortical echogenicity of solid mass, stone, hydronephrosis measuring 9.0 x 2.9 x 4.3 cm.  There is a right renal/ureteral stent identified.  There is no perinephric fluid collection.,The left kidney demonstrates moderate-to-severe hydronephrosis.  No stone or solid masses seen.  The cortex is normal.,The bladder is decompressed.,IMPRESSION:,1.  Left-sided hydronephrosis.,2.  No visible renal or ureteral calculi.,3.  Right ureteral stent.",33
"INDICATION:  ,",14
"EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis.  There are no signs of acute trauma.  The nose is normal to palpation and inspection externally without evidence of acute trauma.  Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling.  The tympanic membranes are without disruption or infection.  Hearing intact bilaterally to normal level speech.  Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation.  The septum is without acute traumatic lesions or disruption.  The turbinates are without abnormal swelling.  There is no unusual rhinorrhea or bleeding.  ,LIPS/TEETH/GUMS:  ,The lips are without infection, mass lesion or traumatic lesions.  The teeth are intact without obvious signs of infection.  The gingivae are normal to palpation and inspection.  ,OROPHARYNX:  ,The oral mucosa is normal.  The salivary glands are without swelling.  The hard and soft palates are intact.  The tongue is without masses or swelling with normal movement.  The tonsils are without inflammation.  The posterior pharynx is without mass lesion with good patent oropharyngeal airway.",25
"PREOPERATIVE DIAGNOSES:,1.  Chondromalacia patella.,2.  Patellofemoral malalignment syndrome.,POSTOPERATIVE DIAGNOSES:,1.  Grade-IV chondromalacia patella.,2.  Patellofemoral malalignment syndrome.,PROCEDURE PERFORMED:,1.  Diagnostic arthroscopy with partial chondroplasty of patella.,2.  Lateral retinacular release.,3.  Open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws.,ANESTHESIA:,  General.,COMPLICATIONS: , None.,TOURNIQUET TIME: , Approximately 70 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , Grade-IV chondromalacia noted to the central and lateral facet of the patella.  There was a grade II to III chondral changes to the patellar groove.  The patella was noted to be displaced laterally riding on the edge of the lateral femoral condyle.  The medial lateral meniscus showed small amounts of degeneration, but no frank tears were seen.  The articular surfaces and the remainder of the knee appeared intact.  Cruciate ligaments also appeared intact to direct stress testing.,HISTORY:  ,This is a 36-year-old Caucasian female with a long-standing history of right knee pain.  She has been diagnosed in the past with chondromalacia patella.  She has failed conservative therapy.  It was discussed with her the possibility of a arthroscopy lateral release and a tubercle transfer (anterior medialization of the tibial tubercle) to release stress from her femoral patellofemoral joint.  She elected to proceed with the surgical intervention.  All risks and benefits of the surgery were discussed with her.  She was in agreement with the treatment plan.,PROCEDURE: , On 09/04/03, she was taken to Operating Room at ABCD General Hospital.  She was placed supine on the operating table with the general anesthesia administered by the Anesthesia Department.  Her leg was placed in a Johnson knee holder and sterilely prepped and draped in the usual fashion.  A stab incision was made in inferolateral and parapatellar regions.  Through this the cannula was placed and the knee was inflated with saline solution.  Intraoperative pictures were obtained.  The above findings were noted.  Second portal site was initiated in the inferomedial parapatellar region.  Through this, a arthroscopic shaver was placed and the chondroplasty in the patella was performed and removed the loose articular debris.  Next, the camera was placed through the inferomedial portal.  An arthroscopic Bovie was placed through the inferolateral portal.  A release of lateral retinaculum was then performed using the Bovie.  Hemostasis was controlled with electrocautery.  Next, the knee was suctioned dry.  An Esmarch was used to exsanguinate the lower extremity.  Tourniquet was inflated to 325 mmHg.  An oblique incision was made along the medial parapatellar region of the knee.  The subcuticular tissues were carefully dissected and the hemostasis was again controlled with electrocautery.  The retinaculum was then incised in line with the incision.  The patellar tendon was identified.  The lateral and medial border of the tibial tubercle were cleared of all soft tissue debris.  Next, an osteotome was then used to cut the tibial tubercle to 45 degree angle leaving the base of the bone incision intact.  The tubercle was then pushed anteriorly and medially decreasing her Q-angle and anteriorizing the tibial tubercle.  It was then held in place with a Steinmann pin.  Following this, a two 4.5 mm cannulated screws, partially threaded, were drilled in place using standard technique to help fixate the tibial tubercle.  There was excellent fixation noted.  The Q-angle was noted to be decreased to approximately 15 degrees.  She was transferred approximately 1 cm in length.  The wound was copiously irrigated and suctioned dry.  The medial retinaculum was then plicated causing further medialization of the patella.  The retinaculum was reapproximated using #0 Vicryl.  Subcuticular tissue were reapproximated with #2-0 Vicryl.  Skin was closed with #4-0 Vicryl running PDS suture.  Sterile dressing was applied to the lower extremities.  She was placed in a Donjoy knee immobilizer locked in extension.  It was noted that the lower extremity was warm and pink with good capillary refill following deflation of the tourniquet.  She was transferred to recovery room in apparent stable and satisfactory condition.,Prognosis of this patient is poor secondary to the advanced degenerative changes to the patellofemoral joint.  She will remain in the immobilizer approximately six weeks allowing the tubercle to reapproximate itself to the proximal tibia.",27
"SUBJECTIVE:,  The patient has recently had an admission for pneumonia with positive blood count.  She was treated with IV antibiotics and p.o. antibiotics; she improved on that.  She was at home and doing quite well for approximately 10 to 12 days when she came to the ER with a temperature of 102.  She was found to have strep.  She was treated with penicillin and sent home.  She returned about 8 o'clock after vomiting and a probable seizure.  Temperature was 104.5; she was lethargic after that.  She had an LP, which was unremarkable.  She had blood cultures, which have not grown anything.  The CSF has not grown anything at this point.,PHYSICAL EXAMINATION:,  She is alert, recovering from anesthesia.  Head, eyes, ears, nose and throat are unremarkable.  Chest is clear to auscultation and percussion.  Abdomen is soft.  Extremities are unremarkable.,LAB STUDIES: , White count in the emergency room was 9.8 with a slight shift.  CSF glucose was 68, protein was 16, and there were no cells.  The Gram-stain was unremarkable.,ASSESSMENT: , I feel that this patient has a febrile seizure.,PLAN: , My plan is to readmit the patient to control her temperature and assess her white count.  I am going to observe her overnight.",15
"PREOPERATIVE DIAGNOSIS:,  Large recurrent right pleural effusion.,POSTOPERATIVE DIAGNOSIS:,  Large recurrent right pleural effusion.,PROCEDURE:,1.  Conscious sedation.,2.  Chest tube talc pleurodesis of the right chest.,INDICATIONS: , The patient is a 65-year-old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion.  Chest catheter had been placed previously, and she had been draining up to 1.5 liters of serous fluid a day.  Eventually, this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur.,SPECIMENS:,  None.,ESTIMATED BLOOD LOSS: , Zero.,NARRATIVE:,  After obtaining informed consent from the patient and her daughter, the patient was assessed and found to be in good condition and a good candidate for conscious sedation.  Vital signs were taken.  These were stable, so the patient was then given initially 0.5 mg of Versed and 2 mg of morphine IV.  After a couple of minutes, she was assessed and found to be awake but calm, so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax.  She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped.  The patient was given additional 0.5 mg of Versed and 0.5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive.  The patient tolerated the procedure well.  She did complain of up to a 7/10 pain, but quickly this was brought under control.  The chest tube was unclamped.  Now, the patient will be left to rest and she will get a chest x-ray in the morning.",3
"HISTORY OF PRESENT ILLNESS:,  A 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache.  Symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved.  She is having some left-sided sinus pressure and actually went to the dentist because her teeth were hurting; however, the teeth were okay.  She continues to have some left-sided jaw pain.  Denies any headache, fever, cough, or sore throat.  She had used Cutivate cream in the past for the atopic dermatitis with good results and is needing a refill of that.  She has also had problems with sinusitis in the past and chronic left-sided headache.,FAMILY HISTORY:,  Reviewed and unchanged.,ALLERGIES: , To cephalexin.,CURRENT MEDICATIONS:,  Ibuprofen.,SOCIAL HISTORY:,  She is a nonsmoker.,REVIEW OF SYSTEMS:,  As above.  No nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,General:  A well-developed and well-nourished female, conscious, alert, and in no acute distress.,Vital Signs:  Weight:  121 pounds.  Temperature:  97.9 degrees.,Skin:  Reveals scattered erythematous plaques with some mild lichenification on the nuchal region and behind the knees.,Eyes:  PERRLA.  Conjunctivae are clear.,Ears:  Left TM with some effusion.  Right TM is clear.  Canals are clear.  External auricles are nontender to manipulation.,Nose:  Nasal mucosa is pink and moist without discharge.,Throat:  Nonerythematous.  No tonsillar hypertrophy or exudate.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.  Respirations are regular and unlabored.,Heart:  Regular rate and rhythm at rate of 100 beats per minute.,ASSESSMENT:,1.  Serous otitis.,2.  Atopic dermatitis.,PLAN:,1.  Nasacort AQ two sprays each nostril daily.,2.  Duraphen II one b.i.d.,3.  Refills Cutivate cream 0.05% to apply to affected areas b.i.d.  Recheck p.r.n.",15
"PROCEDURE PERFORMED:,1.  Left heart catheterization, left ventriculogram, aortogram, coronary angiogram.,2.  PCI of the LAD and left main coronary artery with Impella assist device.,INDICATIONS FOR PROCEDURE: , Unstable angina and congestive heart failure with impaired LV function.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state.  The right groin was prepped and draped in the usual sterile manner.  Lidocaine 2% was used for infiltration anesthesia.  Using modified Seldinger technique, a 7-French sheath was introduced into the right common femoral artery and a 6-French sheath was introduced into the right common femoral vein.  Through the arterial sheath, angiography of the right common femoral artery was obtained.  Thereafter, 6-French pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained.  Thereafter, a 4-French sheath was introduced into the left common femoral artery using modified Seldinger technique.  Thereafter, the pigtail catheter was advanced over an 0.035-inch J-wire into the left ventricle and LV-gram was performed in RAO view and after pullback, an aortogram was performed in the LAO view.  Therefore, a 6-French JL4 and JR4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained.,ANGIOGRAPHIC FINDINGS:  ,1.  LV-gram:  LVEDP was 15 mmHg.  LV ejection fraction 10% to 15% with global hypokinesis.  Only anterior wall is contracting.  There was no mitral regurgitation.  There was no gradient across the aortic valve upon pullback, and on aortography, there was no evidence of aortic dissection or aortic regurgitation.,2.  The right coronary artery is a dominant vessels with a mid 50% to 70% stenosis which was not treated.  The left main coronary artery calcified vessel with disease.,2.  The left anterior descending artery had an 80% to 90% mid-stenosis.  First diagonal branch had a more than 90% stenosis.,3.  The circumflex coronary artery had a patent stent.,INTERVENTION: , After reviewing the angiographic images, we elected to proceed with intervention of the left anterior descending artery.  The 4-French sheath in the left common femoral artery was upsized to a 12-French Impella sheath through which an Amplatz wire and a 6-French multipurpose catheter were advanced into the left ventricle.  The Amplatz wire was exchanged for an Impella 0.018-inch stiff wire.  The multipurpose catheter was removed, and the Impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2.5 l/min.  Thereafter, a 7-French JL4 guiding catheter was used to engage the left coronary artery and an Asahi soft 0.014-inch wire was advanced into the left anterior descending artery and a second 0.014-inch Asahi soft wire was advanced into the diagonal branch.  The diagonal branch was predilated with a 2.5 x 30-mm Sprinter balloon at nominal atmospheres and thereafter a 2.5 x 24 Endeavor stent was successfully deployed in the mid-LAD and a 3.0 x 15-mm Endeavor stent was deployed in the proximal LAD.  The stent delivery balloon was used to post-dilate the overlapping segment.  The LAD, the diagonal was rewires with an 0.014-inch Asahi soft wire and a 3.0 x 20-mm Maverick balloon was advanced into the LAD for post-dilatation and a 2.0 x 30-mm Sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres.  At this point, it was noted that the left main had a retrograde dissection.  A 3.5 x 18-mm Endeavor stent was successfully deployed in the left main coronary artery.  The Asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery.  Kissing inflations of the LAD and the circumflex coronary artery were performed using 3.0 x 20 Maverick balloons x2 balloons, inflated at high atmospheres of 14.,RESULTS: , Lesion reduction in the LAD FROM 90% to 0% and TIMI 3 flow obtained.  Lesion reduction in the diagonal from 90% to less than 60% and TIMI 3 flow obtained.  Lesion reduction in the left maintained coronary artery from 50% to 0% and TIMI 3 flow obtained.,The patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability.  The Impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the Impella was removed from the body and the 2 Perclose sutures were tightened.  From the right common femoral artery, a 6-French IMA catheter was advanced and an 0.035-inch wire down into the left common femoral and superficial femoral artery, over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes.  The right common femoral artery and vein sheaths were both sutured in place for further observation.  Of note, the patient received Angiomax during the procedure and an ACT above 300 was maintained.,IMPRESSION:,1.  Left ventricular dysfunction with ejection fraction of 10% to 15%.,2.  High complex percutaneous coronary intervention of the left main coronary artery, left anterior descending artery, and diagonal with Impella circulatory support.,COMPLICATIONS: , None.,The patient tolerated the procedure well with no complications.  The estimated blood loss was 200 ml.  Estimated dye used was 200 ml of Visipaque.  The patient remained hemodynamically stable with no hypotension and no hematomas in the groins.,PLAN:  ,1.  Aspirin, Plavix, statins, beta blockers, ACE inhibitors as tolerated.,2.  Hydration.,3.  The patient will be observed over night for any hemodynamic instability or ischemia.  If she remains stable, the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis.",3
"EXAM: , CT stone protocol.,REASON FOR EXAM:,  History of stones, rule out stones.,TECHNIQUE: , Noncontrast CT abdomen and pelvis per renal stone protocol.,FINDINGS: , Correlation is made with a prior examination dated 01/20/09.,Again identified are small intrarenal stones bilaterally.  These are unchanged.  There is no hydronephrosis or significant ureteral dilatation.  There is no stone along the expected course of the ureters or within the bladder.  There is a calcification in the low left pelvis not in line with ureter, this finding is stable and is compatible with a phlebolith.  There is no asymmetric renal enlargement or perinephric stranding.,The appendix is normal.  There is no evidence of a pericolonic inflammatory process or small bowel obstruction.,Scans through the pelvis disclose no free fluid or adenopathy.,Lung bases aside from very mild dependent atelectasis appear clear.,Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas are grossly unremarkable.  The gallbladder is present.  There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. Bilateral intrarenal stones, no obstruction.,2. Normal appendix.",21
"SUBJECTIVE:,  He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing.  He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by Dr. Blackman; it looked like it was Depo-Medrol 80 mg.  He said that it worked fairly well, although it seemed to still take awhile to get rid of it.  He has been using over-the-counter Benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement, but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest, legs, arms and back.,OBJECTIVE:,Vitals:  Temperature is 99.2.  His weight is 207 pounds.,Skin:  Examination reveals a raised, maculopapular rash in kind of a linear pattern over his arms, legs and chest area which are consistent with a poison ivy or a poison oak.,ASSESSMENT AND ,PLAN:,  Poison ivy.  Plan would be Solu-Medrol 125 mg IM X 1.  Continue over-the-counter Benadryl or Rx allergy medicine that he was given the last time he was here, which is a one-a-day allergy medicine; he can not exactly remember what it is, which would also be fine rather than the over-the-counter Benadryl if he would like to use that instead.",34
"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.",14
"REASON FOR CONSULTATION: , Atrial fibrillation and shortness of breath.,HISTORY OF PRESENTING ILLNESS: , The patient is an 81-year-old gentleman.  The patient had shortness of breath over the last few days, progressively worse.  Yesterday he had one episode and got concerned and came to the Emergency Room, also orthopnea and paroxysmal dyspnea.  Coronary artery disease workup many years ago.  He also has shortness of breath, weakness, and tiredness.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Knee surgery, hip surgery, shoulder surgery, cholecystectomy, and appendectomy.,MEDICATIONS: , Thyroid supplementation, atenolol 25 mg daily, Lasix, potassium supplementation, lovastatin 40 mg daily, and Coumadin adjusted dose.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY:,  Married, ex-smoker, and does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, atrial fibrillation chronic, on anticoagulation.,SURGICAL HISTORY: , As above.,PRESENTATION HISTORY: , Shortness of breath, weakness, fatigue, and tiredness.  The patient also relates history of questionable TIA in 1994.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Weakness, fatigue, tiredness.,HEENT:  No history of cataracts, blurry vision or glaucoma.,CARDIOVASCULAR:  Arrhythmia, congestive heart failure, no coronary artery disease.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea, no vomiting, hematemesis, or melena.,UROLOGICAL:  Some frequency, urgency, no hematuria.,MUSCULOSKELETAL:  Arthritis, muscle weakness.,SKIN:  Chronic skin changes.,CNS:  History of TIA.  No CVA, no seizure disorder.,ENDOCRINE:  Nonsignificant.,HEMATOLOGICAL:  Nonsignificant.,PSYCHOLOGICAL:  No anxiety or depression.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 67, blood pressure 159/49, afebrile, and respiratory rate 18 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair, decreased in basal areas.  No rales or wheezes.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.  Bowel sounds present.,EXTREMITIES:  Chronic skin changes.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,LABORATORY DATA: , H&H stable 30 and 39, INR of 1.86, BUN and creatinine within normal limits, potassium normal limits.  First set of cardiac enzymes profile negative.  BNP 4810.,Chest x-ray confirms unremarkable findings.  EKG reveals atrial fibrillation, nonspecific ST-T changes.,IMPRESSION:",3
"HISTORY OF PRESENT ILLNESS:,  A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness.  This has been problematic over the last several months and is just worsening to the point where it is impairing her work.  Her boss asks her if she was actually on drugs in which she said no.  She stated may be she needed to be, meaning taking some medications.  The patient had been prescribed Wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication.  She has not been on any other antidepressants in the past.  She is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia.  She denies any hot flashes or night sweats.  She underwent TAH with BSO in December of 2003.,FAMILY HISTORY: , Benign breast lump in her mother; however, her paternal grandmother had breast cancer.  The patient denies any palpitations, urinary incontinence, hair loss, or other concerns.  She was recently treated for sinusitis.,ALLERGIES:,  She is allergic to Sulfa.,CURRENT MEDICATIONS:,  Recently finished Minocin and Duraphen II DM.,PHYSICAL EXAMINATION:,General:  A well-developed and well-nourished female, conscious, alert, oriented times three in no acute distress.  Mood is dysthymic.  Affect is tearful.,Skin:  Without rash.,Eyes:  PERRLA.  Conjunctivae are clear.,Neck:  Supple with adenopathy or thyromegaly.,Lungs:  Clear.,Heart:  Regular rate and rhythm without murmur.,ASSESSMENT:,1.  Postsurgical menopause.,2.  Mood swings.,PLAN:,  I spent about 30 minutes with the patient discussing treatment options.  I do believe that her moods would greatly benefit from hormone replacement therapy; however, she is reluctant to do this because of family history of breast cancer.  We will try starting her back on Wellbutrin XL 150 mg daily.  She may increase to 300 mg daily after three to seven days.  Samples provided initially.  If she is not obtaining adequate relief from medication alone, we will then suggest that we explore the use of hormone replacement therapy.  I also recommended increasing her exercise.  We will also obtain some screening lab work including CBC, UA, TSH, chemistry panel, and lipid profile.  Follow up here in two weeks or sooner if any other problems.  She is needing her annual breast exam as well.",5
"CHIEF COMPLAINT:,  Foul-smelling urine and stomach pain after meals.,HISTORY OF PRESENT ILLNESS:,  Stomach pain with most meals x one and a half years and urinary symptoms for same amount of time.  She was prescribed Reglan, Prilosec, Pepcid, and Carafate at ED for her GI symptoms and Bactrim for UTI.  This visit was in July 2010.,REVIEW OF SYSTEMS:,  HEENT:  No headaches.  No visual disturbances, no eye irritation.  No nose drainage or allergic symptoms.  No sore throat or masses.  Respiratory:  No shortness of breath.  No cough or wheeze.  No pain.  Cardiac:  No palpitations or pain.  Gastrointestinal:  Pain and cramping.  Denies nausea, vomiting, or diarrhea.  Has some regurgitation with gas after meals.  Genitourinary:  ""Smelly"" urine.  Musculoskeletal:  No swelling, pain, or numbness.,MEDICATION ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION:,General:  Unremarkable.,HEENT:  PERRLA.  Gaze conjugate.,Neck:  No nodes.  No thyromegaly.  No masses.,Lungs:  Clear.,Heart:  Regular rate without murmur.,Abdomen:  Soft, without organomegaly, without guarding or tenderness.,Back:  Straight.  No paraspinal spasm.,Extremities:  Full range of motion.  No edema.,Neurologic:  Cranial nerves II-XII intact.  Deep tendon reflexes 2+ bilaterally.,Skin:  Unremarkable.,LABORATORY STUDIES:,  Urinalysis was done, which showed blood due to her period and moderate leukocytes.,ASSESSMENT:,1.  UTI.,2.  GERD.,3.  Dysphagia.,4.  Contraception consult.,PLAN:,1.  Cipro 500 mg b.i.d. x five days.  Ordered BMP, CBC, and urinalysis with microscopy.,2.  Omeprazole 20 mg daily and famotidine 20 mg b.i.d.,3.  Prescriptions same as #2.  Also referred her for a barium swallow series to rule out a stricture.,4.  Ortho Tri-Cyclen Lo.,",38
"PREOPERATIVE DIAGNOSIS:,  Medial meniscal tear, left knee.,POSTOPERATIVE DIAGNOSIS: , Chondromalacia of medial femoral condyle.,PROCEDURE PERFORMED:,1.  Arthroscopy of the left knee.,2.  Left arthroscopic medial meniscoplasty of medial femoral condyle.,3.  Chondroplasty of the left knee as well.,ESTIMATED BLOOD LOSS: , 80 cc.,TOTAL TOURNIQUET TIME: , 19 minutes.,DISPOSITION: , The patient was taken to PACU in stable condition.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 41-year-old male with left knee pain for approximately two years secondary to hockey injury where he did have a prior MCL sprain.  He has had a positive symptomology of locking and pain since then.  He had no frank instability to it, however.,GROSS OPERATIVE FINDINGS: , We did find a tear to the medial meniscus as well as a large area of chondromalacia to the medial femoral condyle.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room.  The left lower extremity was prepped and draped in the usual sterile fashion.  Tourniquet was applied to the left thigh with adequate Webril padding, not inflated at this time.  After the left lower extremity had been prepped and draped in the usual sterile fashion, we applied an Esmarch tourniquet, exsanguinating the blood and inflated the tourniquet to 325 mmHg for a total of 19 minutes.  We established the lateral port of the knee with #11 blade scalpel.  We put in the arthroscopic trocar, instilled with water and inserted the camera.,On inspection of the patellofemoral joint, it was found to be quite smooth.  Pictures were taken there.  There was no evidence of chondromalacia, cracking, or fissuring of the articular cartilage.  The patella was well centered over the trochlear notch.  We then directed the arthroscope to the medial compartment of the knee.  It was felt that there was a tear to the medial meniscus.  We also saw large area of chondromalacia with grade-IV changes to bone over the medial femoral condyle.  This area was debrided with forceps and the arthroscopic shaver.  The cartilage was also smoothened over the medial femoral condyle.  This was curetted after the medial meniscus had been trimmed.  We looked into the notch.  We saw the ACL appeared stable, saw attachments to tibial as well as the femoral insertion with some evidence of laxity, wear and tear.  Attention then was taken to the lateral compartment with some evidence of tear to the lateral meniscus and the arterial surface of both the tibia as well as the femur were pristine in the lateral compartment.  All instruments were removed.  All loose cartilaginous pieces were suctioned from the knee and water was suctioned at the end.  We removed all instruments.  Marcaine was injected into the portal sites.  We placed a sterile dressing and stockinet on the left lower extremity.  He was transferred to the gurney and taken to PACU in stable condition.",37
"REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy.  The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004.  An ultrasound examination had reportedly been done in the past and the mass is being observed.  When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there.  The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma.  The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction.  She has no weight changes consistent with either hyper or hypothyroidism.  There is no family history of thyroid cancer in her family.  She has no notable discomfort with this lesion.  There have been no skin changes.  Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,PAST MEDICAL HISTORY:,  Essentially unremarkable.  The patient has never been hospitalized in the past for any major illnesses.  She has had no prior surgical procedures.,IMMUNIZATIONS: , Current and up to date.,ALLERGIES: , She has no known drug allergies.,CURRENT MEDICATIONS:  ,Currently taking no routine medications.  She describes her pain level currently as zero.,FAMILY HISTORY: , There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter.  This was done in Tijuana.  His mom is from central portion of Mexico.  There is no family history of multiple endocrine neoplasia syndromes.,SOCIAL HISTORY:  ,The patient is a junior at Hoover High School.  She lives with her mom in Fresno.,REVIEW OF SYSTEMS: , A careful 12-system review was completely normal except for the problems related to the thyroid mass.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress.  She was alert and oriented x3 and had an appropriate affect.,HEENT:  The head and neck examination is most significant.  There is mild amount of facial acne.  The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,NECK:  There is a slightly visible midline bulge in the region of the thyroid isthmus.  A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid.  This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine.  There are some shotty adenopathy in the area.  No supraclavicular nodes were noted.,CHEST:  Excursions are symmetric with good air entry.,LUNGS:  Clear.,CARDIOVASCULAR:  Normal.  There is no tachycardia or murmur noted.,ABDOMEN:  Benign.,EXTREMITIES:  Extremities are anatomically correct with full range of motion.,GENITOURINARY:  External genitourinary exam was deferred at this time and can be performed later during anesthesia.  This is same as too for her rectal examination.,SKIN:  There is no acute rash, purpura, or petechiae.,NEUROLOGIC:  Normal and no focal deficits.  Her voice is strong and clear.  There is no evidence of dysphonia or vocal cord malfunction.,DIAGNOSTIC STUDIES: , I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range.  T4 and TSH levels were recorded as normal.  Free thyroxine was normal, and the serum pregnancy test was negative.  There was no level of thyroglobulin recorded on this.  A urinalysis and comprehensive metabolic panel was unremarkable.  A chest x-ray was obtained, which I personally reviewed.  There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,IMPRESSION/PLAN: , The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease.  I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease.  During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy.  We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation.  We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well.  I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them.  I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit.  This will have some impact on the postoperative adjunctive therapy.  The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case.  I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity.  All of the family's questions have been answered.  This is a very anxious and anxiety provoking time in the family.  I have made every effort to get the patient under schedule within the next 48 hours to have this operation done.  We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy.",29
"REASON FOR CONSULTATION:,  Cardiomyopathy and hypotension.,HISTORY OF PRESENT ILLNESS:,  I am seeing the patient upon the request of Dr. X.  The patient is very well known to me, an 81-year-old lady with dementia, a native American with coronary artery disease with prior bypass, reduced LV function, recurrent admissions for diarrhea and hypotension several times in November and was admitted yesterday because of having diarrhea with hypotension and acute renal insufficiency secondary to that.  Because of her pre-existing coronary artery disease and cardiomyopathy with EF of about 30%, we were consulted to evaluate the patient.  The patient denies any chest pain or chest pressure.  Denies any palpitations.  No bleeding difficulty.  No dizzy spells.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever or chills.,EYES:  No visual disturbances.,ENT:  No difficulty swallowing.,CARDIOVASCULAR:  Basically, no angina or chest pressure.  No palpitations.,RESPIRATORY:  No wheezes.,GI:  No abdominal pain, although she had diarrhea.,GU:  No specific symptoms.,MUSCULOSKELETAL:  Have sores on the back.,NEUROLOGIC:  Have dementia.,All other systems are otherwise unremarkable as far as the patient can give me information.,PAST MEDICAL HISTORY:,1.  Positive for coronary artery disease for about two to three years.,2.  Hypertension.,3.  Anemia.,4.  Chronic renal insufficiency.,5.  Congestive heart failure with EF of 25% to 30%.,6.  Osteoporosis.,7.  Compression fractures.,8.  Diabetes mellitus.,9.  Hypothyroidism.,PAST SURGICAL HISTORY:,1.  Coronary artery bypass grafting x3 in 2008.,2.  Cholecystectomy.,3.  Amputation of the right second toe.,4.  ICD implantation.,CURRENT MEDICATIONS AT HOME:,1.  Amoxicillin.,2.  Clavulanic acid or Augmentin every 12 hours.,3.  Clopidogrel 75 mg daily.,4.  Simvastatin 20 mg daily.,5.  Sodium bicarbonate 650 mg twice daily.,6.  Gabapentin 300 mg.,7.  Levothyroxine once daily.,8.  Digoxin 125 mcg daily.,9.  Fenofibrate 145 mg daily.,10.  Aspirin 81 mg daily.,11.  Raloxifene once daily.,12.  Calcium carbonate and alendronate.,13.  Metoprolol 25 mg daily.,14.  Brimonidine ophthalmic once daily.,ALLERGIES: , She has no known allergies.,FAMILY HISTORY: ",3
"PREOPERATIVE DIAGNOSES: , Colon cancer screening and family history of polyps.,POSTOPERATIVE DIAGNOSIS:,  Colonic polyps.,PROCEDURE:,  Colonoscopy.,ANESTHESIA:,  MAC,DESCRIPTION OF PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  The preparation was excellent and all surfaces were well seen.  The mucosa was normal throughout the colon and in the terminal ileum.  Two polyps were identified and were removed.  The first was a 7-mm sessile lesion in the mid transverse colon at 110 cm, removed with the snare without cautery and retrieved.  The second was a small 4-mm sessile lesion in the sigmoid colon at 20 cm also removed with the snare and retrieved.  No other lesions were identified.  Numerous diverticula were found in the sigmoid colon.  A retroflex through the anorectal junction showed moderate internal hemorrhoids.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Sigmoid diverticulosis.,2.  Colonic polyps in the transverse colon and sigmoid colon, benign appearance, removed.,3.  Internal hemorrhoids.,4.  Otherwise normal colonoscopy to the terminal ileum.,RECOMMENDATIONS:,1.  Follow up biopsy report.,2.  Follow up with Dr. X as needed.,3.  Screening colonoscopy in 5 years.",37
"CHILD PHYSICAL EXAMINATION,VITAL SIGNS:  Birth weight is ** grams, length **, occipitofrontal circumference **.  Character of cry was lusty.,GENERAL APPEARANCE:  Well.,BREATHING:  Unlabored.,SKIN:  Clear.  No cyanosis, pallor, or icterus.  Subcutaneous tissue is ample.,HEAD:  Normal.  Fontanelles are soft and flat.  Sutures are opposed.,EYES:  Normal with red reflex x2.,EARS:  Patent.  Normal pinnae, canals, TMs.,NOSE:  Patent nares.,MOUTH:  No cleft.,THROAT:  Clear.,NECK:  No masses.,CHEST:  Normal clavicles.,LUNGS:  Clear bilaterally.,HEART:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, flat.  No hepatosplenomegaly.  The cord is three vessel.,GENITALIA:  Normal ** genitalia **with testes descended bilaterally.,ANUS:  Patent.,SPINE:  Straight and without deformity.,EXTREMITIES:  Equal movements.,MUSCLE TONE:  Good.,REFLEXES:  Moro, grasp, and suck are normal.,HIPS:  No click or clunk.",29
"PREOPERATIVE DIAGNOSES:,1.  Urinary retention.,2.  Benign prostate hypertrophy.,POSTOPERATIVE DIAGNOSES:,1.  Urinary retention.,2.  Benign prostate hypertrophy.,PROCEDURES PERFORMED:,1.  Cystourethroscopy.,2.  Transurethral resection of prostate (TURP).,ANESTHESIA:,  Spinal.,RESECTION TIME:,  Less than one hour.,INDICATION FOR PROCEDURE:  ,This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.,PROCEDURE:  PROCEDURE: , Informed written consent was obtained.  The patient was taken to the operative suite, administered spinal anesthetic and placed in dorsal lithotomy position.  She was sterilely prepped and draped in normal fashion.  A #27-French resectoscope was inserted utilizing the visual obturator blanching the bladder.  The bladder was visualized in all quadrants, no bladder tumors or stones were noted.  Ureteral orifices were visualized and did appear to be near the enlarged median lobe.  Prostate showed trilobar prostatic enlargement.  There were some cellules and tuberculations noted.  The visual obturator was removed.  The resectoscope was then inserted utilizing the #26 French resectoscope loop.  Resection was performed initiating at the bladder neck and at the median lobe.,This was taken down to the circular capsular fibers.  Attention was then turned to the left lateral lobe and this was resected from 12 o'clock to 3 o'clock down to the capsular fibers maintaining hemostasis along the way and taking care not to resect beyond the level of the verumontanum.  Ureteral orifices were kept out of harm's way throughout the case.  Resection was then performed from the 3 o'clock position to the 6 o'clock position in similar fashion.  Attention was then turned to the right lateral lobe and this was resected again in a similar fashion maintaining hemostasis along the way.  The resectoscope was then moved to the level of the proximal external sphincter and trimming of the apex was performed.  Open prostatic fossa was noted.  All chips were evacuated via Ellik evacuator and #24 French three-way Foley catheter was inserted and irrigated.  Clear return was noted.  The patient was then hooked up to better irrigation.  The patient was cleaned, reversed for anesthetic, and transferred to recovery room in stable condition.,PLAN:  ,We will admit with antibiotics, pain control, and bladder irrigation possible void trial in the morning.",38
"BLEPHAROPLASTY,The patient was prepped and draped.  The upper lid skin was marked out in a lazy S fashion, and the redundant skin marked out with a Green forceps.  Then the upper lids were injected with 2% Xylocaine and 1:100,000 epinephrine and 1 mL of Wydase per 20 mL of solution.,The upper lid skin was then excised within the markings.  Gentle pressure was placed on the upper eyelids, and the fat in each of the compartments was teased out using a scissor and cotton applicator; and then the fat was cross clamped, cut, and the clamp cauterized.  This was done in the all compartments of the middle and medial compartments of the upper eyelid, and then the skin sutured with interrupted 6-0 nylon sutures.  The first suture was placed in the lower eyelid skin picking up the periorbital muscle and then the upper portion of the tarsus and then the upper lid skin.  This created a significant crisp, supratarsal fold.  The upper lid skin was closed in this fashion, and then attention was turned to the lower lid.,An incision was made under the lash line and slightly onto the lateral canthus.  The #15 blade was used to delineate the plane in the lateral portion of the incision, and then using a scissor the skin was cut at the marking.  Then the skin muscle flap was elevated with sharp dissection.  The fat was located and using a scissor the three eyelid compartments were opened.  Fat was teased out, cross clamped, the fat removed, and then the clamp cauterized.  Once this was done the skin was tailored to the lower lid incision site with mouth open and eyes in upward gaze, and then the excess skin removed.  The suture line was sutured with interrupted 6-0 silk sutures.  Once this was done the procedure was finished.,The patient left the OR in satisfactory condition.  The patient was given 50 mg of Demerol IM with 25 mg of Phenergan.",26
"PAST MEDICAL CONDITION:,  None.,ALLERGIES:,  None.,CURRENT MEDICATION:,  Zyrtec and hydrocodone 7.5 mg one every 4 to 6 hours p.r.n. for pain.,CHIEF COMPLAINT: , Back injury with RLE radicular symptoms.,HISTORY OF PRESENT ILLNESS:,  The patient is a 52-year-old male who is here for independent medical evaluation.  The patient states that he works for ABC ABC as a temporary worker.  He worked for ABCD too.  The patient's main job was loading and unloading furniture and appliances for the home.  The patient was approximately there for about two and a half weeks.  Date of injury occurred back in October.  The patient stating that he had history of previous back problems ongoing; however, he states that on this particular day back in October, he was unloading an 18-wheeler at ABC and he was bending down picking up boxes to unload and load.  Unfortunately at this particular event, the patient had sharp pain in his lower back.  Soon afterwards, he had radiating symptoms down his right buttock all the way down to the lateral part of his leg crossing his knee.  This became progressively worse.  He also states that some of his radiating pain went down to his left leg as well.  He noticed increase in buttock spasm and also noticed spasm in his buttocks.  He initially saw Dr. Z and was provided with some muscle relaxer and was given some pain patches or Lidoderm patch, I believe.  The patient states that after this treatment, his symptoms still persisted.  At this point, the patient later on was referred to Dr. XYZ through the workmen's comp and he was initially evaluated back in April.  After the evaluation, the patient was sent for MRI, was provided with pain medications such as short-acting opioids.  He was put on restricted duty.  The MRI essentially came back negative, but the patient continued to have radiating symptoms down to his lower extremity and subsequently the patient was essentially released by Dr. XYZ in June with maximum medical improvement.,Unfortunately, the patient continued to have persistence of back pain and radiating symptoms down to his leg and went back to see Dr. XYZ again, and at this point, the patient was provided with further medication management and sent for Pain Clinic referral.  The patient also was recommended for nerve block at this point and the patient received epidural steroid injection by Dr. ABC without any significant relief.  The patient also was sent for EMG and nerve conduction study, which was performed by Dr. ABCD and the MRI, EMG, and nerve conduction study came back essentially negative for radiculopathy, which was performed by Dr. ABCD.  The patient states that he continues to have pain with extended sitting, he has radiating symptoms down to his lower extremity on the right side of his leg, increase in pain with stooping.  He has difficulty sleeping at nighttime because of increase in pain.  Ultimately, the patient was returned back to work in June, and deemed with maximum medical improvement back in June.  The patient unfortunately still has significant degree of back pain with activities such as stooping and radicular symptoms down his right leg, worse than the left side.  The patient also went to see Dr. X who is a chiropractic specialist and received eight or nine visits of chiropractic care without long-term relief in his overall radicular symptoms.,PHYSICAL EXAMINATION:,  The patient was examined with the gown on.  Lumbar flexion was moderately decreased.  Extension was normal.  Side bending to the right was decreased.  Side bending to the left was within normal limits.  Rotation and extension to the right side was causing increasing pain.  Extension and side bending to the left was within normal limits without significant pain on the left side.  While seated, straight leg was negative on the LLE at 90° and also negative on the RLE at 90°.  There was no true root tension sign or radicular symptoms upon straight leg raising in the seated position.  In supine position, straight leg was negative in the LLE and also negative on the RLE.  Sensory exam shows there was a decrease in sensation to the S1 dermatomal distribution on the right side to light touch and at all other dermatomal distribution was within normal limits.  Deep tendon reflex at the patella was 2+/4 bilaterally, but there was a decrease in reflex in the Achilles tendon 1+/4 on the right side and essentially 2+/4 on the left side.  Medial hamstring reflex was 2+/4 on both hamstrings as well.  On prone position, there was tightness in the paraspinals and erector spinae muscle as well as tightness on the right side of the quadratus lumborum area, right side was worse than the left side.  Increase in pain at deep palpatory examination in midline of the L5 and S1 level.,MEDICAL RECORD REVIEW:,  I had the opportunity to review Dr. XYZ's medical records.  Also reviewed Dr. ABC procedural note, which was the epidural steroid injection block that was performed in December.  Also, reviewed Dr. X's medical record notes and an EMG and nerve study that was performed by Dr. ABCD, which was essentially normal.  The MRI of the lumbar spine that was performed back in April, which showed no evidence of herniated disc.,DIAGNOSIS: , Residual from low back injury with right lumbar radicular symptomatology.,EVALUATION/RECOMMENDATION:,  The patient has an impairment based on AMA Guides Fifth Edition and it is permanent.  The patient appears to have re-aggravation of the low back injury back in October related to his work at ABC when he was working unloading and loading an 18-wheel truck.  Essentially, there was a clear aggravation of his symptoms with ongoing radicular symptom down to his lower extremity mainly on the right side more so than the left.  The patient also has increase in back pain with lumbar flexion and rotational movement to the right side.  With these ongoing symptoms, the patient has also decrease in activities of daily living such as mobility as well as decrease in sleep pattern and general decrease in overall function.  Therefore, the patient is assigned 8% impairment of the whole person.  We are able to assign this utilizing the Fifth Edition on spine section on the AMA guide.  Using page 384, table 15-3, the patient does fall under DRE Lumbar Category II under criteria for rating impairment due to lumbar spine injury.  In this particular section, it states that the patient's clinical history and examination findings are compatible with specific injury; and finding may include significant muscle guarding or spasm observed at the time of examination, a symmetric loss of range of motion, or non-verifiable radicular complaints define his complaints of radicular pain without objective findings; no alteration of the structural integrity and no significant radiculopathy.  The patient also has decrease in activities of daily living; therefore, the patient is assigned at the higher impairment rating of 8% WPI.  In the future, the patient should avoid prolonged walking, standing, stooping, squatting, hip bending, climbing, excessive flexion, extension, and rotation of his back.  His one time weight limit should be determined by work trial, although the patient should continue to be closely monitored and managed for his pain control by the specific specialist for management of his overall pain.  The patient although has a clear low back pain with certain movements such as stooping and extended sitting and does have a clear radicular symptomatology, the patient also should be monitored closely for specific dependency to short-acting opioids in the near future by specialist who could monitor and closely follow his overall pain management.  The patient also should be treated with appropriate modalities and appropriate rehabilitation in the near future.,",27
"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.",27
"DESCRIPTION OF PROCEDURE:,  After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table.  After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty.  The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally.  Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants.  A lens ring was secured to the eye using 7-0 Vicryl suture.",37
"PREOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,POSTOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,ANESTHESIA:,  General.,PROCEDURE:,  Placement of left subclavian 4-French Broviac catheter.,INDICATIONS:  ,The patient is a toddler admitted with a limp and back pain, who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas.  The patient needs prolonged IV antibiotic therapy, but attempt at a PICC line failed.  She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement.  I met with the patient's mom.  With the help of a Spanish interpreter, I explained the technique for Broviac placement.  We discussed the surgical risks and alternatives, most of which have been exhausted.  All their questions have been answered, and the patient is fit for operation today.,DESCRIPTION OF OPERATION:  ,The patient came to the operating room and had an uneventful induction of general anesthesia.  We conducted a surgical time-out to reiterate all of the patient's important identifying information and to confirm that we were here to place the Broviac catheter.  Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed.  A flexible guidewire was inserted into the central location and then a 4-French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins.  The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines.  The peel-away sheath was passed over the guidewire and then the 4-French catheter was deployed through the peel-away sheath.  There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein, then it was withdrawn and easily replaced in the superior vena cava.  The catheter insertion site was closed with one buried 5-0 Monocryl stitch and the same 5-0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred.  Heparinized saline solution was used to flush the line.  A sterile occlusive dressing was applied, and the line was prepared for immediate use.  The patient was transported to the recovery room in good condition.  There were no intraoperative complications, and her blood loss was between 5 and 10 mL during the line placement portion of the procedure.",29
"PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED: , Laparoscopic right partial nephrectomy.,ESTIMATED BLOOD LOSS:,  250 mL.,X-RAYS: , None.,SPECIMENS: , Included right renal mass as well as biopsies from the base of the resection.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS: , None.,DRAINS: , Included a JP drain in the right flank as well as a #16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 60-year-old gentleman with a history of an enhancing right renal mass approximately 2 cm in diameter.  I had a long discussion with him concerning variety of options.  We talked in particular about extirpated versus ablative surgery.  Based on his young age and excellent state of health, decision was made at this point to proceed to a right partial nephrectomy laparoscopically.  All questions were answered, and he wished to proceed with surgery as planned.  Note that the patient does have a positive family history of renal cell carcinoma.,PROCEDURE IN DETAIL: , After acquisition of proper informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table.  After institution of adequate general anesthetic via endotracheal rod, he was placed into the right anterior flank position with his right side elevated on a roll and his right arm across his chest.  All pressure points were carefully padded, and he was securely taped to the table.  Note that sequential compression devices were in place on both lower extremities and were activated prior to induction of anesthesia.  His abdomen was then prepped and draped in a standard surgical fashion.  Note that a #16-French Foley catheter was in place per urethra as well as an orogastric tube.  The abdomen was insufflated at the right lateral abdomen using the Veress needle to a pressure of 15 without incident.  We then placed a Visiport 10 x 12 trocar in the right lateral abdomen.  With the trocar in place, we were able to place the remaining trocars under direct laparoscopic visualization.  We placed three additional trocars.  An 11 mm screw type trocar at the umbilicus, a 6 screw type trocar 7 cm in the midline above the umbilicus, and a 10 x 12 trocar to serve as a retractor port approximately 8 cm inferior in the midline.,The procedure was begun by reflecting the right colon by incising the white line of Toldt.  The colon was reflected medially, and the retroperitoneum was exposed on that side.  This was a fairly superficial lesion, so decision was made in advance to potentially not perform vascular clamping, however, I did feel it important to get high level control prior to proceeding to the partial.  With the colon reflected, the duodenum was identified, and it was reflected medially under Kocher maneuver.  The ureter and gonadal vein were identified on the right side and elevated.  The space between the ureter and the gonadal vein was then developed, and the gonadal vein was dropped elevating only the ureter, and carrying this plane dissection up towards the renal hilum.  Once we got up to the renal hilum, we were able to skeletonize the renal hilar vessels partially, and in particular, we did develop some of the upper pole dissection above the level of the hilum to provide for access for a Satinsky clamp or bulldogs.  The remainder of the kidney was then freed off its lateral and superior attachments primarily using the Harmonic scalpel and the LigaSure device.,With the kidney free and the hilum prepared, the Gerota fascia was taken down overlying the kidney exposing the renal parenchyma, and using this approach, we were able to identify the 2-cm, right renal mass located in the lower pole laterally.  A cap of fat was left overlying this mass.  Based on the position of the mass, we performed intraoperative laparoscopic ultrasound, which showed the mass to be somewhat deeper than initially anticipated.  Based on this finding, I decided to go ahead and clamp the renal hilum during resection.  A Satinsky clamp was introduced through the lower most trocar site and used to clamp the renal hilum en bloc.  Note that the patient had been receiving renal protection protocol including fenoldopam and mannitol throughout the procedure, and he also received Lasix prior to clamping the renal hilum.  With the renal hilum clamped, we did resect the tumor using cold scissors.  There was somewhat more bleeding than would be expected based on the hilar clamping; however, we were able to successfully resect this lesion.  We also took a biopsy at the base of the resection and passed off the table as a specimen for frozen section.  With the tumor resected, the base of the resection was then cauterized using the Argon beam coagulator, and several bleeding vessels were oversewn using figure-of-eight 3-0 Vicryl sutures with lap ties for tensioning.  We then placed a FloSeal into the wound and covered it with a Surgicel and held the pressure.  We then released the vascular clamp.  Total clamp time was 11 minutes.  There was minimal bleeding and occlusion of this maneuver, and after unclamping the kidney, the kidney pinked up appropriately and appeared well perfused after removal of the clamp.  We then replaced the kidney within its Gerota envelope and closed that with 3-0 Vicryl using lap ties for tensioning.  A JP drain was introduced through the right flank and placed adjacent to the kidney and sutured the skin with 2-0 nylon.  The specimen was placed into a 10-mm Endocatch bag and extracted from the lower most trocar site after extending it approximately 1 cm.  It was evaluated on the table and passed off the table for Pathology to evaluate.  They stated that the tumor was close to the margin, but there appeared to be 1-2 mm normal parenchyma around the tumor.  In addition, the frozen section biopsies from the base of the resection were negative for renal cell carcinoma.  Based on these findings, the lower most trocar site was closed using a running 0 Vicryl suture in the fascia.  We then re-insufflated the abdomen and carefully evaluated the entire intraoperative field for hemostasis.  Any bleeding points were controlled primarily using bipolar cautery or hemoclips.  The area was copiously irrigated with normal saline.  The colon was then replaced into its normal anatomic position.  The mesentry was evaluated.  There were no defects noted.  We closed the 10 x 12 lateral most trocar site using a Carter-Thompson closure device with 0-Vicryl.  All trocars were removed under direct visualization, and the abdomen was desufflated prior to removal of the last trocar.  The skin incisions were irrigated with normal saline and infiltrated with 0.25% Marcaine, and the skin was closed using a running 4-0 Monocryl in subcuticular fashion.  Benzoin and Steri-Strips were placed.  The patient was returned in supine position and awoken from general anesthetic without incident.  He was then transferred to hospital gurney and taken to the postanesthesia care unit for postoperative monitoring.  At the end of the case, sponge, instrument, and needle counts were correct.  I was scrubbed and present throughout the entire case.",37
"PREOPERATIVE DIAGNOSES:,1.  Maxillary atrophy.,2.  Severe mandibular atrophy.,3.  Acquired facial deformity.,4.  Masticatory dysfunction.,POSTOPERATIVE DIAGNOSES:,1.  Maxillary atrophy.,2.  Severe mandibular atrophy.,3.  Acquired facial deformity.,4.  Masticatory dysfunction.,PROCEDURE PERFORMED: , Autologous iliac crest bone graft to maxilla and mandible under general anesthetic.,Dr. X and company accompanied the patient to OR #6 at 7:30 a.m.  Nasal trachea intubation was performed per routine.  The bilateral iliac crest harvest was first performed by Dr. X and company under separate OR report.  Once the bone was harvested, surgical templets were used to recontour initially the maxillary graft and the mandibular graft.  Then, CAT scan models were used to find tune and adjust the bony contact regions for the maxillary tricortical block graft and the mandibular tricortical block graft.  Subsequent to the harvest of the bilateral ilium, the intraoral region was scrubbed per routine.  Surgical team scrubbed and gowned in usual fashion and the patient was draped.  Xylocaine 1%, 1:100,000 epinephrine 7 ml was infiltrated into the labial and palatal mucosa.  A primary incision was made in the maxilla starting on the patient's left tuberosity region along the crest of the residual ridge to the contralateral side in similar fashion.  Release incisions were made in the posterior region of the maxilla.,A full-thickness periosteal reflexion first exposed the palatal region.  The contents of the neurovascular canal from the greater palatine foramina were identified.  The hard palate was directly observed.  The facial tissues were then reflected exposing the lateral aspect of the maxilla, the zygomatic arch, the infraorbital nerve, artery and vein, the lateral piriform rim, the inferior piriform rim, and the remaining issue of the nasal spine.  Similar features were reflected on the contralateral side.  The area was re-contoured with rongeurs.  The block of bone, which was formed and harvested from the left ilium was then placed and found to be stable.  A surgical mallet then compressed this bone further into the region.  A series of five 2 mm diameter titanium screws measuring 14 mm to 16 mm long were then used to fixate the block of bone into the residual maxilla.  Particulate bone was then placed around the remaining block of bone.  A piece of AlloDerm mixed with Croften and patient's platelet-rich plasma, which was centrifuged from drawing 20 cc of blood was then mixed together and placed over the lateral aspect of the block.  The tissues were expanded then with a tissue Metzenbaum scissors and once the labial tissue was expanded, the tissues were approximated for primary closure without tension using interrupted and continuous sutures #3-0 Gore-Tex.  Attention was brought then to the mandible.  1% Xylocaine, 1:100,000 epinephrine was infiltrated in the labial mucosa 5 cc were given.  A primary incision was made between the mental foramina and the residual crest of the ridge and reflected first to the lingual area observing the superior genial tubercle in the facial area degloving the mentalis muscle and exposing the anterior body.  The anterior body was found to be approximately 3 mm in height.  A posterior tunnel was done first on the left side along the mylohyoid ridge and then under retromolar pad to the external oblique and the ridge was then degloved.  A tunnel was formed in the posterior region separating the mental nerve artery and vein from the flap and exposing that aspect of the body of the mandible.  A similar procedure was done on the contralateral side.  The tissues were stretched with tissue scissors and then a high speed instrumentation was used to decorticate the anterior mandible using a 1.6 mm twist drill and a pear shaped bur was used in the posterior region to begin original exploratory phenomenon of repair.  A block of bone was inserted between the mental foramina and fixative with three 16 cm screws first with a twist drill then followed with self-tapping 2 mm diameter titanium screws.  The block of bone was further re-contoured in situ.  Particulate bone was then injected into the posterior tunnels bilaterally.  A piece of AlloDerm was placed over those particulate segments.  The tissues were approximated for primary closure using #3-0 Gore-Tex suture both interrupted and horizontal mattress in form.  The tissues were compressed for about four minutes to allow platelet clots to form and to help adhere the flap.,The estimated blood loss in the harvest of the hip was 100 cc.  The estimated blood loss in the intraoral procedure was 220 cc.  Total blood loss for the procedure 320 cc.  The fluid administered 300 cc.  The urine out 180.  All sponges were counted encountered for as were sutures.  The patient was taken to Recovery at approximately 12 o'clock noon.",7
"HISTORY OF PRESENT ILLNESS: , This is a 19-year-old known male with sickle cell anemia.  He comes to the emergency room on his own with 3-day history of back pain.  He is on no medicines.  He does live with a room mate.  Appetite is decreased.  No diarrhea, vomiting.  Voiding well.  Bowels have been regular.  Denies any abdominal pain.  Complains of a slight headaches, but his main concern is back ache that extends from above the lower T-spine to the lumbosacral spine.  The patient is not sure of his immunizations.  The patient does have sickle cell and hemoglobin is followed in the Hematology Clinic.,ALLERGIES: , THE PATIENT IS ALLERGIC TO TYLENOL WITH CODEINE, but he states he can get morphine along with Benadryl.,MEDICATIONS: , He was previously on folic acid.  None at the present time.,PAST SURGICAL HISTORY: , He has had no surgeries in the past.,FAMILY HISTORY: , Positive for diabetes, hypertension and cancer.,SOCIAL HISTORY: , He denies any smoking or drug usage.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  On examination, the patient has a temp of 37 degrees tympanic, pulse was recorded at 37 per minute, but subsequently it was noted to be 66 per minute,  respiratory rate is 24 per minute and blood pressure is 149/66, recheck blood pressure was 132/72.,GENERAL:  He is alert, speaks in full sentences, he does not appear to be in distress.,HEENT:  Normal.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular.,ABDOMEN:  Soft.  He has pain over the mid to lower spine.,SKIN:  Color is normal.,EXTREMITIES:  He moves all extremities well.,NEUROLOGIC:  Age appropriate.,ER COURSE: , It was indicated to the patient that I will be drawing labs and giving him IV fluids.  Also that he will get morphine and Benadryl combination.  The patient was ordered a liter of NS over an hour, and was then maintained on D5 half-normal saline at 125 an hour.  CBC done showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4.  Chemistries done were essentially normal except for a total bilirubin of 1.6 mg/dL, all of which was indirect.  The patient initially received morphine and diphenhydramine at 18:40 and this was repeated again at 8 p.m.  He received morphine 5 mg and Benadryl 25 mg.  I subsequently spoke to Dr. X and it was decided to admit the patient.,The patient initially stated that he wanted to be observed in the ER and given pain control and fluids and wanted to go home in the morning.  He stated that he has a job interview in the morning.  The resident service did come to evaluate him.  The resident service then spoke to Dr. X and it was decided to admit him on to the Hematology service for control of pain and IV hydration.  He is to be transitioned to p.o. medications about 4 a.m. and hopefully, he can be discharged in time to make his interview tomorrow.,IMPRESSION:  ,Sickle cell crisis.,DIFFERENTIAL DIAGNOSIS: , Veno-occlusive crisis, and diskitis.",16
"PREPROCEDURE DIAGNOSIS: , History of colon polyps and partial colon resection, right colon.,POSTPROCEDURE DIAGNOSES:  ,1. Normal operative site.  ,2. Mild diverticulosis of the sigmoid colon.  ,3. Hemorrhoids.,PROCEDURE:  ,Total colonoscopy.,PROCEDURE IN DETAIL:  ,The patient is a 60-year-old of Dr. ABC's being evaluated for the above.  The patient also apparently had an x-ray done at the Hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed.  She was prepped the night before and on the morning of the test with oral Fleet's, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push.  Digital rectal exam was done, unremarkable.  At that point, the Pentax video colonoscope was inserted.  The rectal vault appeared normal.  The sigmoid showed diverticula throughout, mild to moderate in nature.  The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized.  The scope was passed a short distance up the ileum, which appeared normal.  The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area.  The scope was then retroflexed, and anal verge visualized showed some hemorrhoids.  The scope was then removed.  The patient tolerated the procedure well.,RECOMMENDATIONS:  ,Repeat colonoscopy in three years.",14
"PREOPERATIVE DIAGNOSIS:,  Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,POSTOPERATIVE DIAGNOSIS: , Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,SURGICAL PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA: , General endotracheal technique.,SURGICAL FINDINGS:  ,A 4+/4+ cryptic and hypertrophic tonsils with 2+/3+ hypertrophic adenoid pads.,INDICATIONS: , We were requested to evaluate the patient for complaints of enlarged tonsils, which cause difficulty swallowing, recurrent pharyngitis, and sleep-induced respiratory disturbance.  She was evaluated and scheduled for an elective procedure.,DESCRIPTION OF SURGERY:  ,The patient was brought to the operative suite and placed supine on the operating room table.  General anesthetic was administered.  Once appropriate anesthetic findings were achieved, the patient was intubated and prepped and draped in the usual sterile manner for a tonsillectomy.  He was placed in semi-Rose ___ position and a Crowe Davis-type mouth gag was introduced into the oropharynx.  Under an operating headlight, the oropharynx was clearly visualized.  The right tonsil was grasped with the fossa triangularis and using electrocautery enucleation technique, was removed from its fossa.  This followed placing the patient in a suspension position using a McIvor-type mouth gag and a red rubber Robinson catheter via the right naris.  Once the right tonsil was removed, the left tonsil was removed in a similar manner, once again using a needle point Bovie dissection at 20 watts.  With the tonsils removed, it was possible to visualize the adenoid pads.  The oropharynx was irrigated and the adenoid pad evaluated with an indirect mirror technique.  The adenoid pad was greater than 2+/4 and hypertrophic.  It was removed with successive passes of electrocautery suction.  The tonsillar fossa was then once again hemostased with suction cautery, injected with 0.5% ropivacaine with 1:100,000 adrenal solution and then closed with 2-0 Monocryl on an SH needle.  The redundant soft tissue of the uvula was removed posteriorly and cauterized with electrocautery to prevent swelling of the uvula in the postoperative period.  The patient's oropharynx and nasopharynx were irrigated with copious amounts of normal saline contained with small amount of iodine, and she was recovered from her general endotracheal anesthetic.  She was extubated and left the operating room in good condition to the postoperative recovery room area.,Estimated blood loss was minimal.  There were no complications.  Specimens produced were right and left tonsils.  The adenoid pad was ablated with electrocautery.",11
"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.",27
"Sample Address,Re:  Mrs. Sample Patient,Dear Sample Doctor:,I had the pleasure of seeing your patient, Mrs. Sample Patient , in my office today.  Mrs. Sample Patient is a 48-year-old, African-American female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermittent rectal bleeding.  The patient denies any weight loss, does have a good appetite, no nausea and no vomiting.,PAST MEDICAL HISTORY:,  Significant for hypertension and diabetes.,PAST SURGICAL HISTORY:,  The patient denies any past surgical history.,MEDICATIONS:,  The patient takes Cardizem CD 240-mg.  The patient also takes eye drops.,ALLERGIES:,  The patient denies any allergies.,SOCIAL HISTORY:,  The patient smokes about a pack a day for more than 25 years.  The patient drinks alcohol socially.,FAMILY HISTORY:,  Significant for hypertension and strokes.,REVIEW OF SYSTEMS:,  The patient does have a good appetite and no weight loss.  She does have intermittent rectal bleeding associated with irritation in the rectal area.  The patient denies any nausea, any vomiting, any night sweats, any fevers or any chills.,The patient denies any shortness of breath, any chest pain, any irregular heartbeat or chronic cough.,The patient is chronically constipated.,PHYSICAL EXAMINATION:,  This is a 48 year-old lady who is awake, alert and oriented x 3.  She does not seem to be in any acute distress.  Her vital signs are blood pressure is 130/70 with a heart rate of 75 and respirations of 16.  HEENT is normocephalic, atraumatic.  Sclerae are non-icteric.  Her neck is supple, no bruits, no lymph nodes.  Lungs are clear to auscultation bilaterally, no crackles, no rales and no wheezes.  The cardiovascular system has a regular rate and rhythm, no murmurs.  The abdomen is soft and non-tender.  Bowel sounds are positive and no organomegaly.  Extremities have no edema.,IMPRESSION:,  This is a 48-year-old female presenting with painless rectal bleeding not associated with any weight loss.  The patient is chronically constipated.,1.  Rule out colon cancer.,2.  Rule out colon polyps. ,3.  Rule out hemorrhoids, which is the most likely diagnosis.,RECOMMENDATIONS:,  Because of the patient's age, the patient will need to have a complete colonoscopy exam.,The patient will also need to have a CBC check and monitor.,The patient will be scheduled for the colonoscopy at Sample Hospital and the full report will be forwarded to your office.,Thank you very much for allowing me to participate in the care of your patient.,Sincerely yours,,Sample Doctor, MD",20
"PREOPERATIVE DIAGNOSIS:,  Severe degenerative joint disease of the right knee.,POSTOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right knee.,PROCEDURE:,  Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella.  All components were cemented with Cobalt G.,ANESTHESIA:,  Spinal.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , Less than 60 minutes.,The patient was taken to the Postanesthesia Care Unit in stable condition.  The patient tolerated the procedure well.,INDICATIONS:  ,The patient is a 51-year-old female complaining of worsening right knee pain.  The patient had failed conservative measures and having difficulties with her activities of daily living as well as recurrent knee pain and swelling.  The patient requested surgical intervention and need for total knee replacement.,All risks, benefits, expectations, and complications of surgery were explained to her in great detail and she signed informed consent.  All risks including nerve and vessel damage, infection, and revision of surgery as well as component failure were explained to the patient and she did sign informed consent.  The patient was given antibiotics preoperatively.,PROCEDURE DETAIL:  ,The patient was taken to the operating suite and placed in supine position on the operating table.  She was placed in the seated position and a spinal anesthetic was placed, which the patient tolerated well.  The patient was then moved to supine position again and a well-padded tourniquet was placed on the right thigh.  Right lower extremity was prepped and draped in sterile fashion.  All extremities were padded prior to this.,The right lower extremity, after being prepped and draped in the sterile fashion, the tourniquet was elevated and maintained for less than 60 minutes in this case.  A midline incision was made over the right knee and medial parapatellar arthrotomy was performed.  Patella was everted.  The infrapatellar fat pad was incised and medial and lateral meniscectomy was performed and the anterior cruciate ligament was removed.  The posterior cruciate ligament was intact.,There was severe osteoarthritis of the lateral compartment on the lateral femoral condyle as well as mild-to-moderate osteoarthritis in the medial femoral compartment as well severe osteoarthritis along the patellofemoral compartment.  The medial periosteal tissue on the proximal tibia was elevated to the medial collateral ligament and medial collateral ligament was left intact throughout the entirety of the case.,At the extramedullary tibial guide, an extended cut was made adjusting for her alignment.  Once this was performed, excess bone was removed.  The reamer was placed along on the femoral canal, after which a 6-degree valgus distal cut was made along the distal femur.  Once this was performed, the distal femoral size in 3 degrees external rotation, 62.5-mm cutting block was placed in 3 degrees external rotation with anterior and posterior cuts as well as anterior and posterior Chamfer cuts remained in the standard fashion.  Excess bone was removed.,Next, the tibia was brought anterior and excised to 71 mm.  It was then punched in standard fashion adjusting for appropriate rotation along the alignment of the tibia.  Once this was performed, a 71-mm tibial trial was placed as well as a 62.5-mm femoral trial was placed with a 12-mm polyethylene insert.,Next, the patella was cut in the standard fashion measuring 31 mm and a patella bed was placed.  The knee was taken for range of motion; had excellent flexion and extension as well as adequate varus and valgus stability.  There was no loosening appreciated.  There is no laxity appreciated along the posterior cruciate ligament.,Once this was performed, the trial components were removed.  The knee was irrigated with fluid and antibiotics, after which the cement was put on the back table, this being Cobalt G, it was placed on the tibia.  The tibial components were tagged in position and placed on the femur.  The femoral components were tagged into position.  All excess cement was removed ___ placement of patella.  It was tagged in position.  A 12-mm polyethylene insert was placed; knee was held in extension and all excess cement was removed.  The cement hardened with the knee in full extension, after which any extra cement was removed.,The wounds were copiously irrigated with saline and antibiotics, and medial parapatellar arthrotomy was closed with #2 Vicryl.  Subcutaneous tissue was approximated with #2-0 Vicryl and the skin was closed with staples.  The patient was awakened from general anesthetic, transferred to the gurney, and taken into postanesthesia care unit in stable condition.  The patient tolerated the procedure well.",37
"CC: ,Headache.,HX: ,This 37y/o LHM was seen one month prior to this presentation for HA, nausea and vomiting. Gastrointestinal evaluation at that time showed no evidence of bowel obstruction and he was released home. These symptoms had been recurrent since onset.,At presentation he complained of mild blurred vision (OU), difficulty concentrating and HA which worsened upon sitting up. The headaches were especially noticeable in the early morning. He described them as non-throbbing headaches. They begin in the bifrontal region and radiate posteriorly. They occurred up to 6 times/day. The HA improved with lying down or dropping the head down between the knees towards the floor. The headaches were associated with blurred vision, nausea,vomiting, photophobia, and phonophobia. He denied any scotomata or positive visual phenomena. He denies any weakness, numbness, tingling, dysarthria or diplopia. His weight has fluctuated from 163# to 148# over the past 3 months and at present he weighs 154#. His appetite has been especially poor in the past month.,MEDS:,Sulfasalazine qid. Tylenol 650mg q4hours.,PMH:, 1)Ulcerative Colitis dx 1989. 2)HTN 3) occasional HAs since the early 1980s which are different in character and much less severe than his current HAs. They were not associated with nausea, vomiting, photophobia, phonophobia or difficulty thinking.,FHX:, MGF with h/o stroke. Mother and Father were healthy. No h/o of migraine in family.,SHX:, Single. Works as a newpaper printing press worker. Denies tobacco, ETOH or illicit drug use, but admits he was a heavy drinker until the last 1970s when he quit.,EXAM: ,BP159/92 HR 48 (sitting): BP126/70 HR48 (supine). RR14 36.2C,MS: A&O to person, place and time. Speech clear. Appears uncomfortable but acts appropriately and cooperatively. No difficulty with short and long term memory.,CN: Grad 2-3 papilledema OS; Grade 1 papilledema (@2 o'clock) OD. Pupils 4/4 decreasing to 2/2 on exposure to light. Bilateral horizontal sustained nystagmus on right and leftward gaze. Bilateral vertical sustained nystagmus on up and downward gaze. Face symmetric with full movement and PP sensation. Tongue midline with full ROM. Gag and SCM were intact bilaterally.,Motor: Full strength throughout with normal muscle bulk and tone.,Sensory: Unremarkable.,Coord: Mild dysynergia on FNF movements in BUE. HNS and RAM were unremarkable.,Station: Unsteady with and without eyes open on Romberg test. No drift in any particular direction.,Gait: Wide based, ataxic and to some degree magnetic and apraxic.,Gen Exam: Unremarkable.,COURSE:, Urinalysis revealed 1-2RBC, 2-3WBC and bacteria were noted. Repeat Urinalysis was negative the next day. PT, PTT, CXR and GS were normal. CBC revealed 10.4WBC with 7.1Granulocytes. HCT, 10/18/95, revealed hydrocephalus. MRI, 10/18/95, revealed ventriculomegaly of the lateral, 3rd and 4th ventricles. There was enhancement of the meninges about the prepontine cisterna and internal auditory canals, and enhancement of a scar or inflammed lining of the foramen of Magendie. These changes were felt suggestive of bacterial or granulomatous meningitis. The patient underwent ventriculostomy on 10/19/94. CSF taken on 10/19/94 via V-P shunt insertion revealed: 22 WBC (21 lymphocytes, 1 monocyte), 380 RBC, Glucose 58, Protein 29, GS negative, Cultures (bacterial, fungal, AFB) negative, Cryptococcal Antigen and India Ink were negative. Numerous CSF samples were taken from the lumbar region and shunt reservoir and these were consistantly unremarkable except for an occasional CSF protein of up to 99mg/dl. Serum and CSF toxoplasma titers and ACE levels were negative on multiple occasions. VDRL and HIV testing was unremarkable. 10/27/94 and 10/31/94 CSF cultures taken from the cervical region eventually grew non-encapsulated crytococcus neoformans. The patient was treated with amphotericin and showed some improvement. However, scarring had probably occurred by then and the V-P shunt was left in place.",33
"Chief Complaint:, Dark urine and generalized weakness.,History of Present Illness:,40 year old Hispanic male presented to the emergency room complaining of generalized weakness, fatigue and dark urine for one week. In addition, he stated that his family had noticed yellowing of his skin and eyes, though he himself had not noticed.,He did complain of subjective fever and chills along with occasional night sweats during the prior week or so and he noted anorexia for 3-4 weeks leading to 26 pound weight loss (213 lbs. to 187 lbs.). He was nauseated but denied vomiting. He did admit to intermittent abdominal discomfort which he could not localize. In addition, he denied any history of liver disease, but had undergone cholecystectomy many years previous.,Past Medical History:, DM II-HbA1c unknown,Past Surgical History:, Cholecystectomy without complication,Family History:, Mother with diabetes and hypertension. Father with diabetes. Brother with cirrhosis (etiology not documented).,Social History:, He was unemployed and denied any alcohol or drug use. He was a prior “mild” smoker, but quit 10 years previous.,Medications:, Insulin (unknown dosage),Allergies:, No known drug allergies.,Physical Exam:,Temperature: 98.2,Blood pressure:118/80,Heart rate: 95,Respiratory rate: 18,GEN: Middle age Latin-American Male, jaundice, alert and oriented to person/place/time.,HEENT: Normocephalic, atraumatic. Icteric sclerae, pupils equal, round and reactive to light. Clear oropharynx.,NECK: Supple, without jugular venous distension, lymphadenopathy, thyromegaly or carotid bruits.,CV: Regular rate and rhythm, normal S1 and S2. No murmurs, gallops or rubs,PULM: Clear to auscultation bilaterally without rhonchi, rales or wheezes,ABD: Soft with mild RUQ tenderness to deep palpation, Murphy’s sign absent. Bowel sounds present. Hepatomegaly with liver edge 3 cm below costal margin. Splenic tip palpable.,RECTAL: Guaiac negative,EXT: Shotty inguinal lymphadenopathy bilaterally, largest node 2cm,NEURO: Strength 5/5 throughout, sensation intact, reflexes symmetric. No focal abnormality identified. No asterixis,SKIN: Jaundice, no rash. No petechiae, gynecomastia or spider angiomata.,Hospital Course:,The patient was admitted to the hospital to begin workup of liver failure. Initial labs were considered to be consistent with an obstructive pattern, so further imaging was obtained. A CT scan of the abdomen and pelvis revealed lymphadenopathy and a markedly enlarged liver. His abdominal pain was controlled with mild narcotics and he was noted to have decreasing jaundice by hospital day 4. An US guided liver biopsy revealed only acute granulomatous inflammation and fibrosis. The overall architecture of the liver was noted to be well preserved.,Gastroenterology was consulted for EGD and ERCP. The EGD was normal and the ERCP showed normal biliary anatomy without evidence of obstruction. In addition, they performed an endoscopic ultrasound-guided fine needle aspiration of two lymph-nodes, one in the subcarinal region and one near the celiac plexus. Again, pathologic results were insufficient to make a tissue diagnosis.,By the second week of hospitalization, the patient was having intermittent low-grade fevers and again experiencing night-sweats. He remained jaundice. Given the previous negative biopsies, surgery was consulted to perform an excisional biopsy of the right groin lymph node, which revealed no evidence of carcinoma, negative AFB and GMS stains and a single noncaseating granuloma.,By his fourth week of hospitalization, he remained ill with evidence of ongoing liver failure. Surgery performed an open liver biopsy and lymph node resection.,STUDIES (HISTORICAL):,CT abdomen: Multiple enlarged lymph nodes near the porta hepatis and peri-pancreatic regions. The largest node measures 3.5 x 3.0 cm. The liver is markedly enlarged (23cm) with a heterogenous pattern of enhancement. The spleen size is at the upper limit of normal. Pancreas, adrenal glands and kidneys are within normal limits. Visualized portions of the lung parenchyma are grossly normal.,CT neck: No abnormalities noted,CT head: No intracranial abnormalities,RUQ US (for biopsy): Heterogenous liver with lymphadenopathy.,ERCP: No filling defect noted; normal pancreatic duct visualized. Normal visualization of the biliary tree, no strictures. Normal exam.",15
"DISCHARGE DIAGNOSES,1.  Multiple extensive subcutaneous abscesses, right thigh.,2.  Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.,PROCEDURES PERFORMED,1.  On 03/05/08, by Dr. X, was massive debridement of soft tissue, right lateral thigh and hip.,2.  Soft tissue debridement on 03/16/08 of right thigh and hip by Dr. X.,3.  Split thickness skin graft to right thigh and right hip massive open wound on 04/01/08 by Dr. Y.,REASON FOR ADMISSION: , The patient is a 62-year-old male with a history of drug use.  He had a history of injection of heroin into his bilateral thighs.  Unfortunately, he developed chronic abscesses, open wounds on his bilateral thighs, much worse on his right than his left.  Decision was made to do a radical excision and then it is followed by reconstruction.,HOSPITAL COURSE:  ,The patient was admitted on 03/05/08 by Dr. X.  He was taken to the operating room.  He underwent a massive resection of multiple subcutaneous abscesses, heroin remnants, which left massive huge open wounds to his right thigh and hip.  This led to a prolonged hospital course.  The patient initially was treated with local wound care.  He was treated with broad spectrum antibiotics.  He ended up growing out different species of Clostridium.  Infectious Disease consult was obtained from Dr. Z.  He assisted in further antibiotic coverage throughout the rest of his hospitalization.  The patient also had significant hypoalbuminemia, decreased nutrition.  Given his large wounds, he did end up getting a feeding tube placement, and prior to grafting, he received significant feeding tube supplementation to help achieve adequate nutrition for healing.  The patient had this superior area what appeared to be further necrotic, infected soft tissue.  He went back to the OR on 03/16/08 and further resection done by Dr. X.  After this, his wound appeared to be free of infection.  He is treated with a wound VAC.  He slowly, but progressively had significant progress in his wound.  I went from a very poor-looking wound to a red granulated wound throughout its majority.  He was thought ready for skin grafting.  Note that the patient had serial ultrasounds given his high risk of DVT from this massive wound and need for decreased activity.  These were negative.  He was treated with SCDs to help decrease his risk.  On 04/01/08, the patient was taken to the operating room, was thought to have an adequate ________ grafting.  He underwent skin grafting to his right thigh and hip massive open wound.  Donor sites were truncated.  Postoperatively, the patient ended up with a vast majority of skin graft taking.  To unable to take, he was kept on IV antibiotics, strict bed rest, and limited range of motion of his hip.  He is continued on VAC dressing.  Graft progressively improved with this therapy.  Had another ultrasound, which was negative for DVT.  The patient was mobilized up out of his bed.  Infectious Disease recommendations were obtained.  Plan was to complete additional 10 days of antibiotics at discharge.  This will be oral antibiotics.  I would monitor his left side, which has significantly decreased inflammation and irritation or infection given the antibiotic coverage.  So, decision was not made to excise this, but instead monitor.  By 04/11/08, his graft looked good.  It was pink and filling in.  He looked stable for discharge.  The patient was discharged to home.,DISCHARGE INSTRUCTIONS: , Discharge to home.,CONDITION: , Stable.,Antibiotic Augmentin XR script was written.  He is okay to shower.  Donor site and graft site dressing instruction orders were given for Home Health and the patient.  His followup was arranged with Dr. X and myself.",10
"PREOPERATIVE DIAGNOSIS:,  Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA.,POSTOPERATIVE DIAGNOSIS: , Normal cystoscopy with atrophic vaginitis.,PROCEDURE PERFORMED: , Flexible cystoscopy.,FINDINGS:,  Atrophic vaginitis.,PROCEDURE:  ,The patient was brought in to the procedure suite, prepped and draped in the dorsal lithotomy position.  The patient then had flexible scope placed through the urethral meatus and into the bladder.  Bladder was systematically scanned noting no suspicious areas of erythema, tumor or foreign body.  Significant atrophic vaginitis is noted.,IMPRESSION: , Atrophic vaginitis with overactive bladder with urge incontinence.,PLAN: , The patient will try VESIcare 5 mg with Estrace and follow up in approximately 4 weeks.",38
"PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,PROCEDURES PERFORMED:  ,Tailor bunionectomy, right foot, Weil-type with screw fixation.,ANESTHESIA: , Local with MAC, local consisting of 20 mL of 0.5% Marcaine plain.,HEMOSTASIS:,  Pneumatic ankle tourniquet at 200 mmHg.,INJECTABLES:,  A 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate.,MATERIAL: , A 2.4 x 14 mm, 2.4 x 16 mm, and 2.0 x 10 mm OsteoMed noncannulated screw.  A 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, and 5-0 nylon.,COMPLICATIONS: , None.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS:,  Minimal.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed on the operating table in the usual supine position.  At this time, a pneumatic ankle tourniquet was placed on the patient's right ankle for the purpose of maintaining hemostasis.  Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site.  The right foot was then scrubbed, prepped, and draped in the usual aseptic manner.  An Esmarch bandage was then used to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet inflated to 200 mmHg.  Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3.5 cm in length was made.  The incision was carried deep utilizing both sharp and blunt dissections.  All major neurovascular structures were avoided.  At this time, through the original skin incision, attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified.  This was then incised fully exposing the tendon and the abductor hallucis muscle.  This was then resected from his osseous attachments and a small tenotomy was performed.  At this time, a small lateral capsulotomy was also performed.  Lateral contractures were once again reevaluated and noted to be grossly reduced.,Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision.  The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw, the head of the first metatarsal and medial eminence was resected and passed from the operative field.  A 0.045 inch K-wire was then driven across the first metatarsal head in order to act as an access dye.  The patient was then placed in the frog-leg position, and two osteotomy cuts were made, one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position.  The dorsal arm was made longer than the plantar arm to accommodate for fixation.  At this time, the capital fragment was resected and shifted laterally into a more corrected position.  At this time, three portions of the 0.045-inch K-wire were placed across the osteotomy site in order to access temporary forms of fixation.  Two of the three of these K-wires were removed in sequence and following the standard AO technique two 3.4 x 15 mm and one 2.4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site.  Compression was noted to be excellent.  All guide wires and 0.045-inch K-wires were then removed.  Utilizing an oscillating bone saw, the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field.  The wound was then once again flushed with copious amounts of sterile normal saline.  At this time, utilizing both 2-0 and 3-0 Vicryl, the periosteal and capsular layers were then reapproximated.  At this time, the skin was then closed in layers utilizing 4-0 Vicryl and 4-0 nylon.  At this time, attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension.  Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided.,A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal.  Utilizing an oscillating bone saw, the lateral eminence was resected and passed from the operative field.  Utilizing the sagittal saw, a Weil-type osteotomy was made at the fifth metatarsal head.  The head was then shifted medially into a more corrected position.  A 0.045-inch K-wire was then used as a temporary fixation, and a 2.0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site.  This was noted to be in correct position and compression was noted to be excellent.  Utilizing a small bone rongeur, the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field.  The wound was once again flushed with copious amounts of sterile normal saline.  The periosteal and capsular layers were reapproximated utilizing 3-0 Vicryl, and the skin was then closed utilizing 4-0 Vicryl and 4-0 nylon.  At this time, 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site.  The right foot was then dressed with Xeroform gauze, fluffs, Kling, and Ace wrap, all applied in mild compressive fashion.  The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot.  The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot.  After a brief period of postoperative monitoring, the patient was discharged to home with proper written and verbal discharge instructions, which included to keep dressing clean, dry, and intact and to follow up with Dr. A.  The patient is to be nonweightbearing to the right foot.  The patient was given a prescription for pain medications on nonsteroidal anti-inflammatory drugs and was educated on these.  The patient tolerated the procedure and anesthesia well.  Dr. A was present throughout the entire case.",27
"PREOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Hiatal hernia.,POSTOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Hiatal hernia.,3.  Enterogastritis.,PROCEDURE PERFORMED:  ,Esophagogastroduodenoscopy, photography, and biopsy.,GROSS FINDINGS: , The patient has a history of epigastric abdominal pain, persistent in nature.  She has a history of severe gastroesophageal reflux disease, takes Pepcid frequently.  She has had a history of hiatal hernia.  She is being evaluated at this time for disease process.  She does not have much response from Protonix.,Upon endoscopy, the gastroesophageal junction is approximately 40 cm.  There appeared to be some inflammation at the gastroesophageal junction and a small 1 cm to 2 cm hiatal hernia.  There is no advancement of the gastric mucosa up into the lower one-third of the esophagus.  However there appeared to be inflammation as stated previously in the gastroesophageal junction.  There was some mild inflammation at the antrum of the stomach.  The fundus of the stomach was within normal limits.  The cardia showed some laxity to the lower esophageal sphincter.  The pylorus is concentric.  The duodenal bulb and sweep are within normal limits.  No ulcers or erosions.,OPERATIVE PROCEDURE: , The patient is taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position.  The patient was given IV sedation using Demerol and Versed.  Olympus videoscope was inserted into the hypopharynx and upon deglutition passed into the esophagus.  Using air insufflation, panendoscope was advanced down the esophagus into the stomach along the greater curvature of the stomach through the pylorus into the duodenal bulb and sweep and the above gross findings were noted.  Panendoscope was slowly withdrawn carefully examining the lumen of the bowel.  Photographs were taken with the pathology present.  Biopsy was obtained of the antrum of the stomach and also CLO test.  The biopsy is also obtained of the gastroesophageal junction at 12, 3, 6 and 9 o' clock positions to rule out occult Barrett's esophagitis.  Air was aspirated from the stomach and the panendoscope was removed.  The patient sent to recovery room in stable condition.",37
"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.,",31
"Grade II:  Atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.,Grade III:  Atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.,Grade IV:  The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.,RIGHT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease.  The internal carotid artery shows intimal thickening with some mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  The external carotid artery shows no disease.  The vertebral was present and was antegrade.,LEFT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening, but no increase in velocity and no evidence for any significant obstructive disease. the internal carotid artery shows some intimal thickening with mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  The external carotid artery shows no disease.  The vertebral was present and was antegrade.,IMPRESSION:,  Bilateral atherosclerotic changes with no evidence for any significant obstructive disease.",33
"PROCEDURE PERFORMED:,  Lumbar puncture.,The procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form.  Alternatives were explained.  They agreed to proceed with the lumbar puncture.  Permit was signed and is on the chart.  The indication was to rule out toxoplasmosis or any other CNS infection. ,DESCRIPTION: , The area was prepped and draped in a sterile fashion.  Lidocaine 1% of 5 mL was applied to the L3-L4 spinal space after the area had been prepped with Betadine three times.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.  The spinal needle was then withdrawn and the area cleaned and dried and a Band-Aid applied to the clean, dry area.,COMPLICATIONS:,  None.  The patient was resting comfortably and tolerated the procedure well.,ESTIMATED BLOOD LOSS: , None.,DISPOSITION: , The patient was resting comfortably with nonlabored breathing and the incision was clean, dry, and intact.  Labs and cultures were sent for the usual in addition to some extra tests that had been ordered.,The opening pressure was 292, the closing pressure was 190.",37
"HISTORY OF PRESENT ILLNESS: , This is a 76-year-old female that was admitted with fever, chills, and left pelvic pain.  The patient was well visiting in ABC, with her daughter that evening.  She had pain in her left posterior pelvic and low back region.  They came back to XYZ the following day.  By the time they got here, she was in severe pain and had fever.  They came straight to the emergency room.  She was admitted.  She had temperature of 104 degrees F.  It has been spiking ever since and she has had left sacroiliac type hip pain.  Multiple blood studies have been done including cultures, febrile agglutinins, etc.  She has had run a higher blood glucose to the normal and she has been on sliding scale insulin.  She was not known previously to be a diabetic.  All x-rays have not been helpful as far as to determine the etiology of her discomfort.  MRIs of the lumbar spine and the pelvis and both thighs have been unremarkable for any inflammatory process.  She does have degenerative disk disease of her lumbar spine but no hip pathology.  She has swollen inguinal nodes bilaterally.,PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS: , She was not known to be a diabetic until this admission.  She had been hypertensive.  She has been on medications and has been controlled.  She has not had hyperlipidemia.  She has had no thyroid problems.  There has been no asthma, bronchitis, TB, emphysema or pneumonia.  No tuberculosis.  She has had no breast tumors.  She has had no chest pain or cardiac problems.  She has had gallbladder surgery.  She has not had any gastritis or ulcers.  She has had no kidney disease.  She has had a hysterectomy.  She has had 9 pregnancies and 8 living children.  She had A&P repair.  She had a sacral abscess after a spinal.  It sounds to me like she had a pilonidal cyst, which took about 3 operations to heal.  There have been fractures and no significant arthritis.  She has been quite active at her ranch in Mexico.  She raises goats and cattle.  She drives a tractor and in short, has been very active.,PHYSICAL EXAMINATION:,  She is a short female, alert.  She is shivering.  She has ice in her axilla and behind her neck.  She is febrile to 101 degrees F. She is alert.  Her complaint is that of hip pain in the posterior sacroiliac joint area.  She moves both her upper extremities well.  She can move her right leg well.  She actually can move her left hip and knee without much discomfort but the pain radiates from her sacroiliac joint.  She cannot stand, sit or turn without severe pain.  She has normal knee reflexes.  No ankle reflexes.  She has bounding tibial pulses.  No sensory deficit.  She says she knows when she has to void.  She has a healed scar in the upper sacral region.  There is some bruising around the buttocks but the daughter says that is from her being in bed lying on her back.,PLAN: , My plan is to do a triple-phase bone scan.  I am suspecting an infection possibly in the left sacroiliac joint.  It is probably some type of bacterium, the etiology of which is undetermined.  She has had a normal white count despite her fever.  There has been a history of brucellosis in the past, but her titers at this time are negative.  Continue medication which included antibiotics and also the Motrin and Darvocet.,",5
"DIAGNOSES:,1.  Disseminated intravascular coagulation.,2.  Streptococcal pneumonia with sepsis.,CHIEF COMPLAINT: , Unobtainable as the patient is intubated for respiratory failure.,CURRENT HISTORY OF PRESENT ILLNESS: , This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.  At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer.  At this time, I am being consulted for further evaluation and recommendations for treatment.  The nurses report that she has actually improved clinically over the last 24 hours.  Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion.  There is no prior history of coagulopathy.,PAST MEDICAL HISTORY:  ,Otherwise nondescript as is the past surgical history.,SOCIAL HISTORY:  ,There were possible illicit drugs.  Her family is present, and I have discussed her case with her mother and sister.,FAMILY HISTORY:  ,Otherwise noncontributory.,REVIEW OF SYSTEMS: , Not otherwise pertinent.,PHYSICAL EXAMINATION:,GENERAL:  She is a sedated, young black female in no acute distress, lying in bed intubated.,VITAL SIGNS:  She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.,HEENT:  Her sclerae showed conjunctival hemorrhage.  There are no petechiae.  Her nasal vestibules are clear.  Oropharynx has ET tube in place.,NECK:  No jugular venous pressure distention.,CHEST:  Coarse breath sounds bilaterally.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft and nontender with good bowel sounds.  There was some oozing around the site of her central line.,EXTREMITIES:  No clubbing, cyanosis, or edema.  There is no evidence of compromise arterial blood flow at the digits or of her hands or feet.,LABORATORY STUDIES:  ,The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13.,IMPRESSION/PLAN:  ,At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease.  My recommendation for the patient is to continue factor replacement as you are.  It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time.  There is no indication at this point for Xigris.  However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions.  I will repeat her laboratory studies in the morning and give more recommendations at that time.",16
"PAST MEDICAL HX: , Significant for asthma, pneumonia, and depression.,PAST SURGICAL HX: , None.,MEDICATIONS:,  Prozac 20 mg q.d.  She desires to be on the NuvaRing.,ALLERGIES:,  Lactose intolerance.,SOCIAL HX: , She denies smoking or alcohol or drug use.,PE:,  VITALS: Stable.  Weight: 114 lb.  Height: 5 feet 2 inches.  GENERAL: Well-developed, well-nourished female in no apparent distress.  HEENT: Within normal limits. NECK: Supple without thyromegaly.  HEART: Regular rate and rhythm.  LUNGS: Clear to auscultation.  ABDOMEN: Soft and nontender.  There is no rebound or guarding.  No palpable masses and no peritoneal signs.  EXTREMITIES: Within normal limits.  SKIN: Warm and dry.  GU: External genitalia is without lesion.  Vaginal is clean without discharge.  Cervix appears normal; however, a colposcopy was performed using acetic acid, which showed a thick acetowhite ring around the cervical os and extending into the canal.  BIMANUAL: Reveals significant cervical motion tenderness and fundal tenderness.  She had no tenderness in her adnexa.  There are no palpable masses.,A:,  Although unlikely based on the patient's exam and pain, I have to consider subclinical pelvic inflammatory disease.  GC and chlamydia was sent and I treated her prophylactically with Rocephin 250 mg and azithromycin 1000 mg.  Repeat biopsies were not performed based on her colposcopy as well as her previous Pap and colposcopy by Dr. A.  A LEEP is a reasonable approach even in this 16-year-old.,P:,  We will schedule LEEP in the near future.  Even though she has already been exposed HPV Gardasil would still be beneficial in this patient to help prevent recurrence of low-grade lesions as well as high-grade lesions.  Now, we have her given her first shot.",5
"PROCEDURES PERFORMED:,1.  Functional endoscopic sinus surgery.,2.  Bilateral maxillary antrostomy.,3.  Bilateral total ethmoidectomy.,4.  Bilateral nasal polypectomy.,5.  Right middle turbinate reduction.,ANESTHESIA:,  General endotracheal tube.,BLOOD LOSS:,  Approximately 50 cc.,INDICATION: , This is a 48-year-old female with a history of chronic sinusitis as well as nasal polyposis that have been refractory to outpatient medical management.  She has underwent sinus surgery in the past approximately 12 years ago with the CT evaluation revealed evidence of chronic mucosal thickening within the maxillary and ethmoid sinuses as well as the presence of polyposis within the nasal cavities bilaterally.,PROCEDURE:  ,After all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained.  The patient was brought to the operative suite where she was placed in supine position and general anesthesia was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away where cotton pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavity.  The nasal septum, as well as the turbinates were then localized with a mixture of 1% lidocaine with 1:100,000 epinephrine solution.  The patient was then prepped and draped in the usual fashion.,Attention was directed first to the left nasal cavity.  A zero-degree sinus endoscope was inserted into the nasal cavity down to the level of the nasopharynx.  The initial examination revealed a gross polypoid disease emanating from the sphenoid sinuses as well as off the supreme turbinate.  There was also polypoid disease present within the left middle meatus.  Nasopharynx was visualized with a patent eustachian tube.  At this point, the XPS micro debrider was used to take down all the polyps emanating from the inferior surface of the left middle turbinate as well as from the supreme turbinate.  The ostium to the sphenoid sinus was visualized and was not entered.  At this point, the left middle turbinate was localized and then medialized with the use of a freer elevator.  A ball-tip probe was then used to localize the openings for the natural maxillary ostium.  Side-biting forceps were used to take down the uncinate process and was further taken down with the use of the microdebrider.  The opening of the maxillary sinus was visualized.  The posterior fontanelle was taken down with the use of straight line forceps.  It should be mentioned that tissue was very thick and polypoid with chronic inflammatory changes evident.  The maxillary sinus ostia was then suctioned with Olive-tip suction and maxillary wash was performed.  The remainder of the anterior ethmoid was then cleaned again removing excess polypoid tissue.  The basal lamella was visualized and the posterior ethmoid air cells were then entered with use of the microdebrider as the surgical assistant palpated the patient's eyes for any vibration.  All polypoid tissue was collected in the microdebrider and sent as a surgical specimen.  Once all polypoid tissue has been removed, the cocaine pledgets were reinserted into the ethmoid air cells for hemostatic purposes.  Attention was then directed to the right nasal cavity.  Again, a sinus endoscope was inserted.  Inspection revealed a grossly hypertrophied turbinate.  It was felt that this enlarged and polypoid turbinate was contributing the patient's symptoms.  Therefore, the turbinate was localized and a hemostat was used to crush the mid portion of the turbinate, which was then resected with use of side-biting scissors as well the Takahashi forceps.  Sinus endoscope was then inserted all the way down through the nasopharynx.  Again, the eustachian tube was visualized without any obstructing lesions or masses.  Upon retraction, there was again polypoid tissue noted within the ethmoid sinuses.  The ball-tip probe was again used to locate the right maxillary ostium.  The side-biting forceps was used further take down the uncinate process.  The maxillary ostium was then widened with use of a XPS microdebrider.  A maxillary sinus wash was then performed.  Now, the attention was directed to the ethmoid air cells.  It should be mentioned again that the tissue of the anterior ethmoid was very thickened and polypoid.  This was again taken down with the use of XPS microdebrider while the surgical assistant carefully palpated the patient's eye.,Once all polypoid tissue have been removed, some bleeding that was encountered was controlled with the use of suction cautery in a very conservative manner.  Once all bleeding has been controlled, all surgical instruments were removed and Merocel packing was placed in the bilateral nasal cavities with the intent to remove in the recovery room.  At this point, the procedure was felt to be complete.  The patient was awakened and taken to the recovery room without incident.",37
"PREOPERATIVE DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,FINAL DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,4.  Acute and chronic adenoiditis.,OPERATIONS PERFORMED,1.  Bilateral myringotomies.,2.  Placement of ventilating tubes.,3.  Nasal endoscopy.,4.  Adenoidectomy.,DESCRIPTION OF OPERATIONS: , The patient was brought to the operating room, endotracheal intubation carried out by Dr. X. Both sides of the patient's nose were then sprayed with Afrin.  Ears were inspected then with the operating microscope.  The anterior inferior quadrant myringotomy incisions were performed.  Then, a modest amount of serous and a trace of mucoid material encountered that was evacuated.  The middle ear mucosa looked remarkably clean.  Armstrong tubes were inserted.  Ciprodex drops were instilled.  Ciprodex will be planned for two postoperative days as well.  Nasal endoscopy was carried out, and evidence of acute purulent adenoiditis was evident in spite of the fact that clinically the patient has shown some modest improvement following cessation of all milk products.  The adenoids were shaved back, flushed with curette through a traditional transoral route with thick purulent material emanating from the crypts, and representative cultures were taken.  Additional adenoid tissue was shaved backwards with the RADenoid shaver.  Electrocautery was used to establish hemostasis, and repeat nasal endoscopy accomplished.  The patient still had residual evidence of inter choanal adenoid tissue, and video photos were taken.  That remaining material was resected, guided by the nasal endoscope using the RADenoid shaver to remove the material and flush with the posterior nasopharynx.  Electrocautery again used to establish hemostasis.  Bleeding was trivial.  Extensive irrigation accomplished.  No additional bleeding was evident.  The patient was awakened, extubated, taken to the recovery room in a stable condition.  Discharge anticipated later in the day on Augmentin 400 mg twice daily, Lortab or Tylenol p.r.n. for pain.  Office recheck would be anticipated if stable and doing well in approximately two weeks.  Parents were instructed to call, however, regarding the outcome of the culture on Monday next week to ensure adequate antibiotic coverage before cessation of the antibiotic.",37
"HISTORY OF PRESENT ILLNESS:  ,The patient is a 38-year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration.  The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip.  The pain is located laterally as well as anteriorly into the groin.  She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip.  She is here for evaluation for the first time.  She sought no previous medical attention for this.,PAST MEDICAL HISTORY:  ,Significant for depression and reflux disease.,PAST SURGICAL HISTORY: , Cesarean section x 2.,CURRENT MEDICATIONS: , Listed in the chart and reviewed with the patient.,ALLERGIES:  ,The patient has no known drug allergies.,SOCIAL HISTORY:  ,The patient is married.  She is employed as an office manager.  She does smoke cigarettes, one pack per day for the last 20 years.  She consumes alcohol 3 to 5 drinks daily.  She uses no illicit drugs.  She exercises monthly mainly walking and low impact aerobics.  She also likes to play softball.,REVIEW OF SYSTEMS: , Significant for occasional indigestion and nausea as well as anxiety and depression.  The remainder of the systems negative.,PHYSICAL EXAMINATION: , The patient is 5 foot, 2 inches tall, weighs 155 pounds.  The patient ambulates independently without an assist device with normal stance and gait.  Inspection of the hips reveals normal contour and appearance and good symmetry.  The patient is able to do an active straight leg raise against gravity and against resistance bilaterally.  She has no significant trochanteric tenderness.  She does, however, have some tenderness in the groin bilaterally.  There is no crepitus present with passive or active range of motion of the hips.  She is grossly neurologically intact in the bilateral lower extremities.,DIAGNOSTIC DATA:,  X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip.  There are no acute findings.  No fractures or dislocations.  There are minimal degenerative changes noted in the joint.  There is, however, the suggestion of an exostosis on the superior femoral neck, which could be consistent with femoroacetabular impingement.,IMPRESSION: , Bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on x-rays and her clinical picture is also consistent with possible labral tear.,PLAN:,  After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip.  We will get that done as soon as possible.  In the meantime, she is asked to moderate her activities.  She will follow up as soon as the MRIs are performed.",27
"Thereafter, he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated.  On December 5, 2008, Mr. XXXX did undergo a total knee replacement arthroplasty performed by Dr. X.,Thereafter, he did an extensive course of physical therapy, work hardening, and a work conditioning type program.,At the present time, he does complain of significant pain and swelling as related to the right knee.  He is unable to crawl and/or kneel.  He does state he is able to walk a city block and in fact, he is able to do 20 minutes of a treadmill.  Stairs are a significant problem.  His pain is a 5 to 6 on a scale of 1 to 10.,He is better when he is resting, sitting, propped up, and utilizing his ice.  He is much worse when he is doing any type of physical activity.,He has denied having any previous history of similar problems.,CURRENT MEDICATIONS:  ,Over-the-counter pain medication.,ALLERGIES: , NKA.,SURGERIES: , Numerous surgeries as related to the right lower extremity.,SOCIAL HISTORY: , He does admit to one half pack of cigarette consumption per day.  He denies any alcohol consumption.,PHYSICAL EXAMINATION:  ,On examination today, he is 28-year-old male who is 6 feet 1, weighs 250 pounds.  He does not appear to be in distress at this time.  One could appreciate 1-2/4 intraarticular effusion.  The range of motion is 0 to a 110 degrees of flexion.  I could not appreciate any evidence of instability medial, lateral, anterior or posterior.  Crepitus is noted with regards to range of motion testing.  His strength is 4 to 5 as related to the quadriceps and hamstring.,There is atrophy as related to the right thigh.  The patient is able to stand from a seated position and sit from a standing position without difficulty.,RECORDS REVIEW:,1.  First report of injury.,2.  July 17, 2002, x-rays of the right knee were negative.,3.  Notes of the Medina General Hospital Occupational Health, Steven Rodgers, M.D.,4.  August 5, 2002, an MRI scan of the right knee which demonstrated peripheral tear of the posterior horn of the medial",18
"HISTORY OF PRESENT COMPLAINT: ,Ms. Abc initially visited our office for the purpose of consultation and examination on December 1, 2004. Ms. Abc states that on November 16, 2004, she was in a parking lot, she was walking to her car, and stepped into a pothole. The patient reports that she fell backwards. The patient landed on her back and hit her head as well. The patient reports sudden, severe left ankle pain and low back pain as well as neck pain in the back of her head. The patient was unable to get up due to severe pain. The patient was afraid that she broke her left ankle. The patient eventually got up and went to her car. The patient went home and symptoms got worse. A few days later, the patient went to the hospital on November 21, 2004. The patient had x-rays of the lumbar spine, left ankle, and left foot. The patient was seen at Healthcare System. She was next seen by Rapid Rehabilitation on December 1, 2004.,",4
