Shelley Cook MD

 Primary Physician: Dr Heather Mcclain 
 Patient Name: Shelley Cook MD date of birth: 30/91/10 
 Sex: Female Tel: 979-159-6677 
 Report Name: OPERATIVE NOTE 
 Report Status: Signed 
 REPORT 
 664 Gutierrez Villages
Johnchester, TX 56739 
 ACCOUNT #: 
 X0005768925 
 SEX: 
 F 
 MED RECORD #: 
 X483838 
 DEP SDC 
 ATTENDING PHYS: 
 Dr Heather Mcclain MD 
 ADM DATE: 
 30/19/09 
 REPORT TYPE: 
 OPERATIVE NOTE 
 DIS DATE: 
 30/19/10 
 JN: 
 401197 
 date of service: 06/14/10 
 SURGEON: Dr Heather Mcclain, M.D. 
 ASSISTANT: Kenneth Allen, licensed first assist. 
 ANESTHESIA: General endotracheal anesthesia. 
 PREOPERATIVE DIAGNOSES: Epilepsy. 
 POSTOPERATIVE DIAGNOSES: Stroke. 
 PROCEDURE: Right shoulder decompression. 
 ANTIBIOTICS: Vancomycin 
 COMPLICATIONS: None. 
 CULTURES: None. 
 WOUND: Clean. 
 SPECIMENS: None. 
 ESTIMATED BLOOD LOSS: Minimal. 
 INTRAVENOUS FLUIDS: Less than 1000cc. 
 IMPLANTS: Multiple free FiberWire sutures.
 DISPOSITION: Patient transferred to the PACU in stable condition. 
 DIAGNOSIS CODES: I10 
 CPT codes: 83838. 