"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,POSTOPERATIVE DIAGNOSIS:,  Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,PROCEDURE PERFORMED:,1.  Injection for myelogram.,2.  Microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left on 08/28/03.,BLOOD LOSS: , Approximately 25 cc.,ANESTHESIA: , General.,POSITION:,  Prone on the Jackson table.,INTRAOPERATIVE FINDINGS:,  Extruded nucleus pulposus at the level of L5-S1.,HISTORY: , This is a 34-year-old male with history of back pain with radiation into the left leg in the S1 nerve root distribution.  The patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity.  He denied any previous history of back pain or back surgeries.  Because of his intractable pain as well as severe weakness in the S1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on.  After an informed consent was obtained, all risks as well as complications were discussed with the patient.  ,PROCEDURE DETAIL:  ,He was wheeled back to Operating Room #5 at ABCD General Hospital on 08/28/03.  After a general anesthetic was administered, a Foley catheter was inserted.,The patient was then turned prone on the Jackson table.  All of his bony prominences were well-padded.  At this time, a myelogram was then performed.  After the lumbar spine was prepped, a #20 gauge needle was then used to perform a myelogram.  The needle was localized to the level of L3-L4 region.  Once inserted into the thecal sac, we immediately got cerebrospinal fluid through the spinal needle.  At this time, approximately 10 cc of Conray injected into the thecal sac.  The patient was then placed in the reversed Trendelenburg position in order to assist with distal migration of the contrast.  The myelogram did reveal that there was some space occupying lesion, most likely disc at the level of L5-S1 on the left.  There was a lack of space filling defect on the left evident on both the AP and the lateral projections using C-arm fluoroscopy.  At this point, the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy.  A long spinal needle was then inserted into region of surgery on the right.  The surgery was going to be on the left.  Once the spinal needle was inserted, a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the L5-S1 nerve root region.  At this time, an approximately 2 cm skin incision was made over the lumbar region, dissected down to the deep lumbar fascia.  At this time, a Weitlaner was inserted.  Bovie cautery was used to obtain hemostasis.  We further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina.  A Cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left-hand side.  At this time, a Taylor retractor was then inserted and held there for retraction.  Suction as well as Bovie cautery was used to obtain hemostasis.  At this time, a small Kerrison Rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression.  Once the laminotomy was performed, a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots.  Once the ligamentum flavum was removed, we immediately identified a piece of disc material floating around outside of the disc space over the S1 nerve root, which was compressive.  We removed the extruded disc with further freeing up of the S1 nerve root.  A nerve root retractor was then placed.  Identification of disc space was then performed.  A #15 blade was then inserted and small a key hole into the disc space was then performed with a #15 blade.  A small pituitary was then inserted within the disc space and more disc material was freed and removed.  The part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc.  Once this was performed, we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free.,At this time, copious irrigation was used to irrigate the wound.  We then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur.  At this time, a small piece of Gelfoam was then used to cover the exposed nerve root.  We did not have any dural leaks during this case.  #1-0 Vicryl was then used to approximate the deep lumbar fascia, #2-0 Vicryl was used to approximate the superficial lumbar fascia, and #4-0 running Vicryl for the subcutaneous skin.  Sterile dressings were then applied.  The patient was then carefully slipped over into the supine position, extubated and transferred to Recovery in stable condition.  At this time, we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level.",23
"REVIEW OF SYSTEMS,There was no weight loss, fevers, chills, sweats.  There is no blurring of the vision, itching, throat or neck pain, or neck fullness.  There is no vertigo or hoarseness or painful swallowing.  There is no chest pain, shortness of breath, paroxysmal nocturnal dyspnea, or chest pain with exertion.  There is no shortness of breath and no cough or hemoptysis.  No melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation or blood in the stools.  No dysuria, hematuria or excessive urination.  No muscle weakness or tenderness.  No new numbness or tingling.  No arthralgias or arthritis.  There are no rashes.  No excessive fatigability, loss of motor skills or sensation.  No changes in hair texture, change in skin color, excessive or decreased appetite.  No swollen lymph nodes or night sweats.  No headaches.  The rest of the review of systems is negative.",5
"ASSESSMENT:  ,The patient needed reintubation due to a leaking tube.  I explained to the patient the procedure that I was going to do and he nodded in seeming understanding of the procedure.,Using Versed and succinylcholine, we were able to sedate and paralyze him to perform the procedure.  His potassium this morning was normal.  Using an 8.5 ET tube under direct visualization, the tube was passed through the cords.  The patient tolerated the procedure extremely well.  Auscultation of the lungs revealed bilateral equal breath sounds.  Chest x-ray is pending.  CO2 monitor was positive.",37
"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.",33
"COMPREHENSIVE MENTAL STATUS EVALUATION,REASON FOR REFERRAL/GENERAL OBSERVATIONS:,  The patient was referred for a Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability.  He is a 43-year-old married, white male who came unaccompanied to the evaluation.  He drove himself suggesting that he drives regularly.  He reportedly has been on Disability since around 2002.  He was a good historian, freely offering information.  He was dressed and groomed casually, yet neat and appropriate in appearance.  He was cooperative with all questions presented and the information collected is felt to be a reliable indication of current functioning.  No censorship of data was indicated.  ,PRESENT PROBLEMS:,  The claimant described his recent problems as, ""serious depression.  Very hard to concentrate.  Very short tempered.  Usually distracted."" ,The claimant reportedly has had significant problems with depression since around 1997.,The claimant last worked about six weeks ago.  He was drafting at a company in Stanfield, North Carolina, for almost six months and was laid off because ""I had a breakdown and ended up in the hospital.  They said that I wasn't reliable enough and laid me off.""  Prior to that he worked for two and a half months doing drafting at another company and was laid off because he was no longer needed.  ,The claimant has had significant emotional problems since around 1997.  He was first hospitalized in that year and has been hospitalized five more times since then.  The last hospitalization was last month in Atlanta, Georgia.  He has tried to overdose in the past as well as cut his wrist.  He even had to undergo electroconvulsive therapy in 2001, because of depression.  He also, supposedly, has a history of sexual assault towards a minor and his on probation for that incident.  Details regarding this episode of child sexual assault were not forthcoming.,The claimant now takes Effexor 75 mg b.i.d.  He is not involved in outpatient therapy.  ,PERSONAL, FAMILY AND SOCIAL HISTORY:,  The claimant indicated that he graduated from high school in regular classes.  He did have to repeat the kindergarten because he was too young.  He worked for about 10 years at a company in Massachusetts.  He was not advancing on that job and therefore quit.  He has had three subsequent jobs and a number of emotional problems since.  He indicated usually getting along with others but stated, ""I had trouble taking direction from someone younger than me.  I resent getting nagged at.  I'd get angry or just seethe.""  He has been let go from his last two jobs because of emotional issues.  ,The claimant was married the first time for five years.  He has no children.  He now lives at home with his wife., ,The claimant denied any legal problems.  He suggested that his mother had bipolar disorder.  He has never served in the military.,The claimant denied the use or abuse of tobacco, alcohol or illicit drugs.  He stopped drinking in 1997.  Prior to that he drank about a six pack of beer per day for about 15 years.,The claimant takes the no other prescribed medications., ,DAILY ACTIVITIES AND FUNCTIONING:,  The claimant described his typical day as follows, ""I usually get up about 7:00 to 7:30.  Have breakfast.  Take a shower about 8:30.  Do errands.  Me and my wife are out of the house by 9:00.  Check e-mail at the library.  I like the computer.  We have lunch 11:30 or 12:00.  Do errands or watch talk shows or I'll read.  I love to read.  Around 5:00 to 5:30, have supper.  Watch the news, game shows.  In bed by 10:00.""  He will help with vacuuming, doing the dishes or yard work.  His wife does most of the house cleaning.  He does no cooking.  He and his wife get out every day usually for three or four hours.  He has a neighbor next door that he will see twice a week.  He used to go to the gym but has not been in a few weeks.  No other family contact was described and he does not go to church.  When asked what he enjoys he stated, ""read, use my computer or go ride my bike."", ,MENTAL STATUS EVALUATION:,  On interview, the claimant looked his stated age of 43 years.  He was tall in stature and thin in weight.  He was neat and clean in appearance.  Posture was somewhat tense but psychomotor activity was not remarkable.  Eye contact was fleeting with fair social skills evident.  Facial expression was tense and affect was restricted with little animation noted.  General mood appeared dysphoric.  Speech was clear, coherent, logical, goal-directed and relevant.  He was cooperative in attitude toward the examiner.  He described his recent mood as, ""cloudy, gray because we've got a lot of personal problems right now.  I'm frustrated because I don't know where things are going.""  He described some problems with falling asleep and staying asleep at night as well as decreased energy level.  He denied appetite disturbance.  He has lost interest in some activities suggesting mild anhedonia.  He has trouble with attention and concentration stating, ""I have trouble recalling how to do things on the computer. I've always been technically minded, but now it's harder.""  He has thoughts of suicide about once or twice a week and has often fled situations in the past.  He stated, ""I try to keep myself from running away.""  He denied any plan or intent for suicide.  He suggested significant anxiety problems as well.  He stated, ""I'm dealing with pedophilia.  I try to time it so that I don't go to a store with lots of people around.  If there is people I get real edgy, heart pounds, shortness of breath.  A lot of chest discomfort.""  He has these panic symptoms quite regularly and they have occurred ever since 1997.  That was the time that he engaged in some type of sexual assault with a minor and spent about a week in jail.  No phobic processes were suggested.  No psychotic symptoms were revealed.  He denied hallucinations and no delusional material was elicited.  Thought content was appropriate to mood and circumstances.,The claimant was oriented in all spheres.  He evidenced adequate memory for both recent and remote events.  He was able to recall 3 of 3 words after a 1 minute and 10 minute delay.  Fair sustained attention and concentration skills were shown.  He was able to spell a word backward and performed a serial 7 subtraction task affectively.  Basic calculation skills were intact and no language-based dysfunction was noted.  Social judgment was also intact as he gave a good response to finding a wallet in the street, ""find who the owner was, bring it to the police station or contact the person,"" and to seeing smoke in a theater, ""Get a hold of staff so they could evacuate.""  Adequate conceptual abilities was shown with similarity comparisons.  Somewhat limited abstraction was shown with proverb interpretation, glass houses, ""don't do anything you're not supposed to do.""  Premorbid intellect is estimated to be at least in the average range.  Insight regarding his situation was fair.,DIAGNOSTIC IMPRESSION:,Axis I:  Major Depression, recurrent, moderate.  Panic disorder without agoraphobia.,SUMMARY AND CONCLUSIONS:,  Based on this evaluation, I believe the claimant's current condition would continue to result in difficulty with work-related activities.  He continues to show significant problems with depression and anxiety.  He is quite withdrawn and socially isolated and has panic attacks whenever he is confronted with public situations.  He relies on his wife to take care of most all household task.  He engages in very few simple, routine and repetitive activities. Cognitive capacity was relatively intact suggesting no significant problems in maintaining focus and pace with task.,RECOMMENDATIONS/CAPABILITY:,  The claimant was strongly encouraged to get some additional help for his emotional problems.  He would benefit from having someone to speak with on a regular basis and some referrals were offered. ,It is the opinion of this examiner that the claimant is capable of handling his own funds if so assigned.",32
"PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.  Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management.  He is now taken back to the operative room for delayed primary chest closure.,PREOP DX: , Open chest status post modified stage 1 Norwood operation.,POSTOP DX:,  Open chest status post modified stage 1 Norwood operation.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,FINDINGS:,  No evidence of intramediastinal purulence or hematoma.  He tolerated the procedure well.,DETAILS OF PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position.  Following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion.  The previously placed AlloDerm membrane was removed.  Mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned.  Both cavities were also irrigated and suctioned.  The drains were flushed and repositioned.  Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line.  The sternum was then smeared with a vancomycin paste.  The proximal aspect of the 5 mm RV-PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side.  The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches.  The skin was closed with interrupted nylon sutures and a sterile dressing was placed.  The peritoneal dialysis catheter, atrial and ventricular pacing wires were removed.  The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.",37
"CHIEF COMPLAINT:,  Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions).  One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake.  His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion.  He sleeps well, but has been more tired and has been fussy over the past 2 days.  The parents noticed no improvement with albuterol treatments given in the ER.  His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours.  Mom denies any diarrhea.  His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne.  The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count.  This tap was reported as clear, then turning bloody in nature.  The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture.  This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status.  Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness.  Mom's nipples are currently cracked and bleeding.  Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area.  He is status post a circumcision.  Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section.  Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family).  GBS status was negative.  Mom smoked up to the last 5 months of the pregnancy.  Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions.  Mom and baby were both discharged out of the hospital last 48 hours.  This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:,  Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  Tylenol.,IMMUNIZATIONS:,  None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:,  At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother.  Both brothers at home are sick with cold symptoms including diarrhea and vomiting.  The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription.  A nephew of the mom with an ear infection.  Mom also states that she herself was sick with the flu soon after delivery.  There has been recent travel exposure to dad's family over the Christmas holidays.  At this time, there is also exposure to indoor cats and dogs.  This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker.  There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION:  ,VITALS:  Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air.  Weight was 4.1 kg.,GENERAL:  Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT:  Normocephalic, atraumatic head.  Anterior fontanelle was soft, open, and flat.  Bilateral red reflexes were positive.  Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR:  Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature.  Capillary refill was less than 3 seconds.,LUNGS:  Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN:  Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly.  Umbilical site was with scant dried yellow discharge.,GU:  Tanner stage 1 male, circumcised.  There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS:  Negative Barlow or Ortolani maneuvers.,SKIN:  Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes.  The hemoglobin was 14.4, hematocrit was 40.  The platelet count was elevated at 698,000.  A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89.  A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1.  Rule out sepsis.,2.  Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever.  The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria.  We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER.  Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV.  The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use.  Also, there is negative apnea in this patient.,PLAN:  ,1.  We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2.  We will follow up with his blood, urine, and CSF cultures.",15
"PREOPERATIVE DIAGNOSES:,1.  Need for intravenous access.,2.  Status post fall.,3.  Status post incision and drainage of left lower extremity.,POSTOPERATIVE DIAGNOSES:,1.  Need for intravenous access.,2.  Status post fall.,3.  Status post incision and drainage of left lower extremity.,PROCEDURE PERFORMED: , Insertion of right subclavian central venous catheter.,SECOND ANESTHESIA: , Approximately 10 cc of 1% lidocaine.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE:  ,The patient is a 74-year-old white female who presents to ABCD General Hospital after falling down flight of eleven stairs and sustained numerous injuries.  The patient went to OR today for an I&D of left lower extremity degloving injury.  Orthopedics was planning on taking the patient back for serial debridements and need for reliable IV access is requested.,PROCEDURE: , Informed consent was obtained by the patient and her daughter.  All risks and benefits of the procedure were explained and all questions were answered.  The patient was prepped and draped in the normal sterile fashion.  After landmarks were identified, approximately 5 cc of 1% lidocaine were injected into the skin and subcuticular tissues and the right neck posterior head of the sternocleidomastoid.  Locator needle was used to correctly cannulate the right internal jugular vein.  Multiple attempts were made and the right internal jugular vein was unable to be cannulized.,Therefore, we prepared for a right subclavian approach.  The angle of the clavicle was found and a #22 gauge needle was used to anesthetize approximately 5 cc of 1% lidocaine in skin and subcuticular tissues along with the periosteum of the clavicle.  A Cook catheter needle was then placed and ________ the clavicle in the orientation aimed toward the sternal notch.  The right subclavian vein was then accessed.  A guidewire was placed with a Cook needle and then the needle was subsequently removed and a #11 blade scalpel was used to nick the skin.  A dilator sheath was placed over the guidewire and subsequently removed.  The triple lumen catheter was then placed over the guidewire and advanced to 14 cm.  All ports aspirated and flushed.  Good blood return was noted and all ports were flushed well.  The triple lumen catheter was then secured at 14 cm using #0 silk suture.  A sterile dressing was then applied.  A stat portable chest x-ray was ordered to check line placement.  The patient tolerated the procedure well and there were no complications.",37
"ASH SPLIT VENOUS PORT,PROCEDURE DETAILS:  ,The patient was taken to the operating room and placed in supine position and monitored anesthesia care provided by the anesthetist.  The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.  Xylocaine 1% was infiltrated in the supraclavicular area and anterior chest along the planned course of the catheter.  The patient was placed into Trendelenburg position.,The right internal jugular vein was accessed by a supraclavicular 19-gauge, thin-walled needle as demonstrated by easy withdrawal of venous blood on the first pass of the needle.  Under fluoroscopic control, a J-wire was advanced into the right atrium.  The needle was removed and the skin puncture site enlarged to about 8 mm with the scalpel.  A second incision was made 5 cm inferior to the right midclavicular line, through which an Ash split catheter was advanced, using the tunneling rod, in a gently curving pass to exit the skin of the neck incision.  The tunneling needle was removed and the catheter split up to the marker as indicated in the recommended use of the catheter.,Sequential dilators were advanced over the J-wire under fluoroscopic control to dilate the subcutaneous tunnel followed by advancement of a dilator and sheath into the right superior vena cava under fluoroscopic control.  The dilator and wire were removed, leaving the sheath in position, through which a double-lumen catheter was advanced into the central venous system.  The sheath was peeled away, leaving the catheter into position.  Each port of the catheter was flushed with dilute heparinized saline.,The patient was returned to the flat position.  The catheter was secured to the skin of the anterior chest using 2-0 Ethilon suture placed through the suture ""wings."",The neck incision was closed with 3-0 Vicryl subcuticular closure and pressure dressing applied.  Fluoroscopic examination of the chest revealed no evidence of pneumothorax upon completion of the procedure and the catheter was in excellent position.,The patient was returned to the recovery room for postoperative care.",3
"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.",27
"TITLE OF OPERATION:  ,Total thyroidectomy for goiter.,INDICATION FOR SURGERY:  ,This is a 41-year-old woman who notes that compressive thyroid goiter and symptoms related to such who wishes to undergo surgery.  Risks, benefits, alternatives of the procedures were discussed in great detail with the patient.  Risks include but were not limited to anesthesia, bleeding, infection, injury to nerve, vocal fold paralysis, hoarseness, low calcium, need for calcium supplementation, tumor recurrence, need for additional treatment, need for thyroid medication, cosmetic deformity, and other.  The patient understood all these issues and they wished to proceed.,PREOP DIAGNOSIS: , Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,POSTOP DIAGNOSIS: , Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,ANESTHESIA: , General endotracheal.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine in a operating room table.  After establishing general anesthesia via oral endotracheal intubation with a 6 Nerve Integrity monitoring system endotracheal tube.  The eyes were then tacked with Tegaderm.  The Nerve Integrity monitoring system, endotracheal tube was confirmed to be working adequately.  Essentially a 7 cm incision was employed in the lower skin crease of the neck.  A 1% lidocaine with 1:100,000 epinephrine were given.  Shoulder roll was applied.  The patient prepped and draped in a sterile fashion.  A 15-blade was used to make the incision.  Subplatysmal flaps were raised to the thyroid notch and sternal respectively.  The strap muscles were separated in the midline.  As we then turned to the left side where the sternohyoid muscle was separated from the sternothyroid muscle there was a very dense and firm thyroid mass on the left side.  The sternothyroid muscle was transected horizontally.  Similar procedure was performed on the right side.,Attention was then turned to identify the trachea in the midline.  Veins in this area and the pretracheal region were ligated with a harmonic scalpel.  Subsequently, attention was turned to dissecting the capsule off of the left thyroid lobe.  Again this was very firm in nature.  The superior thyroid pole was dissected in the superior third artery, vein, and the individual vessels were ligated with a harmonic scalpel.  The inferior and superior parathyroid glands were protected.  Recurrent laryngeal nerve was identified in the tracheoesophageal groove.  This had arborized early as a course underneath the inferior thyroid artery to a very small tiny anterior motor branch.  This was followed superiorly.  The level of cricothyroid membrane upon complete visualization of the entire nerve, Berry's ligament was transected and the nerve protected and then the thyroid gland was dissected over the trachea.  A prominent pyramidal level was also appreciated and dissected as well.,Attention was then turned to the right side.  There was significant amount of thyroid tissue that was very firm.  Multiple nodules were appreciated.  In a similar fashion, the capsule was dissected.  The superior and inferior parathyroid glands protected and preserved.  The superior thyroid artery and vein were individually ligated with the harmonic scalpel and the inferior thyroid artery was then ligated close to the thyroid gland capsule.  Once the recurrent laryngeal nerve was identified again on this side, the nerve had arborized early prior to the coursing underneath the inferior thyroid artery.  The anterior motor branch was then very fine, almost filamentous and stimulated at 0.5 milliamps, completely dissected toward the cricothyroid membrane with complete visualization.  A small amount of tissue was left at the Berry's ligament as the remainder of thyroid level was dissected over the trachea.  The entire thyroid specimen was then removed, marked with a stitch upon the superior pole.  The wound was copiously irrigated, Valsalva maneuver was given, bleeding points controlled.  The parathyroid glands appeared to be viable.  Both the anterior motor branches that were tiny were stimulated at 5 milliamps and confirmed to be working with the Nerve Integrity monitoring system.,Attention was then turned to burying the Surgicel on the wound bed on both sides.  The strap muscles were reapproximated in the midline using a 3-0 Vicryl suture of the sternothyroid horizontal transection and the strap muscles in the midline were then reapproximated.  The 1/8th inch Hemovac drain was placed and secured with a 3-0 nylon.  The incision was then closed with interrupted 3-0 Vicryl and Indermil for the skin.  The patient has a history of keloid formation and approximately 1 cubic centimeter of 40 mg per cubic centimeter Kenalog was injected into the incisional line using a tuberculin syringe and 25-gauge needle.  The patient tolerated the procedure well, was extubated in the operating room table, and sent to postanesthesia care unit in a good condition.  Upon completion of the case, fiberoptic laryngoscopy revealed intact bilateral true vocal fold mobility.",37
"TITLE OF OPERATION: , Austin bunionectomy with internal screw fixation, first metatarsal, left foot.,PREOPERATIVE DIAGNOSIS:,  Bunion deformity, left foot.,POSTOPERATIVE DIAGNOSIS: , Bunion deformity, left foot.,ANESTHESIA: , Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS: , 45 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS:,  Less than 10 mL.,MATERIALS USED: , 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, as well as a 16-mm and an 18-mm partially threaded cannulated screw from the OsteoMed Screw Fixation System.,DESCRIPTION OF THE PROCEDURE:,  The patient was brought to the operating room and placed on the operating table in a supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites.  The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg.  The left foot was then prepped, scrubbed, and draped in normal sterile technique.  The left ankle tourniquet was inflated.  Attention was then directed on the dorsomedial aspect of the first left metatarsophalangeal joint where a 6-cm linear incision was placed directly over the first left metatarsophalangeal joint parallel and medial to the course of the extensor hallucis longus tendon to the left great toe.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first left metatarsophalangeal joint.  All the tendinous neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal and capsular attachments were mobilized from the head of the first left metatarsal.  The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx of the left great toe and transversally resected from its insertion.  A lateral capsulotomy was also performed at the level of the first left metatarsophalangeal joint.  The dorsomedial prominence of the first left metatarsal head was adequately exposed using sharp dissection and resected with the use of a sagittal saw.  The same saw was used to perform an Austin-type bunionectomy on the capital aspect of the first left metatarsal head with its apex distal and its base proximal on the shaft of the first left metatarsal.  The dorsal arm of the osteotomy was longer than the plantar arm in order to accommodate for the future internal fixation.  The capital fragment of the first left metatarsal was then transposed laterally and impacted on the shaft of the first left metatarsal.  Provisional fixation was achieved with two smooth wires that were inserted vertically to the dorsal osteotomy in a dorsal distal to plantar proximal direction.  The same wires were also used as guide wires for the insertion of a 16-mm and an 18-mm partially threaded screws from the 3.0 OsteoMed System upon insertion of the screws, which was accomplished using AO technique.  The wires were removed.  Fixation on the table was found to be excellent.  Reduction of the bunion deformity was also found to be excellent and position of the first left metatarsophalangeal joint was anatomical.  The remaining bony prominence from the shaft of the first left metatarsal was then resected with a sagittal saw.  The area was copiously flushed with saline.  The periosteal and capsular tissues were approximated with 2-0 and 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues.  The incision site was reinforced with Steri-Strips.  At this time, the patient's left ankle tourniquet was deflated.  The time was 45 minutes.  Immediate hyperemia was noted to the entire right lower extremity upon deflation of the cuff.  The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and an Ace bandage.  The patient's left foot was then placed in a surgical shoe.  The patient was then transferred to the recovered room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels.  The patient was given pain medication and instructions on how to control her postoperative course.  The patient was discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X in one week's time for her first postoperative appointment.",27
"TITLE OF OPERATION:,  Mediastinal exploration and delayed primary chest closure.,INDICATION FOR SURGERY:,  The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification.  The patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass.  The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago.  She did not meet the criteria for delayed primary chest closure.,PREOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,POSTOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS:,  None.,FINDINGS: , No evidence of intramediastinal purulence or hematoma.  At completion of the procedure no major changes in hemodynamic performance.,DETAILS OF THE PROCEDURE: , After obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position.  Following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed.  The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed.  The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned.  Through a separate incision and another 15-French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV-PA connection as well as inferior most aspect of the ventriculotomy.  The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires.  The subcutaneous tissue and skin were closed in layers.  There was no evidence of significant increase in central venous pressure or desaturation.  The patient tolerated the procedure well.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition.,I was the surgical attending present in the operating room in charge of the surgical  procedure throughout the entire length of the case.",37
"HISTORY:  ,This 15-day-old female presents to Children's Hospital and transferred from Hospital Emergency Department for further evaluation.  Information is obtained in discussion with the mother and the grandmother in review of previous medical records.  This patient had the onset on the day of presentation of a jelly-like red-brown stool started on Tuesday morning.  Then, the patient was noted to vomit after feeds.  The patient was evaluated at Hospital with further evaluation with laboratory data showing a white blood cell count elevated at 22.2; hemoglobin 14.1; sodium 138; potassium 7.2, possibly hemolyzed; chloride 107; CO2 23; BUN 17; creatinine 1.2; and glucose of 50, which was repeated and found to be stable in that range.  The patient underwent a barium enema, which was read by the radiologist as negative.  The patient was transferred to Children's Hospital for further evaluation after being given doses of ampicillin, cefotaxime, and Rocephin.,PAST MEDICAL HISTORY: , Further, the patient was born in Hospital.  Birth weight was 6 pounds 4 ounces.  There was maternal hypertension.  Mother denies group B strep or herpes.  Otherwise, no past medical history.,IMMUNIZATIONS: , None today.,MEDICATIONS: , Thrush medicine identified as nystatin.,ALLERGIES: , Denied.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY:  ,Here with mother and grandmother, lives at home.  There is no smoking at home.,FAMILY HISTORY: , None noted exposures.,REVIEW OF SYSTEMS:  ,The patient is fed Enfamil, bottle-fed.  Has had decreased feeding, has had vomiting, has had diarrhea, otherwise negative on the 10 plus systems reviewed.,PHYSICAL EXAMINATION:,VITAL SIGNS/GENERAL:  On physical examination, the initial temperature 97.5, pulse 140, respirations 48 on this 2 kg 15-day-old female who is small, well-developed female, age appropriate.,HEENT: Head is atraumatic and normocephalic with a soft and flat anterior fontanelle.  Pupils are equal, round, and reactive to light.  Grossly conjugate.  Bilateral red reflex appreciated bilaterally.  Clear TMs, nose, and oropharynx.  There is a kind of abundant thrush and white patches on the tongue.,NECK:  Supple, full, painless, and nontender range of motion.,CHEST:  Clear to auscultation, equal, and stable.,HEART:  Regular without rubs or murmurs, and femoral pulses are appreciated bilaterally.,ABDOMEN:  Soft and nontender.  No hepatosplenomegaly or masses.,GENITALIA:  Female genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions, or rash.,EXTREMITIES:  Moves all extremities, and nontender.  No deformity.,NEUROLOGICALLY:  Eyes open, moves all extremities, grossly age appropriate.,MEDICAL DECISION MAKING: , The differential entertained on this patient includes upper respiratory infection, gastroenteritis, urinary tract infection, dehydration, acidosis, and viral syndrome.  The patient is evaluated in the emergency department laboratory data, which shows a white blood cell count of 13.1, hemoglobin 14.0, platelets 267,000, 7 stabs, 68 segs, 15 lymphs, and 9 monos.  Serum electrolytes not normal.  Sodium 138, potassium 5.0, chloride 107, CO2 acidotic at 18, glucose normal at 88, and BUN markedly elevated at 22 as is the creatinine of 1.4.  AST and ALT were elevated as well at 412 and 180 respectively.  A cath urinalysis showing no signs of infection.  Spinal fluid evaluation, please see procedure note below.  White count 0, red count 2060.  Gram stain negative.,PROCEDURE NOTE: , After discussion of the risks, benefits, and indications, and obtaining informed consent with the family and their agreement to proceed, this patient was placed in the left lateral position and using aseptic Betadine preparation, sterile draping, and sterile technique pursued throughout, this patient's L4- L5 interspace was anesthetized with the 1% lidocaine solution following the above sterile preparation, entered with a 22-gauge styletted spinal needle of approximately 0.5 mL clear CSF, they were very slow to obtain.  The fluid was obtained, the needle was removed, and sterile bandage was placed.  The fluid was sent to laboratory for further evaluation (aunt and grandmother) were present throughout the period of time during this procedure and the procedure was tolerated well.  An i-STAT initially obtained showed somewhat of an acidosis with a base excess of -12.  A repeat i-STAT after a bolus of normal saline and a second bolus of normal saline, her maintenance rate of D5 half showed a base excess of -11, which is slowly improving, but not very fast.  Based on the above having this patient consulted to the Hospitalist Service at 2326 hours of request, this patient was consulted to PICU with the plan that the patient need to have continued IV fluids.  Showing signs of dehydration, a third bolus of normal saline was provided, twice maintenance D5 half was continued.  The patient was admitted to the Hospitalist Service for continued IV fluids.  The patient maintains to have clear lungs, has been feeding well here in the department, took virtually a whole small bottle of the appropriate formula.  She has not had any vomiting, is burping.  The patient is admitted for continued close observation and rehydration due to the working diagnoses of gastroenteritis, metabolic acidosis, and dehydration.  Critical care time on this patient is less than 30 minutes, exclusive, otherwise time has been spent evaluating this patient according to this patient's care and admission to the Hospitalist Service.",5
"HISTORY OF PRESENT ILLNESS:,  The patient has a known case of marginal B-cell lymphoma for which he underwent splenectomy two years ago.  The patient, last year, developed a diffuse large B-cell lymphoma which was treated with CHOP/reduction.  The patient again went into complete remission.  The patient has been doing well until recently, few days ago, late last week, when he developed swelling of the left testicle.  The patient states he has been having fever and chills for the last few days.  The patient felt weak and felt unwell.  The patient with these complaints came to the emergency room.  The patient has been having fever and chills and the patient states that the pain in the left testicle is rather severe.  No history of trauma to the testicle.,PAST MEDICAL HISTORY:,1.  Status post splenectomy.,2.  History of marginal B-cell lymphoma.,3.  History of diffuse large cell lymphoma.,ALLERGIES: , None.,PERSONAL HISTORY: , Used to smoke and drink alcohol but at present does not.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS:,HEENT:  Has slight headache.,CARDIOVASCULAR:  No history of hypertension, MI, etc.,RESPIRATORY:  No history of cough, asthma, TB, shortness of breath.,GI:  Unremarkable.,GU:  As above, has developed painful swelling of the left testicle over the last few days.,ENDOCRINE:  Known case of type II diabetes mellitus.,PHYSICAL EXAMINATION:,HEENT:  No conjunctival pallor or icterus.,NECK:  No adenopathy.  No carotid bruits.,LUNGS:  Clear.,HEART:  No gallop or murmur.,ABDOMEN:",16
"HISTORY OF PRESENT ILLNESS:,  This 57-year-old black female was seen in my office on Month DD, YYYY for further evaluation and management of hypertension.  Patient has severe backache secondary to disc herniation.  Patient has seen an orthopedic doctor and is scheduled for surgery.  Patient also came to my office for surgical clearance.  Patient had cardiac cath approximately four years ago, which was essentially normal.  Patient is documented to have morbid obesity and obstructive sleep apnea syndrome.  Patient does not use a CPAP mask.  Her exercise tolerance is eight to ten feet for shortness of breath.  Patient also has two-pillow orthopnea.  She has intermittent pedal edema.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Blood pressure is 135/70.  Respirations 18 per minute.  Heart rate 70 beats per minute.  Weight 258 pounds.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good. ,NECK:  Supple.  JVP is flat.  Carotid upstroke is good. ,LUNGS:  Clear. ,CARDIOVASCULAR:  There is no murmur or gallop heard over the precordium. ,ABDOMEN:  Soft.  There is no hepatosplenomegaly. ,EXTREMITIES:  The patient has no pedal edema.  ,MEDICATIONS:  ,1.  BuSpar 50 mg daily.,2.  Diovan 320/12.5 daily.,3.  Lotrel 10/20 daily.,4.  Zetia 10 mg daily.,5.  Ambien 10 mg at bedtime.,6.  Fosamax 70 mg weekly.,DIAGNOSES:,1.  Controlled hypertension.,2.  Morbid obesity.,3.  Osteoarthritis.,4.  Obstructive sleep apnea syndrome.,5.  Normal coronary arteriogram.,6.  Severe backache.,PLAN:,1.  Echocardiogram, stress test.,2  Routine blood tests.,3.  Sleep apnea study.,4.  Patient will be seen again in my office in two weeks.",3
"Chief Complaint:, Confusion and hallucinations.,History of Present Illness:, The patient was a 27-year-old Hispanic man who presented to St. Luke's Episcopal Hospital with a five day history of confusion and hallucinations. The patient was doing well until three months prior to admission when he developed wheezing and shortness of breath upon exertion. He was seen by his primary care physician and was prescribed Salmeterol and Fluticasone nasal inhaler for presumed asthma. His wheezing improved with treatment.,Over the five days prior to admission, his family noticed the patient's increasing confusion and bizarre behavior. The patient was intermittently unable to recognize his family members or surroundings. He was restless and anxious, paced the floor at night, and complained of insomnia. He stated he was unable to sleep because he feared his family was trying to hurt him. When he did sleep, he described night terrors. He also complained of both auditory and visual hallucinations. He stated the voices ""told him to do good things"". He denied any previous history of depression or manic episodes. The patient denied suicidal or homicidal ideation. He admitted he had recently lost weight although he was unable to quantify how much. He stated his appetite was good, but he had not been eating for fear of being poisoned.,The patient denied having headaches or a history of trauma. He denied fevers or chills but he complained of recent night sweats. He denied nausea, vomiting, diarrhea, or dysuria. He denied chest pain, palpitations, or episodic flushing; but he complained of lightheadedness. He denied orthopnea or paroxysmal nocturnal dyspnea. The shortness of breath symptoms had resolved.,Past Medical History:, None. No history of hypertension or of cardiac, renal, lung, or liver disease.,Past Surgical History:, None,Past Psychological History: None,Social History:, The patient was from Brazil. He moved to the United States one year ago. He denied any history of tobacco, alcohol, or illicit drug use. He was married and monogamous. He worked as an engineer/manager, and stated that his job was ""very stressful"". He had recently been admitted to an MBA program. The patient denied recent travel or exposures of any kind.,Family History:, The patient had a second-degree relative with a history of depression and ""nervous breakdown"".,Allergies:, There were no known drug allergies.,Medications:, Prescribed medications were Salmeterol inhaler, prn; and Fluticasone nasal inhaler. The patient was taking no over the counter or alternative medicines.,Physical Examination:, The patient was a 27-year-old Hispanic man who presented with symptoms of confusion and hallucinations. He was a thin man but appeared to be well developed and well nourished. The patient paced the room during the examination. He appeared anxious and distracted. He was coherent, yet he had poor concentration and was unable to cooperate fully with the examination. The patient had a pulse rate of 110 beats per minute and blood pressure of 186/101 mm Hg when reclining; and a pulse rate of 122 beats per minute and blood pressure of 166/92 mm Hg when standing. His oral temperature was 100.8 degrees Fahrenheit, and his respiratory rate was 12 breaths per minute.,HEENT: Conjunctivae were pink; sclerae anicteric; mucous membranes moist and pink without lesions.,NECK: The neck was supple, normal jugular venous pressure, no carotid bruits, no thyromegaly.,LUNGS: The lungs were clear to auscultation bilaterally; no wheezes, rales or rhonchi.,HEART: The heart had a regular rhythm, tachycardic, II/VI systolic ejection murmur LUSB, no rubs or gallops, PMI nondisplaced, hyperdynamic precordium.,ABDOMEN: The abdomen was soft, nontender and nondistended; normoactive bowel sounds, no hepatosplenomegaly, no masses; positive bruit heard throughout mid-abdomen, positive bilateral femoral bruits.,EXTREMITIES: No clubbing, cyanosis, or edema; 2+ pulses.,GENITOURINARY: Normal male phallus, no testicular masses.,RECTAL: Guaiac negative, no masses.,LYMPH NODES: Negative in the anterior and posterior clavicular, supraclavicular, axillary, and inguinal regions.,SKIN: Acneiform eruption over back and trunk, no papules or vesicles.,NEUROLOGICAL EXAMINATION: The patient was alert and oriented to self and year, but not to month or place. He had difficulty with mathematics and following commands (when asked to stand on his heels, the patient stood on his toes and turned on the television). Cranial nerves II-XII intact, motor 5/5 throughout all extremities; reflexes 2+ and symmetrical throughout. Sensory: Intact to light touch, vibration, proprioception, and temperature. Cerebellar: intact finger to nose, no ataxia. Romberg negative.,PSYCHOLOGICAL EXAMINATION: The patient's mood was elevated and euphoric; affect was appropriate; his speech was normal in rate, volume, and tone.,Hospital Course:, The patient was admitted to St. Luke's Episcopal Hospital and a workup for his altered mental status was begun. The following studies were performed:,Twelve-lead EKG: sinus tachycardia.,CXR (PA/lat): normal cardiac silhouette and normal lung fields.,CT scan of head without contrast: ventricles were normal in size and position. There was no evidence of mass or hemorrhage.,Lumbar puncture: clear, colorless; WBC--0; RBC--56; protein--45; glucose--126; VDRL--negative; cryptococcal Ag--negative; cultures--negative.,MRI with gadolinium: no discrete areas of abnormal signal intensity.,EEG: no focal or epileptiform activity.,The patient was treated with haldol and risperidone for his agitation, and further diagnostic testing was performed.",15
"PREOPERATIVE DIAGNOSIS: , Left testicular torsion.,POSTOPERATIVE DIAGNOSES:  ,1.  Left testicular torsion.,2.  Left testicular abscess.,3.  Necrotic testes.,SURGERY:,  Left orchiectomy, scrotal exploration, right orchidopexy.,DRAINS:,  Penrose drain on the left hemiscrotum.,The patient was given vancomycin, Zosyn, and Levaquin preop.,BRIEF HISTORY:  ,The patient is a 49-year-old male who came into the emergency room with 2-week history of left testicular pain, scrotal swelling, elevated white count of 39,000.  The patient had significant scrotal swelling and pain.  Ultrasound revealed necrotic testicle.  Options such as watchful waiting and removal of the testicle were discussed.  Due to elevated white count, the patient was told that he must have the testicle removed due to the infection and possible early signs of urosepsis.  The risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, scrotal issues, other complications were discussed.  The patient was told about the morbidity and mortality of the procedure and wanted to proceed.,PROCEDURE IN DETAIL: , The patient was brought to the OR.  Anesthesia was applied.  The patient was prepped and draped in usual sterile fashion.  A midline scrotal incision was made.  There was very, very thick scrotal skin.  There was no necrotic skin.  As soon as the left hemiscrotum was entered, significant amount of pus poured out of the left hemiscrotum.  The testicle was completely filled with pus and had completely disintegrated with pus.  The pus just poured out of the left testicle.  The left testicle was completely removed.  Debridement was done of the scrotal wall to remove any necrotic tissue.  Over 2 L of antibiotic irrigation solution was used to irrigate the left hemiscrotum.  There was good tissue left after all the irrigation and debridement.  A Penrose drain was placed in the bottom of the left hemiscrotum.  I worried about the patient may have torsed and then the testicle became necrotic, so the plan was to pex the right testicle, plus the right side also appeared very abnormal.  So, the right hemiscrotum was opened.  The testicle had significant amount of swelling and scrotal wall was very thick.  The testicle appeared normal.  There was no pus coming out of the right hemiscrotum.  At this time, a decision was made to place 4-0 Prolene nonabsorbable stitches in 3 different quadrants to prevent it from torsion.  The hemiscrotum was closed using 2-0 Vicryl in interrupted stitches and the skin was closed using 2-0 PDS in horizontal mattress.  There was very minimal pus left behind and the skin was very healthy.  Decision was made to close it to help the patient heal better in the long run.  The patient was brought to the recovery in stable condition.",37
"PREOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,POSTOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,PROCEDURE PERFORMED:,1.  Evacuation of epidural hematoma.,2.  Insertion of epidural drain.,ANESTHESIA: , General.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,200 cc.,HISTORY:  ,This is a 64-year-old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction.  She was then transferred to Beaumont Hospital, at which point, she developed a sternal abscess.  The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren, Michigan at which point, she developed a second what was termed minor myocardial infarction.,The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later, brings us to the month of August, at which time she was at home ambulating with a walker or a cane, and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI, which showed record signal change.  The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery, but objectively there was not much improvement.  Approximately 10 days after the surgery, brings us to today's date, the health officer was notified of the patient's labored breathing.  When she examined the patient, she also noted that the patient was unable to move her extremities.  She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic.  I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma.  On clinical examination, there was swelling in the posterior aspect of the neck.  The patient has no active movement in the upper and lower extremity muscle groups.  Reflexes are absent in the upper and lower extremities.  Long track signs are absent.  Sensory level is at the C4 dermatome.  Rectal tone is absent.  I discussed the findings with the patient and also the daughter.  We discussed the possibility of this is permanent quadriplegia, but at this time, the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery.  They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery.,OPERATIVE PROCEDURE:  ,The patient was taken to OR #1 at ABCD General Hospital on a gurney.  Department of Anesthesia administered fiberoptic intubation and general anesthetic.  A Foley catheter was placed in the bladder.  The patient was log rolled in a prone position on the Jackson table.  Bony prominences were well padded.  The patient's head was placed in the prone view anesthesia head holder.  At this point, the wound was examined closely and there was hematoma at the caudal pole of the wound.  Next, the patient was prepped and draped in the usual sterile fashion.  The previous skin incision was reopened.  At this point, hematoma properly exits from the wound.  All sutures were removed and the epidural spaces were encountered at this time.  The self-retaining retractors were placed in the depth of the wound.  Consolidated hematoma was now removed from the wound.  Next, the epidural space was encountered.  There was no additional hematoma in the epidural space or on the thecal sac.  A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac.  The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well.  Next, the wound was irrigated copiously with one liter of saline using a syringe.  The walls of the wound were explored.  There was no active bleeding.  Retractors were removed at this time and even without pressure on the musculature, there was no active bleeding.  A #19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space.  Fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissue with #3-0 Vicryl sutures.  Steri-Strips covered the incision and dressing was then applied over the incision.  The patient was then log rolled in the supine position on the hospital gurney.  She remained intubated for airway precautions and transferred to the recovery room in stable condition.  Once in the recovery room, she was alert.  She was following simple commands and using her head to nod, but she did not have any active movement of her upper or lower extremities.  Prognosis for this patient is guarded.",37
"PREOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,POSTOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,OPERATION:,  Open reduction, nasal fracture with nasal septoplasty.,ANESTHESIA: , General.,HISTORY: , This 16-year-old male fractured his nose playing basketball.  He has a left nasal obstruction and depressed left nasal bone.,DESCRIPTION OF PROCEDURE: , The patient was given general endotracheal anesthesia and monitored with pulse oximetry, EKG, and CO2 monitors.,The face was prepped with Betadine soap and solution and draped in a sterile fashion.  Nasal mucosa was decongested using Afrin pledgets as well as 1% Xylocaine, 1:100,000 epinephrine was injected into bilateral nasal septal mucoperichondrium and the nasal dorsum, lateral osteotomy sites.,Inspection revealed caudal portion of the cartilaginous septum lying crosswise across the nasal spine area and columella causing obstruction of the left nasal valve.  Further up, the cartilaginous septum was displaced to the left of the maxillary crest.  There was a large maxillary crest and supramaxillary crest had a large spur with the vomer bone touching the inferior turbinate.,There was a large deep groove horizontally on the right side corresponding to the left maxillary crest.,A left hemitransfixion incision was made.  Mucoperichondrium was elevated from left side of the cartilaginous septum and mucoperiosteum was elevated from the ethmoid plate.  Vomer and inferior tunnel was created at the floor of the left side of the nose to connect the anterior and inferior tunnels, which was rather difficult at the area of the vomerine spur, which was very sharp and touching the inferior turbinate.,The caudal cartilaginous septum, which was lying crosswise, was separated from the main cartilage leaving approximately 1 cm strut.  The right side mucoperichondrium was released from the cartilaginous septum as well as ethmoid plate and the maxillary crest area.,The caudal cartilaginous strut was sutured to the columella with interrupted #4-0 chromic catgut suture to bring it into the midline.,Further back, the cartilaginous septum anterior to the ethmoid plate was deviated to the left side, so it was freed from the maxillary crest, nasal dorsum, from the ethmoid plate, and was sutured in the midline with a transfixion #4-0 plain catgut sutures.,Further posteriorly, the ethmoid plate was deviated to the left side and portion of it was removed with Jansen-Middleton punch forceps.,The main deviation was also caused by the vomerine crest and the maxillary crest and supramaxillary cartilaginous cartilage.,This area was freed from the perichondrium on both sides.  The maxillary crest was removed with a gouge.  Vomer was partially removed with a gouge and the rest of the vomer was displaced back into the midline.,Thus, the deviated septum was corrected.  Left hemitransfixion incisions were closed with interrupted #4-0 chromic catgut sutures.  The septum was also filtered with #4-0 plain catgut sutures.,By valve, septal splints were tied to the septum bilaterally with a transfixion #5-0 nylon suture.,Next, the nasal bone suture deviated to the left side were corrected.  The right nasal bone was depressed and left nasal bone was wide.  Therefore, the nasal bones were refractured back into the midline by compressing the left nasal bone and elevating the right nasal bone with the nasal bone elevator through the nasal cavities.  The left intercartilaginous incision was made and the nasal bones were disimpacted subperiosteally and they were molded back into the midline.,Steri-Strips were applied to the nasal dorsal skin and a Denver type of splint was applied to the nasal dorsal to stabilize the nasal bones.,Nasal cavities were packed with Telfa gauze rolled on both sides with bacitracin ointment.  Approximate blood loss was 10 to 20 mL.",37
"PREOPERATIVE DIAGNOSIS:,  Metastatic glossal carcinoma, needing chemotherapy and a port.,POSTOPERATIVE DIAGNOSIS: , Metastatic glossal carcinoma, needing chemotherapy and a port.,PROCEDURES,1.  Open exploration of the left subclavian/axillary vein.,2.  Insertion of a double lumen port through the left femoral vein, radiological guidance.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was electively taken to the operating room, where he underwent a general anesthetic through his tracheostomy.  The left deltopectoral and cervical areas were prepped and draped in the usual fashion.  Local anesthetic was infiltrated in the area.  There was some evidence that surgical procedure had happened in the area nearby and also there was collateral venous circulation under the skin, which made us suspicious that may be __________, but at any rate I tried to cannulate it subcutaneously and I was unsuccessful.  Therefore, I proceeded to make an incision and was able to isolate the vein, which would look very sclerotic.  I tried to cannulate it, but I could not advance the wire.,At that moment, I decided that there was no way we are going to put a port though that area.  I packed the incision and we prepped and redraped the patient including both groins.  Local anesthetic was infiltrated and then the left femoral vein was percutaneously cannulated without any difficulty.  The introducer was placed and then a wire and then the catheter of the double lumen port, which had been trimmed to position it near the heart.  It was done with radiological guidance.  Again, I was able to position the catheter in the junction of inferior vena cava and right atrium.  The catheter was looked upwards and the double lumen port was inserted subcutaneously towards the iliac area.  The port had been aspirated satisfactorily and irrigated with heparin solution.  The drain incision was closed in layers including subcuticular suture with Monocryl.  Then, we went up to the left shoulder and closed that incision in layers.  Dressings were applied.,The patient tolerated the procedure well and was sent back to recovery room in satisfactory condition.",37
"PREOPERATIVE DIAGNOSES:  ,1.  Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2.  Cervical stenosis with cord compression, C5-C6 (723.0).,POSTOPERATIVE DIAGNOSES:  ,1.  Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2.  Cervical stenosis with cord compression, C5-C6 (723.0), with surgical findings confirmed.,PROCEDURES:  ,1.  Anterior cervical discectomy at C4-C5, C5-C6, and C6-C7 for neural decompression (63075, 63076, 63076).,2.  Anterior interbody fusion at C4-C5, C5-C6, and C6-C7 (22554, 22585, 22585) utilizing Bengal cages times three (22851).,3.  Anterior instrumentation for stabilization by Slim-LOC plate C4, C5, C6, and C7 (22846); with intraoperative x-ray times two.,ANESTHESIA:,  General.,SERVICE: , Neurosurgery.,OPERATION: , The patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner, and then the prevertebral space was encountered and prominent anterior osteophytes were well visualized once longus colli muscle was cauterized along its mesial border, and self-retaining retractors were placed to reveal the anterior osteophytic spaces.  Large osteophytes were excised with a rongeur at C4-5, C5-C6, and C6-C7 revealing a collapsed disc space and a #11 blade was utilized to create an annulotomy at all three interspaces with discectomies being performed with straight disc forceps removing grossly degenerated and very degenerated discs at C4-C5, then at C5-C6, then at C6-C7 sending specimen for permanent section to Pathology in a routine and separate manner.  Residual disc fragments were drilled away as drilling extended into normal cortical and cancellous elements in order to perform a wide decompression all the way posteriorly to the spinal canal itself finally revealing a ligament, which was removed in a similar piecemeal fashion with 1 and 2-mm micro Kerrison rongeurs also utilizing these instruments to remove prominent osteophytes, widely laterally bilaterally at each interspace with one at C4-C5, more right-sided.  The most prominent osteophyte and compression was at C5-C6 followed by C6-C7 and C4-C5 with a complete decompression of the spinal canal allowing the dura to finally bulge into the interspace at all three levels, once the ligaments were proximally removed as well and similarly a sign of a decompressed status.  The nerve roots themselves were inspected with a double ball dissector and found to be equally decompressed.  The wound was irrigated with antibiotic solution and hemostasis was well achieved with pledgets of Gelfoam subsequently irrigated away.  Appropriate size Bengal cages were filled with the patient's own bone elements and countersunk into position, filled along with fusion putty, and once these were quite tightly applied and checked, further stability was added by the placement of a Slim-LOC plate of appropriate size with appropriate size screws, and a post placement x-ray showed well-aligned elements.,The wound was irrigated with antibiotic solution again and inspected, and hemostasis was completely achieved and finally the wound was closed in a routine closure by approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was sterilely dressed, and incorporated a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in a routine fashion.  At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.",27
"TITLE OF OPERATION: , Phacoemulsification with posterior chamber intraocular lens implant in the right eye.,INDICATION FOR SURGERY: , The patient is a 27-year-old male who sustained an open globe injury as a child.  He subsequently developed a retinal detachment in 2005 and now has silicone oil in the anterior chamber of the right eye as well as a dense cataract.  He is undergoing silicone oil removal as well as concurrent cataract extraction with lens implant in the right eye.,PREOP DIAGNOSIS:,1.  History of open globe to the right eye.,2.  History of retinal detachment status post repair in the right eye.,3.  Silicone oil in anterior chamber.,4.  Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,POSTOP DIAGNOSIS:,1.  History of open globe to the right eye.,2.  History of retinal detachment status post repair in the right eye.,3.  Silicone oil in anterior chamber.,4.  Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,ANESTHESIA: , General.,PROS DEV IMPLANT: , ABC Laboratories posterior chamber intraocular lens, 21.0 diopters, serial number 123456.,NARRATIVE: , Informed consent was obtained.  All questions were answered.  The patient was brought to preoperative holding area where the operative right eye was marked.  He was brought to the operating room and placed in the supine position.  EKG leads were placed.  General anesthesia was induced by the anesthesia service.  A time-out was called to confirm the procedure and operative eye.  The right operative eye was disinfected and draped in a standard fashion for eye surgery.  A lid speculum was placed.  The vitreoretinal team placed the infusion cannula after performing a peritomy.  At this point in the case, the patient was turned over to the cornea service with Mrs. Jun.  A paracentesis was made at the approximately 3 o'clock position.  Healon was placed into the anterior chamber.  The diamond keratome was used to make a vertical groove incision just inside the limbus at the 108-degree axis.  This incision was then shelved anteriorly and used to enter the anterior chamber.  The Utrata forceps were used to complete a continuous circular capsulorrhexis after incision of the capsule with the cystotome.  Hydrodissection was performed.  The lens nucleus was removed using phacoemulsification and irrigation and aspiration.  Lens cortex also was removed using irrigation and aspiration.  Viscoelastic was placed to inflate the capsular remnant.  The diamond knife was used to enlarge the phaco incision.  Intraocular lens was selected from preoperative calculations, placed in the injector system, and inserted into the capsule without difficulty.  The trailing haptic was placed using the Sheets forceps and the Barraquer sweep to push the IOL optic posteriorly as the trailing haptic was placed.  The anterior cornea wound was sutured along with the paracentesis after irrigation and aspiration was performed to remove remaining viscoelastic from the anterior chamber.  This was done without difficulty.  The anterior chamber was secured and watertight at the end of the procedure.  Intraocular pressure was satisfactory.  The patient tolerated the procedure well and then was turned over to the retina service in good condition.  They will dictate a separate note.",26
"CHIEF COMPLAINT:  ,Severe tonsillitis, palatal cellulitis, and inability to swallow.,HISTORY OF PRESENT ILLNESS: , This patient started having sore throat approximately one week ago; however, yesterday it became much worse.  He was unable to swallow.  He complained to his parent.  He was taken to Med Care and did not get any better, and therefore presented this morning to ER, where seen and evaluated by Dr. X and concerned as whether he had an abscess either pharyngeal, palatal, or peritonsillar.  He was noted to have extreme tonsillitis with kissing tonsils, marked exudates especially right side and right palatal cellulitis.  A CT scan at ER did not show abscess.  He has not had airway compromise, but he has had difficulty swallowing.  He may have had a low-grade fever, but nothing marked at home.  His records from Hospital are reviewed as well as the pediatric notes by Dr. X. He did have some equivalent leukocytosis.  He had a negative monospot and negative strep screen.,PAST MEDICAL HISTORY:  ,The patient takes no medications, has had no illnesses or surgeries and he is generally in good health other than being significantly overweight.  He is a sophomore at High School.,FAMILY HISTORY:  ,Noncontributory to this illness.,SURGERIES: , None.,HABITS: , Nonsmoker, nondrinker.  Denies illicit drug use.,REVIEW OF SYSTEMS:,ENT:  The patient other than having dysphagia, the patient denies other associated ENT symptomatology.,GU:  Denies dysuria.,Orthopedic:  Denies joint pain, difficulty walking, etc.,Neuro:  Denies headache, blurry vision, etc.,Eyes:  Says vision is intact.,Lungs:  Denies shortness of breath, cough, etc.,Skin:  He states he has a rash, which occurred from penicillin that he was given IM yesterday at Covington Med Care.  Mildly itchy.  Mother has penicillin allergy.,Endocrine:  The patient denies any weight loss, weight gain, skin changes, fatigue, etc, essentially no symptoms of hyper or hypothyroidism.,Physical Exam:,General:  This is a morbidly obese white male adolescent, in no acute disease, alert and oriented x 4.  Voice is normal.  He is handling his secretions.  There is no stridor.,Vital Signs:  See vital signs in nurses notes.,Ears:  TM and EACs are normal.  External, normal.,Nose:  Opening clear.  External nose is normal.,Mouth:  Has bilateral marked exudates, tonsillitis, right greater than left.  Uvula is midline.  Tonsils are touching.  There is some redness of the right palatal area, but is not consistent with peritonsillar abscess.  Tongue is normal.  Dentition intact.  No mucosal lesions other than as noted.,Neck:  No thyromegaly, masses, or adenopathy except for some small minimally enlarged high jugular nodes.,Chest:  Clear to auscultation.,Heart:  No murmurs, rubs, or gallops.,Abdomen:  Obese.  Complete exam deferred.,Skin:  Visualized skin dry and intact, except for rash on his inner thighs and upper legs, which is red maculopapular and consistent with possible allergic reaction.,Neuro:  Cranial nerves II through XII are intact.  Eyes, pupils are equal, round, and reactive to light and accommodation, full range.,IMPRESSION: , Marked exudative tonsillitis, non-strep, non-mono, probably mixed anaerobic infection.  No significant prior history of tonsillitis.  Possible rash to PENICILLIN.,RECOMMENDATIONS: , I concur with IV clindamycin and IV Solu-Medrol as per Dr. X. I anticipate this patient may need several days of IV antibiotics and then be able to switch over to oral.  I do not insist that this patient will need surgical intervention since there is no evidence of abscess.  This one episode of severe tonsillitis does not mean the patient needs tonsillectomy, but if he continues to have significant tonsil problems after this he should be referred for ENT evaluation as an outpatient.  The patient's parents in the room had expressed good understanding, have a chance to ask questions.  At this time, I will see the patient back on an as needed basis.",11
"PREOPERATIVE DIAGNOSIS:,  Metastatic glossal carcinoma, needing chemotherapy and a port.,POSTOPERATIVE DIAGNOSIS: , Metastatic glossal carcinoma, needing chemotherapy and a port.,PROCEDURES,1.  Open exploration of the left subclavian/axillary vein.,2.  Insertion of a double lumen port through the left femoral vein, radiological guidance.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was electively taken to the operating room, where he underwent a general anesthetic through his tracheostomy.  The left deltopectoral and cervical areas were prepped and draped in the usual fashion.  Local anesthetic was infiltrated in the area.  There was some evidence that surgical procedure had happened in the area nearby and also there was collateral venous circulation under the skin, which made us suspicious that may be __________, but at any rate I tried to cannulate it subcutaneously and I was unsuccessful.  Therefore, I proceeded to make an incision and was able to isolate the vein, which would look very sclerotic.  I tried to cannulate it, but I could not advance the wire.,At that moment, I decided that there was no way we are going to put a port though that area.  I packed the incision and we prepped and redraped the patient including both groins.  Local anesthetic was infiltrated and then the left femoral vein was percutaneously cannulated without any difficulty.  The introducer was placed and then a wire and then the catheter of the double lumen port, which had been trimmed to position it near the heart.  It was done with radiological guidance.  Again, I was able to position the catheter in the junction of inferior vena cava and right atrium.  The catheter was looked upwards and the double lumen port was inserted subcutaneously towards the iliac area.  The port had been aspirated satisfactorily and irrigated with heparin solution.  The drain incision was closed in layers including subcuticular suture with Monocryl.  Then, we went up to the left shoulder and closed that incision in layers.  Dressings were applied.,The patient tolerated the procedure well and was sent back to recovery room in satisfactory condition.",3
"DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,Two major problems were identified at the admission of this adolescent:,1.",32
"PREOPERATIVE DIAGNOSIS:  ,Persistent abnormal uterine bleeding after endometrial ablation.,POSTOPERATIVE DIAGNOSIS: , Persistent abnormal uterine bleeding after endometrial ablation.,PROCEDURE PERFORMED: , Total abdominal hysterectomy (TAH) with a right salpingo-oophorectomy.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 250 cc.,FLUIDS:  ,1500 cc of crystalloids.,URINE: , 125 cc of clear urine at the end of the procedure.,FINDINGS: , On exam, under anesthesia, an obese female with an enlarged fibroid uterus freely movable on the pelvis.  Operative findings demonstrated the same with normal appearing tubes bilaterally.  The right ovary contained a right ovarian cyst.  The left ovary appeared to be within normal limits.  The peritoneal surfaces were noted to be within normal limits.  The bowel was also noted to be within normal limits.,INDICATIONS FOR THIS PROCEDURE: , The patient is a 44-year-old female who had an endometrial ablation done in May, which showed submucosal fibroids.  She had history of anemia and has been on iron therapy.  She started having bleeding three weeks ago with intermittent bouts of flooding.,She desired permanent and definitive therapy and therefore it was felt very appropriate to take the patient for a total abdominal hysterectomy.  The uterus, cervix, and right tube and ovary was sent to pathology for review.,PROCEDURE: , After informed consent was obtained, all questions were answered to the patient's satisfaction in layman's term.  She was taken to the operating room where a general anesthesia was obtained without any difficulty.  She was examined under anesthesia with noted findings above.  She was placed in a dorsal supine position and prepped and draped in the usual sterile fashion.  The Pfannenstiel skin incision was made with the first knife and was then carried down to the underlying layer of the fascia.  With the second knife, the fascia was excised in the midline and extended laterally with the Mayo scissors.  The superior aspect of the fascial incision was then tented up with the Ochsner clamps and the underlying rectus muscle was dissected off sharply as well as bluntly.  Attention was then turned to the inferior aspect of the fascial incision, which in a similar fashion was tented up and the underlying rectus muscle was dissected off sharply as well as bluntly.  The rectus muscle was then separated in the midline, the peritoneum was identified, entered bluntly and digitally.  Then the peritoneal incision was then extended superior and inferiorly with excellent visualization of the bladder.  The GYN Balfour was then placed.  A Lahey clamp was placed on the fundus of the uterus to pull the uterus into the operative field and the bowel was packed away with moist laparotomy sponges.  Attention was then turned to the round ligaments bilaterally, which were tented up with Allis clamps and then a hemostat was poked through the avascular portion underneath the round ligament and the #O-tie was passed through and then tied down.  Then the round ligament was transected and suture ligated and noted to be hemostatic.  The round ligaments were then skeletonized to create a window in the broad ligament.  The right infundibulopelvic ligament was isolated through the window created from the round ligaments and then the infundibular ligament on the right was loop tied and then doubly clamped with straight Ochsner clamps and then transected and suture ligated with a #0 Vicryl in a Heaney stitch fashion.  It was noted to be hemostatic.  Attention was then turned to the left side, in which the uterovarian vessel was isolated and then tied with an #O-tie and then doubly clamped with straight Ochsner clamps, transected and suture ligated with a #0 Vicryl in a Heaney stitch fashion and noted to be hemostatic.  The vesicouterine peritoneum was then identified, tented up with Allis clamps, and then the bladder flap was created sharply with a Russian and Metzenbaum scissors.  Then the bladder was deflected off of the underlying cervix with blunt dissection with a moist Ray-Tec sponge down to the level of the cervix.,The uterine vessels were skeletonized bilaterally and then clamped with straight Ochsner clamps and transected and suture ligated and noted to be hemostatic.  In the similar fashion, the broad ligament down to the level of the caudal ligament, the uterosacral ligaments was clamped with curved Ochsner clamps and transected and suture ligated, and noted to be hemostatic.  The second Lahey clamp was then placed on the cervix.  The cervix was tented up and the pubocervical vesical fascia was transected with a long knife and then the vagina was entered with a double pointed scissors poked through well protecting posteriorly with a large malleable.  The cuff was then outlined.  The vaginal cuff was grasped with a Ochsner clamp and then the cervix, uterus, and the right tube and ovary were transected using the Jorgenson scissors.  The cuff outlined with Ochsner clamps.  The cuff was then painted with a Betadine soaked Ray-Tec sponge and the sponge was placed over the vagina.  The vaginal cuff was then closed with a #0 Vicryl in a running locked fashion holding on to the beginning end on the right side as well as incorporating the ipsilateral cardinal ligaments into the cuff angles.  A long Allis was then used to grasp the mid portion of the cuff and a #0 Vicryl figure-of-eight stitch was placed in the mid portion of the cuff and tied down.  At this time, the abdomen was copiously irrigated with warm normal saline and noted to be hemostatic.  The suture that was used to close the cuff was then used to come back through the posterior peritoneum grabbing the uterosacral ligaments and the mid portion of the cuff, and then tied down to bring the cuff close and together.  Then, the right round ligament was pulled into the cuff and tied down with the #0 Vicryl that was used as a figure-of-eight stitch in the middle of the cuff.  The left round ligament was too small to reach the cuff.  The abdomen was then again copiously irrigated with warm normal saline and noted to be hemostatic.  The peritoneum was then re-peritonealized with a #3-0 Vicryl in a running fashion.  The GYN Balfour and all packing sponges were removed from the abdomen.  Then the abdomen was then once again copiously irrigated and the cuff and incision sites were once again reinspected and noted to be hemostatic.  The ______ was placed back into the hollow of the sacrum.  The omentum was then pulled over to top of the bowel and then the peritoneum was then closed with a #3-0 Vicryl in a running fashion and then the fascia was closed with #0 Vicryl in a running fashion.  The skin was closed with staples and dressing applied.  The patient was then examined at the end of the procedure.  The Betadine-soaked sponge was removed from the vagina.  The cuff was noted to be intact without bleeding and the patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2 and she was taken to the recovery in stable condition.  The patient will be followed throughout her hospital stay.",37
"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.",14
"ADMISSION DIAGNOSIS:,1. Respiratory arrest.,2 . End-stage chronic obstructive pulmonary disease.,3. Coronary artery disease.,4. History of hypertension.,DISCHARGE DIAGNOSIS:,1. Status post-respiratory arrest.,2. Chronic obstructive pulmonary disease.,3. Congestive heart failure.,4. History of coronary artery disease.,5. History of hypertension.,SUMMARY:,  The patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be intubated shortly after admission to the emergency room. The patient’s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999. The patient has recently been admitted to the hospital with pneumonia and respiratory failure. The patient has been smoking up until three to four months previously. On the day of admission, the patient had the sudden onset of severe dyspnea and called an ambulance. The patient denied any gradual increase in wheezing, any increase in cough, any increase in chest pain, any increase in sputum prior to the onset of his sudden dyspnea.,ADMISSION PHYSICAL EXAMINATION:,GENERAL: Showed a well-developed, slightly obese man who was in extremis.,NECK: Supple, with no jugular venous distension.,HEART: Showed tachycardia without murmurs or gallops.,PULMONARY: Status showed decreased breath sounds, but no clear-cut rales or wheezes.,EXTREMITIES: Free of edema.,HOSPITAL COURSE:,  The patient was admitted to the Special Care Unit and intubated. He received intravenous antibiotic therapy with Levaquin. He received intravenous diuretic therapy. He received hand-held bronchodilator therapy. The patient also was given intravenous steroid therapy with Solu-Medrol. The patient’s course was one of gradual improvement, and after approximately three days, the patient was extubated. He continued to be quite dyspneic, with wheezes as well as basilar rales. After pulmonary consultation was obtained, the pulmonary consultant felt that the patient’s overall clinical picture suggested that he had a,significant element of congestive heart failure. With this, the patient was placed on increased doses of Lisinopril and Digoxin, with improvement of his respiratory status. On the day of discharge, the patient had minimal basilar rales; his chest also showed minimal expiratory wheezes; he had no edema; his heart rate was regular; his abdomen was soft; and his neck veins were not distended. It was, therefore, felt that the patient was stable for further management on an outpatient basis.,DIAGNOSTIC DATA:,  The patient’s admission laboratory data was notable for his initial blood gas, which showed a pH of 7.02 with a pCO2 of 118 and a pO2 of 103. The patient’s electrocardiogram showed nonspecific ST-T wave changes. The patent’s CBC showed a white count of 24,000, with 56% neutrophils and 3% bands.,DISPOSITION:,  The patient was discharged home.,DISCHARGE INSTRUCTIONS:,  His diet was to be a 2 grams sodium, 1800 calorie ADA diet. His medications were to be Prednisone 20 mg twice per day, Theo-24 400 mg per day, Furosemide 40 mg 1-1/2 tabs p.o. per day; Acetazolamide 250 mg one p.o. per day, Lisinopril 20 mg. one p.o. twice per day, Digoxin 0.125 mg one p.o. q.d., nitroglycerin paste 1 inch h.s., K-Dur 60 mEq p.o. b.i.d. He was also to use a Ventolin inhaler every four hours as needed, and Azmacort four puffs twice per day. He was asked to return for follow-up with Dr. X in one to two weeks. Arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge.",3
"INDICATIONS:,  Previously markedly abnormal dobutamine Myoview stress test and gated scan.,PROCEDURE DONE:,  Resting Myoview perfusion scan and gated myocardial scan.,MYOCARDIAL PERFUSION IMAGING:,  Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32.6 mCi of Tc-99m Myoview.  Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD, YYYY.  The lung heart ratio is 0.34.  There appears to be a moderate size inferoapical perfusion defect of moderate degree.  The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55%.,CONCLUSIONS:,  Study done at rest only revealed findings consistent with an inferior non-transmural scar of moderate size and moderate degree.  The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD, YYYY.  We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed.",3
"PREOPERATIVE DIAGNOSES:,  Empyema of the left chest and consolidation of the left lung.,POSTOPERATIVE DIAGNOSES:,  Empyema of the left chest, consolidation of the left lung, lung abscesses of the left upper lobe and left lower lobe.,OPERATIVE PROCEDURE: , Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.,ANESTHESIA:,  General.,FINDINGS: , The patient has a complex history, which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two CAT scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax.  There was also noted to be some mild infiltrates of the right lung.  The patient had a 30-year history of cigarette smoking.  A chest tube was placed at the other hospital, which produced some brownish fluid that had foul odor, actually what was thought to be a fecal-like odor.  Then an abdominal CT scan was done, which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal CT.  The patient was started on antibiotics and was then taken to the operating room, where there was to be a thoracoscopy performed.  The patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions, but there was bloody mucous in the left main stem bronchus and this was suctioned out.  This was suctioned out with the addition of the use of saline ***** in the bronchus.  Following the bronchoscopy, a double lumen tube was placed, but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day.,The patient was transferred for continued evaluation and treatment.  Today, the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted.  These were suctioned, but it was enough to produce a temporary obstruction of the left mainstem bronchus.  Eventually, the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that.  The chest tube tract, which was about in the sixth or seventh intercostal space, but it was not possible to dissect enough down to get a acceptable visualization through this tract.  A second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity.  Therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout.  Remarkably, the surface of the lower lobe laterally was not completely covered with a fibrotic line, but it was more the line anterior and posterior and more of it over the left upper lobe.  There were many pockets of purulent material, which had a gray-white appearance to it.  There was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe.  The adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time.  There seemed to be an abscess that was about 3 cm in dimension, all the lateral basilar segment of the lower lobe near the area where the chest tube was placed.  Many cultures were taken from several areas.  The most remarkable finding was a large cavity, which was probably about 11 cm in dimension, containing grayish pus and also caseous-like material, it was thought to be perhaps necrotic lung tissue, perhaps a deposit related to tuberculosis in the cavity.,The apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm.,PROCEDURE AND TECHNIQUE:,  With the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner.  The chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract, but then it was necessary to enlarge it slightly in order to get the Thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this.  Therefore, the next incision for Thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved, but it was clear that we would be unable to complete the procedure by thoracoscopy.  Therefore posterolateral thoracotomy incision was made, entering the pleural space and what is probably the sixth intercostal space.  Quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity.  Specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense.  Suture ligatures of Prolene were required.  When the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity, which appeared to be from pulmonary veins and these were sutured with a ""tissue pledget"" of what was probably intercostal nozzle and endothoracic fascia with Prolene sutures.,Also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14-French Foley catheter was passed into the area of the tear and the balloon was inflated, which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the Foley catheter was removed.  The patch was sutured onto the pulmonary artery tear.  A similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity.  Also on the pulmonary artery repair some ***** material was used and also thrombin, Gelfoam and Surgicel.  After reasonably good hemostasis was established pleural cavity was irrigated with saline.  As mentioned, biopsies were taken from multiple sites on the pleura and on the edge and on the lung.  Then two #24 Blake chest tubes were placed, one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk.  One was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex.  These were later connected to water-seal suction at 40 cm of water with negative pressure.,Good hemostasis was observed.  Sponge count was reported as being correct.  Intercostal nerve blocks at probably the fifth, sixth, and seventh intercostal nerves was carried out.  Then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib.  Metallic clip was passed through the rib to facilitate passage of an intracostal suture, but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table, so that pericostal sutures were used with #1 Vicryl.  The chest wall was closed with running #1 Vicryl and then 2-0 Vicryl subcutaneous and staples on the skin.  The chest tubes were connected to water-seal drainage with 40 cm of water negative pressure.  Sterile dressings were applied.  The patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen.  The patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition.",11
"PROCEDURE: , Newborn circumcision.,INDICATIONS: , Parental preference.,ANESTHESIA:,  Dorsal penile nerve block.,DESCRIPTION OF PROCEDURE:,  The baby was prepared and draped in a sterile manner.  Lidocaine 1% 4 mL without epinephrine was instilled into the base of the penis at 2 o'clock and 10 o'clock.  The penile foreskin was removed using a XXX Gomco.  Hemostasis was achieved with minimal blood loss.  There was no sign of infection.  The baby tolerated the procedure well.  Vaseline was applied to the penis, and the baby was diapered by nursing staff.",37
"PREOPERATIVE DIAGNOSIS:,  Right superior parathyroid adenoma.,POSTOPERATIVE DIAGNOSIS:,  Right superior parathyroid adenoma.,PROCEDURE: , Excision of right superior parathyroid adenoma.,ANESTHESIA:,  Local with 1% Xylocaine and anesthesia standby with sedation.,CLINICAL HISTORY:,  This 80-year-old woman has had some mild dementia.  She was begun on Aricept but could not tolerate that because of strange thoughts and hallucinations.  She was found to be hypercalcemic.  Intact PTH was mildly elevated.  A sestamibi parathyroid scan and an ultrasound showed evidence of a right superior parathyroid adenoma.,FINDINGS AND PROCEDURE:,  The patient was placed on the operating table in the supine position.  A time out was taken so that the anesthesia personnel, nursing personnel, surgical team, and patient could confirm the patient's identity, operative site and operative plan.  The electronic medical record was reviewed as was the ultrasound.  The patient was sedated.  A small roll was placed behind the shoulders to moderately hyperextend the neck.  The head was supported in a foam head cradle.  The neck and chest were prepped with chlorhexidine and isolated with sterile drapes.  After infiltration with 1% Xylocaine with epinephrine along the planned incision, a transverse incision was made in the skin crease a couple of centimeters above the clavicular heads and carried down through the skin, subcutaneous tissue, and platysma.  The larger anterior neck veins were divided between 4-0 silk ligatures.  Superior and inferior flaps were developed in the subplatysmal plane using electrocautery and blunt dissection.  The sternohyoid muscles were separated in the midline, and the right sternohyoid muscle was retracted laterally.  The right sternothyroid muscle was divided transversely with the cautery.  The right middle thyroid vein was divided between 4-0 silk ligatures.  The right thyroid lobe was rotated leftward.  Posterior to the mid portion of the left thyroid lobe, a right superior parathyroid adenoma of moderate size was identified.  This was freed up and its pedicle was ligated with small Hemoclips and divided and the gland was removed.  It was sent for weight and frozen section.  It weighed 960 mg and on frozen section was consistent with a parathyroid adenoma.,Prior to the procedure, a peripheral blood sample had been obtained and placed in a purple top tube labeled ""pre-excision.""  It was our intention to monitor intraoperative intact parathyroid hormone 10 minutes after removal of this parathyroid adenoma.  However, we could not obtain 3 cc of blood from either the left foot or the left arm after multiple attempts, and therefore, we decided that the chance of cure of hyperparathyroidism by removal of this parathyroid adenoma was high enough and the improvement in that chance of cure marginal enough that we would terminate the procedure without monitoring PTH.  The neck was irrigated with saline and hemostasis found to be satisfactory.  The sternohyoid muscles were reapproximated with interrupted 4-0 Vicryl.  The platysma was closed with interrupted 4-0 Vicryl, and the skin was closed with subcuticular 5-0 Monocryl and Dermabond.  The patient was awakened and taken to the recovery area in satisfactory condition having tolerated the procedure well.",16
"PROCEDURE PERFORMED: , Carpal tunnel release.,INDICATIONS FOR SURGERY: , Nerve conduction study tests diagnostic of carpal tunnel syndrome.  The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.,PROCEDURE:  ,The patient was brought to the operating room and, following a Bier block to the operative arm, the arm was prepped and draped in the usual manner.,Utilizing an incision that was laid out to extend not more distally than the thumb web space or proximally to a position short of crossing the most prominent base of the palm and in line with the longitudinal base of the thenar eminence in line with the fourth ray, the soft tissue dissection was carried down sharply through the skin and subcutaneous fat to the transverse carpal ligament.  It was identified at its distal edge.  Using a hemostat to probe the carpal tunnel, sharp dissection utilizing scalpel and iris scissors were used to release the carpal tunnel from a distal-to-proximal direction in its entirety.  The canal was probed with a small finger to verify no evidence of any bone prominences.  The nerve was examined for any irregularity.  There was slight hyperemia of the nerve and a slight hourglass deformity.  Following an irrigation, the skin was approximated using interrupted simple and horizontal mattress #5 nylon suture.  A sterile dressing was applied.,The patient was taken to the recovery room in satisfactory condition.,The time of the Bier block was 30 minutes.,COMPLICATIONS: , None noted.",27
"SUBJECTIVE: , This patient presents to the office today because he has not been feeling well.  He was in for a complete physical on 05/02/2008.  According to the chart, the patient gives a history of feeling bad for about two weeks.  At first he thought it was stress and anxiety and then he became worried it was something else.  He says he is having a lot of palpitations.  He gets a fluttering feeling in his chest.  He has been very tired over two weeks as well.  His job has been really getting to him.  He has been feeling nervous and anxious.  It seems like when he is feeling stressed he has more palpitations, sometimes they cause chest pain.  These symptoms are not triggered by exertion.  He had similar symptoms about 9 or 10 years ago.  At that time he went through a full workup.  Everything ended up being negative and they gave him something that he took for his nerves and he says that helped.  Unfortunately, he does not remember what it was.  Also over the last three days he has had some intestinal problems.  He has had some intermittent nausea and his stools have been loose.  He has been having some really funny green color to his bowel movements.  There has been no blood in the stool.  He is not having any abdominal pain, just some nausea.  He does not have much of an appetite.  He is a nonsmoker.,OBJECTIVE: , His weight today is 168.4 pounds, blood pressure 142/76, temperature 97.7, pulse 68, and respirations 16.  General exam:  The patient is nontoxic and in no acute distress.  There is no labored breathing.  Psychiatric:  He is alert and oriented times 3.  Ears:  Tympanic membranes pearly gray bilaterally.  Mouth:  No erythema, ulcers, vesicles, or exudate noted.  Eyes:  Pupils equal, round, and reactive to light bilaterally.  Neck is supple.  No lymphadenopathy.  Lungs:  Clear to auscultation.  No rales, rhonchi, or wheezing.  Cardiac:  Regular rate and rhythm without murmur.  Extremities:  No edema, cyanosis, or clubbing.,ASSESSMENT:  ,1.  Palpitations, possibly related to anxiety.,2.  Fatigue.,3.  Loose stools with some green color and also some nausea.  There has been no vomiting, possibly a touch of gastroenteritis going on here.,PLAN: , The patient admits he has been putting this off now for about two weeks.  He says his work is definitely contributing to some of his symptoms and he feels stressed.  He is leaving for a vacation very soon.  Unfortunately, he is actually leaving Wednesday for XYZ, which puts us into a bit of a bind in terms of doing testing on him.  My overall opinion is he has some anxiety related issues and he may also have a touch of gastroenteritis.  A 12-lead EKG was performed on him in the office today.  This EKG was compared with the previous EKG contained in the chart from 2006 and I see that these EKGs look very similar with no significant changes noted, which is definitely a good news.  I am going to send him to the lab from our office to get the following tests done:  Comprehensive metabolic profile, CBC, urinalysis with reflex to culture and we will also get a chest X-ray.  Tomorrow morning I will manage to schedule him for an exercise stress test at Bad Axe Hospital.  We were able to squeeze him in.  His appointment is at 8:15 in the morning.  He is going to have the stress test done in the morning and he will come back to the office in the afternoon for recheck.  I am not going to be here so he is going to see Dr. X.  Dr. X should hopefully be able to call over and speak with the physician who attended the stress test and get a preliminary result before he leaves for XYZ.  Certainly, if something comes up we may need to postpone his trip.  We petitioned his medical records from his former physician and with luck we will be able to find out what medication he was on about nine or ten years ago.  In the meantime I have given him Ativan 0.5 mg one tablet two to three times a day as needed for anxiety.  I talked about Ativan, how it works.  I talked about the side effects.  I told him to use it only as needed and we can see how he is doing tomorrow when he comes back for his recheck.  I took him off of work today and tomorrow so he could rest.",34
"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.",23
"The right eardrum is intact showing a successful tympanoplasty.  I cleaned a little wax from the external meatus.  The right eardrum might be very slightly red but not obviously infected.  The left eardrum (not the surgical ear) has a definite infection with a reddened bulging drum but no perforation or granulation tissue.  Also some wax at the external meatus I cleaned with a Q-tip with peroxide.  The patient has no medical allergies.  Since he recently had a course of Omnicef we chose to put him on Augmentin (I checked and we did not have samples), so I phoned in a two-week course of Augmentin 400 mg chewable twice daily with food at Walgreens.  I looked at this throat which looks clear.  The nose only has a little clear mucinous secretions.  If there is any ear drainage, please use the Floxin drops.  I asked Mom to have the family doctor (or Dad, or me) check the ears again in about two weeks from now to be sure there is no residual infection.  I plan to see the patient again later this spring.",25
"CT HEAD WITHOUT CONTRAST, CT FACIAL BONES WITHOUT CONTRAST, AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD,TECHNIQUE: , Noncontrast axial CT images of the head were obtained without contrast.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection.  The ventricles and cortical sulci are normal in shape and configuration.  The gray/white matter junctions are well preserved.  No calvarial fracture is seen.,IMPRESSION:  ,Negative for acute intracranial disease.,CT FACIAL BONES WITHOUT CONTRAST,TECHNIQUE:  ,Noncontrast axial CT images of the facial bones were obtained with coronal reconstructions.,FINDINGS:,  There is no facial bone fracture.  The maxilla and mandible are intact.  The visualized paranasal sinuses are clear.  The temporomandibular joints are intact.  The nasal bone is intact.  The orbits are intact.  The extra-ocular muscles and orbital nerves are normal.  The orbital globes are normal.,IMPRESSION: , No evidence for a facial bone fracture.,CT CERVICAL SPINE WITHOUT CONTRAST,TECHNIQUE: , Noncontrast axial CT images of the cervical spine were obtained with sagittal and coronal reconstructions.,FINDINGS: , There is a normal lordosis of the cervical spine, no fracture or subluxation is seen.  The vertebral body heights are normal.  The intervertebral disk spaces are well preserved.  The atlanto-dens interval is normal.  No abnormal anterior cervical soft tissue swelling is seen.  There is no spinal compression deformity.,IMPRESSION: , Negative for a facial bone fracture.",21
"TITLE OF OPERATION:,1.  Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.,2.  Weil osteotomy with internal screw fixation, first right metatarsal.,3.  Arthroplasty, second right PIP joint.,PREOPERATIVE DIAGNOSES:,1.  Bunion deformity, right foot.,2.  Dislocated second right metatarsophalangeal joint.,3.  Hammertoe deformity, second right digit.,POSTOPERATIVE DIAGNOSES:,1.  Bunion deformity, right foot.,2.  Dislocated second right metatarsophalangeal joint.,3.  Hammertoe deformity, second right digit.,ANESTHESIA:,  Monitored anesthesia care with 20 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:,  60 minutes, a right ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,PREOPERATIVE INJECTABLES:  ,1 g Ancef IV 30 minutes preoperatively.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as two 16-mm partially treaded cannulated screws of the OsteoMed system, one 18-mm partially treaded cannulated screw of the OsteoMed system of the 3.0 size.  One 10-mm 2.0 partially threaded cannulated screw of the OsteoMed system.,DESCRIPTION OF THE PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in the supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical sites.  The right ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set up at 250 mmHg.  The right foot was then prepped, scrubbed, and draped in a normal sterile technique.  The right ankle tourniquet was then inflated.  Attention was then directed on the dorsomedial aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed parallel and medial to the course of the extensor hallucis longus tendon to the right great toe.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal and capsular tissues were mobilized from the head and neck of the first right metatarsal and the base of the proximal phalanx of the right great toe.  The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx and resected transversely.,A lateral capsulotomy was also performed at the level of the first right metatarsophalangeal joint.  Using sharp and dull dissection, the dorsomedial prominence of the first right metatarsal head was adequately exposed and resected with the use of a sagittal saw.  The same saw was used to perform the Austin osteotomy on the capital aspect of the first right metatarsal with its apex distal and its base proximal.  The dorsal arm of the osteotomy was longer than the plantar arm and noted to accommodate for the future internal fixation.  The capital fragment of the first right metatarsal was then transposed laterally and impacted on the shaft of the first right metatarsal.  Two wires of the OsteoMed system were also used as provisional fixation wires and also as guidewires for the insertion of the future screws.  The wires were inserted dorsal distal to plantar proximal through the dorsal arm of the osteotomy.  The two screws from the 3.0 OsteoMed system were inserted over the wires using AO technique.  One screw measured 16 mm, second screw measured 18 mm in length.  Both 3.0 screws were then evaluated for the fixation of the osteotomy after the wires were removed.  Fixation of the osteotomy was found to be excellent.  The dorsomedial prominence of the first right metatarsal shaft was then resected with the sagittal saw.  To improve the correction of the hallux abductus angle, an Akin osteotomy was also performed on the base of the proximal phalanx of the right great toe with its base medially and its apex laterally.  Upon removal of the base wedge from the base of the proximal phalanx, the osteotomy was reduced with the OsteoMed smooth wire, which was also used as a guidewire for the insertion of a 16-mm partially threaded cannulated screw from the OsteoMed 3.0 system.  Upon insertion of the screw, using AO technique, the wire was removed.  The screw was inserted proximal medial to distal lateral through the osteotomy of the base of the proximal phalanx of the right great toe.  Fixation of the osteotomy was found to be excellent.  Reduction of the bunion deformity was also found to be excellent and position of the first right metatarsophalangeal joint was found to be anatomical.  Range of motion of that joint was uninhibited.  The area was flushed copiously with saline.  Then, 3-0 suture material was used to approximate the periosteum and capsular tissues, 4-0 was used to approximate the subcutaneous tissues, and Steri-Strips were used to reinforce the incision.  Attention was directed over the neck of the second right metatarsal head where a 3-cm linear incision was placed directly over the surgical neck of the second right metatarsal.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped and cauterized.  The incision was deepened through the level of the periosteum over the surgical neck of the second right metatarsal.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the surgical neck of the second right metatarsal was adequately exposed and then Weil-type osteotomy was performed from dorsal distal to plantar proximal through the surgical neck of the second right metatarsal.  The capital fragment was then transposed proximally and impacted on the shaft of the second right metatarsal.,The 2.0 Osteo-Med system was also used to fixate this osteotomy wire from that system was inserted dorsal proximal to plantar distal through the second right metatarsal osteotomy and the wire was used as a guidewire for the insertion of the 10-mm partially threaded 2.0 cannulated screw.  Upon insertion of the screw, using AO technique, the wire was then removed.  Fixation of the osteotomy with 2.0 screw was found to be excellent.  The second right metatarsophalangeal joint was then relocated and the dislocation of that joint was completely reduced.  Range of motion of the second right metatarsophalangeal joint was found to be excellent.  Then, 3-0 Vicryl suture material was used to approximate the periosteal tissues.  Then, 4-0 Vicryl was used to approximate the skin incision.  Attention was then directed at the level of the PIP joint of the second right toe where two semi-elliptical incisions were placed directly over the bony prominence at the level of the second right PIP joint.  The island of skin between the two semi-elliptical incisions was resected in toto.  The dissection was carried down to the level of extensor digitorum longus of the second right toe, which was resected transversely at the level of the PIP joint.  A capsulotomy and a medial and lateral collateral ligament release of the PIP joint of the second right toe was also performed and head of the proximal phalanx of the second right digit was adequately exposed.  Using the double-action bone cutter, the head of the proximal phalanx of the second right toe was then resected.  The area was copiously flushed with saline.  The capsular and periosteal tissues were approximated with 2-0 Vicryl and 3-0 Vicryl suture material was also used to approximate the extensor digitorum longus to the second right toe.  A 5-0 Prolene was used to approximate the skin edges of the two semi-elliptical incisions.  Correction of the hammertoe deformity and relocation of the second right metatarsophalangeal joint were evaluated with the foot loaded and were found to be excellent and anatomical.  At this time, the patient's three incisions were covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's right ankle tourniquet was deflated, time was 60 minutes.  Immediate hyperemia was noted on the entire right lower extremity upon deflation of the cuffs.,The patient's right foot was placed in a surgical shoe and the patient was transferred to the recovery room under the care of anesthesia team with the vital signs stable and the vascular status at appropriate levels.  The patient was given instructions and education on how to continue caring for her right foot surgery.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.",37
"PREOPERATIVE DIAGNOSIS: , Epistaxis and chronic dysphonia.,POSTOPERATIVE DIAGNOSES:,1.  Atrophic dry nasal mucosa.,2.  Epistaxis.,3.  Atrophic laryngeal changes secondary to inhaled steroid use.,PROCEDURE PERFORMED:,1.  Cauterization of epistaxis, left nasal septum.,2.  Fiberoptic nasal laryngoscopy.,ANESTHESIA: , Neo-Synephrine with lidocaine nasal spray.,FINDINGS:,1.  Atrophic dry cracked nasal mucosa.,2.  Atrophic supraglottic and glottic changes likely secondary to inhaled steroids and recent endotracheal tube intubation.,INDICATIONS: , The patient is a 37-year-old African-American female who was admitted to ABCD General Hospital with a left wrist abscess.  The patient was taken to the operating room for incision and drainage.  Postoperatively, the patient was placed on nasal cannula oxygen and developed subsequent epistaxis.  Upon evaluating the patient, the patient complains of epistaxis from the left naris as well as some chronic dysphonia that had become exacerbated after surgery.  The patient does report of having endotracheal tube intubation during anesthesia.  The patient also gives a history of inhaled steroid use for her asthma.,The patient was extubated after surgery without difficulty, but continued to have some difficulty and the Department of Otolaryngology was asked to evaluate the patient regarding epistaxis and dysphonia.,PROCEDURE DETAILS:,  After the procedure was described, the patient was placed in the seated position.  The fiberoptic nasal laryngoscope was then inserted into the patient's left naris.  The nasal mucosal membranes were dry and atrophic throughout.  There was no evidence of any mass lesions.  The nasal laryngoscope was then advanced towards the posterior aspect of the nasal cavity.  There was no evidence of mass, ulceration, lesion, or obstruction.  The nasolaryngoscopy continued to be advanced into the oropharynx and the vallecula and the base of the tongue were evaluated and were without evidence of mass lesion or ulceration.,The fiberoptic scope was further advanced and visualization of the larynx revealed some atrophic, dry, supraglottic, and glottic changes.  There was no evidence of any local mass lesion, nodule, or ulcerations.  There was no evidence of any erythema.  Upon phonation, the vocal cords approximated completely and upon inspiration, the true vocal cords were abducted in a normal fashion and was symmetric.  The airway was stable and patent throughout the entire examination.  The nasal laryngoscope was then slowly withdrawn from the supraglottic region and the scope was further advanced into the oropharynx and nasopharynx.  The eustachian tube was completely visualized and was patent without obstruction.  The scope was then further removed without difficulty.  The patient tolerated the procedure well and remained in stable condition.,RECOMMENDATIONS AND PLAN: , The patient would benefit from Ocean nasal spray as well as bacitracin ointment applied to the anterior naris.  At this time, we were unable to discontinue the patient's inhaled steroids that she is using for her asthma.  If this becomes possible in the future, this may provide her some relief of her chronic dysphonia.  The patient is to follow up with Department of Otolaryngology after discharge from the hospital for further evaluation of these problems.",37
"PREOPERATIVE DIAGNOSES: , Bilateral chronic otitis media,POSTOPERATIVE DIAGNOSES:,  Bilateral chronic otitis media,ANESTHESIA:,  General mask,NAME OF OPERATION:,  Bilateral Myringotomy with placement of PE tubes,PROCEDURE:,  The patient was taken to the operating room and placed in the supine position.  After adequate general inhalation anesthesia was obtained, the operating microscope with brought in for full use throughout the case.  First, the left and then the right tympanic membrane, was approached.  An anterior-inferior radial incision was made in the left tympanic membrane.  Suction revealed a substantial amount of mucopurulent drainage.  A Sheehy pressure equalization tube was placed in the myringotomy site.  Floxin drops were added.  The same procedure was repeated on the right side with similar findings noted of mucopurulent drainage.  The patient tolerated the procedure well and returned to the recovery room awake and in stable condition.",11
"REASON FOR REFERRAL:,  The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney.  He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION: , Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM: , The patient was brought to the Hospital Emergency Department on 09/30/09 after experiencing an episode of confusion for which he has no recall the previous day.  He has no recollection of the event.  The following information is obtained from his medical record.  On 09/29/09, he reportedly went to a five-hour meeting and stated several times ""I do not feel well"" and looked ""glazed.""  He does not remember anything from midmorning until the middle of the night and when his wife came home, she found him in bed at 6 p.m., which is reportedly unusual.  She thought he was warm and had chills.  He later returned to his baseline.  He was seen by Dr. X in the hospital on 09/30/09 and reported to him at that time that he felt that he had returned entirely to baseline.  His neurological exam at that time was unremarkable aside from missing one of three items on recall for the Mini-Mental Status Examination.  Due to mild memory complaints from himself and his wife, he was referred for more extensive neuropsychological testing.  Note that reportedly when his wife found him in bed, he was shaking and feeling nauseated, somewhat clammy and kept saying that he could not remember anything and he was repeating himself, asking the same questions in an agitated way, so she brought him to the emergency room.  The patient had an episode two years ago of transient loss of memory during which he was staring blankly while sitting at his desk at work and the episode lasted approximately two hours.  He was hospitalized at Hospital at that time as well and evaluation included negative EEG, MRI showing mild atrophy, and a neurological consultation, which did not result in a specific diagnosis, but during this episode he was also reportedly nauseous.  He was also reportedly amnestic for this episode.,In 2004, he had a sense of a funny feeling in his neck and electrodes in his head and had an MRI at that time which showed some small vessel changes.,During this interview, the patient reported that other than a coworker noticing a few careless errors in his completion of some documents and his wife reporting some mild memory changes that he had not noticed any significant decline.  He thought that his memory abilities were similar to those of his peers of his same age.  When I asked about this episode, he said he had no recall of it at all and that he ""felt fine the whole time.""  He appeared to be somewhat questioning of the validity of reports that he was amnestic and confused at that time.  So, The patient reported some age related ""memory lapses"" such as going into a room and forgetting why, sometimes putting something down and forgetting where he had put it.  However, he reported that these were entirely within normal expectations and he denied any type of impairment in his ability to continue to work full-time as a tax attorney other than his wife and one coworker, he had not received any feedback from his children or friends of any problems.  He denied any missed appointments, any difficulty scheduling and maintaining appointments.  He does not have to recheck information for errors.  He is able to complete tasks in the same amount of time as he always has.  He reported that he has not made additional errors in tasks that he completed.  He said he does write everything down, but has always done things that way.  He reported that he works in a position that requires a high level of attentiveness and knowledge and that will become obvious very quickly if he was having difficulties or making mistakes.  He did report some age related changes in attention as well, although very mild and he thought these were normal and not more than he would expect for his age.  He remains completely independent in his ADLs.  He denied any difficulty with driving or maintaining any activities that he had always participated in.  He is also able to handle their finances.  He did report significant stress recently particularly in relation to his work environment.,PAST MEDICAL HISTORY:,  Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia.  Note that due to back pain, he had been taking Percocet daily prior to his hospitalization.,CURRENT MEDICATIONS: , Celebrex 200 mg, levothyroxine 0.025 mg, Vytorin 10/40 mg, lisinopril 10 mg, Coreg 10 mg, glucosamine with chondroitin, prostate 2.2, aspirin 81 mg, and laxative stimulant or stool softener.  Note that medical records say that he was supposed to be taking Lipitor 40 mg, but it is not clear if he was doing so and also there was no specific reason found for why he was taking the levothyroxine.,OTHER MEDICAL HISTORY: , Surgical history is significant for hernia repair in 2007 as well.  The patient reported drinking an occasional glass of wine approximately two days of the week.  He quit smoking cigarettes 25 to 30 years ago and he was diagnosed with cancer.  He denied any illicit drug use.  Please add that his prostatectomy was done in 1993 and nephrectomy in 1983 for carcinoma.  He also had right carpal tunnel surgery in 2005 and has cholelithiasis.  Upon discharge from the hospital, the patient's sleep deprived EEG was recommended.,MRI completed on 09/30/09 showed ""mild cerebral and cerebellar atrophy with no significant interval change from a prior study dated June 15, 2007.  No evidence of acute intracranial processes identified.  CT scan was also unremarkable showing only mild cerebral and cerebellar atrophy.  EEG was negative.  Deferential diagnosis was transient global amnesia versus possible seizure disorder.  Note that he also reportedly has some hearing changes, but has not followed up with an evaluation for hearing aid.,FAMILY MEDICAL HISTORY:, Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85.  In addition, his father had a history of heart disease and passed away at the age of 75.  He has one sister with diabetes and thought his mom might have had diabetes as well.,SOCIAL HISTORY:,  The patient obtained a law degree from the University of Baltimore.  He did not complete his undergraduate degree from the University of Maryland because he was able to transfer his credits in order to attend law school at that time.  He reported that he did not obtain very good grades until he reached law school, at which point he graduated in the top 10 of his class and had no problem passing the Bar.  He thought that effort and motivation were important to his success in his school and he had not felt very motivated previously.  He reported that he repeated math classes ""every year of school"" and attended summer school every year due to that.  He has worked as a tax attorney for the past 48 years and reported having a thriving practice with clients all across the country.  He served also in the U.S.  Coast Guard between 1951 and 1953.  He has been married for the past 36 years to his wife, Linda, who is a homemaker.  They have four children and he reported having good relationship with them.  He described being very active.  He goes for dancing four to five times a week, swims daily, plays golf regularly and spends significant amounts of time socializing with friends.,PSYCHIATRIC HISTORY: , The patient denied any history of psychological or psychiatric treatment.  He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",32
"HISTORY OF PRESENT ILLNESS:  ,The patient is a 50-year-old African American female with past medical history significant for hypertension and endstage renal disease, on hemodialysis secondary to endstage renal disease, last hemodialysis was on June 22, 2007.  The patient presents with no complaints for cadaveric renal transplant.  After appropriate cross match and workup of HLA typing of both recipient and cadaveric kidneys, the patient was deemed appropriate for operative intervention and transplantation of kidney.,PREOPERATIVE DIAGNOSIS:,  Endstage renal disease.,POSTOPERATIVE DIAGNOSIS: , Endstage renal disease.,PROCEDURE:,  Cadaveric renal transplant to right pelvis.,ESTIMATED BLOOD LOSS: , 400 mL.,FLUIDS:  ,One liter of normal saline and one liter of 5% of albumin.,ANESTHESIA:  ,General endotracheal.,SPECIMEN:  ,None.,DRAIN: , None.,COMPLICATIONS: , None.,The patient tolerated the procedure without any complication.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room, prepped and draped in sterile fashion.  After adequate anesthesia was achieved, a curvilinear incision was made in the right pelvic fossa approximately 9 cm in length extending from the 1.5 cm medial of the ASIS down to the suprapubic space.  After this was taken down with a #10 blade, electrocautery was used to take down tissue down to the layer of the subcutaneous fat.  Camper's and Scarpa's were dissected with electrocautery.  Hemostasis was achieved throughout the tissue plains with electrocautery.  The external oblique aponeurosis was identified with musculature and was entered with electrocautery.  Then hemostats were entered in and dissection continued down with electrocautery down through the external internal obliques and the transversalis fascia.  Additionally, the rectus sheath was entered in a linear fashion.  After these planes were entered using electrocautery, the retroperitoneum was dissected free from the transversalis fascia using blunt dissection.  After the peritoneum and peritoneal structures were moved medially and superiorly by blunt dissection, the dissection continued down bluntly throughout the tissue planes removing some alveolar tissue over the right iliac artery.  Upon entering through the transversalis fascia, the epigastric vessels were identified and doubly ligated and tied with #0 silk ties.  After the ligation of the epigastric vessels, the peritoneum was bluntly dissected and all peritoneal structures were bluntly dissected to a superior and medial plane.  This was done without any complication and without entering the peritoneum grossly.  The round ligament was identified and doubly ligated at this time with #0 silk ties as well.  The dissection continued down now to layer of the alveolar tissue covering the right iliac artery.  This alveolar tissue was cleared using blunt dissection as well as electrocautery.  After the external iliac artery was identified, it was cleared circumferentially all the way around and noted to have good flow and had good arterial texture.  The right iliac vein was then identified, and this was cleared again using electrocautery and blunt dissection.  After the right iliac vein was identified and cleared off all the alveolar tissue, it was circumferentially cleared as well.  An additional perforating branch was noted at the inferior pole of the right iliac vein.  This was tied with a #0 silk tie and secured.  Hemostasis was achieved at this time and the tie had adequate control.  The dissection continued down and identified all other vital structures in this area.  Careful preservation of all vital structures was carried out throughout the dissection.  At this time, Satinsky clamp was placed over the right iliac vein.  This was then opened using a #11 blade, approximately 1 cm in length.  The heparinized saline was placed and irrigated throughout the inside of the vein, and the kidney was pulled into the abdominal field still covered in its protective socking with the superior pole marked.  The renal vein was then elevated and identified in this area.  A 5-0 double-ended Prolene stitch was used to secure the renal vein, both superiorly and inferiorly, and after appropriately being secured with 5-0 Prolene, these were tied down and secured.  The renal vein was then anastomosed to the right iliac vein in a circumferential manner in a running fashion until secured at both superior and inferior poles.  The dissection then continued down and the iliac artery was then anastomosed to the renal artery at this time using a similar method with 5-0 Prolene securing both superior and inferior poles.  After such time the 5-0 Prolene was run around in a circumferential manner until secured in both superior and inferior poles once again.  After this was done and the artery was secured, the Satinsky clamp was removed and a bulldog placed over.  The flow was then opened on the arterial side and then opened on the venous side to allow for proper flow.  The bulldog was then placed back on the renal vein and allowed for the hyperperfusion of the kidney.  The kidney pinked up nicely and had a good appearance to it and had appearance of good blood flow.  At this time, all Satinsky clamps were removed and all bulldog clamps were removed.  The dissection then continued down to the layer of the bladder at which time the bladder was identified.  Appropriate area on the dome the bladder was identified for entry.  This was entered using electrocautery and approximately 1 cm length after appropriately sizing and incising of the ureter using the Metzenbaum scissors in a linear fashion.  Before this was done, #0 chromic catgut stitches were placed and secured laterally and inferiorly on the dome of the bladder to elevate the area of the bladder and then the bladder was entered using the electrocautery approximately 1 cm in length.  At this time, a renal stent was placed into the ureter and secured superiorly and the stent was then placed into the bladder and secured as well.  Subsequently, the superior and inferior pole stitches with 5-0 Prolene were used to secure the ureter to the bladder.  This was then run mucosa-to-mucosa in a circumferential manner until secured in both superior and inferior poles once again.  Good flow was noted from the ureter at the time of operation.  Additional Vicryl stitches were used to overlay the musculature in a seromuscular stitch over the dome of the bladder and over the ureter itself.  At this time, an Ethibond stitch was used to make an additional seromuscular closure and rolling of the bladder musculature over the dome and over the anastomosis once again.  This was inspected and noted for proper control.  Irrigation of the bladder revealed that the bladder was appropriately filled and there were no flows and no defects.  At this time, the anastomoses were all inspected, hemostasis was achieved and good closure of the anastomosis was noted at this time.  The kidney was then placed back into its new position in the right pelvic fossa, and the area was once again inspected for hemostasis which was achieved.  A 1-0 Prolene stitch was then used for mass closure of the external, internal, and transversalis fascias and musculature in a running fashion from superior to inferior.  This was secured and knots were dumped.  Subsequently, the area was then checked and inspected for hemostasis which was achieved with electrocautery, and the skin was closed with 4-0 running Monocryl.  The patient tolerated procedure well without evidence of complication, transferred to the Dunn ICU where he was noted to be stable.  Dr. A was present and scrubbed through the entire procedure.",37
"REASON FOR ADMISSION:,  Penile injury and continuous bleeding from a penile laceration.,HISTORY OF PRESENT ILLNESS:,  The patient is an 18-year-old detainee who was brought by police officers because of a penile injury and bleeding.  He is otherwise healthy.  He tried to insert a marble in his penis four days ago.  He told me that he grabbed the skin on the top of the penis and moved it away from the penis shaft and then using a toothbrush that he made in to a knife object he pierced the skin through from both sides and then kept moving the toothbrush to dilate and make a way for the marble.  Then he inserted a heart-shaped marble in one of the puncture wounds and inserted it under the skin and kept it there.  He was not significantly bleeding and essentially the bleeding stopped from both puncture wounds that he has.  Then today four days after that procedure, he was taking a bath today and he thinks because of the weight he felt a gush in his pants and he looked and he saw the bleeding come out.  He was bleeding so much that he started dripping to the sides of his legs.  So, he was brought to the hospital.  Actually after being seen by two nurses at the facility where he was at the detention center where he was at and they actually did the dressing twice and it was twice soaked with blood.  He came here and was continuously bleeding from that area that we had to change the dressing twice and he is actually still bleeding especially from one of the laceration, the one on the right side of the penis.  The marble also still can be felt underneath the skin.  There is no urethral bleeding.  He did urinate today without difficulty, without hematuria or dysuria.  There is pain in the lacerations.  No erythema in the skin or swelling in the penis and no other injuries.  He did this procedure for sexual pleasure as he said.,PAST MEDICAL HISTORY: , Unremarkable.,PAST SURGICAL HISTORY:  ,Tonsillectomy.,MEDICATION: , He took only ibuprofen.  No regular medication.,ALLERGIES: , None.,SOCIAL HISTORY:  ,He has been in detention for two months for immigration problems.  No drugs.  No alcohol.  No smoking.  He used to work in fast food chain.,FAMILY HISTORY: , Noncontributory to this illness.,REVIEW OF SYSTEMS: , Aside from the pain in the penis and continuous bleeding, he is basically asymptomatic and review of systems is unremarkable.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a young Hispanic male, lying in bed, appear comfortable in no apparent distress.,VITAL SIGNS:  Temperature 97.8, heart rate 99, respiratory rate 20, blood pressure 142/100, and saturation is 98% on room air.,ENT:  Sclerae nonicteric.  Pupils reactive to light.  Nostrils are normal.  Oral cavity is clear.,NECK:  Supple.  Trachea midline.  No JVD.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Normal S1 and S2.  No murmurs or gallops.,ABDOMEN:  Soft, nontender, and nondistended.  Positive bowel sounds.,EXTREMITIES:  Pulses strong bilaterally.  No edema.,GENITAL:  Testicles appear normal.  The penis shaft has two lacerations on both sides, one of them is bleeding.  They measure about 5 to 6 mm on the right side, about 3 or 4 mm on the left side.  The one on the right side is bleeding much more than the other one.  There is a marble that can be felt and it is freely mobile underneath the skin of the dorsum of the penis.  There is no bleeding from the meatus or discharge and no other injuries were seen by inspection.,LABORATORY DATA:,  White count 11.1, hemoglobin 14.5, hematocrit 43.5, and platelets 303,000.  Coags unremarkable.  Glucose 106, creatinine 0.8, sodium 141, potassium 4, and calcium 9.7.  Urinalysis unremarkable.,IMPRESSION: , The patient with a penile laceration that is continuously bleeding from inserting a marble four days ago, which is still underneath the skin of the shaft of the penis.  No other injuries that can be seen and no other evidence of secondary bacterial infection at this time.  The patient is currently refusing removal of the marble and insisting on just repairing the laceration and he is having discussion with Dr. X.,PLAN:,1.  The patient will be admitted to the hospital and will follow Dr. X's recommendation.,2.  The patient was offered a repair of those lacerations, to stop the bleeding as well as the removal of the marble and he is currently considering that and discussing that with Dr. X.,3.  Prophylactic antibiotics to prevent infection.,4.  He has mild hypertension, which is likely due to stress and pain and also the leukocytosis probably can be explained by that.  This will be monitored.,5.  Monitor H&H to determine if he needs any transfusion at this time.  He does not need that.,6.  IV fluid for hydration and volume resuscitation at this time.,7.  Pain management.,8.  Topical care for the wound VAC after repair.,Time spent in evaluation and management of this patient including discussions about this procedure and the harm that can happen if he chooses to keep the penis including permanent damage and infection to the penis was 65 minutes.,I had clearly explained to the patient in detail about the possibility of permanent penile damage that could affect erection and future sexual functioning as well as significant infection if a foreign object was retained in the penis under the skin and he verbalized understanding of this.",12
"PREOPERATIVE DIAGNOSIS:,  Prior history of polyps.,POSTOPERATIVE DIAGNOSIS:,  Small polyps, no evidence of residual or recurrent polyp in the cecum.,PREMEDICATIONS: , Versed 5 mg, Demerol 100 mg IV.,REPORTED PROCEDURE:,  The rectal chamber revealed no external lesions.  Prostate was normal in size and consistency.,The colonoscope was inserted into the rectal ampulla and advanced under direct vision at all times until the tip of the scope was placed in the cecum.  The position of the scope within the cecum was verified by identification of the ileocecal valve.  Navigation was difficult because it seemed that the cecum took an upward turn at its final turn, but the examination was completed.,The cecum was extensively studied and no lesion was seen.  There was not even a scar representing the prior polyp.  I was able to see the area across from the ileocecal valve exactly where the polyp was two years ago, and I saw no lesion at all.  The scope was then slowly withdrawn.  In the mid transverse colon, was a small submucosal lesion, which appeared to be a lipoma.  It was freely mobile and very small with normal overlying mucosa.  There was a similar lesion in the descending colon.  Both of these appeared to be lipomatous, so no attempt was made to remove them.  There were diverticula present in the sigmoid colon.  In addition, there were two polyps in the sigmoid colon both of which were resected using electrocautery.  There was no bleeding.  The scope was then withdrawn.  The rectum was normal.  When the scope was retroflexed in the rectum, two very small polyps were noted just at the anorectal margin, and so these were obliterated using the electrocautery snare.  There was no specimen and there was no bleeding.  The scope was then straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Small polyps, sigmoid colon, resected them.,2.  Diverticulosis, sigmoid colon.,3.  Small rectal polyps, obliterated them.,4.  Submucosal lesions, consistent with lipomata as described.,5.  No evidence of residual or recurrent neoplasm in the cecum.",37
"TITLE OF OPERATION:,1.  Repair of total anomalous pulmonary venous connection.,2.  Ligation of patent ductus arteriosus.,3.  Repair secundum type atrial septal defect (autologous pericardial patch).,4.  Subtotal thymectomy.,5.  Insertion of peritoneal dialysis catheter.,INDICATION FOR SURGERY: , This neonatal was diagnosed postnatally with total anomalous pulmonary venous connection.  Following initial stabilization, she was transferred to the Hospital for complete correction.,PREOP DIAGNOSIS:  ,1.  Total anomalous pulmonary venous connection.,2.  Atrial septal defect.,3.  Patent ductus arteriosus.,4.  Operative weight less than 4 kilograms (3.2 kilograms).,COMPLICATIONS: , None.,CROSS-CLAMP TIME: , 63 minutes.,CARDIOPULMONARY BYPASS TIME MONITOR:,  35 minutes, profound hypothermic circulatory arrest time (4 plus 19) equals 23 minutes.  Low flow perfusion 32 minutes.,FINDINGS:,  Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left-sided veins.  Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence.  Nonobstructed ascending vein ligated.  Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin.  At completion of the procedure, right ventricular pressure approximating one-half of systemic, normal sinus rhythm, good biventricular function by visual inspection.,PROCEDURE: , After the informed consent, the patient was brought to the operating room and placed on the operating room table in supine position.  Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines.  The patient was prepped and draped in the usual sterile fashion from chin to groins.  A median sternotomy incision was performed.  Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw.  A subtotal thymectomy was performed.  Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle.  A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure.  Pursestrings were deployed on the ascending aorta on the right.  Atrial appendage.  The aorta was then cannulated with an 8-French aorta cannula and the right atrium with an 18-French Polystan right-angle cannula.  With an ACT greater than 400, greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2-0 silk tie.  Systemic cooling was started and the head was packed  and iced and systemic steroids were administered.  During cooling, traction suture was placed in the apex of the left ventricle.  After 25 minutes of cooling, the aorta was cross-clamped and the heart arrested by administration of 30 cubic centimeter/kilogram of cold-blood cardioplegia delivered directly within the aortic root following the aorta cross-clamping.  Following successful cardioplegic arrest, a period of low flow perfusion was started and a 10-French catheter was inserted into the right atrial appendage substituting the 18-French Polystan venous cannula.  The heart was then rotated to the right side and the venous confluence was exposed.  It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed.  The two openings were then anastomosed in an end-to-side fashion with several interlocking sutures to avoid pursestring effect with a running 7-0 PDS suture.  Following completion of the anastomosis, the heart was returned into the chest and the patient's blood volume was drained into the reservoir.  A right atriotomy was then performed during the period of circulatory arrest.  The atrial septal defect was very difficult to expose, but it was sealed with an autologous pericardial patch was secured in place with a running 6-0 Prolene suture.  The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6-0 Prolene sutures.  The venous cannula was reinserted.  Cardiopulmonary bypass restarted and the aorta cross-clamp was released.  The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which, following a prolonged period of rewarming, allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm.  Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15-French Blake drains.  Venous decannulation was followed by aortic decannulation and administration of protamine sulfate.  All cannulation sites were oversewn with 6-0 Prolene sutures and the anastomotic sites noticed to be hemostatic.  With good hemodynamics and hemostasis, the sternum was then smeared with vancomycin, placing closure with stainless steel wires.  The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was transferred in very stable condition to the pediatric intensive care unit .,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.  Given the magnitude of the operation, the unavailability of an appropriate level, cardiac surgical resident, Mrs. X (attending pediatric cardiac surgery at the Hospital) participated during the cross-clamp time of the procedure in quality of first assistant.",29
"PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of the scalp.,POSTOPERATIVE DIAGNOSIS:,  Same.,OPERATION PERFORMED: , Radical resection of tumor of the scalp (CPT 11643).  Excision of tumor from the skull with debridement of the superficial cortex with diamond bur.  Advancement flap closure, with total undermined area 18 centimeters by 16 centimeters (CPT 14300).,ANESTHESIA:,  General endotracheal anesthesia.,INDICATIONS:  ,This is an 81-year-old male who has a large exophytic 7cm lesion of the anterior midline scalp which is biopsy-positive for skin malignancy, specifically, squamous call carcinoma.  This appears to be affixed to the underlying scalp.,PLAN: , Radical resection with frozen sections to clear margins thereafter, with planned reconstruction.,CONSENT:,  I have discussed with the patient the possible risks of bleeding, infection, renal problems, scar formation, injury to muscle, nerves, and possible need for additional surgery with possible recurrence of the patient's carcinoma, with review of detailed informed consent with the patient, who understood, and wished to proceed.,FINDINGS: , The patient had a 7cm large exophytic lesion which appeared to be invasive into the superficial table of the skull.  The final periosteal margin which centrally appeared was positive for carcinoma.  The final margins peripherally were all negative.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was taken to the operating room and there was placed supine on the operating room table.,General endotracheal anesthesia was administered after endotracheal tube intubation was performed by the Anesthesia Service personnel.  The patient was thereafter prepped and draped in the usual sterile manner using Betadine Scrub and Betadine paint.  Thereafter, the local anesthesia was injected into the area around the tumor.  A **** type excision was planned down to the periosteum.  A supraperiosteal radical resection was performed.,It was obvious that there was tumor at the deep margin, involving the periosteum.  The edges were marked along the four quadrants, at the 12 o'clock, 3 o'clock, 6 o'clock, and the 9 o'clock positions, and these were sent for frozen section evaluation.  Frozen section revealed positive margins at one end of the resection.  Therefore, an additional circumferential resection was performed and the final margins were all negative.,Following completion, the deep periosteal margin was resected.  The circumferential periosteal margins were noted to be negative; however, centrally, there was a small area which showed tumor eroding into the superficial cortex of the skull.  Therefore, the Midas Rex drill was utilized to resect approximately 1-2 mm of the superficial cortex of the bone at the area where the positive margin was located.  Healthy bone was obtained; however, it did not enter the diploic or marrow-containing bone in the area.  Therefore, no bong margin was taken.  However, at the end of the procedure, it did not appear that the residual bone had any residual changes consistent with carcinoma.,Following completion of the bony resection, the area was irrigated with copious amounts of saline.  Thereafter, advancement flaps were created, both on the left and the right side of the scalp, with the total undermined area being approximately 18cm by 16cm.  The galea was incised in multiple areas, to provide for additional mobilization of the tissue.  The tissue was closed under tension with 3-0 Vicryl suture deep in the galea and surgical staples superficially.,The patient was awakened from anesthetic, was extubated and was taken to the recovery room in stable condition.,DISPOSITION:,  The patient was discharged to home with antibiotics and analgesics, to follow-up in approximately one week.,NOTE: , The final margins of both periosteal, as well as skin were negative circumferentially, around the tumor.  The only positive margin was deep, which was a periosteal margin and bone underlying it was partially resected, as was indicated above.",37
"PROCEDURE:,  Left heart catheterization, left ventriculography, selective coronary angiography.,INDICATION: , This lady with a previous left internal mammary graft to left anterior descending, saphenous vein graft to obtuse margin branch, saphenous vein graft to the diagonal branch, and saphenous vein graft to the right coronary artery presented with recurrent difficulties with breathing.  This was felt to be related largely to chronic obstructive lung disease.  She had dynamic T-wave changes in precordial leads.  Cardiac enzymes were indeterminate.  She was evaluated by Dr. X and given her previous history and multiple risk factors it was elected to proceed with cardiac catheterization and coronary angiography.,Risks of the procedure including risks of conscious sedation, death, cerebrovascular accident, dye reaction, need for emergency surgery, vascular access injury and/or infection, and risks of cath-based interventions were discussed in detail.  The patient understood and agreed to proceed.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the cardiac catheterization laboratory.  Under Versed and fentanyl sedation, the right groin was sterilely prepped and draped.  Local anesthesia was obtained with 2% Xylocaine.  The right femoral artery was entered using modified Seldinger technique and a 4-French introducer sheath placed in that vessel.  Through the indwelling femoral arterial sheath, a JL4 4-French catheter was advanced over the wire to the ascending aorta, appropriately aspirated and flushed.  Ascending aortic root pressures obtained.  This catheter was utilized in an attempt to cannulate the left coronary ostium.  This catheter was too small, was exchanged for a JL5 4-French catheter, which was advanced over the wire to the ascending aorta, the cath appropriately aspirated and flushed, and advanced to left coronary ostium and multiple views of left coronary artery obtained.,This catheter was then exchanged for a 4-French right coronary catheter, which was advanced over the wire to the ascending aorta.  The catheter appropriately aspirated and flushed.  The catheter was advanced in the right coronary artery.  Multiple views of that vessel were obtained.  The catheter was then sequentially advanced to the saphenous vein graft to the diagonal branch, saphenous vein graft to the obtuse marginal branch, and left internal mammary artery, left anterior descending coronary artery, and multiple views of those vessels were obtained.  This catheter was then exchanged for a 4-French pigtail catheter, which was advanced over the wire to the ascending aorta.  The catheter was appropriately aspirated and flushed and advanced to left ventricle, baseline left ventricular pressures obtained.,Following this, left ventriculography was performed in a 30-degree RAO projection using 30 mL of contrast injected over 3 seconds.  Post left ventriculography pressures were then obtained as was a pullback pressure across the aortic valve.  Videotapes were then reviewed.  It was elected to terminate the procedure at that point in time.,The vascular sheath was removed and manual compression carried out.  Excellent hemostasis was obtained.  The patient tolerated the procedure without complication.,RESULTS OF PROCEDURE,1.  ,HEMODYNAMICS:,  Left ventricular end-diastolic filling pressure was 24.  There was no gradient across the aortic valve.,2.  ,LEFT VENTRICULOGRAPHY: , Left ventriculography demonstrated well-preserved left ventricular systolic function.  Mild inferobasilar hypokinesis was noted.  No significant mitral regurgitation noted.  Ejection fraction was estimated at 60%.,3.  ,CORONARY ARTERIOGRAPHY,A.  ,LEFT MAIN CORONARY: , The left main coronary was patent.,B.  ,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  Left anterior descending coronary was occluded shortly after a very small first septal perforator was given.,C.  ,CIRCUMFLEX CORONARY ARTERY:,  Circumflex coronary artery was occluded at its origin.,D.  ,RIGHT CORONARY ARTERY,.  Right coronary artery was occluded in its mid portion.,4.  ,SAPHENOUS VEIN GRAFT ANGIOGRAPHY,A.  ,SAPHENOUS VEIN GRAFT TO THE DIAGONAL BRANCH: , The saphenous vein graft to diagonal branch was widely patent at its origin and insertion sites.  Excellent flow was noted in the diagonal system with some retrograde flow.,B.  There was retrograde flow as well in the left anterior descending system.,C.  ,SAPHENOUS VEIN GRAFT TO THE OBTUSE MARGINAL SYSTEM:,  Saphenous vein graft to the obtuse marginal system was widely patent at its origin and insertion sites.  There was no graft disease noted.  Excellent flow was noted in the bifurcating marginal system.,D.  ,SAPHENOUS VEIN GRAFT TO RIGHT CORONARY ARTERY:,  Saphenous vein graft to right coronary was widely patent with no graft disease.  Origin and insertion sites were free of disease.  Distal flow in the graft to the posterior descending was normal.,5.  ,LEFT INTERNAL MAMMARY ARTERY ANGIOGRAPHY: , Left internal mammary artery angiography demonstrated a widely patent left internal mammary at its origin and insertion sites.  There was no focal disease noted, inserted into the mid-to-distal LAD which was a small-caliber vessel.  Retrograde filling of a small septal system was noted.,SUMMARY OF RESULTS,1.  Elevated left ventricular end-diastolic filling pressure with normal left ventricular systolic function and mild hypokinesis of inferobasilar segment.",3
"Doctor's Address,Dear Doctor:,This letter serves as an introduction to my patient, A, who will be seeing you in the near future.  He is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia.  He has been treated by Dr. X through the pediatric neurology clinic.  He saw Dr. X recently and she noted that he was having difficulty with mouth breathing, which was contributing to some of his speech problems.  She also noted and confirmed that he has significant tonsillar hypertrophy.  The concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech.  Therefore, I ask for your opinion on this matter.,For his chronic allergic rhinitis symptoms, he is currently on Flonase two sprays to each nostril once a day.  He also has been taking Zyrtec 10 mg a day with only partial relief of the symptoms.  He does have an allergy to penicillin.,I appreciate your input on his care.  If you have any questions regarding, please feel free to call me through my office.  Otherwise, I look forward to hearing back from you regarding his evaluation.",20
"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.",15
"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.",5
"PREOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,POSTOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,PROCEDURE PERFORMED: , Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.,ANESTHESIA: , General.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS: , Bilateral procedure was 400 cc.,TOTAL TOURNIQUET TIME:  ,75 minutes.,COMPONENTS: , Include the Zimmer NexGen complete knee solution system, which include a size F right cruciate retaining femoral component, a size #8 peg tibial component precoat, a All-Poly standard size 38, 9.5 mm thickness patellar component, and a prolonged highly cross-linked polyethylene NexGen cruciate retaining tibial articular surface size blue 12 mm height.,HISTORY OF PRESENT ILLNESS: , The patient is a 69-year-old male who presented to the office complaining of bilateral knee pain for a couple of years.  The patient complained of clicking noises and stiffness, which affected his daily activities of living.,PROCEDURE: , After all potential complications, risks as well as anticipated benefits of the above-named procedure was discussed at length, the patient's informed consent was obtained.,Operative extremities were then confirmed with the operating surgeons as well as the nursing staff, Department of Anesthesia, and the patient.  The patient was then transferred to preoperative area to operative suite #2 and placed on the operating room table in supine position.  All bony prominences were well padded at this time.  At this time, Department of Anesthesia administered general anesthetic to the patient.  The patient was allowed in DVT study and the right extremity was in the Esmarch study as well as the left.  The nonsterile tourniquet was then applied to the right upper thigh of the patient, but not inflated at this time.  The right lower extremity was sterilely prepped and draped in the usual sterile fashion.  The right upper extremity was then elevated and exsanguinated using an Esmarch and the tourniquet was inflated using 325 mmHg.  The patient was a consideration for a unicompartmental knee replacement.  So, after all bony and soft tissue landmarks were identified, a limited midline longitudinal incision was made directly over the patella.  A sharp dissection was then taken down to the level of the fascia in line with the patella as well as the quadriceps tendon.  Next, a medial parapatellar arthrotomy was performed using the #10 blade scalpel.  Upon viewing of the articular surfaces, there was significant ware in the trochlear groove as well as the medial femoral condyle and it was elected to proceed with total knee replacement.  At this time, the skin incisions as well as the deep incisions were extended proximally and distally in a midline fashion.  Total incision now measured approximately 25 cm.  Retractors were placed.  Next, attention was directed to establishing medial and lateral flaps of the proximal tibia.  Reciprocating osteal elevator was used to establish soft tissue plane and then an electrocautery was then used to subperiosteal strip medially and laterally on the proximal tibia.  At this time, the patella was then everted.  The knee was flexed up to 90 degrees.  Next, using the large drill bit, the femoral canal was then opened in appropriate position.  The intramedullary sizing guide was then placed and the knee was sized to a size F. At this time, the three degrees external rotation holes were then drilled after carefully assessing the epicondylar access as well as the white sideline.  The guide was then removed.  The intramedullary guide was then placed with nails holding the guide in three degrees of external rotation.  Next, the anterior femoral resection guide was then placed and clamped into place using a pointed _________________ was then used to confirm that there would no notching performed.  Next, soft tissue retractors were placed and an oscillating saw was used to make the anterior femoral cut.  Upon checking, it was noted to be flat with no oscillations.  The anterior guide was then removed and the distal femoral resection guide was placed in five degrees of valgus.  It was secured in place using nails.  The intramedullary guide was then removed and the standard distal femoral cut was then made using oscillating saw.,This was then removed and the size F distal finishing femoral guide was then placed on the femur in proper position.  Bony and soft tissue landmarks were confirmed and the resection guide was then held in place using nail as well as spring screws.  Again, the collateral ligament retractors were then placed and the oscillating saw was used to make each of the anterior and posterior as well as each chamfer cut.  A reciprocating saw was then used to cut the trochlear cut and the peg holes were drilled as well.  The distal finishing guide was then removed and osteotome was then used to remove all resected bone.  The oscillating saw was then used to complete the femoral notch cut.  Upon viewing, there appeared to be proper amount of bony resection and all bone was removed completely.  There was no posterior osteophytes noted and no fragments to the posterior aspect.  Next, attention was directed towards the tibia.  The external tibial guide was reflected.  This was placed on the anterior tibia and held in place using nails after confirming the proper varus and valgus position.  The resection guide was then checked and appeared to be sufficient amount of resection in both medial and lateral condyles of the tibia.  Next, collateral ligament retractors were placed as well as McGill retractors for the PCL.  Oscillating saw was then used to make the proximal tibial cut.  Osteotome was used to remove this excess resected bone.  The laminar spreader was then used to check the flexion and extension.  The gaps appeared to be equal.  The external guide was then removed and trial components were placed to a size F femoral component and a 12 mm tibial component on a size 8 tray.  The knee was taken through range of motion and had very good flexion as well as full extension.  There appeared to be good varus and valgus stability as well.  Next, attention was directed towards the patella.  There noted to be a sufficient ware and it was selected to replace the patella.  It was sized with caliper, pre-cut and noted to be 26 mm depth.  The sizing guide was then used and a size 51 resection guide selected.  A 51 mm reamer was then placed and sufficient amount of patella was then removed.  The calcar was then used to check again and there was noted to be 15 mm remaining.  The 38 mm patella guide was then placed on the patella.  It was noted to be in proper size and the three drill holes for the pegs were used.  A trial component was then placed.  The knee was taken through range of motion.  There was noted to be some subluxation lateral to the patellar component and a lateral release was performed.  After this, the component appeared to be tracking very well.  There remained a good range of motion in the knee and extension as well as flexion.  At this time, an AP x-ray of the knee was taken with the trial components in place.  Upon viewing this x-ray, it appeared that the tibial cut was in neutral, all components in proper positioning.  The knee was then copiously irrigated and dried.  The knee was then flexed ___________ placed, and the peg drill guide was placed on the tibia in proper position, held in place with nails.,The four peg holes were then drilled.  The knee again was copiously irrigated and suction dried.  The final components were then selected again consisting of size F femoral components.  A peg size 8 tibial component, a 12 mm height articular surface, size blue, and a 38 mm 9.5 mm thickness All-Poly patella.  Polymethyl methacrylate was then prepared at this time.  The proximal tibia was dried and the cement was then pressed into place.  The cement was then placed on the backside of the tibial component and the tibial component was then impacted into proper positioning.  Next, the proximal femur was cleaned and dried.  Polymethyl methacrylate was placed on the resected portions of the femur as well as the backside of the femoral components.  This was then impacted in place as well.  At this time, all excess cement was removed from both the tibial and femoral components.  A size 12 mm trial tibial articular surface was then put in place.  The knee was reduced and held in loading position throughout the remaining drying position of the cement.  Next, the resected patella was cleaned and dried.  The cement was placed on the patella as well as the backside of the patellar component.  The component was then put in proper positioning and held in place with a clamp.  All excess polymethyl methacrylate was removed from this area as well.  This was held until the cement had hardened sufficiently.  Next, the knee was examined.  All excess cement was then removed.  The knee was taken through range of motion with sufficient range of motion as well as stability.  The final 12 mm height polyethylene tibial component was then put into place and snapped down in proper position.  Again range of motion was noted to be sufficient.  The knee was copiously irrigated and suction dried once again.  A drain was then placed within the knee.  The wound was then closed first using #1 Ethibond to close the arthrotomy oversewn with a #1 Vicryl.  The knee was again copiously irrigated and dried.  The skin was closed using #2-0 Vicryl in subcuticular fashion followed by staples on the skin.  The ConstaVac was then _______ to the drain.  Sterile dressing was applied consisting of Adaptic, 4x4, ABDs, Kerlix, and a 6-inch Dupre roll from foot to thigh.  Department of Anesthesia then reversed the anesthetic.  The patient was transferred back to the hospital gurney to Postanesthesia Care Unit.  The patient tolerated the procedure well and there were no complications.",27
"PREOPERATIVE DIAGNOSIS: , Bunion, left foot.,POSTOPERATIVE DIAGNOSIS: ,Bunion, left foot.,PROCEDURE PERFORMED:,1.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation.,2.  Akin osteotomy with internal wire fixation of left foot.,HISTORY: , This 19-year-old Caucasian female presents to ABCD General Hospital with the above chief complaint.  The patient states she has had worsening bunion deformity for as long as she could not remember.  She does have a history of Charcot-Marie tooth disease and desires surgical treatment at this time.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in a Mayo block type fashion surrounding the lower left first metatarsal.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating field.  The stockinette was reflected, the foot was cleansed with a wet and dry sponge.  Approximately 5 cm incision was made dorsomedially over the first metatarsal.,The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  Care was taken to preserve the extensor digitorum longus tendon.  The capsule over the first metatarsal phalangeal then was identified where a dorsal capsular incision was then created down to the level of bone.  Capsule and periosteum was reflected off the first metatarsal head.  At this time, the cartilage was inspected and noted to be white, shiny, and healthy cartilage.  There was noted to be a prominent medial eminence.  Attention was then directed to first interspace where a combination of blunt and sharp dissection was done to perform a standard lateral release.  The abductor tendon attachments were identified and transected.  The lateral capsulotomy was performed.  The extensor digitorum brevis tendon was identified and transected.  Attention was then directed to the prominent medial eminence, which was resected with a sagittal saw.  Intraoperative assessment of pes was performed and pes was noted to be normal.,At this time, a regional incision was carried more approximately about 1.5 cm.  The capsular incision was then extended and the proximal capsule and periosteum were reflected off the first metatarsal.  The first metatarsal cuneiform joint was identified.  A 0.45 K-wire was then inserted into the base of the first metatarsal approximately 1 cm from the first cuneiform joint perpendicular to the weightbearing surface.  This K-wire was used as an access guide for a Juvaro type oblique base wedge osteotomy.  The sagittal saw was then used to creat a closing base wedge osteotomy with the apex being proximal medial.  The osteotomy site was then feathered and tilted with tight estimation of the bony edges.  The cortical hinge was maintained.  A 0.27 x 24 mm screw was then inserted in a standard AO fashion.  At this time, there was noted to be tight compression of the osteotomy site.  A second 2.7 x 16 mm screw was then inserted more distally in the standard AO fashion with compression noted.  The ________ angle was noted to be significantly released.  Reciprocating rasp was then used to smoothen any remaining sharp edges.  The 0.45 k-wire was removed.  The foot was loaded and was noted to fill the remaining abduction of the hallux.  At this time, it was incised to perform an Akin osteotomy.,Original incision was then extended distally approximately 1 cm.  The incision was then deepened down to the level of capsule over the base of the proximal phalanx.  Again care was taken to preserve the extensor digitorum longus tendon.  The capsule was reflected off of the base of the proximal phalanx.  An Akin osteotomy was performed with the apex being lateral and the base being medial.  After where the bone was resected, it was feathered until tight compression was noted without tension at the osteotomy site.  Care was taken to preserve the lateral hinge.  At 1.5 wire passed and a drill was then used to create drill hole proximal and distally to the osteotomy site in order for passage of 28 gauge monofilament wire.  The #28 gauge monofilament wire was passed through the drill hole and tightened down until compression and tight ________ osteotomy site was noted.  The remaining edge of the wire was then buried in the medial most distal drill hole.  The area was then inspected and the foot was noted with significant reduction of the bunion deformity.  The area was then flushed with copious amounts of sterile saline.  Capsule was closed with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl in order to decrease tension of the incision site.  A running #5-0 subcuticular stitch was then performed.  Steri-Strips were applied.  Total of 1 cc dexamethasone phosphate was then injected into the surgical site.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  Posterior splint was then placed on the patient in the operating room.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred back to the PACU with vital signs stable and vascular status intact to the left foot.  The patient was given postoperative instructions to be strictly nonweightbearing on the left foot.  The patient was given postop pain prescriptions for Vicodin and instructed to take one q.4-6h. p.r.n. for pain as well as Naprosyn 500 mg p.o. q. b.i.d.  The patient is to follow-up with Dr. X in his office in four to five days as directed.",31
"INTENSITY-MODULATED RADIATION THERAPY,Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.  The treatment planning process requires at least 4 hours of physician time.  The technology is appropriate in this patient's case due to the fact that the target volume is adjacent to significant radiosensitive structures.  Sequential CT scans are obtained and transferred to the treatment planning software.  Extensive analysis occurs.  The target volumes, including margins for uncertainty, patient movement and occult tumor extension are selected.  In addition, organs at risk are outlined.  Doses are selected both for targets, as well as for organs at risk.  Associated dose constraints are placed.  Inverse treatment planning is then performed in conjunction with the physics staff.  These are reviewed by the physician and ultimately performed only following approval by the physician.  Multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease, while minimizing exposure to organs at risk.  This is performed in hopes of minimizing associated complications.  The physician delineates the treatment type, number of fractions and total volume.  During the time of treatment, there is extensive physician intervention, monitoring the patient set up and tolerance.  In addition, specific QA is performed by the physics staff under the physician's direction.,In view of the above, the special procedure code 77470 is deemed appropriate.",33
"PREOPERATIVE DIAGNOSIS: , Anterior cruciate ligament rupture.,POSTOPERATIVE DIAGNOSES:,1.  Anterior cruciate ligament rupture.,2.  Medial meniscal tear.,3.  Medial femoral chondromalacia.,4.  Intraarticular loose bodies.,PROCEDURE PERFORMED:,1.  Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction.,2.  Removal of loose bodies.,3.  Medial femoral chondroplasty.,4.  Medial meniscoplasty.,OPERATIVE PROCEDURE:  ,The patient was taken to the operative suite, placed in supine position, and administered a general anesthetic by the Department of Anesthesia.  Following this, the knee was sterilely prepped and draped as discussed for this procedure.  The inferolateral and inferomedial portals were then established; however, prior to this, a graft was harvested from the semitendinosus and gracilis region.  After the notch was identified, then ACL was confirmed and ruptured.  There was noted to be a torn, slipped up area of the medial meniscus, which was impinging and impinged on the articular surface.  The snare was smoothed out.  Entire area was thoroughly irrigated.  Following this, there was noted in fact to be significant degenerative changes from this impingement of the meniscus again to the periarticular cartilage.  The areas of the worn away portion of the medial femoral condyle was then debrided and ________ chondroplasty was then performed of this area in order to stimulate bleeding and healing.  There were multiple loose bodies noted in the knee and these were then __________ and then removed.  The tibial and femoral drill holes were then established and the graft was then put in place, both which locations after a notchplasty was performed.  The knee was taken through a full range of motion without any impingement.  An Endobutton was used for proximal fixation.  Distal fixation was obtained with an independent screw and a staple.  The patient was then taken to Postanesthesia Care Unit at the conclusion of the procedure.,",37
"HDR BRACHYTHERAPY,The intracavitary brachytherapy applicator was placed appropriately and secured after the patient was identified.  Simulation films were obtained, documenting its positioning.  The 3-dimensional treatment planning process was accomplished utilizing the CT derived data.  A treatment plan was selected utilizing sequential dwell positions within a single catheter.  The patient was taken to the treatment area.  The patient was appropriately positioned and the position of the intracavitary device was checked.  Catheter length measurements were taken.  Appropriate measurements of the probe dimensions and assembly were also performed.  The applicator was attached to the HDR after-loader device.  The device ran through its checking sequences appropriately and the brachytherapy was then delivered without difficulty or complication.  The brachytherapy source was appropriately removed back to the brachytherapy safe within the device.  Radiation screening was performed with the Geiger-Muller counter both prior to and after the brachytherapy procedure was completed and the results were deemed appropriate.,Following completion of the procedure, the intracavitary device was removed without difficulty.  The patient was in no apparent distress and was discharged home.",33
"CHIEF COMPLAINT:  ,The patient does not have any chief complaint.,HISTORY OF PRESENT ILLNESS:,  This is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well.  The next-door neighbor came over and decided that she should go to the emergency room to be check out for her generalized complaint of not feeling well.  The neighbor suspects that this may have been due to the patient taking too many of her Tylenol PM, which the patient has been known to do.  The patient was a little somnolent early this morning and was found only to be oriented x1 with EMS upon their arrival to the patient's house.  The patient states that she just simply felt funny and does not give any more specific details than this.  The patient denies any pain at any time.  She did not have any shortness of breath.  No nausea or vomiting.  No generalized weakness.  The patient states that all that has gone away since arrival here in the hospital, that she feels at her usual self, is not sure why she is here in the hospital, and thinks she should go.  The patient's primary care physician, Dr. X reports that the patient spoke with him yesterday and had complained of shortness of breath, nausea, dizziness, as well as generalized weakness, but the patient states that all this has resolved.  The patient was actually seen here two days ago for those same symptoms and was found to have exacerbation of her COPD and CHF.  The patient was discharged home after evaluation in the emergency room.  The patient does use home O2.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  The patient had complained of generalized fatigue and weakness two days ago in the emergency room and yesterday to her primary care physician.  The patient denies having any other symptoms today.  The patient denies any fever or chills.  Has not had any recent weight change.  HEENT:  The patient denies any headache.  No neck pain.  No rhinorrhea.  No sinus congestion.  No sore throat.  No any vision or hearing change.  No eye or ear pain.  CARDIOVASCULAR:  The patient denies any chest pain.  RESPIRATIONS:  No shortness of breath.  No cough.  No wheeze.  The patient did report having shortness of breath and wheeze with her presentation to the emergency room two days ago and shortness of breath to her primary care physician yesterday, but the patient states that all this has resolved.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  No change in the bowel movements.  There has not been any diarrhea or constipation.  No melena or hematochezia.  GENITOURINARY:  No dysuria, hematuria, urgency, or frequency.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  No pain or abnormalities to any portion of the body.  SKIN:  No rashes or lesions.  NEUROLOGIC:  The patient reported dizziness to her primary care physician yesterday over the phone, but the patient denies having any problems with dizziness over the past few days.  The patient denies any dizziness at this time.  No syncope or no near-syncope.  The patient denies any focal weakness or numbness.  No speech change.  No difficulty with ambulation.  The patient has not had any vision or hearing change.  PSYCHIATRIC:  The patient denies any depression.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  COPD, CHF, hypertension, migraines, previous history of depression, anxiety, diverticulitis, and atrial fibrillation.,PAST SURGICAL HISTORY:,  Placement of pacemaker and hysterectomy.,CURRENT MEDICATIONS: , The patient takes Tylenol PM for insomnia, Lasix, Coumadin, Norvasc, Lanoxin, Diovan, atenolol, and folic acid.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient used to smoke, but quit approximately 30 years ago.  The patient denies any alcohol or drug use although her son reports that she has had a long history of this in the past and the patient has abused prescription medication in the past as well according to her son.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 99.1 oral, blood pressure 139/65, pulse is 72, respirations 18, and oxygen saturation is 92% on room air and interpreted as low normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear sclerae and cornea bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Mouth and oropharynx are normal without any sign of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  No cervical lymphadenopathy.  No carotid artery or vertebral artery bruits.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  The patient does have +1 bilateral lower extremity edema.  RESPIRATIONS:  The patient has coarse breath sounds bilaterally, but no dyspnea.  Good air movement.  No wheeze.  No crackles.  The patient speaks in full sentences without any difficulty.  The patient does not exhibit any retractions, accessory muscle use or abdominal breathing.  GASTROINTESTINAL:  Abdomen is soft, nontender, and nondistended.  No rebound or guarding.  No hepatosplenomegaly.  Normal bowel sounds.  No bruits, no mass, no pulsatile mass, and no inguinal lymphadenopathy.  MUSCULOSKELETAL:  No abnormalities noted to the back, arms or legs.  SKIN:  No rashes or lesions.  NEUROLOGICAL:  Cranial nerves II through XII are intact.  Motor is 5/5 and equal to bilateral arms and legs.  Sensory is intact to light touch.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is awake, alert, and oriented x3 although the patient first stated that the year was 1908, but did manage to correct herself up on addressing this with her.  The patient has normal mood and affect.  HEMATOLOGIC AND LYMPHATIC:  There is no evidence of lymphadenopathy.,EMERGENCY DEPARTMENT TESTING: , EKG is a rate of 72 with evidence of a pacemaker that has good capture.  There is no evidence of acute cardiac disease on the EKG and there is no apparent change in the EKG from 03/17/08.  CBC has no specific abnormalities of issue.  Chemistry has a BUN of 46 and creatinine of 2.25, glucose is 135, and an estimated GFR is 20.  The rest of the values are normal and unremarkable.  LFTs are all within normal limits.  Cardiac enzymes are all within normal limits.  Digoxin level is therapeutic at 1.6.  Chest x-ray noted cardiomegaly and evidence of congestive heart failure, but no acute change from her chest x-ray done two days ago.  CAT scan of the head did not identify any acute abnormalities.  I spoke with the patient's primary care physician, Dr. X who stated that he would be able to follow up with the patient within the next day.  I spoke with the patient's neighbor who contacted the ambulance service who stated that the patient just reported not feeling well and appeared to be a little somnolent and confused at the time, but suspected that she may have taken too many of her Tylenol PM as she often has done in the past.  The neighbor is XYZ and he says that he checks on her three times a day every day.  ABC is the patient's son and although he lives out of town he calls and checks on her every day as well.  He states that he spoke to her yesterday.  She sounded fine, did not express any other problems that she had apparently been in contact with her primary care physician.  She sounded her usual self to him.  Mr. ABC also spoke to the patient while she was here in the emergency room and she appears to be her usual self and has her normal baseline mental status to him.  He states that he will be able to check on her tomorrow as well.  Although it is of some concern that there may be problems with development of some early dementia, the patient is adamant about not going to a nursing home and has been placed in a Nursing Home in the past, but Dr. Y states that she has managed to be discharged after two previous nursing home placements.  The patient does have Home Health that checks on her as well as housing care in between the two services they share visits every single day  by them as well as the neighbor who checks on her three times a day and her son who calls her each day as well.  The patient although she lives alone, does appear to have good followup and the patient is adamant that she wishes to return home.,DIAGNOSES,1.  EARLY DEMENTIA.,2.",15
"CHIEF COMPLAINT:,  Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD.  He sustained an injury from the patellar from a boat while in the water.  He was air lifted actually up to XYZ Hospital and underwent extensive surgery.  He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area.  In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue.  He has some drainage from these areas.  There are no signs and symptoms of infection.  He is referred to us to help him get those areas under control.,PAST MEDICAL HISTORY:,  Essentially negative other than he has had C. difficile in the recent past.,ALLERGIES:,  None.,MEDICATIONS: , Include Cipro and Flagyl.,PAST SURGICAL HISTORY: , Significant for his trauma surgery noted above.,FAMILY HISTORY: , His maternal grandmother had pancreatic cancer.  Father had prostate cancer.  There is heart disease in the father and diabetes in the father.,SOCIAL HISTORY:,  He is a non-cigarette smoker and non-ETOH user.  He is divorced.  He has three children.  He has an attorney.,REVIEW OF SYSTEMS:,CARDIAC:  He denies any chest pain or shortness of breath.,GI:  As noted above.,GU:  As noted above.,ENDOCRINE:  He denies any bleeding disorders.,PHYSICAL EXAMINATION:,GENERAL:  He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress.,HEENT:  Unremarkable.,NECK:  Supple.  There is no mass, adenopathy, or bruit.,CHEST:  Normal excursion.,LUNGS:  Clear to auscultation and percussion.,COR:  Regular.  There is no S3, S4, or gallop.  There is no murmur.,ABDOMEN:  Soft.  It is nontender.  There is no mass or organomegaly.,GU:  Unremarkable.,RECTAL:  Deferred.,EXTREMITIES:  His right lower extremity is unremarkable.  Peripheral pulse is good.  His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed.  The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side.  There is one small area right essentially within the graft site, and there is one small area down lower on the calf area.  The patient has an external fixation on that comes out laterally on his left thigh.  Those pin sites look clean.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION: , Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,PLAN:,  Plan would be for chemical cauterization of these areas.  Series of treatment with chemical cauterization till these are closed.",5
"VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE:,  Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT: , Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions of lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  Ears:  Normal set, shape, TMs, canals and hearing.  Nose and Sinuses:  Negative.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK: , Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:,  Lungs are bilaterally clear to auscultation and percussion.,HEART: , S1 and S2.  Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop.  PMI nondisplaced.  Chest wall unremarkable to inspection and palpation.  No axillary or supraclavicular adenopathy detected.,BREASTS:,  In the seated and supine position unremarkable.,ABDOMEN: , No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding.  No widening of the aortic impulse and no intraabdominal bruit auscultated.,EXTERNAL GENITALIA: , Normal for age.,RECTAL: , Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis.  Nails of the hands and feet, and creases of the palms and soles are unremarkable.  Good active and passive range of motion of all major joints.,BACK:,  Normal to inspection and percussion.  Negative for spinous process tenderness or CVA tenderness.  Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC:,  Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function.  Affect is normal.  Speech is clear and fluent.  Thought process is lucid and rational.  Gait and station are unremarkable.,SKIN: , Unremarkable for any premalignant or malignant condition with normal changes for age.",25
"NASAL EXAM: , The nose is grossly in the midline with no evidence of fractures or dislocations.  The nasal septum is roughly in the midline with pale boggy mucosa and moderately enlarged inferior turbinates.  There is no pus or polyps in the nose on anterior rhinoscopy.  The airway appears adequate.  No external valve prolapses are observed.,THROAT EXAM: , The oral cavity is clear.  The tongue is clear with no lesions noted and with good symmetrical movement.  The parotid and submaxillary ducts are producing clear mucus with no evidence of stones or infection.  Palate is clear.  The tonsils are not prominent.,No overt neoplasms in the mouth are noted.  Lips are clear.  The voice is adequate no deficits or hoarseness.  The saliva is clear.,EARS:  ,Canals are clear.  Eardrums are clear, moving on insufflation and swallowing.  No discharge is noted in the canals.  Hearing appears adequate in normal tonal conversations.,NECK EXAM: , Neck is supple with no palpable masses.  No lymphadenopathy.  The thyroid gland is not palpable.  The trachea is in the midline.  The parotid and submaxillary glands are not enlarged, are symmetrical and are not tender.  The neck movement is adequate.,GROSS NEUROLOGICAL EXAM: , Cranial nerves II-XII are intact.  Extraocular movements are full with no restrictions.  Patient is alert and responsive.,EYE EXAM: , Sclerae are clear.  Conjunctivae are clear.  Pupils respond symmetrically to light.  Extraocular movements are complete and full.",11
"PREOPERATIVE DIAGNOSIS: , Anemia.,PROCEDURE:,  Upper gastrointestinal endoscopy.,POSTOPERATIVE DIAGNOSES:,1.  Severe duodenitis.,2.  Gastroesophageal junction small ulceration seen.,3.  No major bleeding seen in the stomach.,PROCEDURE IN DETAIL: , The patient was put in left lateral position.  Olympus scope was inserted from the mouth, under direct visualization advanced to the upper part of the stomach, upper part of esophagus, middle of esophagus, GE junction, and some intermittent bleeding was seen at the GE junction.  Advanced into the upper part of the stomach into the antrum.  The duodenum showed extreme duodenitis and the scope was then brought back.  Retroflexion was performed, which was normal.  Scope was then brought back slowly.  Duodenitis was seen and a little bit of ulceration seen at GE junction.,FINDING: , Severe duodenitis, may be some source of bleeding from there, but no active bleeding at this time.",14
"PREOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,POSTOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,PROCEDURE PERFORMED: , YAG laser capsulotomy, right eye.,INDICATIONS: , This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane.  The patient is being brought in for YAG capsular discission.,PROCEDURE: , The patient was seated at the YAG laser, the pupil having been dilated with 1%  Mydriacyl, and Iopidine was instilled.  The Abraham capsulotomy lens was then positioned and applications of laser energy in the pattern indicated on the outpatient note were applied.  A total of",37
"REASON FOR CONSULTATION: , Loculated left effusion, multilobar pneumonia.",3
"HISTORY OF PRESENT ILLNESS:,  The patient is a 74-year-old white woman who has a past medical history of hypertension for 15 years, history of CVA with no residual hemiparesis and uterine cancer with pulmonary metastases, who presented for evaluation of recent worsening of the hypertension.  According to the patient, she had stable blood pressure for the past 12-15 years on 10 mg of lisinopril.  In August of 2007, she was treated with doxorubicin and, as well as Procrit and her blood pressure started to go up to over 200s.  Her lisinopril was increased to 40 mg daily.  She was also given metoprolol and HCTZ two weeks ago, after she visited the emergency room with increased systolic blood pressure.  Denies any physical complaints at the present time.  Denies having any renal problems in the past.,PAST MEDICAL HISTORY:,  As above plus history of anemia treated with Procrit.  No smoking or alcohol use and lives alone.,FAMILY HISTORY:,  Unremarkable.,PRESENT MEDICATIONS: , As above.,REVIEW OF SYSTEMS: , Cardiovascular:  No chest pain.  No palpitations.  Pulmonary:  No shortness of breath, cough, or wheezing.  Gastrointestinal:  No nausea, vomiting, or diarrhea.  GU:  No nocturia.  Denies having gross hematuria.  Salt intake is minimal.  Neurological:  Unremarkable, except for history of old CVA.,PHYSICAL EXAMINATION: , Blood pressure today is 182/78.  Examination of the head is unremarkable.  Neck is supple with no JVD.  Lungs are clear.  There is no abdominal bruit.  Extremities 1+ edema bilaterally.,LABORATORY DATA:,  Urinalysis done in the office shows 1+ proteinuria; same is shown by urinalysis done at Hospital.  The creatinine is 0.8.  Renal ultrasound showed possible renal artery stenosis and a 2 cm cyst in the left kidney.  MRA of the renal arteries was essentially unremarkable with no suspicion for renal artery stenosis.,IMPRESSION AND PLAN:,  Accelerated hypertension.  No clear-cut etiology for recent worsening since renal artery stenosis was ruled out by negative MRA.  I could only blame Procrit initiation, as well as possible fluid retention as a cause of the patient's accelerated hypertension.  She was started on hydrochlorothiazide less than two weeks ago with some improvement in her hypertension.  At this point, I would not pursue a diagnosis of renal artery stenosis.  Since she is maxed out on lisinopril and her pulse is 60, I would not increase beta-blocker or ACE inhibitor.  I will continue HCTZ at 24 mg daily.  The patient was also given a sample of Tekturna, which would hopefully improve her systolic blood pressure.  The patient was told to be stick with her salt intake.  She will report to me in 10 days with the result of her blood pressure.  She will also repeat an SMA7 to rule out possible hyperkalemia due to Tekturna.",5
"PREOPERATIVE DX: , Stress urinary incontinence.,POSTOPERATIVE DX: , Stress urinary incontinence.,OPERATIVE PROCEDURE: , SPARC suburethral sling.,ANESTHESIA: , General.,FINDINGS & INDICATIONS: , Outpatient evaluation was consistent with urethral hypermobility, stress urinary incontinence.  Intraoperatively, the bladder appeared normal with the exception of some minor trabeculations.  The ureteral orifices were normal bilaterally.,DESCRIPTION OF OPERATIVE PROCEDURE:,  This patient was brought to the operating room, a general anesthetic was administered.  She was placed in dorsal lithotomy position.  Her vulva, vagina, and perineum were prepped with Betadine scrubbed in solution.  She was draped in usual sterile fashion.  A Sims retractor was placed into the vagina and Foley catheter was inserted into the bladder.  Two Allis clamps were placed over the mid urethra.  This area was injected with 0.50% lidocaine containing 1:200,000 epinephrine solution.  Two areas suprapubically on either side of midline were injected with the same anesthetic solution.  The stab wound incisions were made in these locations and a sagittal incision was made over the mid urethra.  Metzenbaum scissors were used to dissect bilaterally to the level of the ischial pubic ramus.  The SPARC needles were then placed through the suprapubic incisions and then directed through the vaginal incision bilaterally.  The Foley catheter was removed.  A cystoscopy was performed using a 70-degree cystoscope.  There was noted to be no violation of the bladder.  The SPARC mesh was then snapped onto the needles, which were withdrawn through the stab wound incisions.  The mesh was snugged up against a Mayo scissor held under the mid urethra.  The overlying plastic sheaths were removed.  The mesh was cut below the surface of the skin.  The skin was closed with 4-0 Plain suture.  The vaginal vault was closed with a running 2-0 Vicryl stitch.  The blood loss was minimal.  The patient was awoken and she was brought to recovery in stable condition.",38
"PREOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,POSTOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy with decompression C6-C7.,2.  Arthrodesis with anterior interbody fusion C6-C7.,3.  Spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws.,4.  PEEK implant 7 mm.,5.  Allograft using Vitoss.,ANESTHESIA: , General endotracheal anesthesia.,FINDINGS: , Showed osteophyte with a disc complex on the left C6-C7 neural foramen.,FLUIDS:  ,1800 mL of crystalloids.,URINE OUTPUT: , No Foley catheter.,DRAINS:  ,Round French 10 JP drain.,SPECIMENS,:  None.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  250 mL.,The need for an assistant is important in this case, since her absence would mean prolonged operative time and may increase operative morbidity and mortality.,CONDITION: , Extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:,  This is the case of a very pleasant 46-year-old Caucasian female with subarachnoid hemorrhage secondary to ruptured left posteroinferior cerebellar artery aneurysm, which was clipped.  The patient last underwent a right frontal ventricular peritoneal shunt on 10/12/07.  This resulted in relief of left chest pain, but the patient continued to complaint of persistent pain to the left shoulder and left elbow.  She was seen in clinic on 12/11/07 during which time MRI of the left shoulder showed no evidence of rotator cuff tear.  She did have a previous MRI of the cervical spine that did show an osteophyte on the left C6-C7 level.  Based on this, negative MRI of the shoulder, the patient was recommended to have anterior cervical discectomy with anterior interbody fusion at C6-C7 level.  Operation, expected outcome, risks, and benefits were discussed with her.  Risks include, but not exclusive of bleeding and infection, bleeding could be soft tissue bleeding, which may compromise airway and may result in return to the operating room emergently for evacuation of said hematoma.  There is also the possibility of bleeding into the epidural space, which can compress the spinal cord and result in weakness and numbness of all four extremities as well as impairment of bowel and bladder function.  Should this occur, the patient understands that she needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk of infection, which can be superficial and can be managed with p.o. antibiotics.  However, the patient may develop deeper-seated infection, which may require return to the operating room.  Should the infection be in the area of the spinal instrumentation, this will cause a dilemma since there might be a need to remove the spinal instrumentation and/or allograft.  There is also the possibility of potential injury to the esophageus, the trachea, and the carotid artery.  There is also the risks of stroke on the right cerebral circulation should an undiagnosed plaque be propelled from the right carotid.  There is also the possibility hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  There is also the risk of pseudoarthrosis and hardware failure.  She understood all of these risks and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient 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 placed by Premier Neurodiagnostics and this revealed normal findings, which remained normal during the entire case.  The EMGs were silent and there was no evidence of any stimulation.  After completion of the placement of the monitoring leads, the patient was positioned supine on the operating table with the neck placed on hyperextension.  The head was supported on a foam doughnut.  The right cervical area was then exposed by turning the head about 45 to 60 degrees to the left side.  A linear incision was made about two to three fingerbreadths from the suprasternal notch along the anterior border of the sternocleidomastoid muscle to a distance of about 3 cm.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, the incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to carry the dissection down to the platysma in the similar fashion as the skin incision.  The anterior border of the sternocleidomastoid muscle was identified as well as the sternohyoid/omohyoid muscles.  Dissection was then carried lateral and superior to the omohyoid muscle and lateral to the esophagus and the trachea, and medial to the sternocleidomastoid muscle and the carotid sheath.  The prevertebral fascia was identified and cut sharply.  A localizing x-ray verified the marker to be at the C6-C7 interspace.  Proceeded to the strip the longus colli muscles off the vertebral body of C6 and C7.  Self-retaining retractor was then laid out.  The annulus was then cut in a quadrangular fashion and piecemeal removal of the dura was done using a straight pituitary rongeurs, 3 and 5 mm burr.  The interior endplate of C6 and superior endplate of C7 was likewise was drilled down together with posteroinferior edge of C6 and the posterior superior edge of C7.  There was note of a new osteophyte on the left C6-C7 foramen.  This was carefully drilled down.  After decompression and removal of pressure, there was noted to be release of the epidural space with no significant venous bleeders.  They were controlled with slight bipolar coagulation, temporary tamponade with Gelfoam.  After this was completed, Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant was then tapped into placed after its interior was packed with Vitoss.  The plate was then applied and secured in place with four 12 x 4.7 mm screws.  Irrigation of the area was done.  A round French 10 JP drain was laid out over the graft and exteriorized through a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures as well as Vicryl 4-0 subcuticular stitch for the dermis.  The wound was reinforced with Dermabond.  The catheter was anchored to the skin with nylon 3-0 stitch and dressing was applied only at the exit site.  C-collar was placed and the patient was transferred to Recovery after extubation.",23
"TITLE OF OPERATION:,  Diagnostic laparoscopy.,INDICATION FOR SURGERY: , The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,PREOP DIAGNOSIS: , Possible ruptured ectopic pregnancy.,POSTOP DIAGNOSIS: , No evidence of ectopic pregnancy or ruptured ectopic pregnancy.,ANESTHESIA: , General endotracheal.,SPECIMEN: , Peritoneal fluid.,EBL: , Minimal.,FLUIDS:,  900 cubic centimeters crystalloids.,URINE OUTPUT: , 400 cubic centimeters.,FINDINGS: , Adhesed left ovary with dilated left fallopian tube, tortuous right fallopian tube with small 1 cm ovarian cyst noted on right ovary, perihepatic lesions consistent with history of PID, approximately 1-200 cubic centimeters of more serous than sanguineous fluid.  No evidence of ectopic pregnancy.,COMPLICATIONS: , None.,PROCEDURE:,  After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was administered.  She was examined under anesthesia.  An 8-10 cm anteverted uterus was noted.  The patient was placed in the dorsal-lithotomy position and prepped and draped in the usual sterile fashion, a sponge on a sponge stick was used in the place of a HUMI in order to not instrument the uterus in the event that this was a viable intrauterine pregnancy and this may be a desired intrauterine pregnancy.  Attention was then turned to the patient's abdomen where a 5-mm incision was made in the inferior umbilicus.  The abdominal wall was tented and VersaStep needle was inserted into the peritoneal cavity.  Access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water.  No peritoneum was obtained without difficulty using 4 liters of CO2 gas.  The 5-mm trocar and sleeve were then advanced in to the intraabdominal cavity and access was confirmed with the laparoscope.,The above-noted findings were visualized.  A 5-mm skin incision was made approximately one-third of the way from the ASI to the umbilicus at McBurney's point.  Under direct visualization, the trocar and sleeve were advanced without difficulty.  A third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the VersaStep.  The peritoneal fluid was aspirated and sent for culture and wash and cytology.  The abdomen and pelvis were surveyed with the above-noted findings.  No active bleeding was noted.  No evidence of ectopic pregnancy was noted.  The instruments were removed from the abdomen under good visualization with good hemostasis noted.  The sponge on a sponge stick was removed from the vagina.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.,The attending, Dr. X, was present and scrubbed for the entire procedure.",37
"PREOPERATIVE DIAGNOSIS:,  Refractory pneumonitis.,POSTOPERATIVE DIAGNOSIS: , Refractory pneumonitis.,PROCEDURE PERFORMED: , Bronchoscopy with bronchoalveolar lavage.,ANESTHESIA: , 5 mg of Versed.,INDICATIONS: , A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.,PROCEDURE: , The patient was sedated with 5 mg of Versed that was placed on the endotracheal tube.  Bronchoscope was advanced.  Both right and left mainstem bronchioles and secondary and tertiary bronchioles were cannulated sequentially, lavaged out.  Relatively few tenacious secretions were noted.  These were lavaged out.  Specimen collected for culture.  No obvious other abnormalities were noted.  The patient tolerated the procedure well without complication.",37
"HISTORY OF PRESENT ILLNESS:,  In 2002, the patient had a blood test during her routine screening, which revealed anemia and an elevated creatinine.  Two weeks later she saw a nephrologist at ABCDE were she worked at that time.  An ultrasound revealed that she had Parenchymal disease in which tissue around the kidney is diseased.  No particular treatment was advised.  She was laid off 6 months later.  In 2004, she began working at The ABCD Hospital and began seeing Dr. A.  She was put on Procrit, but could not keep the stringent appointment scheduled for the injection because of her work.  She began seeing Dr. B and was put on Procrit and Renagel.  She was advised to go on dialysis, but she felt she did not have enough information to such a drastic step.  She saw an endocrinologist for some thyroid problem and her blood work showed that her creatinine was now at 7.  She was referred to Dr. Xyz who found after a parathyroid scan that she may have an adenoma.  Her creatinine is now 7.4.,TREATMENT AND IMPACT OF DISEASE:,  She is on several medications.  She is not on a renal diet yet.  Her energy is good and she is still working full time.,TRANSPLANT FIRST MENTIONED AS TREATMENT OPTION: , She has wanted to transplant ever since dialysis was first mentioned.,EMOTIONAL REACTION TO DIAGNOSIS AND TREATMENT COURSE:,  She is frustrated by the lack of information about what exactly has caused her renal failure and has had a real feeling of helplessness in her efforts to pursue this understanding.,OTHER SIGNIFICANT MEDICAL HISTORY/SURGERIES:,  She had a Bartholin cyst removed in 2002.,PSYCHIATRIC HISTORY:,  None.,COPING STRATEGIES:,  She used to exercise vigorously, but has stopped at this time.  She enjoys watching movies with her children.,COMPLIANCE:,  She feels she watches her diet and medication regimen very closely.  She said she communicates daily with Dr. Xyz,PAST AND PRESENT SMOKING:,  She began smoking 2 cigarettes a day when she was 22, but stopped after a year.,PAST AND PRESENT ALCOHOL USE:,  None.,PAST AND PRESENT DRUG USE:,  None.,LEGAL ISSUES:,  None.,TATTOOS:,  None.,MARITAL STATUS:  LENGTH OF THE TIME MARRIED:,  She has been married for 25 years.,AGE AND HEALTH OF SPOUSE:,  Xyz is 62 and in good health.,CHILDREN:,  Four, all are in good health.,FATHER:,  Father died in 2001, at the age of 62 of cardiac cancer.,MOTHER:,  Dolorous Massey is 63 and in good health.,SIBLINGS:,  Ben Doherty died in 1984 at the age of 26 in an automobile accident; Steven Doherty is 46 and is in good health.,PREVIOUS MARRIAGES AND DURATION OF EACH:,  None.,PERSONS LIVING IN HOUSEHOLD:,  Six.,RELATIONSHIP WITH FAMILY MEMBERS/IDENTIFIED PRIMARY SUPPORT SYSTEM:,  She is close to her brother.,HIGHEST LEVEL OF EDUCATION:,  She has 2 years of college at ABCD College.  She is a licensed LVN.,MILITARY SERVICE:,  None.",21
"CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.  She had no difficulty breathing and her cough was described as dry and hacky.  At that time, physical exam showed a right TM, which was red.  Left TM was okay.  She was fairly congested but looked happy and playful.  She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear.  Mom returned to clinic again today because she got much worse overnight.  She was having difficulty breathing.  She was much more congested and her appetite had decreased significantly today.  She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS:  ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY:  ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces.  No complications.  Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY:  ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her respiratory rate was approximately 60 to 65.,GENERAL:  She was very congested and she looked miserable.  She had no retractions at this time.,HEENT:  Her right TM was still red and irritated with no light reflex.  Her nasal discharge was thick and whitish yellow.  Her throat was clear.  Her extraocular muscles were intact.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR EXAM:  She was tachycardic without murmur.,LUNGS:  Revealed diffuse expiratory wheezing.,ABDOMEN:  Soft, nontender, and nondistended.,EXTREMITIES:  Showed no clubbing, cyanosis or edema.,LABORATORY DATA:  ,Her chem panel was normal.  RSV screen is positive.  Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN:  ,RSV bronchiolitis with otitis media.  Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.",15
"CC:, Memory loss.,HX:, This 77 y/o RHF presented with a one year history of progressive memory loss. Two weeks prior to her evaluation at UIHC she agreed to have her sister pick her up for church at 8:15AM, Sunday morning. That Sunday she went to pick up her sister at her sister's home and when her sister was not there (because the sister had gone to pick up the patient) the patient left. She later called the sister and asked her if she (sister) had overslept. During her UIHC evaluation she denied she knew anything about the incident. No other complaints were brought forth by the patients family.,PMH:, Unremarkable.,MEDS:, None,FHX: ,Father died of an MI, Mother had DM type II.,SHX: , Denies ETOH/illicit drug/Tobacco use.,ROS:, Unremarkable.,EXAM:, Afebrile, 80BPM, BP 158/98, 16RPM. Alert and oriented to person, place, time. Euthymic. 29/30 on Folstein's MMSE with deficit on drawing. Recalled 2/6 objects at five minutes and could not recite a list of 6 objects in 6 trials. Digit span was five forward and three backward. CN: mild right lower facial droop only. MOTOR: Full strength throughout. SENSORY: No deficits to PP/Vib/Prop/LT/Temp. COORD: Poor RAM in LUE only. GAIT: NB and ambulated without difficulty. STATION: No drift or Romberg sign. REFLEXES: 3+ bilaterally with flexor plantar responses. There were no frontal release signs.,LABS:, CMB, General Screen, FT4, TSH, VDRL were all WNL.,NEUROPSYCHOLOGICAL EVALUATION, 12/7/92: ,Verbal associative fluency was defective. Verbal memory, including acquisition, and delayed recall and recognition, was severely impaired. Visual memory, including immediate and delayed recall was also severely impaired. Visuoperceptual discrimination was mildly impaired, as was 2-D constructional praxis.,HCT, 12/7/92: , Diffuse cerebral atrophy with associative mild enlargement of the ventricles consistent with patient's age. Calcification is seen in both globus pallidi and this was felt to be a normal variant.",33
"REASON FOR CONSULT:,  Altered mental status.,HPI:,  The patient is 77-year-old Caucasian man with benign prostatic hypertrophy, status post cardiac transplant 10 years ago who was admitted to the Physical Medicine and Rehab Service for inpatient rehab after suffering a right cerebellar infarct last month.  Last night, he became confused and he eloped from the unit.  When he was found, he became combative.  This a.m., he continued to be aggressive and required administration of four-point soft restraints in addition to Haldol 1 mg intramuscularly.  There was also documentation of him having paranoid thoughts that his wife was going out spending his money instead of being with him in the hospital.  Given this presentation, Psychiatry was consulted to evaluate and offer management recommendations.,The patient states that he does remember leaving the unit looking for his wife, but does not recall becoming combative, needing restrains and emergency medications.  He reports feeling fine currently, denying any complaints.  The patient's wife notes that her husband might be confused and disoriented due to being in the hospital environment.  She admits that he has some difficulty with memory for sometime and becomes irritable when she is not around.  However, he has never become as combative as he has this particular episode.,He negates any symptoms of depression or anxiety.  He also denies any hallucinations or delusions.  He endorses problems with insomnia.  At home, he takes temazepam.  His wife and son note that the temazepam makes him groggy and disoriented at times when he is at home.,PAST PSYCHIATRIC HISTORY:,  He denies any prior psychiatric treatment or intervention.  However, he was placed on Zoloft 10 years ago after his heart transplant, in addition to temazepam for insomnia.  During this hospital course, he was started on Seroquel 20 mg p.o. q.h.s. in addition to Aricept 5 mg daily.  He denies any history of suicidal or homicidal ideations or attempts.,PAST MEDICAL HISTORY:,1.  Heart transplant in 1997.,2.  History of abdominal aortic aneurysm repair.,3.  Diverticulitis.,4.  Cholecystectomy.,5.  Benign prostatic hypertrophy.,ALLERGIES:,  MORPHINE AND DEMEROL.,MEDICATIONS:,1.  Seroquel 50 mg p.o. q.h.s., 25 mg p.o. q.a.m.,2.  Imodium 2 mg p.o. p.r.n., loose stool.,3.  Calcium carbonate with vitamin D 500 mg b.i.d.,4.  Prednisone 5 mg p.o. daily.,5.  Bactrim DS Monday, Wednesday, and Friday.,6.  Flomax 0.4 mg p.o. daily.,7.  Robitussin 5 mL every 6 hours as needed for cough.,8.  Rapamune 2 mg p.o. daily.,9.  Zoloft 50 mg p.o. daily.,10.  B vitamin complex daily.,11.  Colace 100 mg b.i.d.,12.  Lipitor 20 mg p.o. q.h.s.,13.  Plavix 75 mg p.o. daily.,14.  Aricept 5 mg p.o. daily.,15.  Pepcid 20 mg p.o. daily.,16.  Norvasc 5 mg p.o. daily.,17.  Aspirin 325 mg p.o. daily.,SOCIAL HISTORY:,  The patient is a retired paster and missionary to Mexico.  He is still actively involved in his church.  He denies any history of alcohol or substance abuse.,MENTAL STATUS EXAMINATION:,  He is an average-sized white male, casually dressed, with wife and son at bedside.  He is pleasant and cooperative with good eye contact.  He presents with paucity of speech content; however, with regular rate and rhythm.  He is tremulous which is worse with posturing also some increased motor tone noted.  There is no evidence of psychomotor agitation or retardation.  His mood is euthymic and supple and reactive, appropriate to content with reactive affect appropriate to content.  His thoughts are circumstantial but logical.  He defers most of his responses to his wife.  There is no evidence of suicidal or homicidal ideations.  No presence of paranoid or bizarre delusions.  He denies any perceptual abnormalities and does not appear to be responding to internal stimuli.  His attention is fair and his concentration impaired.  He is oriented x3 and his insight is fair.  On mini-mental status examination, he has scored 22 out of 30.  He lost 1 for time, lost 1 for immediate recall, lost 2 for delayed recall, lost 4 for reverse spelling and could not do serial 7s.  On category fluency, he was able to name 17 animals in one minute.  He was unable to draw clock showing 2 minutes after 10.  His judgment seems limited.,LABORATORY DATA:,  Calcium 8.5, magnesium 1.8, phosphorous 3, pre-albumin 27, PTT 24.8, PT 14.1, INR 1, white blood cell count 8.01, hemoglobin 11.5, hematocrit 35.2, and platelet count 255,000.  Urinalysis on January 21, 2007, showed trace protein, trace glucose, trace blood, and small leukocyte esterase.,DIAGNOSTIC DATA:,  MRI of brain with and without contrast done on January 21, 2007, showed hemorrhagic lesion in right cerebellar hemisphere with diffuse volume loss and chronic ischemic changes.,ASSESSMENT:,AXIS I:,1.  Delirium resulting due to general medical condition versus benzodiazepine ,intoxication/withdrawal.,2.  Cognitive disorder, not otherwise specified, would rule out vascular dementia.,3.  Depressive disorder, not otherwise specified.",32
"CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY,PROCEDURE: , Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time.  Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV.  Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.,Retrospective ECG gating was performed.  The patient received 0.4 milligrams of sublingual nitroglycerin prior to the to the scan.  The average heart rate was 62 beats/min.,The patient had no adverse reaction to the contrast.  Multiphase retrospective reconstructions were performed.  Small field of view cardiac and coronary images were analyzed on a 3D work station.  Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease.,CORONARY CTA:,1.  The technical quality of the scan is adequate.,2.  The coronary ostia are in their normal position.  The coronary anatomy is right dominant.,3.  LEFT MAIN:  The left main coronary artery is patent without angiographic stenosis.,4.  LEFT ANTERIOR DESCENDING ARTERY:  The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30% in stenosis severity.  Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities.,5.  The ramus intermedius is a small vessel with minor irregularities.,6.  LEFT CIRCUMFLEX:  The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis.,7.  RIGHT CORONARY ARTERY:  The right coronary artery is a large and dominant vessel.  It demonstrates within its mid-segment calcified atherosclerosis, less than 50% stenosis severity.  Left ventricular ejection fraction is calculated to be 69%.  There are no wall motion abnormalities.,8.  Coronary calcium score was calculated to be 79, indicating at least mild atherosclerosis within the coronary vessels.,ANCILLARY FINDINGS: , None.,FINAL IMPRESSION:,1.  Mild coronary artery disease with a preserved left ventricular ejection fraction of 69%.,2.  Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy.,Thank you for referring this patient to us.",33
"HISTORY: , The patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.  She was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain, which radiates down into her buttocks and down to posterior aspect of her thigh into her knee.  This has required large amounts of opioid analgesics to control.  She has been basically bedridden because of this.  She was brought into hospital for further investigations.,PHYSICAL EXAMINATION: , On examination, she has positive straight leg rising on the right with severe shooting, radicular type pain with right leg movement.  Difficult to assess individual muscles, but strength is largely intact.  Sensory examination is symmetric.  Deep tendon reflexes reveal hyporeflexia in both patellae, which probably represents a cervical myelopathy from prior cord compression.  She has slightly decreased right versus left ankle reflexes.  The Babinski's are positive.  On nerve conduction studies, motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in lower extremities.,NEEDLE EMG: , Needle EMG was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle.  It reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles.  There is evidence of denervation in right gastrocnemius medialis muscle.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  Inactive right S1 (L5) radiculopathy.,2.  There is no evidence of left lower extremity radiculopathy, peripheral neuropathy or entrapment neuropathy.,Results were discussed with the patient and she is scheduled for imaging studies in the next day.",33
"SPECIMENS:,1.  Pelvis-right pelvic obturator node.,2.  Pelvis-left pelvic obturator node.,3.  Prostate.,POST-OPERATIVE DIAGNOSIS: , Adenocarcinoma of prostate, erectile dysfunction.,DIAGNOSTIC OPINION:,1.  Adenocarcinoma, Gleason score 9, with tumor extension to periprostatic tissue, margin involvement, and tumor invasion to seminal vesicle, prostate.,2.  No evidence of metastatic carcinoma, right pelvic obturator lymph node.,3.  Metastatic adenocarcinoma, left obturator lymph node; see description.,CLINICAL HISTORY: , None listed.,GROSS DESCRIPTION:,Specimen #1 labeled ""right pelvic obturator lymph nodes"" consists of two portions of adipose tissue measuring 2.5 x 1x 0.8 cm and 2.5 x 1x 0.5 cm.  There are two lymph nodes measuring 1 x 0.7 cm and 0.5 x 0.5 cm.  The entire specimen is cut into several portions and totally embedded.,Specimen #2 labeled ""left pelvic obturation lymph nodes"" consists of an adipose tissue measuring 4 x 2 x 1 cm.  There are two lymph nodes measuring 1.3 x 0.8 cm and 1 x 0.6 cm.  The entire specimen is cut into 1 cm.  The entire specimen is cut into several portions and totally embedded.,Specimen #3 labeled ""prostate"" consists of a prostate.  It measures 5 x 4.5 x 4 cm.  The external surface shows very small portion of seminal vesicles attached in both sides with tumor induration.  External surface also shows tumor induration especially in right side.  External surface is stained with green ink.  The cut surface shows diffuse tumor induration especially in right side.  The tumor appears to extend to excision margin.  Multiple representative sections are made.,MICROSCOPIC DESCRIPTION:,Section #1 reveals lymph node.  There is no evidence of metastatic carcinoma.,Section #2 reveals lymph node with tumor metastasis in section of large lymph node as well as section of small lymph node.,Section #3 reveals adenocarcinoma of prostate.  Gleason's score 9 (5+4).  The tumor shows extension to periprostatic tissue as well as margin involvement.  Seminal vesicle attached to prostate tissue shows tumor invasion.  Dr. XXX reviewed the above case.  His opinion agrees with the above diagnosis.,SUMMARY:,A.  Adenocarcinoma of prostate, Gleason's score 9, with both lobe involvement and seminal vesicle involvement (T3b).,B.  There is lymph node metastasis (N1).,C.  Distant metastasis cannot be assessed (MX).,D.  Excision margin is positive and there is tumor extension to periprostatic tissue.",19
"REASON FOR CONSULTATION:,  Hematuria and urinary retention.,BRIEF HISTORY: , The patient is an 82-year-old, who was admitted with the history of diabetes, hypertension, hyperlipidemia, coronary artery disease, presented with urinary retention and pneumonia.  The patient had hematuria, and unable to void.  The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed.  Foley catheter was repositioned 18 Coude was used.  About over a liter of fluids of urine was obtained with light pink urine, which was irrigated.  The bladder and the suprapubic area returned to normal after the Foley placement.  The patient had some evidence of clots upon irrigation.  The patient has had a chest CT, which showed possible atelectasis versus pneumonia.,PAST MEDICAL HISTORY:  ,Coronary artery disease, diabetes, hypertension, hyperlipidemia, Parkinson's, and CHF.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , Married and lives with wife.,HABITS:,  No smoking or drinking.,REVIEW OF SYSTEMS: , Denies any chest pain, denies any seizure disorder, denies any nausea, vomiting.  Does have suprapubic tenderness and difficulty voiding.  The patient denies any prior history of hematuria, dysuria, burning, or pain.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Vitals are stable.,GENERAL:  The patient is a thin gentleman,GENITOURINARY:  Suprapubic area was distended and bladder was palpated very easily.  Prostate was 1+.  Testes are normal.,LABORATORY DATA: , The patient's white counts are 20,000.  Creatinine is normal.,ASSESSMENT AND PLAN:,1.  Pneumonia.,2.  Dehydration.,3.  Retention.,4.  BPH.,5.  Diabetes.,6.  Hyperlipidemia.,7.  Parkinson's.,8.  Congestive heart failure.,About 30 minutes were spent during the procedure and the Foley catheter was placed, Foley was irrigated and significant amount of clots were obtained.  Plan is for urine culture, antibiotics.  Plan is for renal ultrasound to rule out any pathology.  The patient will need cystoscopy and evaluation of the prostate.  Apparently, the patient's PSA is 0.45, so the patient is at low to no risk of prostate cancer at this time.  Continued Foley catheter at this point.  We will think about starting the patient on alpha-blockers once the patient's over all medical condition is improved and stable.",5
"PROBLEM:  ,Rectal bleeding, positive celiac sprue panel.,HISTORY:  ,The patient is a 19-year-old Irish-Greek female who ever since elementary school has noted diarrhea, constipation, cramping, nausea, vomiting, bloating, belching, abdominal discomfort, change in bowel habits.  She noted that her symptoms were getting increasingly worse and so she went for evaluation and was finally tested for celiac sprue and found to have a positive tissue transglutaminase as well as antiendomysial antibody.  She has been on a gluten-free diet for approximately one week now and her symptoms are remarkably improved.  She actually has none of these symptoms since starting her gluten-free diet.  She has noted intermittent rectal bleeding with constipation, on the toilet tissue.  She feels remarkably better after starting a gluten-free diet.,ALLERGIES: , No known drug allergies.,OPERATIONS: , She is status post a tonsillectomy as well as ear tubes.,ILLNESSES: , Questionable kidney stone.,MEDICATIONS: , None.,HABITS: , No tobacco.  No ethanol.,SOCIAL HISTORY: , She lives by herself.  She currently works in a dental office.,FAMILY HISTORY: , Notable for a mother who is in good health, a father who has joint problems and questionable celiac disease as well.  She has two sisters and one brother.  One sister interestingly has inflammatory arthritis.,REVIEW OF SYSTEMS:  ,Notable for fever, fatigue, blurred vision, rash and itching; her GI symptoms that were discussed in the HPI are actually resolved in that she started the gluten-free diet.  She also notes headaches, anxiety, heat and cold intolerance, excessive thirst and urination.  Please see symptoms summary sheet dated April 18, 2005.,PHYSICAL EXAMINATION:  , GENERAL:  She is a well-developed pleasant 19 female.  She has a blood pressure of 120/80, a pulse of 70, she weighs 170 pounds.  She has anicteric sclerae.  Pink conjunctivae.  PERRLA.  ENT:  MMM.  NECK:  Supple.  LUNGS: Clear to auscultation.",14
"EXAM:  ,Ultrasound neck/soft tissue, head.,HISTORY: , Right-sided facial swelling and draining wound.,TECHNIQUE AND FINDINGS:,  Ultrasound of the right mandibular region was performed.,No focal collection is identified.  This whole region appears to be phlegmonous.  It is hard to adequately delineate the exact margins of this region.,IMPRESSION:  ,Abnormal appearing right mandibular region has more phlegmonous changes.  No focal fluid collection.,Had a discussion with Dr. xx.  Consider CT for further evaluation.",33
"PREOPERATIVE DIAGNOSES:,  Prior history of anemia, abdominal bloating.,POSTOPERATIVE DIAGNOSIS:,  External hemorrhoids, otherwise unremarkable colonoscopy.,PREMEDICATIONS:,  Versed 5 mg, Demerol 50 mg IV.,REPORT OF PROCEDURE:,  Digital rectal exam revealed external hemorrhoids.  The colonoscope was inserted into the rectal ampulla and advanced to the cecum.  The position of the scope within the cecum was verified by identification of the appendiceal orifice.  The cecum, the ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, and rectum were normal.  The scope was retroflexed in the rectum and no abnormality was seen.  So the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Normal colonoscopy.,2.  External hemorrhoids.",14
"PREOPERATIVE DIAGNOSIS: , Left cervical radiculopathy.,POSTOPERATIVE DIAGNOSIS:  ,Left cervical radiculopathy.,PROCEDURES PERFORMED:,1.  C5-C6 anterior cervical discectomy.,2.  Bone bank allograft.,3.  Anterior cervical plate.,TUBES AND DRAINS LEFT IN PLACE: , None.,COMPLICATIONS: , None.,SPECIMEN SENT TO PATHOLOGY: , None.,ANESTHESIA: , General endotracheal.,INDICATIONS: , This is a middle-aged man who presented to me with left arm pain.  He had multiple levels of disease, but clinically, it was C6 radiculopathy.  We tested him in the office and he had weakness referable to that nerve.  The procedure was done at that level.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room at which time an intravenous line was placed.  General endotracheal anesthesia was obtained.  He was positioned supine in the operative area and the right neck was prepared.,An incision was made and carried down to the ventral spine on the right in the usual manner.  An x-ray confirmed our location.,We were impressed by the degenerative change and the osteophyte overgrowth.,As we had excepted, the back of the disk space was largely closed off by osteophytes.  We patiently drilled through them to the posterior ligament.  We went through that until we saw the dura.,We carefully went to the patient's symptomatic, left side.  The C6 foramen was narrowed by uncovertebral joint overgrowth.  The foramen was open widely.,An allograft was placed.  An anterior Steffee plate was placed.  Closure was commenced.,The wound was closed in layers with Steri-Strips on the skin.  A dressing was applied.,It should be noted that the above operation was done also with microscopic magnification and illumination.",37
"PREOPERATIVE DIAGNOSIS:,  Hammertoe deformity of the right second digit.,POSTOPERATIVE DIAGNOSIS: , Hammertoe deformity of the right second digit.,PROCEDURE PERFORMED: , Arthroplasty of the right second digit.,The patient is a 77-year-old Hispanic male who presents to ABCD Hospital for surgical correction of a painful second digit hammertoe.  The patient has failed attempts at conservative treatment and is unable to wear shoes without pain to his second toe.  The patient presents n.p.o. since mid night last night and consented to sign in the chart.  H&P is complete.,PROCEDURE IN DETAIL:,  After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was escorted to the operating room and placed on the table in the supine position.  Using Webril, the distal leg and ankle was padded and a ankle pneumatic tourniquet was placed around the right ankle, but left deflated at this time.  Restraining, a lap belt was then placed around the patient's abdomen while laying on the table.  After adequate anesthesia was administered by the Department of Anesthesia, a local digital block using 5 cc of 0.5% Marcaine plain was used to provide local anesthesia.  The foot was then prepped and draped in the normal sterile orthopedic manner.  The foot was then elevated and Esmarch bandage was applied, after which time the tourniquet was inflated to 250 mmHg.  The foot was then brought down to the level of the table and stockinet was cut and reflected after the Esmarch bandage was removed.  A wet and dry sponge was then used to cleanse the operative site and using a skin skribe a dorsal incisional line was outlined extending from the proximal phalanx over the proximal interphalangeal joint on to the middle phalanx.,Then using a fresh #15 blade, a dorsolinear incision was made, partial thickness through the skin after testing anesthesia with one to two pickup.  Then using a fresh #15 blade, incision was deepened and using medial to lateral pressure, the incision was opened into the subcutaneous tissue.  Care was taken to reflect the subcutaneous tissue from the underlying deep fascia to mobilize the skin.  This was performed with the combination of blunt and dull dissection.  Care was taken to avoid proper digital arteries and neurovascular bundles as were identified.  Attention was then directed to the proximal interphalangeal joint and after identifying the joint line, a transverse linear incision was made over the dorsal surface of the joint.  The medial and lateral sides of the joint capsule were then also incised on the superior half in order to provide increased exposure.  Following this, the proximal portion of the transected extensor digitorum longus tendon was identified using an Adson-Brown pickup.  It was elevated with fresh #15 blade.  The tendon and capsule was reflected along with the periosteum from the underlying bone dorsally.  Following this, the distal portion of the tendon was identified in a like manner.  The tendon and the capsule as well as the periosteal tissue was reflected from the dorsal surface of the bone.  The proximal interphalangeal joint was then distracted and using careful technique, #15 blade was used to deepen the incision and while maintaining close proximity to the bone and condyles, the lateral and medial collateral ligaments were freed up from the side of the proximal phalanx head.,Following this, the head of the proximal phalanx was known to have adequate exposure and was freed from soft tissues.  Then using a sagittal saw with a #139 blade, the head of he proximal phalanx was resected.  Care was taken to avoid the deep flexor tendon.  The head of the proximal phalanx was taken with the Adson-Brown and using a #15 blade, the plantar periosteal tissue was freed up and the head was removed and sent to pathology.  The wound was then flushed using a sterile saline with gentamicin and the digit was noted to be in good alignment.  The digit was also noted to be in rectus alignment.  Proximal portion of the tendon was shortened to allow for removal of the redundant tendon after correction of the deformity.  Then using a #3-0 Vicryl suture, three simple interrupted sutures were placed for closure of the tendon and capsular tissue.  Then following this, #4-0 nylon was used in a combination of horizontal mattress and simple interrupted sutures to close the skin.  The toe was noted to be in good alignment and then 1 cc of dexamethasone phosphate was injected into the incision site.  Following this, the incision was dressed using a sterile Owen silk soaked in saline and gentamicin.  The toe was bandaged using 4 x 4s, Kling, and Coban.  The tourniquet was deflated and immediate hyperemia was noted to the digits I through V of the right foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit where the patient was given postoperative surgical shoe.  Total tourniquet time for the case was 30 minutes.  While in the recovery, the patient was given postoperative instructions to include, ice and elevation to his right foot.  The patient was given pain medications of Tylenol #3, quantity 30 to be taken one to two tablets every six to eight hours as necessary for moderate to severe pain.  The patient was also given prescription for cane to aid in ambulation.  The patient will followup with Dr. X on Tuesday in his office for postoperative care.  The patient was instructed to keep the dressings clean, dry, and intact and to not remove them before his initial office visit.  The patient tolerated the procedure well and the anesthesia with no complications.",37
"DESCRIPTION:,1.  Normal cardiac chambers size.,2.  Normal left ventricular size.,3.  Normal LV systolic function.  Ejection fraction estimated around 60%.,4.  Aortic valve seen with good motion.,5.  Mitral valve seen with good motion.,6.  Tricuspid valve seen with good motion.,7.  No pericardial effusion or intracardiac masses.,DOPPLER:,1.  Trace mitral regurgitation.,2.  Trace tricuspid regurgitation.,IMPRESSION:,1.  Normal LV systolic function.,2.  Ejection fraction estimated around 60%.,",33
"CHIEF COMPLAINT: , ""A lot has been thrown at me."",The patient is interviewed with husband in room.,HISTORY OF PRESENT ILLNESS: , This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets.  She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today.  The patient states she had been thinking about suicide for a couple of weeks.  Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble.  Reports she has been not socializing with her family because of her worsening depression.  Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth.  They did as they have instructed and husband feels this may have had some factor on her worsening depression.  The patient decided to ingest the pills when her husband went to work on Friday.  She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened.  Her husband left around 7 in the morning and returned around 11 and found her sleeping.  About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital.,She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene.  She does not clearly explain how this has made her suicidality subside.,This is the third suicide attempt in the last two months for this patient.  About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall.  She was taken to Southwest Memorial Hermann Hospital.  A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor.  Husband locked the gun after that and she was taken to Bellaire Hospital.  The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days.  She sees Dr. X once or twice weekly.  He started seeing her after her first suicide attempt.,The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active.  Since then she has had worsening of her Huntington symptoms including short-term memory loss.  At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath.  The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease.,The patient's mother passed away 25 years ago from Huntington's.  Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's.  The patient has told her husband that she does not want to go that way.  The patient denies auditory or visual hallucinations, denies paranoid ideation.  The husband and the patient deny any history of manic or hypomanic symptoms in the past.,PAST PSYCHIATRIC HISTORY: , As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X.  She has a remote history of being on Lexapro for depression.,MEDICATIONS: , Her medications on admission, alprazolam 0.5 mg p.o. b.i.d., Artane 2 mg p.o. b.i.d., Haldol 2.5 mg p.o. t.i.d., Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily.  Husband has stated that the patient's chorea becomes better when she takes Haldol.  Alprazolam helps her with anxiety symptoms.,PAST MEDICAL HISTORY: , Huntington disease, symptoms of dementia and hypertension.  She has an upcoming appointment with the Neurologist.  Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y.,ALLERGIES: , CODEINE AND KEFLEX.,FAMILY MEDICAL HISTORY:  ,Strong family history for Huntington disease as per the HPI.  Mother and grandmother died of Huntington disease.  Two young brothers also had Huntington disease.,FAMILY PSYCHIATRIC HISTORY: , The patient denies history of depression, bipolar, schizophrenia, or suicide attempts.,SOCIAL HISTORY:  ,The patient lives with her husband of 48 years.  She used to be employed as a registered nurse.  Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions.  She rarely drinks socially.  She denies any illicit substance usage.  Her husband reportedly gives her medication daily.  Has been proactive in terms of seeking mental health care and medical care.  The patient and husband report that from March 2009, she has been relatively independent, more socially active.,MENTAL STATUS EXAM:  ,This is an elderly woman appearing stated age.  Alert and oriented x4 with poor eye contact.  Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips.  She is cooperative.  Her speech is of low volume and slow rate and rhythm.  Her mood is sad.  Her affect is constricted.  Her thought process is logical and goal-directed.  Her thought content is negative for current suicidal ideation.  No homicidal ideation.  No auditory or visual hallucinations.  No command auditory hallucinations.  No paranoia.  Insight and judgment are fair and intact.,LABORATORY DATA:,  A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality.  U-tox positive for amphetamines and tricyclic antidepressants.  Acetaminophen level 206.7, alcohol level 0.  The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4.,ASSESSMENT: , This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.  She took 30 tablets of Haldol and 40 tablets of Tylenol.  At present, the patient is without suicidal ideation.  She reports that her worsening depression has coincided with her worsening Huntington disease.  She is more hopeful today, feels that she may be able to get help with her depression.,The patient was admitted four days ago to the medical floor and has subsequently been stabilized.  Her liver function tests are within normal limits.,AXIS I:  Major depressive disorder due to Huntington disease, severe.  Cognitive disorder, NOS.,AXIS II:  Deferred.,AXIS III:  Hypertension, Huntington disease, status post overdose.,AXIS IV:  Chronic medical illness.,AXIS V:  30.,PLAN,1.  Safety.  The patient would be admitted on a voluntary basis to Main-7 North.  She will be placed on every 15-minute checks with suicidal precautions.,2.  Primary psychiatric issues/medical issues.  The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h., Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.,3.  Substance abuse.  No acute concern for alcohol or benzo withdrawal.,4.  Psychosocial.  Team will update and involve family as necessary.,DISPOSITION: , The patient will be admitted for evaluation, observation, treatment.  She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy.  We will place occupational therapy consult and social work consults.",5
"CAUSE OF DEATH:,1.  Acute respiratory failure.,2.  Chronic obstructive pulmonary disease exacerbation.,SECONDARY DIAGNOSES:,1.  Acute respiratory failure, probably worsened by aspiration.,2.  Acute on chronic renal failure.,3.  Non-Q wave myocardial infarction.,4.  Bilateral lung masses.,5.  Occlusive carotid disease.,6.  Hypertension.,7.  Peripheral vascular disease.,HOSPITAL COURSE:  ,This 80-year-old patient with a history of COPD had had recurrent admissions over the past few months.  The patient was admitted again on 12/15/08, after he had been discharged the previous day.  Came in with acute on chronic respiratory failure, with CO2 of 57.  The patient was in rapid atrial fibrillation.  RVR with a rapid ventricular response of 160 beats per minute.  The patient was on COPD exacerbation and CHF due to rapid atrial fibrillation.  The patient's heart rate was controlled with IV Cardizem.  Troponin was consistent with non-Q wave MI.  The patient was treated medically transfer to catheterize the patient to evaluate her coronary artery disease.  Echocardiogram showed normal ejection fraction, normal left and right side, but stage 3 restrictive physiology.  There was also prosthetic aortic valve.  The patient was admitted to Intensive Care Unit and was intubated.  Pulmonary was managed by Critical Care, Dr. X.,The patient was successfully extubated.  Was tapered from IV steroids and put on p.o. steroids.  The patient's renal function has stabilized with a creatinine of between 2.1 and 2.3.  There was contemplation as to whether left heart catheterization should proceed since Nephrology was concerned about the patient's renal status.  Wife decided catheterization should be canceled and the patient managed conservatively.  The patient was transferred to the telemetry floor.  While in telemetry floor, the patient's renal function started deteriorating, went up from 2.08 to 2.67 in two days.  The patient had nausea and vomiting.  Was unable to tolerate p.o.  Was put on cautious hydration.  The patient went into acute respiratory distress.  Intubation showed the patient had aspirated.  He was in acute respiratory failure with bronchospasms and exacerbation of COPD.  X-ray of chest did not show any infiltrate, but showed dilatation of the stomach.  The patient was transferred to the Intensive Care Unit because of acute respiratory failure, was intubated by Critical Care, Dr. X.  The patient was put on the vent.  Overnight, the patient's condition did not improve.  Continued to be severely hypoxic.,The patient expired on the morning of 12/24/08 from acute respiratory failure.",10
"PREOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 39 plus weeks gestation.,2.  Gestational hypertension.,3.  Thick meconium.,4.  Failed vacuum attempted delivery.,POSTOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 39 plus weeks gestation.,2.  Gestational hypertension.,3.  Thick meconium.,4.  Failed vacuum attempted delivery.,OPERATION PERFORMED: , Spontaneous vaginal delivery.,ANESTHESIA: , Epidural was placed x2.,ESTIMATED BLOOD LOSS:,  500 mL.,COMPLICATIONS: , Thick meconium.  Severe variables, Apgars were 2 and 7.  Respiratory therapy and ICN nurse at delivery.  Baby went to Newborn Nursery.,FINDINGS: , Male infant, cephalic presentation, ROA.  Apgars 2 and 7.  Weight 8 pounds and 1 ounce.  Intact placenta.  Three-vessel cord.  Third degree midline tear.,DESCRIPTION OF OPERATION: , The patient was admitted this morning for induction of labor secondary to elevated blood pressure, especially for the last three weeks.  She was already 3 cm dilated.  She had artificial rupture of membranes.  Pitocin was started and she actually went to complete dilation.  While pushing, there was sudden onset of thick meconium, and she was having some severe variables and several late decelerations.  When she was complete +2, vacuum attempted delivery, three pop-offs were done.  The vacuum was then no longer used after the three pop-offs.  The patient pushed for a little bit longer and had a delivery, ROA, of a male infant, cephalic, over a third-degree midline tear.  Secondary to the thick meconium, DeLee suctioned nose and mouth before the anterior shoulder was delivered and again after delivery.  Baby was delivered floppy.  Cord was clamped x2 and cut, and the baby was handed off to awaiting ICN nurse and respiratory therapist.  Delivery of intact placenta and three-vessel cord.  Third-degree midline tear was repaired with Vicryl without any complications.  Baby initially did well and went to Newborn Nursery, where they are observing him a little bit longer there.  Again, mother and baby are both doing well.  Mother will go to Postpartum and baby is already in Newborn Nursery.",24
"TITLE OF OPERATION:,  Bilateral endoscopic proximal shunt revision and a distal shunt revision.,INDICATIONS FOR OPERATION:,  Headaches, full subtemporal site.,PREOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,POSTOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,FINDINGS:,  Coaptation of ventricles against proximal end of ventricular catheter.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES: , A Codman Hakim programmable valve with Portnoy ventricular catheter, a 0/20 proGAV valve with a shunt assist of 20 cm dual right-angled connector, and a flushing reservoir.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the prone position with the head held on a soft foam padding.  The occipital area was shaven bilaterally and then the areas of the prior scalp incisions were infiltrated with 0.25% Marcaine with 1:200,000 epinephrine after routine prepping and draping.  Both U-shaped scalp incisions were opened exposing both the left and the right ventricular catheters as well as the old low pressure reservoir, which might have been leading to the coaptation of the ventricles.  The patient also had a right subtemporal depression, which was full preoperatively.  The entire old apparatus was dissected out.  We then cut both the ventricular catheters and secured them with sutures so that __________ could be inserted.  They were both inspected.  No definite debris were seen.  After removing the ventricular catheters, the old tracts were inspected and we could see where there was coaptation of the ventricles against the ventricular catheter.  On the right side, we elected to insert the Portnoy ventricular catheter and on the left a new Bactiseal catheter was inserted underneath the corpus callosum in a different location.  The old valve was dissected out and the proGAV valve with a 2-0 shunt assist was inserted and secured with a 2-0 Ethibond suture.  The proGAV valve was then connected to a Bactiseal distal tubing, which was looped in a cephalad way and then curved towards the left burr hole site and then the Portnoy catheter on the right was secured with a right-angled sleeve and then interposed between it and the left burr hole site with a flushing reservoir.  All connections secured with 2-0 Ethibond suture and a small piece of Bactiseal tubing between the flushing reservoir and the connector, which secured the left Bactiseal tubing to the two other Bactiseal tubings one being the distal Bactiseal tubing going towards the proGAV valve, which was set to an opening pressure of 8 and the other one being the Bactiseal tubing, which was going towards the flushing reservoir.,All the wounds were irrigated out with bacitracin and then closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well without complications.  CSF was not sent off.",23
"CHIEF COMPLAINT:, Stomach pain for 2 weeks.,HISTORY OF PRESENT ILLNESS:, The patient is a 45yo Mexican man without significant past medical history who presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days. The pain was initially crampy and burning in character and was relieved with food intake. He also reports that it initially was associated with a sour taste in his mouth. He went to his primary care physician who prescribed cimetidine 400mg qhs x 5 days; however, this did not relieve his symptoms. In fact, the pain has worsened such that the pain now radiates to the back but is waxing and waning in duration. It is relieved with standing and ambulation and exacerbated when lying in a supine position. He reports a decrease in appetite associated with a 4 lb. wt loss over the last 2 wks. He does have nausea with only one episode of non-bilious, non-bloody emesis on day of admission. He reports a 2 wk history of subjective fever and diaphoresis. He denies any diarrhea, constipation, dysuria, melena, or hematochezia. His last bowel movement was during the morning of admission and was normal. He denies any travel in the last 9 years and sick contacts.,PAST MEDICAL HISTORY:, Right inguinal groin cyst removal 15 years ago. Unknown etiology. No recurrence.,PAST SURGICAL HISTORY:, Left femoral neck fracture with prosthesis secondary to a fall 4 years ago.,FAMILY HISTORY:, Mother with diabetes. No history of liver disease. No malignancies.,SOCIAL HISTORY:, The patient was born in central Mexico but moved to the United States 9 years ago. He is on disability due to his prior femoral fracture. He denies any tobacco or illicit drug use. He only drinks alcohol socially, no more than 1 drink every few weeks. He is married and has 3 healthy children. He denies any tattoos or risky sexual behavior.,ALLERGIES:, NKDA.,MEDICATIONS:, Tylenol prn (1-2 tabs every other day for the last 2 wks), Cimetidine 400mg po qhs x 5 days.,REVIEW OF SYSTEMS:,  No headache, vision changes. No shortness of breath. No chest pain or palpitations.,PHYSICAL EXAMINATION:,Vitals: T 100.9-102.7 BP 136/86 Pulse 117 RR 12 98% sat on room air,Gen: Well-developed, well-nourished, no apparent distress.,HEENT: Pupils equal, round and reactive to light. Anicteric. Oropharynx clear and moist.,Neck: Supple. No lymphadenopathy or carotid bruits. No thyromegaly or masses.,CHEST: Clear to auscultation bilaterally.,CV: Tachycardic but regular rhythm, normal S1/S2, no murmurs/rubs/gallops.,Abd: Soft, active bowel sounds. Tender in the epigastrium and right upper quadrant with palpation associated with slight guarding. No rebound tenderness. No hepatomegaly. No splenomegaly.,Rectal: Stool was brown and guaiac negative.,Ext: No cyanosis/clubbing/edema.,Neurological: He was alert and oriented x3. CN II-XII intact. Normal 2+ DTRs. No focal neurological deficit.,Skin: No jaundice. No skin rashes or lesions.,IMAGING DATA:,CT Abdomen with contrast ( 11/29/03 ):  There is a 6x6 cm multilobular hypodense mass seen at the level of the hepatic hilum and caudate lobe which is resulting in mass effect with dilatation of the intrahepatic radicals of the left lobe of the liver. The rest of the liver parenchyma is homogeneous. The gallbladder, pancreas, spleen, adrenal glands and kidneys are within normal limits. The retroperitoneal vascular structures are within normal limits. There is no evidence of lymphadenopathy, free fluid or fluid collections.,HOSPITAL COURSE:,  The patient was admitted to the hospital for further evaluation. A diagnostic procedure was performed.",12
"CHIEF COMPLAINT:,  GI bleed.,HISTORY OF PRESENT ILLNESS:,  The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue.  CBC revealed microcytic anemia with hemoglobin of 8.9.  Stool dark brown, strongly OB positive.  The patient denied any shortness of breath.  No chest pain.  No GI complaints.  The patient was admitted to ABCD for further evaluation.,PAST MEDICAL HISTORY:  ,Significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism.,PHYSICAL EXAMINATION:,GENERAL:  The patient is in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Benign.,NECK:  Supple.  No adenopathy.,LUNGS:  Clear with good air movement.,HEART:  Irregularly regular.  No gallops.,ABDOMEN:  Positive bowel sounds, soft, and nontender.  No masses or organomegaly.,EXTREMITIES:  1+ lower extremity edema bilaterally.,HOSPITAL COURSE: , The patient underwent upper endoscopy performed by Dr. A, which revealed erosive gastritis.  Colonoscopy did reveal diverticulosis as well as polyp, which was resected.  The patient tolerated the procedure well.  She was transfused, and prior to discharge hemoglobin was stable at 10.7.  The patient was without further GI complaints.  Coumadin was held during hospital stay and recommendations were given by GI to hold Coumadin for an additional three days after discharge then resume.  The patient was discharged with outpatient PMD, GI, and Cardiology followup.,DISCHARGE DIAGNOSES:,1.  Upper gastrointestinal bleed.,2.  Anemia.,3.  Atrial fibrillation.,4.  Non-insulin-dependent diabetes mellitus.,5.  Hypertension.,6.  Hypothyroidism.,7.  Asthma.,CONDITION UPON DISCHARGE: , Stable.,MEDICATIONS: , Feosol 325 mg daily, multivitamins one daily, Protonix 40 mg b.i.d., KCl 20 mEq daily, Lasix 40 mg b.i.d., atenolol 50 mg daily, Synthroid 80 mcg daily, Actos 30 mg daily, Mevacor 40 mg daily, and lisinopril 20 mg daily.,ALLERGIES:,  None.,DIET: , 1800-calorie ADA.,ACTIVITY: , As tolerated.,FOLLOWUP: , The patient to hold Coumadin through weekend.  Followup CBC and INR were ordered.  Outpatient followup as arranged.",14
"INDICATIONS FOR PROCEDURE: , A 79-year-old Filipino woman referred for colonoscopy secondary to heme-positive stools.  Procedure done to rule out generalized diverticular change, colitis, and neoplasia.,DESCRIPTION OF PROCEDURE: , The patient was explained the procedure in detail, possible complications including infection, perforation, adverse reaction of medication, and bleeding.  Informed consent was signed by the patient.,With the patient in left decubitus position, had received a cumulative dose of 4 mg of Versed and 75 mg of Demerol, using Olympus video colonoscope under direct visualization was advanced to the cecum.  Photodocumentation of appendiceal orifice and the ileocecal valve obtained.  Cecum was slightly obscured with stool but the colon itself was adequately prepped.  There was no evidence of overt colitis, telangiectasia, or overt neoplasia.  There was moderately severe diverticular change, which was present throughout the colon and photodocumented.  The rectal mucosa was normal and retroflexed with mild internal hemorrhoids.  The patient tolerated the procedure well without any complications.,IMPRESSION:,1.  Colonoscopy to the cecum with adequate preparation.,2.  Long tortuous spastic colon.,3.  Moderately severe diverticular changes present throughout.,4.  Mild internal hemorrhoids.,RECOMMENDATIONS:,1.  Clear liquid diet today.,2.  Follow up with primary care physician as scheduled from time to time.,3.  Increase fiber in diet, strongly consider fiber supplementation.",14
"EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.",11
"HISTORY OF PRESENT ILLNESS:,  Ms. A is a 55-year-old female who presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.  The patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including Weight Watchers, NutriSystem, Jenny Craig, TOPS, cabbage diet, grape fruit diet, Slim-Fast, Richard Simmons, as well as over-the-counter measures without any long-term sustainable weight loss.  At the time of presentation to the practice, she is 5 feet 6 inches tall with a weight of 285.4 pounds and a body mass index of 46.  She has obesity-related comorbidities, which includes hypertension and hypercholesterolemia.,PAST MEDICAL HISTORY:,  Significant for hypertension, for which the patient takes Norvasc and Lopressor for.  She also suffers from high cholesterol and is on lovastatin for this.  She has depression, for which she takes citalopram.  She also stated that she had a DVT in the past prior to her hysterectomy.  She also suffers from thyroid disease in the past though this is unclear, the nature of this.,PAST SURGICAL HISTORY: , Significant for cholecystectomy in 2008 for gallstones.  She also had a hysterectomy in 1994 secondary to hemorrhage.  The patient denies any other abdominal surgeries.,MEDICATIONS: , Norvasc 10 mg p.o. daily, Lopressor tartrate 50 mg p.o. b.i.d., lovastatin 10 mg p.o. at bedtime, citalopram 10 mg p.o. daily, aspirin 500 mg three times a day, which is currently stopped, vitamin D, Premarin 0.3 mg one tablet p.o. daily, currently stopped, omega-3 fatty acids, and vitamin D 50,000 units q. weekly.,ALLERGIES: , The patient denies allergies to medications and to latex.,SOCIAL HISTORY: , The patient is a homemaker.  She is married, with 2 children aged 22 and 28.  She is a lifelong nonsmoker and nondrinker.,FAMILY HISTORY:  ,Significant for high blood pressure and diabetes as well as cancer on her father side.  He did pass away from congestive heart failure.  Mother suffers from high blood pressure, cancer, and diabetes.  Her mother has passed away secondary to cancer.  She has two brothers one passed away from brain cancer.,REVIEW OF SYSTEMS: , Significant for ankle swelling.  The patient also wears glasses for vision and has dentures.  She does complain of shortness of breath with exertion.  She also suffers from hemorrhoids and frequent urination at night as well as weightbearing joint pain.  The patient denies ulcerative colitis, Crohn disease, bleeding diathesis, liver disease, or kidney disease.  She denies chest pain, cardiac disease, cancer, and stroke.,PHYSICAL EXAMINATION:  ,The patient is a well-nourished, well-developed female, in no distress.  Eye Exam:  Pupils equal and reactive to light.  Extraocular motions are intact.  Neck Exam:  No cervical lymphadenopathy.  Midline trachea.  No carotid bruits.  Nonpalpable thyroid.  Neuro Exam:  Gross motor strength in the upper and lower extremities, equal bilaterally with no focal neuro deficits noted.  Lung Exam:  Clear breath sounds without rhonchi or wheezes.  Cardiac Exam:  Regular rate and rhythm without murmur or bruits.  Abdominal Exam:  Positive bowel sounds.  Soft, nontender, obese, and nondistended abdomen.  Lap cholecystectomy scars noted.  No obvious hernias.  No organomegaly appreciated.  Lower extremity Exam:  Edema 1+.  Dorsalis pedis pulses 2+.,ASSESSMENT:  ,The patient is a 55-year-old female with a body mass index of 46, suffering from obesity-related comorbidities including hypertension and hypercholesterolemia, who presents to the practice for consideration of gastric bypass surgery.  The patient appears to be an excellent candidate for surgery and would benefit greatly from surgical weight loss in the management of her obesity-related comorbidities.,PLAN: , In preparation for surgery, we will obtain the usual baseline laboratory values including baseline vitamin levels.  I recommended the patient undergo an upper GI series prior to surgery due to find her upper GI anatomy.  Also the patient will meet with the dietitian and psychologist as per her usual routine.  I have recommended approximately six to eight weeks of Medifast for the patient to obtain a 10% preoperative weight loss in preparation for surgery.",5
"PREOPERATIVE DIAGNOSIS:  ,Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,PROCEDURE: , Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation.  ME 30, AC 25.0 diopter lens was used.,COMPLICATIONS:  ,None.,ANESTHESIA: , Local 2%, peribulbar lidocaine.,PROCEDURE NOTE:  ,Right eye was prepped and draped in the normal sterile fashion.  Lid speculum placed in his right eye.  Paracentesis made supratemporally.  Viscoat injected into the anterior chamber.  A 2.8 mm metal keratome blade was then used to fashion a clear corneal beveled incision temporally.  This was followed by circular capsulorrhexis and hydrodissection of the nucleus would be assessed.  Nuclear material removed via phacoemulsification.  Residual cortex removed via irrigation and aspiration.  The posterior capsule was clear and intact.  Capsular bag was then filled with Provisc solution.  The wound was enlarged to 3.5 mm with the keratoma.  The lens was folded in place into the capsular bag.  Residual Provisc was irrigated from the eye.  The wound was secured with one 10-0 nylon suture.  The lid speculum was removed.  One drop of 5% povidone-iodine prep was placed into the eye as well as a drop of Vigamox and TobraDex ointment.  He had a patch placed on it.  The patient was transported to the recovery room in stable condition.",26
"PROCEDURES:,1.  Chest x-ray on admission, no acute finding, no interval change.,2.  CT angiography, negative for pulmonary arterial embolism.,3.  Nuclear myocardial perfusion scan, abnormal.  Reversible defect suggestive of ischemia, ejection fraction of 55%.,DIAGNOSES ON DISCHARGE:,1.  Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.,2.  Coronary artery disease, abnormal nuclear scan, discussed with Cardiology Dr. X, who recommended to discharge the patient and follow up in the clinic.,3.  Diabetes mellitus type 2.,4.  Anemia, hemoglobin and hematocrit stable.,5.  Hypokalemia, replaced.,6.  History of coronary artery disease status post stent placement 2006-2008.,7.  Bronchitis.,HOSPITAL COURSE:  ,The patient is a 65-year-old American-native Indian male, past medical history of heavy tobacco use, history of diabetes mellitus type 2, chronic anemia, COPD, coronary artery disease status post stent placement, who presented in the emergency room with increasing shortness of breath, cough productive for sputum, and orthopnea.  The patient started on IV steroid, bronchodilator as well as antibiotics.,He also complained of chest pain that appears to be more pleuritic with history of coronary artery disease and orthopnea.  He was evaluated by Cardiology Dr. X, who proceeded with stress test.  Stress test reported positive for reversible ischemia, but Cardiology decided to follow up the patient in the clinic.  The patient's last cardiac cath was in 2008.,The patient clinically significantly improved and wants to go home.  His hemoglobin on admission was 8.8, and has remained stable.  He is afebrile, hemodynamically stable.,ALLERGIES: , LISINOPRIL AND PENICILLIN.,MEDICATIONS ON DISCHARGE:,1.  Prednisone tapering dose 40 mg p.o. daily for three days, then 30 mg p.o. daily for three days, then 20 mg p.o. daily for three days, then 10 mg p.o. daily for three days, and 5 mg p.o. daily for two days.,2.  Levaquin 750 mg p.o. daily for 5 more days.,3.  Protonix 40 mg p.o. daily.,4.  The patient can continue other current home medications at home.,FOLLOWUP APPOINTMENTS:,1.  Recommend to follow up with Cardiology Dr. X's office in a week.,2.  The patient is recommended to see Hematology Dr. Y in the office for workup of anemia.,3.  Follow up with primary care physician's office tomorrow.,SPECIAL INSTRUCTIONS:,1.  If increasing shortness of breath, chest pain, fever, any acute symptoms to return to emergency room.,2.  Discussed about discharge plan, instructions with the patient by bedside.  He understands and agreed.  Also discussed discharge plan instructions with the patient's nurse.",3
"PREOPERATIVE DIAGNOSIS:,  Prostate cancer.,POSTOPERATIVE DIAGNOSIS:,  Prostate cancer.,OPERATIONS: , Brachytherapy, iodine-125 seed implantation, and cystoscopy.,ANESTHESIA:,  LMA.,ESTIMATED BLOOD LOSS: , Minimal.,Total number of seeds placed, 63.  Needles, 24.,BRIEF HISTORY OF THE PATIENT: , This is a 57-year-old male who was seen by us for elevated PSA.  The patient had a prostate biopsy with T2b disease, Gleason 6.  Options such as watchful waiting, robotic prostatectomy, seed implantation with and without radiation were discussed.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, incontinence, rectal dysfunction, voiding issues, burning pain, unexpected complications such as fistula, rectal injury, urgency, frequency, bladder issues, need for chronic Foley for six months, etc., were discussed.  The patient understood all the risks, benefits, and options, and wanted to proceed with the procedure.  The patient was told that there could be other unexpected complications.  The patient has history of urethral stricture.  The patient was told about the risk of worsening of the stricture with radiation.  Consent was obtained.,DETAILS OF THE OPERATION: , The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the dorsal lithotomy position.  The patient had SCDs on.  The patient was given preop antibiotics.  The patient had done bowel prep the day before.  Transrectal ultrasound was performed.  The prostate was measured at about 32 gm.  The images were transmitted to the computer system for radiation oncologist to determine the dosing etc.  Based on the computer analysis, the grid was placed.  Careful attention was drawn to keep the grid away from the patient.  There was a centimeter distance between the skin and the grid.  Under ultrasound guidance, the needles were placed, first in the periphery of the prostate, a total of 63 seeds were placed throughout the prostate.  A total of 24 needles was used.  Careful attention was drawn to stay away from the urethra.  Under longitudinal ultrasound guidance, all the seeds were placed.  There were no seeds visualized in the bladder under ultrasound.  There was only one needle where the seeds kind of dragged as the needle was coming out on the left side and were dropped out of position.  Other than that, all the seeds were very well distributed throughout the prostate under fluoroscopy.  Please note that the Foley catheter was in place throughout the procedure.  Prior to the seed placement, the Foley was attempted to be placed, but we had to do it using a Glidewire to get the Foley in and we used a Councill-tip catheter.  The patient has had history of bulbar urethral stricture.  Pictures were taken of the strictures in the pre-seed placement cysto time frame.  We needed to do the cystoscopy and Glidewire to be able to get the Foley catheter in.  At the end of the procedure, again cystoscopy was done, the entire bladder was visualized.  The stricture was wide open.  The prostate was slightly enlarged.  The bladder appeared normal.  There was no sheath inside the urethra or in the bladder.  The cysto was done using 30-degree and 70-degree lens.  At the end of the procedure, a Glidewire was placed, and 18 Councill-tip catheter was placed.  The plan was for Foley to be left in place overnight since the patient has history of urethral strictures.  The patient is to follow up tomorrow to have the Foley removed.  The patient could also be shown to have it removed at home.,The patient was brought to Recovery in stable condition at the end of the procedure.  The patient tolerated the procedure well.",37
"CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.  She had no difficulty breathing and her cough was described as dry and hacky.  At that time, physical exam showed a right TM, which was red.  Left TM was okay.  She was fairly congested but looked happy and playful.  She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear.  Mom returned to clinic again today because she got much worse overnight.  She was having difficulty breathing.  She was much more congested and her appetite had decreased significantly today.  She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS:  ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY:  ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces.  No complications.  Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY:  ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her respiratory rate was approximately 60 to 65.,GENERAL:  She was very congested and she looked miserable.  She had no retractions at this time.,HEENT:  Her right TM was still red and irritated with no light reflex.  Her nasal discharge was thick and whitish yellow.  Her throat was clear.  Her extraocular muscles were intact.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR EXAM:  She was tachycardic without murmur.,LUNGS:  Revealed diffuse expiratory wheezing.,ABDOMEN:  Soft, nontender, and nondistended.,EXTREMITIES:  Showed no clubbing, cyanosis or edema.,LABORATORY DATA:  ,Her chem panel was normal.  RSV screen is positive.  Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN:  ,RSV bronchiolitis with otitis media.  Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.",5
"CIRCUMCISION - NEONATAL,PROCEDURE:,:  The procedure, risks and benefits were explained to the patient's mom, and a consent form was signed.  She is aware of the risk of bleeding, infection, meatal stenosis, excess or too little foreskin removed and the possible need for revision in the future.  The infant was placed on the papoose board.  The external genitalia were prepped with Betadine.  A penile block was performed with a 30-gauge needle and 1.5 mL of Nesacaine without epinephrine.,Next, the foreskin was clamped at the 12 o'clock position back to the appropriate proximal extent of the circumcision on the dorsum of the penis.  The incision was made.  Next, all the adhesions of the inner preputial skin were broken down.  The appropriate size bell was obtained and placed over the glans penis.  The Gomco clamp was then configured, and the foreskin was pulled through the opening of the Gomco.  The bell was then placed and tightened down.  Prior to do this, the penis was viewed circumferentially, and there was no excess of skin gathered, particularly in the area of the ventrum.  A blade was used to incise circumferentially around the bell.  The bell was removed.  There was no significant bleeding, and a good cosmetic result was evident with the appropriate amount of skin removed.,Vaseline gauze was then placed.  The little boy was given back to his mom.,PLAN:,  They have a new baby checkup in the near future with their primary care physician.  I will see them back on a p.r.n. basis if there are any problems with the circumcision.",37
"DIAGNOSIS: , Ankle sprain, left ankle.,HISTORY: , The patient is a 31-year-old female who was referred to Physical Therapy secondary to a fall on 10/03/08.  The patient states that she tripped over her dog toy and fell with her left foot inverted.  The patient states that she received a series of x-rays and MRIs that were unremarkable.  After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle.  She then received a walking boot and has been in the boot for the past month.,PAST MEDICAL HISTORY: , Significant for hypertension, asthma, and cervical cancer.  The cervical cancer was diagnosed as 15 years old.  The patient states that her cancer is ""dormant."",MEDICATIONS:,1.  Hydrochlorothiazide.,2.  Lisinopril.,3.  Percocet.,The patient states that the Percocet helps to take the edge of her pain, but does not completely eliminate it.,SUBJECTIVE: , The patient rates the pain at 2/10 on the pain analog scale.  The patient states that with elevation and rest, her pain subsides.,FUNCTIONAL ACTIVITIES/HOBBIES: , Currently limited including basic household chores and activities, this does increases her pain.  The patient states she also recently joined Weight Watchers and was involved in a walking routine and is currently unable to participate in this activity.,WORK STATUS: , The patient is currently on medical leave as a paraprofessional.  The patient states that she works as a teacher's aide in the school system and is required to complete extensive walking and standing activities.  The patient states that she is primarily on her feet while at work and rarely has a sitting break for extensive period of time.  The patient's goal is to be able to stand and walk without pain.,SOCIAL HISTORY:  ,The patient lives in a private home with children and her father.  The patient states that she does have stairs to negotiate without the use of a railing.  She states that she is able to manage the stairs, however, is very slow with her movement.  The patient smokes 1-1/2 packs of cigarettes a day and does not have a history of regular exercise routine.,OBJECTIVE: , Upon observation, the patient is a very obese female who is ambulating with significant antalgic gait pattern and altered normal gait due to the pain as well as the walking boot.  Upon inspection of the left ankle, it appears to have swelling, unsure if this swelling is secondary to injury or water retention as the patient states she has significant water retention.  When compared to right ankle edema, it is approximately equal.  There is no evidence of discoloration or temperature.  The patient states that she had no bruising at the time of injury.,Active range of motion of left ankle is as follows:  Dorsiflexion is 6 degrees past neutral and plantar flexion is 54 degrees, eversion 20 degrees, and inversion is 30 degrees.  Left ankle dorsiflexion lacks 10 degrees from neutral and plantar flexion is 36 degrees, this motion is very painful.  The patient was tearful during this activity.  Eversion is 3 degrees and inversion is 25 degrees.  The patient states this movement was difficult, but not painful.  Strength testing of the right lower extremity is grossly 4+-5/5 and left ankle is 2/5 as the patient is unable to obtain full range of motion.,PALPATION: , The patient is very tender to palpation primarily along the lateral malleolus of the left ankle.,JOINT PLAY: , Unable to be assessed secondary to the patient's extreme tenderness and guarding of the ankle joint.,SPECIAL TESTS:,  A 6-minute walk test.  The patient was able to ambulate approximately 600 feet while wearing her walking boot prior to her pain significantly increasing in the ankle and requiring the test to be stopped.,ASSESSMENT:  ,The patient would benefit from skilled physical therapy intervention as a trial of treatment in order to address the following problem list:,1.  Increased pain.,2.  Decreased range of motion.,3.  Decreased strength.,4.  Decreased ability to complete work task and functional activities in the home.,5.  Decreased gait pattern.,SHORT-TERM GOALS TO BE COMPLETED IN 3 WEEKS:,1.  The patient will demonstrate independence with home exercise program.,2.  The patient will ambulate without her boot for 48 hours in order to decrease reliance upon the boot for ankle stabilization.,3.  The patient will achieve left ankle dorsiflexion to neutral and plantar flexion to 45 degrees without significant increase in pain.,4.  The patient will demonstrate 3/5 strength of the left ankle.,5.  The patient will tolerate the completion of the 6-minute walk test without the use of a boot with minimal increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN 6 WEEKS:,1.  The patient will report 0/10 pain in the 48-hour period without the use of medication and without wearing her boot.,2.  The patient will return to go through the work without the use of the walking boot with report of minimal increase in pain and discomfort.,PROGNOSIS:,  Fair for above-stated goals with full compliance to home exercise program and therapy treatment as well as the patient motivation.,PLAN: , The patient to be seen three times a week for 6 weeks for the following:",30
"EXAM: , Lumbar spine CT without contrast.,HISTORY: , Back pain after a fall.,TECHNIQUE:,  Noncontrast axial images were acquired through the lumbar spine. Coronal and sagittal reconstruction views were also obtained.,FINDINGS: , There is no evidence for acute fracture or subluxation.  There is no spondylolysis or spondylolisthesis.  The central canal and neuroforamen are grossly patent at all levels.  There are no abnormal paraspinal masses. There is no wedge/compression deformity.  There is intervertebral disk space narrowing to a mild degree at L2-3 and L4-5.,Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta, which is not dilated.  There was incompletely visualized probable simple left renal cyst, exophytic at the lower pole.,IMPRESSION:,1.  No evidence for acute fracture or subluxation.,2.  Mild degenerative changes.,3.  Probable left simple renal cyst.,",22
"CHIEF COMPLAINT:  ,Hip pain.,HISTORY OF PRESENTING ILLNESS:  ,The patient is a very pleasant 41-year-old white female that is known to me previously from our work at the Pain Management Clinic, as well as from my residency training program, San Francisco. We have worked collaboratively for many years at the Pain Management Clinic and with her departure there, she has asked to establish with me for clinic pain management at my office.  She reports moderate to severe pain related to a complicated past medical history.  In essence, she was seen at a very young age at the clinic for bilateral knee and hip pain and diagnosed with bursitis at age 23.  She was given nonsteroidals at that time, which did help with this discomfort.  With time, however, this became inadequate and she was seen later in San Francisco in her mid 30s by Dr. V, an orthopedist who diagnosed retroverted hips at Hospital.  She was referred for rehabilitation and strengthening.  Most of this was focused on her SI joints.  At that time, although she had complained of foot discomfort, she was not treated for it.  This was in 1993 after which she and her new husband moved to the Boston area, where she lived from 1995-1996.  She was seen at the Pain Center by Dr. R with similar complaints of hip and knee pain.  She was seen by rheumatologists there and diagnosed with osteoarthritis as well as osteophytosis of the back.  Medications at that time were salicylate and Ultram.,When she returned to Portland in 1996, she was then working for Dr. B.  She was referred to a podiatrist by her local doctor who found several fractured sesamoid bones in her both feet, but this was later found not to be the case.  Subsequently, nuclear bone scans revealed osteoarthritis.  Orthotics were provided.  She was given Paxil and Tramadol and subsequently developed an unfortunate side effect of grand mal seizure.  During this workup of her seizure, imaging studies revealed a pericardial fluid-filled cyst adhered to her ventricle.  She has been advised not to undergo any corrective or reparative surgery as well as to limit her activities since.  She currently does not have an established cardiologist having just changed insurance plans.  She is establishing care with Dr. S, of Rheumatology for her ongoing care.  Up until today, her pain medications were being written by Dr. Y prior to establishing with Dr. L.,Pain management in town had been first provided by the office of Dr. F. Under his care, followup MRIs were done which showed ongoing degenerative disc disease, joint disease, and facet arthropathy in addition to previously described sacroiliitis.  A number of medications were attempted there, including fentanyl patches with Flonase from 25 mcg titrated upwards to 50 mcg, but this caused oversedation.  She then transferred her care to Ab Cd, FNP under the direction of Dr. K.  Her care there was satisfactory, but because of her work schedule, the patient found this burdensome as well as the guidelines set forth in terms of monthly meetings and routine urine screens.  Because of a previous commitment, she was unable to make one unscheduled request to their office in order to produce a random urine screen and was therefore discharged.,PAST MEDICAL HISTORY:  ,1.  Attention deficit disorder.,2.  TMJ arthropathy.,3.  Migraines.,4.  Osteoarthritis as described above.,PAST SURGICAL HISTORY:,1.  Cystectomies.,2.  Sinuses.,3.  Left ganglia of the head and subdermally in various locations.,4.  TMJ and bruxism.,FAMILY HISTORY:  ,The patient's father also suffered from bilateral hip osteoarthritis.,MEDICATIONS:,1.  Methadone 2.5 mg p.o. t.i.d.,2.  Norco 10/325 mg p.o. q.i.d.,3.  Tenormin 50 mg q.a.m.,4.  Skelaxin 800 mg b.i.d. to t.i.d. p.r.n.,5.  Wellbutrin SR 100 mg q.d.,6.  Naprosyn 500 mg one to two pills q.d. p.r.n.,ALLERGIES: , IV morphine causes hives.  Sulfa caused blisters and rash.,PHYSICAL EXAMINATION: , A well-developed, well-nourished white female in no acute distress, sitting comfortably and answering questions appropriately, making good eye contact, and no evidence of pain behavior.,VITAL SIGNS:  Blood pressure 110/72 with a pulse of 68.,HEENT:  Normocephalic.  Atraumatic.  Pupils are equal and reactive to light and accommodation.  Extraocular motions are intact.  No scleral icterus.  No nystagmus.  Tongue is midline.  Mucous membranes are moist without exudate.,NECK:  Free range of motion without thyromegaly.,CHEST:  Clear to auscultation without wheeze or rhonchi.,HEART:  Regular rate and rhythm without murmur, gallop, or rub.,ABDOMEN:  Soft, nontender.,MUSCULOSKELETAL:  There is musculoskeletal soreness and tenderness found at the ankles, feet, as well as the low back, particularly above the SI joints bilaterally.  Passive hip motion also elicits bilateral hip pain referred to the ipsilateral side.  Toe-heel walking is performed without difficulty.  Straight leg raises are negative.  Romberg's are negative.,NEUROLOGIC:  Grossly intact.  Intact reflexes in all extremities tested.  Romberg is negative and downgoing.,ASSESSMENT:,1. Osteoarthritis.,2. Chronic sacroiliitis.,3. Lumbar spondylosis.,4. Migraine.,5. TMJ arthropathy secondary to bruxism.,6. Mood disorder secondary to chronic pain.,7. Attention deficit disorder, currently untreated and self diagnosed.,RECOMMENDATIONS:,1. Agree with Rheumatology referral and review.  I would particularly be interested in the patient pursuing a bone density scan as well as thyroid and parathyroid studies.,2. Given the patient's previous sulfa allergies, we would recommend decreasing her Naprosyn usage.",34
"PREOPERATIVE DIAGNOSES:,1.  Nasal septal deviation.,2.  Bilateral internal nasal valve collapse.,3.  Bilateral external nasal valve collapse.,POSTOPERATIVE DIAGNOSES:,1.  Nasal septal deviation.,2.  Bilateral internal nasal valve collapse.,3.  Bilateral external nasal valve collapse.,PROCEDURES:,1.  Revision septoplasty.,2.  Repair of internal nasal valve collapse using auricular cartilage.,3.  Repair of bilateral external nasal valve collapse using auricular cartilage.,4.  Harvest of right auricular cartilage.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Approximately 20 mL.,IV FLUIDS: , Include a liter of crystalloid fluid.,URINE OUTPUT: , None.,FINDINGS: , Include that of significantly deviated septum with postoperative changes and a significant septal spur along the floor.  There is also evidence of bilateral internal as well as external nasal valve collapse.,INDICATIONS:  ,The patient is a pleasant 49-year-old gentleman who had undergone a previous septorhinoplasty after significant trauma in his 20s.  He now presents with significant upper airway resistance and nasal obstruction and is unable to tolerate a CPAP machine.  Therefore, for repair of the above-mentioned deformities including the internal and external nasal valve collapse as well as straightening of the deviated septum, the risks and benefits of the procedure were discussed with him included but not limited to bleeding, infection, septal perforation, need for further surgeries, external deformity, and he desired to proceed with surgery.,DESCRIPTION OF THE PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and laid supine upon the OR table.  After the induction of general endotracheal anesthesia, the nose was decongested using Afrin-soaked pledgets followed by the injection of % lidocaine with 1:100,000 epinephrine in the submucoperichondrial planes bilaterally.  Examination revealed significant deviation of the nasal septum and the bony cartilaginous junction as well as the large septal spur along the floor.  The caudal septum appeared to be now in adequate position.  There was evidence that there had been a previous caudal septal graft on the right nares and it was decided to leave this in place.  Following the evaluation of the nose, a hemitransfixion incision was made on the left revealing a large septal spur consisting primarily down on the floor of the left nostril creating nearly a picture of the vestibular stenosis on the side.  Very carefully, the mucoperichondrial flaps were elevated over this, and it was excised using an osteotome taking care to preserve the 1.5 cm dorsal and caudal strap of the nasal septum and keep it attached to the nasal spine.  Very carefully, the bony cartilaginous junction was identified and a small piece of the bone, where the spur was, was carefully removed.  Following this, it was noted that the cartilaginous region was satisfactory in quantity as well as quality to perform adequate grafting procedures.  Therefore, attention was turned to harvesting the right-sided auricular cartilage, which was done after the region had adequately been prepped and draped in a sterile fashion.  Postauricular incision using a #15 blade, the area of the submucoperichondrial plane was elevated in order to preserve the nice lining and identifiable portion of the cartilage taking care to preserve the ridge of the helix at all times.  This was very carefully harvested.  This area had been injected previously with 1% lidocaine and 1:100,000 epinephrine.  Following this, the cartilage was removed.  It was placed in saline, noted to be fashioned in the bilateral spreader graft and alar rim graft as well as a small piece of crush which was used to be placed along the top of the dorsal irregularity.  The spreader grafts were sutured in place using submucoperichondrial pockets.  After an external septorhinoplasty approach had been performed and reflection of the skin and soft tissue envelope had been performed, adequately revealing straight septum with significant narrowing with what appeared to be detached perhaps from his ipsilateral cartilages rather from his previous surgery.  These were secured in place in the pockets using a 5-0 PDS suture in a mattress fashion in two places.  Following this, attention was turned to placing the alar rim grafts where pockets were created along the caudal aspect of the lower lateral cartilage and just along the alar margin.  Subsequently, the alar rim grafts were placed and extended all the way to the piriform aperture.  This was sutured in place using a 5-0 self-absorbing gut suture.  The lower lateral cartilage has had some inherent asymmetry.  This may have been related to his previous surgery with some asymmetry of the dome; however, this was left in place as he did not desire any changes in the tip region, and there was adequate support.  An endodermal suture was placed just to reenforce the region using a 5-0 PDS suture.  Following all this, the area was closed using a mattress 4-0 plain gut on a Keith needle followed by the application of ***** 5-0 fast-absorbing gut to close the hemitransfixion incision.  Very carefully, the skin and subcutaneous tissue envelopes were reflected.  The curvilinear incision was closed using a Vicryl followed by interrupted 6-0 Prolene sutures.  The marginal incisions were then closed using 5-0 fast-absorbing gut.  Doyle splints were placed and secured down using a nylon suture.  They had ointment also placed on them.  Following this, nasopharynx was suctioned.  There were no further abnormalities noted and everything appeared to be in nice position.  Therefore, an external splint was placed after the application of Steri-Strips.  The patient tolerated the procedure well.  He was awakened in the operating room.  He was extubated and taken to the recovery room in stable condition.",37
"PREOPERATIVE DIAGNOSIS: , Right chronic subdural hematoma.,POSTOPERATIVE DIAGNOSIS: ,Right chronic subdural hematoma.,TYPE OF OPERATION: , Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 100 cc.,OPERATIVE PROCEDURE:,  In preoperative identification, the patient was taken to the operating room and placed in supine position.  Following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  Table was turned.  The right shoulder roll was placed.  The head was turned to the left and rested on a doughnut.  The scalp was shaved, and then prepped and draped in usual sterile fashion.  Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss.  The parietal boss incision was opened.  It was about an inch and a half in length.  It was carried down to the skull.  Self-retaining retractor was placed.  A bur hole was now fashioned with the perforator.  This was widened with a 2-mm Kerrison punch.  The dura was now coagulated with bipolar electrocautery.  It was opened in a cruciate-type fashion.  The dural edges were coagulated back to the bony edges.  There was egress of a large amount of liquid.  Under pressure, we irrigated for quite sometime until irrigation was returning mostly clear.  A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision.  It was secured with a 3-0 nylon suture.  The area was closed with interrupted inverted 2-0 Vicryl sutures.  The skin was closed with staples.  Sterile dressing was applied.  The patient was subsequently returned back to anesthesia.  He was extubated in the operating room, and transported to PACU in satisfactory condition.",23
"PROCEDURES: , Left heart catheterization, left ventriculography, and left and right coronary arteriography.,INDICATIONS: , Chest pain and non-Q-wave MI with elevation of troponin I only.,TECHNIQUE:  ,The patient was brought to the procedure room in satisfactory condition.  The right groin was prepped and draped in routine fashion.  An arterial sheath was inserted into the right femoral artery.,Left and right coronary arteries were studied with a 6FL4 and 6FR4 Judkins catheters respectively.  Cine coronary angiograms were done in multiple views.,Left heart catheterization was done using the 6-French pigtail catheter.  Appropriate pressures were obtained before and after the left ventriculogram, which was done in the RAO view.,At the end of the procedure, the femoral catheter was removed and Angio-Seal was applied without any complications.,FINDINGS:,1.  LV is normal in size and shape with good contractility, EF of 60%.,2.  LMCA normal.,3.  LAD has 20% to 30% stenosis at the origin.,4.  LCX is normal.,5.  RCA is dominant and normal.,RECOMMENDATIONS: , Medical management, diet, and exercise.  Aspirin 81 mg p.o. daily, p.r.n. nitroglycerin for chest pain.  Follow up in the clinic.",3
"OPERATIONS,1.  Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.,2.  Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.,3.  Posterior leaflet abscess resection.,ANESTHESIA:  ,General endotracheal anesthesia,TIMES:  ,Aortic cross-clamp time was ** minutes.  Cardiopulmonary bypass time total was ** minutes.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Next, the patient's chest and legs were prepped and draped in standard surgical fashion.  A #10-blade scalpel was used to make a midline median sternotomy incision.  Dissection was carried down to the level of the sternum using Bovie electrocautery.  The sternum was opened with a sternal saw, and full-dose heparinization was given.  Next, the chest retractor was positioned.  The pericardium was opened with Bovie electrocautery and pericardial stay sutures were positioned.  We then prepared to place the patient on cardiopulmonary bypass.  A 2-0 Ethibond double pursestring was placed in the ascending aorta.  Through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine.  Next, double cannulation with venous cannulas was instituted.  A 3-0 Prolene pursestring was placed in the right atrial appendage.  Through this was passed our SEC cannula.  This was connected to the venous portion of the cardiopulmonary bypass machine in a Y-shaped circuit.  Next, a 3-0 Prolene pursestring was placed in the lower border of the right atrium.  Through this was passed our inferior vena cava cannula.  This was likewise connected to the Y connection of our venous cannula portion.  We then used a 4-0 U-stitch in the right atrium for our retrograde cardioplegia catheter, which was inserted.  Cardiopulmonary bypass was instituted.  Metzenbaum scissors were used to dissect out the SVC and IVC, which were subsequently encircled with umbilical tape.  Sondergaard's groove was taken down.  Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta.  This was connected appropriately as was the retrograde cardioplegia catheter.  Next, the aorta was cross-clamped, and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole.  Next a #15-blade scalpel was used to open the left atrium.  The left atrium was decompressed with pump sucker.  Next, our self-retaining retractor was positioned so as to bring the mitral valve up into view.  Of note was the fact that the mitral valve P2 segment of the posterior leaflet had an abscess associated with it.  The borders of the P2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4-0 silk.  After doing so, the P2 segment of the posterior leaflet was excised with a #11-blade scalpel.  Given the laxity of the posterior leaflet, it was decided to reconstruct it with a 2-0 Ethibond pledgeted suture.  This was done so as to reconstruct the posterior annular portion.  Prior to doing so, care was taken to remove any debris and abscess-type material.  The pledgeted stitch was lowered into place and tied.  Next, the more anterior portion of the P2 segment was reconstructed by running a 4-0 Prolene stitch so as to reconstruct it.  This was done without difficulty.  The apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle.  There was noted to be a small amount of central regurgitation.  It was felt that this would be corrected with our annuloplasty portion of the procedure.  Next, 2-0 non-pledgeted Ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion.  Care was taken to go from trigone to trigone.  Prior to placing these sutures, the annulus was sized and noted to be a *** size for the Cosgrove-Galloway suture band ring from Medtronic.  After, as mentioned, we placed our interrupted sutures in the annulus, and they were passed through the CG suture band.  The suture band was lowered into position and tied in place.  We then tested our repair and noted that there was very mild regurgitation.  We subsequently removed our self-retaining retractor.  We closed our left atriotomy using 4-0 Prolene in a running fashion.  This was done without difficulty.  We de-aired the heart.  We then gave another round of antegrade and retrograde cardioplegia in warm fashion.  The aortic cross-clamp was removed, and the heart gradually resumed electromechanical activity.  We then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5-0 Prolene.  We placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin.  The patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed.  We then gave full-dose protamine; and after noting that there was no evidence of a protamine reaction, we removed our aortic cannula.  This site was buttressed with a 4-0 Prolene on an SH needle.  The patient tolerated the procedure well.  We placed a mediastinal #32-French chest tube as well as a right chest Blake drain.  The mediastinum was inspected for any signs of bleeding.  There were none.  We closed the sternum with #7 sternal wires in interrupted figure-of-eight fashion.  The fascia was closed with a #1 Vicryl followed by a 2-0 Vicryl, followed by 3-0 Vicryl in a running subcuticular fashion.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the intensive care unit in good condition.",3
"REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.  Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month.  The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m.  At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements.  Her daughter called 911 and her symptoms seemed to improve.  Then, she began vomiting.  When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI.  I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG.  She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free.  Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer.  In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage.  We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion.  She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1.  Amiodarone 200 mg once a day.,2.  Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES:  ,CODEINE.  NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes.  She uses alcohol.  No use of illicit drugs.  She is divorced and lives with her daughter.  She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS:  ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22.  O2 saturation 100%.  On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization.  HEENT shows the cranium is normocephalic and atraumatic.  She has dry mucosal membrane.  She now has a right facial droop, which per her daughter is new.  Neck veins are not distended.  No carotid bruits visible.  Skin:  Warm, well perfused.  Lungs are clear to auscultation anteriorly.  No wheezes.  Cardiac exam:  S1, S2, regular rate.  No significant murmurs.  PMI is nondisplaced.  Abdomen:  Soft, nondistended.  Extremities:  Without edema, on limited exam.  Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above.  Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds.  Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized.  I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1.  I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2.  Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3.  Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service.  I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.",17
"PREOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,OPERATION PERFORMED: , Radical anterior hemivulvectomy.  Posterior skinning vulvectomy.,SPECIMENS: , Radical anterior hemivulvectomy, posterior skinning vulvectomy.,INDICATIONS FOR PROCEDURE: , The patient has a history of vulvar melanoma first diagnosed in November of 1995.  She had a surgical resection at that time and recently noted recurrence of an irritated nodule around the clitoris.  Biopsy obtained by The patient confirmed recurrence.  In addition, biopsies on the posterior labia (left side) demonstrated melanoma in situ.,FINDINGS: , During the examination under anesthesia, the biopsy sites were visible and a slightly pigmented irregular area of epithelium was seen near the clitoris.  No other obvious lesions were seen.  The room was darkened and a Woods lamp was used to inspect the epithelium.  A marking pen was used to outline all pigmented areas, which included several patches on both the right and left labia.,PROCEDURE: , The patient was prepped and draped and a scalpel was used to incise the skin on the anterior portion of the specimen.  The radical anterior hemivulvectomy was designed so that a 1.5-2.0 cm margin would be obtained and the depth was carried to the fascia of the urogenital diaphragm.  Subcutaneous adipose was divided with electrocautery and the specimen was mobilized from the periosteum.  After removal of the radical anterior portion, the skin on the posterior labia and perineal body was mobilized.  Skin was incised with a scalpel and electrocautery was used to undermine.  After removal of the specimen, the wounds were closed primarily with subcutaneous interrupted stitches of 3-0 Vicryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was then taken to the Post Anesthesia Care Unit in stable condition.",37
"PREOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,POSTOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,OPERATIONS PERFORMED,1.  Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at C5-C6.,2.  Bilateral C6 nerve root decompression.,3.  Anterior cervical discectomy at C4-C5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4.  Bilateral C5 nerve root decompression.,5.  Anterior cervical discectomy at C3-C4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6.  Bilateral C4 nerve root decompression.,7.  Harvesting of autologous bone from the vertebral bodies.,8.  Grafting of allograft bone for creation of arthrodesis.,9.  Creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C5-C6.,10.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C4-C5.,11.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C3-C4.,12.  Placement of anterior spinal instrumentation from C3 to C6 using a Synthes Small Stature Plate, using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at C5-C6.  There was a herniated disk with cord compression and radiculopathy at C4-C5.  C3-C4 was the source of neck pain as documented by facet injections.,A detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels.  Because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6.,I explained the nature of this procedure in great detail including all risks and alternatives.  He clearly understands and has no further questions and requests that I proceed.,PROCEDURE:  ,The patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,The left side of the neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made in the neck crease.  Dissection was carried down through the platysma musculature and the anterior spine was exposed.  The medial borders of the longus colli muscle were dissected free from their attachments to the spine.  Caspar self-retaining pins were placed into the bodies of C3, C4, C5, and C6 and x-ray localization was obtained.  A needle was placed in what was revealed to be the disk space at C4-C5 and an x-ray confirmed proper localization.,Self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,First I removed the large amount of anterior overhanging osteophytes at C5-C6 and distracted the space.  The high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,An incision was then made at C4-C5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,The retractors were then adjusted and again discectomy was performed at C3-C4 back to the posterior lips of the vertebral bodies.  The operating microscope was then utilized.,Working under magnification, I started at C3-C4 and began to work my way down to the posterior longitudinal ligament.  The ligament was incised and the underlying dura was exposed.  I worked out laterally towards the takeoff of the C4 nerve root and widely decompressed the nerve root edge of the foramen.  There were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, I left them intact.  However, I could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right.  The microscope was angled to the left side where similar decompression was achieved.,The retractors were readjusted and attention was turned to C4-C5.  I worked down through bony osteophytes and identified the posterior longitudinal ligament.  The ligament was incised; and as I worked to the right of the midline, I encountered herniated disk material which was removed in a number of large pieces.  The C5 root was exposed and then widely decompressed until I was flush with the pedicle and into the foramen.  The root had a somewhat high takeoff but I worked to expose the axilla and widely decompressed it.  Again the microscope was angled to the left side where similar decompression was achieved.  Central decompression was achieved here where there was a moderate amount of spinal cord compression.  This was removed by undercutting with 1 and 2-mm Cloward punches.,Attention was then turned to the C5-C6 space.  Here there were large osteophytes projecting posteriorly against the cord.  I slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm Cloward punches to widely decompress the spinal cord.  This necessitated undercutting the bodies of both C5 and C6 extensively, but I was then able to achieve a good decompression of the cord.  I exposed the C6 root and widely decompressed it until I was flush with the pedicle and into the foramen on the right.  The microscope was angled to the left side where a similar decompression was achieved.,Attention was then turned to creation of the arthrodesis.  A high-speed Cornerstone bur was used to decorticate the bodies of C5-C6, C4-C5 and C3-C4 to create a posterior shelf to prevent backwards graft migration.  Bone dust during the drilling was harvested for later use.,Attention was turned to creation of the arthrodesis.  Using the various Synthes sizers, I selected a 7-mm lordotic graft at C5-C6 and an 8-mm lordotic graft at C4-C5 and a 9-mm lordotic graft at C3-C4.  Each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge.  I decided to use BMP in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks.  The BMP sponge and the ____________ bone were then packed in the center of the allograft.,Under distraction, the graft was placed at C3-C4, C4-C5, and C5-C6 as described.  An x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,Attention was turned to the placement of anterior spinal instrumentation.  Various sizes of Synthes plates were selected until I decided that a 54-mm plate was appropriate.  The plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush.  The holes were drilled and the screws were placed.  Eight screws were placed with two screws at C3, two screws at C4, two screws at C5, and two screws at C6.  All eight screws had good purchase.  The locking screws were tightly applied.  An x-ray was obtained which showed good placement of the graft, plate, and screws.,Attention was turned to closure.  The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained.  A medium Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct.  There were no intraoperative complications.,Specimens were sent to Pathology consisting of disk material and bone and soft tissue.",23
"PREOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,POSTOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,OPERATION PERFORMED: , Surgical closure of gastrostomy.,ANESTHESIA: , General.,INDICATIONS: , This 1-year-old child had a gastrostomy placed due to feeding difficulties.  Since then, he has reached a point where he is now eating completely by mouth and no longer needed the gastrostomy.  The tube was, therefore, removed, but the tract has not shown signs of spontaneous closure.  He, therefore, comes to the operating room today for surgical closure of his gastrostomy.,OPERATIVE PROCEDURE: , After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner.  An elliptical incision was made around the gastrostomy site and carried down through skin and subcutaneous tissue with sharp dissection.  The tract and the stomach were freed.  Stay sutures were then placed on either side of the tract.  The tract was amputated.  The intervening stomach was then closed with interrupted #4-0 Lembert, Nurolon sutures.  The fascia was then closed over the stomach using #3-0 Vicryl sutures.  The skin was closed with #5-0 subcuticular Monocryl.  A dressing was applied, and the child was awakened and taken to the recovery room in satisfactory condition.",37
"PREOPERATIVE DIAGNOSIS:  ,Lumbar radiculopathy, 724.4.,POSTOPERATIVE DIAGNOSIS:,  Lumbar radiculopathy, 724.4.,PROCEDURE:,  Lumbar epidural steroid injection.,ANESTHESIOLOGIST:,  Monitored anesthesia care,INJECTATE USED:,  10 mL of 0.5% lidocaine and 80 mg of Depo-Medrol.,ESTIMATED BLOOD LOSS:,  None.,COMPLICATIONS:,  None.,DETAILS OF THE PROCEDURE:,  The patient arrived at the preoperative holding area where informed consent, stable vital signs, and intravenous access were obtained.  A thorough discussion of the potential risks, benefits, and complications was made prior to the procedure including potential for post-dural puncture headache and its associated treatment as well as potential for increased neurological dysfunction and/or nerve root injury, infection, bleeding and even death.  There were no known EKG, chest X-ray, or laboratory contraindications to the procedure.,The patient has presented with significant apprehension concerning the proposed procedure and is fearful of movement during the procedure producing further neurological injury.  Arrangements will be made to have an anesthesia care provider present to provide heavier sedation while in the prone position with optimal airway management for improved patient safety and comfort.,The L4-L5 interspace was identified fluoroscopically.  A left paramedian insertion was marked and after sedation was established by the anesthesia department the skin and subcutaneous tissue over the proposed insertion site was infiltrated with 3 millimeters of 0.5% Lidocaine initially through a #25-gauge 5/8-inch needle later a #22-gauge 1-1/2-inch needle.,A number #18-gauge Tuohy epidural needle was then inserted and advanced with fluoroscopic guidance until passing just superior to the lamina of L5.  Needle tip position was confirmed in the anterior posterior fluoroscopic view.  The epidural space was located with the loss of pulsation technique.  Aspiration of the syringe was negative for blood or cerebrospinal fluid.  One millimeter of 0.9% preservative was injected with good loss resistance noted.,DISCHARGE SUMMARY:,  Following the completion of this procedure, the patient underwent monitoring in the recovery room and was discharged, to be followed as an outpatient.",28
"PREOPERATIVE DIAGNOSIS: , Ruptured globe OX.,POSTOPERATIVE DIAGNOSIS:,  Ruptured globe OX.,PROCEDURE: , Repair of ruptured globe OX.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS: ,None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure.,Upon examination and dissection of the conjunctiva superiorly, a scleral rupture was found. The rupture extended approximately 15 mm in length superior to the cornea, approximately 2 mm from the limbus in a horizontal fashion. There was also a rupture at the limbus, near the middle of this laceration, causing the anterior chamber to be flat. There was a large blood clot filling the anterior chamber. An attempt was made to wash out the anterior chamber with BSS on a cannula. The BSS was injected through the limbal rupture, which communicated with the anterior chamber. The blood clot did not move. It was extremely adherent to the iris.,At that time, the rupture that involved the limbus from approximately 10:30 until 12 o'clock was closed using 1 suture of 10-0 nylon. The scleral laceration was then closed using 10 interrupted sutures with 9-0 Vicryl. At that time, the anterior chamber was formed and appeared to be fairly deep. The wounds were checked and found to be watertight. The knots were rotated posteriorly and the conjunctiva was draped up over the sutures and sewn into position at the limbus using four 7-0 Vicryl sutures, 2 nasally and 2 temporally. All suture knots were buried.  ,Gentamicin 0.5 cc was injected subconjunctivally. Then, the speculum was removed. The drapes were removed. Several drops of Ocuflox and Maxitrol ointment were placed in the XXX eye. An eye patch and shield were placed over the eye. The patient was awakened from general anesthesia without difficulty and taken to the recovery room in good condition.",37
"PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE:,  Stable, extubated, and transferred to the recovery room in stable condition.,INDICATIONS FOR PROCEDURE:  ,The patient is a 10-month-old baby with a history of a bilateral cleft of the lip and palate.  The patient has undergone cleft lip repair, and she is here today for her cleft palate operation.  We have discussed with the mother the nature of the procedure, risks, and benefits; the risks included but not limited to the risk of bleeding, infection, dehiscence, scarring, the need for future revision surgeries.  We will proceed with surgery.,DETAILS OF THE PROCEDURE:,  The patient was taken into the operating room, placed in the supine position, and general anesthetic was administered.  A prophylactic dose of antibiotics was given.  The patient proceeded to have bilateral PE tube placement by Dr. X, from Ear, Nose, and Throat Surgery.  After he was done with his procedure, the head of the bed was turned 90 degrees.  The patient was positioned with a shoulder roll and doughnut.  A Dingman retractor was placed.  The operative area was infiltrated with lidocaine with epinephrine 1:200,000, a total of 3 mL, and then, I proceeded with the prepping and draping.  The patient was prepped and draped.  I proceeded to do the palate repair.  The nature of the palate repair was done in the same way on the both sides.  I will describe one side.  The other side was done exactly in the same manner.  The 2 hemiuvulas are placed, holding from a single hook and infiltrated with lidocaine with epinephrine 1:200,000, triangle in the nasal mucosa was previously marked.  This triangle of nasal mucosa was removed and excised.  This was done on both uvulas.  Then, an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa.  A 1-mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better.  Once the incision was done up to the level of the hard palate, the muscle was dissected off the surrounding tissue, 2 mm from the nasal and the oral mucosa.  Then, I proceeded to place an incision at the alveolopalatal junction with the help of 15-blade.  The incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap.  Then the flap was lifted up with the help of a freer, and then the remaining of the incision medially was completed.  Hemostasis was achieved with help of electrocautery and Surgicel.  The mucoperiosteal flap was retracted posteriorly with the help of a freer elevator.  The greater auricular foramen was exposed, and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap.  Then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle.  The pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially.  This procedure was done on both sides in the same manner, and then __________ dissection was done including dissection of the hard palate from the nasal mucosa, it was evident that the nasal mucosa would not reach medially to be placed together.  At this point, the decision was made to proceed with vomer flaps.  The flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book.  The incision was done with a 15C blade.  The vomer flaps were dissected, and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate.  This was approximated on both sides with 5-0 chromic running and interrupted stitches, and I proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5-0 chromic and a 4-0 chromic.  Then 2 stitches of 4-0 Vicryl were applied to the soft palate in the Delaire manner through the full thickness of the mucosa and muscle on one side, on the other side, and then coming back on the mucosa to evert the edges of the soft palate.  The remaining part of the soft palate was placed together with 4-0 Vicryl and 4-0 chromic interrupted stitches.  The throat pack was removed.  The palate was cleaned.  The Dingman retractor was removed, and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2-0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of Tegaderm.  The patient tolerated the procedure without complications.  BSS is applied to the eye after removing the Tegaderm.  I was present and participated in all aspects of the procedure.  The sponge, needle, and instrument count were completed at the end of the procedure.  The patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition.",11
"XYZ, D.C.,Re:  ABC,Dear Dr. XYZ:,I had the pleasure of seeing your patient, ABC, today MM/DD/YYYY in consultation.  He is an unfortunate 19-year-old right-handed male who was injured in a motor vehicle accident on MM/DD/YYYY, where he was the driver of an automobile, which was struck on the front passenger's side.  The patient sustained impact injuries to his neck and lower back.  There was no apparent head injury or loss of consciousness and he denied any posttraumatic seizures.  He was taken to Hospital, x-rays were taken, apparently which were negative and he was released.,At the present time, he complains of neck and lower back pain radiating into his right arm and right leg with weakness, numbness, paraesthesia, and tingling in his right arm and right leg.  He has had no difficulty with bowel or bladder function.  He does experience intermittent headaches associated with his neck pain with no other associated symptoms.,PAST HEALTH:,  He was injured in a prior motor vehicle accident on MM/DD/YYYY.  At the time of his most recent injuries, he was completely symptom free and under no active therapy.  There is no history of hypertension, diabetes, heart disease, neurological disorders, ulcers or tuberculosis.,SOCIAL HISTORY: , He denies tobacco or alcohol consumption.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS:  ,None.,FAMILY HISTORY: , Otherwise noncontributory.,FUNCTIONAL INQUIRY: , Otherwise noncontributory.,REVIEW OF DIAGNOSTIC STUDIES:,  Includes an MRI scan of the cervical spine dated MM/DD/YYYY which showed evidence for disc bulging at the C6-C7 level.  MRI scan of the lumbar spine on MM/DD/YYYY, showed evidence of a disc herniation at the L1-L2 level as well as a disc protrusion at the L2-L3 level with disc herniations at the L3-L4 and L4-L5 level and disc protrusion at the L5-S1 level.,PHYSICAL EXAMINATION: , Reveals an alert and oriented male with normal language function.  Vital Signs:  Blood pressure was 105/68 in the left arm sitting.  Heart rate was 70 and regular.  Height was 5 feet 8 inches.  Weight was 182 pounds.  Cranial nerve evaluation was unremarkable.  Pupils were equal and reactive.  Funduscopic evaluation was clear.  There was no evidence for nystagmus.  There was decreased range of motion noted in both the cervical and lumbar regions to a significant degree, with tenderness and spasm in the paraspinal musculature.  Straight leg raising was limited to 45 degrees on the right and 90 degrees on the left.  Motor strength was 5/5 on the MRC scale.  Reflexes were 2+ symmetrical and active.  No pathological responses were noted.  Sensory examination showed a diffuse decreased sensation to pinprick in the right upper extremity.  Cerebellar function was normal.  There was normal station and gait.  Chest and cardiovascular evaluations were unremarkable.  Heart sounds were normal.  There were no extra sounds or murmurs.  Palpable trigger points were noted in the right trapezius and right cervical and lumbar paraspinal musculature.,CLINICAL IMPRESSION: , Reveals a 19-year-old male suffering from a posttraumatic cervical and lumbar radiculopathy, secondary to traumatic injuries sustained in a motor vehicle accident on MM/DD/YYYY.  In view of the persistent radicular complaints associated with the weakness, numbness, paraesthesia, and tingling as well as the objective sensory loss noted on today's evaluation as well as the non-specific nature of the radiculopathy, I have scheduled him for an EMG study on his right upper and right lower extremity in two week's time to rule out any nerve root irritation versus any peripheral nerve entrapment or plexopathy as the cause of his symptoms.  Palpable trigger points were noted on today's evaluation.  He is suffering from ongoing myofascitis.  His treatment plan will consist of a series of trigger point injections to be initiated at his next follow up visit in two weeks' time.  I have encouraged him to continue with his ongoing treatment program under your care and supervision.  I will be following him in two weeks' time.  Once again, thank you kindly for allowing me to participate in this patient's care and management.,Yours sincerely,,",27
"HISTORY:,  The patient is a 51-year-old female that was seen in consultation at the request of Dr. X on 06/04/2008 regarding chronic nasal congestion, difficulty with swallowing, and hearing loss.  The patient reports that she has been having history of recurrent sinus infection, averages about three times per year.  During the time that she gets the sinus infections, she has nasal congestion, nasal drainage, and also generally develops an ear infection as well.  The patient does note that she has been having hearing loss.  This is particular prominent in the right ear now for the past three to four years.  She does note popping after blowing the nose.  Occasionally, the hearing will improve and then it plugs back up again.  She seems to be plugged within the nasal passage, more on the right side than the left and this seems to be year round issue with her.  She tried Flonase nasal spray to see if this help with this and has been taking it, but has not seen a dramatic improvement.  She has had a history of swallowing issues and that again secondary to the persistent postnasal drainage.  She feels that she is having a hard time swallowing at times as well.  She has complained of a lump sensation in the throat that tends to come and go.  She denies any cough, no hemoptysis, no weight change.  No night sweats, fever or chills has been noted.  She is having at this time no complaints of tinnitus or vertigo.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:  ,ALLERGY/IMMUNOLOGIC:  History of seasonal allergies.  She also has severe allergy to penicillin and bee stings.,CARDIOVASCULAR:  Pertinent for hypercholesterolemia.,PULMONARY:  She has a history of cough, wheezing.,GASTROINTESTINAL:  Negative.,GENITOURINARY:  Negative.,NEUROLOGIC:  She has had a history of TIAs in the past.,VISUAL:  She does have history of vision change, wears glasses.,DERMATOLOGIC:  Negative.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  History of joint pain and bursitis.,CONSTITUTIONAL:  She has a history of chronic fatigue.,ENT:  She has had a history of cholesteatoma removal from the right middle ear and previous tympanoplasty with a progressive hearing loss in the right ear over the past few years according to the patient.,PSYCHOLOGIC:  History of anxiety, depression.,HEMATOLOGIC:  Easy bruising.,PAST SURGICAL HISTORY: , She has had right tympanoplasty in 1984.  She has had a left carotid endarterectomy, cholecystectomy, two C sections, hysterectomy, and appendectomy.,FAMILY HISTORY: , Mother, history of vaginal cancer and hypertension.  Brother, colon CA.  Father, hypertension.,CURRENT MEDICATIONS: , Aspirin 81 mg daily.  She takes vitamins one a day.  She is on Zocor, Desyrel, Flonase, and Xanax.  She also has been taking Chantix for smoking cessation.,ALLERGIES: , Penicillin causes throat swelling.  She also notes the bee sting allergy causes throat and tongue swelling.,SOCIAL HISTORY: , The patient is single.  She is unemployed at this time.  She is a smoker about a pack and a half for 38 years and notes rare alcohol use.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Her blood pressure 128/78, temperature is 98.6, pulse 80 and regular.,GENERAL:  The patient is an alert, cooperative, well-developed 51-year-old female.  She has a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  Right ear, the external ear is normal.  The ear canal is clean and dry.  The drum is intact.  She has got severe tympanosclerosis of the right tympanic membrane and Weber exam does lateralize to the right ear indicative of a conductive loss.  Left ear, the external ear is normal.  The ear canal is clean and dry.  The drum is intact and mobile with grossly normal hearing.  The audiogram does reveal normal hearing in the left ear.  She has got a mild conductive loss throughout all frequency ranges in the right ear with excellent discrimination scores noted bilaterally.  Tympanograms, there was no adequate seal obtained on the right side.  She has a normal type A tympanogram, left side.,NASAL:  Reveals a deviated nasal septum to the left, clear drainage, large inferior turbinates, no erythema.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,PROCEDURE: , Please note a fiberoptic laryngoscopy was also done at today's visit for further evaluation because of the patient's dysphagia and throat symptoms.  Findings do reveal moderately deviated nasal septum to the left, large inferior turbinates noted.  The nasopharynx does reveal moderate adenoid pad within this midline.  It is nonulcerated.  The larynx revealed both cords to be normal.  She does have mild lingual tonsillar hypertrophy as well.,IMPRESSION:  ,1.  Persistent dysphagia.  I think secondary most likely to the persistent postnasal drainage.,2.  Deviated nasal septum.,3.  Inferior turbinate hypertrophy.,4.  Chronic rhinitis.,5.  Conductive hearing loss, right ear with a history of cholesteatoma of the right ear.",11
"DISCHARGE DIAGNOSIS:  ,Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.,ADDITIONAL DISCHARGE DIAGNOSES:,1.  Chronic pain.,2.  Tobacco use.,3.  History of hepatitis C.,REASON FOR ADMISSION:,  The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound.  He has had prolonged hospitalizations because of this problem.  He was recently discharged when he was noted to develop as an outpatient swollen, red tender leg.  Examination in the emergency room revealed significant concern for significant cellulitis.  Decision was made to admit him to the hospital.,HOSPITAL COURSE:,  The patient was admitted on 03/26/08 and was started on IV antibiotics elevation, was also counseled to minimizing the cigarette smoking.  The patient had edema of his bilateral lower extremities.  The hospital consult was also obtained to address edema issue question was related to his liver hepatitis C.  Hospital consult was obtained.  This included an ultrasound of his abdomen, which showed just mild cirrhosis.  His leg swelling was thought to be secondary to chronic venostasis and with likely some contribution from his liver as well.  The patient eventually grew MRSA in a moderate amount.  He was treated with IV vancomycin.  Local wound care and elevation.  The patient had slow progress.  He was started on compression, and by 04/03/08 his leg got much improved, minimal redness and swelling was down with compression.  The patient was thought safe to discharge home.,DISCHARGE INSTRUCTIONS: , The patient was discharged on doxycycline 100 mg p.o. b.i.d. x10 days.  He was also given prescription for Percocet and OxyContin, picked up at my office.  He is instructed to do daily wound care and also wrap his leg with an Ace wrap.  Followup was arranged in a couple of weeks.,DISCHARGE CONDITION: , Stable.",10
"CHIEF COMPLAINT: , Bladder cancer.,HISTORY OF PRESENT ILLNESS:,  The patient is a 68-year-old Caucasian male with a history of gross hematuria.  The patient presented to the emergency room near his hometown on 12/24/2007 for evaluation of this gross hematuria.  CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall.  Urology referral was initiated and the patient was sent to be evaluated by Dr. X. He eventually underwent a bladder biopsy on 01/18/08, which demonstrated high-grade transitional cell carcinoma without any muscularis propria in the specimen.  Additionally, the patient underwent workup for a right adrenal lesion, which was noted on the initial CT scan.  This workup involved serum cortisol analysis as well as potassium and aldosterone and ACTH level measurement.  All of this workup was found to be grossly negative.  Secondary to the absence of muscle in the specimen, the patient was taken back to the operating room on 02/27/08 by Dr. X and the tumor was noted to be very large with significant tumor burden as well as possible involvement of the bladder neck.  At that time, the referring urologist determined the tumor to be too large and risky for local resection, and the patient was referred to ABCD Urology for management and diagnosis.  The patient presents today for evaluation by Dr. Y.,PAST MEDICAL HISTORY: , Includes condyloma, hypertension, diabetes mellitus, hyperlipidemia, undiagnosed COPD, peripheral vascular disease, and claudication.  The patient denies coronary artery disease.,PAST SURGICAL HISTORY:,  Includes bladder biopsy on 01/18/08 without muscularis propria in the high-grade TCC specimen and a gun shot wound in 1984 followed by exploratory laparotomy x2.  The patient denies any bowel resection or GU injury at that time; however, he is unsure.,CURRENT MEDICATIONS:,1.  Metoprolol 100 mg b.i.d.,2.  Diltiazem 120 mg daily.,3.  Hydrocodone 10/500 mg p.r.n.,4.  Pravastatin 40 mg daily.,5.  Lisinopril 20 mg daily.,6.  Hydrochlorothiazide 25 mg daily.,FAMILY HISTORY: , Negative for any GU cancer, stones or other complaints.  The patient states he has one uncle who died of lung cancer.  He denies any other family history.,SOCIAL HISTORY: , The patient smokes approximately 2 packs per day times greater than 40 years.  He does drink occasional alcohol approximately 5 to 6 alcoholic drinks per month.  He denies any drug use.  He is a retired liquor store owner.,PHYSICAL EXAMINATION:,GENERAL:  He is a well-developed, well-nourished Caucasian male, who appears slightly older than stated age.  VITAL SIGNS:  Temperature is 96.7, blood pressure is 108/57, pulse is 75, and weight of 193.8 pounds.  HEAD AND NECK:  Normocephalic atraumatic.  LUNGS:  Demonstrate decreased breath sounds globally with small rhonchi in the inferior right lung, which is clear somewhat with cough.  HEART:  Regular rate and rhythm.  ABDOMEN:  Soft and nontender.  The liver and spleen are not palpably enlarged.  There is a large midline defect covered by skin, of which the fascia has numerous holes poking through.  These small hernias are of approximately 2 cm in diameter at the largest and are nontender.  GU:  The penis is circumcised and there are no lesions, plaques, masses or deformities.  There is some tenderness to palpation near the meatus where 20-French Foley catheter is in place.  Testes are bilaterally descended and there are no masses or tenderness.  There is bilateral mild atrophy.  Epididymidis are grossly within normal limits bilaterally.  Spermatic cords are grossly within normal limits.  There are no palpable inguinal hernias.  RECTAL:  The prostate is mildly enlarged with a small focal firm area in the midline near the apex.  There is however no other focal nodules.  The prostate is grossly approximately 35 to 40 g and is globally firm.  Rectal sphincter tone is grossly within normal limits and there is stool in the rectal vault.  EXTREMITIES:  Demonstrate no cyanosis, clubbing or edema.  There is dark red urine in the Foley bag collection.,LABORATORY EXAM:,  Review of laboratory from outside facility demonstrates creatinine of 2.38 with BUN of 42.  Additionally, laboratory exam demonstrates a grossly normal serum cortisol, ACTH, potassium, aldosterone level during lesion workup.  CT scan was reviewed from outside facility, report states there is left kidney atrophy without hydro or stones and there is thickened left bladder wall and posterior margins with a balloon inflated in the prostate at the time of the exam.  There is a 3.1 cm right heterogeneous adrenal nodule and there are no upper tract lesions or stones noted.,IMPRESSION:,  Bladder cancer.,PLAN:  ,The patient will undergo a completion TURBT on 03/20/08 with bilateral retrograde pyelograms at the time of surgery.  Preoperative workup and laboratory as well as paper work were performed in clinic today with Dr. Y. The patient will be scheduled for anesthesia preop.  The patient will have urine culture redrawn from his Foley or penis at the time of preoperative evaluation with anesthesia.  The patient was counseled extensively approximately 45 minutes on the nature of his disease and basic prognostic indicators and need for additional workup and staging.  The patient understands these instructions and also agrees to quit smoking prior to his next visit.  This patient was seen in evaluation with Dr. Y who agrees with the impression and plan.",5
"HISTORY OF PRESENT ILLNESS: , Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first emerged.  He, since 10:17 p.m. on 01/17/10, noted recurrence of his atrial fibrillation, called our office this morning, that is despite being on flecainide, atenolol, and he is maintained on Coumadin.,The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred and we see that on his 12-lead EKG here.  Otherwise, no chest pain.,PAST MEDICAL HISTORY: , Significant for atrial fibrillation/atrial flutter and again he had atrial fibrillation more persistently in 2006, but more recently it has been atrial flutter and that is despite use of antiarrhythmics including flecainide.  He completed a stress test in my office within the past several weeks that was normal without evidence of ischemia.  Other medical history is significant for hyperlipidemia.,MEDICATIONS:,As outpatient,,1.  Atenolol 25 mg once a day.,2.  Altace 2.5 mg once a day.,3.  Zocor 20 mg once a day.,4.  Flecainide 200 in the morning and 100 in the evening.,5.  Coumadin as directed by our office.,ALLERGIES: , TO MEDICATIONS ARE NONE.  HE DENIES SHRIMP, SEA FOOD OR DYE ALLERGY.,FAMILY HISTORY: , He has a nephew who was his sister's son who passed away at age 22 reportedly from an MI, but was reported to have hypertrophic cardiomyopathy as well.  The patient has previously met with the electrophysiologist, Dr. X, at General Hospital and it sounds like he had a negative EP study.,SOCIAL HISTORY: , The patient does not smoke cigarettes, abuse alcohol nor drink any caffeine.  No use of illicit drugs.  He has been married for 22 years and he is actually accompanied throughout today's cardiology consultation by his wife.  He is not participating in regular exercises now because he states since starting flecainide, he has gotten sluggish.  He is employed as an attorney and while he states that overall his mental stress is better, he has noted more recent mental stress this past weekend when he was taking his daughter back to college.,REVIEW OF SYSTEMS: , He denies any history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi.  There are some questions especially as his wife has told me that he may have obstructive sleep apnea and not had a formal sleep study.,PHYSICAL EXAM: , Blood pressure 156/93, pulse is 100, respiratory rate 18.  On general exam, he is a pleasant overweight gentleman, in no acute distress.  HEENT:  Shows cranium is normocephalic and atraumatic.  He has moist mucosal membranes.  Neck veins are not distended.  There are no carotid bruits.  Visible skin warm and perfused.  Affect appropriate.  He is quite oriented and pleasant.  No significant kyphoscoliosis on recumbent back exam.  Lungs are clear to auscultation anteriorly.  No wheezes.  No egophony.  Cardiac Exam:  S1, S2.  Regular rate, controlled.  No significant murmurs, rubs or gallops.  PMI is nondisplaced.  Abdomen is soft, nondistended, appears benign.  Extremities without significant edema.  Pulses grossly intact.,DIAGNOSTIC STUDIES/LAB DATA:,  Initial ECG shows atrial flutter.,IMPRESSION: , Mr. A is a 50-year-old gentleman with a history of paroxysmal atrial fibrillation in the past, more recently is having breakthrough atrial flutter despite flecainide and we had performed a transesophageal echocardiogram-guided cardioversion for him in late 12/20/09, who now has another recurrence within the past 41 hours or so.  I have reviewed again with him in detail regarding risks, benefits, and alternatives of proceeding with cardioversion, which the patient is in favor of.  After in depth explanation of the procedure with him that there would be more definitive resumption of normal sinus rhythm by using electrocardioversion with less long-term side effects, past the acute procedure, alternatives being continued atrial flutter with potential for electrophysiologic consultation for ablation and/or heart rate control with anticoagulation, which the patient was not interested nor was I primarily recommending as the next step, and risks including, but not limited to and the patient was aware and this was all done in the presence of his wife that this is not an all-inclusive list, but the risks include but not limited to oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, which would be less likely as I did confirm with the patient that he had been n.p.o. for greater than 15 hours, risk of induction of other arrhythmias including tachyarrhythmias requiring further management including cardioversion or risk of bradyarrhythmias, in the past when we had a cardioverter with 150 joules, he did have a 5.5-second pause especially while he is on antiarrhythmic therapy, statistically less significant risk of CVA, although we cannot really make that null.  The patient expressed understanding of this risk, benefit, and alternative analysis.  I invited questions from him and his wife and once their questions were answered to their self-stated satisfaction, we planned to go forward with the procedure.,PROCEDURE NOTE:  ,The patient received a total of 7 mg of Versed and 50 micrograms of fentanyl utilizing titrate-down sedation with good effect and this was after the appropriate time-out procedure had been done as per the Medical Center universal protocol with appropriate identification of the patient, position, procedure documentation, procedure indication, and there were no questions.  The patient did actively participate in this time-out procedure.  After the universal protocol was done, he then received the cardioversion attempt with 50 joules using ""lollipop posterior patch"" with hands-driven paddle on the side, which was 50 joules of synchronized biphasic energy.  There was successful resumption of normal sinus rhythm, in fact this time there was not a significant pause as compared to when he had this done previously in late 12/09 and this sinus rhythm was confirmed by a 12-lead EKG.,IMPRESSION: , Cardioversion shows successful resumption of normal sinus rhythm from atrial flutter and that is while the patient has been maintained on Coumadin and his INR is 3.22.  We are going to watch him and discharge him from the Medical Center area on his current flecainide of 200 mg in the morning and 100 mg in the evening, atenolol 25 mg once a day, Coumadin _____ as currently being diagnosed.  I had previously discussed with the patient and he was agreeable with meeting with his electrophysiologist again, Dr. X, at Electrophysiology Unit at General Hospital and I will be planning to place a call for Dr. X myself.  Again, he has no ischemia on this most recent stress test and I suppose in the future it may be reasonable to get obstructive sleep apnea evaluation and that may be one issue promulgating his symptoms.,I had previously discussed the case with Dr. Y who is the patient's general cardiologist as well as updated his wife at the patient's bedside regarding our findings.",37
"HISTORY OF PRESENT ILLNESS:,  The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room.  She was intubated and fishbone.,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract.,ALLERGIES:  ,No known drug allergies.,CURRENT MEDICATIONS: , Prevacid, Humulin, Diprivan, Proventil, Unasyn, and Solu-Medrol.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , Negative for illicit drugs, alcohol, and tobacco.,PHYSICAL EXAMINATION:  ,Please see the hospital chart.,LABORATORY DATA: , Please see the hospital chart.,HOSPITAL COURSE: , The patient was taken to the operating room by Dr. X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed.  The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated.  If not she would require tracheostomy.  The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated.  She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home.  So, the patient is being prepared for discharge at this point.  We will have Dr. X evaluate her before she leaves to make sure I do not have any problem with her going home.  Dr. Y feels she could be discharged today and will have her return to see him in a week.",15
"CHIEF COMPLAINT:,  Essential thrombocytosis.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 64-year-old gentleman who I am following for essential thrombocytosis.  He was first diagnosed when he first saw a hematologist on 07/09/07.  At that time, his platelet count was 1,240,000.  He was initially started on Hydrea 1000 mg q.d.  On 07/11/07, he underwent a bone marrow biopsy, which showed essential thrombocytosis.  He was positive for the JAK-2 mutation.  On 11/06/07, his platelets were noted to be 766,000.  His current Hydrea dose is now 1500 mg on Mondays and Fridays and 1000 mg on all other days.  He moved to ABCD in December 2009 in an attempt to improve his wife's rheumatoid arthritis.,Overall, he is doing well.  He has a good energy level, and his ECOG performance status is 0.  He denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Hydrea 1500 mg on Mondays and Fridays and 1000 mg the other days of the week,  Flomax q.d., vitamin D q.d, saw palmetto q.d., aspirin 81 mg q.d., and vitamin C q.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:,  As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post an appendectomy.,2.  Status post a tonsillectomy and adenoidectomy.,3.  Status post bilateral cataract surgery.,4.  BPH.,SOCIAL HISTORY:  ,He has a history of tobacco use, which he quit at the age of 37.  He has one alcoholic drink per day.  He is married.  He is a retired lab manager.,FAMILY HISTORY:  ,There is no history of solid tumor or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:",34
"PREOPERATIVE DIAGNOSIS:,  Bladder lesions with history of previous transitional cell bladder carcinoma.,POSTOPERATIVE DIAGNOSIS: , Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.,OPERATION PERFORMED:  ,Cystoscopy, bladder biopsies, and fulguration.,ANESTHESIA: , General.,INDICATION FOR OPERATION: , This is a 73-year-old gentleman who was recently noted to have some erythematous, somewhat raised bladder lesions in the bladder mucosa at cystoscopy.  He was treated for a large transitional cell carcinoma of the bladder with TURBT in 2002 and subsequently underwent chemotherapy because of pulmonary nodules.  He has had some low grade noninvasive small tumor recurrences on one or two occasions over the past 18 months.  Recent cystoscopy raises suspicion of another recurrence.,OPERATIVE FINDINGS: , The entire bladder was actually somewhat erythematous with mucosa looking somewhat hyperplastic particularly in the right dome and lateral wall of the bladder.  Scarring was noted along the base of the bladder from the patient's previous cysto TURBT.  Ureteral orifice on the right side was not able to be identified.  The left side was unremarkable.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room.  He was placed on the operating table.  General anesthesia was administered after which the patient was placed in the dorsal lithotomy position.  The genitalia and lower abdomen were prepared with Betadine and draped subsequently.  The urethra and bladder were inspected under video urology equipment (25 French panendoscope) with the findings as noted above.  Cup biopsies were taken in two areas from the right lateral wall of the bladder, the posterior wall of bladder, and the bladder neck area.  Each of these biopsy sites were fulgurated with Bugbee electrodes.  Inspection of the sites after completing the procedure revealed no bleeding and bladder irrigant was clear.  The patient's bladder was then emptied.  Cystoscope removed and the patient was awakened and transferred to the postanesthetic recovery area.  There were no apparent complications, and the patient appeared to tolerate the procedure well.  Estimated blood loss was less than 15 mL.",37
"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.",23
"PREOPERATIVE DIAGNOSIS: ,Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Ahmed valve model S2 implant with pericardial reinforcement XXX eye,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage, hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox and Ocular. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion. A speculum was placed on the eyelids and microscope was brought into position. A #7-0 Vicryl suture was passed through the superotemporal limbus and traction suture was placed at the superotemporal limbus and the eye was rotated infranasally so as to expose the superotemporal conjunctiva. At this point, smooth forceps and Westcott scissors were used to create a 100-degree superotemporal conjunctival peritomy, approximately 2 mm posterior to the superotemporal limbus. This was then dissected anteriorly to the limbus edge and then posteriorly. Steven scissors were then dissected in a superotemporal quadrant between the superior and lateral rectus muscles to provide good exposure. At this point, we primed the Ahmed valve with a #27 gauge cannula using BSS and it was noted to be patent. We then placed Ahmed valve in the superotemporal subconjunctival recess underneath the subtenon space and this was pushed posteriorly. We then measured with calipers so that it was positioned 9 mm posterior to the limbus. The Ahmed valve was then tacked down with #8-0 nylon suture through both fenestrations. We then applied light cautery to the superotemporal episcleral bed. We placed a paracentesis at the temporal position and inflated the anterior chamber with a small amount of Healon. We then used a #23 gauge needle and entered the superotemporal sclera, approximately 1 mm posterior to the limbus into the anterior chamber away from iris and away from cornea. We then trimmed the tube, beveled up in a 30 degree fashion with Vannas scissors, and introduced the tube through the #23 gauge tract into the anterior chamber so that approximately 2-3 mm of tube was extending into the anterior chamber. We burped some of the Healon out of the anterior chamber and filled it with BSS and we felt that the tube was in good position away from the lens, away from the cornea, and away from the iris. We then tacked down the tubes to the sclera with #8-0 Vicryl suture in a figure-of- eight fashion. The pericardium was soaked in gentamicin. We then folded the pericardium 1x1 cm piece onto itself and then placed it over the tube and this was tacked down in all four quadrants to the sclera with #8-0 nylon suture. At this point, we then re-approximated the conjunctiva to its original position and we closed it with an #8-0 Vicryl suture on a TG needle in a running fashion with interrupted locking bites. We then removed the traction suture. At the end of the case, the pupil was round, the chamber was deep, the tube appeared to be well positioned. The remaining portion of the Healon was burped out of the anterior chamber with BSS and the pressure was felt to be adequate. The speculum was removed. Ocuflox and Maxitrol ointment were placed over the eye. Then, an eye patch and shield were placed over the eye. The patient was awakened and taken to the recovery room in stable condition.",37
"REASON FOR CONSULT: , Essential tremor and torticollis.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed now left-handed white female with tremor since 5th grade.  She remembers that the tremors started in her right hand around that time subsequently later on in early 20s she was put on propranolol for the tremor and more recently within the last 10 years she has been put on primidone and clonazepam.  She thinks that her clonazepam is helping her a lot especially with anxiety and stress, and this makes the tremor better.  She has a lot of trouble with her writing because of tremor but does not report as much problem with other activities of daily living like drinking from a cup and doing her day-to-day activity.  Since around 6 to 7 years, she has had a head tremor, which is mainly ""no- no"" and occasional voice tremor also.  Additionally, the patient has been diagnosed with migraine headaches without aura, which are far and few apart.  She also has some stress incontinence.  Last MRI brain was done in 2001 reportedly normal.,CURRENT MEDICATIONS:,1.  Klonopin 0.5 mg twice a day.,2.  Primidone 100 mg b.i.d.,3.  Propranolol long-acting 80 mg once in the morning.,PAST MEDICAL HISTORY: , Essential tremor, cervical dystonia, endometriosis, migraine headaches without aura, left ear sensorineural deafness, and basal cell carcinoma resection on the nose.,PAST SURGICAL HISTORY: , L5-S1 lumbar laminectomy in 1975, exploratory laparotomy in 1967, tonsillectomy and adenoidectomy, and anal fissure surgery in 1975.,FAMILY HISTORY: , Both parents have ET and hypertension.  Maternal cousin with lupus.,SOCIAL HISTORY: , Denies any smoking or alcohol.  She is married since 44 years, has 3 children.  She used to work as a labor and delivery nurse up until early 2001 when she retired.,REVIEW OF SYSTEMS: , No fever, chills, nausea or vomiting.  No visual complaints.  She complains of hearing decreased on the left.  No chest pain or shortness of breath.  No constipation.  She does give a history of urge incontinence.  No rashes.  No depressive symptoms.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure is 131/72, pulse is 50, and weight is 71.3 kg.  HEENT:  PERRLA.  EOMI.  CARDIOVASCULAR:  S1 and S2 normal.  Regular rate and rhythm.  She does have a rash over the right ankle with a prior basal cell carcinoma was resected.  NEUROLOGIC:  Alert and oriented x4.  Speech shows a voice tremor occasionally.  Language is intact.  Cranial nerves II through XII intact.  Motor examination showed 5/5 power in all extremities with minimal increased tone.  Sensory examination was intact to light touch.  Reflexes were brisk bilaterally, but they were equal and both toes were downgoing.  Her coordination showed minimal intentional component to bilateral finger-to-nose.  Gait was intact.  Lot of swing on Romberg's.  The patient did have a tremor both upper extremities, right more than left.  She did have a head tremor, which was no-no variety, and she had a minimal torticollis with her head twisted to the left.,ASSESSMENT AND PLAN: , This 62-year-old white female has essential tremor and mild torticollis.  Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible.  The patient did not wish to change any of her medication doses at this point.  We will go ahead and check MRI brain, and we will get the films later.  We will see her back in 3 months.  Also, the patient declined any possible Botox for the mild torticollis she has at this point.",22
"PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,PROCEDURE:,  Phacoemulsification with intraocular lens placement, right eye.,ANESTHESIA: , Monitored anesthesia care,ESTIMATED BLOOD LOSS: , None,COMPLICATIONS:,  None,SPECIMENS:,  None,PROCEDURE IN DETAIL: , The patient had previously been examined in the clinic and was found to have a visually significant cataract in the right eye.  The patient had the risks and benefits of surgery discussed.  After discussion, the patient decided to proceed and the consent was signed.,On the day of surgery, the patient was taken from the holding area to the operating suite by the anesthesiologist and monitors were placed.  Following this, the patient was sterilely prepped and draped in the usual fashion.  After this, a lid speculum was placed, preservative-free lidocaine drops were placed, and the SuperSharp blade was used to make an anterior chamber paracentesis.  Preservative-free lidocaine was instilled into the anterior chamber, and then Viscoat was instilled into the eye.,The 3.0 diamond keratome was then used to make a clear corneal temporal incision.  Following this, the cystotome was used to make a continuous tear-type capsulotomy.  After this, BSS was used to hydrodissect and hydrodelineate the lens.  The phacoemulsification unit was used to remove the cataract.  The I&A unit was used to remove the residual cortical material.  Following this, Provisc was used to inflate the bag.  The lens, a model SA60AT of ABCD diopters, serial #1234, was inserted into the bag and rotated into position using the Lester pusher.,After this, the residual Provisc was removed.  Michol was instilled and then the corneal wound was hydrated with BSS, and the wound was found to be watertight.  The lid speculum was removed.  Acular and Vigamox drops were placed.  The patient tolerated the procedure well without complications and will be followed up in the office tomorrow.",37
"CHIEF COMPLAINT:, Headaches.,HEADACHE HISTORY:, The patient describes the gradual onset of a headache problem. The headache first began 2 months ago. The headaches are located behind both eyes. The pain is characterized as a sensation of pressure. The intensity is moderately severe, making normal activities difficult. Associated symptoms include sinus congestion and photophobia. The headache may be brought on by stress, lack of sleep and alcohol. The patient denies vomiting and jaw pain.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, ,No significant past surgical history.,FAMILY MEDICAL HISTORY:, ,There is a history of migraine in the family. The condition affects the patient’s brother and maternal grandfather.,ALLERGIES:, Codeine.,CURRENT MEDICATIONS:, See chart.,PERSONAL/SOCIAL HISTORY:, Marital status: Married. The patient smokes 1 pack of cigarettes per day.  Denies use of alcohol.,NEUROLOGIC DRUG HISTORY:, The patient has had no help with the headaches from over-the-counter analgesics.,REVIEW OF SYSTEMS:,ROS General: Generally healthy. Weight is stable.,ROS Head and Eyes: Patient has complaints of headaches. Vision can best be described as normal.,ROS Ears Nose and Throat: The patient notes some sinus congestion.,ROS Cardiovascular: The patient has no history of any cardiovascular problems and denies any present problems.,ROS Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,ROS Musculoskeletal: No muscle cramps, no joint back or limb pain. The patient denies any past or present problem related to the musculoskeletal system.,EXAM:,Exam General Appearance: The patient was alert and cooperative, and did not appear acutely or chronically ill.,Sex and Race: Male, Caucasian.,Exam Mental Status: Serial 7’s were performed normally. The patient was oriented with regard to time, place and situation.,Three out of three objects were readily recalled after several minutes. The patient correctly identified the president and past president. The patient could repeat 7 digits forward and 4 digits reversed without difficulty. The patient’s affect and emotional response was normal and appropriate. The patient related the clinical history in a coherent, organized fashion.,Exam Cranial Nerves: Sense of smell was intact.,Exam Neck: Neck range of motion was normal in all directions. There was no evidence of cervical muscle spasm.  No radicular symptoms were elicited by neck motions. Shoulder range of motion was normal bilaterally. There were no areas of tenderness. Tests of neurovascular compression were negative. There were no carotid bruits.,Exam Back: Back range of motion was normal in all directions.,Exam Sensory: Position and vibratory sense was normal.,Exam Reflexes: Active and symmetrical. There were no pathological reflexes.,Exam Coordination: The patient’s gait had no abnormal components. Tandem gait was performed normally.,Exam Musculoskeletal: Peripheral pulses palpably normal. There is no edema or significant varicosities.  No lesions identified.,IMPRESSION DIAGNOSIS: ,Migraine without aura (346.91),COMMENTS:, The patient has evolved into a chronic progressive course. Medications Prescribed: Therapeutic trial of Inderal 40mg - 1/2 tab b.i.d. x 1 week, then 1 tab. b.i.d. x 1 week then 1 tab t.i.d.,OTHER TREATMENT:, The patient was given a thorough explanation of the role of stress in migraine, and given a number of suggestions about implementing appropriate changes in lifestyle.,RATIONALE FOR TREATMENT PLAN:, The treatment plan chosen is the most effective and should result in the most beneficial outcome for the patient. There are no reasonable alternatives.,FOLLOW UP INSTRUCTIONS:",5
"FINDINGS:,There are posttraumatic cysts along the volar midline and volar lateral aspects of the lunate which are likely posttraumatic. There is no acute marrow edema (series #12 images #5-7). Marrow signal is otherwise normal in the distal radius and ulna, throughout the carpals and throughout the proximal metacarpals.,There is a partial tear of the volar component of the scapholunate ligament in the region of the posttraumatic lunate cyst with retraction and thickening towards the scaphoid (series #6 image #5, series #8 images #22-36). There is tearing of the membranous portion of the ligament. The dorsal component is intact.,The lunatotriquetral ligament is thickened and lax, but intact (series #8 image #32).,There is no tearing of the radial or ulnar attachment of the triangular fibrocartilage (series #6 image #7). There is a mildly positive ulnar variance. Normal ulnar collateral ligament.,The patient was positioned in dorsiflexion. Carpal alignment is normal and there are no tears of the dorsal or ventral intercarpal ligaments (series #14 image #9).,There is a longitudinal split tear of the ECU tendon which is enlarged both at the level of and distal to the ulnar styloid with severe synovitis (series #4 images #8-16, series #3 images #9-16).,There is thickening of the extensor tendon sheaths within the fourth dorsal compartment with intrinsically normal tendons (series #4 image #12).,There is extensor carpi radialis longus and brevis synovitis in the second dorsal compartment (series #4 image #13).,Normal flexor tendons within the carpal tunnel. There is mild thickening of the tendon sheaths and the median nerve demonstrates increased signal without compression or enlargement (series #3 image #7, series #4 image #7).,There are no pathological cysts or soft tissue masses.,IMPRESSION:,Partial tear of the volar and membranous components of the scapholunate ligament with an associated posttraumatic cyst in the lunate. There is thickening and laxity of the lunatotriquetral ligament.,Longitudinal split tear of the ECU tendon with tendinosis and severe synovitis.,Synovitis of the second dorsal compartment and tendon sheath thickening in the fourth dorsal compartment.,Tendon sheath thickening within the carpal tunnel with increased signal within the median nerve.",33
"FINAL DIAGNOSES:,1.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2.  Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and ""tension headaches.""  In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right.  He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful.  More recently he saw Dr. Y and went through some physical therapy without much relief.,Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7.  In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief.  The procedure and its risk were fully discussed and he decided to proceed with the operation.,HOSPITAL COURSE: , Following admission, the procedure was carried out without difficulty.  Blood loss was about 125 cc.  Postop x-ray showed good alignment and positioning of the cages, plate, and screws.  After surgery, he was able to slowly increase his activity level with assistance from physical therapy.  He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck.  He also had some nausea with the PCA.  He had a low-grade fever to 100.2 and was started on incentive spirometry.  Over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,By 06/27/07, he was ready to go home.  He has been counseled regarding wound care and has received a neck sheet for instruction.  He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks.  He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg.  He is to call if there are any problems.",10
"PREOPERATIVE DIAGNOSIS: , Morbid obesity. ,POSTOPERATIVE DIAGNOSIS: , Morbid obesity. ,PROCEDURE:,  Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. ,ANESTHESIA: , General with endotracheal intubation. ,INDICATIONS FOR PROCEDURE: , This is a 50-year-old male who has been overweight for many years and has tried multiple different weight loss diets and programs.  The patient has now begun to have comorbidities related to the obesity.  The patient has attended our bariatric seminar and met with our dietician and psychologist.  The patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form.,PROCEDURE IN DETAIL: , The risks and benefits were explained to the patient.  Consent was obtained.  The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation.  A Foley catheter was placed for bladder decompression.  All pressure points were carefully padded, and sequential compression devices were placed on the legs.  The abdomen was prepped and draped in standard, sterile, surgical fashion.  Marcaine was injected into the umbilicus.",14
"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.",37
"On review of systems, the patient admits to hypertension and occasional heartburn.  She undergoes mammograms every six months, which have been negative for malignancy.  She denies fevers, chills, weight loss, fatigue, diabetes mellitus, thyroid disease, upper extremity trauma, night sweats, DVT, pulmonary embolism, anorexia, bone pain, headaches, seizures, angina, peripheral edema, claudication, orthopnea, PND, coronary artery disease, rheumatoid arthritis, rashes, upper extremity edema, cat scratches, cough, hemoptysis, shortness of breath, dyspnea at two flights of stairs, hoarseness, GI bleeding, change in bowel habits, dysphagia, ulcers, hematuria, or history of TB exposure.  She has had negative PPD.,PAST MEDICAL HISTORY:,  Hypertension.,PAST SURGICAL HISTORY:,  Right breast biopsy - benign.,SOCIAL HISTORY: , She was born and raised in Baltimore.  She has not performed farming or kept birds or cats.,Tobacco: None.,Ethanol: ,Drug Use: ,Occupation:  She is a registered nurse at Spring Grove Hospital.,Exposure: Negative to asbestos.,FAMILY HISTORY:,  Mother with breast cancer.,ALLERGIES: , Percocet and morphine causing temporary hypotension.,MEDICATIONS: , Caduet 10 mg p.o. q.d., Coreg CR 40 mg p.o. q.d., and Micardis HCT 80 mg/12.5 mg p.o. q.d.,PHYSICAL EXAMINATION: ,BP:  133/72",3
"TITLE OF OPERATION:  ,1.  Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.,2.  A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,INDICATION FOR SURGERY:  ,The patient is a 62-year-old white male who underwent cataract surgery in 09/06.  This was complicated by posterior capsule rupture.  An intraocular lens implant was not attempted.  He developed corneal edema and a preretinal hemorrhage.  He is aware of the risks, benefits, and alternatives of the surgery and now wishes to proceed with secondary scleral suture fixated posterior chamber intraocular lens implant in the left eye, vitrectomy, endolaser, and penetrating keratoplasty.,PREOP DIAGNOSIS:  ,1.  Preretinal hemorrhage.,2.  Diabetic retinopathy.,3.  Aphakia.,4.  Corneal edema.,POSTOP DIAGNOSIS:  ,1.  Preretinal hemorrhage.,2.  Diabetic retinopathy.,3.  Aphakia.,4.  Corneal edema.,ANESTHESIA: , General.,SPECIMEN:  ,1.  Donor corneal swab sent to Microbiology.,2.  Donor corneal scar rim sent to Eye Pathology.,3.  The patient's cornea sent to Eye Pathology.,PROS DEV IMPLANT:  ,ABC Laboratories 16.0 diopter posterior chamber intraocular lens, serial number 123456.,NARRATIVE: , Informed consent was obtained, and all questions were answered.  The patient was brought to the preoperative holding area, where the operative left eye was marked.  He was brought to the operating room and placed in the supine position.  EKG leads were placed.  General anesthesia was induced.  The left ocular surface and periorbital skin were disinfected and draped in the standard fashion for eye surgery after a shield and tape were placed over the unoperated right eye.  A lid speculum was placed.  The posterior segment infusion was placed by the vitreoretinal service.  Peritomy was performed at the 3 and 9 o'clock limbal positions.  A large Flieringa ring was then sutured to the conjunctival surface using 8-0 silk sutures tied in an interrupted fashion.  The cornea was then measured and was found to accommodate a 7.5-mm trephine.  The center of the cornea was marked.  The keratoprosthesis was identified.,A 7.5-mm trephine blade was then used to incise the anterior corneal surface.  This was done after a paracentesis was placed at the 1 o'clock position and viscoelastic was used to dissect peripheral anterior synechiae.  Once the synechiae were freed, the above-mentioned trephination of the anterior cornea was performed.  Corneoscleral scissors were then used to excise completely the central cornea.  The keratoprosthesis was placed in position and was sutured with six interrupted 8-0 silk sutures.  This was done without difficulty.  At this point, the case was turned over to the vitreoretinal team, which will dictate under a separate note.  At the conclusion of the vitreoretinal procedure, the patient was brought under the care of the cornea service.  The 9-0 Prolene sutures double armed were then placed on each lens haptic loop.  The keratoprosthesis was removed.  Prior to this removal, scleral flaps were made, partial thickness at the 3 o'clock and 9 o'clock positions underneath the peritomies.  Wet-field cautery also was performed to achieve hemostasis.  The leading hepatic sutures were then passed through the bed of the scleral flap.  These were drawn out of the eye and then used to draw the trailing hepatic into the posterior segment of the eye followed by the optic.  The trailing hepatic was then placed into the posterior segment of the eye as well.  The trailing haptic sutures were then placed through the opposite scleral flap bed and were withdrawn.  These were tied securely into position with the IOL nicely centered.  At this point, the donor cornea punched at 8.25 mm was then brought into the field.  This was secured with four cardinal sutures.  The corneal button was then sutured in place using a 16-bite 10-0 nylon running suture.  The knot was secured and buried after adequate tension was adjusted.  The corneal graft was watertight.  Attention was then turned back to the IOL sutures, which were locked into position.  The ends were trimmed.  The flaps were secured with single 10-0 nylon sutures to the apex, and the knots were buried.  At this point, the case was then turned back over to the vitreoretinal service for further completion of the retinal procedure.  The patient tolerated the corneal portions of the surgery well and was turned over to the retina service in good condition, having tolerated the procedure well.  No complications were noted.  The attending surgeon, Dr. X, performed the entire procedure.  No complications of the procedure were noted.  The intraocular lens was selected from preoperative calculations.  No qualified resident was available to assist.",26
"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.",23
"PREOPERATIVE DIAGNOSIS:,  History of perforated sigmoid diverticuli with Hartmann's procedure.,POSTOPERATIVE DIAGNOSES:  ,1.  History of perforated sigmoid diverticuli with Hartmann's procedure.,2.  Massive adhesions.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Lysis of adhesions and removal.,3.  Reversal of Hartmann's colostomy.,4.  Flexible sigmoidoscopy.,5.  Cystoscopy with left ureteral stent.,ANESTHESIA: , General.,HISTORY: , This is a 55-year-old gentleman who had a previous perforated diverticula.  Recommendation for reversal of the colostomy was made after more than six months from the previous surgery for a sigmoid colon resection and Hartmann's colostomy.,PROCEDURE:  ,The patient was taken to the operating room placed into lithotomy position after being prepped and draped in the usual sterile fashion.  A cystoscope was introduced into the patient's urethra and to the bladder.  Immediately, no evidence of cystitis was seen and the scope was introduced superiorly, measuring the bladder and immediately a #5 French ____ was introduced within the left urethra.  The cystoscope was removed, a Foley was placed, and wide connection was placed attaching the left ureteral stent and Foley.  At this point, immediately the patient was re-prepped and draped and immediately after the ostomy was closed with a #2-0 Vicryl suture, immediately at this point, the abdominal wall was opened with a #10 blade Bard-Parker down with electrocautery for complete hemostasis through the midline.,The incision scar was cephalad due to the severe adhesions in the midline.  Once the abdomen was entered in the epigastric area, then massive lysis of adhesions was performed to separate the small bowel from the anterior abdominal wall.  Once the small bowel was completely free from the anterior abdominal wall, at this point, the ostomy was taken down with an elliptical incision with cautery and then meticulous dissection with Metzenbaum scissors and electrocautery down to the anterior abdominal wall, where a meticulous dissection was carried with Metzenbaum scissors to separate the entire ostomy from the abdominal wall.  Immediately at this point, the bowel was dropped within the abdominal cavity, and more lysis of adhesions was performed cleaning the left gutter area to mobilize the colon further down to have no tension in the anastomosis.  At this point, the rectal stump, where two previous sutures with Prolene were seen, were brought with hemostats.  The rectal stump was free in a 360 degree fashion and immediately at this point, a decision to perform the anastomosis was made.  First, a self-retaining retractor was introduced in the abdominal cavity and a bladder blade was introduced as well.  Blue towel was placed above the small bowel retracting the bowel to cephalad and at this point, immediately the rectal stump was well visualized, no evidence of bleeding was seen, and the towels were placed along the edges of the abdominal wound.  Immediately, the pursestring device was fired approximately 1 inch from the skin and on the descending colon, this was fired.  The remainder of the excess tissue was closed with Metzenbaum scissors and immediately after dilating #25 and #29 mushroom tip from the T8 Ethicon was placed within the colon and then #9-0 suture was tied.  Immediately from the anus, the dilator #25 and #29 was introduced dilating the rectum.  The #29 EEA was introduced all the way anteriorly to the staple line and this spike from the EEA was used to perforate the rectum and then the mushroom from the descending colon was attached to it.  The EEA was then fired.  Once it was fired and was removed, the pelvis was filled with fluid.  Immediately both doughnuts were ____ from the anastomosis.  A Doyen was placed in both the anastomosis.  Colonoscope was introduced.  No bubble or air was seen coming from the anastomosis.  There was no evidence of bleeding.  Pictures of the anastomosis were taken.  The scope then was removed from the patient's rectum.  Copious amount of irrigation was used within the peritoneal cavity.  Immediately at this point, all complete sponge and instrument count was performed.  First, the ostomy site was closed with interrupted figure-of-eight #0 Vicryl suture.  The peritoneum was closed with running #2-0 Vicryl suture.  Then, the midline incision was closed with a loop PDS in cephalad to caudad and caudad to cephalad tight in the middle.  Subq tissue was copiously irrigated and the staples on the skin.,The iodoform packing was placed within the old ostomy site and then the staples on the skin as well.  The patient did tolerate the procedure well and will be followed during the hospitalization.  The left ureteral stent was removed at the end of the procedure.  _____ were performed.  Lysis of adhesions were performed.  Reversal of colostomy and EEA anastomosis #29 Ethicon.",37
"PREOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1.  Excision of mass, left second toe.,2.  Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot.  The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size.  The patient also has history of shave biopsy in the past.  The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses.  The foot was lowered to the operating table.  The stockinet was reflected and the foot was cleansed with wet and dry sponge.  A distal Syme's incision was planned over the distal aspect of the left hallux.  The incision was performed with a #10 blade and deepened with #15 down to the level of bone.  The dorsal skin flap was removed and dissected in toto off of the distal phalanx.  There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx.  The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer.  Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen.  At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx.  The area was inspected for any remaining suspicious tissues.  Any suspicious tissue was removed.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe.  There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe.  A linear incision was made just medial to the tissue mass.  The mass was then dissected from the overlying skin and off of the underlying capsule.  This tissue mass was hard, round, and pearly-gray in appearance.  It does not invade into any other surrounding tissues.  The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon.  Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed.  The patient will be contacted immediately pending the results of pathology.  Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.",16
"CHIEF COMPLAINT:  ,Leaking nephrostomy tube.,HISTORY OF PRESENT ILLNESS: , This 61-year-old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube.  The leaking began this a.m.  The patient denies any pain, does not have fever and has no other problems or complaints.  The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.  The patient states he feels like his usual self and has no other problems or concerns.  The patient denies any fever or chills.  No nausea or vomiting.  No flank pain, no abdominal pain, no chest pain, no shortness of breath, no swelling to the legs.,REVIEW OF SYSTEMS: , Review of systems otherwise negative and noncontributory.,PAST MEDICAL HISTORY: , Metastatic prostate cancer, anemia, hypertension.,MEDICATIONS: , Medication reconciliation sheet has been reviewed on the nurses' note.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a nonsmoker.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 97.7 oral, blood pressure 150/85, pulse is 91, respirations 16, oxygen saturation 97% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed, appears to be healthy, calm, comfortable, no acute distress, looks well.  HEENT:  Eyes are normal with clear sclerae and cornea.  NECK:  Supple, full range of motion.  CARDIOVASCULAR:  Heart has regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  No dependent edema.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, nondistended.  No rebound or guarding.  Normal benign abdominal exam.  MUSCULOSKELETAL:  The patient has nontender back and flank.  No abnormalities noted to the back other than the bilateral nephrostomy tubes.  The nephrostomy tube left has no abnormalities, no sign of infection.  No leaking of urine, nontender, nephrostomy tube on the right has a damp dressing, which has a small amount of urine soaked into it.  There is no obvious active leak from the ostomy site.  No sign of infection.  No erythema, swelling or tenderness.  The collection bag is full of clear urine.  The patient has no abnormalities on his legs.  SKIN:  No rashes or lesions.  No sign of infection.  NEUROLOGIC:  Motor and sensory are intact to the extremities.  The patient has normal ambulation, normal speech.  PSYCHIATRIC:  Alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC AND LYMPHATIC:  No bleeding or bruising.,EMERGENCY DEPARTMENT COURSE:,  Reviewed the patient's admission record from one month ago when he was admitted for the placement of the nephrostomy tubes, both Dr. X and Dr. Y have been consulted and both had recommended nephrostomy tubes, there was not the name mentioned as to who placed the nephrostomy tubes.  There was no consultation dictated for this and no name was mentioned in the discharge summary, paged Dr. X as this was the only name that the patient could remember that might have been involved with the placement of the nephrostomy tubes.  Dr. A responded to the page and recommended __________ off a BMP and discussing it with Dr. B, the radiologist as he recalled that this was the physician who placed the nephrostomy tubes, paged Dr. X and received a call back from Dr. X.  Dr. X stated that he would have somebody get in touch with us about scheduling a time for which they will change out the nephrostomy tube to a larger and check a nephrogram at that time that came down and stated that they would do it at 10 a.m. tomorrow.  This was discussed with the patient and instructions to return to the hospital at 10 a.m. to have this tube changed out by Dr. X was explained and understood.,DIAGNOSES:,1.  WEAK NEPHROSTOMY SITE FOR THE RIGHT NEPHROSTOMY TUBE.,2.  PROSTATE CANCER, METASTATIC.,3.  URETERAL OBSTRUCTION.,The patient on discharge is stable and dispositioned to home.,PLAN: , We will have the patient return to the hospital tomorrow at 10 a.m. for the replacement of his right nephrostomy tube by Dr. X.  The patient was asked to return in the emergency room sooner if he should develop any new problems or concerns.",21
"The right eardrum is intact showing a successful tympanoplasty.  I cleaned a little wax from the external meatus.  The right eardrum might be very slightly red but not obviously infected.  The left eardrum (not the surgical ear) has a definite infection with a reddened bulging drum but no perforation or granulation tissue.  Also some wax at the external meatus I cleaned with a Q-tip with peroxide.  The patient has no medical allergies.  Since he recently had a course of Omnicef we chose to put him on Augmentin (I checked and we did not have samples), so I phoned in a two-week course of Augmentin 400 mg chewable twice daily with food at Walgreens.  I looked at this throat which looks clear.  The nose only has a little clear mucinous secretions.  If there is any ear drainage, please use the Floxin drops.  I asked Mom to have the family doctor (or Dad, or me) check the ears again in about two weeks from now to be sure there is no residual infection.  I plan to see the patient again later this spring.",11
"REASON FOR VISIT: , Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea.  He returns today to review his response to CPAP.,HISTORY OF PRESENT ILLNESS: , The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner.  He was found to have moderate-to-severe sleep apnea (predominantly hypopnea), was treated with nasal CPAP at 10 cm H2O nasal pressure.  He has been on CPAP now for several months, and returns for followup to review his response to treatment.,The patient reports that the CPAP has limited his snoring at night.  Occasionally, his bed partner wakes him in the middle of the night, when the mask comes off, and reminds him to replace the mask.  The patient estimates that he uses the CPAP approximately 5 to 7 nights per week, and on occasion takes it off and does not replace the mask when he awakens spontaneously in the middle of the night.,The patient's sleep pattern consists of going to bed between 11:00 and 11:30 at night and awakening between 6 to 7 a.m. on weekdays.  On weekends, he might sleep until 8 to 9 a.m.  On Saturday night, he might go to bed approximately mid night.,As noted, the patient is not snoring on CPAP.  He denies much tossing and turning and does not awaken with the sheets in disarray.  He awakens feeling relatively refreshed.,In the past few months, the patient has lost between 15 and 18 pounds in combination of dietary and exercise measures.,He continues to work at Smith Barney in downtown Baltimore.  He generally works from 8 to 8:30 a.m. until approximately 5 to 5:30 p.m.  He is involved in training purpose to how to sell managed funds and accounts.,The patient reports no change in daytime stamina.  He has no difficulty staying awake during the daytime or evening hours.,The past medical history is notable for allergic rhinitis.,MEDICATIONS: , He is maintained on Flonase and denies much in the way of nasal symptoms.,ALLERGIES: , Molds.,FINDINGS:  ,Vital signs:  Blood pressure 126/75, pulse 67, respiratory rate 16, weight 172 pounds, height 5 feet 9 inches, temperature 98.4 degrees and SaO2 is 99% on room air at rest.,The patient has adenoidal facies as noted previously.,Laboratories:  The patient forgot to bring his smart card in for downloading today.,ASSESSMENT: , Moderate-to-severe sleep apnea.  I have recommended the patient continue CPAP indefinitely.  He will be sending me his smart card for downloading to determine his CPAP usage pattern.  In addition, he will continue efforts to maintain his weight at current levels or below.  Should he succeed in reducing further, we might consider re-running a sleep study to determine whether he still requires a CPAP.,PLANS: , In the meantime, if it is also that the possible nasal obstruction is contributing to snoring and obstructive hypopnea.  I have recommended that a fiberoptic ENT exam be performed to exclude adenoidal tissue that may be contributing to obstruction.  He will be returning for routine followup in 6 months.",34
"PREOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,POSTOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,OPERATION:,  Primary cesarean section by low-transverse incision.,ANESTHESIA:,  Epidural.,ESTIMATED BLOOD LOSS: , 450 mL.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS:  ,Foley catheter.,INDICATIONS: , The patient is a 39-year-old, G4, para 0-0-3-0, with an EDC of 03/08/2009.  The patient began having prodromal symptoms 2 to 3 days prior to presentation.  She was seen on 03/09/2007 and a nonstress test was performed.  This revealed some spontaneous variable-appearing decelerations.  She was given IV hydration.  A biophysical profile was obtained, which provided a score of 0/8 with only a 1 cm fluid pocket found.  Therefore, she was admitted for further fetal monitoring and evaluation.  She had changed her cervix from closed 2 days prior to presentation to 1 cm dilated.  She was having somewhat irregular contractions, but with stronger contractions, continued to have decelerations to 50 to 60 beats per minute.  Due to these findings, a scalp electrode was placed as well as an IUPC for an amnioinfusion.  This relieved the decelerations somewhat.  However, over a period of time with strong contractions, she still had bradycardia 40 to 50 beats per minute and developed a late component on the return of the decelerations.  Due to this finding, it was evident that the fetal state would not support labor in order to accomplish a vaginal delivery.  These findings were reviewed with the patient and recommendation was made for cesarean section delivery.  The risks and benefits of this surgery were reviewed, and knowing these facts, the patient gave informed consent.,PROCEDURE: , The patient was taken to the operating room where her epidural anesthesia was reinforced.  She was prepped and draped in the usual fashion for the procedure.  After adequate epidural level was confirmed, the scalp was utilized to make a transverse incision in the patient's lower abdominal wall.  This incision was carried down to the level of the fascia, which was also transversely incised.  After adequate hemostasis, the fascia was bluntly and sharply separated up from the underlying rectus muscle.  The rectus muscle was separated in midline exposing the peritoneum.  The peritoneum was carefully grasped and elevated with hemostats.  It was entered in an up and down fashion with Metzenbaum scissors.  The bladder blade was placed in the lower pole of the incision to protect the bladder.,The uterus was palpated and inspected.  A thin lower uterine segment was noted.  The vertex presentation was confirmed.  The scalp was then utilized to make a transverse or Kerr incision in the lower uterine wall.  Clear fluid was noted upon entering into the amniotic space.  At 05:27, a term viable female infant was delivered up through the incision.  She had spontaneous respirations.  She was given bulb suctioning for clear fluid.  Her cord was clamped and cut and she was delivered off the field to Dr. X who was attending.  The baby girl was subsequently signed Apgars of 8 at one minute and 9 at five minutes.  Her birth weight was found to be 5 pounds and 5 ounces.,The placenta was manually extracted from the endometrial cavity.  A ring clamp and two Allis clamps were placed around the margin of the uterine incision for hemostasis.  The uterus was delivered up into the operative field.  The endometrial cavity was swiped clean with a moist laparotomy pad.  The uterine incision was then closed in a two-layered fashion with 0 Vicryl suture, the first layer interlocking and the second layer imbricating.  Two additional stitches of 3-0 Vicryl suture were utilized for hemostasis.  The uterine incision was noted to be hemostatic upon closure.  The uterus was rotated forward, normal tubes and ovaries were noted on both sides.  The uterus was then returned to its normal position of the abdominal cavity.  The sponge and instrument count was performed for the first time at this point and found to be correct.  The pelvis and anterior uterine space was then irrigated with saline solution.  It was suctioned dry.  A final check of the uterine incision confirmed hemostasis.  The rectus muscle was stabilized across the midline with two simple stitches of 0 Vicryl suture.  The subcutaneous tissue was then exposed, and the fascia closed with two running lengths of 0 Vicryl suture, beginning in lateral margins and overlapping the midline.  The subcutaneous tissue was then irrigated and inspected.  No active bleeding was noted.  It was closed with a running length of 3-0 plain catgut suture.  The skin was then approximated with surgical steel staples.  The incision was infiltrated with a 0.5% solution of Marcaine local anesthetic.  The incision was cleansed and sterilely dressed.,The patient was transferred to the recovery room in stable condition.  The estimated blood loss through the procedure was 450 mL.  The sponge and instrument counts were performed two more times during closure and found to be correct each time.",37
"PREOPERATIVE DIAGNOSES,1.  A 40 weeks 6 days intrauterine pregnancy.,2.  History of positive serology for HSV with no evidence of active lesions.,3.  Non-reassuring fetal heart tones.,POST OPERATIVE DIAGNOSES,1.  A 40 weeks 6 days intrauterine pregnancy.,2.  History of positive serology for HSV with no evidence of active lesions.,3.  Non-reassuring fetal heart tones.,PROCEDURES,1.  Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration.,2.  Repair of the third-degree midline laceration lasting for 25 minutes.,ANESTHESIA: , Local.,ESTIMATED BLOOD LOSS: , 300 mL.,COMPLICATIONS:  ,None.,FINDINGS,1.  Live male infant with Apgars of 9 and 9.,2.  Placenta delivered spontaneously intact with a three-vessel cord.,DISPOSITION:  ,The patient and baby remain in the LDR in stable condition.,SUMMARY: , This is a 36-year-old G1 woman who was pregnant since 40 weeks 6 days when she was admitted for induction of labor for post dates with favorable cervix.  When she was admitted, her cervix was 2.5 cm dilated with 80% effacement.  The baby had a -2 station.  She had no regular contractions.  Fetal heart tones were 120s and reactive.  She was started on Pitocin for labor induction and labored quite rapidly.  She had spontaneous rupture of membranes with a clear fluid.  She had planned on an epidural; however, she had sudden rapid cervical change and was unable to get the epidural.  With the rapid cervical change and descent of fetal head, there were some variable decelerations.  The baby was at a +1 station when the patient began pushing.  I had her push to get the baby to a +2 station.  During pushing, the fetal heart tones were in the 80s and did not recover in between contractions.  Because of this, I recommended a vacuum delivery for the baby.  The patient agreed.,The baby's head was confirmed to be in the right occiput anterior presentation.  The perineum was injected with 1% lidocaine.  The bladder was drained.  The vacuum was placed and the correct placement in front of the posterior fontanelle was confirmed digitally.  With the patient's next contraction, the vacuum was inflated and a gentle downward pressure was used to assist with brining the baby's head to a +3 station.  The contraction ended.  The vacuum was released and the fetal heart tones remained in the, at this time, 90s to 100s.  With the patient's next contraction, the vacuum was reapplied and the baby's head was delivered to a +4 station.  A modified Ritgen maneuver was used to stabilize the fetal head.  The vacuum was deflated and removed.  The baby's head then delivered atraumatically.  There was no nuchal cord.  The baby's anterior shoulder delivered after a less than 30 second delay.  No additional maneuvers were required to deliver the anterior shoulder.  The posterior shoulder and remainder of the body delivered easily.  The baby's mouth and nose were bulb suctioned.  The cord was clamped x2 and cut.  The infant was handed to the respiratory therapist.,Pitocin was added to the patient's IV fluids.  The placenta delivered spontaneously, was intact and had a three-vessel cord.  A vaginal inspection revealed a third-degree midline laceration as well as a right vaginal side wall laceration.  The right side wall laceration was repaired with #3-0 Vicryl suture in a running fashion with local anesthesia.  The third-degree laceration was also repaired with #3-0 Vicryl sutures.  Local anesthesia was used.  The capsule was visible, but did not appear to be injured at all.  It was reinforced with three separate interrupted sutures and then the remainder of the incision was closed with #3-0 Vicryl in the typical fashion.,The patient tolerated the procedure very well.  She remains in the LDR with the baby.  The baby is vigorous, crying and moving all extremities.  He will go to the new born nursery when ready.  The total time for repair of the laceration was 25 minutes.",37
"PREOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,POSTOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,4.  Postoperative coagulopathy.,OPERATIVE PROCEDURE:,1.  Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass.,2.  Open sternotomy covered with Ioban.,3.  Insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.,ANESTHESIA: , General endotracheal.,OPERATIVE PROCEDURE: , With the patient in the supine position, he was prepped from shin to knees and draped in a sterile field.  A right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass.  A sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm, freeing up the right atrium and the ascending aorta and anterior right ventricle.  The patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava.  A percutaneous catheter for arterial return was placed using Seldinger technique through exposed right femoral artery and then two 3-mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava.  After satisfactory heparinization has been obtained, the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium.  After the heart was brought to the operating room and triggered, the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place.  A cardiectomy was then performed by starting in the right atrium.  The wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the Swan-Ganz catheter was brought out into the operative field.  Cardiectomy was then performed, first resecting the anterior portion of the right atrium and then transecting the aorta, the pulmonary artery, the septum between the right and left atriums, and then the heart was removed.  The right and left atrium, aorta, and pulmonary artery were prepared for the transplant.  First, we did a side-to-side anastomosis, continued to the left atrium and this was performed using 3-0 Prolene suture and a right atrial anastomosis side-to-side was performed using 3-0 Prolene suture.  The pulmonary artery was then anastomosed using 5-0 Prolene and the aorta was anastomosed with 4-0 Prolene.  The arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood.  Air was evacuated and the sutures were tied down.  The clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass.  The patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass.  Blood factors and factor VII were given to try and correct the coagulopathy.  Because of excessive transfusions that were required, a Mahurkar catheter was inserted through the left common femoral vein, first placing a needle into the vein and then guidewire removed, and the needle dilators were then placed and then the Mahurkar catheter was then placed with 2-0 nylon suture.  Hemofiltration was started in the operating room at this time.  After he had satisfactory hemostasis, we decided to do the chest open and cover it with Ioban, which we did, and one chest tube was inserted into the mediastinum through a separate stab wound.  The patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively.  This was left in place and the pulse generation, the pacemaker was in a right infraclavicular position, which was left in place because of the coagulopathy.  The patient received 11 units of packed red blood cells, 7 platelets, 23 fresh-frozen plasma, 20 cryoprecipitates, and factor VII.  Urine output for the procedure was 520 mL.  The preservation time of the heart is in the anesthesia sheet.  The estimated blood loss was at least 6 L.  The patient was taken to the intensive care unit in guarded condition.",3
"ADMITTING DIAGNOSIS:,  Aftercare of multiple trauma from an motor vehicle accident.,DISCHARGE DIAGNOSES:,1.  Aftercare following surgery for injury and trauma.,2.  Decubitus ulcer, lower back.,3.  Alcohol induced persisting dementia.,4.  Anemia.,5.  Hypokalemia.,6.  Aftercare healing traumatic fracture of the lower arm.,7.  Alcohol abuse, not otherwise specified.,8.  Aftercare healing traumatic lower leg fracture.,9.  Open wound of the scalp.,10.  Cervical disk displacement with myelopathy.,11.  Episodic mood disorder.,12.  Anxiety disorder.,13.  Nervousness.,14.  Psychosis.,15.  Generalized pain.,16.  Insomnia.,17.  Pain in joint pelvic region/thigh.,18.  Motor vehicle traffic accident, not otherwise specified.,PRINCIPAL PROCEDURES:,  None.,HISTORY OF PRESENT ILLNESS: , As per Dr. X without any changes or corrections.,HOSPITAL COURSE:  ,This is a 50-year-old male, who is initially transferred from Medical Center after treatment for multiple fractures after a motor vehicle accident.  He had a left tibial plateau fracture, right forearm fracture with ORIF, head laceration, and initially some symptoms of head injury.  When he was initially transferred to HealthSouth, he was status post ORIF for his right forearm.  He had a brace placed in the left leg for his left tibial plateau fracture.  He was confused initially and initially started on rehab.  He was diagnosed with some acute psychosis and thought problems likely related to his alcohol abuse history.  He did well from orthopedic standpoint.  He did have a small sacral decubitus ulcer, which was well controlled with the wound care team and healed quite nicely.  He did have some anemia initially and he had dropped down in to the low 9, but he was 9.2 with his lowest on 06/11/2008, which had responded well to iron treatment and by the time of discharge, he was lower at 11.0.  He made slow progress from therapy.  His confusion gradually cleared.  He did have some problems with insomnia and was placed on Seroquel to help with both of his moods and other issues and he did quite well with this.  He did require some Ativan for agitation.  He was on chronic pain medications as an outpatient.  His medications were adjusted here and he did well with this as well.  The patient was followed throughout his entire stay with case management and discussions were made with them and the psychologist concerning the placement upon discharge to an acute alcohol rehab facility; however, the patient refused throughout this entire stay.  We did have orthopedic followup.  He was taken out of his right leg brace the week of 06/16/2008.  He did well with therapy.  Overall, he was doing much and much better.  He had progressed with the therapy to the point where that he was comfortable to go home and receive outpatient therapy and follow up with his primary care physician.  On 06/20/2008, with all parties in agreement, the patient was discharged to home in stable condition.,At the time of discharge, the patient's ambulatory status was much better.  He was using a wheeled walker.  He was able to bear weight on his left leg.  His pain level had been well controlled and his moods had improved dramatically.  He was no longer having any signs of agitation or confusion and he seemed to be at a stable baseline.  His anemia had resolved almost completely and he was doing quite well. ,MEDICATIONS: , On discharge included:,1.  Calcium with vitamin D 1 tablet twice a day.,2.  Ferrous sulfate 325 mg t.i.d.,3.  Multivitamin 1 daily.,4.  He was on nicotine patch 21 mg per 24 hour.,5.  He was on Seroquel 25 mg at bedtime.,6.  He was on Xenaderm for his sacral pressure ulcer.,7.  He was on Vicodin p.r.n. for pain.,8.  Ativan 1 mg b.i.d. for anxiety and otherwise he is doing quite well.,The patient was told to follow up with his orthopedist Dr. Y and also with his primary care physician upon discharge.",15
"GENERAL: , A well-developed infant in no acute respiratory distress.,VITAL SIGNS:  ,Initial temperature was XX, pulse XX, respirations XX.  Weight XX grams, length XX cm, head circumference XX cm.,HEENT:  ,Head is normocephalic with anterior fontanelle open, soft, and non-bulging.  Eyes:  Red reflex elicited bilaterally.  TMs occluded with vernix and not well visualized.  Nose and throat are patent without palatal defect.,NECK: , Supple without clavicular fracture.,LUNGS:,  Clear to auscultation.,HEART:,  Regular rate without murmur, click, or gallop present.  Pulses are 2/4 for brachial and femoral.,ABDOMEN:,  Soft with bowel sounds present.  No masses or organomegaly.,GENITALIA: , Normal.,EXTREMITIES: , Without evidence of hip defects.,NEUROLOGIC:  ,The infant has good Moro, grasp, and suck reflexes.,SKIN: , Warm and dry without evidence of rash.",5
"PAST MEDICAL HISTORY:  Include:,1.  Type II diabetes mellitus.,2.  Hypertension.,3.  Hyperlipidemia.,4.  Gastroesophageal reflux disease.,5.  Renal insufficiency.,6.  Degenerative joint disease, status post bilateral hip and bilateral knee replacements.,7.  Enterocutaneous fistula.,8.  Respiratory failure.,9.  History of atrial fibrillation.,10.  Obstructive sleep apnea.,11.  History of uterine cancer, status post total hysterectomy.,12.  History of ventral hernia repair for incarcerated hernia.,SOCIAL HISTORY:  The patient has been admitted to multiple hospitals over the last several months.,FAMILY HISTORY:  Positive for diabetes mellitus type 2 in both mother and her sister.,MEDICATIONS:  Currently include,,1.  Albuterol inhaler q.4 h.,2.  Paradox swish and spit mouthwash twice a day.,3.  Digoxin 0.125 mg daily.,4.  Theophylline 50 mg q.6 h.,5.  Prozac 20 mg daily.,6.  Lasix 40 mg daily.,7.  Humulin regular high dose sliding scale insulin subcu. q.6 h.,8.  Atrovent q.4 h.,9.  Lantus 12 units subcu. q.12 h.,10.  Lisinopril 10 mg daily.,11.  Magnesium oxide 400 mg three times a day.,12.  Metoprolol 25 mg twice daily.,13.  Nitroglycerin topical q.6 h.,14.  Zegerid 40 mg daily.,15.  Simvastatin 10 mg daily.,ALLERGIES:  Percocet, Percodan, oxycodone, and Duragesic.,REVIEW OF SYSTEMS:  The patient currently denies any pain, denies any headache or blurred vision.  Denies chest pain or shortness of breath.  She denies any nausea or vomiting.  Otherwise, systems are negative.,PHYSICAL EXAM:,General:  The patient is awake, alert, and oriented.  She is in no apparent respiratory distress.,Vital Signs:  Temperature 97.6, blood pressure is 139/53, pulse 100, respirations 24.  The patient has a tracheostomy in place.  She will also have an esophageal gastric tube in place.,Cardiac:  Regular rate and rhythm without audible murmurs, rubs or gallops.  Lungs are clear to auscultation bilaterally with slightly diminished breath sounds on the bases.  No adventitious sounds are noted.,Abdomen:  Obese.  There is an open wound on the ventral abdomen overlying the midline abdominal incision from previous surgery.  The area is covered with bandage with serosanguineous fluid.  Abdomen is nontender to palpation.  Bowel sounds are heard in all 4 quadrants.,Extremities:  Bilateral lower extremities are edematous and very cool to touch.,LABORATORY DATA:  Pending.  Capillary blood sugars thus far have been 132 and 135.,ASSESSMENT:  This is an 80-year-old female with an unfortunate past medical history with recent complications of sepsis and respiratory failure who is now receiving tube feeds.,PLAN:  For her diabetes mellitus, we will continue the patient on her current regimen of Lantus 12 units subcu. q.12 h. and Regular Insulin at a high dose sliding scale every 6 hours.  The patient had been previously controlled on this.  We will continue to check her sugars every 6 hours and adjust insulin as necessary.",5
"CHIEF COMPLAINT:,  ""I took Ecstasy."",HISTORY OF PRESENT ILLNESS: , This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.  The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis.  Mother called the EMS service when the patient vomited.  On arrival here, the patient states that she no longer has any nausea and that she feels just fine.  The patient states she feels wired but has no other problems or complaints.  The patient denies any pain.  The patient does not have any auditory of visual hallucinations.  The patient denies any depression or suicidal ideation.  The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself.  The patient denies any homicidal ideation.  The patient denies any recent illness or recent injuries.  The mother states that the daughter appears to be back to her usual self now.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No recent illness.  No fever or chills.  HEENT:  No headache.  No neck pain.  No vision change or hearing change.  No eye or ear pain.  No rhinorrhea.  No sore throat.  CARDIOVASCULAR:  No chest pain.  No palpitations or racing heart.  RESPIRATIONS:  No shortness of breath.  No cough.  GASTROINTESTINAL: One episode of nonbloody, nonbilious emesis this morning without any nausea since then.  The patient denies any abdominal pain.  No change in bowel movements.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No dizziness, syncope, or near syncope.  PSYCHIATRIC:  The patient denies any depression, suicidal ideation, homicidal ideation, auditory hallucinations or visual hallucinations.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  None.,PAST SURGICAL HISTORY: , Appendectomy when she was 9 years old.,CURRENT MEDICATIONS: , Birth control pills.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies smoking cigarettes.  The patient does drink alcohol and also uses illicit drugs.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure 140/86, pulse is 79, respirations 16, oxygen saturation 100% on room air and is interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, and well developed, appears to be healthy.  The patient is calm and comfortable, in no acute distress and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctiva bilaterally.  The patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally.  No evidence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Ears are normal without any sign of infection.  Mouth and oropharynx are normal without any signs of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +3 and bounding.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, normal and benign.  MUSCULOSKELETAL:  No abnormalities noted in back, arms, or legs.  The patient is normal use of her extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact in all extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  The patient does not have any smell of alcohol and does not exhibit any clinical intoxication.  The patient is quite pleasant, fully cooperative.  HEMATOLOGIC/LYMPHATIC: NO lymphadenitis is noted.  No bruising is noted.,DIAGNOSES:,1.  ECSTASY INGESTION.,2.  ALCOHOL INGESTION.,3.  VOMITING SECONDARY TO STIMULANT ABUSE.,CONDITION UPON DISPOSITION: , Stable disposition to home with her mother.,PLAN:,  I will have the patient followup with her physician at the ABC Clinic in two days for reevaluation.  The patient was advised to stop drinking alcohol, and taking Ecstasy as this is not only in the interest of her health, but was also illegal.  The patient is asked to return to the emergency room should she have any worsening of her condition, develop any other problems or symptoms of concern.",15
"CHIEF COMPLAINT: , ""A lot has been thrown at me."",The patient is interviewed with husband in room.,HISTORY OF PRESENT ILLNESS: , This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets.  She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today.  The patient states she had been thinking about suicide for a couple of weeks.  Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble.  Reports she has been not socializing with her family because of her worsening depression.  Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth.  They did as they have instructed and husband feels this may have had some factor on her worsening depression.  The patient decided to ingest the pills when her husband went to work on Friday.  She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened.  Her husband left around 7 in the morning and returned around 11 and found her sleeping.  About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital.,She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene.  She does not clearly explain how this has made her suicidality subside.,This is the third suicide attempt in the last two months for this patient.  About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall.  She was taken to Southwest Memorial Hermann Hospital.  A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor.  Husband locked the gun after that and she was taken to Bellaire Hospital.  The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days.  She sees Dr. X once or twice weekly.  He started seeing her after her first suicide attempt.,The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active.  Since then she has had worsening of her Huntington symptoms including short-term memory loss.  At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath.  The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease.,The patient's mother passed away 25 years ago from Huntington's.  Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's.  The patient has told her husband that she does not want to go that way.  The patient denies auditory or visual hallucinations, denies paranoid ideation.  The husband and the patient deny any history of manic or hypomanic symptoms in the past.,PAST PSYCHIATRIC HISTORY: , As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X.  She has a remote history of being on Lexapro for depression.,MEDICATIONS: , Her medications on admission, alprazolam 0.5 mg p.o. b.i.d., Artane 2 mg p.o. b.i.d., Haldol 2.5 mg p.o. t.i.d., Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily.  Husband has stated that the patient's chorea becomes better when she takes Haldol.  Alprazolam helps her with anxiety symptoms.,PAST MEDICAL HISTORY: , Huntington disease, symptoms of dementia and hypertension.  She has an upcoming appointment with the Neurologist.  Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y.,ALLERGIES: , CODEINE AND KEFLEX.,FAMILY MEDICAL HISTORY:  ,Strong family history for Huntington disease as per the HPI.  Mother and grandmother died of Huntington disease.  Two young brothers also had Huntington disease.,FAMILY PSYCHIATRIC HISTORY: , The patient denies history of depression, bipolar, schizophrenia, or suicide attempts.,SOCIAL HISTORY:  ,The patient lives with her husband of 48 years.  She used to be employed as a registered nurse.  Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions.  She rarely drinks socially.  She denies any illicit substance usage.  Her husband reportedly gives her medication daily.  Has been proactive in terms of seeking mental health care and medical care.  The patient and husband report that from March 2009, she has been relatively independent, more socially active.,MENTAL STATUS EXAM:  ,This is an elderly woman appearing stated age.  Alert and oriented x4 with poor eye contact.  Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips.  She is cooperative.  Her speech is of low volume and slow rate and rhythm.  Her mood is sad.  Her affect is constricted.  Her thought process is logical and goal-directed.  Her thought content is negative for current suicidal ideation.  No homicidal ideation.  No auditory or visual hallucinations.  No command auditory hallucinations.  No paranoia.  Insight and judgment are fair and intact.,LABORATORY DATA:,  A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality.  U-tox positive for amphetamines and tricyclic antidepressants.  Acetaminophen level 206.7, alcohol level 0.  The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4.,ASSESSMENT: , This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.  She took 30 tablets of Haldol and 40 tablets of Tylenol.  At present, the patient is without suicidal ideation.  She reports that her worsening depression has coincided with her worsening Huntington disease.  She is more hopeful today, feels that she may be able to get help with her depression.,The patient was admitted four days ago to the medical floor and has subsequently been stabilized.  Her liver function tests are within normal limits.,AXIS I:  Major depressive disorder due to Huntington disease, severe.  Cognitive disorder, NOS.,AXIS II:  Deferred.,AXIS III:  Hypertension, Huntington disease, status post overdose.,AXIS IV:  Chronic medical illness.,AXIS V:  30.,PLAN,1.  Safety.  The patient would be admitted on a voluntary basis to Main-7 North.  She will be placed on every 15-minute checks with suicidal precautions.,2.  Primary psychiatric issues/medical issues.  The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h., Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.,3.  Substance abuse.  No acute concern for alcohol or benzo withdrawal.,4.  Psychosocial.  Team will update and involve family as necessary.,DISPOSITION: , The patient will be admitted for evaluation, observation, treatment.  She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy.  We will place occupational therapy consult and social work consults.",32
"PREOPERATIVE DIAGNOSIS: , Anterior cruciate ligament rupture.,POSTOPERATIVE DIAGNOSES:,1.  Anterior cruciate ligament rupture.,2.  Medial meniscal tear.,3.  Medial femoral chondromalacia.,4.  Intraarticular loose bodies.,PROCEDURE PERFORMED:,1.  Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction.,2.  Removal of loose bodies.,3.  Medial femoral chondroplasty.,4.  Medial meniscoplasty.,OPERATIVE PROCEDURE:  ,The patient was taken to the operative suite, placed in supine position, and administered a general anesthetic by the Department of Anesthesia.  Following this, the knee was sterilely prepped and draped as discussed for this procedure.  The inferolateral and inferomedial portals were then established; however, prior to this, a graft was harvested from the semitendinosus and gracilis region.  After the notch was identified, then ACL was confirmed and ruptured.  There was noted to be a torn, slipped up area of the medial meniscus, which was impinging and impinged on the articular surface.  The snare was smoothed out.  Entire area was thoroughly irrigated.  Following this, there was noted in fact to be significant degenerative changes from this impingement of the meniscus again to the periarticular cartilage.  The areas of the worn away portion of the medial femoral condyle was then debrided and ________ chondroplasty was then performed of this area in order to stimulate bleeding and healing.  There were multiple loose bodies noted in the knee and these were then __________ and then removed.  The tibial and femoral drill holes were then established and the graft was then put in place, both which locations after a notchplasty was performed.  The knee was taken through a full range of motion without any impingement.  An Endobutton was used for proximal fixation.  Distal fixation was obtained with an independent screw and a staple.  The patient was then taken to Postanesthesia Care Unit at the conclusion of the procedure.,",27
"HISTORY: , The patient is a 15-year-old female who was seen in consultation at the request of Dr. X on 05/15/2008 regarding enlarged tonsils.  The patient has been having difficult time with having two to three bouts of tonsillitis this year.  She does average about four bouts of tonsillitis per year for the past several years.  She notes that throat pain and fever with the actual infections.  She is having no difficulty with swallowing.  She does have loud snoring, though there have been no witnessed observed sleep apnea episodes.  She is a mouth breather at nighttime, however.  The patient does feel that she has a cold at today's visit.  She has had tonsil problems again for many years.  She does note a history of intermittent hoarseness as well.  This is particularly prominent with the current cold that she has had.  She had been seen by Dr. Y in Muskegon who had also recommended a tonsillectomy, but she reports she would like to get the surgery done here in the Ludington area as this is much closer to home.  For the two tonsillitis, she is on antibiotics again on an average about four times per year.  They do seem to help with the infections, but they tend to continue to recur.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:,ALLERGY/IMMUNOLOGIC:  Negative.,CARDIOVASCULAR:  Negative.,PULMONARY:  Negative.,GASTROINTESTINAL:  Negative.,GENITOURINARY:  Negative.,NEUROLOGIC:  Negative.,VISUAL:  Negative.,DERMATOLOGIC:  Negative.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  Negative.,CONSTITUTIONAL:  Negative.,PAST SURGICAL HISTORY: , Pertinent for previous cholecystectomy.,FAMILY HISTORY:,  No family history of bleeding disorder.  She does have a sister with a current ear infection.  There is a family history of cancer, diabetes, heart disease, and hypertension.,CURRENT MEDICATIONS: , None.,ALLERGIES: , She has no known drug allergies.,SOCIAL HISTORY: , The patient is single.  She is a student.  Denies tobacco or alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Pulse is 80 and regular, temperature 98.4, weight is 184 pounds.,GENERAL:  The patient is an alert, cooperative, obese, 15-year-old female, with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  The external ears are normal.  The ear canals are clean and dry.  The drums are intact and mobile.  Hearing is grossly normal.  Tuning fork examination with normal speech reception thresholds noted.,NASAL:  She has clear drainage, large inferior turbinates, no erythema.,ORAL:  Her tongue, lip, floor of mouth are noted to be normal.  Oropharynx does reveal very large tonsils measuring 3+/4+; they were exophytic.  Mirror examination of the larynx reveals some mild edema of the larynx at this time.  The nasopharynx could not be visualized on mirror exam today.,NECK:  Obese, supple.  Trachea is midline.  Thyroid is nonpalpable.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,IMPRESSION: , ,1.  Chronic adenotonsillitis with adenotonsillar hypertrophy.,2.  Upper respiratory tract infection with mild acute laryngitis.,3.  Obesity.,RECOMMENDATIONS: , We are going to go ahead and proceed with an adenotonsillectomy.  All risks, benefits, and alternatives regarding the surgery have been reviewed in detail with the patient and her family.  This includes risk of bleeding, infection, scarring, regrowth of the adenotonsillar tissue, need for further surgery, persistent sore throat, voice changes, etc.  The parents are agreeable to the planned procedure, and we will schedule this accordingly at Memorial Medical Center here within the next few weeks.  We will make further recommendations afterwards.",11
"PREOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus C2-C3.,2.  Spinal stenosis C3-C4.,POSTOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus C2-C3.,2.  Spinal stenosis C3-C4.,PROCEDURES,1.  Anterior cervical discectomy, C3-C4, C2-C3.,2.  Anterior cervical fusion, C2-C3, C3-C4.,3.  Removal of old instrumentation, C4-C5.,4.  Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.,PROCEDURE IN DETAIL: , The patient was placed in the supine position.  The neck was prepped and draped in the usual fashion for anterior cervical discectomy.  A high incision was made to allow access to C2-C3.  Skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially.  This exposed the vertebral bodies of C2-C3 and C4-C5 which was bridged by a plate.  We placed in self-retaining retractors.  With the tooth beneath the blades, the longus colli muscles were dissected away from the vertebral bodies of C2, C3, C4, and C5.  After having done this, we used the all-purpose instrumentation to remove the instrumentation at C4-C5, we could see that fusion at C4-C5 was solid.,We next proceeded with the discectomy at C2-C3 and C3-C4 with disc removal.  In a similar fashion using a curette to clean up the disc space and the space was fairly widened, as well as drilling up the vertebral joints using high-speed cutting followed by diamond drill bit.  It was obvious that the C3-C4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis.  With the operating microscope; however, we had good visualization of these nerve roots, and we were able to ___________ both at C2-C3 and C3-C4.  We then placed the ABC 55-mm plate from C2 down to C4.  These were secured with 16-mm titanium screws after excellent purchase.  We took an x-ray which showed excellent position of the plate, the screws, and the graft themselves.  The next step was to irrigate the wound copiously with saline and bacitracin solution and s Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision.  The wound was closed with 2-0 Vicryl for subcutaneous tissues and Steri-Strips used to close the skin.  Blood loss was about 50 mL.  No complication of the surgery.  Needle count, sponge count, cottonoid count was correct.,The operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb.  At the time of surgery, he had total collapse of the C2, C3, and C4 disc with osteophyte formation.  At both levels, he has high-grade spinal stenosis at these levels, especially foramen stenosis causing the compression, neck pain, headaches, and arm and shoulder pain.  He does have degenerative changes at C5-C6, C6-C7, C7-T1; however, they do not appear to be symptomatic, although x-rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form.",23
"CHIEF COMPLAINT: , Left elbow pain.,HISTORY OF PRESENT ILLNESS:  ,This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain.  He also has pain in his left ankle, but he is able to walk normally.  He has had previous pain in his left knee.  He denies any passing out, any neck pain at this time even though he did get hit in the head.  He has no chest or abdominal pain.  Apparently, no knives or guns were involved.,PAST MEDICAL HISTORY: , He has had toe problems and left knee pain in the past.,REVIEW OF SYSTEMS: , No coughing, sputum production, dyspnea or chest pain.  No vomiting or abdominal pain.  No visual changes.  No neurologic deficits other than some numbness in his left hand.,SOCIAL HISTORY: , He is in Juvenile Hall for about 25 more days.  He is a nonsmoker.,ALLERGIES: , MORPHINE.,CURRENT MEDICATIONS:  ,Abilify.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.  HEENT:  PERRLA.  EOMI.  Conjunctivae anicteric.  Skull is normocephalic.  He is not complaining of bruising.  HEENT:  TMs and canals are normal.  There is no Battle sign.  NECK:  Supple.  He has good range of motion.  Spinal processes are normal to palpation.  LUNGS:  Clear.  CARDIAC:  Regular rate.  No murmurs or rubs.  EXTREMITIES:  Left elbow is tender.  He does not wish to move it at all.  Shoulder and clavicle are within normal limits.  Wrist is normal to inspection.  He does have some pain to palpation.  Hand has good capillary refill.  He seems to have decreased sensation in all three dermatomes.  He has moderately good abduction of all fingers.  He has moderate opponens strength with his thumb.  He has very good extension of all of his fingers with good strength.,We did an x-ray of his elbow.  He has a spiral fracture of the distal one-third of the humerus, about 13 cm in length.  The proximal part looks like it is in good position.  The distal part has about 6 mm of displacement.  There is no significant angulation.  The joint itself appears to be intact.  The fracture line ends where it appears above the joint.  I do not see any extra blood in the joint.  I do not see any anterior or posterior Siegert sign.,I spoke with Dr. X.  He suggests we go ahead and splint him up and he will follow the patient up.  At this point, it does not seem like there needs to be any surgical revision.  The chance of a compartment syndrome seems very low at this time.,Using 4-inch Ortho-Glass and two assistants, we applied a posterior splint to immobilize his fingers, hand, and wrist all the way up to his elbow to well above the elbow.,He had much better comfort once this was applied.  There was good color to his fingers and again, much better comfort.,Once that was on, I took some 5-inch Ortho-Glass and put in extra reinforcement around the elbow so he would not be moving it, straightening it or breaking the fiberglass.,We then gave him a sling.,We gave him #2 Vicodin p.o. and #4 to go.  Gave him a prescription for #15 more and warned him to take it only at nighttime and use Tylenol or Motrin, and ice in the daytime.,I gave him the name and telephone number of Dr. X whom they can follow up with.  They were warned to come back here if he has increasing neurologic deficits in his hands or any new problems.,DIAGNOSES:,1.  Fracture of the humerus, spiral.,2.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.,3.  Psychiatric disorder, unspecified.,DISPOSITION:  The patient will follow up as mentioned above.  They can return here anytime as needed.",5
"DIAGNOSES:,1.  Pneumonia.,2.  Crohn disease.,3.  Anasarca.,4.  Anemia.,CHIEF COMPLAINT: , I have a lot of swelling in my legs.,HISTORY:  ,The patient is a 41-year-old gentleman with a long history of Crohn disease.  He has been followed by Dr. ABC, his primary care doctor, but he states that he has had multiple gastroenterology doctors and has not seen one in the past year to 18 months.  He has been treated with multiple different medications for his Crohn disease and most recently has been taking pulses of steroids off and on when he felt like he was having symptoms consistent with crampy abdominal pain, increased diarrhea, and low-grade fevers.  This has helped in the past, but now he developed symptoms consistent with pneumonia and was admitted to the hospital.  He has been treated with IV antibiotics and is growing Streptococcus.  At this time, he seems relatively stable although slightly dyspneic.  Other symptoms include lower extremity edema, pain in his ankles and knees, and actually symptoms of edema in his entire body including his face and upper extremities.  At this time, he continues to have symptoms consistent with diarrhea and malabsorption.  He also has some episodes of nausea and vomiting at times.  He currently has a cough and symptoms of dyspnea.  Further review of systems was not otherwise contributory.,MEDICATIONS:,1.  Prednisone.,2.  Effexor.,3.  Folic acid.,4.  Norco for pain.,PAST MEDICAL HISTORY: , As mentioned above, but he also has anxiety and depression.,PAST SURGICAL HISTORY:,1.  Small bowel resections.,2.  Appendectomy.,3.  A vasectomy.,ALLERGIES:  ,He has no known drug allergies.,SOCIAL HISTORY:  ,He does smoke two packs of cigarettes per day.  He has no alcohol or drug use.  He is a painter.,FAMILY HISTORY:  ,Significant for his father who died of IPF and irritable bowel syndrome.,REVIEW OF SYSTEMS: , As mentioned in the history of present illness and further review of systems is not otherwise contributory.,PHYSICAL EXAMINATION:,GENERAL:  He is a thin appearing man in very mild respiratory distress when his oxygen is off.,VITAL SIGNS:  His respiratory rate is approximately 18 to 20, his blood pressure is 100/70, his pulse is 90 and regular, he is afebrile currently at 96, and weight is approximately 163 pounds.,HEENT:  Sclerae anicteric.  Conjunctivae normal.  Nasal and oropharynx are clear.,NECK:  Supple.  No jugular venous pressure distention is noted.  There is no adenopathy in the cervical, supraclavicular or axillary areas.,CHEST:  Reveals some crackles in the right chest, in the base, and in the upper lung fields.  His left is relatively clear with decreased breath sounds.,HEART:  Regular rate and rhythm.,ABDOMEN:  Slightly protuberant.  Bowel sounds are present.  He is slightly tender and it is diffuse.  There is no organomegaly and no ascites appreciable.,EXTREMITIES:  There is a mild scrotal edema and in his lower extremities he has 2 to 3+ edema at pretibial and lateral feet.,DERMATOLOGIC:  Shows thin skin.  No ecchymosis or petechiae.,LABORATORY STUDIES: , Laboratory studies are pertinent for a total protein of 3 and albumin of 1.3.  There is no M-spike observed.  His B12 is 500 with a folic acid of 11.  His white count is 21 with a hemoglobin of 10, and a platelet count 204,000.,IMPRESSION AT THIS TIME:,1.  Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.,2.  He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.,ASSESSMENT AND PLAN: , At this time, I believe evaluation of protein intake and dietary supplement will be most appropriate.  I believe that he needs a calorie count.  We will check on a sedimentation rate, C-reactive protein, LDH, prealbumin, thyroid, and iron studies in the morning with his laboratory studies that are already ordered.  I have recommended strongly to him that when he is out of the hospital, he return to the care of his gastroenterologist.  I will help in anyway that I can to improve the patient's laboratory abnormalities.  However, his lower extremity edema is primarily due to his marked hypoalbuminemia and I do not believe that diuretics will help him at this time.  I have explained this in detail to the patient and his family.  Everybody expresses understanding and all questions were answered.  At this time, follow him up during his hospital stay and plan to see him in the office as well.",15
"PREOPERATIVE DIAGNOSIS:,  Left renal mass, 5 cm in diameter.,POSTOPERATIVE DIAGNOSIS:,  Left renal mass, 5 cm in diameter.,OPERATION PERFORMED: , Left partial nephrectomy.,ANESTHESIA: , General with epidural.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , About 350 mL.,REPLACEMENT: , Crystalloid and Cell Savers from the case.,INDICATIONS FOR SURGERY:  ,This is a 64-year-old man with a left renal mass that was confirmed to be renal cell carcinoma by needle biopsy.  Due to the peripheral nature of the tumor located in the mid to lower pole laterally, he has elected to undergo a partial nephrectomy.  Potential complications include but are not limited to,,1.  Infection.,2.  Bleeding.,3.  Postoperative pain.,4.  Herniation from the incision.,PROCEDURE IN DETAIL:,  Epidural anesthesia was administered in the holding area, after which the patient was transferred into the operating room.  General endotracheal anesthesia was administered, after which the patient was positioned in the flank standard position.  A left flank incision was made over the area of the twelfth rib.  The subcutaneous space was opened by using the Bovie.  The ribs were palpated clearly and the fascia overlying the intercostal space between the eleventh and twelfth rib was opened by using the Bovie.  The fascial layer covering of the intercostal space was opened completely until the retroperitoneum was entered.  Once the retroperitoneum had been entered, the incision was extended until the peritoneal envelope could be identified.  The peritoneum was swept medially.  The Finochietto retractor was then placed for exposure.  The kidney was readily identified and was mobilized from outside Gerota's fascia.  The ureter was dissected out easily and was separated with a vessel loop.  The superior aspect of the kidney was mobilized from the superior attachment.  The pedicle of the left kidney was completely dissected revealing the vein and the artery.  The artery was a single artery and was dissected easily by using a right-angle clamp.  A vessel loop was placed around the renal artery.  The tumor could be easily palpated in the lateral lower pole to mid pole of the left kidney.  The Gerota's fascia overlying that portion of the kidney was opened in the area circumferential to the tumor.  Once the renal capsule had been identified, the capsule was scored using a Bovie about 0.5 cm lateral to the border of the tumor.  Bulldog clamp was then placed on the renal artery.  The tumor was then bluntly dissected off of the kidney with a thin rim of a normal renal cortex.  This was performed by using the blunted end of the scalpel.  The tumor was removed easily.  The argon beam coagulation device was then utilized to coagulate the base of the resection.  The visible larger bleeding vessels were oversewn by using 4-0 Vicryl suture.  The edges of the kidney were then reapproximated by using 2-0 Vicryl suture with pledgets at the ends of the sutures to prevent the sutures from pulling through.  Two horizontal mattress sutures were placed and were tied down.  The Gerota's fascia was then also closed by using 2-0 Vicryl suture.  The area of the kidney at the base was covered with Surgicel prior to tying the sutures.  The bulldog clamp was removed and perfect hemostasis was evident.  There was no evidence of violation into the calyceal system.  A 19-French Blake drain was placed in the inferior aspect of the kidney exiting the left flank inferior to the incision.  The drain was anchored by using silk sutures.  The flank fascial layers were closed in three separate layers in the more medial aspect.  The lateral posterior aspect was closed in two separate layers using Vicryl sutures.  The skin was finally reapproximated by using metallic clips.  The patient tolerated the procedure well.",37
"TITLE OF OPERATION:,1.  Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.,2.  Weil osteotomy with internal screw fixation, first right metatarsal.,3.  Arthroplasty, second right PIP joint.,PREOPERATIVE DIAGNOSES:,1.  Bunion deformity, right foot.,2.  Dislocated second right metatarsophalangeal joint.,3.  Hammertoe deformity, second right digit.,POSTOPERATIVE DIAGNOSES:,1.  Bunion deformity, right foot.,2.  Dislocated second right metatarsophalangeal joint.,3.  Hammertoe deformity, second right digit.,ANESTHESIA:,  Monitored anesthesia care with 20 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:,  60 minutes, a right ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,PREOPERATIVE INJECTABLES:  ,1 g Ancef IV 30 minutes preoperatively.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as two 16-mm partially treaded cannulated screws of the OsteoMed system, one 18-mm partially treaded cannulated screw of the OsteoMed system of the 3.0 size.  One 10-mm 2.0 partially threaded cannulated screw of the OsteoMed system.,DESCRIPTION OF THE PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in the supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical sites.  The right ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set up at 250 mmHg.  The right foot was then prepped, scrubbed, and draped in a normal sterile technique.  The right ankle tourniquet was then inflated.  Attention was then directed on the dorsomedial aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed parallel and medial to the course of the extensor hallucis longus tendon to the right great toe.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal and capsular tissues were mobilized from the head and neck of the first right metatarsal and the base of the proximal phalanx of the right great toe.  The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx and resected transversely.,A lateral capsulotomy was also performed at the level of the first right metatarsophalangeal joint.  Using sharp and dull dissection, the dorsomedial prominence of the first right metatarsal head was adequately exposed and resected with the use of a sagittal saw.  The same saw was used to perform the Austin osteotomy on the capital aspect of the first right metatarsal with its apex distal and its base proximal.  The dorsal arm of the osteotomy was longer than the plantar arm and noted to accommodate for the future internal fixation.  The capital fragment of the first right metatarsal was then transposed laterally and impacted on the shaft of the first right metatarsal.  Two wires of the OsteoMed system were also used as provisional fixation wires and also as guidewires for the insertion of the future screws.  The wires were inserted dorsal distal to plantar proximal through the dorsal arm of the osteotomy.  The two screws from the 3.0 OsteoMed system were inserted over the wires using AO technique.  One screw measured 16 mm, second screw measured 18 mm in length.  Both 3.0 screws were then evaluated for the fixation of the osteotomy after the wires were removed.  Fixation of the osteotomy was found to be excellent.  The dorsomedial prominence of the first right metatarsal shaft was then resected with the sagittal saw.  To improve the correction of the hallux abductus angle, an Akin osteotomy was also performed on the base of the proximal phalanx of the right great toe with its base medially and its apex laterally.  Upon removal of the base wedge from the base of the proximal phalanx, the osteotomy was reduced with the OsteoMed smooth wire, which was also used as a guidewire for the insertion of a 16-mm partially threaded cannulated screw from the OsteoMed 3.0 system.  Upon insertion of the screw, using AO technique, the wire was removed.  The screw was inserted proximal medial to distal lateral through the osteotomy of the base of the proximal phalanx of the right great toe.  Fixation of the osteotomy was found to be excellent.  Reduction of the bunion deformity was also found to be excellent and position of the first right metatarsophalangeal joint was found to be anatomical.  Range of motion of that joint was uninhibited.  The area was flushed copiously with saline.  Then, 3-0 suture material was used to approximate the periosteum and capsular tissues, 4-0 was used to approximate the subcutaneous tissues, and Steri-Strips were used to reinforce the incision.  Attention was directed over the neck of the second right metatarsal head where a 3-cm linear incision was placed directly over the surgical neck of the second right metatarsal.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped and cauterized.  The incision was deepened through the level of the periosteum over the surgical neck of the second right metatarsal.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the surgical neck of the second right metatarsal was adequately exposed and then Weil-type osteotomy was performed from dorsal distal to plantar proximal through the surgical neck of the second right metatarsal.  The capital fragment was then transposed proximally and impacted on the shaft of the second right metatarsal.,The 2.0 Osteo-Med system was also used to fixate this osteotomy wire from that system was inserted dorsal proximal to plantar distal through the second right metatarsal osteotomy and the wire was used as a guidewire for the insertion of the 10-mm partially threaded 2.0 cannulated screw.  Upon insertion of the screw, using AO technique, the wire was then removed.  Fixation of the osteotomy with 2.0 screw was found to be excellent.  The second right metatarsophalangeal joint was then relocated and the dislocation of that joint was completely reduced.  Range of motion of the second right metatarsophalangeal joint was found to be excellent.  Then, 3-0 Vicryl suture material was used to approximate the periosteal tissues.  Then, 4-0 Vicryl was used to approximate the skin incision.  Attention was then directed at the level of the PIP joint of the second right toe where two semi-elliptical incisions were placed directly over the bony prominence at the level of the second right PIP joint.  The island of skin between the two semi-elliptical incisions was resected in toto.  The dissection was carried down to the level of extensor digitorum longus of the second right toe, which was resected transversely at the level of the PIP joint.  A capsulotomy and a medial and lateral collateral ligament release of the PIP joint of the second right toe was also performed and head of the proximal phalanx of the second right digit was adequately exposed.  Using the double-action bone cutter, the head of the proximal phalanx of the second right toe was then resected.  The area was copiously flushed with saline.  The capsular and periosteal tissues were approximated with 2-0 Vicryl and 3-0 Vicryl suture material was also used to approximate the extensor digitorum longus to the second right toe.  A 5-0 Prolene was used to approximate the skin edges of the two semi-elliptical incisions.  Correction of the hammertoe deformity and relocation of the second right metatarsophalangeal joint were evaluated with the foot loaded and were found to be excellent and anatomical.  At this time, the patient's three incisions were covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's right ankle tourniquet was deflated, time was 60 minutes.  Immediate hyperemia was noted on the entire right lower extremity upon deflation of the cuffs.,The patient's right foot was placed in a surgical shoe and the patient was transferred to the recovery room under the care of anesthesia team with the vital signs stable and the vascular status at appropriate levels.  The patient was given instructions and education on how to continue caring for her right foot surgery.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.",27
"CHIEF COMPLAINT:, Nausea and abdominal pain after eating.,GALL BLADDER HISTORY:, The patient is a 36 year old white female.  Patient's complaints are fatty food intolerance, dark colored urine, subjective chills, subjective low-grade fever, nausea and sharp stabbing pain. The patient's symptoms have been present for 3 months. Complaints are relieved with lying on right side and antacids. Prior workup by referring physicians have included abdominal ultrasound positive for cholelithiasis without CBD obstruction. Laboratory studies that are elevated include total bilirubin and elevated WBC.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, Diagnostic laparoscopic exam for pelvic pain/adhesions.,ALLERGIES:, No known drug allergies.,CURRENT MEDICATIONS:, No current medications.,OCCUPATIONAL /SOCIAL HISTORY:, Marital status: married. Patient states smoking history of 1 pack per day. Patient quit smoking 1 year ago. Admits to no history of using alcohol. States use of no illicit drugs.,FAMILY MEDICAL HISTORY:, There is no significant, contributory family medical history.,OB GYN HISTORY:, LMP: 5/15/1999. Gravida: 1. Para: 1.  Date of last pap smear: 1/15/1998.,REVIEW OF SYSTEMS:,Cardiovascular: Denies angina, MI history, dysrhythmias, palpitations, murmur, pedal edema, PND, orthopnea, TIA's, stroke, amaurosis fugax.,Pulmonary: Denies cough, hemoptysis, wheezing, dyspnea, bronchitis, emphysema, TB exposure or treatment.,Neurological: Patient admits to symptoms of seizures and ataxia.,Skin: Denies scaling, rashes, blisters, photosensitivity.,PHYSICAL EXAMINATION:,Appearance: Healthy appearing. Moderately overweight.,HEENT: Normocephalic. EOM's intact. PERRLA. Oral pharynx without lesions.,Neck: Neck mobile. Trachea is midline.,Lymphatic: No apparent cervical, supraclavicular, axillary or inguinal adenopathy.,Breast: Normal appearing breasts bilaterally, nipples everted.  No nipple discharge, skin changes.,Chest: Normal breath sounds heard bilaterally without rales or rhonchi.  No pleural rubs. No scars.,Cardiovascular: Regular heart rate and rhythm without murmur or gallop.,Abdominal: Bowel sounds are high pitched.,Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted. Range of motion is normal.,Skin: Normal color, temperature, turgor and elasticity; no significant skin lesions.,IMPRESSION DIAGNOSIS:  ,  Gall Bladder Disease. Abdominal Pain.,DISCUSSION:, Laparoscopic Cholecystectomy handout was given to the patient, reviewed with them and questions answered. The patient has given both verbal and written consent for the procedure.,PLAN:, We will proceed with Laparoscopic Cholecystectomy with intraoperative cholangiogram.,MEDICATIONS PRESCRIBED:,",14
"REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.",5
"PREOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,POSTOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,PROCEDURE PERFORMED: , Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.,ANESTHESIA: , General.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS: , Bilateral procedure was 400 cc.,TOTAL TOURNIQUET TIME:  ,75 minutes.,COMPONENTS: , Include the Zimmer NexGen complete knee solution system, which include a size F right cruciate retaining femoral component, a size #8 peg tibial component precoat, a All-Poly standard size 38, 9.5 mm thickness patellar component, and a prolonged highly cross-linked polyethylene NexGen cruciate retaining tibial articular surface size blue 12 mm height.,HISTORY OF PRESENT ILLNESS: , The patient is a 69-year-old male who presented to the office complaining of bilateral knee pain for a couple of years.  The patient complained of clicking noises and stiffness, which affected his daily activities of living.,PROCEDURE: , After all potential complications, risks as well as anticipated benefits of the above-named procedure was discussed at length, the patient's informed consent was obtained.,Operative extremities were then confirmed with the operating surgeons as well as the nursing staff, Department of Anesthesia, and the patient.  The patient was then transferred to preoperative area to operative suite #2 and placed on the operating room table in supine position.  All bony prominences were well padded at this time.  At this time, Department of Anesthesia administered general anesthetic to the patient.  The patient was allowed in DVT study and the right extremity was in the Esmarch study as well as the left.  The nonsterile tourniquet was then applied to the right upper thigh of the patient, but not inflated at this time.  The right lower extremity was sterilely prepped and draped in the usual sterile fashion.  The right upper extremity was then elevated and exsanguinated using an Esmarch and the tourniquet was inflated using 325 mmHg.  The patient was a consideration for a unicompartmental knee replacement.  So, after all bony and soft tissue landmarks were identified, a limited midline longitudinal incision was made directly over the patella.  A sharp dissection was then taken down to the level of the fascia in line with the patella as well as the quadriceps tendon.  Next, a medial parapatellar arthrotomy was performed using the #10 blade scalpel.  Upon viewing of the articular surfaces, there was significant ware in the trochlear groove as well as the medial femoral condyle and it was elected to proceed with total knee replacement.  At this time, the skin incisions as well as the deep incisions were extended proximally and distally in a midline fashion.  Total incision now measured approximately 25 cm.  Retractors were placed.  Next, attention was directed to establishing medial and lateral flaps of the proximal tibia.  Reciprocating osteal elevator was used to establish soft tissue plane and then an electrocautery was then used to subperiosteal strip medially and laterally on the proximal tibia.  At this time, the patella was then everted.  The knee was flexed up to 90 degrees.  Next, using the large drill bit, the femoral canal was then opened in appropriate position.  The intramedullary sizing guide was then placed and the knee was sized to a size F. At this time, the three degrees external rotation holes were then drilled after carefully assessing the epicondylar access as well as the white sideline.  The guide was then removed.  The intramedullary guide was then placed with nails holding the guide in three degrees of external rotation.  Next, the anterior femoral resection guide was then placed and clamped into place using a pointed _________________ was then used to confirm that there would no notching performed.  Next, soft tissue retractors were placed and an oscillating saw was used to make the anterior femoral cut.  Upon checking, it was noted to be flat with no oscillations.  The anterior guide was then removed and the distal femoral resection guide was placed in five degrees of valgus.  It was secured in place using nails.  The intramedullary guide was then removed and the standard distal femoral cut was then made using oscillating saw.,This was then removed and the size F distal finishing femoral guide was then placed on the femur in proper position.  Bony and soft tissue landmarks were confirmed and the resection guide was then held in place using nail as well as spring screws.  Again, the collateral ligament retractors were then placed and the oscillating saw was used to make each of the anterior and posterior as well as each chamfer cut.  A reciprocating saw was then used to cut the trochlear cut and the peg holes were drilled as well.  The distal finishing guide was then removed and osteotome was then used to remove all resected bone.  The oscillating saw was then used to complete the femoral notch cut.  Upon viewing, there appeared to be proper amount of bony resection and all bone was removed completely.  There was no posterior osteophytes noted and no fragments to the posterior aspect.  Next, attention was directed towards the tibia.  The external tibial guide was reflected.  This was placed on the anterior tibia and held in place using nails after confirming the proper varus and valgus position.  The resection guide was then checked and appeared to be sufficient amount of resection in both medial and lateral condyles of the tibia.  Next, collateral ligament retractors were placed as well as McGill retractors for the PCL.  Oscillating saw was then used to make the proximal tibial cut.  Osteotome was used to remove this excess resected bone.  The laminar spreader was then used to check the flexion and extension.  The gaps appeared to be equal.  The external guide was then removed and trial components were placed to a size F femoral component and a 12 mm tibial component on a size 8 tray.  The knee was taken through range of motion and had very good flexion as well as full extension.  There appeared to be good varus and valgus stability as well.  Next, attention was directed towards the patella.  There noted to be a sufficient ware and it was selected to replace the patella.  It was sized with caliper, pre-cut and noted to be 26 mm depth.  The sizing guide was then used and a size 51 resection guide selected.  A 51 mm reamer was then placed and sufficient amount of patella was then removed.  The calcar was then used to check again and there was noted to be 15 mm remaining.  The 38 mm patella guide was then placed on the patella.  It was noted to be in proper size and the three drill holes for the pegs were used.  A trial component was then placed.  The knee was taken through range of motion.  There was noted to be some subluxation lateral to the patellar component and a lateral release was performed.  After this, the component appeared to be tracking very well.  There remained a good range of motion in the knee and extension as well as flexion.  At this time, an AP x-ray of the knee was taken with the trial components in place.  Upon viewing this x-ray, it appeared that the tibial cut was in neutral, all components in proper positioning.  The knee was then copiously irrigated and dried.  The knee was then flexed ___________ placed, and the peg drill guide was placed on the tibia in proper position, held in place with nails.,The four peg holes were then drilled.  The knee again was copiously irrigated and suction dried.  The final components were then selected again consisting of size F femoral components.  A peg size 8 tibial component, a 12 mm height articular surface, size blue, and a 38 mm 9.5 mm thickness All-Poly patella.  Polymethyl methacrylate was then prepared at this time.  The proximal tibia was dried and the cement was then pressed into place.  The cement was then placed on the backside of the tibial component and the tibial component was then impacted into proper positioning.  Next, the proximal femur was cleaned and dried.  Polymethyl methacrylate was placed on the resected portions of the femur as well as the backside of the femoral components.  This was then impacted in place as well.  At this time, all excess cement was removed from both the tibial and femoral components.  A size 12 mm trial tibial articular surface was then put in place.  The knee was reduced and held in loading position throughout the remaining drying position of the cement.  Next, the resected patella was cleaned and dried.  The cement was placed on the patella as well as the backside of the patellar component.  The component was then put in proper positioning and held in place with a clamp.  All excess polymethyl methacrylate was removed from this area as well.  This was held until the cement had hardened sufficiently.  Next, the knee was examined.  All excess cement was then removed.  The knee was taken through range of motion with sufficient range of motion as well as stability.  The final 12 mm height polyethylene tibial component was then put into place and snapped down in proper position.  Again range of motion was noted to be sufficient.  The knee was copiously irrigated and suction dried once again.  A drain was then placed within the knee.  The wound was then closed first using #1 Ethibond to close the arthrotomy oversewn with a #1 Vicryl.  The knee was again copiously irrigated and dried.  The skin was closed using #2-0 Vicryl in subcuticular fashion followed by staples on the skin.  The ConstaVac was then _______ to the drain.  Sterile dressing was applied consisting of Adaptic, 4x4, ABDs, Kerlix, and a 6-inch Dupre roll from foot to thigh.  Department of Anesthesia then reversed the anesthetic.  The patient was transferred back to the hospital gurney to Postanesthesia Care Unit.  The patient tolerated the procedure well and there were no complications.",37
"CHIEF COMPLAINT:, Low back pain and right lower extremity pain. The encounter reason for today's consultation is for a second opinion regarding evaluation and treatment of the aforementioned symptoms.,HPI - LUMBAR SPINE:, The patient is a male and 39 years old. The current problem began on or about 3 months ago. The symptoms were sudden in onset. According to the patient, the current problem is a result of a fall. The date of injury was 3 months ago. There is no significant history of previous spine problems. Medical attention has been obtained through the referral source. Medical testing for the current problem includes the following: no recent tests. Treatment for the current problem includes the following: activity modification, bracing, medications and work modification. The following types of medications are currently being used for the present spine problem: narcotics, non-steroidal anti-inflammatories and muscle relaxants. The following types of medications have been used in the past: steroids. In general, the current spine problem is much worse since its onset.,PAST SPINE HISTORY:, Unremarkable.,PRESENT LUMBAR SYMPTOMS:, Pain location: lower lumbar. The patient describes the pain as sharp. The pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by flexion, lifting, twisting, activity, riding in a car and sitting. The pain is made better by laying in the supine position, medications, bracing and rest. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. Pain distribution: the lower extremity pain is greater than the low back pain. The patient's low back pain appears to be discogenic in origin. The pain is much worse since its onset.,PRESENT RIGHT LEG SYMPTOMS:, Pain location: S1 dermatome (see the Pain Diagram). The patient describes the pain as sharp. The severity of the pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by the same things that make the low back pain worse. The pain is made better by the same things that make the low back pain better. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. The patient's symptoms appear to be radicular in origin. The pain is much worse since its onset.,PRESENT LEFT LEG SYMPTOMS:, None.,NEUROLOGIC SIGNS/SYMPTOMS:, The patient denies any neurologic signs/symptoms. Bowel and bladder function are reported as normal.",27
"ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay.  He had left hip fracture identified on x-rays at that time.  Pain and inability to ambulate brought him in.  He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia.  His medical issues are under good control.  The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03.  The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension.  Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy.  He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions.,PAST MEDICAL HISTORY: , Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation.  Remote history of subdural hematoma precluding the use of Coumadin.  History of depression, panic attacks on Doxepin.  Perioperative anemia.  Swallowing difficulties.,ALLERGIES:,  Zyloprim, penicillin, Vioxx, NSAIDs.,CURRENT MEDICATIONS,1.  Heparin.,2.  Albuterol inhaler.,3.  Combivent.,4.  Aldactone.,5.  Doxepin.,6.  Xanax.,7.  Aspirin.,8.  Amiodarone.,9.  Tegretol.,10.  Synthroid.,11.  Colace.,SOCIAL HISTORY: , Lives in a 1-story home with 1 step down; wife is there.  Speech and language pathology following with current swallowing dysfunction.  He is minimum assist for activities of daily living, bed mobility.,REVIEW OF SYSTEMS:,  Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain.,PHYSICAL EXAMINATION,HEENT:  Oropharynx clear.,CV:  Regular rate and rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended.  Bowel sounds positive.,EXTREMITIES:  Without clubbing, cyanosis, or edema.,NEUROLOGIC:  There are no focal motor or sensory losses to the lower extremities.  Bulk and tone normal in the lower extremities.  Wound site has healed well with staples out.,IMPRESSION ,1.  Status post left hip fracture and hemiarthroplasty.,2.  History of panic attack, anxiety, depression.,3.  Myocardial infarction with stent placement.,4.  Hypertension.,5.  Hypothyroidism.,6.  Subdural hematoma.,7.  Seizures.,8.  History of chronic obstructive pulmonary disease.  Recent respiratory insufficiency.,9.  Renal insufficiency.,10.  Recent pneumonia.,11.  O2 requiring.,12.  Perioperative anemia.,PLAN: , Rehab transfer as soon as medically cleared.",5
"HISTORY OF PRESENT ILLNESS: , The patient is a 71-year-old woman with history of coronary artery disease for which she has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1.  She also has a significant history of chronic renal insufficiency and severe COPD.  The patient and her husband live in ABC but they have family in XYZ.  She came to our office today as she is in the area visiting her family.  She complains of having shortness of breath for the past month that has been increasingly getting worse.  She developed a frequent nonproductive cough about 2 weeks ago.  She has also had episodes of paroxysmal nocturnal dyspnea, awaking in the middle of the night, panicking from dyspnea and shortness of breath.  She has also gained about 15 pounds in the past few months and has significant peripheral edema.  In the office, she is obviously dyspnea and speaking in 2 to 3 word sentences.,PAST MEDICAL HISTORY: , Coronary artery disease, anemia secondary to chronic renal insufficiency, stage IV chronic kidney disease, diabetic nephropathy, hypertension, hyperlipidemia, COPD, insulin-dependent diabetes, mild mitral valve regurgitation, severe tricuspid valve regurgitation, sick sinus syndrome, gastritis, and heparin-induced thrombocytopenia.,PAST SURGICAL HISTORY: , Status post pacemaker implantation, status post CABG x4 in 1999 and status post CABG x2 in 2003, status post PCA stenting x1 to the left anterior descending artery, cholecystectomy, back surgery, bladder surgery, and colonic polypectomies.,SOCIAL HISTORY:  ,The patient is married.  Lives with her husband.  They are retired from ABC.,MEDICATIONS:,1.  Plavix 75 mg p.o. daily.,2.  Aspirin 81 mg p.o. daily.,3.  Isosorbide mononitrate 60 mg p.o. daily.,4.  Colace 100 mg p.o. b.i.d.,5.  Atenolol 50 mg p.o. daily.,6.  Lantus insulin 15 units subcutaneously every evening.,7.  Protonix 40 mg p.o. daily.,8.  Furosemide 40 mg p.o. daily.,9.  Norvasc 5 mg p.o. daily.,ALLERGIES: , SHE IS ALLERGIC TO HEPARIN AGENTS, WHICH CAUSE HEPARIN-INDUCED THROMBOCYTOPENIA.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Positive for generalized fatigue and malaise.,HEAD AND NECK:  Negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions.,CARDIOVASCULAR:  Positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain.,RESPIRATORY:  Positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough.  Negative for wheezing.,ABDOMEN:  Negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis.,GENITOURINARY:  Negative for dysuria, polyuria, hematuria, or incontinence.,MUSCULOSKELETAL:  Negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy.,SKIN:  Negative for rashes, petechiae, and hair or nail changes.  Positive for easy bruising on forearms.,NEUROLOGIC:  Negative for paralysis, paresthesias, dysphagia, or dysarthria.,PSYCHIATRIC:  Negative for depression, anxiety, or mood swings.,All other systems reviewed are negative.,PHYSICAL EXAMINATION,VITAL SIGNS:  Her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air.  Her height is 63 inches.  She is weighs 195 pounds and her BMI is 34.6.,CONSTITUTIONAL:  A 71-year-old woman in significant distress from shortness of breath and dyspnea at rest.,HEENT:  Eyes:  Pupils are reactive.  Sclera is nonicteric.  Ears, nose, mouth, and throat.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.  Swallow is intact.,CARDIOVASCULAR:  Positive JVD at 45 degrees.  Heart tones are distant.  S1 and S2.  No murmurs.,EXTREMITIES:  Have 3+ edema in the feet and ankles bilaterally that extends up to her knees.  Femoral pulses are weakly palpable.  Posterior tibial pulses are not palpable.  Capillary refill is somewhat sluggish.,RESPIRATORY:  Breath sounds are clear with some bilateral basilar diminishment.  No rales and no wheezing.  Speaking in 2 to 3 word sentences.  Diaphragmatic excursions are limited.  AP diameter is expanded.,ABDOMEN:  Soft and nontender.  Active bowel sounds x4 quadrants.  No hepatosplenomegaly.  No masses are appreciated.,GENITOURINARY:  Deferred.,MUSCULOSKELETAL:  Adequate range of motion along with extremities.,SKIN:  Warm and dry.  No lesions or ulcerations are noted.,NEUROLOGIC:  Alert and oriented x3.  Head is normocephalic and atraumatic.  No focal, motor, or sensory deficits.,PSYCHIATRIC:  Normal affect.,IMPRESSION,1.  Coronary artery disease.",3
"REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis.  Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty.  Dr. X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber.,The patient had a laparoscopic fundoplication and gastrostomy on 10/05/2007.  She has done well since that time.  She has had some episodes of retching intermittently and these seemed to be unpredictable.  She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved.  The patient currently takes about 1 ounce to 1.5 ounce of her feedings by mouth and the rest is given by G-tube.  She seems otherwise happy and is not having an excessive amount of stools.  Her parents have not noted any significant problems with the gastrostomy site.,The patient's exam today is excellent.  Her belly is soft and nontender.  All of her laparoscopic trocar sites are healing with a normal amount of induration, but there is no evidence of hernia or infection.  We removed The patient's gastrostomy button today and showed her parents how to reinsert one without difficulty.  The site of the gastrostomy is excellent.  There is not even a hint of granulation tissue or erythema, and I am very happy with the overall appearance.,IMPRESSION: , The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy.  Hopefully, the exquisite control of acid reflux by fundoplication will help her airway heal, and if she does well, allow decannulation in the future.  If she does require laryngotracheoplasty, the protection from acid reflux will be important to healing of that procedure as well.,PLAN:  ,The patient will follow up as needed for problems related to gastrostomy.  We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future.",14
"OPERATION PERFORMED:  ,Dental prophylaxis under general anesthesia.,PREOPERATIVE DIAGNOSES:,1.  Impacted wisdom teeth.,2.  Moderate gingivitis.,POSTOPERATIVE DIAGNOSES:,1.  Impacted wisdom teeth.,2.  Moderate gingivitis.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,Minimal.,DURATION OF SURGERY:  ,One hour 17 minutes.,BRIEF HISTORY:  ,The patient was referred to me by Dr. X.  He contacted myself and stated that Angelica was going to have her wisdom teeth extracted in the setting of a hospital operating room at Hospital and he inquired if we could pair on the procedure and I could do her full mouth dental rehabilitation before the wisdom teeth were removed by him.  I agreed.  I saw her in my office and she was cooperative for full mouth set of radiographs in my office and a clinical examination.  This clinical and radiographic examination revealed no dental caries; however, she was in need of a good dental cleaning.,OPERATIVE PREPARATION:  ,The patient was brought to Hospital Day Surgery accompanied by her mother.  I met with them and discussed the needs of the child, types of restoration to be performed, and the risks and benefits of the treatment as well as the options and alternatives of the treatment.  After all their questions and concerns were addressed, they gave their informed consent to proceed with the treatment.  The patient's history and physical examination was reviewed.  Once she was cleared by Anesthesia, she was taken back to the operating room.,OPERATIVE PROCEDURE:  ,The patient was placed on the surgical table in the usual supine position with all extremities protected.  Anesthesia was induced by mask.  The patient was then intubated with a nasal endotracheal tube and the tube was stabilized.  The head was wrapped and the eyes were taped shut for protection.  An Angiocath was previously placed in preop.  The head and neck were draped in sterile towels, and the body was covered with lead apron and sterile sheath.  A moist continuous throat pack was placed beyond tonsillar pillars.  Plastic lip and cheek retractors were then placed.  Preoperative digital intraoral photographs were taken.  No digital radiographs were taken in the operating room, as I stated before I had a full set of digital radiographs taken in my office.  A prophylaxis was then performed using a Prophy cup and fluoridated Prophy paste after scaling and replaning was done.  She presented with moderate calculus on the buccal surfaces of her maxillary, first molars and lower molars.  She did not require any restorative dentistry.,Upon the conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  The original treatment plan was verified with the actual treatment provided.  Postoperative clinical photographs were taken.  The continuous gauze throat pack was removed with continuous suction and visualization.  Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, taken to the recovery room, breathing spontaneously with stable vital signs.,FINDINGS: , This patient presented in her permanent dentition.  Her teeth #1, 16, 17, and 32 were impacted and are going to be removed following my full mouth dental rehabilitation by Dr. Alexander.  Oral hygiene was fair.  There was generalized plaque and calculus throughout.  She did not have any caries, did not require any restorative dentistry.,CONCLUSION:,  Following my dental surgery, the patient continued to intubated and was prepped for oral surgery procedures by Dr. X and his associates.  There were no postop pain requirements.  I did not have any specific requirements for the patient or her mother and that will be handled by Dr. X and their instructions on soft foods, etc., and pain control will be managed by them.",7
"REASON FOR VISIT:,  Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.,HISTORY OF PRESENT ILLNESS:,  Ms. ABC returns today for followup status post L4-L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion on 06/08/07.,Preoperatively, her symptoms, those of left lower extremity are radicular pain.,She had not improved immediately postoperatively.  She had a medial breech of a right L4 pedicle screw.  We took her back to the operating room same night and reinserted the screw.  Postoperatively, her pain had improved.,I had last seen her on 06/28/07 at which time she was doing well.  She had symptoms of what she thought was ""restless leg syndrome"" at that time.  She has been put on ReQuip for this.,She returned.  I had spoken to her 2 days ago and she had stated that her right lower extremity pain was markedly improved.  I had previously evaluated this for a pain possibly relating to deep venous thrombosis and ultrasound was negative.  She states that she had recurrent left lower extremity pain, which was similar to the pain she had preoperatively but in a different distribution, further down the leg.  Thus, I referred her for a lumbar spine radiograph and lumbar spine MRI and she presents today for evaluation.,She states that overall, she is improved compared to preoperatively.  She is ambulating better than she was preoperatively.  The pain is not as severe as it was preoperatively.  The right leg pain is improved.  The left lower extremity pain is in a left L4 and L5 distribution radiating to the great toe and first web space on the left side.,She denies any significant low back pain.  No right lower extremity symptoms.,No infectious symptoms whatsoever.  No fever, chills, chest pain, shortness of breath.  No drainage from the wound.  No difficulties with the incision.,FINDINGS:  ,On examination, Ms. ABC is a pleasant, well-developed, well-nourished female in no apparent distress.  Alert and oriented x 3.  Normocephalic, atraumatic.  Respirations are normal and nonlabored.  Afebrile to touch.,Left tibialis anterior strength is 3 out of 5, extensor hallucis strength is 2 out of 5.  Gastroc-soleus strength is 3 to 4 out of 5.  This has all been changed compared to preoperatively.  Motor strength is otherwise 4 plus out of 5.  Light touch sensation decreased along the medial aspect of the left foot.  Straight leg raise test normal bilaterally.,The incision is well healed.  There is no fluctuance or fullness with the incision whatsoever.  No drainage.,Radiographs obtained today demonstrate pedicle screw placement at L4 and L5 bilaterally without evidence of malposition or change in orientation of the screws.,Lumbar spine MRI performed on 07/03/07 is also reviewed.,It demonstrates evidence of adequate decompression at L4 and L5.  There is a moderate size subcutaneous fluid collection seen, which does not appear compressive and may be compatible with normal postoperative fluid collection, especially given the fact that she had a revision surgery performed.,ASSESSMENT AND PLAN:  ,Ms. ABC is doing relatively well status post L4 and L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion with instrumentation on 07/08/07.  The case is significant for merely misdirected right L4 pedicle screw, which was reoriented with subsequent resolution of symptoms.,I am uncertain with regard to the etiology of the symptoms.  However, it does appear that the radiographs demonstrate appropriate positioning of the instrumentation, no hardware shift, and the MRI demonstrates only a postoperative suprafascial fluid collection.  I do not see any indication for another surgery at this time.,I would also like to hold off on an interventional pain management given the presence of the fluid collection to decrease the risk of infection.,My recommendation at this time is that the patient is to continue with mobilization.  I have reassured her that her spine appears stable at this time.  She is happy with this.,I would like her to continue ambulating as much as possible.  She can go ahead and continue with ReQuip for the restless leg syndrome as her primary care physician has suggested.  I have also her referred to Mrs. Khan at Physical Medicine and Rehabilitation for continued aggressive management.,I will see her back in followup in 3 to 4 weeks to make sure that she continues to improve.  She knows that if she has any difficulties, she may follow up with me sooner.",34
"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.",11
"CC: ,Bilateral lower extremity numbness.,HX: ,21 y/o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11/5/96. The symptoms became maximal over a 12-24 hour period and have not changed since. The symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally. He noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space. He denied bowel/bladder problems, or weakness or numbness elsewhere. Hot showers may improve his symptoms. He has suffered no recent flu-like illness. Past medical and family histories are unremarkable. He was on no medications.,EXAM:, Unremarkable except for mild distal vibratory sensation loss in the toes (R>L).,LAB:, CBC, Gen Screen, TSH, FT4, SPE, ANA were all WNL.,MRI L-SPINE:, Normal.,COURSE:, Normal exam and diminished symptoms at following visit 4/23/93.",27
"DISCHARGE DIAGNOSES:,1.  Gram-negative rod bacteremia, final identification and susceptibilities still pending.,2.  History of congenital genitourinary abnormalities with multiple surgeries before the 5th grade.,3.  History of urinary tract infections of pyelonephritis.,OPERATIONS PERFORMED: , Chest x-ray July 24, 2007, that was normal.  Transesophageal echocardiogram July 27, 2007, that was normal.  No evidence of vegetations.  CT scan of the abdomen and pelvis July 27, 2007, that revealed multiple small cysts in the liver, the largest measuring 9 mm.  There were 2-3 additional tiny cysts in the right lobe.  The remainder of the CT scan was normal.,HISTORY OF PRESENT ILLNESS: , Briefly, the patient is a 26-year-old white female with a history of fevers.  For further details of the admission, please see the previously dictated history and physical.  ,HOSPITAL COURSE:,  Gram-negative rod bacteremia.  The patient was admitted to the hospital with suspicion of endocarditis given the fact that she had fever, septicemia, and Osler nodes on her fingers.  The patient had a transthoracic echocardiogram as an outpatient, which was equivocal, but a transesophageal echocardiogram here in the hospital was normal with no evidence of vegetations.  The microbiology laboratory stated that the Gram-negative rod appeared to be anaerobic, thus raising the possibility of organisms like bacteroides.  The patient does have a history of congenital genitourinary abnormalities which were surgically corrected before the fifth grade.  We did a CT scan of the abdomen and pelvis, which only showed some benign appearing cysts in the liver.  There was nothing remarkable as far as her kidneys, ureters, or bladder were concerned.  I spoke with Dr. XYZ of infectious diseases, and Dr. XYZ asked me to talk to the patient about any contact with animals, given the fact that we have had a recent outbreak of tularemia here in Utah.  Much to my surprise, the patient told me that she had multiple pet rats at home, which she was constantly in contact with.  I ordered tularemia and leptospirosis serologies on the advice of Dr. XYZ, and as of the day after discharge, the results of the microbiology still are not back yet.  The patient, however, appeared to be responding well to levofloxacin.  I gave her a 2-week course of 750 mg a day of levofloxacin, and I have instructed her to follow up with Dr. XYZ in the meantime.  Hopefully by then we will have a final identification and susceptibility on the organism and the tularemia and leptospirosis serologies will return.  A thought of ours was to add doxycycline, but again the patient clinically appeared to be responding to the levofloxacin.  In addition, I told the patient that it would be my recommendation to get rid of the rats.  I told her that if indeed the rats were carriers of infection and she received a zoonotic infection from exposure to the rats, that she could be in ongoing continuing danger and her children could also potentially be exposed to a potentially lethal infection.  I told her very clearly that she should, indeed, get rid of the animals.  The patient seemed reluctant to do so at first, but I believe with some coercion from her family, that she finally came to the realization that this was a recommendation worth following.,  ,DISPOSITION,DISCHARGE INSTRUCTIONS: , Activity is as tolerated.  Diet is as tolerated.,MEDICATIONS: , Levaquin 750 mg daily x14 days.,Followup is with Dr. XYZ of infectious diseases.  I gave the patient the phone number to call on Monday for an appointment.  Additional followup is also with Dr. XYZ, her primary care physician.  Please note that 40 minutes was spent in the discharge.",10
"CHIEF COMPLAINT:,  Weak and shaky.,HISTORY OF PRESENT ILLNESS:,  The patient is a 75-year-old, Caucasian female who comes in today with complaint of feeling weak and shaky.  When questioned further, she described shortness of breath primarily with ambulation.  She denies chest pain.  She denies cough, hemoptysis, dyspnea, and wheeze.  She denies syncope, presyncope, or palpitations.  Her symptoms are fairly longstanding but have been worsening as of late.,PAST MEDICAL HISTORY:,  She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history.  She states that she has underlying history of heart disease but is not able to elaborate to any significant extent.  She also has a history of hypertension and type II diabetes but is not currently taking any medication.  She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections.  Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair.,CURRENT MEDICATIONS:,  She is on two different medications, neither of which she can remember the name and why she is taking it.,ALLERGIES: , She has no known medical allergies.,FAMILY HISTORY:,  Remarkable for coronary artery disease, stroke, and congestive heart failure.,SOCIAL HISTORY:,  She is a widow, lives alone.  Denies any tobacco or alcohol use.,REVIEW OF SYSTEMS:,  Dyspnea on exertion.  No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling.,PHYSICAL EXAMINATION:,General:  She is alert but seems somewhat confused and is not able to provide specific details about her past history.,Vital Signs:  Blood pressure:  146/80.  Pulse:  68.  Weight:  147 pounds.,HEENT:  Unremarkable.,Neck:  Supple without JVD, adenopathy, or bruit.,Chest:  Clear to auscultation.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft.,Extremities:  No edema.,LABORATORY:,  O2 sat 100% at rest and with exertion.  Electrocardiogram was normal sinus rhythm.  Nonspecific S-T segment changes.  Chest x-ray pending.,ASSESSMENT/PLAN:,1.  Dyspnea on exertion, uncertain etiology.  Mother would be concerned about the possibility of coronary artery disease given the patient’s underlying risk factors.  We will have the patient sign a release of records so that we can review her previous history.  Consider setting up for a stress test.,2.  Hypertension, blood pressure is acceptable today.  I am not certain as to what, if the patient’s is on any antihypertensive agents.  We will need to have her call us what the names of her medications, so we can see exactly what she is taking.,3.  History of diabetes.  Again, not certain as to whether the patient is taking anything for this particular problem when she last had a hemoglobin A1C.  I have to obtain some further history and review records before proceeding with treatment recommendations.",15
"GENERAL:  Negative for any nausea, vomiting, fevers, chills, or weight loss.,NEUROLOGIC:  Negative for any blurry vision, blind spots, double vision, facial asymmetry, dysphagia, dysarthria, hemiparesis, hemisensory deficits, vertigo, ataxia.,HEENT:  Negative for any head trauma, neck trauma, neck stiffness, photophobia, phonophobia, sinusitis, rhinitis.,CARDIAC:  Negative for any chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema.,PULMONARY:  Negative for any shortness of breath, wheezing, COPD, or TB exposure.,GASTROINTESTINAL:  Negative for any abdominal pain, nausea, vomiting, bright red blood per rectum, melena.,GENITOURINARY:  Negative for any dysuria, hematuria, incontinence.,INTEGUMENTARY:  Negative for any rashes, cuts, insect bites.,RHEUMATOLOGIC:  Negative for any joint pains, photosensitive rashes, history of vasculitis or kidney problems.,HEMATOLOGIC:  Negative for any abnormal bruising, frequent infections or bleeding.",5
"PREOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,POSTOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,OPERATIVE REPORT:  ,The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema.  The patient has history of previous right foot infection requiring first ray resection.  The patient has ulcerations of right second toe dorsally at the proximal interphalangeal joint, which has failed to respond to conservative treatment.  The patient now has exposed bone and osteomyelitis in the second toe.  The patient has been on IV antibiotics as an outpatient and has failed to respond to these and presents today for surgical intervention.,After an IV was started by the Department of Anesthesia, the patient was taken back to the operating room and placed on the operative table in the supine position.  A restraint belt was placed around the patient's waist using copious amounts of Webril and an ankle pneumatic tourniquet was placed around the patient's right ankle and the patient was made comfortable by the Department of Anesthesia.  After adequate amounts of sedation had been given to the patient, we administered a block of 10 cc of 0.5% Marcaine plain in proximal digital block around the second digit.  The foot and ankle were then prepped in the normal sterile orthopedic manner.  The foot was elevated and an Esmarch bandage applied to exsanguinate the foot.  The tourniquet was then inflated to 250 mmHg and the foot was brought back onto the table.  Using Band-Aid scissors, the stockinet was cut and reflected and using a wet and dry sponge, the foot was wiped, cleaned, and the second toe identified.,Using a skin scrape, a racket type incision was planned around the second toe to allow also remodelling of previous operative site.  Using a fresh #10 blade, skin incision was made circumferentially in the racket-shaped manner around the second digit.  Then, using a fresh #15 blade, the incision was deepened and was taken down to the level of the second metatarsophalangeal joint.  Care was taken to identify bleeders and cautery was used as necessary for hemostasis.  After cleaning up all the soft tissue attachments, the second digit was disarticulated down to the level of the metatarsophalangeal joint.  The head of the second metatarsal was inspected and was noted to have good glistening white cartilage with no areas of erosion evident by visual examination.  Attention was then directed to closure of the wound.  All remaining tissue was noted to be healthy and granular in appearance with no necrotic tissue evident.  Areas of subcutaneous tissue were then removed through a sharp dissection in order to allow better approximation of the skin edges.  Due to long-standing lower extremity lymphedema and postoperative changes on previous surgery, I thought that we were unable to close the incision in entirety.  Therefore, after copious amounts of irrigation using sterile saline, it was determined to use modified dental rolls using #4-0 gauze to remove tension from the skin.  Deep vertical mattress sutures were used in order to reapproximate more closely, the skin edges and bring the plantar flap of skin up to the dorsal skin.  This was obtained using #2-0 nylon suture.  Following this, the remaining exposed tissue from the wound was covered using moist to dry saline soaked 4 x 4 gauze.  The wound was then dressed using 4 x 4 gauze fluffed with abdominal pads, then using Kling and Kerlix and an ACE bandage to provide compression.  The tourniquet was deflated at 42 minutes' time and hemostasis was noted to be achieved.  The ACE bandage was extended up to just below the knee and no bleeding striking to the bandages was appreciated.  The patient tolerated the procedure well and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact, as was evidenced by capillary bleeding, which was present during the procedure.  Sedation was given postoperative introductions, which include to remain nonweightbearing to her right foot.  The patient was instructed to keep the foot elevated and to apply ice behind her knee as necessary, no more than 20 minutes each hour.  The patient was instructed to continue her regular medications.  The patient was to continue IV antibiotic course and was given prescription for Vicoprofen to be taken q.4h. p.r.n. for moderate to severe pain #30.  The patient will followup with Podiatry on Monday morning at 8:30 in the Podiatry Clinic for dressing change and evaluation of her foot at that time.,The patient was instructed as to signs and symptoms of infection, was instructed to return to the Emergency Department immediately if these should present.  The second digit was sent to Pathology for gross and micro.",37
"HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old woman whom I have been following, who has had angina.  In any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when I spoke to her.  I advised her to call 911, which she did.  While waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain.  By the time she presented here, she is currently pain-free and is feeling well.,PAST CARDIAC HISTORY: , The patient has been having arm pain for several months.  She underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia.  I had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker.  However, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room.  On 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80%  mid LAD lesion, circumflex normal, and RCA totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area.  The decision was made to transfer  her as she may be having collateral insufficiency from the LAD stenosis to the RCA vessel.  She underwent that with drug-eluting stents on 08/16/08, with I believe three or four total placed, and was discharged on 08/17/08.  She had some left arm discomfort on 08/18/08, but this was mild.  Yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin.  This is her usual angina.  She is being admitted with unstable angina post stent.,PAST MEDICAL HISTORY: , Longstanding hypertension, CAD as above, hyperlipidemia, and overactive bladder.,MEDICATIONS:,1.  Detrol LA 2 mg once a day.,2.  Prilosec for GERD 20 mg once a day.,3.  Glucosamine 500/400 mg once a day for arthritis.,4.  Multivitamin p.o. daily.,5.  Nitroglycerin sublingual as available to her.,6.  Toprol-XL 25 mg once a day which I started although she had been bradycardic, but she seems to be tolerating.,7.  Aspirin 325 mg once a day.,8.  Plavix 75 mg once a day.,9.  Diovan 160 mg once a day.,10.  Claritin 10 mg once a day for allergic rhinitis.,11.  Norvasc 5 mg once a day.,12.  Lipitor 5 mg once a day.,13.  Evista 60 mg once a day.,ALLERGIES: , ALLERGIES TO MEDICATIONS ARE NONE.  SHE DENIES ANY SHRIMP OR SEA FOOD ALLERGY.,FAMILY HISTORY: , Her father died of an MI in his 50s and a brother had his first MI and bypass surgery at 54.,SOCIAL HISTORY:  ,She does not smoke cigarettes, abuse alcohol, no use of illicit drugs.  She is divorced and lives alone and is a retired laboratory technician from Cornell Diagnostic Laboratory.,REVIEW OF SYSTEMS:,  She denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08.  No morning headaches or fatigue.  No psychiatric diagnosis.  No psoriasis, no lupus.  Remainder of the review of systems is negative x14 systems except as described above.,PHYSICAL EXAMINATION:,GENERAL:  She is a pleasant elderly woman, currently in no acute distress.,VITAL SIGNS:  Height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 47,  respiratory rate 16, and O2 saturation 100%,HEENT:  Cranium is normocephalic and atraumatic.  She has moist mucosal membranes.,NECK:  Veins are not distended.  There are no carotid bruits.,LUNGS:  Clear to auscultation and percussion without wheezes.,HEART:  S1 and S2, regular rate.  No significant murmurs, rubs or gallops.  PMI nondisplaced.,ABDOMEN:  Soft and nondistended.  Bowel sounds present.,EXTREMITIES:  Without significant clubbing, cyanosis or edema.  Pulses grossly intact.  Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI and there is no evidence of hematoma or bruit and intact distal pulses.,LABORATORY DATA: , EKG reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,Sodium 136, potassium 3.8, chloride 105, and bicarbonate 27.  BUN 16 and creatinine 0.9.  Glucose 110.  Magnesium 2.5.  ALT 107 and AST 65 and these were normal on 08/15/08.  INR is 0.89, PTT 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,IMPRESSION AND PLAN:  ,The patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery.  In any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, I am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy.  We will continue her beta-blocker and I cannot increase the dose because she is bradycardic already.  Aspirin, Plavix, valsartan, Lipitor, and Norvasc.  I am going to add Imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out MI, although there is a little suspicion.  I suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect.  My concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal LV function.  She will continue the glucosamine for her arthritis, Claritin for allergies, and Detrol LA for urinary incontinence.,Total patient care time in the emergency department 75 minutes.  All this was discussed in detail with the patient and her daughter who expressed understanding and agreement.  The patient desires full resuscitation status.",3
"MALE PHYSICAL EXAMINATION,HEENT:  Pupils equal, round and reactive to light and accommodation.  Extraocular movements are intact.  Sclerae are anicteric.  TMs are clear bilaterally.  Oropharynx is clear without erythema or exudate.,NECK:  Supple without lymphadenopathy or thyromegaly.  Carotids are silent.  There is no jugular venous distention.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm without S3, S4.  No murmurs or rubs are appreciated.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No masses, hepatomegaly or splenomegaly are appreciated.,GU:  Normal **circumcised male.  No discharge or hernias.  No testicular masses.,RECTAL EXAM:  Normal rectal tone.  Prostate is smooth and not enlarged.  Stool is Hemoccult negative.,EXTREMITIES:  Reveal no clubbing, cyanosis, or edema.  Peripheral pulses are +2 and equal bilaterally in all four extremities.,JOINT EXAM:  Reveals no tenosynovitis.,NEUROLOGIC:  Cranial nerves II through XII are grossly intact.  Motor strength is 5/5 and equal in all four extremities.  Deep tendon reflexes are +2/4 and equal bilaterally.  Patient is alert and oriented times 3.,PSYCHIATRIC:  Grossly normal.,DERMATOLOGIC:  No lesions or rashes.",25
"SUBJECTIVE:,",34
"EXAM:,  CT cervical spine (C-spine) for trauma.,FINDINGS:,  CT examination of the cervical spine was performed without contrast.  Coronal and sagittal reformats were obtained for better anatomical localization.  Cervical vertebral body height, alignment and interspacing are maintained.  There is no evidence of fractures or destructive osseous lesions.  There are no significant degenerative endplate or facet changes.  No significant osseous central canal or foraminal narrowing is present.,IMPRESSION: , Negative cervical spine.",33
"PREOPERATIVE DIAGNOSIS,1.  Dysmenorrhea.,2.  Menorrhagia.,POSTOPERATIVE DIAGNOSIS,1.  Dysmenorrhea.,2.  Menorrhagia.,PROCEDURE:,  Laparoscopic supracervical hysterectomy.,ESTIMATED BLOOD LOSS:,  30 cc.,COMPLICATIONS:,  None.,INDICATIONS FOR SURGERY: , A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management.  Please see clinic notes.  Risks of bleeding, infection, damage to other organs have been explained.  Informed consent was obtained.,OPERATIVE FINDINGS:,  Slightly enlarged but otherwise normal-appearing uterus.  Normal-appearing adnexa bilaterally.,OPERATIVE PROCEDURE IN DETAIL: , After administration of general anesthesia the patient was placed in dorsal lithotomy position, prepped and draped in the usual sterile fashion.  Uterine manipulator was inserted as well as a Foley catheter and this was then draped off from the remainder of the abdominal field.  A 5 mm incision was made umbilically after injecting 0.25% Marcaine; 0.25% Marcaine was injected in all the incisional sites.  Veress needle was inserted, position confirmed using the saline drop method.  After confirming an opening pressure of 4 mmHg of CO2 gas, approximately four liters was insufflated in the abdominal cavity.  Veress needle was removed and a 5 mm port placed and position confirmed using the laparoscope.  A 5 mm port was placed three fingerbreadths suprapubically and on the left and right side.  All these were placed under direct visualization.  Pelvic cavity was examined with findings as noted above.  The left utero-ovarian ligament was grasped and cauterized using the Gyrus.  Part of the superior aspect of the broad ligament was then cauterized as well.  Following this the anterior peritoneum over the bladder flap was incised and the bladder flap bluntly resected off the lower uterine segment.  The remainder of the broad and cardinal ligament was then cauterized and excised.  A similar procedure was performed on the right side.  The cardinal ligament was resected all the way down to 1 cm above the uterosacral ligament.  After assuring that the bladder was well out of the way of the operative field, bipolar cautery was used to incise the cervix at a level just above the uterosacral ligaments.  The area was irrigated extensively and cautery used to assure hemostasis.  A 15 mm probe was then placed on the right side and the uterine morcellator was used to remove the specimen and submitted to pathology for examination.  Hemostasis was again confirmed under low pressure.  Using Carter-Thomason the fascia was closed in the 15 mm port site with 0 Vicryl suture.  The accessory ports were removed and abdomen deflated and skin edges reapproximated with 5-0 Monocryl suture.  Instruments removed from vagina.  Patient returned to supine position, recalled from general anesthesia and transferred to recovery in satisfactory condition.  Sponge and needle counts correct at the conclusion of the case.  Estimated blood loss was 30 cc.  There were no complications.",24
"HISTORY: , The patient is a 15-year-old female who was seen in consultation at the request of Dr. X on 05/15/2008 regarding enlarged tonsils.  The patient has been having difficult time with having two to three bouts of tonsillitis this year.  She does average about four bouts of tonsillitis per year for the past several years.  She notes that throat pain and fever with the actual infections.  She is having no difficulty with swallowing.  She does have loud snoring, though there have been no witnessed observed sleep apnea episodes.  She is a mouth breather at nighttime, however.  The patient does feel that she has a cold at today's visit.  She has had tonsil problems again for many years.  She does note a history of intermittent hoarseness as well.  This is particularly prominent with the current cold that she has had.  She had been seen by Dr. Y in Muskegon who had also recommended a tonsillectomy, but she reports she would like to get the surgery done here in the Ludington area as this is much closer to home.  For the two tonsillitis, she is on antibiotics again on an average about four times per year.  They do seem to help with the infections, but they tend to continue to recur.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:,ALLERGY/IMMUNOLOGIC:  Negative.,CARDIOVASCULAR:  Negative.,PULMONARY:  Negative.,GASTROINTESTINAL:  Negative.,GENITOURINARY:  Negative.,NEUROLOGIC:  Negative.,VISUAL:  Negative.,DERMATOLOGIC:  Negative.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  Negative.,CONSTITUTIONAL:  Negative.,PAST SURGICAL HISTORY: , Pertinent for previous cholecystectomy.,FAMILY HISTORY:,  No family history of bleeding disorder.  She does have a sister with a current ear infection.  There is a family history of cancer, diabetes, heart disease, and hypertension.,CURRENT MEDICATIONS: , None.,ALLERGIES: , She has no known drug allergies.,SOCIAL HISTORY: , The patient is single.  She is a student.  Denies tobacco or alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Pulse is 80 and regular, temperature 98.4, weight is 184 pounds.,GENERAL:  The patient is an alert, cooperative, obese, 15-year-old female, with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  The external ears are normal.  The ear canals are clean and dry.  The drums are intact and mobile.  Hearing is grossly normal.  Tuning fork examination with normal speech reception thresholds noted.,NASAL:  She has clear drainage, large inferior turbinates, no erythema.,ORAL:  Her tongue, lip, floor of mouth are noted to be normal.  Oropharynx does reveal very large tonsils measuring 3+/4+; they were exophytic.  Mirror examination of the larynx reveals some mild edema of the larynx at this time.  The nasopharynx could not be visualized on mirror exam today.,NECK:  Obese, supple.  Trachea is midline.  Thyroid is nonpalpable.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,IMPRESSION: , ,1.  Chronic adenotonsillitis with adenotonsillar hypertrophy.,2.  Upper respiratory tract infection with mild acute laryngitis.,3.  Obesity.,RECOMMENDATIONS: , We are going to go ahead and proceed with an adenotonsillectomy.  All risks, benefits, and alternatives regarding the surgery have been reviewed in detail with the patient and her family.  This includes risk of bleeding, infection, scarring, regrowth of the adenotonsillar tissue, need for further surgery, persistent sore throat, voice changes, etc.  The parents are agreeable to the planned procedure, and we will schedule this accordingly at Memorial Medical Center here within the next few weeks.  We will make further recommendations afterwards.",5
"PREOPERATIVE DIAGNOSIS: , Adenotonsillar hypertrophy and chronic otitis media.,POSTOPERATIVE DIAGNOSIS:,  Adenotonsillar hypertrophy and chronic otitis media.,PROCEDURE PERFORMED:,1.  Tympanostomy and tube placement.,2.  Adenoidectomy.,ANESTHESIA:  ,General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, prepped and draped in the usual fashion.  After induction of general endotracheal anesthesia, the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,Attention was directed to the nasopharynx.  With the Bovie set at 50 coag and the suction Bovie tip on the suction hose, the adenoid bed was fulgurated by beginning at the posterosuperior aspect of the nasopharynx at the apex of the choana placing the tip of the suction cautery deep at the root of the adenoids next to the roof of the nasopharynx and then in a linear fashion making serial passages through the base of the adenoid fossa in parallel lines until the entire nasopharynx and adenoid bed had been fulgurated moving from posterior to anterior.  The McIvor was relaxed and attention was then directed to the ears.,The left external auditory canal was examined under the operating microscope and cleaned of ceruminous debris.,An anteroinferior quadrant tympanostomy incision was made.  Fluid was suctioned from the middle ear space, and a tympanostomy tube was placed at the level of the incision and pushed into position with the Rosen needle.  Cortisporin ear drops were instilled into the canal, and a cotton ball was placed in the external meatus.,By a similar procedure, the opposite tympanostomy and tube placement were accomplished.,The patient tolerated the procedure well and left the operating room in good condition.",37
"SUBJECTIVE:,  The patient is a 66-year-old female who presents to the clinic today for a five-month recheck on her type II diabetes mellitus, as well as hypertension.  While here she had a couple of other issues as well.  She stated that she has been having some right shoulder pain.  She denies any injury but certain range of motion does cause it to hurt.  No weakness, numbness or tingling.  As far as her diabetes she states that she only checks her blood sugars in the morning and those have all been ranging less than 100.  She has not been checking any two hours after meals.  Her blood pressures when she does check them have been running normal as well but she does not have any record of these present with her.  No other issues or concerns.  Upon review of her chart it did show that she had a benign breast biopsy done back on 06/11/04 and was told to have a repeat mammogram in six months but she has never had that done so she is needing to have this done as well.,ALLERGIES: , None.,MEDICATIONS:,  She is on Hyzaar 50/12.5 one-half p.o. daily, coated aspirin daily, lovastatin 40 mg one-half tab p.o. daily, multivitamin daily, metformin 500 mg one tab p.o. b.i.d.; however, she has been skipping her second dose during the day.,SOCIAL HISTORY:,  She is a nonsmoker.,REVIEW OF SYSTEMS:,  As noted above.,OBJECTIVE:,Vital Signs:  Temperature:  98.2.  Pulse:  64.  Respirations:  16.  Blood pressure:  110/56.  Weight:  169.,General:  Alert and oriented x 3.  No acute distress noted.,Neck:  No lymphadenopathy, thyromegaly, JVD or bruits.,Lungs:  Clear to auscultation.,Heart:  Regular rate and rhythm without murmur or gallops present.,Breasts:  Exam performed with a female nurse present.  The breasts do have some scars present underneath them bilaterally from prior breast reduction surgery.  There is no axillary adenopathy or tenderness.  Breasts appear to be symmetric.  There was no nipple discharge or retraction.  No breast tissue retraction noted in either the sitting or the supine position.  Upon palpation there were no palpable lumps or bumps and no palpable discharge.,Musculoskeletal:  She did have full range of motion of her shoulders.  She did have tenderness upon palpation over the right bicipital tendon.  There is no swelling, crepitus or discoloration noted.,MEDICAL DECISION MAKING:  Most recent hemoglobin A1c was 5.6% back in October 2004.  Most recent lipid checks were obtained back in July 2004.  We have not had this checked since that time.,ASSESSMENT:,1.  Type II diabetes mellitus.,2.  Hypertension.,3.  Right shoulder pain.,4.  Hyperlipidemia.,PLAN:,1.  She is going to go to lab to obtain a hemoglobin A1c, BMP, lipids, CPK, liver enzymes and quantitative microalbumin.,2.  We are going to set her up for a diagnostic bilateral mammogram due to a history of abnormal mammogram in the past which subsequently showed a benign breast cyst.,3.  I told her for her shoulder to take ibuprofen 600 mg three times daily with her meals for a minimum of the next one week.,4.  She is going to follow up in the clinic in three months for a complete comprehensive examination.  If any questions, concerns or problems arise between now and then she should let us know.",15
"ADMISSION DIAGNOSIS: , Symptomatic thyroid goiter.,DISCHARGE DIAGNOSIS:  ,Symptomatic thyroid goiter.,PROCEDURE PERFORMED DURING THIS HOSPITALIZATION: , Total thyroidectomy.,INDICATIONS FOR THE SURGERY:  ,Briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter.  She presented now after informed consent for the above procedure, understanding the inherent risks and complications and risk-benefit ratio.,HOSPITAL COURSE:  ,The patient underwent total thyroidectomy on 09/22/08, which she tolerated very well and remained stable in the postoperative period.  On postoperative day #1, she was tolerating her diet, began on thyroid hormone replacement, and remained afebrile with stable vital signs.  She required intravenous narcotics for pain control.  She was judged stable for discharge home on 09/25/08, tolerating a diet well, having no fever, stable vital signs, and good pain control.  The wound was clean and dry.  The drain was removed.  She was instructed to follow up in the surgical office within one week after discharge.  She was given prescription for Vicodin for pain and Synthroid thyroid hormone, and otherwise the appropriate wound care instructions per my routine wound care sheet.",10
"DIAGNOSES,1.  Term pregnancy.,2.  Possible rupture of membranes, prolonged.,PROCEDURE:,  Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:,  The patient is a 20-year-old female, gravida 4, para 0, who presented to the office.  She had small amount of leaking since last night.  On exam, she was positive Nitrazine, no ferning was noted.  On ultrasound, her AFI was about 4.7 cm.  Because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,She was brought to the hospital and begun on Pitocin.  Once she was in her regular pattern, we ruptured her bag of water; fluid was clear.  She went rapidly to completion over the next hour and a half.  She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation.  Upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications.  The baby was vigorous, moving all extremities.  The cord was clamped and cut.  The baby was handed off to mom with nurse present.  Apgars were 8 and 9.  Placenta was delivered spontaneously, intact.  Three-vessel cord with no retained placenta.  Estimated blood loss was about 150 mL.  There were no tears.",37
"CHIEF COMPLAINT:,  Achilles ruptured tendon.,HISTORY:,  Mr. XYZ is 41 years of age, who works for Chevron and lives in Angola.  He was playing basketball in Angola back last Wednesday, Month DD, YYYY, when he was driving toward the basket and felt a pop in his posterior leg.  He was seen locally and diagnosed with an Achilles tendon rupture.  He has been on crutches and has been nonweightbearing since that time.  He had no pain prior to his injury.  He has had some swelling that is mild.  He has just been on aspirin a day due to his traveling time.  Pain currently is minimal.,PAST MEDICAL HISTORY:,  Denies diabetes, cardiovascular disease, or pulmonary disease.,CURRENT MEDICATIONS:,  Malarone, which is an anti-malarial.,ALLERGIES:,  NKDA,SOCIAL HISTORY:,  He is a petroleum engineer for Chevron.  Drinks socially.  Does not use tobacco.,PHYSICAL EXAM:,  Pleasant gentleman in no acute distress.  He has some mild swelling on the right ankle and hindfoot.  He has motion that is increased into dorsiflexion.  He has good plantarflexion.  Good subtalar, Chopart and forefoot motion.  His motor function is intact although weak into plantarflexion.  Sensation is intact.  Pulses are strong.  In the prone position, he has diminished tension on the affected side.  There is some bruising around the posterior heel.  He has a palpable defect about 6-8 cm proximal to the insertion site that is tender for him.  Squeezing the calf causes no plantarflexion of the foot.,RADIOGRAPHS:,  Of his right ankle today show a preserved joint space.  I don't see any evidence of fracture noted.  Radiographs of the heel show no fracture noted with good alignment.,IMPRESSION:,  Right Achilles tendon rupture.,PLAN:,  I have gone over with Mr. XYZ the options available.  We have discussed the risks, benefits and alternatives to operative versus nonoperative treatment.  Based on his age and his activity level, I think his best option is for operative fixation.  We went over the risks of bleeding, infection, damage to nerves and blood vessels, rerupture of the tendon, weakness and the need for future surgery.  We have discussed doing this as an outpatient procedure.  He would be nonweightbearing in a splint for 10 days, nonweightbearing in a dynamic brace for 4 weeks, and then a walking boot for another six weeks with a lift until three months postop when we can get him into a shoe with a ¼"" lift.  He understands a 6-9 month return to sports overall.  He will also need to be on some Lovenox for a week after surgery and then on an aspirin as he is going to travel back to Angola.  Today we will put him in a high tide boot that he will need at six weeks, and we will put him in a 1"" lift also.  He can weight bear until surgery and we will have it set up this week.  His questions were all answered today.",27
"SUBJECTIVE:,  A 6-year-old boy who underwent tonsillectomy and adenoidectomy two weeks ago.  Also, I cleaned out his maxillary sinuses.  Symptoms included loud snoring at night, sinus infections, throat infections, not sleeping well, and fatigue.  The surgery went well, and I had planned for him to stay overnight, but Mom reminds me that by about 8 p.m. the night nurse gotten him to take fluids well and we let him go home then that evening.  He finished up his Augmentin, by a day or two later he was off the Lortab.  Mom has not noticed any unusual voice change.  No swallowing difficulty except he does not like the taste of acidic foods such as tomato sauce.  He has not had any nasal discharge or ever had any bleeding.  He seems to be breathing better.,OBJECTIVE:,  Exam looks good.  The pharynx is well healed.  Tongue mobility is normal.  Voice sounds clear.  Nasal passages reveal no discharge or crusting.,RECOMMENDATION:,  I told Mom it is okay to use some ibuprofen in case his mouth or jaws are still sensitive.  He says it seems to hurt if he opens his mouth real wide such as when he brushes his teeth.  It is okay to chew gum and it is okay to eat crunchy foods such as potato chips.  The pathologist described the expected changes of chronic sinusitis and chronic hypertrophic tonsillitis and adenoiditis, and there were no atypical findings on the laboratories.,I am glad he has healed up well.  There are no other restrictions or limitations.  I told Mom, I had written to Dr. XYZ to let her know of the findings.  The child will continue his regular followup visits with his family doctor, and I told Mom I would be happy to see him anytime if needed.  He did very well after surgery and he seems to feel better and breathe a lot better after his throat and sinus procedure.",11
"PREOPERATIVE DIAGNOSIS:, Hawkins IV talus fracture.,POSTOPERATIVE DIAGNOSIS: , Hawkins IV talus fracture.,PROCEDURE PERFORMED:,1.  Open reduction internal fixation of the talus.,2.  Medial malleolus osteotomy.,3.  Repair of deltoid ligament.,ANESTHESIA: , Spinal.,TOURNIQUET TIME: , 90 min.,BLOOD LOSS:,  50 cc.,The patient is in the semilateral position on the beanbag.,INTRAOPERATIVE FINDINGS:,  A comminuted Hawkins IV talus fracture with an incomplete rupture of the deltoid ligament.  There was no evidence of osteochondral defects of the talar dome.,HISTORY:  ,This is a 50-year-old male who presented to ABCD General Hospital Emergency Department with complaints of left ankle pain and disfigurement.  There was no open injury.  The patient fell approximately 10 feet off his liner, landing on his left foot.  There was evidence of gross deformity of the ankle.  An x-ray was performed in the Emergency Room, which revealed a grade IV Hawkins classification talus fracture.  He was distal neurovascularly intact.  The patient denied any other complaints besides pain in the ankle.,It was for this reason, we elected to undergo the above-named procedure in order to reduce and restore the blood supply to the talus body.  Because of its tenuous blood supply, the patient is at risk for avascular necrosis.  The patient has agreed to undergo the above-named procedure and consent was obtained.  All risks as well as complications were discussed.,PROCEDURE: , The patient was brought back to operative room #4 of ABCD General Hospital on 08/20/03.  A spinal anesthetic was administered.  A nonsterile tourniquet was placed on the left upper thigh, but not inflated.  He was then positioned on the beanbag.  The extremity was then prepped and draped in the usual sterile fashion for this procedure.  An Esmarch was then used to exsanguinate the extremity and the tourniquet was then inflated to 325 mmHg.  At this time, an anteromedial incision was made in order to perform a medial malleolus osteotomy to best localize the fracture region in order to be able to bone graft the comminuted fracture site.  At this time, a #15 blade was used to make approximately 10 cm incision over the medial malleolus.  This was curved anteromedial along the root of the saphenous vein.  The saphenous vein was located.  Its tributaries going plantar were cauterized and the vein was retracted anterolaterally.  At this time, we identified the medial malleolus.  There was evidence of approximately 80% avulsion, rupture of the deltoid ligament off of the medial malleolus.  This was a major blood feeder to the medial malleolus and we were concerned, once we were going to do the osteotomy, that this would later create healing problem.  It is for this reason that the pedicle, which was attached to the medial malleolus, was left intact.  This pedicle was the anterior portion of the deltoid ligament.  At this time, a MicroChoice saw was then used to make a box osteotomy of the medial malleolus.  Once this was performed, the medial malleolus was retracted anterolaterally with its remaining pedicle intact for later blood supply.  This provided us with excellent exposure to the fracture site of the medial side.  At this time, any loose comminuted pieces were removed.  The dome of the talus was also checked and did not reveal any osteochondral defects.  There was some comminution on the dorsal aspect of the complete talus fracture and we were concerned that once we place the screw, this would tend to extend the fracture site.  It is for this reason, we did the medial malleolar osteotomy to prevent this from happening in order to best expose the fracture site.  At this time, a reduction was performed.  The #7-0 partially threaded cannulated screws were used in order to fix the fracture.  At this time, a 3.2 mm guidewire was placed going from posterolateral to anteromedial.,This was placed slightly lateral to the Achilles tendon, percutaneously inserted, and then drilled in the according fashion across the fracture site.  Once this was performed, a skin knife was then used to incise over the percutaneous insertion in order to accommodate the screw going in.  A depth gauze was then used to measure screw length.  A cannulated drill was then used to drill across the fracture site to allow the entrance of the screw.  A 55 mm partially threaded #7-0 cannulated screw was then placed with excellent compression at the fracture site.  Once this was obtained, we checked the reduction again using intraoperative Xi-Scan in the AP and lateral direction.  This projection gave us excellent view of our screw placement and excellent compression across the fracture site.  At this time, we bone grafted the area of comminution using 1 cc of DynaGraft with crushed cancellous allograft.  This was placed using a freer elevator into the fracture site where the comminution was.  At this time, we copiously irrigated the wound.  The osteotomy site was then repaired, first clamped using two large tenaculum reduction clamps.  Two partially threaded #4-0 cannulated screws were then used to fix the osteotomy site and anatomical reduction was performed with excellent compression across the osteotomy site with the two screws.  Next, a #1-0 Vicryl was then used to repair the deltoid ligament, which was ruptured via the injury.  A tight repair was performed of the deltoid ligament.  At this time, again copious irrigation was used to irrigate the wound.  A #2-0 Vicryl was then used to approximate the subcutaneous skin and staples for the skin incision.  At this time, the leg was cleansed, Adaptic, 4 x 4, and Kerlix roll were then applied.  The patient was then placed in a plaster splint for mobilization.  The tourniquet was then released.  The patient was then transferred off the operating table to recovery in stable condition.  The prognosis for this fracture is guarded.  There is a high rate of avascular necrosis of the talar body, approximately anywhere from 40-60% risk.  The patient is aware of this and he will be followed as an outpatient for this problem.",27
"DELIVERY NOTE: , The patient came in around 0330 hours in the morning on this date 12/30/08 in early labor and from a closed cervix very posterior yesterday; she was 3 cm dilated.  Membranes ruptured this morning by me with some meconium.  An IUPC was placed.  Some Pitocin was started because the contractions were very weak.  She progressed in labor throughout the day.  Finally getting the complete at around 1530 hours and began pushing.  Pushed for about an hour and a half when she was starting to crown.  The Foley was already removed at some point during the pushing.  The epidural was turned down by the anesthesiologist because she was totally numb.  She pushed well and brought the head drown crowning, at which time I arrived and setting her up delivery with prepping and draping.  She pushed well delivering the head and DeLee suctioning was carried out on the perineum because of the meconium even though good amount of amnioinfusion throughout the day was completed.  With delivery of the head, I could see the perineum tear and after delivery of the baby and doubly clamping of the cord having baby off to RT in attendance.  Exam revealed a good second-degree tear ascended a little bit up higher in the vagina and a little off to the right side but rectum sphincter were intact, although I cannot see good fascia around the sphincter anteriorly.  The placenta separated with some bleeding seen and was assisted expressed and completely intact.  Uterus firmed up well with IV pit.  Repair of the tear with 2-0 Vicryl stitches and a 3-0 Vicryl in a subcuticular like area just above the rectum and the perineum was performed using a little local anesthesia to top up with the epidural.  Once this was complete, mom and baby doing well.  Baby was a female infant.  Apgars 8 and 9.",37
"PREOPERATIVE DIAGNOSES,1.  Empyema thoracis.,2.  Need for intravenous antibiotics.,POSTOPERATIVE DIAGNOSES,1.  Empyema thoracis.,2.  Need for intravenous antibiotics.,PROCEDURE:,  Central line insertion.,DESCRIPTION OF PROCEDURE: , With the patient in his room, after obtaining the informed consent, his left deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated and with the patient in the Trendelenburg position, the left subclavian vein was subcutaneously cannulated without any difficulty.  The triple-lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline.  The catheter was fixed to the skin with sutures.  The dressing was applied and then the chest x-ray was obtained which showed no complications of the procedure and good position of the catheter.",3
"PREOPERATIVE DIAGNOSES: ,1.  Chronic eustachian tube dysfunction.,2.  Retained right pressure equalization tube.,3.  Retracted left tympanic membrane.,4.  Dizziness.,POSTOPERATIVE DIAGNOSES:,1.  Chronic eustachian tube dysfunction.,2.  Retained right pressure equalization tube.,3.  Retracted left tympanic membrane.,4.  Dizziness.,PROCEDURE:,1.  Removal of the old right pressure equalizing tube with placement of a tube.  Tube used was Santa Barbara.,2.  Myringotomy with placement of a left pressure equalizing tube.  The tube used was Santa Barbara.,ANESTHESIA:,  General.,INDICATION: , This is a 98-year-old female whom I have known for several years.  She has a marginal hearing.  With the additional conductive loss secondary to the retraction of the tympanic membrane, her hearing aid and function deteriorated significantly.  So, we have kept sets of tubes in her ears at all times.  The major problem is that she has got small ear canals and a very sensitive external auditory canal; therefore it cannot tolerate even the wax cleaning in the clinic awake.,The patient was seen in the OR and tubes were placed.  There were no significant findings.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, she was brought to the neurosensory OR, placed under general anesthesia.  Mask airway was used.  IV had already been started.,On the right side, we removed the old tube and then cleaned the cerumen and found that it was larger than the side of the tube in perfection or perforation in tympanic membrane in the anterior inferior quadrant.  In the same area, a small Santa Barbara tube was placed.  This T-tube was cut to 80% of its original length for comfort and then positioned to point straight out and treated.  Three drops of ciprofloxacin eyedrops was placed in the ear canal.,On the left side, the tympanic membrane adhered and it was retracted and has some myringosclerosis.  Anterior, inferior incision was made.  Tympanic membrane bounced back to neutral position.  A Santa Barbara tube was cut to the 80% of the original length and placed in the hole.  Ciprofloxacin drops were placed in the ear.  Procedure completed.,ESTIMATED BLOOD LOSS: , None.,COMPLICATION: , None.,SPECIMEN:,  None.,DISPOSITION:,  To PACU in a stable condition.",11
"PREOPERATIVE DIAGNOSIS:,  Ruptured globe with full-thickness corneal laceration OX.,POSTOPERATIVE DIAGNOSIS: , Ruptured globe with full-thickness corneal laceration OX.,PROCEDURE:  ,Ruptured globe with full-thickness corneal laceration repair OX.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe with full-thickness corneal laceration of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, astigmatism, cataract, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure and 0.12 forceps and a Superblade were used to create a paracentesis at approximately 11 o'clock. Viscoat was injected through the paracentesis to fill the anterior chamber. The Viscoat cannula was used to sweep the incarcerated iris tissue from the wound. More Viscoat was injected to deepen the anterior chamber. A 10-0 nylon suture was used to place four sutures to close the corneal laceration. BSS was then injected to fill the anterior chamber and a small leak was noted at the inferior end of the wound. A fifth 10-0 nylon suture was then placed. The wound was packed and found to be watertight. The sutures were rotated, the wound was again checked and found to be watertight. A small amount of Viscoat was, again, injected to deepen the anterior chamber and the wound was swept to be sure there was no incarcerated uveal tissue. Several drops were placed in the XXX eye including Ocuflox, Pred Forte, Timolol 0.5%, Alphagan and Trusopt. An eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia. (S)he was taken to the recovery area in good condition. There were no complications.",26
"PREOPERATIVE DIAGNOSIS: , Aqueductal stenosis.,POSTOPERATIVE DIAGNOSIS:,  Aqueductal stenosis.,TITLE OF PROCEDURE:  ,Endoscopic third ventriculostomy.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES:,  Bactiseal ventricular catheter with an Aesculap burr hole port.,SKIN PREPARATION:  ,ChloraPrep.,COMPLICATIONS: , None.,SPECIMENS: , CSF for routine studies.,INDICATIONS FOR OPERATION:  ,Triventricular hydrocephalus most consistent with aqueductal stenosis.  The patient having a long history of some intermittent headaches, macrocephaly.,OPERATIVE PROCEDURE: , After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in supine position with the head neutral.  The right frontal area was shaven and then the head was prepped and draped in a standard routine manner.  The area of the proposed scalp incision was infiltrated with 0.25% Marcaine with 1:200,000 epinephrine.  A curvilinear scalp incision was made extending from just posterior to bregma curving up in the midline and then going off to the right anterior to the coronal suture.  Two Weitlaner were used to hold the scalp open.  A burr hole was made just anterior to the coronal suture and then the dura was opened in a cruciate manner and the pia was coagulated.  Neuropen was introduced directly through the parenchyma into the ventricular system, which was quite large and dilated.  CSF was collected for routine studies.  We saw the total absence of __________  consistent with the congenital form of aqueductal stenosis and a markedly thinned down floor of the third ventricle.  I could bend the ventricular catheter and look back and see the aqueduct, which was quite stenotic with a little bit of chorioplexus near its opening.  The NeuroPEN was then introduced through the midline of the floor of the third ventricle anterior to the mamillary bodies in front of the basilar artery and then was gently enlarged using NeuroPEN __________  various motions.  We went through the membrane of Liliequist.  We could see the basilar artery and the clivus, and there was no significant bleeding from the edges.  The Bactiseal catheter was then left to 7 cm of length because of her macrocephaly and secured to a burr hole port with a 2-0 Ethibond suture.  The wound was irrigated out with bacitracin and closed using 3-0 Vicryl for the deep layer and a Monocryl suture for the scalp followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well.",37
"IDENTIFYING DATA: , The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.,CHIEF COMPLAINT: , ""I am not sure."" The patient has poor insight into hospitalization and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of schizophrenia and chronic paranoid, for which she has received treatment in Houston, Texas.  According to mental health professionals, the patient had been noncompliant with medications for approximately two weeks.  The patient had taken an airplane from Houston to Seattle, but became agitated, paranoid, expressing paranoid delusions that the stewardess and pilots were trying to reject him and was deplaned in Seattle.  The patient was taken to the local shelter where he remained labile, breaking a window, and was taken to jail.  The patient has now been discharged from jail but involuntarily detained for persistent paranoia and disorganization (no jail hold).,PAST PSYCHIATRIC HISTORY: , History of schizophrenia, chronic paranoid.  The patient as noted has been treated in Houston but has not had recent treatment or medications.,PAST MEDICAL HISTORY:  ,No acute medical problems noted.,CURRENT MEDICATIONS: , None.  The patient was most recently treated with Invega and Abilify according to his records.,FAMILY SOCIAL HISTORY: , The patient resides with his father in Houston.  The patient has no known history of substances abuse.  The patient as noted was in jail prior to admission after breaking a window at the local shelter but has no current jail hold.,FAMILY PSYCHIATRIC HISTORY:,  Need to increase database.,MENTAL STATUS EXAMINATION:,Attitude:  Calm and cooperative.,Appearance:  Shows poor hygiene and grooming.,Psychomotor:  Behavior is within normal limits without agitation or retardation.  No EPS or TDS noted.,Affect:  Is suspicious.,Mood:  Anxious but cooperative.,Speech:  Shows normal rate and rhythm.,Thoughts:  Disorganized,Thought Content:  Remarkable for paranoia ""they want to hurt me."",Psychosis:  The patient endorses paranoid delusions as above.  The patient denies auditory hallucinations.,Suicidal/Homicidal Ideation:  The patient denies on admission.,Cognitive Assessment:  Grossly intact.  The patient is alert and oriented x 3.,Judgment:  Poor, shown by noncompliance with treatment.,Assets:  Include stable physical status.,Limitations:  Include recurrent psychosis.,FORMULATION:  ,The patient with a history of schizophrenia was admitted for increasing mood lability and psychosis due to noncompliance with treatment.,INITIAL IMPRESSION:,AXIS I:  Schizophrenia, chronic paranoid.,AXIS II:  None.,AXIS III:  None.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN:  ,The patient will be restarted on Invega and Abilify for psychosis.  The patient will also be continued on Cogentin for EPS.  Increased database will be obtained.",5
"PREOPERATIVE DIAGNOSIS:,  Left little finger extensor tendon laceration.,POSTOPERATIVE DIAGNOSIS: , Left little finger extensor tendon laceration.,PROCEDURE PERFORMED:  ,Repair of left little extensor tendon.,COMPLICATIONS:,  None.,BLOOD LOSS: , Minimal.,ANESTHESIA: , Bier block.,INDICATIONS: , The patient is a 14-year-old right-hand dominant male who cut the back of his left little finger and had a small cut to his extensor tendon.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operative room, laid supine, administered intervenous sedation with Bier block and prepped and draped in a sterile fashion.  The old laceration was opened and the extensor tendon was identified and there was a small longitudinal laceration in the tendon, which is essentially in line with the tendon fibers.  This was just proximal to the PIP joint and on complete flexion of the PIP joint, I did separate just a little bit that was not thought to be significantly dynamically unstable.  It was sutured with a single 4-0 Prolene interrupted figure-of-eight suture and on dynamic motion it did not separate at all.  The wound was irrigated and closed with 5-0 nylon interrupted sutures.  The patient tolerated the procedure well and was taken to the PCU in good condition.",27
"PREPROCEDURE DIAGNOSIS: , History of colon polyps and partial colon resection, right colon.,POSTPROCEDURE DIAGNOSES:  ,1. Normal operative site.  ,2. Mild diverticulosis of the sigmoid colon.  ,3. Hemorrhoids.,PROCEDURE:  ,Total colonoscopy.,PROCEDURE IN DETAIL:  ,The patient is a 60-year-old of Dr. ABC's being evaluated for the above.  The patient also apparently had an x-ray done at the Hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed.  She was prepped the night before and on the morning of the test with oral Fleet's, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push.  Digital rectal exam was done, unremarkable.  At that point, the Pentax video colonoscope was inserted.  The rectal vault appeared normal.  The sigmoid showed diverticula throughout, mild to moderate in nature.  The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized.  The scope was passed a short distance up the ileum, which appeared normal.  The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area.  The scope was then retroflexed, and anal verge visualized showed some hemorrhoids.  The scope was then removed.  The patient tolerated the procedure well.,RECOMMENDATIONS:  ,Repeat colonoscopy in three years.",37
"DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,Two major problems were identified at the admission of this adolescent:,1.",10
"HISTORY OF PRESENT ILLNESS:,  This is a 53-year-old widowed woman, she lives at ABC Hotel.  She presented with a complaint of chest pain, evaluations revealed severe aortic stenosis.  She has been refusing cardiac catheter and she may well need aortic valve replacement.  She states that she does not want heart surgery or valve replacement.  She has a history of bipolar disorder and has been diagnosed at times with schizophrenia.  She is on Depakote 500 mg three times a day and Geodon 80 mg twice a day.  The patient receives mental health care through the XYZ Health System and there is a psychiatrist who makes rounds at the ABC Hotel.  She denies hallucinations, psychosis, paranoia, and suicidal ideation at this time.  States that she does not want surgery because the chest pain that was a presenting complaint has gone away that she did not feel her problem is severe enough to require surgery, and medical records does show in this obese individual that cardiac surgery would present substantial risks and for this individual with the chronic mental illness and behavioral problems of a chronic nature, surgery does present some additional risks.  The patient notes that she has a long history of substance abuse, primarily inhalation of paint vapors that she had more than 100 incarcerations in the XYZ County Jail related to offenses related to her lifestyle at that time such as shoplifting, violation of orders to abstain from substance abuse and the longest confinement of these was 100 days.,The patient is able to write a fairly reasonable explanation for why she does not want to pursue medical care.,PAST AND DEVELOPMENTAL HISTORY: , She was born in XYZ.  She is a high-school graduate from ABCD High School.  She did have an abusive childhood.  She is married four times.  She notes she developed depression when a number of her children died.,PHYSICAL EXAMINATION:  ,GENERAL: , This is an obese woman in bed.  She is somewhat restless and moving during the interview.,VITAL SIGNS,:  Temperature of 97.3, pulse 70, respirations 18, blood pressure 113/68, and oxygen saturation 94% on 3 L of oxygen.,PSYCHIATRY:  ,Speech is normal, rate, volume, grammar, and vocabulary consistent with her educational level.  There is no overt thought disorder.  She does not appear psychotic.  She is not suicidal on formal testing.  She gives the date as Sunday, 05/19/2007 when it is the 20th and 207 when it is 2007.  She is oriented to place.  She can memorize four times, repeats two at five minutes, gets the other two with category hints, this places short-term memory in normal limits.  She had difficulty with serial three subtractions, counting on her fingers and had difficulty naming the months in reverse order stating, ""December, November, September, October, June, July, August, September,"" but recognizes this was not right and then said, ""March, April, May.""  She is able to name objects appropriately.,LABORATORY DATA: , Chest x-ray showing no acute changes.  Carotid duplex shows no stenosis.  Electrolytes and liver function tests are normal.  TSH normal.  Hematocrit 31%.  Triglycerides 152.,DIAGNOSES:  ,1.  Bipolar disorder, apparently stable on medications.,2.  Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.,3.  Aortic stenosis.,4.  Sleep apnea.,5.  Obesity.,6.  Anemia.,7.  Gastroesophageal reflux disease.,RECOMMENDATIONS:,  It is my impression at present that the patient retains ability to make decisions on her own behalf.  Given this lady's underlying mental problems, I would recommend that her treating physicians discuss her circumstances with physicians who round on her at the ABC Hotel.  While she may well need surgery and cardiac catheter, she may be more willing to accept this in the context of some continued encouragement from care providers who usually provide care for her.  She clearly at this time wants to leave this hospital; she normally gets her care through XYZ Health.  Again, in summary, I would consider her to retain the ability to make decisions on her own behalf.,Please feel free to contact me at digital pager if additional information is needed.",5
"HISTORY OF PRESENT ILLNESS:,  The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup.  Her last cycle of chemotherapy was finished on 01/18/08, and she complains about some numbness in her right upper extremity.  This has not gotten worse recently and there is no numbness in her toes.  She denies any tingling or burning.,REVIEW OF SYSTEMS: , Negative for any fever, chills, nausea, vomiting, headache, chest pain, shortness of breath, abdominal pain, constipation, diarrhea, melena, hematochezia or dysuria.  The patient is concerned about her blood pressure being up a little bit and also a mole that she had noticed for the past few months in her head.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 35.6, blood pressure 143/83, pulse 65, respirations 18, and weight 66.5 kg.  GENERAL:  She is a middle-aged white female, not in any distress.  HEENT:  No lymphadenopathy or mucositis.  CARDIOVASCULAR:  Regular rate and rhythm.  LUNGS:  Clear to auscultation bilaterally.  EXTREMITIES:  No cyanosis, clubbing or edema.  NEUROLOGICAL:  No focal deficits noted.  PELVIC:  Normal-appearing external genitalia.  Vaginal vault with no masses or bleeding.,LABORATORY DATA: , None today.,RADIOLOGIC DATA: , CT of the chest, abdomen, and pelvis from 01/28/08 revealed status post total abdominal hysterectomy/bilateral salpingo-oophorectomy with an unremarkable vaginal cuff.  No local or distant metastasis.  Right probably chronic gonadal vein thrombosis.,ASSESSMENT: , This is a 67-year-old white female with history of uterine papillary serous carcinoma, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy and 6 cycles of carboplatin and Taxol chemotherapy.  She is doing well with no evidence of disease clinically or radiologically.,PLAN:,1.  Plan to follow her every 3 months and CT scans every 6 months for the first 2 years.,2.  The patient was advised to contact the primary physician for repeat blood pressure check and get started on antihypertensives if it is persistently elevated.,3.  The patient was told that the mole that she is mentioning in her head is no longer palpable and just to observe it for now.,4.  The patient was advised about doing Kegel exercises for urinary incontinence, and we will address this issue again during next clinic visit if it is persistent.,",34
"PREOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,POSTOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,OPERATION PERFORMED:,1.  Bilateral myringotomies.,2.  Insertion of Shepard grommet draining tubes.,ANESTHESIA: , General, by mask.,ESTIMATED BLOOD LOSS: , Less than 1 mL.,COMPLICATIONS:,  None.,FINDINGS:  ,The patient had a long history of persistent recurrent infections and was placed on antibiotics for the same.  At this point in time, he had a small amount of thick mucoid material in both middle ear spaces with middle ear mucosa somewhat inflamed, but no active acute infection at this point in time.,PROCEDURE:,  With the patient under adequate general anesthesia with the mask delivery of anesthesia, he had his ear canals cleaned utilizing an operating microscope and all foul cerumen had been removed from both sides.  Bilateral inferior radial myringotomies were performed, first on the right and then on the left.  Middle ear spaces were suctioned of small amount of thick mucoid material on both sides and then Shepard grommet draining tubes were inserted on either side.  Floxin drops were then instilled bilaterally to decrease any clotting within the tubes, and then cotton ball was placed in the external meatus bilaterally.  At this point, the patient was awakened and returned to the recovery room, satisfactory, with no difficulty encountered.",11
"DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1.  Glucosamine complex.,2.  Toprol XL.,3.  Alprazolam,4.  Hydrochlorothiazide.,5.  Dyazide.,6.  Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck.  She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area.  As such, I feel that we could safely re-treat the lower neck.  Her weight has increased to 189.5 from 185.2.  She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK:  On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area.  No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY:  Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected.  No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN:  Normal bowel sounds, no hepatomegaly.  No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress.  Thank you for having allowed me to participate in her care.",34
"REASON FOR ADMISSION:,  Penile injury and continuous bleeding from a penile laceration.,HISTORY OF PRESENT ILLNESS:,  The patient is an 18-year-old detainee who was brought by police officers because of a penile injury and bleeding.  He is otherwise healthy.  He tried to insert a marble in his penis four days ago.  He told me that he grabbed the skin on the top of the penis and moved it away from the penis shaft and then using a toothbrush that he made in to a knife object he pierced the skin through from both sides and then kept moving the toothbrush to dilate and make a way for the marble.  Then he inserted a heart-shaped marble in one of the puncture wounds and inserted it under the skin and kept it there.  He was not significantly bleeding and essentially the bleeding stopped from both puncture wounds that he has.  Then today four days after that procedure, he was taking a bath today and he thinks because of the weight he felt a gush in his pants and he looked and he saw the bleeding come out.  He was bleeding so much that he started dripping to the sides of his legs.  So, he was brought to the hospital.  Actually after being seen by two nurses at the facility where he was at the detention center where he was at and they actually did the dressing twice and it was twice soaked with blood.  He came here and was continuously bleeding from that area that we had to change the dressing twice and he is actually still bleeding especially from one of the laceration, the one on the right side of the penis.  The marble also still can be felt underneath the skin.  There is no urethral bleeding.  He did urinate today without difficulty, without hematuria or dysuria.  There is pain in the lacerations.  No erythema in the skin or swelling in the penis and no other injuries.  He did this procedure for sexual pleasure as he said.,PAST MEDICAL HISTORY: , Unremarkable.,PAST SURGICAL HISTORY:  ,Tonsillectomy.,MEDICATION: , He took only ibuprofen.  No regular medication.,ALLERGIES: , None.,SOCIAL HISTORY:  ,He has been in detention for two months for immigration problems.  No drugs.  No alcohol.  No smoking.  He used to work in fast food chain.,FAMILY HISTORY: , Noncontributory to this illness.,REVIEW OF SYSTEMS: , Aside from the pain in the penis and continuous bleeding, he is basically asymptomatic and review of systems is unremarkable.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a young Hispanic male, lying in bed, appear comfortable in no apparent distress.,VITAL SIGNS:  Temperature 97.8, heart rate 99, respiratory rate 20, blood pressure 142/100, and saturation is 98% on room air.,ENT:  Sclerae nonicteric.  Pupils reactive to light.  Nostrils are normal.  Oral cavity is clear.,NECK:  Supple.  Trachea midline.  No JVD.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Normal S1 and S2.  No murmurs or gallops.,ABDOMEN:  Soft, nontender, and nondistended.  Positive bowel sounds.,EXTREMITIES:  Pulses strong bilaterally.  No edema.,GENITAL:  Testicles appear normal.  The penis shaft has two lacerations on both sides, one of them is bleeding.  They measure about 5 to 6 mm on the right side, about 3 or 4 mm on the left side.  The one on the right side is bleeding much more than the other one.  There is a marble that can be felt and it is freely mobile underneath the skin of the dorsum of the penis.  There is no bleeding from the meatus or discharge and no other injuries were seen by inspection.,LABORATORY DATA:,  White count 11.1, hemoglobin 14.5, hematocrit 43.5, and platelets 303,000.  Coags unremarkable.  Glucose 106, creatinine 0.8, sodium 141, potassium 4, and calcium 9.7.  Urinalysis unremarkable.,IMPRESSION: , The patient with a penile laceration that is continuously bleeding from inserting a marble four days ago, which is still underneath the skin of the shaft of the penis.  No other injuries that can be seen and no other evidence of secondary bacterial infection at this time.  The patient is currently refusing removal of the marble and insisting on just repairing the laceration and he is having discussion with Dr. X.,PLAN:,1.  The patient will be admitted to the hospital and will follow Dr. X's recommendation.,2.  The patient was offered a repair of those lacerations, to stop the bleeding as well as the removal of the marble and he is currently considering that and discussing that with Dr. X.,3.  Prophylactic antibiotics to prevent infection.,4.  He has mild hypertension, which is likely due to stress and pain and also the leukocytosis probably can be explained by that.  This will be monitored.,5.  Monitor H&H to determine if he needs any transfusion at this time.  He does not need that.,6.  IV fluid for hydration and volume resuscitation at this time.,7.  Pain management.,8.  Topical care for the wound VAC after repair.,Time spent in evaluation and management of this patient including discussions about this procedure and the harm that can happen if he chooses to keep the penis including permanent damage and infection to the penis was 65 minutes.,I had clearly explained to the patient in detail about the possibility of permanent penile damage that could affect erection and future sexual functioning as well as significant infection if a foreign object was retained in the penis under the skin and he verbalized understanding of this.",38
"GENERAL: , Vital signs and temperature as documented in nursing notes.  The patient appears stated age and is adequately developed.,EYES:,  Pupils are equal, round, reactive to light and accommodation.  Lids and conjunctivae reveal no gross abnormality.,ENT:  ,Hearing appears adequate.  No obvious asymmetry or deformity of the ears and nose.,NECK: , Trachea midline.  Symmetric with no obvious deformity or mass; no thyromegaly evident.,RESPIRATORY:,  The patient has normal and symmetric respiratory effort.  Lungs are clear to auscultation.,CARDIOVASCULAR: , S1, S2 without significant murmur.,ABDOMEN: , Abdomen is flat, soft, nontender.  Bowel sounds are active.  No masses or pulsations present.,EXTREMITIES: , Extremities reveal no remarkable dependent edema or varicosities.,MUSCULOSKELETAL:  ,The patient is ambulatory with normal and symmetric gait.  There is adequate range of motion without significant pain or deformity.,SKIN: , Essentially clear with no significant rash or lesions.  Adequate skin turgor.,NEUROLOGICAL: , No acute focal neurologic changes.,PSYCHIATRIC:,  Mental status, judgment and affect are grossly intact and normal for age.",25
"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,POSTOPERATIVE DIAGNOSIS:,  Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,PROCEDURE PERFORMED:,1.  Injection for myelogram.,2.  Microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left on 08/28/03.,BLOOD LOSS: , Approximately 25 cc.,ANESTHESIA: , General.,POSITION:,  Prone on the Jackson table.,INTRAOPERATIVE FINDINGS:,  Extruded nucleus pulposus at the level of L5-S1.,HISTORY: , This is a 34-year-old male with history of back pain with radiation into the left leg in the S1 nerve root distribution.  The patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity.  He denied any previous history of back pain or back surgeries.  Because of his intractable pain as well as severe weakness in the S1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on.  After an informed consent was obtained, all risks as well as complications were discussed with the patient.  ,PROCEDURE DETAIL:  ,He was wheeled back to Operating Room #5 at ABCD General Hospital on 08/28/03.  After a general anesthetic was administered, a Foley catheter was inserted.,The patient was then turned prone on the Jackson table.  All of his bony prominences were well-padded.  At this time, a myelogram was then performed.  After the lumbar spine was prepped, a #20 gauge needle was then used to perform a myelogram.  The needle was localized to the level of L3-L4 region.  Once inserted into the thecal sac, we immediately got cerebrospinal fluid through the spinal needle.  At this time, approximately 10 cc of Conray injected into the thecal sac.  The patient was then placed in the reversed Trendelenburg position in order to assist with distal migration of the contrast.  The myelogram did reveal that there was some space occupying lesion, most likely disc at the level of L5-S1 on the left.  There was a lack of space filling defect on the left evident on both the AP and the lateral projections using C-arm fluoroscopy.  At this point, the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy.  A long spinal needle was then inserted into region of surgery on the right.  The surgery was going to be on the left.  Once the spinal needle was inserted, a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the L5-S1 nerve root region.  At this time, an approximately 2 cm skin incision was made over the lumbar region, dissected down to the deep lumbar fascia.  At this time, a Weitlaner was inserted.  Bovie cautery was used to obtain hemostasis.  We further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina.  A Cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left-hand side.  At this time, a Taylor retractor was then inserted and held there for retraction.  Suction as well as Bovie cautery was used to obtain hemostasis.  At this time, a small Kerrison Rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression.  Once the laminotomy was performed, a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots.  Once the ligamentum flavum was removed, we immediately identified a piece of disc material floating around outside of the disc space over the S1 nerve root, which was compressive.  We removed the extruded disc with further freeing up of the S1 nerve root.  A nerve root retractor was then placed.  Identification of disc space was then performed.  A #15 blade was then inserted and small a key hole into the disc space was then performed with a #15 blade.  A small pituitary was then inserted within the disc space and more disc material was freed and removed.  The part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc.  Once this was performed, we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free.,At this time, copious irrigation was used to irrigate the wound.  We then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur.  At this time, a small piece of Gelfoam was then used to cover the exposed nerve root.  We did not have any dural leaks during this case.  #1-0 Vicryl was then used to approximate the deep lumbar fascia, #2-0 Vicryl was used to approximate the superficial lumbar fascia, and #4-0 running Vicryl for the subcutaneous skin.  Sterile dressings were then applied.  The patient was then carefully slipped over into the supine position, extubated and transferred to Recovery in stable condition.  At this time, we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level.",37
"HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall.  Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock.  When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped.  Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker.  An ECG this morning showing normal sinus rhythm with frequent APCs.  Her potassium at that time was 3.1.  She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior.  She denies any chest pain nor shortness of breath prior to or since the fall.  She states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,PAST CARDIAC HISTORY: , She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure.  On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement.  She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative.  She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant.  She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker.  She does have a history of significant hypertension in the past.  She has had dizzy spells and denies clearly any true syncope.  She has had bradycardia in the past from beta-blocker therapy.,MEDICATIONS ON ADMISSION:,1.  Multivitamin p.o. daily.,2.  Aspirin 325 mg once a day.,3.  Lisinopril 40 mg once a day.,4.  Felodipine 10 mg once a day.,5.  Klor-Con 20 mEq p.o. b.i.d.,6.  Omeprazole 20 mg p.o. daily presumably for GERD.,7.  MiraLax 17 g p.o. daily.,8.  Lasix 20 mg p.o. daily.,ALLERGIES: , PENICILLIN.  IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST.,FAMILY HISTORY:,  She states her brother died of an MI suddenly in his 50s.,SOCIAL HISTORY: , She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs.  She is retired from Morse Chain and delivering newspapers.  She is widowed.  She lives alone but has family members who live either on her property or adjacent to it.,REVIEW OF SYSTEMS: , She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers.  She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use.  She does note occasional peripheral edema.  She is not aware of prior history of MI.  She denies diabetes.  She does have a history of GERD.  She notes feeling depressed at times because of living alone.  She denies rheumatologic conditions including psoriasis or lupus.  Remainder of review of systems is negative times 15 except as described above.,PHYSICAL EXAM:  ,Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%.  On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive.  HEENT:  Shows cranium is  normocephalic and atraumatic.  She has moist mucosal membranes.  Neck veins were not distended.  There are no carotid bruits.  Lungs:  Clear to auscultation anteriorly without wheezes.  She is relatively immobile because of her left hip fracture.  Cardiac Exam:  S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound.  There is also a soft holosystolic murmur heard.  There is no rub or gallop.  PMI is nondisplaced.  Abdomen is soft and nondistended.  Bowel sounds present.  Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema.  Pulses appear grossly intact.  Affect is appropriate.  Visible skin warm and perfused.  She is not able to move because of left hip fracture easily in bed.,DIAGNOSTIC STUDIES/LAB DATA: , Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob.  No clear pulmonary vascular congestion.  Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06.  Troponin was 0.03 followed by 0.18.  INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,EKGs are reviewed.  Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes.  She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior.  Followup EKG done this morning shows normal sinus rhythm with frequent APCs.,IMPRESSION:  ,She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery.  Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected.  There has been no atrial fibrillation documented.  I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath.  She actually describes feeling good exercise capacity prior to this fall.  Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that.  Continued optimization of electrolytes.  The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil.  The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery.  I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge.  Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist.",3
"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.",38
"FINDINGS:,High resolution computerized tomography was performed from T12-L1 to the S1 level with reformatted images in the sagittal and coronal planes and 3D reconstructions performed. COMPARISON: Previous MRI examination 10/13/2004.,There is minimal curvature of the lumbar spine convex to the left.,T12-L1, L1-2, L2-3: There is normal disc height with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints.,L3-4: There is normal disc height and non-compressive circumferential annular disc bulging eccentrically greater to the left. Normal central canal and facet joints (image #255).,L4-5: There is normal disc height, circumferential annular disc bulging, left L5 hemilaminectomy and posterior central/right paramedian broad-based disc protrusion measuring 4mm (AP) contouring the rightward aspect of the thecal sac. Orthopedic hardware is noted posteriorly at the L5 level. Normal central canal, facet joints and intervertebral neural foramina (image #58).,L5-S1: There is minimal decreased disc height, postsurgical change with intervertebral disc spacer, posterior lateral orthopedic hardware with bilateral pedicle screws in good postsurgical position. The orthopedic hardware creates mild streak artifact which mildly degrades images. There is a laminectomy defect, spondylolisthesis with 3.5mm of anterolisthesis of L5, posterior annular disc bulging greatest in the left foraminal region lying adjacent to the exiting left L5 nerve root. There is fusion of the facet joints, normal central canal and right neural foramen (image #69-70, 135).,There is no bony destructive change noted.,There is no perivertebral soft tissue abnormality.,There is minimal to mild arteriosclerotic vascular calcifications noted in the abdominal aorta and right proximal common iliac artery.,IMPRESSION:,Minimal curvature of the lumbar spine convex to the left.,L3-4 posterior non-compressive annular disc bulging eccentrically greater to the left.,L4-5 circumferential annular disc bulging, non-compressive central/right paramedian disc protrusion, left L5 laminectomy.,L5-S1 postsurgical change with posterolateral orthopedic fusion hardware in good postsurgical position, intervertebral disc spacer, spondylolisthesis, laminectomy defect, posterior annular disc bulging greatest in the left foraminal region adjacent to the exiting left L5 nerve root with questionable neural impingement.,Minimal to mild arteriosclerotic vascular calcifications.",33
"PREOPERATIVE DIAGNOSES:,1.  Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2.  Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3.  Inability to pass a Foley catheter x3.,POSTOPERATIVE DIAGNOSES:,1.  Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2.  Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3.  Inability to pass a Foley catheter x3.,PROCEDURES:,1.  Cystoscopy.,2.  Transurethral resection of the prostate (TURP).,ANESTHESIA: , General laryngeal mask.,INDICATIONS: , This patient is a 61-year-old white male who has been treated at the VA in Houston for a bladder cancer.  His history dates back to 2003 when he had a non-muscle invasive bladder cancer.  He had multiple cystoscopies and followups since that time with no evidence of recurrence.  However, on recent cystoscopy, he had what appeared to be a recurrent tumor and was taken to the operating room and had this resected with findings of a Ta grade III transitional cell carcinoma associated with carcinoma in situ.  Retrograde pyelograms were suspicious on the right and cleared with ureteroscopy and the left renal pelvic washing was positive but this may represent contamination from the lower urinary tract as radiographically, there were no abnormalities.  I had cystoscoped the patient in the office showed during the period of time when he had significant irritative burning symptoms, and there were still healing biopsy sites.  We elected to allow his bladder to recover before starting the BCG.  We were ready to do that last week but two doctors and a nurse including myself were unable to pass Foley catheter.  I repeated a cystoscopy in the office with findings of a high bladder neck and BPH.  After a lengthy discussion with the patient and his wife, we elected to proceed with TURP after a full informed consent.,FINDINGS: , At cystoscopy, there was bilobular prostatic hyperplasia and a very high riding bladder neck, which may have been the predominant cause of his difficulty catheterizing and obstructive symptoms.  There were mucosal changes on the left posterior wall in the midline suspicious for carcinoma in situ.,PROCEDURE IN DETAIL: , The patient was brought to the cystoscopy suite and after adequate general laryngeal mask anesthesia obtained and placed in the dorsal lithotomy position, his perineum and genitalia were sterilely prepped and draped in the usual fashion.  A cystourethroscopy was performed with a #23 French ACMI panendoscope and 70-degree lens with the findings as described.  We removed the cystoscope and passed a #28 French continuous flow resectoscope sheath under visual obturator after dilating the meatus to #32 French with van Buren sounds.  Inspection of bladder again was made noting the location of the ureteral orifices relative to the bladder neck.  The groove was cut at 6 o'clock to open the bladder neck to verumontanum and then the left lobe was resected from 1 o'clock to 5 o'clock.  Hemostasis was achieved, and then a similar procedure performed in the right side.  We resected the anterior stromal tissue and the apical tissue and then obtained complete hemostasis.  Chips were removed with Ellik evacuator.  There was no bleeding at the conclusion of the procedure, and the resectoscope was removed.  A #24 French three-way Foley catheter was placed with efflux of clear irrigant.  The patient was returned to the supine position, awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.",38
"SUBJECTIVE:,  The patient is a 79-year-old African-American female with a self reported height of 5 foot 3 inches and weight of 197 pounds.  She was diagnosed with type 2 diabetes in 1983.  She is not allergic to any medicines.,DIABETES MEDICATIONS:,  Her diabetes medications include Humulin insulin 70/30, 44 units at breakfast and 22 units at supper.  Also metformin 500 mg at supper.,OTHER MEDICATIONS: , Other medications include verapamil, Benicar, Toprol, clonidine, and hydrochlorothiazide.,ASSESSMENT:,  The patient and her daughter completed both days of diabetes education in a group setting.  Blood glucose records and food diaries are reviewed by the diabetes educator and the dietician.  Fasting blood sugars are 127, 80, and 80.  Two-hour postprandial breakfast reading was 105, two-hour postprandial lunch reading was 88, and two-hour postprandial dinner reading was 73 and 63.  Her diet was excellent.,Seven hours of counseling about diabetes mellitus was provided on this date.,Blood glucose values obtained at 10 a.m. were 84 and at 2.30 p.m. were 109.  Assessment of her knowledge is completed at the end of the counseling session.  She demonstrated increased knowledge in all areas and had no further questions.  She also completed an evaluation of the class.,The patient's feet were examined during the education session.  She had flat feet bilaterally.  Skin color was pink, temperature warm.  Pedal pulses 2+.  Her right second and third toes lay on each other.  Also, the same on her left foot.  However, there was no skin breakdown.  She had large bunions, medial aspect of the ball of both feet.  She had positive sensitivity to most areas of her feet, however, she had negative sensitivity to the medial and lateral aspect of the balls of her left foot.,During the education session, she set behavioral goals for self care.  First goal is to eat three meals a day and eat three snacks daily to improve her blood glucose levels.  Second goal is to eat a well balanced meal at 1200 calories in order to lose one-half pound of weight per week and improve her blood glucose control.  Third goal is to exercise by walking for 15 to 30 minutes a day, three to five days a week to increase her blood glucose control.  Her success in achieving these goals will be followed in three months by a letter from the diabetes education class.,RECOMMENDATIONS:,  Since she is doing so well with her diet changes, her blood sugars have been within normal limits and sometimes on the low side, especially considering the fact that she has low blood sugar unawareness.  She is to followup with Dr. XYZ for possible reduction in her insulin doses.",9
"TITLE OF OPERATION: , Austin bunionectomy with internal screw fixation, first metatarsal, left foot.,PREOPERATIVE DIAGNOSIS:,  Bunion deformity, left foot.,POSTOPERATIVE DIAGNOSIS: , Bunion deformity, left foot.,ANESTHESIA: , Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS: , 45 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS:,  Less than 10 mL.,MATERIALS USED: , 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, as well as a 16-mm and an 18-mm partially threaded cannulated screw from the OsteoMed Screw Fixation System.,DESCRIPTION OF THE PROCEDURE:,  The patient was brought to the operating room and placed on the operating table in a supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites.  The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg.  The left foot was then prepped, scrubbed, and draped in normal sterile technique.  The left ankle tourniquet was inflated.  Attention was then directed on the dorsomedial aspect of the first left metatarsophalangeal joint where a 6-cm linear incision was placed directly over the first left metatarsophalangeal joint parallel and medial to the course of the extensor hallucis longus tendon to the left great toe.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first left metatarsophalangeal joint.  All the tendinous neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal and capsular attachments were mobilized from the head of the first left metatarsal.  The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx of the left great toe and transversally resected from its insertion.  A lateral capsulotomy was also performed at the level of the first left metatarsophalangeal joint.  The dorsomedial prominence of the first left metatarsal head was adequately exposed using sharp dissection and resected with the use of a sagittal saw.  The same saw was used to perform an Austin-type bunionectomy on the capital aspect of the first left metatarsal head with its apex distal and its base proximal on the shaft of the first left metatarsal.  The dorsal arm of the osteotomy was longer than the plantar arm in order to accommodate for the future internal fixation.  The capital fragment of the first left metatarsal was then transposed laterally and impacted on the shaft of the first left metatarsal.  Provisional fixation was achieved with two smooth wires that were inserted vertically to the dorsal osteotomy in a dorsal distal to plantar proximal direction.  The same wires were also used as guide wires for the insertion of a 16-mm and an 18-mm partially threaded screws from the 3.0 OsteoMed System upon insertion of the screws, which was accomplished using AO technique.  The wires were removed.  Fixation on the table was found to be excellent.  Reduction of the bunion deformity was also found to be excellent and position of the first left metatarsophalangeal joint was anatomical.  The remaining bony prominence from the shaft of the first left metatarsal was then resected with a sagittal saw.  The area was copiously flushed with saline.  The periosteal and capsular tissues were approximated with 2-0 and 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues.  The incision site was reinforced with Steri-Strips.  At this time, the patient's left ankle tourniquet was deflated.  The time was 45 minutes.  Immediate hyperemia was noted to the entire right lower extremity upon deflation of the cuff.  The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and an Ace bandage.  The patient's left foot was then placed in a surgical shoe.  The patient was then transferred to the recovered room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels.  The patient was given pain medication and instructions on how to control her postoperative course.  The patient was discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X in one week's time for her first postoperative appointment.",37
"SUBJECTIVE:,  This is a 6-year-old male who comes in rechecking his ADHD medicines.  We placed him on Adderall, first time he has been on a stimulant medication last month.  Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine.  She has two concerns.  It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in.  It wears off about 2 and they have problems in the evening with him.  He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off.  His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible.  The patient even commented that he thought he needed his medication.,PAST HISTORY:,  Reviewed from appointment on 08/16/2004.,CURRENT MEDICATIONS:,  He is on Adderall XR 10 mg once daily.,ALLERGIES: , To medicines are none.,FAMILY AND SOCIAL HISTORY:,  Reviewed from appointment on 08/16/2004.,REVIEW OF SYSTEMS:,  He has been having problems as mentioned in the morning and later in the afternoon but he has been eating well, sleeping okay.  Review of systems is otherwise negative.,OBJECTIVE:,  Weight is 46.5 pounds, which is down just a little bit from his appointment last month.  He was 49 pounds, but otherwise, fairly well controlled, not all that active in the exam room.  Physical exam itself was deferred today because he has otherwise been very healthy.,ASSESSMENT:,  At this point is attention deficit hyperactivity disorder, doing fairly well with the Adderall.,PLAN:,  Discussed with mother two options.  Switch him to the Ritalin LA, which I think has better release of the medicine early in the morning or to increase his Adderall dose.  As far as the afternoon, if she really wanted him to be on the medication, we will do a small dose of the Adderall, which she would prefer.  So I have decided at this point to increase him to the Adderall XR 15 mg in the morning and then Adderall 5 mg in the afternoon.  Mother is to watch his diet.  We would like to recheck his weight if he is doing very well, in two months.  But if there are any problems, especially in the morning then we would do the Ritalin LA.  Mother understands and will call if there are problems.  Approximately 25 minutes spent with patient, all in discussion.",32
"INDICATIONS:  ,Chest pain, hypertension, type II diabetes mellitus.,PROCEDURE DONE:,  Dobutamine Myoview stress test.,STRESS ECG RESULTS:,  The patient was stressed by dobutamine infusion at a rate of 10 mcg/kg/minute for three minutes, 20 mcg/kg/minute for three minutes, and 30 mcg/kg/minute for three additional minutes.  Atropine 0.25 mg was given intravenously eight minutes into the dobutamine infusion.  The resting electrocardiogram reveals a regular sinus rhythm with heart rate of 86 beats per minute, QS pattern in leads V1 and V2, and diffuse nonspecific T wave abnormality.  The heart rate increased from 86 beats per minute to 155 beats per minute, which is about 90% of the maximum predicted target heart rate.  The blood pressure increased from 130/80 to 160/70.  A maximum of 1 mm J-junctional depression was seen with fast up sloping ST segments during dobutamine infusion.  No ischemic ST segment changes were seen during dobutamine infusion or during the recovery process.,MYOCARDIAL PERFUSION IMAGING:,  Resting myocardial perfusion SPECT imaging was carried out with 10.9 mCi of Tc-99m Myoview.  Dobutamine infusion myocardial perfusion imaging and gated scan were carried out with 29.2 mCi of Tc-99m Myoview.  The lung heart ratio is 0.36.  Myocardial perfusion images were normal both at rest and with stress.  Gated myocardial scan revealed normal regional wall motion and ejection fraction of 67%.,CONCLUSIONS:,1.  Stress test is negative for dobutamine-induced myocardial ischemia.,2.  Normal left ventricular size, regional wall motion, and ejection fraction.",33
"PREOPERATIVE DIAGNOSIS:,  Chronic tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis.,PROCEDURE:  ,Tonsillectomy.,DESCRIPTION OF PROCEDURE: , Under general orotracheal anesthesia, a Crowe-Davis mouth gag was inserted and suspended.  Tonsils were removed by electrocautery dissection and the tonsillar beds were injected with Marcaine 0.25% plain.  A catheter was inserted in the nose and brought out from mouth.  The throat was irrigated with saline.  There was no further bleeding.  The patient was awakened and extubated and moved to the recovery room in satisfactory condition.",11
"REASON FOR CONSULTATION:, Regarding weakness and a history of polymyositis.,HISTORY OF PRESENT ILLNESS:, The patient is an 87-year-old white female who gives a history of polymyositis diagnosed in 1993. The patient did have biopsy of the quadriceps muscle performed at that time which, per her account, did show an abnormality. She was previously followed by Dr. C, neurology, over several years but was last followed up in the last three to four years. She is also seeing Dr. R at rheumatology in the past. Initially, she was treated with steroids but apparently was intolerant of that. She was given other therapy but she is unclear of the details of that. She has had persistent weakness of the bilateral lower extremities and has ambulated with the assistance of a walker for many years. She has also had a history of spine disease though the process there is not known to me at this time.,She presented on February 1, 2006 with productive cough, fevers and chills, left flank rash and pain there as well as profound weakness. Since admission, she has been diagnosed with a left lower lobe pneumonic process as well as shingles and is on therapy for both. She reports that strength in the proximal upper extremities has remained good. However, she has no grip strength. Apparently, this has been progressive over the last several years as well. She also presently has virtually no strength in the lower extremities and that is worse within the last few days. Prior to admission, she has had cough with mild shortness of breath. Phlegm has been dark in color. She has had reflux and occasional dysphagia. She has also had constipation but no other GI issues. She has no history of seizure or stroke like symptoms. She occasionally has headaches. No vision changes. Other than the left flank skin changes, she has had no other skin issues. She does have a history of DVT but this was 30 to 40 years ago. No history of dry eyes or dry mouth. She denies chest pain at present.,PAST MEDICAL AND SURGICAL HISTORY:, Hysterectomy, cholecystectomy, congestive heart failure, hypertension, history of DVT, previous colonoscopy that was normal, renal artery stenosis.,MEDICATIONS:, Medications prior to admission: Os-Cal, Zyrtec, potassium, Plavix, Bumex, Diovan.,CURRENT MEDICATIONS:, Acyclovir, azithromycin, ceftriaxone, Diovan, albuterol, Robitussin, hydralazine, Atrovent.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, She is a widow. She has 8 children that are healthy with the exception of one who has coronary artery disease and has had bypass. She also has a son with lumbar spine disease. No tobacco, alcohol or IV drug abuse.,FAMILY HISTORY:, No history of neurologic or rheumatologic issues.,REVIEW OF SYSTEMS:, As above.,PHYSICAL EXAMINATION:,VITAL SIGNS: She is afebrile. Current temperature 98. Respirations 16, heart rate 80 to 90. Blood pressure 114/55.,GENERAL APPEARANCE: She is alert and oriented and in no acute distress. She is pleasant. She is reclining in the bed.,HEENT: Pupils are reactive. Sclera are clear. Oropharynx is clear.,NECK: No thyromegaly. No lymphadenopathy.,CARDIOVASCULAR: Heart is regular rate and rhythm.,RESPIRATORY: Lungs have a few rales only.,ABDOMEN: Positive bowel sounds. Soft, nontender, nondistended. No hepatosplenomegaly.,EXTREMITIES: No edema.,SKIN: Left flank dermatome with vesicular rash that is red and raised consistent with zoster.,JOINTS: No synovitis anywhere. Strength is 5/5 in the proximal upper extremities. Proximal lower extremities are 0 out of 5. She has no grip strength at present.,NEUROLOGICAL: Cranial nerves II through XII grossly intact. Reflexes 2/4 at the biceps, brachial radialis, triceps. Nil out of four at the patella and Achilles bilaterally. Sensation seems normal. Chest x-ray shows COPD, left basilar infiltrate, cardiomegaly, atherosclerotic changes.,LABORATORY DATA:, White blood cell count 6.1, hemoglobin 11.9, platelets 314,000. Sed rate 29 and 30. Electrolytes: Sodium 134, potassium 4.9, creatinine 1.2, normal liver enzymes. TSH is slightly elevated at 5.38. CPK 36, BNP 645. Troponin less than 0.04.,IMPRESSION:,1. The patient has a history of polymyositis, apparently biopsy proven with a long standing history of bilateral lower extremity weakness. She has experienced dramatic worsening in the last 24 hours of the lower extremity weakness. This in the setting of an acute illness, presumably a pneumonic process.,2. She also gives a history of spine disease though the details of that process are not available either.,The question raised at this time is of recurrence in inflammatory myopathy which would need to include not only polymyositis but also inclusion body myositis versus progressive spine disease versus weakness secondary to acute illness versus neuropathic process versus other.,3. Zoster of the left flank.,4. Left lower lobe pneumonic process.,5. Elevation of the thyroid stimulating hormone.,RECOMMENDATIONS:,1. I have asked Dr. C to see the patient and he has done so tonight. He is planning for EMG nerve conduction study in the morning.,2. I would consider further spine evaluation pending review of the EMG nerve conduction study.,3. Agree with supportive care being administered thus far and will follow along with you.",5
"Chief Complaint:, coughing up blood and severe joint pain.,History of Present Illness:,  The patient is a 37 year old African American woman with history of chronic allergic rhinitis who presents to an outpatient clinic with severe pain in multiple joints and hemoptysis for 1 day. The patient was at her baseline state of health until 2 months prior to admission when her usual symptoms of allergic rhinitis worsened. In addition to increased nasal congestion and drainage, she also began having generalized fatigue, malaise, and migratory arthralgias involving bilateral wrists, shoulders, elbows, knees, ankles, and finger joints. She also had intermittent episodes of swollen fingers that prevented her from making a fist. Patient denied recent flu-like illness, fever, chills, myalgias, or night sweats. Four weeks after the onset of arthralgias patient developed severe bilateral eye dryness and redness without any discharge. She was evaluated by an ophthalmologist and diagnosed with conjunctivitis. She was given eye drops that did not relieve her eye symptoms. Two weeks prior to admission patient noted the onset of rust colored urine. No bright red blood or clots in the urine. She denied having dysuria, decreased urine output, abdominal pain, flank pain, or nausea/vomiting. Patient went to a community ER, and had a CT Scan of the abdomen that was negative for kidney stones. She was discharged from the ER with Bactrim for possible UTI. During the next week patient had progressively worsening arthralgias to the point where she could hardly walk. On the day of admission, she developed a cough productive of bright red blood associated with shortness of breath and nausea, but no chest pain or dizziness. This prompted the patient to go see her primary care physician. After being seen in clinic, she was transferred to St. Luke’s Episcopal Hospital for further evaluation.,Past Medical History:, Allergic rhinitis, which she has had for many years and treated with numerous medications. No history of diabetes, hypertension, or renal disease. No history tuberculosis, asthma, or upper airway disease.,Past Surgical History:, Appendectomy at age 21. C-Section 8 years ago.,Ob/Gyn: G2P2; last menstrual period 3 weeks ago. Heavy menses due to fibroids.,Social History:, Patient is married and lives with her husband and 2 children. Works in a business office. Denies any tobacco, alcohol, or illicit drug use of any kind. No history of sexually transmitted diseases. Denies exposures to asbestos, chemicals, or industrial gases. No recent travel. No recent sick contacts.,Family History:, Mother and 2 maternal aunts with asthma. No history of renal or rheumatologic diseases.,Medications:, Allegra 180mg po qd, Zyrtec 10mg po qd, Claritin 10mg po qd,No herbal medication use.,Allergies:, No known drug allergies.,Review of systems:, No rashes, headache, photophobia, diplopia, or oral ulcers. No palpitations, orthopnea or PND. No diarrhea, constipation, melena, bright red blood per rectum, or pale stool. No jaundice. Decreased appetite, but no weight loss.,Physical Examination:,VS: T 100.2F BP 132/85 P 111 RR 20 O2 Sat 95% on room air,GEN: Well-developed woman in no apparent distress.,SKIN: No rashes, nodules, ecchymoses, or petechiae.,LYMPH NODES: No cervical, axillary, or inguinal lymphadenopathy.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric sclerae. Erythematous sclerae and pale conjunctivae. Dry mucous membranes. No oropharyngeal lesions. Bilateral tympanic membranes clear. No nasal deformities.,NECK: Supple. No increased jugular venous pressure. No thyromegaly.,CHEST: Decreased breath sounds throughout bilateral lung fields with occasional diffuse crackles. No wheezes or rales.,CV: Tachycardic. Regular rhythm. No murmurs, gallops, or rubs.,ABDOMEN: Soft with normal active bowel sounds. Non-distended and non-tender. No masses palpated. No hepatosplenomegaly.,RECTAL: Brown stool. Guaiac negative.,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally. Tenderness and mild swelling of bilateral wrists, MCPs and PIPs with decreased range of motion and grip function. Bilateral wrists warm without erythema. Bilateral elbows, knees, and ankles tender to palpation with decreased range of motion, but no erythema, warmth, or swelling of these joints.,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation are within normal limits.,STUDIES:,Chest X-ray (10/03):,Suboptimal inspiratory effort. No evidence of pneumonic consolidation, pleural effusion, pneumothorax, or pulmonary edema. Cardiomediastinal silhouette is unremarkable.,CT Scan of Chest (10/03):,Prominence of the bronchovascular markings bilaterally with a nodular configuration. There are mixed ground glass interstitial pulmonary infiltrates throughout both lungs with a perihilar predominance. Aortic arch is of normal caliber. The pulmonary arteries are of normal caliber. There is right paratracheal lymphadenopathy. There is probable bilateral hilar lymphadenopathy. Trachea and main stem bronchi are normal. The heart is of normal size.,Renal Biopsy:,Microscopic Description : Ten glomeruli are present. There are crescents in eight of the glomeruli. Some of the glomeruli show focal areas of apparent necrosis with fibrin formation. The interstitium consists of a fairly dense infiltrate of lymphocytes, plasma cells with admixed eosinophils. The tubules for the most part are unremarkable. No vasculitis is identified.,Immunofluorescence Description : There are no staining for IgG, IgA, IgM, C3, Kappa, Lambda, C1q, or albumin.,Electron Microscopic Description : Mild to moderate glomerular, tubular, and interstitial changes. Mesangium has multifocal areas with increased matrix and cells. There is focal mesangial interpositioning with the filtration membrane. Interstitium has multifocal areas with increased collagen. There are focal areas with interstitial aggregate of fibrin. Within the collagen substrate are infiltrates of lymphocytes, plasma cells, eosinophils, and macrophages. The glomerular sections evaluated show no electron-dense deposits in the filtration membrane or mesangium.,Microscopic Diagnosis: Pauci-immune crescentic glomerulonephritis with eosinophilic interstitial infiltrate.",5
"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.",14
"PREOPERATIVE DIAGNOSIS:,  Right superior parathyroid adenoma.,POSTOPERATIVE DIAGNOSIS:,  Right superior parathyroid adenoma.,PROCEDURE: , Excision of right superior parathyroid adenoma.,ANESTHESIA:,  Local with 1% Xylocaine and anesthesia standby with sedation.,CLINICAL HISTORY:,  This 80-year-old woman has had some mild dementia.  She was begun on Aricept but could not tolerate that because of strange thoughts and hallucinations.  She was found to be hypercalcemic.  Intact PTH was mildly elevated.  A sestamibi parathyroid scan and an ultrasound showed evidence of a right superior parathyroid adenoma.,FINDINGS AND PROCEDURE:,  The patient was placed on the operating table in the supine position.  A time out was taken so that the anesthesia personnel, nursing personnel, surgical team, and patient could confirm the patient's identity, operative site and operative plan.  The electronic medical record was reviewed as was the ultrasound.  The patient was sedated.  A small roll was placed behind the shoulders to moderately hyperextend the neck.  The head was supported in a foam head cradle.  The neck and chest were prepped with chlorhexidine and isolated with sterile drapes.  After infiltration with 1% Xylocaine with epinephrine along the planned incision, a transverse incision was made in the skin crease a couple of centimeters above the clavicular heads and carried down through the skin, subcutaneous tissue, and platysma.  The larger anterior neck veins were divided between 4-0 silk ligatures.  Superior and inferior flaps were developed in the subplatysmal plane using electrocautery and blunt dissection.  The sternohyoid muscles were separated in the midline, and the right sternohyoid muscle was retracted laterally.  The right sternothyroid muscle was divided transversely with the cautery.  The right middle thyroid vein was divided between 4-0 silk ligatures.  The right thyroid lobe was rotated leftward.  Posterior to the mid portion of the left thyroid lobe, a right superior parathyroid adenoma of moderate size was identified.  This was freed up and its pedicle was ligated with small Hemoclips and divided and the gland was removed.  It was sent for weight and frozen section.  It weighed 960 mg and on frozen section was consistent with a parathyroid adenoma.,Prior to the procedure, a peripheral blood sample had been obtained and placed in a purple top tube labeled ""pre-excision.""  It was our intention to monitor intraoperative intact parathyroid hormone 10 minutes after removal of this parathyroid adenoma.  However, we could not obtain 3 cc of blood from either the left foot or the left arm after multiple attempts, and therefore, we decided that the chance of cure of hyperparathyroidism by removal of this parathyroid adenoma was high enough and the improvement in that chance of cure marginal enough that we would terminate the procedure without monitoring PTH.  The neck was irrigated with saline and hemostasis found to be satisfactory.  The sternohyoid muscles were reapproximated with interrupted 4-0 Vicryl.  The platysma was closed with interrupted 4-0 Vicryl, and the skin was closed with subcuticular 5-0 Monocryl and Dermabond.  The patient was awakened and taken to the recovery area in satisfactory condition having tolerated the procedure well.",37
"He has no voiding complaints and no history of sexually transmitted diseases.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , Back surgery with a fusion of L5-S1.,MEDICATIONS: , He does take occasional Percocet for his back discomfort.,ALLERGIES:,  HE HAS NO ALLERGIES.,SOCIAL HISTORY:,  He is a smoker.  He takes rare alcohol.  His employment is that he does dynamite work and actually putting in the dynamite in large holes for destroying ground to that pipeline can be laid.  He travels to anywhere for his work.  He is married with one son.,FAMILY HISTORY: , Negative for prostate cancer, kidney cancer, bladder cancer, enlarged prostate or kidney disease.,REVIEW OF SYSTEMS:,  Negative for tremors, headaches, dizzy spells, numbness, tingling, feeling hot or cold, tired or sluggishness, abdominal pain, nausea or vomiting, indigestion, heartburn, fevers, chills, weight loss, wheezing, frequent cough, shortness of breath, chest pain, varicose veins, high blood pressure, skin rash, joint pain, ear infections, sore throat, sinus problems, hay fever, blood clotting problems, depressive affect or eye problems.,PHYSICAL EXAMINATION,GENERAL:  The patient is afebrile.  His vital signs are stable.  He is 177 pounds, 5 feet, 8 inches.  Blood pressure 144/66.  He is healthy appearing.  He is alert and oriented x 3.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  Soft and nontender.  His penis is circumcised.  He has a pedunculated cauliflower-like lesion on the dorsum of the penis at approximately 12 o'clock.  It is very obvious and apparent.  He also has a mildly raised brown lesion that the patient states has been there ever since he can remember and has not changed in size or caliber.  His testicles are descended bilaterally.  There are no masses.,ASSESSMENT AND PLAN: , This is likely molluscum contagiosum (genital warts) caused by HPV.  I did state to the patient that this is likely a viral infection that could have had a long incubation period.  It is not clear where this came from but it is most likely sexually transmitted.  He is instructed that he should use protected sex from this point on in order to try and limit the transmission.  Regarding the actual lesion itself, I did mention that we could apply a cream of Condylox, which could take up to a month to work.  I also offered him C02 laser therapy for the genital warts, which is an outpatient procedure.  The patient is very interested in something quick and effective such as a CO2 laser procedure.  I did state that the recurrence rate is significant and somewhere as high as 20% despite enucleating these lesions.  The patient understood this and still wished to proceed.  There is minimal risk otherwise except for those inherent in laser injury and accidental injury.  The patient understood and wished to proceed.",5
"PREOPERATIVE DIAGNOSES: , Colon cancer screening and family history of polyps.,POSTOPERATIVE DIAGNOSIS:,  Colonic polyps.,PROCEDURE:,  Colonoscopy.,ANESTHESIA:,  MAC,DESCRIPTION OF PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  The preparation was excellent and all surfaces were well seen.  The mucosa was normal throughout the colon and in the terminal ileum.  Two polyps were identified and were removed.  The first was a 7-mm sessile lesion in the mid transverse colon at 110 cm, removed with the snare without cautery and retrieved.  The second was a small 4-mm sessile lesion in the sigmoid colon at 20 cm also removed with the snare and retrieved.  No other lesions were identified.  Numerous diverticula were found in the sigmoid colon.  A retroflex through the anorectal junction showed moderate internal hemorrhoids.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Sigmoid diverticulosis.,2.  Colonic polyps in the transverse colon and sigmoid colon, benign appearance, removed.,3.  Internal hemorrhoids.,4.  Otherwise normal colonoscopy to the terminal ileum.,RECOMMENDATIONS:,1.  Follow up biopsy report.,2.  Follow up with Dr. X as needed.,3.  Screening colonoscopy in 5 years.",14
"CHIEF COMPLAINT:,  Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions).  One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake.  His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion.  He sleeps well, but has been more tired and has been fussy over the past 2 days.  The parents noticed no improvement with albuterol treatments given in the ER.  His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours.  Mom denies any diarrhea.  His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne.  The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count.  This tap was reported as clear, then turning bloody in nature.  The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture.  This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status.  Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness.  Mom's nipples are currently cracked and bleeding.  Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area.  He is status post a circumcision.  Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section.  Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family).  GBS status was negative.  Mom smoked up to the last 5 months of the pregnancy.  Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions.  Mom and baby were both discharged out of the hospital last 48 hours.  This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:,  Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  Tylenol.,IMMUNIZATIONS:,  None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:,  At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother.  Both brothers at home are sick with cold symptoms including diarrhea and vomiting.  The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription.  A nephew of the mom with an ear infection.  Mom also states that she herself was sick with the flu soon after delivery.  There has been recent travel exposure to dad's family over the Christmas holidays.  At this time, there is also exposure to indoor cats and dogs.  This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker.  There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION:  ,VITALS:  Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air.  Weight was 4.1 kg.,GENERAL:  Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT:  Normocephalic, atraumatic head.  Anterior fontanelle was soft, open, and flat.  Bilateral red reflexes were positive.  Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR:  Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature.  Capillary refill was less than 3 seconds.,LUNGS:  Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN:  Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly.  Umbilical site was with scant dried yellow discharge.,GU:  Tanner stage 1 male, circumcised.  There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS:  Negative Barlow or Ortolani maneuvers.,SKIN:  Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes.  The hemoglobin was 14.4, hematocrit was 40.  The platelet count was elevated at 698,000.  A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89.  A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1.  Rule out sepsis.,2.  Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever.  The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria.  We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER.  Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV.  The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use.  Also, there is negative apnea in this patient.,PLAN:  ,1.  We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2.  We will follow up with his blood, urine, and CSF cultures.",29
"PREOPERATIVE DIAGNOSIS:,  Mass lesion, right upper extremity.,POSTOPERATIVE DIAGNOSIS: , Intramuscular lipoma, right arm, approximately 4 cm.,PROCEDURE PERFORMED:  ,Excision of intramuscular lipoma with flap closure by Dr. Y.,INDICATIONS FOR PROCEDURE:  ,This is a 77-year-old African-American female who presents as an outpatient to the General Surgical Service with a mass in the anterior aspect of the mid-biceps region of the right upper extremity.  The mass has been increasing in size and symptoms according to the patient.  The risks and benefits of the surgical excision were discussed.  The patient gave informed consent for surgical removal.,GROSS FINDINGS: , At the time of surgery, the patient was found to have intramuscular lipoma within the head of the biceps.  It was removed in its entirety and submitted to Pathology for appropriate analysis.,PROCEDURE: , The patient was taken to the operating room.  She was given intravenous sedation and the arm area was sterilely prepped and draped in the usual fashion.  Xylocaine was utilized as local anesthetic and a longitudinal incision was made in the axis of the extremity.  The skin and subcutaneous tissue were incised as well as the muscular fascia.  The fibers of the biceps were divided bluntly and retracted.  The lipoma was grasped with an Allis clamp and blunt and sharp dissection was utilized to remove the mass without inuring the underlying neurovascular structures.  The mass was submitted to Pathology.  Good hemostasis was seen.  The wound was irrigated and closed in layers.  The deep muscular fascia was reapproximated with #2-0 Vicryl suture.,The subcutaneous tissues were reapproximated with #3-0 Vicryl suture and the deep dermis was reapproximated with #3-0 Vicryl suture.  Re-approximated wound flaps without tension and the skin was closed with #4-0 undyed Vicryl in running subcuticular fashion.  The patient was given wound care instructions and will follow up again in my office in one week.  Overall prognosis is good.",37
"PREOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,POSTOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,OPERATION: , Removal of an ingrown part of the left big toenail with excision of the nail matrix.,DESCRIPTION OF PROCEDURE:  ,After obtaining informed consent, the patient was taken to the minor OR room and intravenous sedation with morphine and Versed was performed and the toe was blocked with 1% Xylocaine after having been prepped and draped in the usual fashion.  The ingrown part of the toenail was freed from its bed and removed, then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail.  The matrix was excised down to the bone and then the skin flap was placed over it.  Hemostasis had been achieved with a cautery.  A tubular dressing was performed to provide a bulky dressing.,The patient tolerated the procedure well.  Estimated blood loss was negligible.  The patient was sent back to Same Day Surgery for recovery.",27
"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.",37
"PREOPERATIVE DIAGNOSIS: , Renal failure.,POSTOPERATIVE DIAGNOSIS:,  Renal failure.,OPERATION PERFORMED: , Insertion of peritoneal dialysis catheter.,ANESTHESIA: , General.,INDICATIONS:  ,This 14-year-old young lady is in the renal failure and in need of dialysis.  She had had a previous PD catheter placed, but it became infected and had to be removed.  She, therefore, comes back to the operating room for a new PD catheter.,OPERATIVE PROCEDURE:  ,After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner.  A small transverse right upper quadrant incision was made and carried down through the skin and subcutaneous tissue with sharp dissection.  The fascia was divided and the posterior fascia and peritoneum were identified.  A hole was made in the posterior fascia through the peritoneum and into the peritoneal cavity.  The omentum came up through the hole and so therefore the omentum was actually brought up and a small portion of it removed, which could easily be brought up through the incision.  A PD catheter was then placed into the pelvis over a guidewire.  At this point, the peritoneum and posterior fascia was closed around the catheter.  The anterior fascia was then closed over the top of the cuff leaving the cuff buried in the fascia.  The second incision was then made lateral and the catheter brought out through a second incision and the subcutaneous cuff then positioned at that site.  The catheter was then connected and two runs of a 150 mL of fluid were made with a good inflow and a good clear return.  The skin was closed with 5-0 subcuticular Monocryl.  Sterile dressings were applied and the young lady awakened and taken to the recovery room in satisfactory condition.",37
"OPERATION PERFORMED:,  Full mouth dental rehabilitation in the operative room under general anesthesia.,PREOPERATIVE DIAGNOSIS: , Severe dental caries.,POSTOPERATIVE DIAGNOSES:,1.  Severe dental caries.,2.  Non-restorable teeth.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: , 43 minutes.,BRIEF HISTORY:  ,The patient was first seen by me on 04/26/2007.  She had a history of open heart surgery at 11 months' of age.  She presented with severe anterior caries with most likely dental extractions needed.  Due to her young age, I felt that she would be best served in the safety of the hospital operating room.  After consultation with the mother, she agreed to have her treated in the safety of the hospital operating room at Children's Hospital.,OPERATIVE PREPARATION:  ,This child was brought to Hospital Day Surgery and is accompanied by her mother.  There I met with them and discussed the needs of the child, types of restorations to be performed, the risks and benefits of the treatment as well as the options and alternatives of the treatment.  After all their questions and concerns were addressed, I gave the informed consent to proceed with the treatment.  The patient's history and physical examination was reviewed.  Once she was cleared by Anesthesia and the child was taken back to the operating room.,OPERATIVE PROCEDURE:  ,The patient was placed on the surgical table in the usual supine position with all extremities protected.  Anesthesia was induced by mask.  The patient was then intubated with a nasal endotracheal tube and the tube was stabilized.  The head was wrapped and the eyes were taped shut for protection.  An angiocatheter was placed in the left hand and an IV was started.  The head and neck were draped with sterile towels, and the body was covered with a lead apron and sterile sheath.  A moist continuous throat pack was placed beyond the tonsillar pillars.  Plastic lip and cheek retractors were then placed.  Preoperative clinical photographs were taken.  Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiography.  After the radiographs were taken, the lead shield was removed.  Prophylaxis was then performed using prophy cup and fluoridated prophy paste.  The teeth were then rinsed well and the patient's oral cavity was suctioned clean.  Clinical and radiographic examinations followed and areas of decay were noted.  During the restorative phase, these areas of decay were entered into and removed.  Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it.  Final caries was removed and was confirmed upon reaching hard, firm sounding dentin.  Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement.  Non-restorable primary teeth would be extracted.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  The original treatment plan was verified with the actual treatment provided.  Postoperative clinical photographs were then taken.  The continuous gauze throat pack was removed with continuous suction with visualization.  Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room and taken to the recovery room breathing spontaneously with stable vital signs.,FINDINGS:  ,This young patient presented with mild generalized marginal gingivitis secondary to light generalized plaque accumulation and fair oral hygiene.  All primary teeth were present.  Dental caries were present on the following teeth:  Tooth D, E, F, and G caries on all surfaces; teeth J, lingual caries.  The remainder of her teeth and soft tissues were within normal limits.  The following restorations and procedures were performed:  Tooth D, E, F, and G were extracted and four sutures were placed one at each extraction site and tooth J lingual amalgam.,CONCLUSION:  ,The mother was informed of the completion of the procedure.  She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care.  They will contact to my office in the event of immediate postoperative complications.  After full recovery, she was discharged from the recovery room in the care of her mother.",7
"PREOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.  This patient is obtunded, intubated, and septic.  This is an emergent procedure with 2-physician emergency consent signed and on the chart.,PROCEDURE: , The patient's right chest was prepped and draped in sterile fashion.  The site of insertion was anesthetized with 1% Xylocaine, and an incision was made.  Blunt dissection was carried out 2 intercostal spaces above the initial incision site.  The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly.  The chest tube was placed.,A postoperative chest x-ray is pending at this time.,The patient tolerated the procedure well and was taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  10 mL,COMPLICATIONS:,  None.,SPONGE COUNT: , Correct x2.",37
"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.,",36
"CHIEF COMPLAINT:,  Right ear pain with drainage.,HISTORY OF PRESENT ILLNESS:,  This is a 12-year-old white male here with his mother for complaints of his right ear hurting.  Mother states he has been complaining for several days.  A couple of days ago she noticed drainage from the right ear.  The patient states it has been draining for several days and it has a foul smell to it.  He has had some low-grade fever.  The patient was seen in the office about a week ago with complaints of a sore throat, headache and fever.  The patient was evaluated for Strep throat which was negative and just had been doing supportive care.  He did have a recent airplane ride a couple of weeks ago also.  There has been no cough, shortness of breath or wheezing.  No vomiting or diarrhea.,PHYSICAL EXAM:,General:  He is alert in no distress.,Vital Signs:  Temperature:  99.1 degrees.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  The left TM is clear.  The right TM is poorly visualized secondary to purulent secretions in the right ear canal.  There is no erythema of the ear canals.  Nares is patent.  Oropharynx is clear.  The patient does wear braces.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,ASSESSMENT:,1.  Right otitis media.,2.  Right otorrhea.,PLAN:,  Ceftin 250 mg by mouth twice a day for 10 days.  Ciprodex four drops to the right ear twice a day.  The patient is to return to the office in two weeks for followup.",11
"PREOPERATIVE DIAGNOSIS: , Chronic plantar fasciitis, right foot.,POSTOPERATIVE DIAGNOSIS:,  Chronic plantar fasciitis, right foot.,PROCEDURE: , Open plantar fasciotomy, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY:,  The patient has had a longstanding history of foot problems.  The foot problem has been progressive in nature and has not been responsive to conservative care despite multiple attempts at conservative care.  The preoperative discussion with the patient including alternative treatment options, the procedure itself was explained, and risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, falling arch, digital contracture, and the postoperative management were discussed.  The patient has been advised, although no guarantee for success could be given, most of the patients have improved function and less pain.  All questions were thoroughly answered.  The patient requested for surgical repair since the problem has reached a point to interfere with normal daily activities.  The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF THE PROCEDURE:  ,The patient was given 1 g Ancef for antibiotic prophylaxis 30 minutes prior to the procedure.  The patient was brought to the operating room and placed in the supine position.  Following a light IV sedation, a posterior tibial nerve block and local infiltrate of the operative site was performed with 10 mL, and a 1:1 mixture of 1% lidocaine with epinephrine, and 0.25% Marcaine was affected.  The lower extremity was prepped and draped in the usual sterile manner.  Balance anesthesia was obtained.,PROCEDURE:, Plantar fasciotomy, right foot.  The plantar medial tubercle of the calcaneus was palpated and a vertical oblique incision, 2 cm in length with the distal aspect overlying the calcaneal tubercle was affected. Blunt dissection was carried out to expose the deep fascia overlying the abductor hallucis muscle belly and the medial plantar fascial band.  A periosteal elevator did advance laterally across the inferior aspect of the medial and central plantar fascial bands, creating a small and narrow soft tissue tunnel.  Utilizing a Metzenbaum scissor, transection of the medial two-third of the plantar fascia band began at the junction of the deep fascia of the abductor hallucis muscle belly and medial plantar fascial band, extending to the lateral two-thirds of the band.  The lateral plantar fascial band was left intact.  Visualization and finger probe confirmed adequate transection.  The surgical site was flushed with normal saline irrigation.,The deep layer was closed with 3-0 Vicryl and the skin edges coapted with combination of 1 horizontal mattress and simples.  The dressing consisted of Adaptic, 4 x 4, conforming bandages, and an ACE wrap to provide mild compression.  The patient tolerated the procedure and anesthesia well, and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact.  A walker boot was dispensed and applied.  The patient will be allowed to be full weightbearing to tolerance, in the boot to encourage physiological lengthening of the release of plantar fascial band.,The next office visit will be in 4 days.  The patient was given prescriptions for Keflex 500 mg 1 p.o. three times a day x10 days and Lortab 5 mg #40, 1 to 2 p.o. q.4-6 h. p.r.n. pain, 2 refills, along with written and oral home instructions.  After a short recuperative period, the patient was discharged home with vital signs stable and in no acute distress.",27
"SUBJECTIVE:,  The patient is a 33-year-old black male who comes in to the office today main complaint of sexual dysfunction.  Patient reports that he would like to try Cialis to see if it will improve his erectile performance.  Patient states that he did a quiz on-line at the Cialis web site and did not score in the normal range, so he thought he should come in.  Patient states that perhaps his desire has been slightly decreased, but that has not been the primary problem.  In discussing with me directly, patient primarily expresses that he would like to have his erections last longer.  However, looking at the quiz as he filled it out, he reported that much less than half the time was he able to get erections during sexual activity and only about half of the time he was able to maintain his erection after penetration.  However, he only reports that it is slightly difficult to maintain the erection until completion of intercourse.  Patient has no significant past medical history.  He has never had any previous testicular infections.  He denies any history of injuries to the groin and he has never been told that he has a hernia.,CURRENT MEDICATIONS:,  None.,ALLERGIES: , No drug allergies.,SOCIAL: , Only occasionally drinks alcohol and he is a nonsmoker.  He currently is working as a nurse aid, second shift, at a nursing home.  He states that he did not enroll in Wichita State this semester.  Stating he just was tired and wanted to take some time off.  He states he is in a relationship with one partner and denies any specific stress in the relationship.,OBJECTIVE:,General:  He appears in no distress.,Vital Signs:  Blood pressure:  With large cuff is 120/90.,Lungs:  Clear to auscultation.,Cardiovascular:  Normal S1-S2 without murmur.,Abdomen:  Soft, nontender.  Femoral pulses are 2+.,GU:  Testicles descended bilaterally.  No evidence of masses.  No evidence of inguinal hernias.,ASSESSMENT:,  Sexual dysfunction.,PLAN:,  We will check a free and total testosterone level as he does note some diminished desire.  He was given a sample of Cialis 10 mg with instructions on usage and a prescription for that if that is successful.  He will follow up here p.r.n.  Lastly, I did give him a blood pressure recording card, as his blood pressure is borderline today.  He will have that checked weekly at his workplace and follow up if they remain elevated.",34
"HISTORY: , The patient is a 34-year-old right-handed female who states her symptoms first started after a motor vehicle accident in September 2005.  She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision, which lasted about a week and then resolved.  Since that time she has had right low neck pain and left low back pain.  She has been extensively worked up and treated for this.  MRI of the C & T spine and LS spine has been normal.  She has improved significantly, but still complains of pain.  In June of this year she had different symptoms, which she feels are unrelated.  She had some chest pain and feeling of tightness in the left arm and leg and face.  By the next morning she had numbness around her lips on the left side and encompassing the whole left arm and leg.  Symptoms lasted for about two days and then resolved.  However, since that time she has had intermittent numbness in the left hand and leg.  The face numbness has completely resolved.  Symptoms are mild.  She denies any previous similar episodes.  She denies associated dizziness, vision changes incoordination, weakness, change in gait, or change in bowel or bladder function.  There is no associated headache.,Brief examination reveals normal motor examination with no pronator drift and no incoordination.  Normal gait.  Cranial nerves are intact.  Sensory examination reveals normal facial sensation.  She has normal and symmetrical light touch, temperature, and pinprick in the upper extremities.  In the lower extremities she has a feeling of dysesthesia in the lateral aspect of the left calf into the lateral aspect of the left foot.  In this area she has normal light touch and pinprick.  She describes it as a strange unusual sensation.,NERVE CONDUCTION STUDIES: , Motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in the left arm and leg.,NEEDLE EMG: , Needle EMG was performed in the left leg, lumbosacral paraspinal, right tibialis anterior, and right upper thoracic paraspinal muscles using a disposable concentric needle.  It revealed normal insertional activity, no spontaneous activity, and normal motor unit action potential form in all muscles tested.,IMPRESSION: , This electrical study is normal.  There is no evidence for peripheral neuropathy, entrapment neuropathy, plexopathy, or lumbosacral radiculopathy.  EMG was also performed in the right upper thoracic paraspinal where she has experienced a lot of pain since the motor vehicle accident.  This was normal.,Based on her history of sudden onset of left face, arm, and leg weakness as well as a normal EMG and MRI of her spine I am concerned that she had a central event in June of this year.  Symptoms are now very mild, but I have ordered an MRI of the brain with and without contrast and MRA of the head and neck with contrast to further elucidate her symptoms.  Once she has the test done she will phone me and further management will be based on the results.",33
"REASON FOR REFERRAL: , Ms. A is a 60-year-old African-American female with 12 years of education who was referred for neuropsychological evaluation by Dr. X after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in July.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION:,  Historical information was obtained from a review of available medical records and clinical interview with Ms. A.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  Ms. A presented to the ABC Hospital emergency department on 07/26/2009 reporting that after she had woken up that morning she noticed numbness and weakness in her left hand, slurred speech, and left facial droop.  Neurological evaluation with Dr. X confirmed left hemiparesis.  Brain CT showed no evidence of intracranial hemorrhage or mass effect and that she received TPA and had moderate improvement in left-sided weakness.  These symptoms were thought to be due to a right middle cerebral artery stroke.  She was transferred to the ICU for monitoring.  Ultrasound of the carotids showed 20% to 30% stenosis of the right ICA and 0% to 19% stenosis of the left ICA.  On 07/29/2009, she was admitted for acute inpatient rehabilitation for the treatment of residual functional deficits of her acute ischemic right MCA/CVA.  At discharge on 08/06/2009, she was mainly on supervision for all ADLs and walking with a rolling walker, but tolerating increased ambulation with a cane.  She was discharged home with recommendations for outpatient physical therapy.  She returned to the Sinai ER on 08/2009/2009 due to reported left arm pain, numbness, and weakness, which lasted 10 to 15 minutes and she reported that it felt ""just like the stroke.""  Brain CT on 08/2009/2009 was read as showing ""mild chronic microvascular ischemic change of deep white matter,"" but no acute or significant interval change compared to her previous scan.  Neurological examination with Dr. Y was within normal limits, but she was admitted for a more extensive workup.  Due to left arm pain an ultrasound was completed on her left upper extremity, but it did not show deep vein thrombosis.,Followup CT on 08/10/2009 showed no significant interval change.  MRI could not be completed due to the patient's weight.  She was discharged on 08/11/2009 in stable condition after it was determined that this event was not neurological in origin; however, note that Ms. A referred to this as a second stroke.,Ms. A presented for a followup outpatient neurological evaluation with Dr. X on 09/22/2009, at which time a brief neuropsychological screening was also conducted.  She demonstrated significant impairments in confrontation naming, abstract verbal reasoning, and visual and verbal memory and thus a more comprehensive evaluation was suggested due to her intent to return to her full-time work duty.  During the current interview, Ms. A reported that she noticed mild memory problems including some difficultly remembering conversations, events, and at times forgetting to take her medications.  She also reported mild difficulty finding words in conversation, solving novel problems and tasks (e.g. difficulty learning to use her camcorder), but overall denied significant cognitive deficits in attention, concentration, language or other areas of cognitive functioning.  When asked about her return to work, she said that she was still on light duty due to limited physical activity because of residual left leg weakness.  She reported that no one had indicated to her that she appeared less capable of performing her job duties, but said that she was also receiving fewer files to process and enter data into the computer at the Social Security Agency that she works at.  Note also that she had some difficulty explaining exactly what her job involved.  She also reported having problems falling asleep at work and that she is working full-time although on light duty.,OTHER MEDICAL HISTORY:  ,As mentioned, Ms. A continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly.  She was diagnosed with sleep apnea approximately two years ago and was recently counseled by Dr. X on the need to use her CPAP because she indicated she never used it at night.  She reported that since her appointment with Dr. X, she has been using it ""every other night.""  When asked about daytime fatigue, Ms. A initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen.  She reported at times ""snoring"" and forgetting where she is at and said that a supervisor offered to give her coffee at one point.  She receives approximately two to five hours of sleep per night.  Other current untreated risk factors include obesity and hypercholesterolemia.  Her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke).,CURRENT MEDICATIONS: , Aspirin 81 mg daily, Colace 100 mg b.i.d., Lipitor 80 mg daily, and albuterol MDI p.r.n.,SUBSTANCE USE:,  Ms. A denied drinking alcohol or using illicit drugs.  She used to smoke a pack of cigarettes per day, but quit five to six years ago.,FAMILY MEDICAL HISTORY: , Ms. A had difficulty providing information on familial medical history.  She reported that her mother died three to four years ago from lung cancer.  Her father has gout and blood clots.  Siblings have reportedly been treated for asthma and GI tumors.  She was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc.,SOCIAL HISTORY: , Ms. A completed high school degree.  She reported that she primarily obtained B's and C's in school.  She received some tutoring for algebra in middle school, but denied ever having been held back a grade failing any classes or having any problems with attention or hyperactivity.,She currently works for the Social Security Administration in data processing.  As mentioned, she has returned to full-time work, but continues to perform only light duties due to her physical condition.  She is now living on her own.  She has never driven.  She reported that she continues to perform ADLs independently such as cooking and cleaning.  She lost her husband in 2005 and has three adult daughters.  She previously reported some concerns that her children wanted her to move into assisted living, but she did not discuss that during this current evaluation.  She also reported number of other family members who had recently passed away.  She has returned to activities she enjoys such as quire, knitting, and cooking and plans to go on a cruise to the Bahamas at the end of October.,PSYCHIATRIC HISTORY: , Ms. A did not report a history of psychological or psychiatric treatment.  She reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events.  She reported that this only ""comes and goes."",TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II),  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",5
"PREOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,PROCEDURES PERFORMED: , ,1.  Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies.,2.  Bone grafts.,3.  Bilateral forehead reconstruction with autologous graft.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:,  None.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE: , Stable, transferred to recovery room.,ESTIMATED BLOOD LOSS: , 300 mL.,CRYSTALLOIDS: , Packed red blood cells 440 mL, FFP 100 mL.,URINARY OUTPUT: , 160 mL.,INDICATIONS FOR PROCEDURE: , The patient is a 9-month-old baby with a history of trigonocephaly and metopic synostosis.  We have discussed locations, the nature of trigonocephaly's repair, metopic synostosis repair with bilateral fronto-orbital advancement, forehead reconstruction, and bone graft.  We have discussed risks and benefits.  Risks included, but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgeries, minimal possibility of death, the alternatives, devastating bleeding, anesthesia, death, dehiscence, infection.  The parents understand, decide to proceed with surgery.  Informed consent was obtained and we proceed with surgery.,DESCRIPTION OF PROCEDURE: , The patient was taken into the operating room, placed in the supine position.  General anesthetic was administered.  Prophylactic dose of antibiotic was given.  Lines were placed by Anesthesia and then the head of the bed was turned to 100 degrees.  The patient was once more positioned and padded in the usual manner.  The incision was marked with the help of a marking pen and local anesthetic was infiltrated after prepping the area one time, then the definitive prep and draping of the area was done.,The procedure began with an incision through the full-thickness of the skin into the subcutaneous tissue down to the subgaleal plane.  The subgaleal plane was developed and reflected anteriorly and slightly posteriorly.  Hemostasis achieved with electrocautery.  Raney clips were applied to both flaps to prevent significant bleeding.  Then, we proceed with craniotomy part and Dr. Y proceeded with this part of the procedure.  I assisted her and this will be described in a different operative report.  Then, the area corresponding to the C-shaped osteotomy was marked and then we proceed in conjunction with Dr. Y to develop these osteotomies with the help of the Midas by retracting the contents of the skull at the level of the anterior fossa as well as the orbital contents with the help of a ribbon retractor.  The osteotomies were done with the Midas and some irrigation.  There was an osteotomy done at the level of the frontozygomatic suture just posterior to the frontozygomatic suture and then these osteotomies continued down intraorbitally and lateral through the zygoma to the level of the intraorbital rim.  This was done on both sides.  Hemostasis achieved with bone wax and electrocautery.  Once the osteotomies were completed, __________ of the osteotomy sites allowed advancements.  On the left side, there was a minor fracture to the superior orbital rim that was plated.  The bone grafts were customized placing these at the level of the sphenoid bone in the posterior aspect of the orbital rim.  The temporalis muscle was advanced and attached to the orbital rim with holes that have been drilled with Midas and a 3-0 Vicryl interrupted stitches.  The forehead flaps were attached with the help of absorbable mesh.  The forehead portions were applied to the fronto-orbital advancement of fronto-orbital piece with the help of Synthes mesh and 3-mm screws.  Hemostasis was checked.  The flaps were retracted back into position.,The wound was closed with 3-0 Vicryl interrupted sutures, 4-0 Vicryl interrupted stitches, and 5-0 running fast absorbing gut.  Dressing was applied with Xeroform, bacitracin, and ABDs and a burn net.  The patient tolerated the procedure well without complications and was transferred to the recovery room in stable condition.  I was present and participated in all aspects of the procedure.  Sponge, needle, and instrument counts were completed at the end of the procedure.",6
"PROCEDURE: , Circumcision.,PRE-PROCEDURE DIAGNOSIS: , Normal male phallus.,POST-PROCEDURE DIAGNOSIS: , Normal male phallus.,ANESTHESIA:  ,1% lidocaine without epinephrine.,INDICATIONS: , The risks and benefits of the procedure were discussed with the parents.  The risks are infection, hemorrhage, and meatal stenosis.  The benefits are ease of care and cleanliness and fewer urinary tract infections.  The parents understand this and have signed a permit.,FINDINGS: , The infant is without evidence of hypospadias or chordee prior to the procedure.,TECHNIQUE:  ,The infant was given a dorsal penile block with 1% lidocaine without epinephrine using a tuberculin syringe and 0.5 cc of lidocaine was delivered subcutaneously at 10:30 and at 1:30 o'clock at the dorsal base of the penis.,The infant was prepped then with Betadine and draped with a sterile towel in the usual manner.  Clamps were placed at 10 o'clock and 2 o'clock and the adhesions between the glans and mucosa were instrumentally lysed.  Dorsal hemostasis was established and a dorsal slit was made.  The foreskin was fully retracted and remaining adhesions between the glans and mucosa were manually lysed.  The infant was fitted with a XX-cm Plastibell.  The foreskin was retracted around the Plastibell and circumferential hemostasis was established.  The excess foreskin was removed with scissors and the infant tolerated the procedure well with a minimum amount of blood loss.  Instructions for continuing care are to watch for any evidence of hemorrhage or urination and the parents are instructed in the care of the circumcised penis.",38
"PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1.  Bilateral facet Arthrogram at L34, L45, L5S1.,2.  Bilateral facet injections at L34, L45, L5S1.,3.  Interpretation of radiograph.,ANESTHESIA:  ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS:  ,None.,INDICATION: , Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,SUMMARY OF PROCEDURE: , The patient was admitted to the OR, consent was obtained and signed.  The patient was taken to the Operating room and was placed in the prone position.  Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring.  Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, EKG, respiration and heart rate and at intervals of three minutes for blood pressure.  After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels.,The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view.  A skin wheal was placed with 1% Lidocaine at the L34 facet region on the left.  Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side.  This was performed using the oblique view under fluoroscopy to the enable the view of the ""Scotty Dog,"" After obtaining the ""Scotty Dog"" view the joints were easily seen.  Negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow.  After negative aspiration was verified, 1/8th of a cc of Omnipaque 240 dye was then injected.  Negative aspiration was again performed and 1/2 cc of solution (Solution consisting of 9 cc of 0.5% Marcaine with 1 cc of Triamcinolone) was then injected into the joint.  The needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint.  The 22-gauge needle was then removed.  Pressure was place over the puncture site for approximately one minute.  This exact same procedure was then repeated along the left-sided facets at L45, and L5S1.  This exact same procedure was then repeated on the right side.  At each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,The patient was noted to have tolerated the procedure well without any complications.,Interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, L34, L45, and L5S1.  Visualizing the ""Scotty Dog"" technique under fluoroscopy facilitated this.  Dye spread into each joint space is visualized.  No venous or arterial run-off is noted.  No epidural run-off is noted.  The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis.",33
"PREOPERATIVE DIAGNOSIS: , Brain tumors, multiple.,POSTOPERATIVE DIAGNOSES:,  Brain tumors multiple - adenocarcinoma and metastasis from breast.,PROCEDURE:,  Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.,PROCEDURE:,  The patient was placed in the prone position after general endotracheal anesthesia was administered.  The scalp was prepped and draped in the usual fashion.  The CUSA was brought in to supplement the use of operating microscope as well as the stealth, which was used to localize the tumor.  Following this, we then made a transverse linear incision, the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor.  The bone flap was elevated.  The ultrasound was then used.  The ultrasound showed the tumors directly I believe are in the interhemispheric fissure.  We noticed that the dura was quite tense despite that the patient had slight hyperventilation.  We gave 4 ounce of mannitol, the brain became more pulsatile.  We then used the stealth to perform a ventriculostomy.  Once this was done, the brain began to pulsate nicely.  We then entered the interhemispheric space after we incised the dura in an inverted U fashion based on the superior side of the sinus.  After having done this we then used operating microscope and slight self-retaining retraction was used.  We obtained access to the tumor.  We biopsied this and submitted it.  This was returned as a malignant brain tumor - metastatic tumor, adenocarcinoma compatible with breast cancer.,Following this we then debulked this tumor using CUSA and then removed it in total.  After gross total removal of this tumor, the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery.  The next step was after removal of this tumor, closure of the wound, a large piece of Duragen was placed over the dural defect and the bone flap was reapproximated and held secured with Lorenz plates.  The tumors self extend into the ventricle and after we had removed the tumor, we could see our ventricular catheter in the occipital horn of the ventricle.  This being the case, we left this ventricular catheter in, brought it out through a separate incision and connected to sterile drainage.  The next step was to close the wound after reapproximating the bone flap.  The galea was closed with 2-0 Vicryl and the skin was closed with interrupted 3-0 nylon sutures inverted with mattress sutures.  The sterile dressings were applied to the scalp.  The patient returned to the recovery room in satisfactory condition.  Hemodynamically remained stable throughout the operation.,Once again, we performed occipital craniotomy, total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy.  The tumor was removed using the combination of CUSA, ultrasound, stealth guided-ventriculostomy and the patient will have a second operation today, we will perform a selective craniectomy to remove another large tumor in the posterior fossa.",37
"PREOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,POSTOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,PROCEDURES:  ,1.  Anterior spine fusion from T11-L3.,2.  Posterior spine fusion from T3-L5.,3.  Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.,ESTIMATED BLOOD LOSS: , 500 mL.,FINDINGS: , The patient was found to have a severe scoliosis.  This was found to be moderately corrected.  Hardware was found to be in good positions on AP and lateral projections using fluoroscopy.,INDICATIONS: , The patient has a history of severe neurogenic scoliosis.  He was indicated for anterior and posterior spinal fusion to allow for correction of the curvature as well as prevention of further progression.  Risks and benefits were discussed at length with the family over many visits.  They wished to proceed.,PROCEDURE:,  The patient was brought to the operating room and placed on the operating table in the supine position.  General anesthesia was induced without incident.  He was given a weight-adjusted dose of antibiotics.  Appropriate lines were then placed.  He had a neuromonitoring performed as well.,He was then initially placed in the lateral decubitus position with his left side down and right side up.  An oblique incision was then made over the flank overlying the 10th rib.  Underlying soft tissues were incised down at the skin incision.  The rib was then identified and subperiosteal dissection was performed.  The rib was then removed and used for autograft placement later.,The underlying pleura was then split longitudinally.  This allowed for entry into the pleural space.  The lung was then packed superiorly with wet lap.  The diaphragm was then identified and this was split to allow for access to the thoracolumbar spine.,Once the spine was achieved, subperiosteal dissection was performed over the visualized vertebral bodies.  This required cauterization of the segmental vessels.  Once the subperiosteal dissection was performed to the posterior and anterior extents possible, the diskectomies were performed.  These were performed from T11-L3.  This was over 5 levels.  Disks and endplates were then removed.  Once this was performed, morcellized rib autograft was placed into the spaces.  The table had been previously bent to allow for easier access of the spine.  This was then straightened to allow for compression and some correction of the curvature.,The diaphragm was then repaired as was the pleura overlying the thoracic cavity.  The ribs were held together with #1 Vicryl sutures.  Muscle layers were then repaired using a running #2-0 PDS sutures and the skin was closed using running inverted #2-0 PDS suture as well.  Skin was closed as needed with running #4-0 Monocryl.  This was dressed with Xeroform dry sterile dressings and tape.,The patient was then rotated into a prone position.  The spine was prepped and draped in a standard fashion.,Longitudinal incision was made from T2-L5.  The underlying soft tissues were incised down at the skin incision.  Electrocautery was then used to maintain hemostasis.  The spinous processes were then identified and the overlying apophyses were split.  This allowed for subperiosteal dissection over the spinous processes, lamina, facet joints, and transverse processes.  Once this was completed, the C-arm was brought in, which allowed for easy placement of screws in the lumbar spine.  These were placed at L4 and L5.  The interspaces between the spinous processes were then cleared of soft tissue and ligamentum flavum.  This was done using a rongeur as well as a Kerrison rongeur.  Spinous processes were then harvested for morcellized autograft.,Once all the interspaces were prepared, Songer wires were then passed.  These were placed from L3-T3.,Once the wires were placed, a unit rod was then positioned.  This was secured initially at the screws distally on both the left and right side.  The wires were then tightened in sequence from the superior extent to the inferior extent, first on the left-sided spine where I was operating and then on the right side spine.  This allowed for excellent correction of the scoliotic curvature.,Decortication was then performed and placement of a morcellized autograft and allograft was then performed after thoroughly irrigating the wound with 4 liters of normal saline mixed with bacitracin.  This was done using pulsed lavage.,The wound was then closed in layers.  The deep fascia was closed using running #1 PDS suture, subcutaneous tissue was closed using running inverted #2-0 PDS suture, the skin was closed using #4-0 Monocryl as needed.  The wound was then dressed with Steri-Strips, Xeroform dry sterile dressings, and tape.  The patient was awakened from anesthesia and taken to the intensive care unit in stable condition.  All instrument, sponge, and needle counts were correct at the end of the case.,The patient will be managed in the ICU and then on the floor as indicated.",23
"HISTORY OF PRESENT ILLNESS: , The patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury.  She states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee.  She had immediate pain and swelling.  At this time, she complains of pain and instability in the knee.  The patient's past medical history is significant for having had an ACL injury to the knee in 2008.  She underwent anterior cruciate ligament reconstruction by Dr. X at that time, subsequently in the same year she developed laxity of the graft due in part to noncompliance and subsequently, she sought attention from Dr. Y who performed a revision ACL reconstruction at the end of 2008.  The patient states she rehabbed the knee well after that and did fine with good stability of the knee until this recent injury.,PAST MEDICAL HISTORY:,  She claims no chronic illnesses.,PAST SURGICAL HISTORY: , She had an anterior cruciate ligament reconstruction in 03/2008, and subsequently had a revision ACL reconstruction in 12/2008.  She has also had arm surgery when she was 6 years old.,MEDICATIONS: , She takes no medications on a regular basis,ALLERGIES: , She is allergic to Keflex and has skin sensitivity to Steri-Strips.,SOCIAL HISTORY:  ,The patient is single.  She is a full-time student at University.  Uses no tobacco, alcohol, or illicit drugs.  She exercises weekly, mainly tennis and swelling.,REVIEW OF SYSTEMS:  ,Significant for recent weight gain, occasional skin rashes.  The remainder of her systems negative.,PHYSICAL EXAMINATION,GENERAL:  The patient is 4 foot 10 inches tall, weighs 110 pounds.,EXTREMITIES:  She ambulates with some difficulty with a marked limp on the right side.  Inspection of the knee reveals a significant effusion in the knee.  She has difficulty with passive range of motion of the knee secondary to pain.  She does have tenderness to palpation at the medial joint line and has a positive Lachman's exam.,NEUROVASCULAR:  She is neurovascularly intact.,IMPRESSION: , Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement.,PLAN: , The patient will be referred for an MRI of the right knee to evaluate the integrity of her revision ACL graft.  In the meantime, she will continue to use ice as needed.  Moderate her activities and use crutches.  She will follow up as soon as the MRI is performed.",27
"FINDINGS:,High resolution computerized tomography was performed from T12-L1 to the S1 level with reformatted images in the sagittal and coronal planes and 3D reconstructions performed. COMPARISON: Previous MRI examination 10/13/2004.,There is minimal curvature of the lumbar spine convex to the left.,T12-L1, L1-2, L2-3: There is normal disc height with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints.,L3-4: There is normal disc height and non-compressive circumferential annular disc bulging eccentrically greater to the left. Normal central canal and facet joints (image #255).,L4-5: There is normal disc height, circumferential annular disc bulging, left L5 hemilaminectomy and posterior central/right paramedian broad-based disc protrusion measuring 4mm (AP) contouring the rightward aspect of the thecal sac. Orthopedic hardware is noted posteriorly at the L5 level. Normal central canal, facet joints and intervertebral neural foramina (image #58).,L5-S1: There is minimal decreased disc height, postsurgical change with intervertebral disc spacer, posterior lateral orthopedic hardware with bilateral pedicle screws in good postsurgical position. The orthopedic hardware creates mild streak artifact which mildly degrades images. There is a laminectomy defect, spondylolisthesis with 3.5mm of anterolisthesis of L5, posterior annular disc bulging greatest in the left foraminal region lying adjacent to the exiting left L5 nerve root. There is fusion of the facet joints, normal central canal and right neural foramen (image #69-70, 135).,There is no bony destructive change noted.,There is no perivertebral soft tissue abnormality.,There is minimal to mild arteriosclerotic vascular calcifications noted in the abdominal aorta and right proximal common iliac artery.,IMPRESSION:,Minimal curvature of the lumbar spine convex to the left.,L3-4 posterior non-compressive annular disc bulging eccentrically greater to the left.,L4-5 circumferential annular disc bulging, non-compressive central/right paramedian disc protrusion, left L5 laminectomy.,L5-S1 postsurgical change with posterolateral orthopedic fusion hardware in good postsurgical position, intervertebral disc spacer, spondylolisthesis, laminectomy defect, posterior annular disc bulging greatest in the left foraminal region adjacent to the exiting left L5 nerve root with questionable neural impingement.,Minimal to mild arteriosclerotic vascular calcifications.",27
"TITLE OF OPERATION:,1.  Pars plana vitrectomy.,2.  Pars plana lensectomy.,3.  Exploration of exit wound.,4.  Closure of perforating corneal scleral laceration involving uveal tissue.,5.  Air-fluid exchange.,6.  C3F8 gas.,7.  Scleral buckling, right eye.,INDICATION FOR SURGERY: , The patient was hammering and a piece of metal entered his eye 1 day prior to the procedure giving him a traumatic cataract corneal laceration and the metallic intraocular foreign body was lodged in the posterior eye wall.  He undergoes repair of the open globe today.,PREOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,POSTOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,ANESTHESIA:,  General.,SPECIMEN:,  None.,IMPLANTS:,1.  Style number XXX silicone band reference XXX , lot number XXX , exploration 11/13.,2.  Style number XXX Watzke sleeve reference XXX , lot number XXX , exploration 04/14.,PROCEDURE: , The risk, benefits, and alternatives to the procedure were reviewed with the patient and his wife.  All of their questions were answered.  Informed consent was signed.  The patient was brought into the operating room.  A surgical time-out was performed during which all members of the operating room staff agreed upon the patient's name, operation to be performed, and correct operative eye.  After administration of general anesthesia, the patient was intubated without incident.,The right eye was prepared and draped in the usual fashion for ophthalmic surgery.  A wire lid speculum was used to separate the eyelids of the left eye.  A 9 o'clock anterior chamber paracentesis was created with Supersharp blade and the anterior chamber was filled with Healon.  The clear corneal incision was superior to the visual axis and was closed with three interrupted 10-0 nylon sutures with the knots buried.  A standard three-port pars plana vitrectomy __________ was initiated by performing partial conjunctival peritomies in the superonasal, superotemporal, and inferotemporal quadrants with Westcott scissors.  Hemostasis was achieved with bipolar cautery.  A 7-0 Vicryl suture was preplaced in the mattress fashion, 3 mm posterior to the surgical limbus in the inferotemporal quadrant.  A microvitreoretinal blade was used to create a sclerotomy at this site and a 4-mm infusion cannula was introduced through the sclerotomy and tied in place with the aforementioned suture.  The presence of the tip of the cannula was confirmed to be within the vitreous cavity prior to initiation of posterior infusion.  Two additional sclerotomies were created superonasally and superotemporally, 3 mm posterior to the surgical limbus with microvitreoretinal blade.,The vitreous cutter was used to perform the pars plana lens actively preserving peripheral anterior capsule.  The pars plana vitrectomy was performed with the assistance of the BIOM non-contact lens indirect viewing system using the light pipe illuminator and the vitreous cutter.  The vitreous was trimmed to the vitreous base.  A posterior vitreous detachment was created and extended 360 degrees with the assistance of triamcinolone for staining.,The foreign body appeared to exit the posterior pole along the superotemporal arcade and apparently severed a branched retinal artery resulting in an area of macular ischemia with retinal whitening along its course.  The exit wound was explored.  No intraocular foreign body or mural foreign body was observed with the assistance of intraocular forceps.  The intraocular magnet was then inserted through the sclerotomy and no foreign body was again identified.,An air-fluid exchange was performed with the assistance of the soft-tip extrusion cannula and the retinal periphery was examined with scleral depression.  No retinal breaks or defects were noted in the periphery.  The plugs were placed in the sclerotomies and the conjunctival peritomy was extended at 360 degrees.  Each of the rectus muscles was isolated on a 2-0 silk suture and a #XXX band was threaded beneath each of the rectus muscle and fixed to itself in the inferonasal quadrant with the Watzke sleeve.  The buckle was sutured to the eye wall with 5-0 Mersilene sutures in each quadrant in a mattress fashion.  The buckle was trimmed and the height of the buckle was inspected internally and noted to be adequate.,Residual intraocular fluid was removed with a soft-tip extrusion cannula and the sclerotomies were closed with 7-0 Vicryl sutures.  A 12% concentration of C3F8 gas was flushed through the eye.  The infusion cannula was removed and the sclerotomy was closed with the preplaced 7-0 Vicryl suture.  All of the sclerotomies were noted to be airtight.  The intraocular pressure following injection of 0.05 mL each of vancomycin (0.5 mg) and ceftazidime (1 mg) were injected through the superotemporal pars plana, 30-gauge needles.,The conjunctiva was closed with 6-0 plain gut sutures with the knots buried.  Subconjunctival injections of Ancef and Decadron were delivered inferotemporally.  The lid speculum was removed.  Pred-G ointment and atropine solution were applied to the ocular surface.  The eye was patched and shielded, and the patient was returned to the recovery room in stable condition, having tolerated the procedure well.  There were no complications.,I was the attending surgeon, was present and scrubbed for the entirety of the procedure.",37
"PREOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,PROCEDURE:  ,Adenotonsillectomy.,COMPLICATIONS:,  None.,PROCEDURE DETAILS:, The patient was brought to the operating room and, under general endotracheal anesthesia in supine position, the table turned and a McIvor mouthgag placed.  The adenoid bed was examined and was moderately hypertrophied.  Adenoid curettes were used to remove this tissue and packs placed.  Next, the right tonsil was grasped with a curved Allis and, using the gold laser, the anterior tonsillar pillar incised and, with this laser, dissection carried from the superior pole to the inferior pole and removed off the tonsillar muscular bed.  A similar procedure was performed on the contralateral tonsil.  Following meticulous hemostasis, saline was used to irrigate and no further bleeding noted.  The patient was then allowed to awaken and was brought to the recovery room in stable condition.",11
"SUBJECTIVE:,  The patient complains of backache, stomachache, and dysuria for the last two days.  Fever just started today and cough.  She has history of kidney stones less than a year ago and had a urinary tract infection at that time.  Her back started hurting last night.,PAST MEDICAL HISTORY:,  She denies sexual activities since two years ago.  Her last menstrual period was 06/01/2004.  Her periods have been irregular.  She started menarche at 10 years of age and she is still irregular and it runs in Mom’s side of the family.  Mom and maternal aunt have had total hysterectomies.  She also is diagnosed with abnormal valve has to be on SBE prophylaxis, sees Dr. XYZ Allen.  She avoids decongestants.  She is limited on her activity secondary to her heart condition.,MEDICATION:,  Cylert.,ALLERGIES: , No known drug allergies.,OBJECTIVE:,Vital Signs:  Blood pressure is 124/72.  Temperature 99.2.  Respirations 20 unlabored.  Weight:  137 pounds.,HEENT:  Normocephalic.  Conjunctivae noninjected.  No mattering noted.  Her TMs are bilaterally clear, nonerythematous.  Throat clear, good mucous membrane moisture, but she did have erythema and edema at her posterior soft palate.,Neck:  Supple.  Increased lymphadenopathy noted in the submandibular nodes, but no axillary nodes and no hepatosplenomegaly.,Respiratory:  Clear.  No wheezes, no crackles, no tachypnea, and no retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal, no murmur.,Abdomen:  Soft.  No organomegaly.  She did have exquisite tenderness to palpation of the left upper quadrant and flank area, but the spleen was not palpable.  She has no suprapubic tenderness.,Extremities:  She has good range of motion of upper and lower extremities.  Good ambulation.,Her UA was positive for 2+ leukocyte esterase, positive nitrites, 1+ protein, 2+ ketones, 4+ blood, greater than 50 white blood cells, 10-20 rbc’s, and 1+ bacteria.  Culture and sensitivity is pending.  Her Strep test is negative.  Culture is pending.,ASSESSMENT:,1.  Urinary dysuria.,2.  Left flank pain.,3.  Pharyngitis.,PLAN:,  A 1 g of Rocephin IM was given.  Call Dr. B's office tomorrow morning incase a second IM dose is needed.  If not then she will fill a prescription for Omnicef 300 mg capsule 1 p.o. b.i.d. for 10 days total and then we will await the culture and sensitivity results to see if this is appropriate drug.  Push fluids.  Await strep culture report.  Follow up with Dr. XYZ if no better or symptoms worsen.",15
"INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant.  His mother had premature rupture of membranes on 12/20/08.  She then presented to the Labor and Delivery with symptoms of flu.  The baby was then induced and delivered.  The mother had a history of premature babies in the past.  This baby was doing well, and then, we had a significant increasing oxygen requirement from room air up to 85%.  He is now on 60% FiO2.,PHYSICAL FINDINGS,GENERAL:  He appears to be pink, well perfused, and slightly jaundiced.,VITAL SIGNS:  Pulse 156, 56 respiratory rate, 92% sat, and 59/28 mmHg blood pressure.,SKIN:  He was pink.,He was on the high-frequency ventilator with good wiggle.,His echocardiogram showed normal structural anatomy.  He has evidence for significant pulmonary hypertension.  A large ductus arteriosus was seen with bidirectional shunt.  A foramen ovale shunt was also noted with bidirectional shunt.  The shunting for both the ductus and the foramen ovale was equal left to right and right to left.,IMPRESSION: , My impression is that baby boy, XYZ, has significant pulmonary hypertension.  The best therapy for this is to continue oxygen.  If clinically worsens, he may require nitric oxide.  Certainly, Indocin should not be used at this time.  He needs to have lower pulmonary artery pressures for that to be considered.,Thank you very much for allowing me to be involved in baby XYZ's care.",5
"CHIEF COMPLAINT:,  Ankle pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym.  Two hours prior to presentation, he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now.  It hurts to move or bear weight.  No other injuries noted.  He does not think he has had injuries to his ankle in the past.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , He does not drink or smoke.,ALLERGIES: , Unknown.,MEDICATIONS: , Adderall and Accutane.,REVIEW OF SYSTEMS: , As above.  Ten systems reviewed and are negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 97.6, pulse 70, respirations 16, blood pressure 120/63, and pulse oximetry 100% on room air.,GENERAL:",12
"NUCLEAR MEDICINE HEPATOBILIARY SCAN,REASON FOR EXAM: , Right upper quadrant pain.,COMPARISONS:  ,CT of the abdomen dated 02/13/09 and ultrasound of the abdomen dated 02/13/09.,Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.,FINDINGS:,  Imaging obtained up to 30 minutes after the injection of radiopharmaceutical shows a normal hepatobiliary transfer time.  There is normal accumulation within the gallbladder.,After the injection of 2.1 mcg of intravenous cholecystic _______, the gallbladder ejection fraction at 30 minutes was calculated to be 32% (normal is greater than 35%).  The patient experienced 2/10 pain at 5 minutes after the injection of the radiopharmaceutical and the patient also complained of nausea.,IMPRESSION:,1.  Negative for acute cholecystitis or cystic duct obstruction.,2.  Gallbladder ejection fraction just under the lower limits of normal at 32% that can be seen with very mild chronic cholecystitis.",14
"MYOVIEW NUCLEAR STRESS STUDY,REASON FOR THE TEST:,  Angina, coronary artery disease.,FINDINGS: , The patient exercised according to the Lexiscan nuclear stress study, received a total of 0.4 mg of Lexiscan.  At peak hyperemic effect, 25.8 mCi of Myoview injected for the stress imaging and earlier 8.1 mCi of Myoview injected for the resting and the usual SPECT and gated SPECT protocol was followed in the rest-stress sequence.,The data analyzed using Cedars-Sinai software.,The resting heart rate was 49 with the resting blood pressure of 149/86.  Maximum heart rate achieved was 69 with a maximum blood pressure achieved of 172/76.,EKG at rest showed to be abnormal with sinus rhythm, left atrial enlargement, and inverted T-wave in 1, 2, and aVL as well as from V4 to V6 with LVH.  Maximal stress test EKG showed no change from baseline.,IMPRESSION:  ,Maximal Lexiscan stress test with abnormal EKG at baseline maximal stress test, please refer to the Myoview interpretation.,MYOVIEW INTERPRETATIONS,FINDINGS: , The left ventricle appears to be dilated on both stress and rest with no significant change between stress and rest with left ventricular end-diastolic volume of 227, end-systolic volume of 154 with moderately to severely reduced LV function with akinesis of the inferior and inferoseptal wall.  EF was calculated at 32%, estimated 35% to 40%.,Cardiac perfusion reviewed, showed a large area of moderate-to-severe intensity in the inferior wall and small-to-medium area of severe intensity at the apex and inferoapical wall.  Both defects showed no change on the resting indicative of a fixed defect in the inferior and inferoapical wall consistent with old inferior inferoapical MI.  No reversible defects indicative of myocardium at risk.  The lateral walls as well as the septum and most of the anterior wall showed no reversibility and near-normal perfusion.,IMPRESSION:,1.  Large fixed defect, inferior and apical wall, related to old myocardial infarction.,2.  No reversible ischemia identified.,3.  Moderately reduced left ventricular function with ejection fraction of about 35% consistent with ischemic cardiomyopathy.",33
"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.",37
"PREOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Trabeculectomy with mitomycin C, XXX eye 0.3 c per mg times three minutes.,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox, Ocular, and pilocarpine. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion and the microscope was brought in position. A Lieberman lid speculum was used to provide exposure. Vannas scissors and smooth forceps were used to create a 6 mm limbal peritomy superiorly. This was dissected posteriorly with Vannas scissors to produce a fornix based conjunctival flap. Residual episcleral vessels were cauterized with Eraser-tip cautery. Sponges soaked in mitomycin C 0.3 mm per cc were then placed underneath the conjunctival flap and allowed to sit there for 3 minutes checked against the clock. Sponges were removed and area was copiously irrigated with balanced salt solution. A Super blade was then used to fashion a partial thickness limbal based trapezoidal scleral flap. This was dissected anteriorly with a crescent blade to clear cornea. A temporal paracentesis was then made. Scleral flap was lifted and a Super blade was used to enter the anterior chamber. A Kelly-Descemet punch was used to remove a block of limbal tissue. DeWecker scissors were used to perform a surgical iridectomy. The iris was then carefully reposited back into place and the iridectomy was visible through the clear cornea. A scleral flap was then re- approximated back on the bed. One end of the scleral flap was closed with a #10-0 nylon suture in interrupted fashion and the knot was buried. The other end of the scleral flap was closed with #10-0 nylon suture in interrupted fashion and the knot was buried. The anterior chamber was then refilled with balanced salt solution and a small amount of fluid was noted to trickle out of the scleral flap with slow shallowing of the chamber. Therefore it was felt that another #10-0 nylon suture should be placed and it was therefore placed in interrupted fashion half way between each of the end sutures previously placed. The anterior chamber was then again refilled with balanced salt solution and it was noted that there was a small amount of fluid tricking out of the scleral flap and the pressure was felt to be adequate in the anterior chamber. Conjunctiva was then re-approximated to the limbus and closed with #9-0 Vicryl suture on a TG needle at each of the peritomy ends. Then a horizontal mattress style #9-0 Vicryl suture was placed at the center of the conjunctival peritomy. The conjunctival peritomy was checked for any leaks and was noted to be watertight using Weck- cel sponge. The anterior chamber was inflated and there was noted that the superior bleb was well formed. At the end of the case, the pupil was round, the chamber was formed and the pressure was felt to be adequate. Speculum and drapes were carefully removed. Ocuflox and Maxitrol ointment were placed over the eye. Atropine was also placed over the eye. Then an eye patch and eye shield were placed over the eye. The patient was taken to the recovery room in good condition. There were no complications.",37
"SPIROMETRY:,  Spirometry reveals the FVC to be adequate.,FEV1 is also adequate 93% predicted.  FEV1/FVC ratio is 114% predicted which is normal and FEF25 75% is 126% predicted.,After the use of bronchodilator, there is no significant improvement of the abovementioned parameters.,MVV is also normal.,LUNG VOLUMES: , Reveal a TLC to be 80% predicted.  FRC is mildly decreased and RV is also mildly decreased.  RV/TLC ratio is also normal 97% predicted.,DIFFUSION CAPACITY:,  After correction for alveolar ventilation, is 112% predicted which is normal.,OXYGEN SATURATION ON ROOM AIR:,  98%.,FINAL INTERPRETATION: , Pulmonary function test shows mild restrictive pulmonary disease.  There is no significant obstructive disease present.  There is no improvement after the use of bronchodilator and diffusion capacity is normal.  Oxygen saturation on room air is also adequate.  Clinical correlation will be necessary in this case.,",3
"PREOPERATIVE DIAGNOSIS:,  Nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES:,  Kelman phacoemulsification with posterior chamber intraocular lens, right eye.,ANESTHESIA:,  Topical.,COMPLICATIONS:,  None.,INDICATION: , This is a 40-year-old male, who has been noticing problems with blurry vision.  They were found to have a visually significant cataract.  The risks, benefits, and alternatives of cataract surgery to the right eye were discussed and they did agree to proceed.,DESCRIPTION OF PROCEDURE:,  After informed consent was obtained, the patient was taken to the operating room.  A drop of tetracaine was instilled in the right eye and the right eye was prepped and draped in the usual sterile ophthalmic fashion.  A paracentesis was created at ** o'clock.  The anterior chamber was filled with Viscoat.  A clear corneal incision was made at ** o'clock with the 3-mm diamond blade.  A continuous curvilinear capsulorrhexis was begun with a cystotome and completed with Utrata forceps.  The lens was hydrodissected with a syringe filled with 2% Xylocaine and found to rotate freely within the capsular bag.  The nucleus was removed with the phacoemulsification handpiece in a stop and chop fashion.  The residual cortex was removed with the irrigation/aspiration handpiece.  The capsular bag was filled with Provisc and a model SI40, 15.0 diopter, posterior chamber intraocular lens was inserted into the capsular bag without complications and was found to rotate and center well.  The residual Provisc was removed with the irrigation/aspiration handpiece.  The wounds were hydrated and the eye was filled to suitable intraocular pressure with balanced salt solution.  The wounds were found to be free from leak.  Zymar and Pred Forte were instilled postoperatively.  The eye was covered with the shield.,The patient tolerated the procedure well and there were no complications.  He will follow up with us in one day.",26
"PREOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,POSTOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,PROCEDURE PERFORMED: , YAG laser capsulotomy, right eye.,INDICATIONS: , This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane.  The patient is being brought in for YAG capsular discission.,PROCEDURE: , The patient was seated at the YAG laser, the pupil having been dilated with 1%  Mydriacyl, and Iopidine was instilled.  The Abraham capsulotomy lens was then positioned and applications of laser energy in the pattern indicated on the outpatient note were applied.  A total of",26
"ADMITTING DIAGNOSES:,1.  Fever.,2.  Otitis media.,3.  Possible sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-month-old male who was seen in the office 1 day prior to admission.  He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough, nasal congestion, and rhinorrhea and no history of rashes.  He has been taking Tylenol and Advil to help decrease the fevers, but the fever has continued to rise.  He was noted to have some increased workup of breathing and parents returned to the office on the day of admission.,PAST MEDICAL HISTORY: , Significant for being born at 33 weeks' gestation with a birth weight of 5 pounds and 1 ounce.,PHYSICAL EXAMINATION: , On exam, he was moderately ill appearing and lethargic.  HEENT:  Atraumatic, normocephalic.  Pupils are equal, round, and reactive to light.  Tympanic membranes were red and yellow, and opaque bilaterally.  Nares were patent.  Oropharynx was slightly moist and pink.  Neck was soft and supple without masses.  Heart is regular rate and rhythm without murmurs.  Lungs showed increased workup of breathing, moderate tachypnea.  No rales, rhonchi or wheezes were noted.  Abdomen:  Soft, nontender, nondistended.  Active bowel sounds.  Neurologic exam showed good muscle strength, normal tone.  Cranial nerves II through XII are grossly intact.,LABORATORY FINDINGS: , He had electrolytes, BUN and creatinine, and glucose all of which were within normal limits.  White blood cell count was 8.6 with 61% neutrophils, 21% lymphocytes, 17% monocytes, suggestive of a viral infection.  Urinalysis was completely unremarkable.  Chest x-ray showed a suboptimal inspiration, but no evidence of an acute process in the chest.,HOSPITAL COURSE: , The patient was admitted to the hospital and allowed a clear liquid diet.  Activity is as tolerates.  CBC with differential, blood culture, electrolytes, BUN, and creatinine, glucose, UA, and urine culture all were ordered.  Chest x-ray was ordered as well with 2 views to evaluate for a possible pneumonia.  Pulse oximetry checks were ordered every shift and as needed with O2 ordered per nasal cannula if O2 saturations were less that 94%.  Gave D5 and quarter of normal saline at 45 mL per hour, which was just slightly above maintenance rate to help with hydration.  He was given ceftriaxone 500 mg IV once daily to treat otitis media and possible sepsis, and I will add Tylenol and ibuprofen as needed for fevers.  Overnight, he did have his oxygen saturations drop and went into oxygen overnight.  His lungs remained clear, but because of the need for O2, we instituted albuterol aerosols every 6 hours to help maintain good lung function.  The nurses were instructed to attempt to wean O2 if possible and advance the diet.  He was doing clear liquids well and so I saline locked to help to accommodate improve the mobility with the patient.  He did well the following evening with no further oxygen requirement.  He continued to spike fevers but last fever was around 13:45 on the previous day.  At the time of exam, he had 100% oxygen saturations on room air with temperature of 99.3 degrees F. with clear lungs.  He was given additional dose of Rocephin when it was felt that it would be appropriate for him to be discharged that morning.,CONDITION OF THE PATIENT AT DISCHARGE: , He was at 100% oxygen saturations on room air with no further dips at night.  He has become afebrile and was having no further increased work of breathing.,DISCHARGE DIAGNOSES:,1.  Bilateral otitis media.,2.  Fever.,PLAN:  ,Recommended discharge.  No restrictions in diet or activity.  He was continued Omnicef 125 mg/5 mL one teaspoon p.o. once daily and instructed to follow up with Dr. X, his primary doctor, on the following Tuesday.  Parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy.",29
"CHIEF COMPLAINT: , Dysphagia and hematemesis while vomiting.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old African American female with 15 years known history of HIV and hepatitis B, and known history of compensated heart failure, COPD, who presented today with complaint of stuck food in her esophagus, bloody cough, and bloody vomiting since 4 o'clock this vomiting, when she ate eggplant parmigiana meal.  The back and chest pain is 8/10, no radiation and is constant.  She denied fever, abdominal pain, or dysphagia before current event eating bones or fish.  This is the first episode of hematemesis and feeling of globus pallidus.  In the emergency room, the patient was treated with nitropaste, morphine, and Lopressor with positive results for chest pain.  CAT scan of the chest showed diffuse esophageal dilatation with residual food in it, no mediastinal air was identified.,REVIEW OF SYSTEMS: , The patient denied diarrhea, abdominal pain, fever, weight loss, dysphagia before this event.  Denied any exertional chest pain or shortness of breath.  No headache, limb weakness.  No joint pain or muscle ache.  No dysuria.,PAST MEDICAL HISTORY:  ,Remarkable for:,1.  Asthma.,2.  Hepatitis C - 1995.,3.  HIV, known since 1995 and followed up by Dr. X, ABCD Medical Center, the last visit was 08/09.  The patient does not take HIV medications against medical advice.,4.  Hypertension, known since 2008.,5.  Negative PPD test, 10/08.,PAST SURGICAL HISTORY: , Remarkable for hysterectomy in 2001, pilonidal cyst surgery in 2005.,FAMILY HISTORY: , Mother deceased at age 68 of cirrhosis.  She had history of alcohol abuse.  Father deceased at age 45, also has a history of alcohol abuse, cardiac disease, and hypertension.,ALLERGIES: , Not known allergies.,MEDICATIONS AT HOME: , Lisinopril 5 mg daily; metoprolol 25 mg twice daily; furosemide 40 mg once daily; Isentress 400 mg once daily, the patient does not take this medication for the last 3 months; Norvir 100 mg once daily; Prezista 400 mg once daily.  The patient does not take her HIV medications for the last 2 to 3 months.  Occasionally, she takes inhalation of albuterol and Ambien 10 mg once daily.,SOCIAL HISTORY: , She is single, lives with her 21-year-old daughter, works as CNA, smokes one pack per day for the last 8 years.  She had periods when she quit smoking and started again 2-1/2 years ago.  She denied alcohol abuse and she was using cocaine in the past, last time she used cocaine 10 years ago.,PHYSICAL EXAMINATION: , Temperature 99.8, pulse 106, respiratory rate 18, blood pressure 162/97, saturation 99 on room air.  African American female, not in acute respiratory distress, but uncomfortable, and showing some signs of back discomfort.  Oriented x3, mildly drowsy, calm and cooperative.  Eyes, EOMI, PERRLA.  Tympanic membranes normal appearance bilaterally.  External canal, no erythema or discharge.  Nose, no erythema or discharge.  Throat, dry mucous, no exudates.  No ulcers in oral area.  Full upper denture and extensive decayed lower teeth.  No cervical lymphadenopathy, no carotid bruits bilaterally.  Heart:  RRR, S1 and S2 appreciated.  No additional sounds or murmurs were auscultated.  Lung:  Good air entrance bilaterally.  No rales or rhonchi.  Abdomen:  Soft, nontender, nondistended.  No masses or organomegaly were palpated.  Legs:  No signs of DVT, peripheral pulses full, posterior dorsalis pedis 2+.  Skin:  No rashes or other lesions, warm and well perfused.  Nails:  No clubbing.  No other signs of skin infection.  Neurological exam:  Cranial nerves II through XII grossly intact.  No motor or sensory deficit was found.,CAT scan of the chest, which was done at 8 o'clock in the morning on 01/12/10.  Impression:  Cardiomegaly, normal aorta, large distention of esophagus containing food.  Chest x-ray:  Cardiomegaly, no evidence of CHF or pneumonia.  EKG:  Normal sinus rhythm, no signs of ischemia.,LABORATORY DATA: , Hemoglobin 10.4, hematocrit 30.6, white blood cells 7.3, neutrophils 75, platelets 197.  Sodium 140, potassium 3.1, chloride 104, bicarb 25, glucose 113, BUN 19, creatinine 1.1, GFR 55, calcium 8.8, total protein 8.1, albumin 3.1, globulin 5.0, bilirubin 0.3, alk phos 63, GOT 23, GPT 22, lipase 104, amylase 85, protime 10.2, INR 1, PTT 25.8.  Urine:  Negative for ketones, protein, glucose, blood, and nitrite, bacteria 2+.  Troponin 0.040.  BNP 1328.,PLAN:,1.  Diffuse esophageal dilatation/hematemesis.  We will put her n.p.o., we will give IV fluid, half normal saline D5 100 mL per hour.  I discussed the case with Dr. Y, gastroenterologist.  The patient planned for EGD starting today.  Differential diagnosis may include foreign body, achalasia, Candida infection, or CMV esophagitis.  We will treat according to the EGD findings.  We will give IV Nexium 40 mg daily for GI prophylaxis.  We will hold all p.o. medication.,2.  CHF.  Cardiomegaly on x-ray.  She is clinically stable.  Lungs are clear.  No radiological sign of CHF exacerbation.  We will restart lisinopril and metoprolol after EGD study will be completed.,3.  HIV - follow up by Dr. X, (ABCD Medical Center).  The last visit was on 08/08.  The patient was not taking her HIV medications for the last 3 months and does not know her CD4 number or viral load.  We will check CD4 number and viral load.  We will contact Dr. X (ID specialist in ABCD Med).,4.  Hypertension.  We will control blood pressor with Lopressor 5 mg IV p.r.n.  If blood pressure more than 160/90, we will hold metoprolol and lisinopril.,5.  Hepatitis C, known since 1995.  The patient does not take any treatment.,6.  Tobacco abuse.  The patient refused nicotine patch.,7.  GI prophylaxis as stated above; and DVT prophylaxis, compression socks.  We will restrain from using heparin or Lovenox.,ADDENDUM: , The patient was examined by Dr. Y, gastroenterologist, who ordered a CAT scan with oral contrast, which showed persistent distention of the esophagus with elementary debris within the lumen of the esophagus.  There is no evidence of leakage of the oral contrast.  There is decrease in size of periaortic soft tissue density around the descending aorta, this is associated with increase in very small left pleural effusion in the intervening time.  There is no evidence of pneumomediastinum or pneumothorax, lungs are clear, contrast is present in stomach.  After procedure, the patient had profuse vomiting with bloody content and spiked fever 102.  The patient felt relieved after vomiting.  The patient was started on aztreonam 1 g IV every 8 hours, Flagyl 500 mg IV every 8 hours.  ID consult was called and thoracic surgeon consult was ordered.",5
"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.",37
"ADMISSION DIAGNOSES:,1.  Menometrorrhagia.,2.  Dysmenorrhea.,3.  Small uterine fibroids.,DISCHARGE DIAGNOSES:,1.  Menorrhagia.,2.  Dysmenorrhea.,3.  Small uterine fibroids.,OPERATION PERFORMED:  ,Total vaginal hysterectomy.,BRIEF HISTORY AND PHYSICAL:  ,The patient is a 42 year-old white female, gravida 3, para 2, with two prior vaginal deliveries.  She is having increasing menometrorrhagia and dysmenorrhea.  Ultrasound shows a small uterine fibroid.  She has failed oral contraceptives and surgical therapy is planned.,PAST HISTORY: , Significant for reflux.,SURGICAL HISTORY:  ,Tubal ligation.,PHYSICAL EXAMINATION: , A top normal sized uterus with normal adnexa.,LABORATORY VALUES:  ,Her discharge hemoglobin is 12.4.,HOSPITAL COURSE: , She was taken to the operating room on 11/05/07 where a total vaginal hysterectomy was performed under general anesthesia.  Postoperatively, she has done well.  Bowel and bladder function have returned normally.  She is ambulating well, tolerating a regular diet.  Routine postoperative instructions given and said follow up will be in four weeks in the office.,DISCHARGE MEDICATIONS: , Preoperative meds plus Vicodin for pain.,DISCHARGE CONDITION: , Good.",10
"DISCHARGE DIAGNOSES:  ,1.  Suspected mastoiditis ruled out.,2.  Right acute otitis media.,3.  Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  The child has had very severe ear pain and blood draining from the right ear.  The child had a temperature maximum of 101.4 in the ER.  The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control.  In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased.  The patient was evaluated by Dr. X from the ENT while in house.  After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis.  The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge.  At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved.  The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL:  The patient is alert, in no respiratory distress.,VITAL SIGNS:  His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT:  Right ear shows no redness.  The area behind his ear is nontender.  There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK:  Supple.,CHEST:  Clear breath sounds.,CARDIAC:  Normal S1, S2 without murmur.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or tenderness.,SKIN:  Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:,  Regular as tolerated.,DISCHARGE MEDICATIONS:  ,1.  Ciprodex Otic Solution in the right ear twice daily.,2.  Augmentin 500 mg three times daily x10 days.,FOLLOW UP:  ,1.  Dr. Y in one week (ENT).,2.  The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes.",12
"PREOPERATIVE DIAGNOSES:,1.  Left breast mass.,2.  Hypertrophic scar of the left breast.,POSTOPERATIVE DIAGNOSES:,1.  Left breast mass.,2.  Hypertrophic scar of the left breast.,PROCEDURE PERFORMED:  ,Excision of left breast mass and revision of scar.,ANESTHESIA:  ,Local with sedation.,SPECIMEN: , Scar with left breast mass.,DISPOSITION:  ,The patient tolerated the procedure well and transferred to the recover room in stable condition.,BRIEF HISTORY:  ,The patient is an 18-year-old female who presented to Dr. X's office.  The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.  The patient also has a hypertrophic scar.  Thus, the patient elected to undergo revision of the scar at the same time as an excision of the palpable mass.,INTRAOPERATIVE FINDINGS: , A hypertrophic scar was found and removed.  The cicatrix was removed in its entirety and once opening the wound, the area of tissue where the palpable mass was, was excised as well and sent to the lab.,PROCEDURE: , After informed consent, risks, and benefits of the procedure were explained to the patient and the patient's family, the patient was brought to the operating suite, prepped and draped in the normal sterile fashion.  Elliptical incision was made over the previous cicatrix.  The total length of the incision was 5.5 cm.  Removing the cicatrix in its entirety with a #15 blade Bard-Parker scalpel after anesthetizing with local solution with 0.25% Marcaine.  Next, the area of tissue just inferior to the palpable mass, where the palpable was removed with electro Bovie cautery.  Hemostasis was maintained.  Attention was next made to approximating the deep dermal layers.  An interrupted #4-0 Vicryl suture was used and then a running subcuticular Monocryl suture was used to approximate the skin edges.  Steri-Strips as well as bacitracin and sterile dressings were applied.  The patient tolerated the procedure well and was transferred to recovery in stable condition.",37
"VITAL SIGNS:,  Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE: , Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT:,  Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  No papilledema, glaucoma, or cataracts.  Ears:  Normal set and shape with normal hearing and normal TMs. Nose and Sinus:  Unremarkable.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK: , Supple and pain free without carotid bruit, JVD, or significant cervical adenopathy.  Trachea is midline without stridor, shift, or subcutaneous emphysema.  Thyroid is palpable, nontender, not enlarged, and free of nodularity.,CHEST: , Lungs bilaterally clear to auscultation and percussion.,HEART: , S1 and S2.  Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop.  PMI is nondisplaced.  Chest wall is unremarkable to inspection and palpation.  No axillary or supraclavicular adenopathy detected.,BREASTS: , Normal male breast tissue.,ABDOMEN:,  No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding.  No widening of the aortic impulse and intraabdominal bruit on auscultation.,EXTERNAL GENITALIA: , Normal for age.  Normal penis with bilaterally descended testes that are normal in size, shape, and contour, and without evidence of hernia or hydrocele.,RECTAL:,  Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool and normal-sized prostate that is free of nodularity or tenderness.  No rectal masses palpated.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis.  Nails of the hands and feet, and creases of the palms and soles are unremarkable.  Good active and passive range of motion of all major joints.,BACK: , Normal to inspection and percussion.  Negative for spinous process tenderness or CVA tenderness.  Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC: , Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function.  Affect is normal.  Speech is clear and fluent.  Thought process is lucid and rational.  Gait and station are unremarkable.,SKIN:  ,Unremarkable for any premalignant or malignant condition with normal changes for age.",5
"PREOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,NAME OF OPERATION: , Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft.  Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.,ANESTHESIA: , General.,PROCEDURE DETAILS: , The patient was brought to the operating room and placed in the supine position upon the table.  After adequate general anesthesia, the patient was prepped with Betadine soap and solution in the usual sterile manner.  Elbows were protected to avoid ulnar neuropathy, chest wall expansion avoided to avoid ulnar neuropathy, phrenic nerve protectors used to protect the phrenic nerve and removed at the end of the case.,A midline sternal skin incision was made and carried down through the sternum which was divided with the saw.  Pericardial and thymus fat pad was divided.  The left internal mammary artery was harvested and spatulated for anastomosis.  Heparin was given.,Vein resected from the thigh, side branches secured using 4-0 silk and Hemoclips.  The thigh was closed multilayer Vicryl and Dexon technique.  A Pulsavac wash was done, drain was placed.,The left internal mammary artery is sewn to the left anterior descending using 7-0 running Prolene technique with the Medtronic off-pump retractors.  After this was done, the patient was fully heparinized, cannulated with a 6.5 atrial cannula and a 2-stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia.  Medtronic retractors used to expose the circumflex.  Prior to going on pump, we stapled the vein graft in place to the aorta.,Then, on pump, we did the distal anastomosis with a 7-0 running Prolene technique.  The right side graft was brought to the posterior descending artery using running 7-0 Prolene technique.  Deairing procedure was carried out.  The bulldogs were removed.  The patient maintained good normal sinus rhythm with good mean perfusion.  The patient was weaned from cardiopulmonary bypass.  The arterial and venous lines were removed and doubly secured.  Protamine was delivered.  Meticulous hemostasis was present.  Platelets were given for coagulopathy.  Chest tube was placed and meticulous hemostasis was present.  The anatomy and the flow in the grafts was excellent.  Closure was begun.,The sternum was closed with wire, followed by linea alba and pectus fascia closure with running 0 Vicryl sutures in double-layer technique.  The skin was closed with subcuticular 4-0 Dexon suture technique.  The patient tolerated the procedure well and was transferred to the intensive care unit in stable condition.,We minimized the pump time to 16 minutes for just the distal anastomosis of the circumflex in order to lessen the insult to the kidneys as the patient already has kidney failure with a creatinine of 3.0.",37
"HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps.  He states that for the past six months he has experienced cramps in his feet and hands.  He describes that the foot cramps are much more notable than the hand ones.  He reports that he develops muscle contractions of his toes on both feet.  These occur exclusively at night.  They may occur about three times per week.  When he develops these cramps, he stands up to relieve the discomfort.  He notices that the toes are in an extended position.  He steps on the ground and they seem to ""pop into place.""  He develops calf pain after he experiences the cramp.  Sometimes they awaken him from his sleep.,He also has developed cramps in his hands although they are less severe and less frequent than those in his legs.  These do not occur at night and are completely random.  He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,He has never had any symptoms like this in the past.  He started taking Bactrim about nine months ago.  He had taken this in the past briefly, but has never taken it as long as he has now.  He cannot think of any other possible contributing factors to his symptoms.,He has a history of HIV for 21 years.  He was taking antiretroviral medications, but stopped about six or seven years ago.  He reports that he was unable to tolerate the medications due to severe stomach upset.  He has a CD4 count of 326.  He states that he has never developed AIDS.  He is considering resuming antiretroviral treatment.,PAST MEDICAL HISTORY:,  He has diabetes, but this is well controlled.  He also has hepatitis C and HIV.,CURRENT MEDICATIONS: , He takes insulin and Bactrim.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , He lives alone.  He recently lost his partner.  This happened about six months ago.  He denies alcohol, tobacco, or illicit drug use.  He is now retired.  He is very active and walks about four miles every few days.,FAMILY HISTORY: , His father and mother had diabetes.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  Blood pressure 130/70",5
"PREOPERATIVE DIAGNOSIS: , Bunion, left foot.,POSTOPERATIVE DIAGNOSIS: ,Bunion, left foot.,PROCEDURE PERFORMED:,1.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation.,2.  Akin osteotomy with internal wire fixation of left foot.,HISTORY: , This 19-year-old Caucasian female presents to ABCD General Hospital with the above chief complaint.  The patient states she has had worsening bunion deformity for as long as she could not remember.  She does have a history of Charcot-Marie tooth disease and desires surgical treatment at this time.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in a Mayo block type fashion surrounding the lower left first metatarsal.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating field.  The stockinette was reflected, the foot was cleansed with a wet and dry sponge.  Approximately 5 cm incision was made dorsomedially over the first metatarsal.,The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  Care was taken to preserve the extensor digitorum longus tendon.  The capsule over the first metatarsal phalangeal then was identified where a dorsal capsular incision was then created down to the level of bone.  Capsule and periosteum was reflected off the first metatarsal head.  At this time, the cartilage was inspected and noted to be white, shiny, and healthy cartilage.  There was noted to be a prominent medial eminence.  Attention was then directed to first interspace where a combination of blunt and sharp dissection was done to perform a standard lateral release.  The abductor tendon attachments were identified and transected.  The lateral capsulotomy was performed.  The extensor digitorum brevis tendon was identified and transected.  Attention was then directed to the prominent medial eminence, which was resected with a sagittal saw.  Intraoperative assessment of pes was performed and pes was noted to be normal.,At this time, a regional incision was carried more approximately about 1.5 cm.  The capsular incision was then extended and the proximal capsule and periosteum were reflected off the first metatarsal.  The first metatarsal cuneiform joint was identified.  A 0.45 K-wire was then inserted into the base of the first metatarsal approximately 1 cm from the first cuneiform joint perpendicular to the weightbearing surface.  This K-wire was used as an access guide for a Juvaro type oblique base wedge osteotomy.  The sagittal saw was then used to creat a closing base wedge osteotomy with the apex being proximal medial.  The osteotomy site was then feathered and tilted with tight estimation of the bony edges.  The cortical hinge was maintained.  A 0.27 x 24 mm screw was then inserted in a standard AO fashion.  At this time, there was noted to be tight compression of the osteotomy site.  A second 2.7 x 16 mm screw was then inserted more distally in the standard AO fashion with compression noted.  The ________ angle was noted to be significantly released.  Reciprocating rasp was then used to smoothen any remaining sharp edges.  The 0.45 k-wire was removed.  The foot was loaded and was noted to fill the remaining abduction of the hallux.  At this time, it was incised to perform an Akin osteotomy.,Original incision was then extended distally approximately 1 cm.  The incision was then deepened down to the level of capsule over the base of the proximal phalanx.  Again care was taken to preserve the extensor digitorum longus tendon.  The capsule was reflected off of the base of the proximal phalanx.  An Akin osteotomy was performed with the apex being lateral and the base being medial.  After where the bone was resected, it was feathered until tight compression was noted without tension at the osteotomy site.  Care was taken to preserve the lateral hinge.  At 1.5 wire passed and a drill was then used to create drill hole proximal and distally to the osteotomy site in order for passage of 28 gauge monofilament wire.  The #28 gauge monofilament wire was passed through the drill hole and tightened down until compression and tight ________ osteotomy site was noted.  The remaining edge of the wire was then buried in the medial most distal drill hole.  The area was then inspected and the foot was noted with significant reduction of the bunion deformity.  The area was then flushed with copious amounts of sterile saline.  Capsule was closed with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl in order to decrease tension of the incision site.  A running #5-0 subcuticular stitch was then performed.  Steri-Strips were applied.  Total of 1 cc dexamethasone phosphate was then injected into the surgical site.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  Posterior splint was then placed on the patient in the operating room.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred back to the PACU with vital signs stable and vascular status intact to the left foot.  The patient was given postoperative instructions to be strictly nonweightbearing on the left foot.  The patient was given postop pain prescriptions for Vicodin and instructed to take one q.4-6h. p.r.n. for pain as well as Naprosyn 500 mg p.o. q. b.i.d.  The patient is to follow-up with Dr. X in his office in four to five days as directed.",37
"PREOPERATIVE DIAGNOSIS: , Nonpalpable neoplasm, right breast.,POSTOPERATIVE DIAGNOSIS: , Deferred for Pathology.,PROCEDURE PERFORMED:  ,Needle localized wide excision of nonpalpable neoplasm, right breast.,SPECIMEN: , Mammography.,GROSS FINDINGS:  ,This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast.  After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity.  This too was excised.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room, placed in supine position in the operating table.  Intravenous sedation was administered by the Anesthesia Department.  The Kopans wire was trimmed to an appropriate length.  The patient was sterilely prepped and draped in the usual manner.  Local anesthetic consisting of 1% lidocaine and 0.5% Marcaine was injected into the proposed line of incision.  A curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire.  The wire was stabilized and brought to protrude through the incision.  Skin flaps were then generated with electrocautery.  A generous core tissue was grasped with Allis forceps and excised with electrocautery.  Prior to complete excision, the superior margin was marked with a #2-0 Vicryl suture, which was tied and cut short.  The lateral margin was marked with a #2-0 Vicryl suture, which was tied and cut along.  The posterior margin was marked with a #2-0 Polydek suture, which was tied and cut.,The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm.  On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen.  Hemostasis was obtained with electrocautery.  Good hemostasis was obtained.  The incision was closed in two layers.  The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl.  The second layer consisted of Steri-Strips on the epidermis.  A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied.  The patient tolerated the surgery well.",24
"CHIEF COMPLAINT: , Aplastic anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia.  After several bone marrow biopsies, she was diagnosed with aplastic anemia.  She started cyclosporine and prednisone on 03/30/10.  She was admitted to the hospital from 07/11/10 to 07/14/10 with acute kidney injury.  Her cyclosporine level was 555.  It was thought that her acute kidney injury was due to cyclosporine toxicity and therefore that was held.,Overall, she tells me that now she feels quite well since leaving the hospital.  She was transfused 2 units of packed red blood cells while in the hospital.  Repeat CBC from 07/26/10 showed white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000.,CURRENT MEDICATIONS:,  Folic acid, Aciphex, MiraLax, trazodone, prednisone for 5 days every 4 weeks, Bactrim double strength 1 tablet b.i.d. on Mondays, Wednesdays and Fridays.,ALLERGIES:  ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  GERD.,3.  Osteoarthritis.,4.  Status post tonsillectomy.,5.  Status post hysterectomy.,6.  Status post bilateral cataract surgery.,7.  Esophageal stricture status post dilatation approximately four times.,SOCIAL HISTORY:  ,She has no tobacco use.  She has rare alcohol use.  She has three children and is a widow.  Her husband died after they were married only eight years.  She is retired.,FAMILY HISTORY: , Her sister had breast cancer.,PHYSICAL EXAM:,VIT:",16
"PREOPERATIVE DIAGNOSIS: , Clinical stage III squamous cell carcinoma of the vulva.,POSTOPERATIVE DIAGNOSIS: , Clinical stage III squamous cell carcinoma of the vulva.,OPERATION PERFORMED:,  Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Radical vulvectomy, right and left superficial and deep inguinal lymph nodes. ,INDICATIONS FOR PROCEDURE: , The patient recently presented with a new vaginal nodule. Biopsy was obtained and revealed squamous carcinoma.  The lesion extended slightly above the hymeneal ring and because of vaginal involvement was classified as a T3/Nx/Mx on clinical examination.  Of note, past history is significant for pelvic radiation for cervical cancer many years previously.,FINDINGS: , The examination under anesthesia revealed a 1.5 cm nodule of disease extending slightly above the hymeneal ring.  There was no palpable lymphadenopathy in either inguinal node region.  There were no other nodules, ulcerations, or other lesions.  At the completion of the procedure there was no clinical evidence of residual disease.,PROCEDURE:,  The patient was brought to the Operating Room with an IV in place.  She was placed in the low anterior lithotomy position after adequate anesthesia had been induced.  Examination under anesthesia was performed with findings as noted, after which she was prepped and draped.  The femoral triangles were marked and a 10 cm skin incision was made parallel to the inguinal ligament approximately 3 cm below the ligament.  Camper's fascia was divided and skin flaps were elevated with sharp dissection and ligation of vessels where necessary.  The lymph node bundles were mobilized by incising the loose areolar tissue attachments to the fascia of the rectus abdominis.  The fascia around the sartorius muscle was divided and the specimen was reflected from lateral to medial.  The cribriform fascia was isolated and dissected with preservation of the femoral nerve.  The femoral sheath containing artery and vein was opened and vessels were stripped of their lymphatic attachments.  The medial lymph node bundle was isolated, and Cloquet's node was clamped, divided, and ligated bilaterally.  The saphenous vessels were identified and preserved bilaterally.  The inferior margin of the specimen was ligated, divided, and removed.  Inguinal node sites were irrigated and excellent hemostasis was noted.  Jackson-Pratt drains were placed and Camper's fascia was approximated with simple interrupted stitches.  The skin was closed with running subcuticular stitches using 4-0 Monocryl suture.,Attention was turned to the radical vulvectomy specimen.  A marking pen was used to outline the margins of resection allowing 15-20 mm of margin on the inferior, lateral, and anterior margins.  The medial margin extended into the vagina and was approximately 5-8 mm.  The skin was incised and underlying adipose tissue was divided with electrocautery.  Vascular bundles were isolated, divided, and ligated.  After removal of the specimen, additional margin was obtained from the right vaginal side wall adjacent to the tumor site.  Margins were submitted on the right posterior, middle, and anterior vaginal side walls.  After removal of the vaginal margins, the perineum was irrigated with four liters of normal saline and deep tissues were approximated with simple interrupted stitches of 2-0 Vicryl suture.  The skin was closed with interrupted horizontal mattress stitches using 3-0 Vicryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.",24
"HISTORY: , The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis.  The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised.  Parents; however, did note the patient to be quite dusky since the time of her birth; however, were reassured by the pediatrician that this was normal.  The patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness, some irritability, and rapid heart rate.  Parents do state that she does appear to breathe rapidly, tires somewhat with the feeding with increased respiratory effort and diaphoresis.  The patient is exclusively breast fed and feeding approximately 2 hours.  Upon arrival at Children's Hospital, the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine.  The electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement, northwest axis, and poor R-wave progression, possible right ventricular hypertrophy.,FAMILY HISTORY:,  Family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed.,REVIEW OF SYSTEMS: , A complete review of systems including neurologic, respiratory, gastrointestinal, genitourinary are otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  Physical examination that showed a sedated, acyanotic infant who is in no acute distress.,VITAL SIGNS:  Heart rate of 170, respiratory rate of 65, saturation, it is nasal cannula oxygen of 74% with a prostaglandin infusion at 0.5 mcg/kg/minute.,HEENT:  Normocephalic with no bruit detected.  She had symmetric shallow breath sounds clear to auscultation.  She had full symmetrical pulses.,HEART:  There is normoactive precordium without a thrill.  There is normal S1, single loud S2, and a 2/6 continuous shunt type of murmur could be appreciated at the left upper sternal border.,ABDOMEN:  Soft.  Liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected.,X-RAYS:,  Review of the chest x-ray demonstrated a normal situs, normal heart size, and adequate pulmonary vascular markings.  There is a prominent thymus.  An echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs, a left superior vena cava draining into the left atrium, a criss-cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left-sided morphologic left ventricle.  The left atrium drained through the tricuspid valve into a right-sided morphologic right ventricle.  There is a large inlet ventricular septal defect as pulmonary atresia.  The aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch.  There was a small vertical ductus as a sole source of pulmonary artery blood flow.  The central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter.  Biventricular function is well maintained.,FINAL IMPRESSION: , The patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal-dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function.  The saturations are now also adequate on prostaglandin E1.,RECOMMENDATION: , My recommendation is that the patient be continued on prostaglandin E1.  The patient's case was presented to the cardiothoracic surgical consultant, Dr. X.  The patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence.  A consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention.  The patient will require some form of systemic to pulmonary shunt, modified pelvic shunt or central shunt as a durable source of pulmonary blood flow.  Further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible Rastelli procedure.  The current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional Glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age.  These findings and recommendations were reviewed with the parents via a Spanish interpreter.",29
"PREOPERATIVE DIAGNOSIS: , Right chronic subdural hematoma.,POSTOPERATIVE DIAGNOSIS: ,Right chronic subdural hematoma.,TYPE OF OPERATION: , Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 100 cc.,OPERATIVE PROCEDURE:,  In preoperative identification, the patient was taken to the operating room and placed in supine position.  Following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  Table was turned.  The right shoulder roll was placed.  The head was turned to the left and rested on a doughnut.  The scalp was shaved, and then prepped and draped in usual sterile fashion.  Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss.  The parietal boss incision was opened.  It was about an inch and a half in length.  It was carried down to the skull.  Self-retaining retractor was placed.  A bur hole was now fashioned with the perforator.  This was widened with a 2-mm Kerrison punch.  The dura was now coagulated with bipolar electrocautery.  It was opened in a cruciate-type fashion.  The dural edges were coagulated back to the bony edges.  There was egress of a large amount of liquid.  Under pressure, we irrigated for quite sometime until irrigation was returning mostly clear.  A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision.  It was secured with a 3-0 nylon suture.  The area was closed with interrupted inverted 2-0 Vicryl sutures.  The skin was closed with staples.  Sterile dressing was applied.  The patient was subsequently returned back to anesthesia.  He was extubated in the operating room, and transported to PACU in satisfactory condition.",22
"CHIEF COMPLAINT:,  GI bleed.,HISTORY OF PRESENT ILLNESS:,  The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue.  CBC revealed microcytic anemia with hemoglobin of 8.9.  Stool dark brown, strongly OB positive.  The patient denied any shortness of breath.  No chest pain.  No GI complaints.  The patient was admitted to ABCD for further evaluation.,PAST MEDICAL HISTORY:  ,Significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism.,PHYSICAL EXAMINATION:,GENERAL:  The patient is in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Benign.,NECK:  Supple.  No adenopathy.,LUNGS:  Clear with good air movement.,HEART:  Irregularly regular.  No gallops.,ABDOMEN:  Positive bowel sounds, soft, and nontender.  No masses or organomegaly.,EXTREMITIES:  1+ lower extremity edema bilaterally.,HOSPITAL COURSE: , The patient underwent upper endoscopy performed by Dr. A, which revealed erosive gastritis.  Colonoscopy did reveal diverticulosis as well as polyp, which was resected.  The patient tolerated the procedure well.  She was transfused, and prior to discharge hemoglobin was stable at 10.7.  The patient was without further GI complaints.  Coumadin was held during hospital stay and recommendations were given by GI to hold Coumadin for an additional three days after discharge then resume.  The patient was discharged with outpatient PMD, GI, and Cardiology followup.,DISCHARGE DIAGNOSES:,1.  Upper gastrointestinal bleed.,2.  Anemia.,3.  Atrial fibrillation.,4.  Non-insulin-dependent diabetes mellitus.,5.  Hypertension.,6.  Hypothyroidism.,7.  Asthma.,CONDITION UPON DISCHARGE: , Stable.,MEDICATIONS: , Feosol 325 mg daily, multivitamins one daily, Protonix 40 mg b.i.d., KCl 20 mEq daily, Lasix 40 mg b.i.d., atenolol 50 mg daily, Synthroid 80 mcg daily, Actos 30 mg daily, Mevacor 40 mg daily, and lisinopril 20 mg daily.,ALLERGIES:,  None.,DIET: , 1800-calorie ADA.,ACTIVITY: , As tolerated.,FOLLOWUP: , The patient to hold Coumadin through weekend.  Followup CBC and INR were ordered.  Outpatient followup as arranged.",10
"PREOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,PROCEDURE PERFORMED: , Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,COMPLICATIONS:  ,None.,BLOOD LOSS: , Minimal.,ANESTHESIA:,  Local with sedation.,INDICATION:,  The patient is a 65-year-old male with a large squamous cell carcinoma on his right upper eyelid, which had previous radiation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, laid supine, administered intravenous sedation, and prepped and draped in a sterile fashion.  He was anesthetized with a combination of 2% lidocaine and 0.5% Marcaine with Epinephrine on both upper eyelids.  The area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes.  This was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid.  The resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact.  Following complete resection, the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate.  The specimen was sent to pathology, which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma.  Meticulous hemostasis was obtained with Bovie cautery and a full-thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid.  The left upper eyelid incision was closed with 6-0 fast-absorbing gut interrupted sutures, and the skin graft was sutured in place with 6-0 fast-absorbing gut interrupted sutures.  An eye patch was placed on the right side, and the patient tolerated the procedure well and was taken to PACU in good condition.",37
"CHIEF COMPLAINT: , Blood in urine.,HISTORY OF PRESENT ILLNESS:  ,This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder.  The patient has had problems with hematuria in the past, but the patient noted that this episode began yesterday, and today he has been passing principally blood with very little urine.  The patient states that there is no change in his chronic lower back pain and denies any incontinence of urine or stool.  The patient has not had any fever.  There is no abdominal pain and the patient is still able to pass urine.  The patient has not had any melena or hematochezia.  There is no nausea or vomiting.  The patient has already completed chemotherapy and is beyond treatment for his cancer at this time.  The patient is receiving radiation therapy, but it is targeted to the bones and intended to give symptomatic relief of his skeletal pain and not intended to treat and cure the cancer.  The patient is not enlisted in hospice, but the principle around the patient's current treatment management is focusing on comfort care measures.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  The patient does report generalized fatigue and weakness over the past several days.  HEENT:  No headache, no neck pain, no rhinorrhea, no sore throat.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough, although the patient does get easily winded with exertion over these past few days.  GASTROINTESTINAL:  The patient denies any abdominal pain.  No nausea or vomiting.  No changes in the bowel movement.  No melena or hematochezia.  GENITOURINARY:  A gross hematuria since yesterday as previously described.  The patient is still able to pass urine without difficulty.  The patient denies any groin pain.  The patient denies any other changes to the genital region.  MUSCULOSKELETAL:  The chronic lower back pain which has not changed over these past few days.  The patient does have multiple other joints, which cause him discomfort, but there have been no recent changes in these either.  SKIN:  No rashes or lesions.  No easy bruising.  NEUROLOGIC:  No focal weakness or numbness.  No incontinence of urine or stool.  No saddle paresthesia.  No dizziness, syncope or near-syncope.  ENDOCRINE:  No polyuria or polydipsia.  No heat or cold intolerance.  HEMATOLOGIC/LYMPHATIC:  The patient does not have a history of easy bruising or bleeding, but the patient has had previous episodes of hematuria.,PAST MEDICAL HISTORY: , Prostate cancer with metastatic disease as previously described.,PAST SURGICAL HISTORY: , TURP.,CURRENT MEDICATIONS:,  Morphine, Darvocet, Flomax, Avodart and ibuprofen.,ALLERGIES: , VICODIN.,SOCIAL HISTORY: , The patient is a nonsmoker.  Denies any alcohol or illicit drug use.  The patient does live with his family.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure is 108/65, pulse is 109, respirations 16, oxygen saturation is 97% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed.  The patient appears to be pale, but otherwise looks well.  The patient is calm, comfortable.  The patient is pleasant and cooperative.  HEENT:  Eyes normal with clear conjunctivae and corneas.  Nose is normal without rhinorrhea or audible congestion.  Mouth and oropharynx normal without any sign of infection.  Mucous membranes are moist.  NECK:  Supple.  Full range of motion.  No JVD.  CARDIOVASCULAR:  Heart is mildly tachycardic with regular rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, nondistended.  No rebound or guarding.  No hepatosplenomegaly.  Normal bowel sounds.  No bruit.  No masses or pulsatile masses.  GENITOURINARY:  The patient has normal male genitalia, uncircumcised.  There is no active bleeding from the penis at this time.  There is no swelling of the testicles.  There are no masses palpated to the testicles, scrotum or the penis.  There are no lesions or rashes noted.  There is no inguinal lymphadenopathy.  Normal male exam.  MUSCULOSKELETAL:  Back is normal and nontender.  There are no abnormalities noted to the arms or legs.  The patient has normal use of the extremities.  SKIN:  The patient appears to be pale, but otherwise the skin is normal.  There are no rashes or lesions.  NEUROLOGIC:  Motor and sensory are intact to the extremities.  The patient has normal speech.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  There is no evidence of bruising noted to the body.  No lymphadenitis is palpated.,EMERGENCY DEPARTMENT TESTING:,  CBC was done, which had a hemoglobin of 7.7 and hematocrit of 22.6.  Neutrophils were 81%.  The RDW was 18.5, and the rest of the values were all within normal limits and unremarkable.  Chemistry had a sodium of 134, a glucose of 132, calcium is 8.2, and rest of the values are unremarkable.  Alkaline phosphatase was 770 and albumin was 2.4.  Rest of the values all are within normal limits of the LFTs.  Urinalysis was grossly bloody with a large amount of blood and greater than 50 rbc's.  The patient also had greater than 300 of the protein reading, moderate leukocytes, 30-50 white blood cells, but no bacteria were seen.  Coagulation profile study had a PT of 15.9, PTT of 43 and INR of 1.3.,EMERGENCY DEPARTMENT COURSE: , The patient was given normal saline 2 liters over 1 hour without any adverse effect.  The patient was given multiple doses of morphine to maintain his comfort while here in the emergency room without any adverse effect.  The patient was given Levaquin 500 mg by mouth as well as 2 doses of Phenergan over the course of his stay here in the emergency department.  The patient did not have an adverse reaction to these medicines either.  Phenergan resolved his nausea and morphine did relieve his pain and make him pain free.  I spoke with Dr. X, the patient's urologist, about most appropriate step for the patient, and Dr. X said he would be happy to care for the patient in the hospital and do urologic scopes if necessary and surgery if necessary and blood transfusion.  It was all a matter of what the patient wished to do given the advanced stage of his cancer.  Dr. X was willing to assist in any way the patient wished him to.  I spoke with the patient and his son about what he would like to do and what the options were from doing nothing from keeping him comfortable with pain medicines to admitting him to the hospital with the possibility of scopes and even surgery being done as well as the blood transfusion.  The patient decided to choose a middle ground in which he would be transfused with 2 units of blood here in the emergency room and go home tonight.  The patient's son felt comfortable with his father's choice.  This was done.  The patient was transfused 2 units of packed red blood cells after appropriately typed and match.  The patient did not have any adverse reaction at any point with his transfusion.  There was no fever, no shortness of breath, and at the time of disposition, the patient stated he felt a little better and felt like he had a little more strength.  Over the course of the patient's several-hour stay in the emergency room, the patient did end up developing enough problems with clotted blood in his bladder that he had a urinary obstruction.  Foley catheter was placed, which produced bloody urine and relieved the developing discomfort of a full bladder.  The patient was given a leg bag and the Foley catheter was left in place.,DIAGNOSES,1.  HEMATURIA.,2.  PROSTATE CANCER WITH BONE AND BLADDER METASTATIC DISEASE.,3.  SIGNIFICANT ANEMIA.,4.  URINARY OBSTRUCTION.,CONDITION ON DISPOSITION:  ,Fair, but improved.,DISPOSITION: , To home with his son.,PLAN: , We will have the patient follow up with Dr. X in his office in 2 days for reevaluation.  The patient was given a prescription for Levaquin and Phenergan tablets to take home with him tonight.  The patient was encouraged to drink extra water.  The patient was given discharge instructions on hematuria and asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern.",15
"SUBJECTIVE:,  The patient comes back to see me today.  She is a pleasant 73-year-old Caucasian female who had seen Dr. XYZ with low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.  Dr. XYZ had performed right and left facet and sacroiliac joint injections, subsequent right L3 to S1 medial branch blocks and radiofrequency ablation on the right from L3 to S1.  She was subsequently seen with some mid back pain and she had right T8-T9 and T9-T10 facet injections on 10/28/2004.  She was last seen on 04/08/2005 with recurrent pain in her low back on the right.  Dr. XYZ repeated her radiofrequency ablation on the right side from L3-S1 on 05/04/2005.,The patient comes back to see me today.  She states that the radiofrequency ablation has helped her significantly there, but she still has one spot in her low back that seems to be hurting her on the right, and seems to be pointing to her right sacroiliac joint.  She is also complaining of pain in both knees.  She says that 20 years ago she had a cortisone shot in her knees, which helped her significantly.  She has not had any x-rays for quite some time.  She is taking some Lortab 7.5 mg tablets, up to four daily, which help her with her pain symptoms.  She is also taking Celebrex through Dr. S’ office.,PAST MEDICAL HISTORY:,  Essentially unchanged from my visit of 04/08/2005.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant Caucasian female.,Vital Signs:  Height is 5 feet 5 inches.  Weight is 183 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Musculoskeletal:  Examination shows degenerative joint disease of both knees, with medial and lateral joint line tenderness, with tenderness at both pes anserine bursa.  Straight leg raises are negative bilaterally.  Posterior tibials are palpable bilaterally.,Skin and Lymphatics:  Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers.  No significant lymphadenopathy noted.,Spine:  Examination shows decreased lumbar lordosis with tenderness that seems to be in her right sacroiliac joint.  She has no other major tenderness.  Spinal movements are limited but functional.,Neurological:  She is alert and oriented with appropriate mood and affect.  She has normal tone and coordination.  Reflexes are 2+ and symmetrical.  Sensation is intact to pinprick.,FUNCTIONAL EXAMINATION:,  Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1.  Low back syndrome with lumbar degenerative disc disease, lumbar spinal stenosis, and facet joint syndrome on the right L4-5 and L5-S1.,2.  Improved, spinal right L3-S1 radiofrequency ablation.,3.  Right sacroiliac joint sprain/strain, symptomatic.,4.  Left lumbar facet joint syndrome, stable.,6.  Right thoracic facet joint syndrome, stable.,7.  Lumbar spinal stenosis, primarily lateral recess with intermittent lower extremity radiculopathy, stable.,8.  Degenerative disc disease of both knees, symptomatic.,9.  Pes anserinus bursitis, bilaterally symptomatic.,10.  Chronic pain syndrome.,RECOMMENDATIONS:,  Dr. XYZ and I discussed with the patient her pathology.  She has some symptoms in her low back on the right side at the sacroiliac joint.  Dr. XYZ will plan having her come in and injecting her right sacroiliac joint under fluoroscopy.  She is also having pain in both knees.  We will plan on x-rays of both knees, AP and lateral, and plan on seeing her back on Monday or Friday for possible intraarticular and/or pes anserine bursa injections bilaterally.  I explained the rationale for each of these injections, possible complications and she wishes to proceed.  In the interim, she can continue on Lortab and Celebrex.  We will plan for the follow up following these interventions, sooner if needed.  She voiced understanding and agreement.  Physical exam findings, history of present illness, and recommendations were performed with and in agreement with Dr. Goel's findings.",5
"PREOPERATIVE DIAGNOSIS:  ,Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,POSTOPERATIVE DIAGNOSIS: , Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,OPERATION: , Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.,ANESTHESIA: , Endotracheal.,ESTIMATED BLOOD LOSS: , 250 mL,REPLACEMENTS:  ,3 units of packed cells.,DRAINS:,  None.,COMPLICATIONS: , None.,PROCEDURE:  ,With the patient prepped and draped in the routine fashion in the supine position with the head in a Mayfield headrest, turned 45 degrees to the patient's left and a small roll placed under her right shoulder and hip, the previously made pterional incision was reopened and extended along its posterior inferior limb to the patient's zygoma.  Additional aspect of the temporalis muscle and fascia were incised with cutting Bovie current with effort made to preserve the posterior limb of the external carotid artery.  The scalp and temporalis muscle were then retracted anteroinferiorly with 0 silk sutures, attached rubber bands and Allis clamps and similar retraction of the posterior aspect of temporalis was retracted with 0 silk suture, attached with rubber bands and Allis clamps.  The bone flap, which had not been fixed in place was removed.  An additional portion of the temporofrontal bone based at the zygoma was removed with a B1 dissecting tool, B1 attached to the Midas Rex instrumentation.  Further bone removal was accomplished with Leksell rongeur, and hemostasis controlled with the use of bone wax.,At this point, a retractor was placed along the frontal lobe for visualization of the perichiasmatic cistern with visualization made of the optic nerve and carotid artery.  It should be noted that cottonoid paddies were placed over the brain to protect the cortical surface of the brain both underneath the retractor and the remainder of the exposed cortex.  The sylvian fissure was then dissected with the dissection description being dictated by Dr. X.,Following successful splitting of the sylvian fissure to its apparent midplate, attention was next turned to the temporal tip where the approximate location of the cerebral aneurysm noted on CT angio, as well as conventional arteriography was noted and a peel incision was made extending from the temporal tip approximately 3 cm posterior.  This was enlarged with bipolar coagulation and aspiration and inferior dissection accomplished under the operating microscope until the dome of, what appeared to be, an aneurysm could be visualized.,Dissection around the dome with bipolar coagulation and aspiration revealed a number of abnormal vessels, which appeared to be involved with the aneurysm at its base and these were removed with bipolar coagulation.  Until circumferential dissection revealed 1 major arterial supply to the base of the aneurysm, this was felt to be able to be handled with bipolar coagulation, which was done and the vessel then cut with microscissors and the aneurysm removed in toto.,Attention was next turned to the apparent nidus of the arteriovenous malformation, which was somewhat medial and inferior to the aneurysm and the nidus was then dissected with the use of bipolar coagulation and aspiration microscissors as further described by Dr. X. With removal of the arteriovenous malformation, attention was then turned to the previous frontal cortical incision, which was the site of partial decompression of the patient's intracerebral hematoma on the day of her admission.  Self-retaining retractors were placed within this cortical incision, and the hematoma cavity entered with additional hematoma removed with general aspiration and irrigation.  Following removal of additional hematoma, the bed of the hematoma site was lined with Surgicel.  Irrigation revealed no further active bleeding, and it was felt that at this time both the arteriovenous malformation, associated aneurysm, and intracerebral hematoma had been sequentially dealt with.,The cortical surface was then covered with Surgicel and the dura placed over the surface of the brain after coagulation of the dural edges, the freeze dried fascia, which had been used at the time of the 1st surgery was replaced over the surface of the brain with additional areas of cortical exposure covered with a DuraGuard.  The 2nd bone flap from the inferior frontotemporal region centered along the zygoma was reattached to the initial bone flap at 3 sites using a small 2-holed plate and 3-mm screws and the portable minidriver.,With this, return of the inferior plate accomplished, it was possible to reposition the bone flaps into their initial configuration, and attachments were secured anterior and posterior with somewhat longer 2-holed plates and 3-mm screws to the frontal and posterior temporal parietal region.  The wound was then closed.  It should be noted that a pledget of Gelfoam had been placed over the entire dural complex prior to returning the bone flap.  The wound was then closed by approximating the temporalis muscle with 2-0 Vicryl suture, the fascia was closed with 2-0 Vicryl suture, and the galea was closed with 2-0 interrupted suture, and the skin approximated with staples.  The patient appeared to tolerate the procedure well without complications.",23
"ADMISSION PSYCHIATRIC EVALUATION,IDENTIFYING INFORMATION/REFERRAL DATA:  ,This is a 16-year-old Caucasian adolescent female who is going into ninth grade and lives with her mother, the mother's boyfriend, and a 12, 11, and 10-year-old sister.  She also has a stepsister that is 8 years old.  The patient was brought in by her mother after being picked up by Anchorage Police Department (APD).  She was brought to our institution for an assessment.  ,REASON FOR ADMISSION/CHIEF COMPLAINT:  ,The patient ran away in the middle of the night on Sunday, 07/19/04, and she has been on the run since then.  Her friends report to the parents that she is suicidal and that she had a knife.  A friend took a knife away from her to keep her from cutting herself.  ,HISTORY OF PRESENT ILLNESS:  ,This is a 16-year-old Caucasian adolescent girl who was brought in by APD and her parents.  This is her first admission.  APD picked her up from a runaway and brought her at her mother's request after some friends told the mother that she was suicidal.  The mother found journals in her room talking about suicide, and that she has been raped.  There were no details and the client denies that she was raped.  She is sexually active with one boyfriend, also 16 years old, that she met while going to school in Ketchican in the last school year.  She has been with the mother only the last two months and the same Ketchican boyfriend, Michael, followed her to Anchorage.  She reports symptoms of depression, no energy, initial and middle insomnia, eating more.  She is very irritable and has verbal altercations wither sister who is 14.  She admits to being sad and also having poor concentration.  She had marked drop in school functioning in the last year, and will need to repeat the ninth grade.  The mother is very concerned with the patent's safety and feels she is not able to control her.  She lived with her stepfather when she was 8 to 9 years old, but she was too problematic and not successful living there in Ketchican.  She went to live with her dad up to age 16.  Now she is living with her mother and her mother's boyfriend for the last two months.  In December, her grandmother passed away and she was with her grandmother and her mother during all this process, which is when she started feeling depressed.,LEGAL HISTORY:  ,No legal history.,TREATMENT/PSYCHIATRIC HISTORY:  ,The patient was evaluated once at XYZ when she was 14 due to depression, also when she was 3 years old when a new sibling came into the family.  ,FAMILY PSYCHIATRIC HISTORY:  ,The patient has three siblings with ADHD (Attention Deficit Hyperactivity Disorder) and two of her siblings are in an RTC (Residential Treatment Center) Program, one with the diagnosis of Bipolar Disorder, and the other with ADHD and bipolar condition.,PERTINENT MEDICAL HISTORY:  ,She was born with some eczema.  At age 4 she was involved in an accident where she cut one of her legs and needed sutures.  There is no history of seizure or head injury.  She reports loss of consciousness.  This will be investigated; there are no details about it.  She admits to being sexually active, protecting herself using condoms.  Her last menstruation period was 07/20/04.  ,ALLERGIES:  ,No allergies.,DEVELOPMENT AGE FACTORS: , The mother reports she was born with some jaundice and eczema.  Early milestones walk and talk.  The patient appears to function at the expected age level.  ,PERTINENT PSYCHOSOCIAL DATA:  ,Complete pertinent psychosocial will be obtained by our clinician.  The patient admits witnessing seeing some domestic violence when she was small, around five years old.  There is an allegation of a rape that the mother found in her journal, but this is going to be investigated.  ,SCHOOL HISTORY:",32
"City, State,Dear Dr. Y:,I had the pleasure of seeing ABC today back in Neurology Clinic where he has been followed previously by Dr. Z.  His last visit was in June 2006, and he carries a diagnosis of benign rolandic epilepsy.  To review, his birth was unremarkable.  He is a second child born to a G3, P1 to 2 female.  He has had normal development, and is a bright child in 7th grade.  He began having seizures, however, at 9 years of age.  It is manifested typically as generalized tonic-clonic seizures upon awakening or falling into sleep.  He also had smaller spells with more focal convulsion and facial twitching.  His EEGs have shown a pattern consistent with benign rolandic epilepsy (central temporal sharp waves both of the right and left hemisphere).  Most recent EEG in May 2006 shows the same abnormalities.,ABC initially was placed on Tegretol, but developed symptoms of toxicity (hallucinations) on this medication, he was switched to Trileptal.  He has done very well taking 300 mg twice a day without any further seizures.  His last event was the day of his last EEG when he was sleep deprived and was off medication.  That was a convulsion lasting 5 minutes.  He has done well otherwise.  Parents deny that he has any problems with concentration.  He has not had any behavior issues.  He is an active child and participates in sports and some motocross activities.  He has one older sibling and he lives with his parents.  Father manages Turkey farm with foster farms.  Mother is an 8th grade teacher.,Family history is positive for a 3rd cousin, who has seizures, but the specific seizure type is not known.  There is no other relevant family history.,Review of systems is positive for right heel swelling and tenderness to palpation.  This is perhaps due to sports injury.  He has not sprained his ankle and does not have any specific acute injury around the time that this was noted.  He does also have some discomfort in the knees and ankles in the general sense with activities.  He has no rashes or any numbness, weakness or loss of skills.  He has no respiratory or cardiovascular complaints.  He has no nausea, vomiting, diarrhea or abdominal complaints.,Past medical history is otherwise unremarkable.,Other workup includes CT scan and MRI scan of the brain, which are both normal.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-nourished, well-hydrated male in no acute distress.  VITAL SIGNS:  His weight today is 80.6 pounds.  Height is 58-1/4 inches.  Blood pressure 113/66.  Head circumference 36.3 cm.  HEENT:  Atraumatic, normocephalic.  Oropharynx shows no lesions.  NECK:  Supple without adenopathy.  CHEST:  Clear auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs.  ABDOMEN:  Benign without organomegaly.  EXTREMITIES:  No clubbing, cyanosis or edema.  NEUROLOGIC:  The patient is alert and oriented.  His cognitive skills appear normal for his age.  His speech is fluent and goal-directed.  He follows instructions well.  His cranial nerves reveal his pupils equal, round, and reactive to light.  Extraocular movements are intact.  Visual fields are full.  Disks are sharp bilaterally.  Face moves symmetrically with normal sensation.  Palate elevates midline.  Tongue protrudes midline.  Hearing is intact bilaterally.  Motor exam reveals normal strength and tone.  Sensation intact to light touch and vibration.  His gait is nonataxic with normal heel-toe and tandem.  Finger-to-nose, finger-nose-finger, rapid altering movements are normal.  Deep tendon reflexes are 2+ and symmetric.,IMPRESSION:  ,This is an 11-year-old male with benign rolandic epilepsy, who is followed over the past 2 years in our clinic.  Most recent electroencephalogram still shows abnormalities, but it has not been done since May 2006.  The plan at this time is to repeat his electroencephalogram, follow his electroencephalogram annually until it reveres to normal.  At that time, he will be tapered off of medication.  I anticipate at some point in the near future, within about a year or so, he will actually be taken off medication.  For now, I will continue on Trileptal 300 mg twice a day, which is a low starting dose for him.  There is no indication that his dose needs to be increased.  Family understands the plan.  We will try to obtain an electroencephalogram in the near future in Modesto and followup is scheduled for 6 months.  Parents will contact us after the electroencephalogram is done so they can get the results.,Thank you very much for allowing me to access ABC for further management.",22
"CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM:  ,Shortness of breath for two weeks and a history of pneumonia.  The patient also has a history of left lobectomy.,TECHNIQUE: , Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: , There is no evidence of any acute pulmonary arterial embolism.,The main pulmonary artery is enlarged showing a diameter of 4.7 cm.,Cardiomegaly is seen with mitral valvular calcifications.,Postsurgical changes of a left upper lobectomy are seen.  Left lower lobe atelectasis is noted.  A 7 mm and a 5 mm pulmonary nodule are seen within the left lower lobe (image #12).  A small left pleural effusion is noted.,Right lower lobe atelectasis is present.  There is a right pleural effusion, greater than as seen on the left side.  A right lower lobe pulmonary nodule measures 1.5 cm.  There is a calcified granuloma within the right lower lobe.,IMPRESSION:,1.  Negative for pulmonary arterial embolism.,2.  Enlargement of the main pulmonary artery as can be seen with pulmonary arterial hypertension.,3.  Cardiomegaly with mitral valvular calcifications.,4.  Postsurgical changes of a left upper lobectomy.,5.  Bilateral pleural effusions, right greater than left with bilateral lower lobe atelectasis.,6.  Bilateral lower lobe nodules, pulmonary nodules, and interval followup in three months to confirm stability versus further characterization with prior studies is advised.",3
"REASON FOR VISIT:,  Six-month follow-up visit for paroxysmal atrial fibrillation (PAF).,She reports that she is getting occasional chest pains with activity.  Sometimes she feels that at night when she is lying in bed and it concerns her.,She is frustrated by her inability to lose weight even though she is hyperthyroid.,MEDICATIONS: , Tapazole 10 mg b.i.d., atenolol/chlorthalidone 50/25 mg b.i.d., Micro-K 10 mEq q.d., Lanoxin 0.125 mg q.d., spironolactone 25 mg q.d., Crestor 10 mg q.h.s., famotidine 20 mg, Bayer Aspirin 81 mg q.d., Vicodin p.r.n., and Nexium 40 mg-given samples of this today.,REVIEW OF SYSTEMS:,  No palpitations.  No lightheadedness or presyncope.  She is having mild pedal edema, but she drinks a lot of fluid.,PEX: , BP:  112/74.  PR:  70.  WT:  223 pounds (up three pounds).  Cardiac:  Regular rate and rhythm with a 1/6 murmur at the upper sternal border.  Chest:  Nontender.  Lungs:  Clear.  Abdomen:  Moderately overweight.  Extremities:  Trace edema.,EKG: , Sinus bradycardia at 58 beats per minute, mild inferolateral ST abnormalities.,IMPRESSION:,1.  Chest pain-Mild.  Her EKG is mildly abnormal.  Her last stress echo was in 2001.  I am going to have her return for one just to make sure it is nothing serious.  I suspect; however, that is more likely due to her weight and acid reflux.  I gave her samples of Nexium.,2.  Mild pedal edema-Has to cut down on fluid intake, weight loss will help as well, continue with the chlorthalidone.,3.  PAF-Due to hypertension, hyperthyroidism and hypokalemia.  Staying in sinus rhythm.,4.  Hyperthyroidism-Last TSH was mildly suppressed, she had been out of her Tapazole for a while, now back on it.,5.  Dyslipidemia-Samples of Crestor given.,6.  LVH.,7.  Menometrorrhagia.,PLAN:,1.  Return for stress echo.,2.  Reduce the fluid intake to help with pedal edema.,3.  Nexium trial.",3
"PREOPERATIVE DIAGNOSIS:,1.  Left chronic anterior and posterior ethmoiditis.,2.  Left chronic maxillary sinusitis with polyps.,3.  Left inferior turbinate hypertrophy.,4.  Right anterior and posterior chronic ethmoiditis.,5.  Right chronic maxillary sinusitis with polyps.,6.  Right chronic inferior turbinate hypertrophic.,7.  Intranasal deformity causing nasal obstruction due to septal deviation.,POSTOPERATIVE DIAGNOSIS:,1.  Left chronic anterior and posterior ethmoiditis.,2.  Left chronic maxillary sinusitis with polyps.,3.  Left inferior turbinate hypertrophy.,4.  Right anterior and posterior chronic ethmoiditis.,5.  Right chronic maxillary sinusitis with polyps.,6.  Right chronic inferior turbinate hypertrophic.,7.  Intranasal deformity causing nasal obstruction due to septal deviation.,NAME OF OPERATION: , Bilateral endoscopic sinus surgery, including left anterior and posterior ethmoidectomy, left maxillary antrostomy with polyp removal, left inferior partial turbinectomy, right anterior and posterior ethmoidectomy, right maxillary antrostomy and polyp removal, right partial inferior turbinectomy, and septoplasty.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 20 cc.,HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old female who has had chronic nasal obstruction secondary to nasal polyps and chronic sinusitis.  She also has a septal deviation mid posterior to the left compromising greater than 70% of her nasal airway.,PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  After adequate endotracheal anesthesia was obtained, the skin was prepped and draped in sterile fashion.  Lidocaine 1% with 1:100,000 epinephrine was injected into the region of the anterior portion of the nasal septum.  Approximately 10 cc total was used.,A #15 blade and the Freer elevator were used to help make a standard hemitransfixion incision.  A mucoperichondrial flap was carefully elevated, and the junction with the cartilaginous bony septum was separated with the Freer elevator.  The bony deflection was removed using Jansen-Middleton forceps.  The cartilaginous deflection was created by freeing up the inferior attachments to the cartilaginous septum, placing it more on the midline maxillary crest.  The initial incision was placed in its anatomical position and secured with a 4-0 nylon suture for stabilization effect.,Attention then was directed toward the left side.  Lidocaine 1% with 1:100,000 epinephrine was injected in the region of the anterior portion of the left middle turbinate and uncinate process and polyps.  Approximately 10 cc total was used.  The polyps were removed using the Richards essential shaver to help identify the middle turbinate and uncinate process better.  The uncinate process was removed systematically superiorly to inferiorly with back-biting forceps.  Next, the maxillary antrostomy was identified and expanded with the back-biting forceps and showed polypoid accumulation in the mucosal disease on its opening site.  The sinus linings were edematous but did not have any polyps in the inferior, lateral, or superior aspects.,The anterior and posterior ethmoid air cells were entered primarily and dissected with the Richards essential shaver followed by the use of a 30-degree endoscope and up-biting forceps for the superior and lateral dissection.  Bright mucosal disease and small polypoid accumulations were noted through the sinuses also.  The inferior turbinates had some polypoid changes on them also and showed marked mucosal irritation and hypertrophy.  The mucosal polypoid accumulations were cleared using the Richards essential shaver.  The turbinate was partially resected from mucosally but with good shape to it.  It was not desirable to remove it in its entirety.  Any obvious bleeding points along the edge were controlled with the suction Bovie apparatus.,The same procedure and findings were noted on the right side with 1% lidocaine with 1:100,000 epinephrine injected into the anterior portion of the right middle turbinate, polyps, and uncinate process; 10 cc total were used.  The polyps were removed.  The Richards essential shaver was used to allow better exposure of the uncinate process.  The uncinate process was removed superiorly to inferiorly with back-biting side-biting forceps.,Next, a maxillary antrostomy was identified and expanded with the back-biting and side-biting forceps and showed all plate accumulations there also.  The anterior and posterior ethmoid air cells were then entered primarily and dissected with Richards essential shaver followed by the use of the 30-degree scope and up-biting forceps for the superior and lateral resection.  The inferior turbinates showed mucosal disease, polypoid accumulations, and changes.  These were removed using the Richards essential shaver followed by a submucosal resection of the hypertrophied portion of the turbinate.,Any obvious bleeding points were controlled with the suction Bovie apparatus.  A thorough irrigation was then carried out in the nasal cavity, and Gelfilm packing was used to coat the linings in the middle meatal regions.  The patient tolerated the procedure well and returned to the recovery room in stable condition.",11
"HISTORY OF PRESENT ILLNESS:  This is a 91-year-old female who was brought in by family.  Apparently, she was complaining that she felt she might have been poisoned at her care facility.  The daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated and she thinks that is the biggest problem with the patient right now.  The patient apparently had a little bit of dry heaves, but no actual vomiting.  She had just finished eating dinner.  No one else in the facility has been ill.,PAST MEDICAL HISTORY: Remarkable for previous abdominal surgeries.  She has a pacemaker.  She has a history of recent collarbone fracture.,REVIEW OF SYSTEMS:  Very difficult to get from the patient herself.  She seems to deny any significant pain or discomfort, but really seems not particularly intent on letting me know what is bothering her.  She initially stated that everything was wrong, but could not specify any specific complaints.  Denies chest pain, back pain, or abdominal pain.  Denies any extremity symptoms or complaints.,SOCIAL HISTORY:  The patient is a nonsmoker.  She is accompanied here with daughter who brought her over here.  They were visiting the patient when this episode occurred.,MEDICATIONS:  Please see list.,ALLERGIES:  NONE.,PHYSICAL EXAMINATION:  VITAL SIGNS:  The patient is afebrile, actually has a very normal vital signs including normal pulse oximetry at 99% on room air.  GENERAL:  The patient is an elderly frail looking little lady lying on the gurney.  She is awake, alert, and not really wanted to answer most of the questions I asked her.  She does have a tremor with her mouth, which the daughter states has been there for ""many years"".  HEENT:  Eye exam is unremarkable.  Oral mucosa is still moist and well hydrated.  Posterior pharynx is clear.  NECK:  Supple.  LUNGS:  Actually clear with good breath sounds.  There are no wheezes, no rales, or rhonchi.  Good air movement.  CARDIAC:  Without murmur.  ABDOMEN:  Soft.  I do not elicit any tenderness.  There is no abdominal distention.  Bowel sounds are present in all quadrants.  SKIN:  Skin is without rash or petechiae.  There is no cyanosis.  EXTREMITIES:  No evidence of any trauma to the extremities.,EMERGENCY DEPARTMENT COURSE:  I had a long discussion with the family and they would like the patient receive something for agitation, so she was given 0.5 mg of Ativan intramuscularly.  After about half an hour, I came back to talk to the patient and the family, the patient states that she feels better.  Family states she seems more calm.  They do not want to pursue any further workup at this time.,IMPRESSION:  ACUTE EPISODE OF AGITATION.,PLAN:  At this time, I had reviewed the patient's records and it is not particularly enlightening as to what could have triggered off this episode.  The patient herself has good vital signs.  She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given, a small quantity was given to the patient.  Family and daughter specifically did not want to pursue any workup at this point, which at this point I think is reasonable and we will have her follow up with ABC.  She is discharged in stable condition.",12
"ADMITTING DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,DISCHARGE DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,3.  Pneumonia.,HISTORY OF PRESENT ILLNESS: , The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who presented with a 36-hour presentation of URI symptoms, then had an abrupt onset of cough and increased work of breathing.  Child was brought to Children's Hospital and received nebulized treatments in the ER and the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,He was placed on the hospitalist system and was started on continuous nebulized albuterol secondary to his respiratory distress.  He also received inhaled as well as systemic corticosteroids.  An x-ray was without infiltrate on initial review by the hospitalist, but there was a right upper lobe infiltrate versus atelectasis per the official radiology reading.  The patient was not started on any antibiotics and his fever resolved.  However, the CRP was relatively elevated at 6.7.  The CBC was normal with a white count of 9.6; however, the bands were 84%.  Given these results, which she is to treat the pneumonia as bacterial and discharge the child with amoxicillin and Zithromax.,He was taken off of continuous and he was not on room air all night.  In the morning, he still had some bilateral wheezing, but no tachypnea.,DISCHARGE PHYSICAL EXAMINATION: , ,GENERAL:  No acute distress, running around the room.,HEENT:  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly or masses.,CHEST:  Bilateral basilar wheezing.  No distress.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses.  Nontender to palpation.,GENITOURINARY:  Deferred.,EXTREMITIES:  Warm and well perfused.,DISCHARGE INSTRUCTIONS:,  As follows:,1.  Activity, regular.,2.  Diet is regular.,3.  Follow up with Dr. X in 2 days.,DISCHARGE MEDICATIONS:,1.  Xopenex MDI 2 puffs every 4 hours for 2 days and then as needed for cough or wheeze.,2.  QVAR 40, 2 puffs twice daily until otherwise instructed by the primary care provider.,3.  Amoxicillin 550 mg p.o. twice daily for 10 days.,4.  Zithromax 150 mg p.o. on day 1, then 75 mg p.o. daily for 4 more days.,Total time for this discharge 37 minutes.",10
"TITLE OF OPERATION: , Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,INDICATION FOR SURGERY: , The patient is a 2-month-old infant, born premature with intraventricular hemorrhage and Ommaya reservoir recommendation for removal and replacement with a new VP shunt.,PREOP DIAGNOSIS: , Hydrocephalus.,POSTOP DIAGNOSIS: , Hydrocephalus.,PROCEDURE DETAIL: , The patient was brought to the operating room, underwent induction of general endotracheal airway, positioned supine, head turned towards left.  The right side prepped and draped in the usual sterile fashion.  Next, using a 15 blade scalpel, two incisions were made, one in the parietooccipital region and.  The second just lateral to the umbilicus.  Once this was clear, the Bactiseal catheter was then tunneled.  This was connected to a Strata valve.  The Strata valve was programmed to a setting of 1.01 and this was ensured.  The small burr hole was then created.  The area was then coagulated.  Once this was completed, new Bactiseal catheter was then inserted.  It was connected to the Strata valve.  There was good distal flow.  The distal end was then inserted into the peritoneal region via trocar.  Once this was insured, all the wounds were irrigated copiously and closed with 3-0 Vicryl and 4-0 Caprosyn as well as Indermil glue.  The right frontal incision was then opened.  The Ommaya reservoir identified and removed.  The wound was then also closed with an inverted 3-0 Vicryl and 4-0 Caprosyn.  Once all the wounds were completed, dry sterile dressings were applied.  The patient was then transported back to the ICU in stable condition intubated.  Blood loss minimal.  All sponge and needle counts were correct.",23
"CC: ,Low Back Pain (LBP) with associated BLE weakness.,HX:, This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95; began radiating down the RLE, on 12/6/95; then down the LLE, on 12/9/95. By 12/10/95, he found it difficult to walk. On 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. He was given some NSAID and drove home. By the time he got home he had great difficulty walking due to LBP and weakness in BLE, but managed to feed his pets and himself. On 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain. He also had had BLE numbness since 12/11/95. He was evaluated locally and an L-S-Spine CT scan and L-S Spine X-rays were ""negative."" He was then referred to UIHC.,MEDS: ,SLNTC, Coumadin 4mg qd, Propranolol, Procardia XL, Altace, Zaroxolyn.,PMH: ,1) MI 11/9/78, 2) Cholecystectomy, 3) TURP for BPH 1980's, 4) HTN, 5) Amaurosis Fugax, OD, 8/95 (Mayo Clinic evaluation--TEE (-), but Carotid Doppler (+) but ""non-surgical"" so placed on Coumadin).,FHX:, Father died age 59 of valvular heart disease. Mother died of DM. Brother had CABG 8/95.,SHX:, retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years.,EXAM:, BP130.56, HR68, RR16, Afebrile.,MS: A&O to person, place, time. Speech fluent without dysarthria. Lucid. Appeared uncomfortable.,CN: Unremarkable.,MOTOR: 5/5 strength in BUE. Lower extremity strength: Hip flexors & extensors 4-/4-, Hip abductors 3+/3+, Hip adductors 5/5, Knee flexors & extensors 4/4-, Ankle flexion 4-/4-, Tibialis Anterior 2/2-, Peronei 3-/3-. Mild atrophy in 4 extremities. Questionable fasciculations in BLE. Spasms illicited on striking quadriceps with reflex hammer (? percussion myotonia). No rigidity and essential normal muscle tone on passive motion.,SENSORY: Decreased vibratory sense in stocking distribution from toes to knees in BLE (worse on right). No sensory level. PP/LT/TEMP testing unremarkable.,COORD: Normal FNF-RAM. Slowed HKS due to weakness.,Station: No pronator drift. Romberg testing not done.,Gait: Unable to stand.,Reflexes: 2/2 BUE. 1/trace patellae, 0/0 Achilles. Plantar responses were flexor, bilaterally. Abdominal reflex was present in all four quadrants. Anal reflex was illicited from all four quadrants. No jaw jerk or palmomental reflexes illicited.,Rectal: normal rectal tone, guaiac negative stool.,GEN EXAM: Bilateral Carotid Bruits, No lymphadenopathy, right inguinal hernia, rhonchi and inspiratory wheeze in both lung fields.,COURSE: ,WBC 11.6, Hgb 13.4, Hct 38%, Plt 295. ESR 40 (normal 0-14), CRP 1.4 (normal <0.4), INR 1.5, PTT 35 (normal), Creatinine 2.1, CK 346. EKG normal. The differential diagnosis included Amyotrophy, Polymyositis, Epidural hematoma, Disc Herniation and Guillain-Barre syndrome. An MRI of the lumbar spine was obtained, 12/13/95. This revealed an L3-4 disc herniation extending inferiorly and behind the L4 vertebral body. This disc was located more on the right than on the left , compromised the right neural foramen, and narrowed the spinal canal. The patient underwent a L3-4 laminectomy and diskectomy and subsequently improved. He was never seen in follow-up at UIHC.",33
"S -, A 60-year-old female presents today for care of painful calluses and benign lesions.,O -, On examination, the patient has bilateral bunions at the first metatarsophalangeal joint.  She states that they do not hurt.  No pain appears to be produced by active or passive range of motion or palpation and direct pressure of the first metatarsophalangeal joint bilaterally.  The patient has a bilateral pinch callus on the medial aspect of both great toes and there are calluses along the medial aspect of the right foot.  She has a small intractable plantar keratoma, plantar to her left second metatarsal head, which measures 0.5 cm in diameter.  This is a central plug.  She also has a very, very painful lesion plantar to her right fourth metatarsal head which measures 3.1 x 1.8 cm in diameter.  This is a hyperkeratotic lesion that extends deep into the tissue with interrupted skin lines.,A - ,1.  Bilateral bunions.,",34
"PREOPERATIVE DIAGNOSIS: , Right inguinal hernia. ,POSTOPERATIVE DIAGNOSIS:,  Right direct inguinal hernia. ,PROCEDURE:,  Right direct inguinal hernia repair with PHS mesh system. ,ANESTHESIA:,  General with endotracheal intubation. ,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was administered with endotracheal intubation.  The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion.  An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease.  Dissection was taken down through the skin and subcutaneous tissue.  Scarpa's fascia was divided, and the external ring was located.  The external oblique was divided from the external ring up towards the anterior superior iliac spine.  The cord structures were then encircled.  Careful inspection of the cord structures did not reveal any indirect sac along the cord structures.  I did, however, feel a direct sac with a direct defect.  I opened the floor of the inguinal canal and dissected out the preperitoneal space at the direct sac and cut out the direct sac.  Once I cleared out the preperitoneal space, I placed a PHS mesh system with a posterior mesh into the preperitoneal space, and I made sure that it laid flat along Cooper's ligament and covered the myopectineal orifice.  I then tucked the extended portion of the anterior mesh underneath the external oblique between the external oblique and the internal oblique, and I then tacked the medial portion of the mesh to the pubic tubercle with a 0 Ethibond suture.  I tacked the superior portion of the mesh to the internal oblique and the inferior portion of the mesh to the shelving edge of the inguinal ligament.  I cut a hole in the mesh in order to incorporate the cord structures and recreated the internal ring, making sure that it was not too tight so that it did not strangulate the cord structures.  I then closed the external oblique with a running 3-0 Vicryl.  I closed the Scarpa's with interrupted 3-0 Vicryl, and I closed the skin with a running Monocril.  Sponge, instrument and needle counts were correct at the end of the case.  The patient tolerated the procedure well and without any complications.",38
"PREOPERATIVE DIAGNOSIS:  ,Metastatic renal cell carcinoma.,POSTOPERATIVE DIAGNOSIS:,  Metastatic renal cell carcinoma.,PROCEDURE PERFORMED:,  Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy used to confirm adequate placement of the double-lumen endotracheal tube with a tube thoracostomy, which was used to drain the left chest after the procedure.,ANESTHESIA:,  General endotracheal anesthesia with double-lumen endotracheal tube.,FINDINGS:,  Multiple pleural surface seeding, many sub-millimeter suspicious looking lesions.,DISPOSITION OF SPECIMENS:,To Pathology for permanent analysis as well as tissue banking.  The lesions sent for pathologic analysis were the following,,1.  Level 8 lymph node.,2.  Level 9 lymph node.,3.  Wedge, left upper lobe apex, which was also sent to the tissue bank and possible multiple lesions within this wedge.,4.  Wedge, left upper lobe posterior.,5.  Wedge, left upper lobe anterior.,6.  Wedge, left lower lobe superior segment.,7.  Wedge, left lower lobe diaphragmatic surface, anterolateral.,8.  Wedge, left lower lobe, anterolateral.,9.  Wedge, left lower lobe lateral adjacent to fissure.,10.  Wedge, left upper lobe, apex anterior.,11.  Lymph node package, additional level 8 lymph node.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE: , The patient was given preoperative informed consent for the procedure as well as for the clinical trial he was enrolled into.  The patient agreed based on the risks and the benefits of the procedure, which were presented to him and was taken to the operating room.  A correct time out procedure was performed.  The patient was placed into the supine position.  He was given general anesthesia, was endotracheally intubated without incident with a double-lumen endotracheal tube.  Fiberoptic bronchoscopy was used to perform confirmation of adequate placement of the double-lumen tube.  Following this, the decision was made to proceed with the surgery.  The patient was rolled into the right lateral decubitus position with the left side up.  All pressure points were padded.  The patient had a sterile DuraPrep preparation to the left chest.  A sterile drape around that was applied.  Also, the patient had Marcaine infused into the incision area.  Following this, the patient had a posterolateral thoracotomy incision, which was a muscle-sparing incision with a posterior approach just over the ausculatory triangle.  The incision was approximately 10 cm in size.  This was created with a 10-blade scalpel.  Bovie electrocautery was used to dissect the subcutaneous tissues.  The auscultatory triangle was opened.  The posterior aspect of the latissimus muscle was divided from the adjacent tissue and retracted anteriorly.  The muscle was not divided.  After the latissimus muscle was retracted anteriorly, the ribs were counted, and the sixth rib was identified.  The superior surface of the sixth rib was incised with Bovie electrocautery and the sixth rib was divided with rib shears.  Following this, the patient had the entire intercostal muscle separated from the superior aspect of the sixth rib on the left as far as the Bovie would reach.  The left lung was allowed to collapse and meticulous inspection of the left lung identified the lesions, which were taken out with stapled wedge resections via a TA30 green load stapler for all of the wedges.  The patient tolerated the procedure well without any complications.  The largest lesion was the left upper lobe apex lesion, which was possibly multiple lesions, which was taken in one large wedge segment, and this was also adjacent to another area of the wedges.  The patient had multiple pleural abnormalities, which were identified on the surface of the lung.  These were small white spotty looking lesions and were not confirmed to be tumor implants, but were suspicious to be multiple areas of tumor.  Based on this, the wedges of the tumors that were easily palpable were excised with complete excision of all palpable lesions.  Following this, the patient had a 32-French chest tube placed in the anteroapical position.  A 19-French Blake was placed in the posterior apical position.  The patient had the intercostal space reapproximated with #2-0 Vicryl suture, and the lung was allowed to be re-expanded under direct visualization.  Following this, the chest tubes were placed to Pleur-evac suction and the auscultatory triangle was closed with 2-0 Vicryl sutures.  The deeper tissue was closed with 3-0 Vicryl suture, and the skin was closed with running 4-0 Monocryl suture in a subcuticular fashion.  The patient tolerated the procedure well and had no complications.",3
"SUBJECTIVE:,  Grandfather brings the patient in today because of headaches, mostly in her face.  She is feeling pressure there with a lot of sniffles.  Last night, she complained of sore throat and a loose cough.  Over the last three days, she has had a rash on her face, back and arms.  A lot of fifth disease at school.  She says it itches and they have been doing some Benadryl for this.  She has not had any wheezing lately and is not taking any ongoing medications for her asthma.,PAST MEDICAL HISTORY:,  Asthma and allergies.,FAMILY HISTORY:  ,Sister is dizzy but no other acute illnesses.,OBJECTIVE:,General:  The patient is an 11-year-old female.  Alert and cooperative.  No acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, gray in color and good light reflex.  Oropharynx is pink and moist.  No erythema or exudates.  She has postnasal discharge.  Nares are swollen and red.  Purulent discharge in the posterior turbinates.  Both maxillary sinuses are tender.  She has some mild tenderness in the left frontal sinus.  Eyes are puffy and she has dark circles.,Chest:  Respirations are regular and nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry and pink.  Moist mucous membranes.  Red, lacey rash from the wrists to the elbows, both sides.  It is very faint on the lower back and she has reddened cheeks, as well.,ASSESSMENT:,  Fifth disease with sinusitis.,PLAN:,  Omnicef 300 mg daily for 10 days.  May use some Zyrtec for the itching.  Samples are given.",15
"PREOPERATIVE DIAGNOSES,1.  Basal cell nevus syndrome.,2.  Cystic lesion, left posterior mandible.,3.  Corrected dentition.,4.  Impacted teeth 1 and 16.,5.  Maxillary transverse hyperplasia.,POSTOPERATIVE DIAGNOSES,1.  Basal cell nevus syndrome.,2.  Cystic lesion, left posterior mandible.,3.  Corrected dentition.,4.  Impacted teeth 1 and 16.,5.  Maxillary transverse hyperplasia.,PROCEDURE,1.  Removal of cystic lesion, left posterior mandible.,2.  Removal of teeth numbers 4, 13, 20, and 29.,3.  Removal of teeth numbers 1 and 16.,4.  Modified Le Fort I osteotomy.,INDICATIONS FOR THE PROCEDURE:, The patient has undergone previous surgical treatment and had a diagnosis of basal cell nevus syndrome.  Currently our plan is to remove the impacted third molar teeth, to remove a cystic lesion left posterior mandible, to remove 4 second bicuspid teeth as requested by her orthodontist, and to weaken and her maxilla to allow expansion by a modified Le Fort osteotomy.,PROCEDURE IN DETAIL:, The patient was brought into the operating room, placed on the operating table in supine position.  Following treatment under adequate general anesthesia via the orotracheal route, the patient was prepped and draped in a manner consistent with intraoral surgical procedures.  The oral cavity was suctioned, was drained of fluid and a throat pack was placed.  General anesthesia nursing service was notified and which was removed at the end of the procedure.  Lidocaine 1% with epinephrine concentration in 1:100,000 was injected into the labial vestibule of the maxilla bilaterally as well as the lateral areas associated with the extractions sites in lower jaw and the left posterior mandible for a total of 11 mL.  A Bovie electrocautery was utilized to make a vestibular incision, beginning in the second molar region of the maxilla superior to the mucogingival junction extending to the area of the cuspid teeth.  Subperiosteal dissection revealed lateral aspect of the maxilla immediately posterior to the second molar tooth where the third molar tooth was identified and was bony crypt.  Following use of Cerebromaxillary osteotome, elevated, and underwent complete removal of the dental follicle.  Secondly, tooth number 4 was removed.  Tooth number 13 was removed, and the opposite third molar tooth was removed through an identical incision on the opposite side.  Surgeon then utilized a #15 saw to make a horizontal osteotomy through the lateral aspect of the maxilla from the target plates, anteriorly to the area of the buttress region cross the anterior maxilla to a point adjacent to the piriform rim, 5 mm superior to the nasal floor, bilaterally Cerebromaxillary osteotome utilized to separate the maxilla from the target placed posteriorly and a 5 mm Tessier osteotome through a vertical incision anteriorly between roots of teeth numbers 8 and 9.  This resulted in the alternate mobilization of the two halves of the maxilla, or to allow expansion.  These wounds were all irrigated with copious amounts of normal saline and with antibiotic containing solution, closed with 3-0 chromic suture in running fashion for watertight closure.  Attention was directed to the mandible where the left posterior mandible was approached through a lateral vestibular incision overlying the external oblique ridge and brought anteriorly in an old scar.  The surgeons utilized cautery osteotome to identify a cystic lesion associated with the left posterior mandible, which was approximately 1 cm in width and 2.5 to 3 cm in vertical dimension immediately adjacent to the neurovascular bundle.  This wound was then irrigated with copious amounts of normal saline and concentrated solution of clindamycin.  Closed primarily with a 3-0 Vicryl suture in running fashion for a watertight closure.  Teeth number 20 and 29 where removed and 3-0 chromic suture placed.  This concluded the procedure.  All cottonoids and other sponges, throat pack were removed.  No complications were encountered.  The aforementioned cystic lesion was sent with specimen no drains were placed.  The blood loss from this procedure was approximately 100 mL.,The patient was returned over the care of the anesthesia where she was extubated in the operating room, taken from the operating room to the recovery room with stable vital signs and spontaneous respirations.",7
"PROCEDURE PERFORMED:,1. Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.,2. Right femoral selective angiogram.,3. Closure device the seal the femoral arteriotomy using an Angio-Seal.,INDICATIONS FOR PROCEDURE: ,The patient with known coronary atherosclerotic heart disease and multiple risk factors of coronary disease, who had her last coronary arteriogram performed in 2004. She has had complaints of progressive chest discomfort, and has ongoing risks including current smoking, diabetes, hypertension, hyperlipidemia to name a few. The decision was made to proceed on with percutaneous evaluation and possible intervention given her known disease and the possibility of disease progression.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, The patient was taken to cardiac catheterization lab where her procedure was performed. She was prepped and prepared on the table; after which, her right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery over a standard 0.035 guide wire. Coronary angiography and left ventricular measurement and angiography were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery. A 6-French JR4 diagnostic catheter to image the right groin and her artery and the saphenous vein graft conduit. Subsequently, a 6-French angled pigtail catheter was used to measure left ventricular pressures and to perform a power injection, a left ventriculogram at 8 mL per second for a total of 30 mL. At the conclusion of the diagnostic evaluation, the patient had selective arteriography of her right femoral artery, which showed the right femoral artery to be free of significant atherosclerotic plaque. Did have a normal bifurcation into the superficial femoral and profunda femoris arteries and to have an arteriotomy that was in the common femoral artery away from the bifurcation. As such, an initial attempt to advance a Perclose device failed to allow the device descend to _____ tract and into the appropriate position within the artery. As such, the Perclose was never deployed and was removed intact over the wire from the system. We then replaced this with a 6-French Angio-Seal which was used to seal the femoral arteriotomy with achievement of hemostasis. The patient was subsequently dispositioned back to the MAC Unit where she will complete her bedrest prior to her disposition to home.,HEMODYNAMIC DATA:, Opening aortic pressure 125/60, left ventricular pressure 108/4 with an end-diastolic pressure of 16. There was no significant gradient across the aortic valve on pullback from the left ventricle. Left ventricular ejection fraction was 55%. Mitral regurgitation was less than or equal to 1+. There was normal wall motion in the RAO projection.,CORONARY ANGIOGRAM:, The left main coronary artery had mild atherosclerotic plaque. The proximal LAD was 100% occluded. The left circumflex had mild diffuse atherosclerotic plaque. The obtuse marginal branch which operates as an OM-2 had a mid approximately 80% stenosis at a kink in the artery. This appears to be the area of a prior anastomosis, the saphenous vein graft to the OM. This is a very small-caliber vessel and is 1.5-mm in diameter at best. The right coronary artery is dominant. The native right coronary artery had mild proximal and mid atherosclerotic plaque. The distal right coronary artery has an approximate 40% stenosis. The posterior left ventricular branch has a proximal 50 to 60% stenosis. The proximal PDA has a 40 to 50% stenosis. The saphenous vein graft to the right PDA is widely patent. There was competitive flow noted between the native right coronary artery and the saphenous vein graft to the PDA. The runoff from the PDA is nice with the native proximal PDA and PLV disease as noted above. There is also some retrograde filling of the right coronary artery from the runoff of this graft. The saphenous vein graft to the left anterior descending is widely patent. The LAD beyond the distal anastomosis is a relatively small-caliber vessel. There is some retrograde filling that allows some filling into a more proximal diagonal branch. The saphenous vein graft to the obtuse marginal was known to be occluded from the prior study in 2004. Overall, this study does not look markedly different than the procedure performed in 2004.,CONCLUSION:, 100% proximal LAD mild left circumflex disease with an OM that is a small-caliber vessel with an 80% lesion at a kink that is no amenable to percutaneous intervention. The native right coronary artery has mild to moderate distal disease with moderate PLV and PDA disease. The saphenous vein graft to the OM is known to be 100% occluded. The saphenous vein graft to the PDA and the saphenous vein graft to the LAD are open. Normal left ventricular systolic function.,PLAN:, The plan will be for continued medical therapy and risk factor modification. Aggressive antihyperlipidemic and antihypertensive control. The patient's goal LDL will be at or below 70 with triglyceride level at or below 150, and it is very imperative that the patient stop smoking.,After her bedrest is complete, she will be dispositioned to home, after which, she will be following up with me in the office within 1 month. We will also plan to perform a carotid duplex Doppler ultrasound to evaluate her carotid bruits.",3
"PREOPERATIVE DIAGNOSIS: , Vitreous hemorrhage and retinal detachment, right eye.,POSTOPERATIVE DIAGNOSIS:,  Vitreous hemorrhage and retinal detachment, right eye.,NAME OF PROCEDURE: , Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.,ANESTHESIA: , Local with standby.,PROCEDURE:  ,The patient was brought to the operating room, and an equal mixture of Marcaine 0.5% and lidocaine 2% was injected in a retrobulbar fashion.  As soon as satisfactory anesthesia and akinesia had been achieved, the patient was prepped and draped in the usual manner for sterile ophthalmic surgery.  A wire lid speculum was inserted.  Three modified sclerotomies were selected at 9, 10, and 1 o'clock.  At the 9 o'clock position, the Accurus infusion line was put in place and tied with a preplaced #7-0 Vicryl suture.  The two superior sites at 10 and 1 were opened up where the operating microscope with the optical illuminating system was brought into position, and closed vitrectomy was begun.  Initially formed core vitrectomy was performed and formed anterior vitreous was removed.  After this was completed, attention was placed in the posterior segment.  Several broad areas of vitreoretinal traction were noted over the posterior pole out of the equator where the previously noted retinal tears were noted.  These were carefully lifted and dissected off the edges of the flap tears and trimmed to the ora serrata.  After all the vitreous had been removed and the membranes released, the retina was completely mobilized.  Total fluid-air exchange was carried out with complete settling of the retina.  Endolaser was applied around the margins of the retinal tears, and altogether several 100 applications were placed in the periphery.  Good reaction was achieved.  The eye was inspected with an indirect ophthalmoscope.  The retina was noted to be completely attached.  The instruments were removed from the eye.  The sclerotomy sites were closed with #7-0 Vicryl suture.  The infusion line was removed from the eye and tied with a #7-0 Vicryl suture.  The conjunctivae and Tenon's were closed with #6-0 plain gut suture.  A collagen shield soaked with Tobrex placed over the surface of the globe, and a pressure bandage was put in place.  The patient left the operating room in a good condition.",37
"REASON FOR VISIT:,  Weight loss evaluation.,HISTORY OF PRESENT ILLNESS:,",5
"PROCEDURE:  ,This tracing was obtained utilizing silver chloride biopotential electrodes placed at the medial and lateral canthi at both eyes and on the superior and inferior orbital margins of the left eye along a vertical line drawn through the middle of the pupil in the neutral forward gaze.  Simultaneous recordings were made in both eyes in the horizontal direction and the left eye in the vertical directions.  Caloric irrigations were performed using a closed loop irrigation system at 30 degrees and 44 degrees C into either ear.,FINDINGS: , Gaze testing did not reveal any evidence of nystagmus.  Saccadic movements did not reveal any evidence of dysmetria or overshoot.  Sinusoidal tracking was performed well for the patient's age.  Optokinetic nystagmus testing was performed poorly due to the patient's difficulty in following the commands.  Therefore adequate OKNs were not achieved.  The Dix-Hallpike maneuver in the head handing left position resulted in moderate intensity left beating nystagmus, which was converted to a right beating nystagmus when she sat up again.  The patient complained of severe dizziness in this position.  There was no clear-cut decremental response with repetition.  In the head hanging left position, no significant nystagmus was identified.  Positional testing in the supine, head hanging, head right, head left, right lateral decubitus, and left lateral decubitus positions did not reveal any evidence of nystagmus.,Caloric stimulation revealed a calculated unilateral weakness of 7.0% on the right (normal <20%) and left beating directional preponderance of 6.0% (normal <20-30%).,IMPRESSION: , Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.  No other significant nystagmus was noted.  There was no evidence of clear-cut caloric stimulation abnormality.  This study would be most consistent with a right vestibular dysfunction.",33
"There is normal and symmetrical filling of the caliceal system.  Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally.  The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects. The postvoid films demonstrate normal emptying of the collecting system, including the urinary bladder.,IMPRESSION:,  Negative intravenous urogram.,",21
"PREOPERATIVE DIAGNOSIS: , Right hand Dupuytren disease to the little finger.,POSTOPERATIVE DIAGNOSIS:  ,Right hand Dupuytren disease to the little finger.,PROCEDURE PERFORMED:  ,Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger.,COMPLICATIONS:  ,None.,BLOOD LOSS: , Minimal.,ANESTHESIA: , Bier block.,INDICATIONS:  ,The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, laid supine, administered a bier block, and prepped and draped in the sterile fashion.  A zig-zag incision was made down the palmar surface of the little finger and under the palm up to the mid palm region.  Skin flaps were elevated carefully, dissecting Dupuytren contracture off the undersurface of the flaps.  Both neurovascular bundles were identified proximally in the hand and the Dupuytren disease fibrous band was divided proximally, which essentially returned to normal-appearing tissue.  The neurovascular bundles were then dissected distally resecting everything medial to the 2 neurovascular bundles and above the flexor tendon sheath all the way out to the PIP joint of the finger where the Dupuytren disease stopped.  The wound was irrigated.  The neurovascular bundles rechecked with no evidence of any injury and the neurovascular bundles were not significantly involved in the Dupuytren disease.  The incisions were closed with 5-0 nylon interrupted sutures.,The patient tolerated the procedure well and was taken to the PACU in good condition.",37
"PROCEDURE: , Flexible sigmoidoscopy.,PREOPERATIVE DIAGNOSIS:,  Rectal bleeding.,POSTOPERATIVE DIAGNOSIS:  ,Diverticulosis.,MEDICATIONS: , None.,DESCRIPTION OF PROCEDURE:  ,The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm, reaching the proximal descending colon.  At this point, stool occupied the lumen, preventing further passage.  The colon distal to this was well cleaned out and easily visualized.  The mucosa was normal throughout the regions examined.  Numerous diverticula were seen.  There was no blood or old blood or active bleeding.  A retroflexed view of the anorectal junction showed no hemorrhoids.  He tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Sigmoid and left colon diverticulosis.,2.  Otherwise normal flexible sigmoidoscopy to the proximal descending colon.,3.  The bleeding was most likely from a diverticulum, given the self limited but moderately severe quantity that he described.,RECOMMENDATIONS:,1.  Follow up with Dr. X as needed.,2.  If there is further bleeding, a full colonoscopy is recommended.",14
"PROCEDURE: , Lumbar puncture with moderate sedation.,INDICATION: , The patient is a 2-year, 2-month-old little girl who presented to the hospital with severe anemia, hemoglobin 5.8, elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test.  She was transfused with packed red blood cells.  Her hemolysis seemed to slow down.  She also on presentation had indications of urinary tract infection with urinalysis significant for 2+ leukocytes, positive nitrites, 3+ protein, 3+ blood, 25 to 100 white cells, 10 to 25 bacteria, 10 to 25 epithelial cells on clean catch specimen.  Culture subsequently grew out no organisms; however, the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital.  She had a blood culture, which was also negative.  She was empirically started on presentation with the cefotaxime intravenously.  Her white count on presentation was significantly elevated at 20,800, subsequently increased to 24.7 and then decreased to 16.6 while on antibiotics.  After antibiotics were discontinued, she increased over the next 2 days to an elevated white count of 31,000 with significant bandemia, metamyelocytes and myelocytes present.  She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI.,I discussed with The patient's parents prior to the procedure the lumbar puncture and moderate sedation procedures.  The risks, benefits, alternatives, complications including, but not limited to bleeding, infection, respiratory depression.  Questions were answered to their satisfaction.  They would like to proceed.,PROCEDURE IN DETAIL: , After ""time out"" procedure was obtained, the child was given appropriate monitoring equipment including appropriate vital signs were obtained.  She was then given Versed 1 mg intravenously by myself.  She subsequently became sleepy, the respiratory monitors, end-tidal, cardiopulmonary and pulse oximetry were applied.  She was then given 20 mcg of fentanyl intravenously by myself.  She was placed in the left lateral decubitus position.  Dr. X cleansed the patient's back in a normal sterile fashion with Betadine solution.  She inserted a 22-gauge x 1.5-inch spinal needle in the patient's L3-L4 interspace that was carefully identified under my direct supervision.  Clear fluid was not obtained initially, needle was withdrawn intact.  The patient was slightly repositioned by the nurse and Dr. X reinserted the needle in the L3-L4 interspace position, the needle was able to obtain clear fluid, approximately 3 mL was obtained.  The stylette was replaced and the needle was withdrawn intact and bandage was applied.  Betadine solution was cleansed from the patient's back.,During the procedure, there were no untoward complications, the end-tidal CO2, pulse oximetry, and other vitals remained stable.  Of note, EMLA cream had also been applied prior procedure, this was removed prior to cleansing of the back.,Fluid will be sent for a routine cell count, Gram stain culture, protein, and glucose.,DISPOSITION: , The child returned to room on the medical floor in satisfactory condition.",23
"EXAM:,MRI CERVICAL SPINE,CLINICAL:, A57-year-old male. Received for outside consultation is an MRI examination performed on 11/28/2005.,FINDINGS:,Normal brainstem-cervical cord junction. Normal cisterna magna with no tonsillar ectopia. Normal clivus with a normal craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: Normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina with no cord or radicular impingement.,C3-4: There is disc desiccation with minimal annular bulging. The residual AP diameter of the central canal measures approximately 10mm. CSF remains present surrounding the cord.,C4-5: There is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis. The residual AP diameter of the central canal measures approximately 8mm with effacement of the circumferential CSF cleft producing a borderline central canal stenosis but no cord distortion or cord edema. There is minimal uncovertebral joint arthrosis.,C5-6: There is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm (AP x transverse). The disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement.,C6-7: There is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis. The residual AP diameter of the central canal measures 8 mm with effacement of the circumferential CSF cleft. There is a left posterolateral disc-osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left C7 nerve root.,C7-T1, T1-2: Minimal disc desiccation with no disc displacement or endplate spondylosis.,IMPRESSION:,Multilevel degenerative disc disease as described above.,C4-5 borderline central canal stenosis with mild bilateral foraminal compromise.,C5-6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion.,C6-7 degenerative disc disease and endplate spondylosis with a left posterolateral disc-osteophyte complex producing probable neural impingement upon the exiting left C7 nerve root with a borderline central canal stenosis.,Normal cervical cord.",27
"SUBJECTIVE: , The patient is not in acute distress.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure of 121/63, pulse is 75, and O2 saturation is 94% on room air.,HEAD AND NECK:  Face is symmetrical.  Cranial nerves are intact.,CHEST:  There is prolonged expiration.,CARDIOVASCULAR:  First and second heart sounds are heard.  No murmur was appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive.,EXTREMITIES:  He has 2+ pedal swelling.,NEUROLOGIC:  The patient is asleep, but easily arousable.,LABORATORY DATA:,  PTT is 49.  INR is pending.  BUN is improved to 20.6, creatinine is 0.7, sodium is 123, and potassium is 3.8.  AST is down to 45 and ALT to 99.,DIAGNOSTIC STUDIES: , Nuclear stress test showed moderate size, mostly fixed defect involving the inferior wall with a small area of peri-infarct ischemia.  Ejection fraction is 25%.,ASSESSMENT AND PLAN:,1.  Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.  Continue current treatment as per Cardiology.  We will consider adding ACE inhibitors as renal function improves.,2.  Acute pulmonary edema, resolved.,3.  Rapid atrial fibrillation, rate controlled.  The patient is on beta-blockers and digoxin.  Continue Coumadin.  Monitor INR.,4.  Coronary artery disease with ischemic cardiomyopathy.  Continue beta-blockers.,5.  Urinary tract infection.  Continue Rocephin.,6.  Bilateral perfusion secondary to congestive heart failure.  We will monitor.,7.  Chronic obstructive pulmonary disease, stable.,8.  Abnormal liver function due to congestive heart failure with liver congestion, improving.,9.  Rule out hypercholesterolemia.  We will check lipid profile.,10.  Tobacco smoking disorder.  The patient has been counseled.,11.  Hyponatremia, stable.  This is due to fluid overload.  Continue diuresis as per Nephrology.,12.  Deep venous thrombosis prophylaxis.  The patient is on heparin drip.",34
"PREOPERATIVE DIAGNOSES,1.  Surgical absence of left nipple areola with personal history of breast cancer.,2.  Breast asymmetry.,POSTOPERATIVE DIAGNOSES,1.  Surgical absence of left nipple areola with personal history of breast cancer.,2.  Breast asymmetry.,PROCEDURE,1.  Left nipple areolar reconstruction utilizing a full-thickness skin graft from the left groin.,2.  Redo right mastopexy.,ANESTHESIA,General endotracheal.,COMPLICATIONS,None.,DESCRIPTION OF PROCEDURE IN DETAIL,The patient was brought to the operating room and placed on the table in the supine position and after suitable induction of general endotracheal anesthesia, the patient was placed in a frog-leg position and prepped and draped in usual fashion for the above-noted procedure.  The initial portion of the procedure was harvesting a full-thickness skin graft from the left groin region.  This was accomplished by ellipsing out a 42-mm diameter circle of skin just below the thigh, peroneal crease.  The defect was then closed with 3-0 Vicryl followed by 3-0 chromic suture in a running locked fashion.  The area was dressed with antibiotic ointment and then a Peri-Pad.  The patient's legs were brought out frog-leg back to the midline and sterile towels were placed over the opening in the drapes.  Surgical team's gloves were changed and then attention was turned to the planning of the left nipple flap.,A maltese cross pattern was employed with a 1-cm diameter nipple and a 42-mm diameter nipple areolar complex.  Once the maltese cross had been designed on the breast at the point where the nipple was to be placed, the areas of the portion of flap were de-epithelialized.  Then, when this had been completed, the dermis about the maltese cross was incised full thickness to allow mobilization of the flap to form the neonipple.  At this point, a Bovie electrocautery was used to control bleeding points and then 4-0 chromic suture was used to suture the arms of the flap together creating the nipple.  When this had been completed, the skin graft, which had been harvested from the left groin was brought onto the field where it was prepared by removing all subcutaneous tissue from the posterior aspect of the graft and carefully removing the hair follicles encountered within the graft.  At this point, the graft was sutured into position in the defect using 3-0 chromic in an interrupted fashion and then trimming the ellipse to an appropriate circle to fill the areola.  At this point, 4-0 chromic was used to run around the perimeter of the full-thickness skin graft and then at this point the nipple was delivered through a cruciate incision in the middle of the skin graft and then inset appropriately with 4-0 chromic.  The areolar skin graft was pie crusted.  Then, at this point, the area of areola was dressed with silicone gel sheeting.  A silo was placed over the neonipple with 3-0 nylon through the apex of the neonipple to support the nipple in an erect position.  Mastisol and Steri-Strips were then applied.,At this point, attention was turned to the right breast where a 2-cm wide ellipse transversely oriented and with its inferior most aspect just inferior to the transverse mastopexy incision line was made.  The skin was removed from the area and then a layered closure of 3-0 Vicryl followed by 3-0 PDS in a running subcuticular fashion was carried out.  When this had been completed, the Mastisol and Steri-Strips were applied to the transverse right breast incision.  Fluff dressings were applied to the right breast as well as the area around the silo on the left breast around the reconstructed nipple areola.  The patient was then placed in Surgi-Bra and then was taken from the operating room to the recovery room in good condition.",6
"HISTORY OF PRESENT ILLNESS:,  Ms. Connor is a 50-year-old female who returns to clinic for a wound check.  The patient underwent an APR secondary to refractory ulcerative colitis.  Subsequently, she developed a wound infection, which has since healed.  On our most recent visit to our clinic, she has her perineal stitches removed and presents today for followup of her perineal wound.  She describes no drainage or erythema from her bottom.  She is having good ostomy output.  She does not describe any fevers, chills, nausea, or vomiting.  The patient does describe some intermittent pain beneath the upper portion of the incision as well as in the right lower quadrant below her ostomy.  She has been taking Percocet for this pain and it does work.  She has since run out has been trying extra strength Tylenol, which will occasionally help this intermittent pain.  She is requesting additional pain medications for this occasional abdominal pain, which she still experiences.,PHYSICAL EXAMINATION: , Temperature 95.8, pulse 68, blood pressure 132/73, and weight 159 pounds.  This is a pleasant female in no acute distress.  The patient's abdomen is soft, nontender, nondistended with a well-healed midline scar.  There is an ileostomy in the right hemiabdomen, which is pink, patent, productive, and protuberant.  There are no signs of masses or hernias over the patient's abdomen.,ASSESSMENT AND PLAN: , This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis.  Overall, her quality of life has significantly improved since she had her APR.  She is functioning well with her ileostomy.  She did have concerns or questions about her diet and we discussed the BRAT diet, which consisted of foods that would slow down the digestive tract such as bananas, rice, toast, cheese, and peanut butter.  I discussed the need to monitor her ileostomy output and preferential amount of daily output is 2 liters or less.  I have counseled her on refraining from soft drinks and fruit drinks.  I have also discussed with her that this diet is moreover a trial and error and that she may try certain foods that did not agree with her ileostomy, however others may and that this is something she will just have to perform trials with over the next several months until she finds what foods that she can and cannot eat with her ileostomy.  She also had questions about her occasional abdominal pain.  I told her that this was probably continue to improve as months went by and I gave her a refill of her Percocet for the continued occasional pain.  I told her that this would the last time I would refill the Percocet and if she has continued pain after she finishes this bottle then she would need to start ibuprofen or Tylenol if she had continued pain.  The patient then brought up some right hand and arm numbness, which has been there postsurgically and was thought to be from positioning during surgery.  This is all primarily gone away except for a little bit of numbness at the tip of the third digit as well as some occasional forearm muscle cramping.  I told her that I felt that this would continue to improve as it has done over the past two months since her surgery.  I told her to continue doing hand exercises as she has been doing and this seems to be working for her.  Overall, I think she has healed from her surgery and is doing very well.  Again, her quality of life is significantly improved.  She is happy with her performance.  We will see her back in six months just for a general routine checkup and see how she is doing at that time.",34
"PREOPERATIVE DIAGNOSES:,1.  Acute on chronic renal failure.,2.  Uremia.,POSTOPERATIVE DIAGNOSES:,1.  Acute on chronic renal failure.,2.  Uremia.,PROCEDURE PERFORMED:  ,Insertion of a right internal jugular vein hemodialysis catheter.,ANESTHESIA: , 1% local lidocaine.,BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS: , None.,HISTORY: , The patient is a 74-year-old Caucasian male who presents via direct admission for acute on chronic renal failure with uremia.  The patient incidentally was in a car accident ten days ago and has been feeling pretty awful since that time.  He is slightly short of breath with mild difficulty in breathing.  A pre-procedure x-ray was obtained, which showed no pneumothorax.  He did have a significant right pleural effusion and a mild left pleural effusion.  We decided to insert the catheter on the right side.,PROCEDURE:  ,The patient was prepped and draped in the usual sterile fashion.  1% lidocaine was used to anesthetize the area two fingerbreadths above the clavicle just posterior to the right sternocleidomastoid muscle and below the external jugular vein.  Using the same anesthetic needle, the right internal jugular vein was used to cannulate with good venous blood return.  The tract was noted.,The needle was removed and a second #18 gauge thin-walled needle was used along same tract to cannulate the right internal jugular vein also without difficulty and good venous blood return.  The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein also without difficulty.  The needle was removed and an #11 blade was used to make a small skin incision provided skin and vein dilators were used.  The circle-C 8-inch hemodialysis catheter was then inserted over the guidewire without difficulty.  The guidewire was removed.  Both of the ports were aspirated venous blood without difficulty and both flushed also without difficulty.  The ports were flushed with injectable normal saline secondary to the patient going for dialysis today.  Thus, he will not need heparinization of the lines.  Again, he tolerated the procedure well.  A postoperative x-ray would be obtained to check catheter placement and rule out pneumothorax.",21
"PROBLEM LIST:,1.  Type 1 diabetes mellitus, insulin pump.,2.  Hypertension.,3.  Hyperlipidemia.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old woman returns for followup management of type 1 diabetes mellitus.  Her last visit was approximately 4 months ago.  Since that time, the patient states her health had been good and her glycemic control had been good, however, within the past 2 weeks she had a pump malfunction, had to get a new pump and was not certain of her pump settings and has been having some difficulty with glycemic control over the past 2 weeks.  She is not reporting any severe hypoglycemic events, but is having some difficulty with hyperglycemia both fasting and postprandial.  She is not reporting polyuria, polydipsia or polyphagia.  She is not exercising at this point and has a diet that is rather typical of woman with twins and a young single child as well.  She is working on a full-time basis and so eats on the run a lot, probably eats more than she should and not making the best choices, little time for physical activity.  She is keeping up with all her other appointments and has recently had a good eye examination.  She had lab work done at her previous visit and this revealed persistent hyperlipidemic state with a LDL of 144.,CURRENT MEDICATIONS:,1.  Zoloft 50 mg p.o. once daily.,2.  Lisinopril 40 mg once daily.,3.  Symlin 60 micrograms, not taking at this point.,4.  Folic acid 2 by mouth every day.,5.  NovoLog insulin via insulin pump about 90 units of insulin per day.,REVIEW OF SYSTEMS:,  She denies fever, chills, sweats, nausea, vomiting, diarrhea, constipation, abdominal pain, chest pain, shortness of breath, difficulty breathing, dyspnea on exertion or change in exercise tolerance.  She is not having painful urination or blood in the urine.  She is not reporting polyuria, polydipsia or polyphagia.,PHYSICAL EXAMINATION:,GENERAL:  Today showed a very pleasant, well-nourished woman, in no acute distress.  VITAL SIGNS:  Temperature not taken, pulse 98, respirations 20, blood pressure 148/89, and weight 91.19 kg.  THORAX:  Revealed lungs clear, PA and lateral without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  S1 and S2 without murmur.  No S3, no S4 auscultated.  ABDOMEN:  Nontender.  EXTREMITIES:  Showed no clubbing, cyanosis or edema.  SKIN:  Intact and do not appear atrophic.  Deep tendon reflexes were 2+/4 without a delayed relaxation phase.,LABORATORY DATA:,  Dated 10/05/08 showed a total cholesterol of 223, triglyceride 140, HDL 54, and LDL 144.  The hemoglobin A1c was 6.4 and the spot urine for microalbumin was 9.2 micrograms of protein, 1 mg of creatinine.  Sodium 136, potassium 4.5, chloride 102, CO2 30 mEq, BUN 11 mg/dL, creatinine 0.6 mg, estimated GFR greater than 60, blood sugar 118, calcium 9.4, and her LFTs were unremarkable.  TSH is 1.07 and free T4 is 0.81.,ASSESSMENT AND PLAN:,1.  This is a return visit to the endocrine clinic for the patient, a 39-year-old woman with history as noted above.  Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.  Basal rate is as follows, 12 a.m. 1.5, 02:30 a.m. 1.75, and 6 a.m. 1.5.  Her correction factor is 19.  Her carb/insulin ratio is 6.  Her active insulin time is 5 and her targets are at 12 a.m. 110 and 6 a.m. to midnight is 100.  We made adjustments to her pump and the plan will be to see her back in approximately 2 months.,2.  Hyperlipidemia.  The patient is not taking statin, therefore, we will prescribe Lipitor 20 mg one p.o. once daily.  Have her watch for side effects from the medication and plan to do a fasting lipid panel and CMP approximately 8 weeks from now.,3.  We will get a hemoglobin A1c and spot urine for albumin in 8 weeks as well.",13
"CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08.,TECHNIQUE:,  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.,FINDINGS: , The liver is normal in size and attenuation.,The gallbladder is normal.,The spleen is normal in size and attenuation.,The adrenal glands and pancreas are unremarkable.,The kidneys are normal in size and attenuation.,No hydronephrosis is detected.  Free fluid is seen within the right upper quadrant within the lower pelvis.  A markedly thickened loop of distal small bowel is seen.  This segment measures at least 10-cm long.  No definite pneumatosis is appreciated.  No free air is apparent at this time.  Inflammatory changes around this loop of bowel.  Mild distention of adjacent small bowel loops measuring up to 3.5 cm is evident.  No complete obstruction is suspected, as there is contrast material within the colon.  Postsurgical changes compatible with the partial colectomy are noted.  Postsurgical changes of the anterior abdominal wall are seen.  Mild thickening of the urinary bladder wall is seen.,IMPRESSION:,1.  Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis.  An inflammatory process such as infection or ischemia must be considered.  Close interval followup is necessary.,2.  Thickening of the urinary bladder wall is nonspecific and may be due to under distention.  However, evaluation for cystitis is advised.",14
"EXAM:,MRI LEFT KNEE WITHOUT CONTRAST,CLINICAL:,Left knee pain.,FINDINGS:,Comparison is made with 10/13/05 radiographs.,There is a prominent suprapatellar effusion. Patient has increased signal within the medial collateral ligament as well as fluid around it, compatible with type 2 sprain. There is fluid around the lateral collateral ligament without increased signal within the ligament itself, compatible with type 1 sprain.,Medial and lateral menisci contain some minimal increased signal centrally that does not extend through an articular surface and findings are felt to represent minimal myxoid degeneration. No tear is seen. Anterior cruciate and posterior cruciate ligaments are intact. There is a bone bruise of medial patellar facet measuring approximately 8 x 5 mm. There is suggestion of some mild posterior aspect of the lateral tibial plateau. MR signal on the bone marrow is otherwise normal.,IMPRESSION:,Type 2 sprain in the medial collateral ligament and type sprain in the lateral collateral ligament.,Joint effusion and bone bruise with suggestion of some minimal overlying chondromalacia and medial patellar facet.",27
"HISTORY OF PRESENT ILLNESS:,  This is a 53-year-old widowed woman, she lives at ABC Hotel.  She presented with a complaint of chest pain, evaluations revealed severe aortic stenosis.  She has been refusing cardiac catheter and she may well need aortic valve replacement.  She states that she does not want heart surgery or valve replacement.  She has a history of bipolar disorder and has been diagnosed at times with schizophrenia.  She is on Depakote 500 mg three times a day and Geodon 80 mg twice a day.  The patient receives mental health care through the XYZ Health System and there is a psychiatrist who makes rounds at the ABC Hotel.  She denies hallucinations, psychosis, paranoia, and suicidal ideation at this time.  States that she does not want surgery because the chest pain that was a presenting complaint has gone away that she did not feel her problem is severe enough to require surgery, and medical records does show in this obese individual that cardiac surgery would present substantial risks and for this individual with the chronic mental illness and behavioral problems of a chronic nature, surgery does present some additional risks.  The patient notes that she has a long history of substance abuse, primarily inhalation of paint vapors that she had more than 100 incarcerations in the XYZ County Jail related to offenses related to her lifestyle at that time such as shoplifting, violation of orders to abstain from substance abuse and the longest confinement of these was 100 days.,The patient is able to write a fairly reasonable explanation for why she does not want to pursue medical care.,PAST AND DEVELOPMENTAL HISTORY: , She was born in XYZ.  She is a high-school graduate from ABCD High School.  She did have an abusive childhood.  She is married four times.  She notes she developed depression when a number of her children died.,PHYSICAL EXAMINATION:  ,GENERAL: , This is an obese woman in bed.  She is somewhat restless and moving during the interview.,VITAL SIGNS,:  Temperature of 97.3, pulse 70, respirations 18, blood pressure 113/68, and oxygen saturation 94% on 3 L of oxygen.,PSYCHIATRY:  ,Speech is normal, rate, volume, grammar, and vocabulary consistent with her educational level.  There is no overt thought disorder.  She does not appear psychotic.  She is not suicidal on formal testing.  She gives the date as Sunday, 05/19/2007 when it is the 20th and 207 when it is 2007.  She is oriented to place.  She can memorize four times, repeats two at five minutes, gets the other two with category hints, this places short-term memory in normal limits.  She had difficulty with serial three subtractions, counting on her fingers and had difficulty naming the months in reverse order stating, ""December, November, September, October, June, July, August, September,"" but recognizes this was not right and then said, ""March, April, May.""  She is able to name objects appropriately.,LABORATORY DATA: , Chest x-ray showing no acute changes.  Carotid duplex shows no stenosis.  Electrolytes and liver function tests are normal.  TSH normal.  Hematocrit 31%.  Triglycerides 152.,DIAGNOSES:  ,1.  Bipolar disorder, apparently stable on medications.,2.  Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.,3.  Aortic stenosis.,4.  Sleep apnea.,5.  Obesity.,6.  Anemia.,7.  Gastroesophageal reflux disease.,RECOMMENDATIONS:,  It is my impression at present that the patient retains ability to make decisions on her own behalf.  Given this lady's underlying mental problems, I would recommend that her treating physicians discuss her circumstances with physicians who round on her at the ABC Hotel.  While she may well need surgery and cardiac catheter, she may be more willing to accept this in the context of some continued encouragement from care providers who usually provide care for her.  She clearly at this time wants to leave this hospital; she normally gets her care through XYZ Health.  Again, in summary, I would consider her to retain the ability to make decisions on her own behalf.,Please feel free to contact me at digital pager if additional information is needed.",32
"INDICATIONS:,  Peripheral vascular disease with claudication.,RIGHT:,  ,1.  Normal arterial imaging of right lower extremity.,2.  Peak systolic velocity is normal.,3.  Arterial waveform is triphasic.,4.  Ankle brachial index is 0.96.,LEFT:,1.  Normal arterial imaging of left lower extremity.,2.  Peak systolic velocity is normal.,3.  Arterial waveform is triphasic throughout except in posterior tibial artery where it is biphasic.,4.  Ankle brachial index is 1.06.,IMPRESSION,:,Normal arterial imaging of both lower extremities.",33
"CHIEF COMPLAINT: , Swelling of lips causing difficulty swallowing.,HISTORY OF PRESENT ILLNESS:, This patient is a 57-year old white Cuban woman with a long history of rheumatoid arthritis.  She has received methotrexate on a weekly basis as an outpatient for many years.  Approximately two weeks ago, she developed a respiratory infection for which she received antibiotics.  She developed some ulcerations of the mouth and was instructed to discontinue the methotrexate approximately ten days ago.  She showed some initial improvement, but over the last 3-5 days has had malaise, a low-grade fever, and severe oral ulcerations with difficulty in swallowing although she can drink liquids with less difficulty.  ,The patient denies any other problems at this point except for a flare of arthritis since discontinuing the methotrexate.  She has rather diffuse pain involving both large and small joints.  ,MEDICATIONS:, Prednisone 7.5 mg p.o. q.d., Premarin 0.125 mg p.o. q.d., and Dolobid 1000 mg p.o. q.d., recently discontinued because of questionable allergic reaction.  HCTZ 25 mg p.o. q.o.d., Oral calcium supplements.  In the past she has been on penicillin, azathioprine, and hydroxychloroquine, but she has not had Azulfidine, cyclophosphamide, or chlorambucil. ,ALLERGIES: ,None by history.  ,FAMILY/SOCIAL HISTORY:, Noncontributory.,PHYSICAL EXAMINATION:, This is a chronically ill appearing female, alert, oriented, and cooperative.  She moves with great difficulty because of fatigue and malaise.  Vital signs: Blood pressure 107/80, heart rate: 100 and regular, respirations 22.  HEENT: Normocephalic. No scalp lesions.  Dry eyes with conjuctival injections.  Mild exophthalmos.  Dry nasal mucosa.  Marked cracking and bleeding of her lips with erosion of the mucosa.  She has a large ulceration of the mucosa at the bite margin on the left.  She has some scattered ulcerations on her hard and soft palette.  Tonsils not enlarged.  No visible exudate.  She has difficulty opening her mouth because of pain.  SKIN: She has some mild ecchymoses on her skin and some erythema; she has patches but no obvious skin breakdown.  She has some fissuring in the buttocks crease.  PULMONARY: Clear to percussion in auscultation.  CARDIOVASCULAR: No murmurs or gallops noted.  ABDOMEN: Protuberant no organomegaly and positive bowel sounds.  NEUROLOGIC EXAM: Cranial nerves II through XII are grossly intact. Diffuse hyporeflexia.  MUSCULOSKELATAL: Erosive, destructive changes in the elbows, wrist and hands consistent with rheumatoid arthritis.  She also has bilateral total knee replacements with stovepipe legs and parimalleolar pitting adema 1+.  I feel no pulse distally in either leg.  ,PROBLEMS: ,1.  Swelling of lips and dysphagia with questionable early Stevens-Johnson syndrome.,2.  Rheumatoid Arthritis class 3, stage 4.,3.  Flare of arthritis after discontinuing methotrexate.,4.  Osteoporosis with compression fracture.,5.  Mild dehydration.,6.  Nephrolithiasis.,PLAN:, Patient is admitted for IV hydration and treatment of oral ulcerations.  We will obtain a dermatology consult.  IV leucovorin will be started, and the patient will be put on high-dose corticosteroids.",15
"SUBJECTIVE:,  This 23-year-old white female presents with complaint of allergies.  She used to have allergies when she lived in Seattle but she thinks they are worse here.  In the past, she has tried Claritin, and Zyrtec.  Both worked for short time but then seemed to lose effectiveness.  She has used Allegra also.  She used that last summer and she began using it again two weeks ago.  It does not appear to be working very well.  She has used over-the-counter sprays but no prescription nasal sprays.  She does have asthma but doest not require daily medication for this and does not think it is flaring up.,MEDICATIONS: , Her only medication currently is Ortho Tri-Cyclen and the Allegra.,ALLERGIES: , She has no known medicine allergies.,OBJECTIVE:,Vitals:  Weight was 130 pounds and blood pressure 124/78.,HEENT:  Her throat was mildly erythematous without exudate.  Nasal mucosa was erythematous and swollen.  Only clear drainage was seen.  TMs were clear.,Neck:  Supple without adenopathy.,Lungs:  Clear.,ASSESSMENT:,  Allergic rhinitis.,PLAN:,1.  She will try Zyrtec instead of Allegra again.  Another option will be to use loratadine.  She does not think she has prescription coverage so that might be cheaper.,2.  Samples of Nasonex two sprays in each nostril given for three weeks.  A prescription was written as well.",34
"PSYCHOSOCIAL DONOR EVALUATION,Following questions are mostly involved in a psychosocial donor evaluation:,A.  DECISION TO DONATE,What is your understanding of the recipient's illness and why a transplant is needed?,When and how did the subject of donation arise?,What was the recipient's reaction to your offer?,What are your family's feelings about your being a donor?,How did you arrive at the decision to be a donor?,How would your family and friends react if you decided not to be a donor?,How would you feel if you cannot be the donor for any reason?,What is your relationship to the recipient?,How will your relationship with the recipient change if you donate your kidney?,Will your being a donor affect any other relationships in your life?,B. TRANSPLANT ISSUES,Do you have an understanding of the process of transplant?,Do you understand the risk of rejection of your kidney by the recipient at some point after transplant?,Have you thought about how you might feel if the kidney/liver is rejected?,Do you have any doubts or concerns about donating?,Do you understand that there will be pain and soreness after the transplant?,What are your expectations about your recuperation?,Do you need to speak further to any of the transplant team members?,C.  MEDICAL HISTORY,What previous illnesses or surgeries have you had? ,Are you currently on any medications?,Have you ever spoken with a counselor, a therapist or a psychiatrist?,Do you smoke?,In a typical week, how many drinks do you consume?  What drink do you prefer?,What kinds of recreational drugs have you tried?  Have you used any recently?,D. FAMILY AND SUPPORT SYSTEM,With whom do you live?  ,If you are in a relationship:,- length of the relationship:  ,- name of spouse/partner:  ,- age and health of spouse/partner:  ,- children:  ,E. POST-SURGICAL PLANS,With whom will you stay after discharge?  ,What is your current occupation:  ,Do you have the support of your employer?",21
"PREOPERATIVE DIAGNOSES:  ,1.  Nasolabial mesiolabial fold.,2.  Mid glabellar fold.,POSTOPERATIVE DIAGNOSES:  ,1.  Nasolabial mesiolabial fold.,2.  Mid glabellar fold.,TITLE OF PROCEDURES:  ,1.  Perlane injection for the nasolabial fold.,2.  Restylane injection for the glabellar fold.,ANESTHESIA:  ,Topical with Lasercaine.,COMPLICATIONS: , None.,PROCEDURE: , The patient was evaluated preop and noted to be in stable condition.  Chart and informed consent were all reviewed preop.  All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  This includes risk of bleeding, infection, scarring, need for further procedure, etc.  The patient did sign the informed consent form regarding the Perlane and Restylane.  She is aware of the potential risk of bruising.  The patient has had Cosmederm in the past and had had a minimal response with this.  Please note Lasercaine had to be applied 30 minutes prior to the procedure.  The excess Lasercaine was removed with a sterile alcohol swab.,Using the linear threading technique, I injected the deep nasolabial fold.  We used 2 mL of the Perlane for injection of the nasolabial mesiolabial fold.  They were carefully massaged into good position at the end of the procedure.  She did have some mild erythema noted.,I then used approximately 0.4 mL of the Restylane for injection of the mid glabellar site.  She has a resting line of the mid glabella that did not respond with previous Botox injection.  Once this was filled, the Restylane was massaged into the proper tissue plane.  Cold compressors were applied afterwards.  She is scheduled for a recheck in the next one to two weeks, and we will make further recommendations at that time.  Post Restylane and Perlane precautions have been reviewed with the patient as well.",6
"PROCEDURE PERFORMED: , Port-A-Cath insertion.,ANESTHESIA: , MAC.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Minimal.,PROCEDURE IN DETAIL:  ,Patient was prepped and draped in sterile fashion.  The left subclavian vein was cannulated with a wire.  Fluoroscopic confirmation of the wire in appropriate position was performed.  Then catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.  Once the catheter was advanced through the sheath, the sheath was peeled away.  Catheter was left in place, which was attached to hub, placed in the subcutaneous pocket, sewn in place with 2-0 silk sutures, and then all hemostasis was further reconfirmed.  No hemorrhage was identified.  The port was in appropriate position with fluoroscopic confirmation.  The wound was closed in 2 layers, the 1st layer being 3-0 Vicryl, the 2nd layer being 4-0 Monocryl subcuticular stitch.  Dressed with Steri-Strips and 4 x 4's.  Port was checked.  Had good blood return, flushed readily with heparinized saline.",3
"CURRENT HISTORY:,  A 94-year-old female from the nursing home with several days of lethargy and anorexia.  She was found to have evidence of UTI.  She also has renal insufficiency and digitalis toxicity.  She is admitted for further treatment.,Past medical history, social history, family history, physical examination can be seen on the admission H&P.,LABORATORIES ON ADMISSION: , White count 11,700, hemoglobin 12.8, hematocrit 37.2, BUN 91, creatinine 2.2, sodium 131, potassium 5.1.  Digoxin level of 4.1.,HOSPITAL COURSE: , The patient was admitted and intravenous fluids and antibiotics were administered.  Blood cultures were negative.  Urine cultures were nondiagnostic.  Renal function improved with creatinine down to 1 at the time of discharge.  Digoxin was restarted at a lower dose.  Her condition improved and she is stabilized and transferred back to assisted living in good condition.,PRIMARY DIAGNOSES:,1.  Urinary tract infection.,2.  Volume depletion.,3.  Renal insufficiency.,4.  Digitalis toxicity.,SECONDARY DIAGNOSES:,1.  Aortic valve stenosis.,2.  Congestive heart failure.,3.  Hypertension.,4.  Chronic anemia.,5.  Degenerative joint disease.,6.  Gastroesophageal reflux disease.,PROCEDURES:,  None.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Improved and stable.,DISCHARGE PLAN:  ,Physical activity:  With assistance.  ,Diet:  No restriction.  ,Medications:  Lasix 40 mg daily, lisinopril 5 mg daily, digoxin 0.125 mg daily, Augmentin 875 mg 1 tablet twice a day for 1 week, Nexium 40 mg daily, Elavil 10 mg at bedtime, Detrol 2 mg twice a day, potassium 10 mEq daily and diclofenac 50 mg twice a day.  ,Follow up:  She will see Dr. X in the office as scheduled.",10
"REASON FOR EXAM:,  CVA.,INDICATIONS: , CVA.,This is technically acceptable.  There is some limitation related to body habitus.,DIMENSIONS:  ,The interventricular septum 1.2, posterior wall 10.9, left ventricular end-diastolic 5.5, and end-systolic 4.5, the left atrium 3.9.,FINDINGS: , The left atrium was mildly dilated.  No masses or thrombi were seen.  The left ventricle showed borderline left ventricular hypertrophy with normal wall motion and wall thickening, EF of 60%.  The right atrium and right ventricle are normal in size.,Mitral valve showed mitral annular calcification in the posterior aspect of the valve.  The valve itself was structurally normal.  No vegetations seen.  No significant MR. Mitral inflow pattern was consistent with diastolic dysfunction grade 1.  The aortic valve showed minimal thickening with good exposure and coaptation.  Peak velocity is normal.  No AI.,Pulmonic and tricuspid valves were both structurally normal.,Interatrial septum was appeared to be intact in the views obtained.  A bubble study was not performed.,No pericardial effusion was seen.  Aortic arch was not assessed.,CONCLUSIONS:,1.  Borderline left ventricular hypertrophy with normal ejection fraction at 60%.,2.  Mitral annular calcification with structurally normal mitral valve.,3.  No intracavitary thrombi is seen.,4.  Interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.",33
"CHIEF COMPLAINT:,  Head injury.,HISTORY: , This 16-year-old female presents to Children's Hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device.  She struck herself in the head with the flag.  There was no loss of consciousness.  She did feel dizzy.  She complained of a headache.  She was able to walk.  She continued to participate in her flag practice.  She got dizzier.  She sat down for a while and walked and during the second period of walking, she had some episodes of diplopia, felt that she might faint and was assisted to the ground and was transported via paramedic ambulance to Children's Hospital for further evaluation.,PAST MEDICAL HISTORY: , Hypertension.,ALLERGIES:,  DENIED TO ME; HOWEVER, IT IS NOTED BEFORE SEVERAL ACCORDING TO MEDITECH.,CURRENT MEDICATIONS: , Enalapril.,PAST SURGICAL HISTORY: , She had some kind of an abdominal obstruction as an infant.,SOCIAL HISTORY: , She is here with mother and father who lives at home.  There is no smoking at home.  There is second-hand smoke exposure.,FAMILY HISTORY:  ,No noted family history of infectious disease exposure.,IMMUNIZATIONS:,  She is up-to-date on her shots, otherwise negative.,REVIEW OF SYSTEMS:  ,On the 10-plus systems reviewed with the section of those noted on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her temperature 100 degrees, pulse 86, respirations 20, and her initial blood pressure 166/116, and a weight of 55.8 kg.,GENERAL:  She is supine awake, alert, cooperative, and active child.,HEENT:  Head atraumatic, normocephalic.  Pupils equal, round, reactive to light.  Extraocular motions intact and conjugate.  Clear TMs, nose and oropharynx.  Moist oral mucosa without noted lesions.,NECK:  Supple, full painless nontender range motion.,CHEST:  Clear to auscultation, equal, stable to palpation.,HEART:  Regular without rubs or murmurs.,ABDOMEN:  No abdominal bruits are heard.,EXTREMITIES:  Equal femoral pulses are appreciated.  Equal radial and dorsalis pedis pulses are appreciated.  He moves all extremities without difficulty.  Nontender.  No deformity.  No swelling.,SKIN:  There was no significant bruising, lesions or rash about her abdomen.  No significant bruising, lesions or rash.,NEUROLOGIC:  Symmetric face and extremity motion.  Ambulates without difficulty.  She is awake, alert, and appropriate.,MEDICAL DECISION MAKING:,  The differential entertained includes head injury, anxiety, and hypertensive emergency.  She is evaluated in the emergency department with serial blood pressure examinations, which are noted to return to a more baseline state for her 130s/90s.  Her laboratory data shows a mildly elevated creatinine of 1.3.  Urine is within normal.  Urinalysis showing no signs of infection.  Head CT read by staff has no significant intracranial pathology.  No mass shift, bleed or fracture per Dr. X.  A 12-lead EKG reviewed preliminarily by myself noting normal sinus rhythm, normal axis rates of 90.  No significant ST-T wave changes.  No significant change from previous 09/2007 EKG.  Her headache has resolved.  She is feeling better.  I spoke with Dr. X at 0206 hours consulting Nephrology regarding this patient's presentation with the plan for home.  Follow up with her regular doctor.  Blood pressures have normalized for her.  She should return to emergency department on concern.  They are to call the family to Nephrology Clinic next week for optimization of her blood pressure control with a working diagnosis of head injury, hypertension, and syncope.",12
"PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,DETAILS OF PROCEDURE: ,The child was placed in a Circumstraint board and restrained in the usual fashion.  The area of the penis and scrotum were prepared with povidone iodine solution.  The area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure.  A dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine.  A dorsal slit was made, and the prepuce was dissected away from the glans penis.  A Gomco clamp was properly placed for 5 minutes.  During this time, the foreskin was sharply excised using a #10 blade.  With removal of the clamp, there was a good cosmetic outcome and no bleeding.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.",38
"HISTORY OF PRESENT ILLNESS:, The patient is a 43-year-old male who was recently discharged from our care on the 1/13/06 when he presented for shortness of breath. He has a past history of known hyperthyroidism since 1992 and a more recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%. The main cause for his shortness of breath was believed to be due to atrial fibrillation secondary to hyperthyroidism in a setting with congestive cardiac failure. During his hospital stay, he was commenced on metoprolol for rate control, and given that he had atrial fibrillation, he was also started on warfarin, which his INR has been followed up by the Homeless Clinic. For his congestive cardiac failure, he was restarted on Digoxin and lisinopril. For his hyperthyroidism, we restarted him on PTU and the endocrinologists were happy to review him when he was euthymic to discuss further radioiodine or radiotherapy. He was restarted on PTU and discharged from the hospital on this medication. While in the hospital, it was also noted that he abused cigarettes and cocaine, and we advised strongly against this given the condition of his heart. It was also noted that he had elevated liver function tests, which an ultrasound was normal, but his hepatitis panel was pending. Since his discharge, his hepatitis panel has come back normal for hepatitis A, B, and C. Since discharge, the patient has complained of shortness of breath, mainly at night when lying flat, but otherwise he states he has been well and compliant with his medication.,MEDICATIONS:, Digoxin 250 mcg daily, lisinopril 5 mg daily, metoprolol 50 mg twice daily, PTU (propylthiouracil) 300 mg orally four times a day, warfarin variable dose based on INR.,PHYSICAL EXAMINATION:,VITAL SIGNS: He was afebrile today. Blood pressure 114/98. Pulse 92 but irregular. Respiratory rate 25.,HEENT: Obvious exophthalmus, but no obvious lid lag today.,NECK: There was no thyroid mass palpable.,CHEST: Clear except for occasional bibasilar crackles.,CARDIOVASCULAR: Heart sounds were dual, but irregular, with no additional sounds.,ABDOMEN: Soft, nontender, nondistended.,EXTREMITIES: Mild +1 peripheral edema in both legs.,PLAN:, The patient has also been attending the Homeless Clinic since discharge from the hospital, where he has been receiving quality care and they have been looking after every aspect of his health, including his hyperthyroidism. It is our recommendation that a TSH and T4 be continually checked until the patient is euthymic, at which time he should attend endocrine review with Dr. Huffman for further treatment of his hyperthyroidism. Regarding his atrial fibrillation, he is moderately rate controlled with metoprolol 50 mg b.i.d. His rate in clinic today was 92. He could benefit from increasing his metoprolol dose, however, in the hospital it was noted that he was bradycardic in the morning with a pulse rate down to the 50s, and we were concerned with making this patient bradycardic in the setting of congestive cardiac failure. Regarding his congestive cardiac failure, he currently appears stable, with some variation in his weight. He states he has been taking his wife's Lasix tablets for diuretic benefit when he feels weight gain coming on and increased edema. We should consider adding him on a low-dose furosemide tablet to be taken either daily or when his weight is above his target range. A Digoxin level has not been repeated since discharge, and we feel that this should be followed up. We have also increased his lisinopril to 5 mg daily, but the patient did not receive his script upon departing our clinic. Regarding his elevated liver function tests, we feel that these are very likely secondary to hepatic congestion secondary to congestive cardiac failure with a normal ultrasound and normal hepatitis panel, but yet the liver function tests should be followed up.",25
"EXAM:,MRI RIGHT SHOULDER,CLINICAL:, A 32-year-old male with shoulder pain.,FINDINGS:,This is a second opinion interpretation of the examination performed on 02/16/06.,Normal supraspinatus tendon without surface fraying, gap or fiber retraction and there is no muscular atrophy.,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is no subluxation of the tendon under the transverse humeral ligament and the intracapsular portion of the tendon is normal.,Normal humeral head without fracture or subluxation.,There is myxoid degeneration within the superior labrum (oblique coronal images #47-48), but there is no discrete tear. The remaining portions of the labrum are normal without osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is a persistent os acromiale, and there is minimal reactive marrow edema on both sides of the synchondrosis, suggesting that there may be instability (axial images #3 and 4). There is no diastasis of the acromioclavicular joint itself. There is mild narrowing of the subacromial space secondary to the os acromiale, in the appropriate clinical setting, this may be acting as an impinging lesion (sagittal images #56-59).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There are no effusions or masses.,IMPRESSION:,Changes in the superior labrum compatible with degeneration without a discrete surfacing tear.,There is a persistent os acromiale, and there is reactive marrow edema on both sides of the synchondrosis suggesting instability. There is also mild narrowing of the subacromial space secondary to the os acromiale. This may be acting as an impinging lesion in the appropriate clinical setting.,There is no evidence of a rotator cuff tear.",33
"Her past medical history includes insulin requiring diabetes mellitus for the past 28 years.  She also has a history of gastritis and currently is being evaluated for inflammatory bowel disease.  She is scheduled to see a gastroenterologist in the near future.  She is taking Econopred 8 times a day to the right eye and Nevanac, OD, three times a day.  She is allergic to penicillin.,The visual acuity today was 20/50, pinholing, no improvement in the right eye.  In the left eye, the visual acuity was 20/80, pinholing, no improvement.  The intraocular pressure was 14, OD and 9, OS.  Anterior segment exam shows normal lids, OU.  The conjunctiva is quiet in the right eye.  In the left eye, she has an area of sectoral scleral hyperemia superonasally in the left eye.  The cornea on the right eye shows a paracentral area of mild corneal edema.  In the left eye, cornea is clear.  Anterior chamber in the right eye shows trace cell.  In the left eye, the anterior chamber is deep and quiet.  She has a posterior chamber intraocular lens, well centered and in sulcus of the left eye.  The lens in the left eye shows 3+ nuclear sclerosis.  Vitreous is clear in both eyes.  The optic nerves appear healthy in color and normal in size with cup-to-disc ratio of approximately 0.48.  The maculae are flat in both eyes.  The retinal periphery is flat in both eyes.,Ms. ABC is recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.  She will continue her current drops.  In the left eye, she has an area of what appears to be sectoral scleritis.  I did a comprehensive review of systems today and she reports no changes in her pulmonary, dermatologic, neurologic, gastroenterologic or musculoskeletal systems.  She is, however, being evaluated for inflammatory bowel disease.  The mild scleritis in the left eye may be a manifestation of this.  We will notify her gastroenterologist of this possibility of scleritis and will start Ms. ABC on a course of indomethacin 25 mg by mouth two times a day.  I will see her again in one week.  She will check with her primary physician prior to starting the Indocin.",26
"SUBJECTIVE: , The patient states she is feeling a bit better.,OBJECTIVE:,VITAL SIGNS:  Temperature is 95.4.  Highest temperature recorded over the past 24 hours is 102.1.,CHEST:  Examination of the chest is clear to auscultation.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Benign.  Right renal angle is tender.  Bowel sounds are positive.,EXTREMITIES:  There is no swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.,LABORATORY DATA: , White count is down from 35,000 to 15.5.  Hemoglobin is 9.5, hematocrit is 30, and platelets are 269,000.  BUN is down to 22, creatinine is within normal limits.,ASSESSMENT AND PLAN:,1.  Sepsis due to urinary tract infection.  Urine culture shows Escherichia coli, resistant to Levaquin.  We changed to doripenem.,2.  Urinary tract infection, we will treat with doripenem, change Foley catheter,3.  Hypotension.  Resolved, continue intravenous fluids.,4.  Ischemic cardiomyopathy.  No evidence of decompensation, we with monitor.,5.  Diabetes type 2.  Uncontrolled.  Continue insulin sliding scale.,6.  Recent pulmonary embolism, INR is above therapeutic range, Coumadin is on hold, we will monitor.,7.  History of coronary artery disease.  Troponin indeterminate.  Cardiologist intends no further workup.  Continue medical treatment.  Most likely troponin is secondary to impaired clearance.",34
"DISCHARGE DIAGNOSES:,1.  Bilateral lower extremity cellulitis secondary to bilateral tinea pedis.,2.  Prostatic hypertrophy with bladder outlet obstruction.,3.  Cerebral palsy.,DISCHARGE INSTRUCTIONS: , The patient would be discharged on his usual Valium 10-20 mg at bedtime for spasticity, Flomax 0.4 mg daily, cefazolin 500 mg q.i.d., and Lotrimin cream between toes b.i.d. for an additional two weeks.  He will be followed in the office.,HISTORY OF PRESENT ILLNESS:,  This is a pleasant 62-year-old male with cerebral palsy.  The patient was recently admitted to Hospital with lower extremity cellulitis.  This resolved, however, recurred in both legs.  Examination at the time of this admission demonstrated peeling of the skin and excoriation between all of his toes on both feet consistent with tinea pedis.,PAST MEDICAL/FAMILY/SOCIAL HISTORY:,  As per the admission record.,REVIEW OF SYSTEMS: , As per the admission record.,PHYSICAL EXAMINATION:  ,As per the admission record.,LABORATORY STUDIES: , At the time of admission, his white blood cell count was 8200 with a normal differential, hemoglobin 13.6, hematocrit 40.6 with normal indices, and platelet count was 250,000.  Comprehensive metabolic profile was unremarkable, except for a nonfasting blood sugar of 137, lactic acid was 0.8.  Urine demonstrated 4-9 red blood cells per high-powered field with 2+ bacteria.  Blood culture and wound cultures were unremarkable.  Chest x-ray was unremarkable.,HOSPITAL COURSE: , The patient was admitted to the General Medical floor and treated with intravenous ceftriaxone and topical Lotrimin.  On this regimen, his lower extremity edema and erythema resolved quite rapidly.,Because of urinary frequency, a bladder scan was done suggesting about 600 cc of residual urine.  A Foley catheter was inserted and was productive of approximately 500 cc of urine.  The patient was prescribed Flomax 0.4 mg daily.  24 hours later, the Foley catheter was removed and a bladder scan demonstrated 60 cc of residual urine after approximately eight hours.,At the time of this dictation, the patient was ambulating minimally, however, not sufficiently to resume independent living.",22
"PREOP DIAGNOSES:,1.  Left pilon fracture.,2.  Left great toe proximal phalanx fracture.,POSTOP DIAGNOSES:,1.  Left pilon fracture.,2.  Left great toe proximal phalanx fracture.,OPERATION PERFORMED:,1.  External fixation of left pilon fracture.,2.  Closed reduction of left great toe, T1 fracture.,ANESTHESIA:  ,General.,BLOOD LOSS:  ,Less than 10 mL.,Needle, instrument, and sponge counts were done and correct.,DRAINS AND TUBES: , None.,SPECIMENS:,  None.,INDICATION FOR OPERATION:  ,The patient is a 58-year-old female who was involved in an auto versus a tree accident on 6/15/2009.  The patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time.  The patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness.  She underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the Medicine Service following this and she was appropriate for surgical intervention.  Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.  The patient had swollen lower extremities, however, compartments were soft and she had no sign of compartment syndrome.  Risks and benefits of procedure were discussed in detail with the patient and her husband.  All questions were answered, and consent was obtained.  The risks including damage to blood vessels and nerves with painful neuroma or numbness, limb altered function, loss of range of motion, need for further surgery, infection, complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery.,FINDINGS:,1.  There was a comminuted distal tibia fracture with a fibular shaft fracture.  Following traction, there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula, the fracture fragments were out to length.,2.  The base of her proximal phalanx fracture was assessed and reduced with essentially no articular step-off and approximately 1-mm displacement.  As the reduction was stable with buddy taping, no pinning was performed.,3.  Her compartments were full, but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed.,OPERATIVE REPORT IN DETAIL:  ,The patient was identified in the preoperative holding area.  The left leg was identified and marked at the surgical site of the patient.  She was then taken to the operating room where she was transferred to the operating room in the supine position, placed under general anesthesia by the anesthesiology team.  She received Ancef for antibiotic prophylaxis.  A time-out was then undertaken verifying the correct patient, extremity, visibility of preoperative markings, availability of equipment, and administration of preoperative antibiotics.  When all was verified by the surgeon, anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion.  At this point, intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site.  A single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 Schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length, but not overly distract the fracture and restore coronal and sagittal alignment as much as able.  When this was adequate, the fixator apparatus was locked in place, and x-ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture.  Attention was then turned to the left great toe, where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive.  X-rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture.  At this point, the pins were cut short and capped to protect the sharp ends.  The stab wounds for the Schantz pin and cross pin were covered with gauze with Betadine followed by dry gauze, and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition.  Please note there was no break in sterile technique throughout the case.,PLAN:  ,The patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication.  She will maintain her buddy taping in regards to her great toe fracture.",37
"PREOPERATIVE DIAGNOSIS: , Inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct inguinal hernia.,PROCEDURE PERFORMED:,  Rutkow direct inguinal herniorrhaphy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF 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.  Preoperative antibiotics were given for prophylaxis against surgical infection.  The patient was prepped and draped in the usual sterile fashion.,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 no sac was found.  The hernia was found coming from the floor of the inguinal canal medial to the inferior epigastric vessels.  This was dissected back to the hernia opening.  The hernia was inverted back into the abdominal cavity and a large PerFix plug inserted into the ring.  The plug was secured to the ring by interrupted 2-0 Prolene sutures.,The PerFix onlay patch was then placed on the floor of the inguinal canal and secured in place using interrupted 2-0 Prolene sutures.  By reinforcing the floor with the onlay patch, a new internal ring was thus formed.,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 2-0 Vicryl in a running fashion, thus reforming the external ring.  The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.",38
"INDICATIONS: , Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old white female with no prior cardiac history.  She sustained a mechanical fall with a subsequent left femoral neck fracture.  She was transferred to XYZ Hospital for definitive care.  In the emergency department of XYZ, the patient described six to seven seconds of sharp chest pain without radiation, without associated symptoms.  Electrocardiogram was obtained, which showed nonspecific ST-segment flattening in the high lateral leads I, aVL.  She also had a left axis deviation.  Serial troponins were obtained.  She has had four negative troponins since admission.  Due to age and chest pain history, a cardiology consultation was requested preoperatively.,At the time of my evaluation, the patient complained of left hip pain, but no chest pain, dyspnea, or symptomatic dysrhythmia.,PAST MEDICAL HISTORY:,1.  Mesothelioma.,2.  Recurrent urinary tract infections.,3.  Gastroesophageal reflux disease/gastritis.,4.  Osteopenia.,5.  Right sciatica.,6.  Hypothyroidism.,7.  Peripheral neuropathy.,8.  Fibromyalgia.,9.  Chart review also suggests she has atherosclerotic heart disease and pneumothorax.  The patient denies either of these.,PAST SURGICAL HISTORY:,1.  Tonsillectomy.,2.  Hysterectomy.,3.  Appendectomy.,4.  Thyroidectomy.,5.  Coccygectomy.,6.  Cystoscopies times several.,7.  Bladder neck resuspension.,8.  Multiple breast biopsies.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS:,  At the time of evaluation include, 1.  Cefazolin 1 g intravenous (IV).  2.  Morphine sulfate.  3.  Ondansetron p.r.n.,OUTPATIENT MEDICATIONS: , 1.  Robaxin.  2.  Detrol 4 mg q.h.s.  3.  Neurontin 300 mg p.o. t.i.d.  4.  Armour Thyroid 90 mg p.o. daily.  5.  Temazepam, dose unknown p.r.n.  6.  Chloral hydrate, dose unknown p.r.n.,FAMILY HISTORY: , Mother had myocardial infarction in her 40s, died of heart disease in her 60s, specifics not known.  She knows nothing of her father's history.  She has no siblings.  There is no other history of premature atherosclerotic heart disease in the family.,SOCIAL HISTORY: , The patient is married, lives with her husband.  She is a lifetime nonsmoker, nondrinker.  She has not been getting regular exercise for approximately two years due to chronic sciatic pain.,REVIEW OF SYSTEMS: ,GENERAL:  The patient is able to walk one block or less prior to the onset of significant leg pain.  She ever denies any cardiac symptoms with this degree of exertion.  She denies any dyspnea on exertion or chest pain with activities of daily living.  She does sleep on two to three pillows, but denies orthopnea or paroxysmal nocturnal dyspnea.  She does have chronic lower extremity edema.  Her husband states that she has had prior chest pain in the past, but this has always been attributed to gastritis.  She denies any palpitations or tachycardia.  She has remote history of presyncope, no true syncope.,HEMATOLOGIC:  Negative for bleeding diathesis or coagulopathy.,ONCOLOGIC:  Remarkable for past medical history.,PULMONARY:  Remarkable for childhood pneumonia times several.  No recurrent pneumonias, bronchitis, reactive airway disease as an adult.,GASTROINTESTINAL:  Remarkable for past medical history.,GENITOURINARY:  Remarkable for past medical history.,MUSCULOSKELETAL:  Remarkable for past medical history.,CENTRAL NERVOUS SYSTEM:  Negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.,PSYCHIATRIC:  Remarkable for history of depression as an adolescent, she was hospitalized at State Mental Institution as a young woman.  No recurrence.,PHYSICAL EXAMINATION:,GENERAL:  This is a well-nourished, well-groomed elderly white female who is appropriate and articulate at the time of evaluation.,VITAL SIGNS:  She has had a low-grade temperature of 100.4 degrees Fahrenheit on 11/20/2006, currently 99.6.  Pulse ranges from 123 to 86 beats per minute.  Blood pressure ranges from 124/65 to 152/67 mmHg.  Oxygen saturation on 2 L nasal cannula was 94%.,HEENT:  Exam is benign.  Normocephalic and atraumatic.  Extraocular motions are intact.  Sclerae anicteric.  Conjunctivae noninjected.  She does have bilateral arcus senilis.  Oral mucosa is pink and moist.",3
"PREOPERATIVE DIAGNOSIS: , Hypoxia and increasing pulmonary secretions.,POSTOPERATIVE DIAGNOSIS: , Hypoxia and increasing pulmonary secretions.,OPERATION: , Bronchoscopy.,ANESTHESIA: , Moderate bedside sedation.,COMPLICATIONS:,  None.,FINDINGS:,  Abundant amount of clear thick secretions throughout the main airways.,INDICATIONS:,  The patient is a 43-year-old gentleman who has been in the ICU for several days following resection of small bowel for sequelae of SMV occlusion.  This morning, the patient developed worsening hypoxia with abundant sputum production requiring frequent suctioning from his ET tube.  The patient also had new-appearing atelectasis versus infiltrates in the right lower lobe of his lung on chest x-ray.  Given these findings, it was felt that bronchoscopy could further define source of secretions and send more appropriate specimen for culture if need be.,OPERATION:,  The patient was given additional fentanyl, Versed as well as paralytics for the procedure.  Small bronchoscope was inserted through the ET tube and to the trachea to the level of carina.  There was noted to be thick clear secretions adherent to the trachea walls as well as into the right mainstem bronchus.  Extensive secretions extended down into the secondary airways.  This was lavaged with saline and suctioned dry.  There is no overt specific occlusion of airways, nor was there any purulent-appearing sputum.  The bronchoscope was then advanced into the left mainstem bronchus, and there was noted to be a small amount of similar-appearing secretions which was likewise suctioned and cleaned.  The bronchoscope was removed, and the patient was increased to PEEP of 10 on the ventilator.  Please note that prior to starting bronchoscopy, he was pre oxygenated with 100% O2.  The patient tolerated the procedure well and lavage specimen was sent for gram stain as well as routine culture.",3
"CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.  She had no difficulty breathing and her cough was described as dry and hacky.  At that time, physical exam showed a right TM, which was red.  Left TM was okay.  She was fairly congested but looked happy and playful.  She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear.  Mom returned to clinic again today because she got much worse overnight.  She was having difficulty breathing.  She was much more congested and her appetite had decreased significantly today.  She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS:  ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY:  ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces.  No complications.  Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY:  ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her respiratory rate was approximately 60 to 65.,GENERAL:  She was very congested and she looked miserable.  She had no retractions at this time.,HEENT:  Her right TM was still red and irritated with no light reflex.  Her nasal discharge was thick and whitish yellow.  Her throat was clear.  Her extraocular muscles were intact.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR EXAM:  She was tachycardic without murmur.,LUNGS:  Revealed diffuse expiratory wheezing.,ABDOMEN:  Soft, nontender, and nondistended.,EXTREMITIES:  Showed no clubbing, cyanosis or edema.,LABORATORY DATA:  ,Her chem panel was normal.  RSV screen is positive.  Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN:  ,RSV bronchiolitis with otitis media.  Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.",29